NSG 533 Module 3 Flashcards
Before initiating treatment for ED, a physical examination and thorough medical, social, and medication histories with emphasis on cardiac disease must be taken to assess for ability to safely perform sexual activity and to assess for possible drug interactions.
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o Non-pharmacological interventions for ED
Reduce fat and cholesterol in diet
Decrease or limit alcohol consumption
Eliminate tobacco use and substance abuse
Weight loss if appropriate
Regular exercise
(Regarding ED treatment)
If a medication is removed, consider that it probably will have to be replaced with a reasonable alternative.
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SS____ (psych drug class) are a potential cause of ED. A reasonable replacement or addition (to offset the ED) might be bup_______ (psych med) (assuming no contraindications)
SSRIs
bupropion
du__________ (med for BPH) is a common cause of ED. tar_________ (med) as a replacement for or in combination with a 5-alpha reductase might be reasonable (assuming no contraindications).
Dutasteride
Tardenafil
Note: There are occasions where an offending medication can NOT be discontinued because of a compelling indication and / or lack of a reasonable alternative (eg Beta-blockers in heart failure or SIHD).
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One must consider if the patient is healthy enough for sexual activity (table 51-3) and if so, possible alternatives such as vacuum erection devices or medications
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PD_______ (drug class) - Often considered drug of choice for ED when pharmacotherapy is necessary. There is no convincing evidence that one agent in this class is superior to another. Choice may be based on patient preference, cost, and
PDE5Is
PDE5Is:
Phosphodiesterase type 5 inhibitors
Phosphodiesterase type 5 inhibitors
PDE5Is
Regarding PD________ (ED drug class):
If one agent does not work it may be reasonable to try another from the same class. It is also imperative that patient is properly educated regarding onset and duration of effect, impact of high fat meals, the need for sexual stimulation and an explanation that a single trial is inadequate.
PDE5Is
Regarding ___________ (ED drug class):
There is no drug effect without some type of sexual stimulation because these drugs do not cause penile erections; they only provide the ability of the penis to respond to sexual stimulation.
PDE5Is
Regarding ___________ (ED drug class):
Headache and flushing most common ADRs. Serious cardiac events possible.
PDE5Is
Regarding ___________ (ED drug class):
Significant DIs exist
(+) nitrates - severe hypotension
In an emergent situation, a patient who has taken sildenafil may be given a nitrate after 24 hours; for tadalafil, after 48 hours. Vardenafil does not have a suggested time interval, but blood pressure and heart rate did not change when the drug was taken 24 hours before nitrate administration. These suggested intervals are a direct correlation to half-life and duration of action
PDE5Is
Regarding PD___s (ED drug class):
Prolonging of QT interval (especially vardenafil)
PDE5Is
Regarding ___________ (ED drug class):
Serious cardiovascular events have been associated with these drugs; therefore, they should not be used in patients in whom sexual intercourse is inadvisable because of poor cardiac status.
PDE5Is
Testosterone replacement regimens should ______ be administered to men with normal serum testosterone levels, or in patients with isolated erectile dysfunction as the only sign of hypogonadism.
never
Before initiating any testosterone replacement regimen in patients ____ years and older, patients should be screened for breast cancer, benign prostatic hyperplasia, and prostate cancer. All are testosterone-dependent conditions and theoretically could be worsened by exogenous administration of testosterone
40
Regarding testosterone replacement:
Several medications may contribute to decreased testosterone: _________________________________.
(cimetidine, spironolactone, ketoconazole, etc).
Absolute contraindications in testosterone replacement:
- documented history of prostate cancer
- hx of breast cancer
- hct 55% or more
- sensitivity to ingredients in T formulations
______ - PgE1 analog administered by intracavernosal injection & intraurethral inserts
Alprostadil
OTC / Herbals (____________, etc) - limited evidence. Not recommended
Yohimbine
_____ increases urethral resistance, resulting in compensatory changes in bladder function. Obstruction-induced changes in detrusor function, including smooth muscle hypertrophy, compounded by age-related changes in the functioning of the bladder, lead to urinary frequency, urgency, and nocturia, the most bothersome _____-related complaints.
