ED and BPH Flashcards
What are 6 risk factors for ED?
(Please hold her darn purse already )
- Peripheral vascular disease
- HTN
- HLD
- Diabetes
- Psychiatric disorders
- Age
What are the 3 functioning body systems that are required for an erection?
- Hormonal
- nervous
- Vascular
Whats the role of the nervous system in erection?
- sexual stimulus
- parasympathetic activation
- outflow of Ach to muscarinic R’s on penile arteries
What’s the role of vascular system in erection?
- after sexual stimulation , ACh vasodilates the arteries
- corpus cavernosum fills with blood
- tunica albuginea compresses penile arteries and veins, trapping blood in corpora
What are some conditions that decr testosterone (hypogonadism)? (3)
What are some conditions that decr receptiveness and affect nervous system? (4)
What are some conditions that decr blood flow? (3)
- Removal of testicles, hypothalamic/pituitary disorders, aging
- depression/anxiety, sedation, Alz’s
- Periph vascular disease, HTN, Smoking
Describe how Nitric oxide is involved in vascular system that results in erection
- ACh activates M R’s –> NO production in vasc endothel cells
- NO activates guanylate cyclase in vascular smooth muscle cells which converts GTP to cGMP
- cGMP acted on by protein kinase G which leads to arterial vasodilation
Role of hormonal system in an erection ?
Testosterone produced in leydig cells of testes –> testosterone contributes to Libido
Drugs that cause ED that affect hormonal system? (4)
Vascular system? (5)
Nervous system? (4)
- Dopamine antags (antipsychotics), estrogens, spirono, digoxin
- anticholinergics, alpha2agonists, beta blockers, diuretics, 5alpha reductase inhibs
- CNS depressants, alcohol, BZD’s, opioids
What should be tried first for ED?
Lifestyle mods
- lower cardio risks by exercising, weight loss BMI = 25, healthy diet
- avoid tobacco, and excessive alcohol
TX Pathway for ED
- what do you start with ?
a. if effective?
b. If ineffective? what happens after this step if it is still ineffective? Afterwards if still ineffective?
c. if CI?
- PDE5 inhibitor +/- testosterone supplementation if hypogonadism
a. continue
b. ensure tx given at correct time and titrate up dose –> Consider ALPROSTADIL –> Consider penile prosthesis
c. vacuum device
PDE5I MOA ?
Blocks PDE5 from breaking down cGMP to GMP –> continued vasodilation!
What are the initial doses for the following?
- Sildenafil (Viagra)
- Vardenafil ( Levitra)
- Vardenafil (Staxyn)
- Tadalafil ( Cialis )
- Avanafil (Stendra)
- 50 mg PO prn 1 hour before
intercourse - 10 mg PO prn 1 hour before
intercourse - 10 mg dissolved on tongue prn
1 hour before intercourse - 10 mg PO prn 30 min before
intercourse - 100 mg PO prn 30 min before
intercourse
If the initial dose is ineffective after 7-8 trials, what should u do?
titrate by doubling dose ! But u should limit that doubled dose to ONCE DAILY dosing only
-vardenafil (staxyn) stays normal at 10 mg once daily dosing
PDE5 I DOsing considerations (KIM LOOK AT CHART)
See chart
PDE5I : Monitoring
- what are some AE’s
- What are some drug interactions to avoid?
- Sx’s of HYPOtension (Dizzy, light headedness) , HA, flushing, Loss of blue green color discrimination with silden, tadal, avana, priapism lasting >4hr, hearing loss v rare, sudden blindness v rare, QT prolong with varden
- ALL drugs should avoid nitrates and grapefruit juice.
with vardenafil, type 1a or type 3 antiarryhthmics (additive QT prolongation)
Patient education :
1. u will still require?
2. take on ___ if silden or varden
3. Max ___ dose daily
4. What do u do if erection lasts > 4 hrs?
- sexual stimulation
- empty stomach
- 1
- seek emergency care
Testosterone is only indicated if?
What are some signs of hypogonadism? (4)
Hypogonadism is present
- serum testost < 300 ng/dL measured in early morning with repeat 4 wks later for confirmation
- small testicles
- decr body hair
- gynecomastia
Testosterone Dosing
- Testost patch (androderm)
- Testost Gel 1% (AndroGel)
- Testosterone Cypionate IM injection (Depo-Testosterone)
- 4 mg applied to upper arm, back, abdomen, or thigh qHS
- 5-10 gm of gel applied to shoulder, upper arm, or abdomen qAM
- 100-200 mg IM q2-4 wks
Therapeutic Dose Monitoring
- If gel or patch collect trough level when?
