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IPFC 3 Midterm 2 > Men's health therapeutics > Flashcards

Men's health therapeutics Flashcards

1
Q

What does health Canada warn about using Testosterone? When should it be used

A

Possible CV problems

Used only if
- Lab tests confirm low testosterone + other possible causes of symptoms excluded if they have non-specific symptoms
- 18+
- Man

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2
Q

What are ABSOLUTE contraindications for testosterone therapy (2)

A
  • Men with known or suspected breast cancer
  • Men with known or suspected prostate cancer
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3
Q

What are RELATIVE contraindications for testosterone therapy (2)

A

men treated for localized prostate cancer with surgery or radiotherapy
- without evidence of active disease
- caution testosterone therapy

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4
Q

What are goals of therapy in testosterone replacement therapies (2)

A
  1. Improvement in symptoms
  2. Achievement of eugonadal testosterone levels
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5
Q

After starting testosterone therapy, what do you do if there is
- improvement
- adverse event NOT related to dose or route of admin

A

Stop treatment

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6
Q

After starting testosterone therapy, what do you do if there is
- improvement
- adverse event related to dose or route of admin

A

Reduce dose or change route
or do both

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7
Q

After starting testosterone therapy, what do you do if there is
- no improvement

A

Measure testosterone again

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8
Q

After starting testosterone therapy, what do you do if there is
- no improvement
- low level of testosterone after testing

A
  • Consider poor compliance
  • consider dose increase
  • consider changing route of admin
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9
Q

After starting testosterone therapy, what do you do if there is
- no improvement
- normal level of testosterone after testing

A
  • consider other diagnosis
    or
    referral to TDS
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10
Q

Monitoring parameter: Symptom response
When to monitor?
What to look for?

A

When to monitor?
- At 3 + 6 months after starting therapy

What to look for?
-psychological and sexual symptoms may improve 1-3 months
- somatic symptoms may take 6-12 months to improve

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11
Q

Monitoring parameter: Testosterone level
When to monitor?
What to look for?

A

When to monitor?
- At 3 + 6 months
- In AM

What to look for?
- change in 30%+ of TT levels between 2 appropriately timed collections

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12
Q

Monitoring parameter: Hematocrit level
When to monitor?
What to look for?

A

When to monitor?
- 3 + 6 months
- then annually

What to look for?
- if 54% over, discontinue therapy
- more likely to clot, VTE, MI = CV risks

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13
Q

Monitoring parameter: PSA level, DRE, BMD
When to monitor?

A

PSA
- 3 + 6 months after therapy
- annually after

DRE
- 6 months after therapy

BMD
- after 1-2 years

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14
Q

When to measure testosterone for the following formulations:
Oral/Intranasal:
Injection:
Transdermal gel:
Transdermal patch:

A

Oral/Intranasal: 2-3 hours after dose

Injection: midpoint of dosing interval

Transdermal gel: anytime after first 1-2 weeks
- then at any time

Transdermal patch: 2-12 hours after application

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15
Q

What are the drug interactions with testosterone (5)

A
  1. Insulin
    - test may decrease BG, lower insulin dose
  2. Anticoagulants
    - warfarin need to lower dose
    - DOAC’s unaffected
  3. Corticosteroids
    - test can enhance edema
    - caution in cardiac, renal, hepatic disease patients
  4. Cyclosporine
    - test can inc risk of nephrotoxicity
  5. Thyroid function tests
    - can increase thyroxin binding globulin -> dec total T4 levels
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16
Q

How can you reduce transdermal patch skin irritations (3)

A
  • topical steroid
  • inhaled steroid
  • put patch on a different spot after each application
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17
Q

When switching to a transdermal gel, when and where can you apply it and can you shower?

A

Apply to shoulder, abdomen, or upper arms

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18
Q

Which minoxidil is more effective? 5% foam or 2% solution

A

5% foam

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19
Q

How long does it take for topical minoxidil to see evident re-growth? Efficacy?

A

2 months or longer
- can take 12 months for patients to notice effect

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20
Q

When do you assess for treatment response with minoxidil?