BPH
Diagnosis of BPH includes components such as ________________________.
symptom assessment (AUA score), PE and PSA
_____ is present in small quantities in the serum of men with healthy prostates, but is often elevated in the presence of prostate cancer or other prostate disorders. _____ is not uniquely an indicator of prostate cancer, but may also detect prostatitis or BPH. _____ correlates with prostate size and can be used as a prognostic marker
PSA
Regarding ____ treatment:
Watchful waiting is the most conservative approach for patients with mild symptoms or those with moderate symptoms without bother
◦Appropriate option for patients with mild symptoms (AUA-SI score ≤ 7), and for many with moderate to severe symptoms (AUA-SI ≥ 8) if they are not bothered
◦Behavior modification includes restricting fluids close to bedtime, minimizing caffeine, sweetened drinks and alcohol intake, frequent emptying of the bladder during waking hours (to avoid overflow incontinence and urgency), and avoiding drugs that could exacerbate voiding symptoms (e.g. antihistamines, decongestants).
◦At each visit, assess the patient’s risk of developing acute urinary retention by evaluating the patient’s prostate size or using PSA as a surrogate marker of prostate enlargement
BPH
Regarding _____ the level of symptom distress that individual men are able to tolerate is variable.
BPH
__________ (ED/cardiac drug class) - fairly rapid onset (2-4 weeks) with relatively rapid symptom resolution , durable effect (years) with AUA symptom index (AUASI) improving 30-45%. No effect on prostate size (PSA) or disease progression.
o Relax smooth muscle in bladder neck, urethra & prostate
Alpha-blockers
Regarding BPH, new second generation (a________) (med) and third generation (t___________ and s____________) (med) agents are preferred because of uroselectivity, no need for dose titration and limited orthostasis
alfuzosin
tamsulosin and silodosin
_____________________
Management of moderate to severe BPH in patients with enlarged prostate glands.
Management of patients who desire medical therapy but cannot tolerate alpha-1-adrenergic antagonists and do not have predominately irritant symptoms or concomitant erectile dysfunction (Symptoms are non-bothersome, so the delay in onset would not interfere with Qol)
5 alpha reductase inhibitors (5ARIs)
finasteride/dutasteride
Regarding BPH, this drug class:
Reduce prostate size (and PSA) and thus outlet obstruction
5A__s (BPH med)
5 alpha reductase inhibitors (5ARIs)
___
finasteride/dutasteride
Regarding BPH, this drug class, 5A_____:
- Reverses/Slows disease progression
- Decreases the risk of disease complications
Note: although dutasteride blocks both the Type I and Type II iso-enzymes of 5-alpha reductase while finasteride only blocks Type II, there is not a clinically significant difference in outcomes when either is used
5 alpha reductase inhibitors (5ARIs)
finasteride/dutasteride
ADRs – (androgen insufficiency) decreased libido, impotence & ejaculatory disorder, breast tenderness & enlargement
_______ (BP/BPH drug class, -sterides)
5 alpha reductase inhibitors (5ARIs)
finasteride/dutasteride
Peak effect 6-12 months, effect is only durable as long as drug is continued (prostate will return to pre-treatment size (or larger) when / if 5ARIs are stopped
Finasteride & Dutasteride reduces, but does not stop the prostate from producing PSA
If PSA fails to decline by 50% after 6-12 months or an increase of 0.3 ng/L or more above the baseline nadir level, patient should be evaluated for prostate cancer. May also indicate worsening condition or non-compliance with 5 a-reductase inhibitors
5 alpha reductase inhibitors (5ARIs)
finasteride/dutasteride
o Treatment of the signs and symptoms of benign prostatic hyperplasia +/- ED
Relaxes smooth muscle of urethra, prostate and bladder neck
PDE5Is (tadalafil) -
tad______________ may be prescribed alone, or along with an α1-adrenergic antagonist and/or 5α-reductase inhibitor. Although other phosphodiesterase type 5 inhibitors share the same mechanism of action as tadalafil and can improve the AUA Symptom Score, tadalafil (which is the only PDE5I approved by the FDA for this indication) is preferred because of its longer plasma half-life, which is theoretically beneficial in the management of BPH, a chronic disease.
Tadalafil
Comparable efficacy to alpha-blockers for LUTS, but does not increase flow rate or reduce PVR
Peak onset 1-4 weeks
Which med?
t__________ (PDE5I, -fil)
Tadalafil
Adverse reactions
◦Use with alpha-blockers, antihypertensives or substantial amounts of alcohol may lead to hypotension
◦headache, dizziness, flushing, back pain, myalgia, and cyanopsia
Tadalafil
Precautions regarding this med, t____________ (ED drug class).
◦Unstable angina, uncontrolled or high-risk arrhythmias, persistent hypotension, poorly controlled hypertension, or New York Heart Association Classification IV congestive heart failure
Tadalafil
Contraindication
◦Current use of nitrates
Tadalafil
Alpha-blockers offer immediate relief of BPH; 5 alpha-RIs reduce prostate enlargement over time.