- If injection collect trough level when ?
- Incr dose if trough serum testosterone is ?
- Decr dose if trough serum testosterone is ??
- prior to week 2 dose
- prior to 4th dose
- <450 ng/dL
- > 600 ng/dL
What’s the dosing range for the following :
- Testosterone patch
- Testost gel 1%
- Testost cypionate IM injection
- 2-6 mg
- 5-10 gm
- 200-400 mg
Testosterone Monitoring :
- what are the 4 ae’s ?
- Which 3 scenarios should u be cautious to use Testost in ?
- sodium retention, HLD, mood swings, hepatotoxicity
- hf, hx of myocard infarction or stroke , avoid in untreated prostate cancer
Testost Gel Patient education :
- Cover application site to avoid?
- Who should avoid contact with unwashed area?
- After using u should?
- Avoid ___ and ___ for ___ after application
Testost Patch
1. how often should u rotate application site?
2. avoid __ and ___ for 3 hrs after application
- inadvertent transfer to others
- women and children
- wash hands
- swimming, showering, 3hrs
- every 7 days
- swimming, showering
Alprostadil (PGE1) : MOA ?
Available dosage forms? (2)
It activates EP2 receptor in vascular smooth muscle cells which can act on Adenylate cyclase to convert ATP to cAMP which acts on protein kinase A –> arterial vasodilation
Intracavernosal injection, intraurethral pill
Alprostadil Dosing
- Alprostadil Intracavernosal injection (Caverject)
- Alprostadil Intraurethral pill (Muse)
- 10 mcg injected 5-10 min
prior to intercourse - 250 mcg intraurethrally 5-
10 min prior to intercourse
Titration :
For injection , increase by ___ every ___ to achieve a firm erection for ___ (performed in physicians office)
For intraurethral, incr by ___ on separate occasions until firm erection for 1 hr (Initial dose should be done in ? )
2.5 mcg increments, 30 min , 1 hr
250 mcg increments, physician office
Dose Range
1. Carverject?
2.Muse?
- 60 mcg, max once per day and 3x per week with a 24-hr interval
between doses - 1000 mcg, max 2 doses per day
Alprostadil AE’s ? (5)
- Hematoma at site of injection (caverject)
- Infection with caverject
- hypotension, dizzy (uncommon)
- Priapism (rare)
- pain at site of injection or insertion
Injection Patient Education
1. Inject into shaft at what degree angle?
2. For penile pain, use ?
3. Prior to use u should ?
4. AFter injection what should u do to reduce risk of hematoma?
Intraurethral (Muse) Pt education
1. To moisten the urethra?
2. After insertion do what?
- 90 degree
- tylenol
- wash hands
- apply pressure for 5 mins
- void
- massage penis to enhance drug dissolution
BPH is characterized by ?
- what are the DHT mediated effects?
- Adrenergic tone mediated effects?
enlargement of the prostate
1.Testost –> 5alphareductase –> DHT –> prostatic growth
- incr adrenergic tone (with NE) –> Alpha1 R on smooth muscle cells of prostate –> prostatic contraction around urethra
Which meds exacerbate BPH? (3)
- Anticholinergics (Diphenhydramine , TCA) –> prevent contraction of bladder detrusor muscles (Urinary retention)
- Alpha agonists like pseudoephedrine
- Testost replacement
Obstructive Sxs of BPH (3)
Irritative sx’s ? (2)
Signs? (4)
- diminished urinary flow rate, straining to urinate, suprapubic pain
- incr urinary frequency, incr urinary urgency
- enlargement based on digital rectal exam >20 gm , possible serum prostate specific antigen > 1.5 ng/mL , possible elevated Scr and BUN
-AUA sx score.
<=7 is mild
8-19 mod
>= 20 severe
What are some recc lifestyle mods?
What should pt’s avoid?
- Void before bedtime, exercise, restrict fluids before bedtime, healthy diet
- excessive caffeine, excessive alc
TX PATHWAY FOR BPH
- What happens if they have BPH with MILD AUA score?
- SEVERE AUA score + complications OR unresponsive to therapy?