A

at 6 months

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21
Q

What to expect within the first 2-6 weeks of using minoxidil?

A

Some hair loss may occur
- continue therapy unless hair loss period is greater than 2 weeks

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22
Q

What happens when you stop minoxidil?

A

discontinuation results in loss of effectiveness
- takes 3 months for newly re-grown hair to be lost

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23
Q

What are the adverse effects of minoxidil even though it’s generally well tolerated (3)

A
  1. Dermatitis
    - 5% foam is free of propylene glycol (less irritating to skin)
  2. Hypertrichosis (hair growth) on face
  3. caution is patients with CV disease
    - oral is a potent vasodilator and reduces BP
    - if skin barrier compromised, topical can be systemic
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24
Q

Dosing for 2% solution and 5% foam. How long do you leave on scalp?

A

2% solution
- 1mL = 6 pumps BID
- leave on scalp 4h to maximize absorption

5% foam
- 1/2 capful BID

Do not apply to entire scalp

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25
Q

Finasteride 1mg/day MOA
When do you see a clinical difference

A

Type II 5-alpha-reductase inhibitor
- lowers serum and scalp DHT
- no affinity for androgen receptor/ does not interfere with testosterone

clinical difference may take up to 12 months

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26
Q

What happens when you stop finasteride

A

hair regrowth lost in 6-9 months

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27
Q

What are the adverse effects of finasteride? (5)

A
  1. decreased sexual function
  2. Reduced sperm count
  3. Teratogenic to the child
  4. PSA levels might be lower
  5. Rare side effects: testicular pain, depression at high doses
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28
Q

What is the MOA of of dutasteride

A

type I and II 5-alpha-reductase inhibitor
- 100x more potent for type 1 than finasteride
- 3x more potent for type 2 than finasteride
- reduces serum DHT by 94%

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29
Q

When is dutasteride used?

A

After failed finasteride 1mg/day for 12 months

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30
Q

Which is more superior for hair growth?
Finasteride or dutasteride

A

Dutasteride
- however limited number of studies regarding safety therefore we use finasteride

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31
Q

Direct comparative effectiveness for:
Finasteride 1mg/day vs 5% minoxidil

A

At 12 months: better response to finasteride 1mg/day

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32
Q

Finasteride 1mg/day vs 2% minoxidil

A

At 3 months: Minoxidil had more hair growth
At 12 months: Finasteride had more hair growth

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33
Q

Finasteride 1mg/day vs
minoxidil 2% vs
finasteride + minoxidil vs
finasteride + ketoconazole 2% shampoo

A

At 12 months Finasteride ALONE or finasteride + ketoconazole was significantly more effective

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34
Q

What combination therapy works?

A

Finasteride 1mg/day + topical minoxidil (5% foam) -> may lead to better improvement compared to monotherapies

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35
Q

What is the fun wise mneumonic

A

F frequency
U urgency
N nocturia
W weak stream
I intermittency
S straining
E emptying (sensation of incomplete emptying)

36
Q

Explain boyarsky index

A

5 questions to assess obstructive symptoms
4 questions to assess irritative symptoms

37
Q

what is the AUA score for BPH severity for MILD?
What are the typical signs and symptoms?

A

7 or under
- Asymptomatic
- Peak urinary flow rate <10 ml/s
- PVR urine volume >25-50 mL

38
Q

what is the AUA score for BPH severity for MODERATE?
What are the typical signs and symptoms?

A

8-19
- all the mild symptoms
- obstructive and irritative voiding symptoms

39
Q

what is the AUA score for BPH severity for SEVERE?
What are the typical signs and symptoms?

