Exam 5 Flashcards
When should testosterone levels be measured?
in the morning
Technical term for incomplete/ delayed puberty?
hypogonadism
what defines hypogonadism?
delayed puberty; lack of testicular growth at 14 years old
treatment for hypogonadism?
IM testosterone esters 50mg monthly; used short-term
What age group is testicular cancer most common in?
young men; 15-35 years
testicular cancer treatment
surgery, radiation, chemotherapy
what is the cause of alopecia?
androgenic alopecia; conversion of testosterone to DHT
what is alopecia areata?
an autoimmune disorder; small round patches of hair lost
what is alopecia universalis?
autoimmune disorder; complete hair loss on scalp and body
traction alopecia
caused by tension on hair due to buns, braids, etc
What is first-line treatment for alopecia?
finasteride 1mg po once daily
What is the MOA of finasteride
it is a type II 5-alpha reductase inhibitor; inhibits conversion of testosterone to DHT; stops progression of hair loss
Counseling points for finasteride for alopecia
- must be used continuously to maintain efficacy
- SE include decreased libido, ED, and decreased ejaculate volume.
What is the MOA for Minoxidil?
- a very potent vasodilator
- enlarges miniaturized hair follicles by increasing blood supply to the hair follicle
- stimulates hair follicle to the growth phase
Minoxidil strength and counseling
- 5% foam/solution
- apply to scalp twice daily every day
- apply to dry scalp and hair
- may take up to 4 months to see benefit
- must be used continuously to see results/ maintain benefit
Hypogonadism definition
hormonal deficiency in testosterone
How to diagnose hypogonadism
low testosterone levels WITH symptoms
What tests/ results are required to confirm low testosterone levels?
- total testosterone level of <300ng/dL
- a free testosterone level of <5ng/dL
When should testosterone replacement be used?
Only when hypogonadism is diagnosed; Low T and symptoms
What dosage form of testosterone therapy is most similar to physiologic testosterone levels?
patch; 1-2 patches applied nightly
What is Jatenzo?
Testosterone undecanoate capsules; 158-396mg BID with food
What are contraindications to Testosterone hormone therapy?
- prostate cancer
- breast cancer
- hematocrit >50% (caused by low O2)
- PSA greater than 4 ng/dl or PSA >3ng/mL in men at high cancer risk
- recent or poorly controlled CVD
Testosterone black box warnings
- risk of exposure to children via gel formulation
- cardiac risk
What dosage form of testosterone has the highest cardiac risk?
Injection> patches and gels
What is a goal testosterone level?
400 to 700ng/dL
What should be monitored within 3-6 months of initiating testosterone therapy?
- testosterone levels
- hematocrit levels
erectile dysfunction definition
a consistent inability to obtain or sustain an erection sufficient for intercourse in at least 50% of attempts
What are some potential causes of ED?
- DM
- HTN
- coronary artery disease
- neurological diseases (MD, Parkinson’s, stroke)
- low testosterone levels
what drugs are responsible for drug-induced ED?
- Antidepressants (SSRIs)
- some antihypertensive agents
- estrogens/ anti-androgens
- 5- alpha reductase inhibitors (finasteride)
- cancer chemotherapy
What is the physiology of an erection?
- after sexual stimulation, ACh is released, which causes the release of nitrous oxide in the penis
- GTP is converted to cGMP
- Ca++ is released and produces smooth muscle relaxation in the penis
first-line treatment of ED
- non-pharmacologic; treat any known causes
- change meds if drug-induced
First-line pharmacologic treatment of ED
- Oral PDE-5 inhibitors
(if contraindicated, use vacuum erection device)
PDE-5 inhibitor MOA
- promotion of smooth muscle relation in the penis by inhibition of phosphodiesterase 5
- inhibits breakdown of cyclic AMP
- sexual stimulation is required; more for maintaining an erection than obtaining an erection
What to do is PDE-5 inhibitor does not work?
- increase dose; adjust dose to produce an erection that lasts no longer than 1 hour
Drug interactions with PDE-5 inhibitors
CYP3A4 inhibitors
- cimetidine, ketoconazole, erythromycin, ritonavir, grapefruit juice, others
- affects metabolism; prolongs the effect of the drugs
Other counseling notes for PDE-5 inhibitors
- food delays the absorption of sildenafil and vardenafil (Levitra) by one hour
potential side effects of PDE-5 inhibitors
- headache
-flushing - dyspepsia
- nasal congestion
- light sensitivity
- NAION (sudden vision loss)
Major contraindication with PDE-5 inhibitors
- transdermal nitrates (nitroglycerin)
- causes a massive drop in blood pressure (hypotension) and may cause syncope
alpha blockers + PDE-5 inhibitors
- start patients on a lower dose of the PDE-5 inhibitor
- may cause dizziness
When to report an erection to your doctor?
