ED Pharmacotherapy Exam 3 Flashcards
What level of testosterone is usually associated with a hypogonadal state? (not an objective)
< 400 ng/dL
Therapy options for ED
- First line: PDE5i
- Second line: PGEi intraurethral, PGEi intracavernous, Vacuum erection devices (VED)
- Last line: Penile prosthesis implantation
Sildenafil initial and maintenance dose
- initial: 30 min to 4 hrs
- maintenance: 30 min to 4 hrs
Vardenafil initial and maintenance dose
- initial: 1 hr
- maintenance: 1 hr
Vardenafil initial and maintenance dose
- initial: 1 hr
- maintenance: 1 hr
Tadalafil initial and maintenance dose
- initial: 30 min or once daily
- maintenance: 30 min or once daily
Avanafil initial and maintenance dose
- initial: 15-30 min
- maintenance: 15-30 min
Sildenafil patient population
- Use 25 mg initially in >65 yoa
- Renal dosing and hepatic dosing
Vardenafil patient population
- Start with 5 mg in ≥65 yoa
- no renal dosing
Vardenafil patient population
- No renal dosing
- C/I in hepatic impairment
Tadalafil patient population
- Renal dosing
- C/I in hepatic impairment
Avanafil patient population
- Not recommended: CrCl <30
- severe hepatic impairment
Sildenafil counseling points
Take without food
PDE5i drug interactions
- use caution with Caution with alpha blockers and CYP3A4
- C/I in pts taking alpha blockers and CYP3A4 for avanafil
ADE of PDE5i
- Headache
- Flushing
- Dyspepsia
- Nasal congestion
- Abnormal vision is usually transient (sildenafil, vardenafil, avanafil)
- Priapism
- Hypotension
Acute hearing loss
PDE5i Advantages
- Convenient route of administration
- Low incidence of serious A/E
- Effective
- Discreet use
PDE5i Disadvantages
Expensive
PDE5i counseling points
- C/I in pts no short and long acting nitrates
- increase risk of hypotension
- may contribute to MI
- try 5-8 doses before declaring failure
- avoid alcohol (can cause drowsiness and hypotension)
Alprostadil (Caverject, Edex) population
Avoid in patients with sickle cell anemia, multiple myeloma, leukemia, severe coagulopathy, schizophrenia, poor manual dexterity, severe venous incompetence, severe CVD, or Peyronie’s disease
Alprostadil (Caverject, Edex) dosing
Titrate dose to achieve results
Alprostadil (MUSE) population
anyone can use
MOA of Alprostadi
- induces erection by dilation of arteries in the corpora cavernosa with resulting increased blood flow to the erectile tissue
- effectiveness increase when used with actis (penile constriction device)
ADE of PGE1
- Intracavernosal: Penile pain, Hematoma at injection site, Fibrotic nodules along penile shaft
- Intraurethral: Urethral pain or burning, Female partner may experience vaginal pain and burning sensation, Testicular pain
- Both: Dizziness, Headache, Decreased blood pressure
PGE1 Advantages
- Local application of medication
- Minimal systemic effects
- Rarity of drug interactions (only significant one is PDE5i)
PGE1 Disadvantages
Patient will require training on proper technique
PGE1 clinical pearls
- intracavernosal route is more effective
- efficacy is 70-90% for intracavernosal and 65% for intraurethral
- efficacy is dose related
- onset is 5-10 minutes and duration 30-60 minutes
MOA of VED
- Once pump is activated to produce negative pressure, there is arteriolar blood into the corpora cavernosa
- Constriction bands can be placed at the base of the penis to prolong the erection
- Onset is 3-20 minutes
ADE of VED
- Penile pain
- Bruising
- Penis may feel cold or numb
- If constriction bands are placed longer than 30 minutes, the penile shaft may turn blue and hurt
VED Advantages
- One-time single purchase, reusable device
- Onset 3 to 20 minutes
VED Disadvantages
Not discreet
VED contraindications
- Sickle cell disease
- History of prolonged erections
- Patients with severe penile curvature
VED precaution
patients on warfarin
VED clinical pearls
Can try in combination with PDE5i or PGE1 before moving to more invasive surgical option
testosterone effects
- improved libido, sexual function and mood
- Enhances release of nitric oxide from the endothelium inside the walls of the blood vessels supplying the corpora cavernosa
