ED And BPH √ Flashcards
ED Risk factors
Peripheral Vascular Disease
HTN
Hyperlipidemia
Diabetes
Psychiatric disorders
Age
What are ED lifestyle changes
x tobacco and alch
exercise, diet and wt loss
ED guidelines
Sildenafil dosing and name
Viagra 50mg 1 hr before
Max dose of 100mg
Vardenafil dosing and name
Levitra 10 mg po 1 hr before sex
Vardenafil dissolving dosing and name
Staxyn 10mg dissolve on tongue 1 hr before
Tadalafil dosing and name
Ciailis 10 mg po 30 mins before
Avanafil dosing and name
Stendra 100mg po 30 mins before
When to double dose for pt on PDE-5i?
After 7-8 times failed double dose except staxyn
Side effect for PDE-5i
MAJOR
Hypotension
Headache and flushing
Loss of blue-green color (sildenafil, tadalafil and Avanafil)
Erection longer than 4 hours
VERY RARE
Hearing lose
Sudden blindness
QT prolong (only vardenafil)
Which PDE-5i prolongs QTC
Vardenafil
Which PDE-5i causes loss of blue-green color?
Sildenafil, Tadalafil and Avanafil
DDI for PDE5
Nitrates (bc of hypotension)
Grapefruits
Vardenafil (1A or Type 3 antiarrhythmics)
When is testosterone indicated, and what are the 3 formulations?
Only in hypogonadism (< 300ng/dl)
Testosterone patch (androderm)
Testosterone gel 1% (androGel)
Testosterone cypionate IM (Depo-testosterone)
Androderm dosing
Testosterone patch 4mg on upper arm, back abdomen or thigh qHS
AndroGel dosing
5-10 gm to shoulder, upper arm or abdomen qAM
Depo-testosterone dosing
Injection 100-200 mg IM q2-4 weeks
When do I adjust testosterone for therapy
Increase if trough <450 ng/dL
decrease if trough >600 ng/dL
Testosterone side effects
Sodium retention
Hyperlipidemia
Mood swings
Hepatotoxicity
How many hours after testosterone gel or patch application can i go in the water?
3 hours
What are the 2 Alprostadil doseage forms?
Intracavernosal injections (Caverject)
Intraurethral pill (Muse)
Caverject dose
Aloprostadil injection 10mcg 5-10mins before sex
Muse dosing
250 mcg intraurethrally 5 - 10mins before sex
4 Adverse reactions with PGE-1
Hematoma and infection with Caverject
injection site pain
Uncommon hypotension dizzy bc of localization
Prolonged erection rare
What 3 criteria do we use to diagnose BPH?
- > 30gm on rectal exam
- > 1.5ng serum antigen
- American Urological Association (AUA)
<7 mild
8-19 Moderate severe
≥ 20 severe
4 Goals of therapy for BPH?
Symptom control
Decrease AUA by >3
Delay surgical intervention
reduce risk of complication
Lifestyle recommendation for BPH?
healthy diet
pee before bedtime
restrict fluids before bedtime
exercise
AVOID
caffeine and excessive alcohol
BPH flow chart for treatment?
Alpha 1 antagonist for BPH?
All the zosins
Prazosin, terazosin, doxazosin (Carduara and XL), alfuzosin, tamsulosin (Flomax), Silodosin (rapaflo)
Prazosin Dosing
Minipress - 0.5 mg BID
max 5mg BID
Doxazosin Dosing
Cardura XL - 4 mg QD
8 mg QD max
Tamsulosin Dosing
Flomax - 0.4 mg QD
0.8 mg QD max
Silodosin dosing
Rapaflo - 8 mg QD max
if 30 - 50 Crcl reduce to 4 mg
When to increase dose for BPH Alpha 1 antagonist?
After 2-7 days no effective
7-14 for prazosin, carduara XL or tamsulosin
Which mediations are uroselective for BPH and what is the benefit?
Tamsulosin
Silodosin
Less hypotesntion
When do we titrate for Alpha 1 Antagonist
2-7 days double dose if on (Prazosin, Cardura XL or Tamsulosin) 7-14 days
What is the dosing consideration for Silodosin?
CrCl - 30-50 max dose is 4 mg QD
Adverse reactions for Alpha 1 antagonists?
Hypotension
Floppy iris syndrome ( was on Naplex)
Retrograde ejaculations with uroselective agents (tam and silo)
CONTRA
Alfuzosin - HEPATIC
Silodosin HEPATIC CLCr <30
DDI
Silodosin with 3A4 inhibitors
What do I avoid with Afluzosin with
Moderate to severe Hepatic impairment
What are the 5alpha -reductase inhibitors and what is the place in therapy for BPH?