- when it lasts longer than 4 hours
Patient education about PDE-5 inhibitors
- take 1-2 hours prior to intercourse
- do not take with food (delays absorption)
- report erections that last longer than 4 hours
- report visual and hearing complaints
- report palpitations or dizziness
- avoid with nitrates
PDE-5 inhibitors for pulmonary hypertension
- routine dose
- sildenafil 20mg PO TID
- tadalafil 40mg PO once daily
vacuum erection device
- very effective
- use for patients with contraindications to PDE-5 inhibitors
- avoid in sickle cell patients
Alprostadil pellets MOA and counseling
- increased cAMP production and produces smooth muscle relaxation
- less effective than injection, but more acceptable to patients
- onset is 5-10 minutes
- may cause pain, burning
- can be used with PDE-5 inhibitors
Alprostadil injections MOA and counseling
- increased cAMP production and produces smooth muscle relaxation
- drug of choice if patient fails PDE-5 inhibitors
- used for neurogenic ED
- onset within 5 minutes
- overall most effective; no sexual stimulation required
- max of 1/day or 3/week
- may cause local irritation, pain, burning
- titrate to dose producing an erection that lasts one hour
- usual range= 10-20mcg; max of 60mcg
penile prostheses counseling
- only used when drug therapy and other therapies fail
- semi-rigid insert with a pump
- replace every 5-10 years.
OTC recommendations
OTC therapies are not recommended; many seized at border contain sildenafil
what is priapism
- condition in which a penis remains erect for hours in the absence of stimulation
- classified into painful (ischemic) and non-painful (non-ischemic)
drugs that could cause priapism
- ED drugs
- antidepressants
- antipsychotics
- anticoagulants
- cocaine
- others
treatment of priapism
ischemic:
- phenylephrine injection
- blood aspiration
- saline irrigation
non-ischemic:
- cold packs and compression
What is peyronie’s disease and how is it treated?
- erections bent at least 30 degrees; may also be painful
- treatment: Xiaflex injection (collagenase closridium histolyticum)
- treatment is in urologist office
prostate cancer risk factors
- increasing age
- african ancestry
- family history
What is PSA screening and what is a normal value?
- Prostate specific antigen
- most men without prostate cancer have PSA levels under 4ng/mL of blood.
- men with levels between 4-10 have a 25% chance of having prostate cancer
- men with levels above 10 have a 50% chance of having prostate cancer
pathophysiology of BPH
- growth in the prostate gland
- type II 5-alpha reductase converts testosterone to DHT.
- responsible for prostate enlargement and growth.
Irritative symptoms of BPH
- nocturia
- redistribution of edema
complications of BPH
- chronic renal failure
- overflow urinary incontinence
- recurrent UTIs
- diminished QOL
What is the AUA and resulting categories
- score of symptoms
- <7=mild
- 8-19= moderate
- > 20= severe
goals of BPH therapy
- control symptoms
- decrease AUA score
treatment for mild symptoms
watchful waiting
moderate symptoms with erectile dysfunction
- a adrenergic antagonist, PDE-5 inhibitor, or both
moderate symptoms with small prostate and low PSA
a adrenergic antagonist
moderate symptoms with large prostate and increased PSA
- 5 a reductase inhibitor
- or 5 a reductase inhibitor and a adrenergic antagonist
moderate symptoms with predominant irritative voiding symptoms
- a adrenergic antagonist and anticholinergic agent
severe symptoms with complications
surgery
What drugs to avoid in BPH
- drugs with strong anti-cholinergic properties
- first gen antihistamines
- tricyclic antidepressants
cogentin, artane, scopolamine - antimuscarinics
When to use detrol LA
- when the patient has BPH and incontinence
- avoid in patients with a high post-void residual and max urine flow rate less than 5
drug therapy for mild bph otc
saw palmetto; safe but may not be verry effective
alpha-1a adrenergic blocker MOA
- relaxes smooth muscle tone of prostate gland and bladder neck to improve urine flow
Alpha-1a adrenergic blocker counseling
- does not reduce size of prostate gland
- onset in 1-6 weeks
- take tamsulosin 1/2 hour after same meal each day to increase effectiveness
A-1a adrenergic blockers
alfuzosin, doxazosin, silodosin, tamsulosin, terazosin
A-1a adrenergic blockers side effects
- dizziness, fatigue, HA, orthostatic hypotension, decreased volume of ejaculation
PDE-5 inhibitors for treatment of BPH
- indicated if pt also has ED
- effectiveness similar to alpha antagonists
- tadalafil 5mg daily
- relaxes smooth muscle of prostate gland and bladder neck to improve urine flow
5-a reductase inhibitors for treatment of BPH
- indicated if the patient has a prostate larger than 40g
- decreases prostate size
- use in conjunction with alpha antagonist
- onset of action may take up to 6 months
- finasteride 5mg po daily
- dutasteride 0.5mg po daily
combination therapy options
- finasteride and tamsulosin: for patients with enlarged prostate glands
- finasteride and tadalafil: for patients with BPH and ED
- tamsulosin and tolterodine: for patients with BPH and OAB
how many extra calories in prenatal diet?