Methyltestosterone (Android, Testred, Methitest) pearls
- oral once daily
- Extensive first pass hepatic catabolism and risk of hepatotoxicity
Fluoxymesterone (Androxy) pearls
- oral once daily
- Risk of hepatotoxicity
- C/I in severe renal or hepatic impairment
Testosterone buccal (Striant) pearls
- buccal twice daily
- Remove before toothbrushing, place above incisor tooth on both sides of the mouth and hold in place for 30 seconds to adhere
Testosterone cypionate (DepoTestosterone) pearls
- IM injection q 2-4/6 wks
- C/I in severe renal or hepatic impairment and serious cardiac disease
- may occur leading to mood swings if levels are high
Testosterone enanthate (Delatestryl) pearls
- IM injection q 2-4/6 wks
- Avoid in severe renal or hepatic impairment
- may occur leading to mood swings if levels are high
Testosterone undecanoate (Aveed) pearls
- IM injection; one dose at day 1, week 4, then Q10 wks
- REMS
- Patients must be monitored for at least 30 minutes after each injection for the duration of therapy
- may cause anaphylaxis or a POME reaction
POME
- pulmonary oil microembolism
- cased by Aveed
- caused when tiny droplets of oil travel to the lung
- characterized by difficulty breathing and chest pain
Testosterone Transdermal patch (Androderm) pearls
- transdermal QHS
- Caution in patients with renal or hepatic impairment
- Application sites: upper arm, back, abdomen, and thigh.
- Rotate site every 7 days.
- Avoid swimming, showering or washing for 3 hrs after application
Testosterone Transdermal Spray (Fortesta) pearls
- sprays once daily, titrate 14-35d interval
- Cover site to avoid transfer.
- Avoid swimming, showering or washing for 2 hrs
- Sites: front and inner thigh
Testosterone Transdermal Solution (Axiron) pearls
- one axilla daily; rotate; titrate 35d interval
- apply deodorant first
- Avoid swimming, showering, or washing for 2 hrs
Testosterone Gel (Androgel 1%, Testim 1%) pearls
- AM dose, titrate q14d
- Cover site to avoid transfer
- Avoid swimming, shower, or washing for 2 hrs
- Application sites: shoulders, upper arms, or abdomen.
- Available in premeasured dose packets or from pump dispenser
Testosterone Gel (Androgel 1.6%) pearls
- AM dose, titrate 14-28d
- Apply to shoulder and upper arms
- Avoid swimming, shower, or washing for 2 hrs
Testosterone Gel disadvantages
Virilization of children exposed to testosterone gel secondarily may occur.
Testosterone Subcutaneous Pellet (Testopel) pearls
- q3-6 months
- Onset is delayed 3-4 months after initial dose
Testosterone Subcutaneous Pellet (Testopel) advantages
compliance
Testosterone Subcutaneous Pellet (Testopel) disadvantages
in the case of complications, the pellets would have to be removed with a surgical procedure (local excision and removal)
ADE of Testosterone
- Sodium and water retention
- Hyperlipidemia
- Increased hematocrit
- Gynecomastia
- Sleep apnea
- Mood swings
- Oligospermia
- Hepatotoxicity
- Prostate enlargement
- POME with Aveed
Testosterone contraindications
- Breast cancer
- Prostate cancer
Normal Testosterone range
300 to 1100 ng/dL
When to check Free Testosterone levels after oral tablets?
2-3 hours after dose
When to check Free Testosterone levels after IM injection (cypionate, enanthate)?
Midpoint of dosing interval
When to check Free Testosterone levels after IM injection (undecanoate)?
Right before the 4th dose
When to check Free Testosterone levels after gel?
Anytime after the first 1-2 weeks of continued use
When to check Free Testosterone levels after patch?
3-12 hours after patch application
When to check Free Testosterone levels after subQ implant?
1-4 months after implantation
When to check Free Testosterone levels after buccal?
Before a dose
When should free testosterone levels be checked?
between 8-11am
Testosterone monitoring parameters
- Hematocrit
- Hemoglobin
- Lipid
- Liver function tests
- rostate-specific antigen (PSA)
- digital rectal examination (DRE)
Surgery for ED
- Semi-rigid or inflatable prostheses
- These devices produce an unnatural erection and there is a risk for infection