A

20+
- all moderate + mild symptoms
- 1 or more BPH complications

40
Q

What are the goals of therapy with BPH treatment? (5)

A
  1. Reduce LUTS associated with BPH
    - Minimal clinical important is reduction in 3 points of AUA
    - increase in urinary flow rate
    - Normalization of post-void residual less than 50 mL
  2. Improve quality of life
  3. Reduce the risk of surgical intervention
  4. Prevent progression of disease
  5. Decrease long-term sequalae of bladder outlet obstruction
41
Q

How to manage if you have mild symptoms of BPH

A

Watchful waiting

42
Q

How to manage if you have moderate symptoms of BPH WITH ED

A
  • a-adrenergic antagonist
  • PDE-5 inhibitor

OR BOTH

43
Q

How to manage if you have moderate symptoms of BPH WITH small prostate and low PSA

A

a-adrenergic antagonist

44
Q

How to manage if you have moderate symptoms of BPH WITH large prostate and inc PSA

A

5-a-reductase inhibitors (finasteride, dutasteride) AND
a-adrenergic antagonist

45
Q

How to manage if you have moderate symptoms of BPH WITH predominant irritative voiding symptoms

A

a-adrenergic antagonist + anticholinergic agent/miragebron

46
Q

How to manage if you have severe symptoms of BPH WITH complications of BPH

A

Minimally invasive surgery or prostatectomy

47
Q

What are the potential complications of BPH (7)

A
  1. Acute and painful urinary retention (lead to acute renal failure)
  2. Gross hematuria
  3. Overflow urinary incontinence/unstable bladder
  4. Recurrent UTIs
  5. Bladder diverticula (out-pouching of bladder)
  6. bladder stones
  7. chronic renal failure from (long bladder obstruction)
48
Q

What targets the dynamic bladder outlet obstruction

A

A-adrenergic receptors
causes smooth muscle relaxation of:
- prostate
- bladder neck
- prostatic urethra

49
Q

What targets the static bladder outlet obstruction

A

5a-reductase enzymes
- inhibits the conversion of testosterone to DHT

50
Q

Where do the muscarinic receptors work
M3 selective
M2 non-selective

A

Bladder lining

51
Q

When doing watchful waiting for mild symptoms for BPH, what/when do you follow up? (4)

A
  • follow up at 6-12 months
  • standardized questionnaire for symptoms
  • objective tests to assess urinary flow rate and post-void residual
  • assess prostate size via DRE +/- digital rectal exam
52
Q

When doing watchful waiting for mild symptoms for BPH, what patient education/lifestyle modification (4)

A
  • Restricting fluids at bedtime
  • Minimizing caffeine and alcohol intake
  • frequently emptying bladder
  • avoiding drugs that can exacerbate voiding symptoms
53
Q

Which drugs improve storage capacity of bladder?
MOA

A

Relaxes detrusor of muscle bladder
- tolterodine
- oxybutynin
- trospium
- solifenacin/darifenacin
- fesoterodine
- Mirabegron

54
Q

Which drug is associated with floppy iris syndrome although rare?

A

Tamsulosin

55
Q

What are the non-selective Alpha-1 adrenergic blockers? (3)

A

Doxazosin
Prazosin
Terazosin

56
Q

Which non-selective Alpha-1 adrenergic blocker is not associated with orthostatic hypotension?

A

Prazosin

57
Q

What are the general ADRs associated with non-selective Alpha-1 adrenergic blockers? (6)

A
  • Orthostatic hypotension
  • Dizziness
  • headache
  • asthenia (lack of energy)
  • nasal congestion
  • syncope (temporary loss of BP)
58
Q

Which selective Alpha-1 adrenergic blocker has an ADR of orthostatic hypotension

A

Silodosin

59
Q

Which selective Alpha-1 adrenergic blocker has an ADR of URTI

A

Alfuzosin

60
Q

What is the first-dose phenomenon in alpha adrenergic blockers? How to prevent it?

A

Fast and large drop in BP and syncope in first dose
- risk is greatest with doxazosin, prazosin, terazosin

Prevent by starting with a low dose and titrating up slowly

61
Q

What is the ADR of 5-alpha-reductase inhibitors

A

Sexual dysfunction, decreased libido, difficulty achieving erection

62
Q

What values do 5-alpha-reductase inhibitors reduce? (2)

A

Reduce prostate volume by 20-30%
50% reduction in PSA levels after 6 months

63
Q

Which 5-alpha-reductase inhibitors has less drug interactions?