300-400 extra calories per day
what to limit in prenatal diet
artificial sweeteners, dairy, eggs, unwashed produce, herbal teas, undercooked meats, caffeine
what is the caffeine limit in pregnancy?
200mg/day
prenatal supplement reccomendations
- folate 400-600mcg daily
- calcium 1000-1300mg daily
- iron 27-30mg daily
when should prenatal supplements be started?
- 3 months prior to conception
- folic acid at least one month prior to conception
vaccine reccomendations for pregnancy
- inactivated flu before the end of october
- Tdap between 27-36
- covid-19 vaccination
vaccines to avoid in pregnancy
- HPV
- MMR
- live flu
- varicella
- yellow fever
- typhoid fever
common teratogens
- warfarin
- lisinopril
- lithium
- methotrexate
- alcohol
- isotretinoin
- statins
preferred treatment of diabetes during pregnancy
- insulin
preferred treatment of hypertension during pregnancy
- labetalol
- amlodipine
- nifedipine
- hctz
- hydralazine
- methadopa
agents to avoid for hypertension during pregnancy
- ACE inhibitors (lisinopril, verapimil, etc)
- ARBS (valsartan, candesartan, etc)
treatment of nausea and vomiting during pregnancy:
1st line : non-pharmacologic
2nd line:
- pyridoxine
- doxylamine and pyridoxine
- meclizine, dyphenhydramine
- last line: ondansetron, metoclopramide
treatment of heartburn in pregnancy
- antacids (magnesium hydroxide, calcium carbonate)
- sucralfate
- H2 agonists
treatment of constipation
- high fiber foods
- increased fluid intake
- regular exercise
pharmacologic treatment of constipation
- osmotic laxatives (PEG and Lactulose)
- stool softeners (docusate)
- bulk laxatives (psyllium)
treatment of pain in pregnancy
1st line: acetaminophen
avoid NSAIDS after 32 weeks gestation
recommended antibiotic treatment for UTIs in pregnancy
- 1st gen cephalosporins (keflex)
- macrobid
- amoxicillin
-ampicillin
antibiotics to avoid in pregnancy
- fluoroquinolones: ciprofloxacin and levofloxacin
- tetracyclines: doxycycline and minocycline
- Bactrim DS
treatment for gestational diabetes
- monitor blood glucose
- insulin
pharmacologic treatment for thromboembolism in pregnancy
- anticoag agents
- avoid warfarin
preeclampsia definition
sudden spike in blood pressure plus proteinuria
preeclampsia treatment
-aspirin 60-80 mg starting in late first trimester
- hydralazine, labetalol, nifedipine
seizure management in pregnancy
- magnesium sulfate 4-6g IV bolus
- may also use phenytoin or benzodiazepines (lorazepam)
HELLP syndrome and treatment
- hemolysis
- low platelet count
- elevated liver enzymes
treat with: - platelets
- corticosteroids
- monitor lab values
what is preterm labor?
labor before week 37 gestation
medications to treat preterm birth
progesterone
premature membrane rupture treatment
- corticosteroids
- antibiotics
- magnesium sulfate
preterm labor treatment
- corticosteroids help with lungs
- antibiotics: ampicillin + erythromycin
