Erectile dysfunction (ED), low T Flashcards
medication classes associated with ED
- antihypertensives
- CNS depressants
- lipid meds
- antidepressants/ antipsychotics
- anticonvulsants
-GI agents (h2RAs, PPI)
-antiadrogens & hormones (5a-reductase inhibitors, steroids)
-recreational drugs (ethanol, etc)
factors associated with ED
-HTN
-DM
-BPH
-coronary & peripheral vasc
-neurologic disorders (MS, Parkinson)
-endocrine (hypogonadism, pituitary)
-psychiatric disorders
-dyslipidemia
-RF
-liver disease
-penile disease
lifestyle:
smoking, excessive alcohol consumption, obesity, overall poor health and reduced physical activity
dy
before initiating treatment
-physical exam
-thorough medical, social, med hx w/ emphasis on cardiac disease
-labs
labs
-fasting glucose or HbA1c
-PSA
-FLP (fasting lipid panel)
-testosterone
non-pharm interventions
lifestyle modifications:
-reduce fat & cholesterol in diet
-decrease/limit alcohol consumption
-eliminate tobacco use & substance abuse
-wt loss if needed
-regular exercises
1st line treatment
oral PDE5 inhibitors w/ vacuum erection devices (VEDs)
choice therapy should be individualized
oral drugs
Sildenafil (Viagra)
Tadalafil (Cialis)
Vardenafil (Levitra)
Avanafil (Stendra)
Testosterone undecanoate (Jatenzo_
intracavernosal
into penis
alprostadil (Caverjet) 1st inj at docto’s office; wait until erection subsides
routes of drug administration
oral
intracavernosal
intraurethral
IM
topical
buccal
sub implantable pellet
PDE5-is
drug choice (all agents are equal)
educate: onset, duration, impact of high fat meals, need for sexual stimulation, single trial is inadequate
most 4-5h, tadalafil 36h
headache, flushing; ***serious cardiac events possible
contraindicated for nitrate, alpha-blockers
examples of drugs from PDE5-i
avanafil
sildenafil
tandalafil (LATS assoc BPH)
vardenafil
PDE5-i abbr
phosphodiesterase type 5 inhibitors
if one agent from PDE5i doesn’t work, try
another agent from the same class
prolonged cGMP activity
smooth muscle relaxation is induced, leading to an erection
MOA: PDE5i
increases cGMP (vasodilator secondary messenger that up regulates the response to nitric oxide by activating protein kinase G. This decreases intracellular calcium levels, resulting in smooth muscle relaxation, enhanced arterial flow to the corpora cavernosa, and enhanced blood filling of cavernosal sinuses)
after 24h on sildenafil or tadalafil 48h, rx
nitrate
vandernafil
associated with QT interval
vardenafil and sildenafil may cause
blurred vision, difficulty in discriminating blue from green, bluish tones in vision, or difficulty seeing in dim light due to cross-reactivity w/ PDE type in the retina
alprostadil
prostaglandin E1 analog induces erection by stimulating adenyl cyclase, leading to inc cAMP, smooth muscle relaxation, rapid arterial inflow, and inc penile rigidity
(intravernosal inj) or intraurethral suppository (MUSE)
most invasive and low patient acceptance; 2nd/3rd line of therapy
onset of alprostadil
30-60m
success 30-55%
a/e of alprostadil
Aching in the penis, testicles, legs, and perineum; warmth or burning sensation in the urethra, minor urethral bleeding or spotting, priapism; and light-headedness
do NOT use with pregnant partner unless using condom
testosterone replacement regimens should never be administered to men
with normal serum testosterone levels or in pts w/ isolated erectile dysfunction as the only sign of hypogonadism
before initiating any testosterone replacement regimen in pts 40+ screen for
breast cancer
BPH
prostate cancer
(these conditions could worse with exogenous testosterone)
which medications contribute to low testosterone
cimetidine
spironolactone
ketoconazole
etc.