A

Finasteride

64
Q

What adverse event do you have to be aware with anti-muscarinic

A

Delerium

65
Q

What other drug class and drug can be used to treat BPH?
MOA

A

Tadalafil (cialis)
Relaxes smooth muscle around the prostate
5mg daily

66
Q

What are the drug class & indications for mirabegron
important Side effect?

A

Class: Beta-3 adrenergic agonist
Indication: Overactive bladder with symptoms of urgency, incontinence, and frequency

Can increase BP–> monitor

67
Q

Desmopressin MOA?
indication?

A

Replacement for endogenous antidiuretic hormone

can be useful for problematic nocturia

68
Q

What is the gold standard for surgery?

A

Prostatectomy

69
Q

Prior to initiating drug therapy for ED? what risk factors should you look at? (6)

A
  • Sexual history
  • Medical history
  • DRUG HISTORY
  • Physical exam
  • Lab tests
70
Q

Which PDE-5 inhibitor is NOT affected by food? which is?

A

Tadalafil cialis not affected

Sildenifil viagara –> will delay by 60 min

71
Q

What is required for PDE-5 inhibitors to work?

A

Sexual stimulation to be effective

72
Q

What are the side effects of PDE-5 inhibitor? What properties are they related to?

A

Headache
Flushing
Dyspepsia (indigestion)
Nasal congestion

Vasodilatory properties

73
Q

What are the rare but more serious adverse events of PDE-5 inhibitors (4)

A
  1. Vision changes
  2. Nonarteritic anterior ischemic optic neuropathy (NAION)
  3. Hearing loss
  4. Priapism
74
Q

Explain vision changes in PDE-5 inhibitors

A
  • impairment of blue-green discrimination
  • light sensitivity, blurred vision
  • transient, dose-related
75
Q

Explain Nonarteritic anterior ischemic optic neuropathy (NAION) in PDE-5 inhibitors

A
  • rare, sudden, unilateral, painless blindness
  • higher risk if any comorbidities, smoker
  • if has any vision loss –> D/C
76
Q

Explain hearing loss in PDE-5 inhibitors

A
  • unilateral
  • occurs within the first 24 hours of PDE-5 inhibitor use
  • temporary for 1/3 patients
77
Q

Explain priapism in PDE-5 inhibitors

A

Erect for 4+ hours without sexual stimulation or desire
- more risk with sildenafil and vardenafil due to shorter half-lives

78
Q

What is an absolute contraindication to PDE-5 inhibitors? Why? MOA?

A

Nitrates

Why?
- a large drop in blood pressure
- increase risk of hypotension and syncope

MOA
- nitrate inc cGMP + inhibiting PDE-5 inc cGMP = synergistic effect

79
Q

How do you manage PDE-5 inhibitor + nitrate interactions

A

sildenifil (viagara) = do not administer nitrates within 24 hours

Tadalafil (cialis) = do not administer nitrate within 48 hours

80
Q

What do if patient has anginal symptoms and uses a nitrate product?

A
  • Assess how serious is it
  • Consider beta-block or calcium channel blocker
81
Q

would you wait shorter or longer to adminsiter a nitrate after stopping a PDE-5 inhibitor if a patient had renal or hepatic dysfunction and taking a CYP3A4 inhibitor

A

Longer

82
Q

Effect of CYP 3A4 inhibitors (erythromycin, ketoconazole) on PDE-5 inhibitors

A

Drug accumulation

inc risk of hypotension, syncope, prolonged erections

83
Q

Effect of CYP 3A4 inducers (rifampin, phenytoin) on PDE-5 inhibitors

A

More drug cleared

  • reduces effectiveness of drug
84
Q

What are high risk of CV for patients considering a PDE-5 inhibitor? Management?

A
  • unstable or refractory angina
  • unctrolled hypertension
  • Recent MI (<2wk), stroke
  • Moderate/severe valvular disease

Refer for specialized CV management
defer treatment

85
Q

What are other options if PDE-5 inhibitors are ineffective?

A

Alprostadil CAVERJECT (inject Prostaglandin E1)
Alprostadil MUSE synthetic PGE1, micro suppositories transurethral

IPFC 3 Midterm 2 (7 decks)

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