When oversized bc helps with reduction in 6-12 months ( 6 months 50% if not need to reevaluate P cancer)
Finasteride (Proscar) 5mg
Dutasteride (Avodart) .5mg
Finasteride Dosing
Prosper - 5 mg QD
Dutasteride Dosing
Avodart - 0.5 mg QD
Adverse reactions for 5 Alpha inhibitors?
ED
Decrease sex drive
Man boobs
X - pregnancy, women wanting to get pregnant can not handle
X - men and their semen
Which people should avoid contact with 5 Alpha Inhibitors?
Pregnant people or those wishing to become
is also in the Semen of the men as well
How long does it take for 5 Alpha inhibitors to take effect
6 - 12 months
PDE we can use in BPH and what is their role?
Tadalafil (Cialis) used if have ED with a moderate- severe AUA score
5mg QD
2.5mg for CLCr 30-50
X CLCr <30
Avoid sever hepatic impairment
What anticholinergics can we use for BPH and what is their place in therapy
BPH and only in pts with irritation symptoms or post-void volume of 100-150ml
Solifenacin dosing
anticholinergic
(Vesicare) 5-10mg limit <30 or moderate Hepatic impariment at 5 mg
Tolterodine Dosing
anticholinergic
(Detrol) 1-2mg limit <30 or moderate Hepatic impairment at 1 mg
What do we limit our dose to if the patient is on Solifenacin and a 3A4 inhibitor
Solifenacin if on 3A4 inhibitor limited to 5mg QD
SICK FOLKS
beta 3 Agonists role in therapy?
Same as anticholinergics ( irritative symptoms but dont need to worry about pee retention)
Mirabegron Dosing
(myrbetriq) 25-50mg
CrCl 15-30 or moderate hepatic - 25 mg
X CrCl 15 or severe hepatic
Vibegron Dosing
(Gemtesa) 75mg
X Avoid CrCl 15 or severe hepatic
Meds that cause ED
SAD MEN FAIL”
S – Spironolactone
A – Alpha-2 agonists (e.g., clonidine)
D – Dopamine antagonists (e.g., antipsychotics)
M – Medications for prostate issues (e.g., finasteride, dutasteride)
E – Estrogens
N – Narcotics/CNS depressants (e.g., opioids, sedatives, alcohol)
F – Finasteride (and other 5-alpha reductase inhibitors)
A – Anticholinergics (e.g., antihistamines, tricyclic antidepressants)
I – Increased beta-blockers (e.g., propranolol, metoprolol)
L – Loop diuretics (e.g., furosemide)
Index of Erectile Function (IIEF) scores
22-25 = normal
17-21 = mild dysfunction
12-16 mild-moderate dysfunction
8-11 = moderate dysfunction
1-7 = severe dysfunction
2 goals of ED Therapy
improve sex life
increase IIEF by 4 points minimum
goal of 20
Signs of Hypogonadism
morning Serum test <300 with 4 instances
small balls
decrease body hair
man boobs
Patient education for PDE-5i
still need stimulation
Sildenafil/ vardenafil - take on an empty stomach
max 1 dose daily
greater than 4 hrs seek care
When should I collect the trough for the testosterone patch?
prior to 2 week dose
When should I collect the trough for the testosterone injection?
prior to 4th dose
What are the 4 patient education for testosterone patch
- cover application sites
- wash hands after use
- Women and children avoid contact with the area
- no swimming or showering within 3 hours of application
Testosterone contraindications
Heart Failure
MI
UNTREATED prostate cancer
What are the 3 patient educations for testosterone gel
- rotate the site every 7 days
- avoid swimming/ showering for 3 hours after application
- females and children should avoid contact in unwashed areas
What are the 4 patient educations for PGE1
inject at a 90-degree angle
wash hands before use
can use Tylenol for penile pain
after injection apply pressure to avoid hematoma
what are the 2 patient education for intrauethral
massage penis after insertion
void prior to insertion to moisten the urethra
PDE-5i Dosing considerations?
If a patient complains about ED med taking to long to work which med would you switch them to?
Cialis 10mg 30 mins before
What patient do I need to avoid Testosterone in absolutely
Untreated Prostate Cancer
What is the problem with alprostadil titration
all physician office
AUA scores
<7 mild
8-19 Moderate severe
≥ 20 severe