- MODERATE-SEVERE AUA score AND
a. prostate < 40 gm and PSA < 1.4 ng/mL
b. Prostate > 40 gm OR PSA > 1.4 ng/mL
c. They have ED
d. Predom irritative voiding sx’s
- wait and see
- Surgery
a. alpha 1 antag
b. Alpha 1 antag PLUS 5alphareductase inhib
c. PDE5I +/- Alpha1 antag
d. anticholinergic PLUS alpha 1 antag ORRRR Mirabegron PLUS alpha1 antag
What can alpha 1 blockers do to ameliorate BPH pt’s?
This MOA will relax SM cells to allow better ___ BUT DOES NOT ___
They block Alpha 1 receptor so that there’s no prostatic contraction around the urethra.
urine flow, reduce prostate size
ALPHA 1 ANTAGS DOSING, TITRATION, MAX DOSE : KIM SEE CHART
See chart
Which alpha 1 antags are uroselective and preferentially block alpha 1 r’s resulting in less ___ risk?
HYPOTENSION
-Tamsulosin, and Silodosin
Alpha1 Antags : AE’s ?
CI for Alfuzosin? Silodosin?
DDI’s for silodosin?
sx’s of hypotension mainly w/nonuroselective agents (dizzy)
-floppy iris syndrome
-retrograde ejaculation mainly w/uroselective agents
1.Mod-severe hepatic impairment
- Severe hepatic impairment or ClCr < 30
Need to avoid strong 3A4 inhibitors with silodosin
5Alpha Reductase inhibitors will result in decreased ___ over the course of ___
prostate size, 6-12 months
5Alpha Reductase Inhibs Dosing
- Finasteride (proscar)
- Dutasteride (Avodart)
AE’s ? (3)
CI?
PSA (prostate specific antigen) should decrease by ___ by ___ months. If it doesnt , evaluate for ?
When should u see the full effects of the drug?
- 5 mg PO daily
- 0.5 mg PO daily
- ED, decr libido, gynecomastia
- Preg category X. preg females or females wanting to become preg should avoid handling the drug , should also avoid contact with semen of men on the drug
50%, 6, Prostate cancer
6-12 months to see full effects
PDE5 Inhibs used for BPH
- Tadalafil Dosing?
- if ClCr 30-50?
- Avoid if?
- Avoid if?
- AE’s and Drugs to avoid refer to card for ED
- 5 mg PO daily
- 2.5 mg daily
- ClCr <30
- severe hepatic impairment
Anticholinergics MOA ?
Irritative sx’s in BPH are a result of?
Blocks M3 receptor –> no contraction of detrusor muscle preventing irritative sx’s
overactive bladder
Anticholinergics : Dosing
- Use only if pt has irritative sx’s and has a post void residual urine volume of ?
- what are the 2 drugs?
- Dosing Solifenacin (Vesicare) , if ClCr < 30 or mod hepa impair, avoid in?
- Dosing Tolterodine (Detrol) , if ClCr < 30 or mod hepatic impairment ?
- < 100-150 mL
- Solifenacin and Tolterodine
- 5-10 mg PO daily
- limit to 5 mg daily
-severe hepatic impairment - 1-2 mg PO BID
-limit to 1 mg BID
Anticholinergic ae’s ? (6)
Drug interactions with Solifenacin?
- Blurry vision
- urinary retention,
- dry mouth
- constipation
- drowsiness
- tachycardia
if on strong 3A4 inhibs, limit to 5 mg daily
Beta 3 Agonists
- what are the 2 drugs?
- what’s their MOA?
- Unlike anticholinergics, beta3 agonists dont cause?
- Use ONLY IF pt has?
- Mirabegron, vibegron
- Acts on B3 R to relax detrusor muscle!
- urinary retention
- Irritative sx’s
Beta3 Agonists : Dosing
- Mirabegron (Myrbetriq)
-if ClCr 15-30 or mod hepatic impairment?
-Avoid in ? - Vibegron (Gemtesa) Dosing
-Avoid in ClCr < ?? or ???
- 25-50 mg PO DAILY
- limit to 25 mg daily
- ClCr < 15 or severe hepatic impairment - 75 mg PO DAILY
-<15, severe hepatic impairment
Beta 3 Agonists : Monitoring
- AE’s ?
- For myrbetriq –> small incr in BP
for all –> MILD HA, dry mouth, N/D
Follow up timeline?
When to check PSA?
Annual ___ exam?
Minimum 6-12 weeks after starting therapy, assess AUA score for improvement
at 6 months if on 5alpha reductase inhib
Digital rectal