Alpha-blockers are the “zosins.” Doxazosin, prazosin, terazosin. α1-adrenergic antagonists are alpha-blockers.
5 alpha-RIs are the “sterides.” Finasteride, dutasteride.
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Regarding ___________ _________ for BPH:
Alpha-blocker offer immediate relief; 5 alpha-RIs reduce prostate enlargement over time
◦In patients with an enlarged prostate gland and an elevated PSA ≥1.4 ng/mL, combination drug therapy with an α1-adrenergic antagonist and a 5α-reductase inhibitor is more beneficial than single drug therapy.
◦Rationale
a-blocker offer immediate relief
5a-RIs reduce prostate enlargement
◦Works better for those with obstructive symptoms
◦May consider stopping a-blocker after 6-12 months, but should continue in those patients with severe symptoms as long as they are responding
Combination therapy
◦-blocker and ______________
(combination therapy BPH)
For men with low post-void residual urine volumes and irritative symptoms (e.g., frequency, urgency) that persist during treatment with an alpha-adrenergic antagonist, combination treatment with an ______________ agent can be tried.
Improved storage voiding parameters and frequency compared with alpha-1-adrenergic antagonist therapy alone
anticholinergic (or β3 agonist)
Regarding combination therapy for BPH using an alpha-blocker and an anticholinergic:
For patients who poorly tolerate anticholinergic adverse effects, an alternative is m________________ (med).
Mirabegron
Combination therapy for BPH utilizing alpha-blocker and an anticholinergic.
The risk of side effects, increased post-void residual urine volume, decreased maximal urinary flow rate, or acute urinary retention is low.
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alpha-blocker and PDE-5Is:
(Comination therapy for BPH and ED)
For men with moderate symptoms of BPH and erectile dysfunction, treatment with daily tadalafil (5 mg/day) alone or in combination with tamsulosin (0.4 mg/day) can be considered
Addition of PDE-5Is to alpha blockers may improve lower urinary tract symptoms
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PDE-5i and 5a-RIs
Addition of PDE-5i to 5a-RIs can offset erectile dysfunction commonly seen with 5a-RIs
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Herbals: No dietary supplement, combination phytotherapeutic agent or other nonconventional therapy is recommended for the management of LUTS (lower urinary tract symptoms) secondary to BPH.
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Commonly used / teratogenic
o __________, Phenytoin, __________________, Carbamazepine, Lithium, ___________________, Thalidomide, _____________, statins
o Warfarin, Phenytoin, Valproic Acid, Carbamazepine, Lithium, ACE inhibitors/ARBs, Thalidomide, Ethanol, statins
Commonly used / teratogenic
o Warfarin, _____________, Valproic Acid, _______________, Lithium, ACE inhibitors/ARBs, __________________, Ethanol, _______________
o Warfarin, Phenytoin, Valproic Acid, Carbamazepine, Lithium, ACE inhibitors/ARBs, Thalidomide, Ethanol, statins
Regarding COC (combined oral contraception)
World Health Organization and the Food and Drug Administration recommend using the lowest dose pill that is effective (as noted below, efficacy can be impacted by several factors .. including other medications. Thus, the lowest dose available is not always the lowest most effective dose)
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Concomitant use of broad spectrum antibiotics and combination contraceptives may result in decreased _________________;
contraceptive efficacy
If a typical failure rate of 1% to 3% is a concern for the patient, consider additional or alternative forms of _______________.
birth control
o Concomitant use of ________________________________ may result in decreased contraceptive efficacy
P450 enzyme inducers (rifampin, phenytoin, carbamazepine, phenobarbital)
o Concomitant use of P450 enzyme inducers (rifampin, phenytoin, carbamazepine, phenobarbital) may result in decreased contraceptive efficacy
If use COC – use higher doses (at least 35 mcg EE) + high progestin, shorten hormone free interval to 4 days or less
Avoid low progestin – the patch, POP
Consider additional or alternative forms of birth control
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Concomitant use of Anti-HIV protease inhibitors can either increase or decrease serum levels of estrogens and progestins – may need backup method.
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Regarding birth control:
d________________ (med) can cause hyperkalemia, especially if used with other agents that can increase potassium (ACEIs, heparin, aldosterone antagonists, etc)
Drospirenone
_______________________ - indicated in Breastfeeding (post-partum phase), older women, women who cannot take estrogen
Progestin Only oral contraceptives
HTN in pregnancy:
- When SBP reaches 160 or DBP reaches 110
- Continue treatment when multiple hypertensive’s were required before pregnancy or when end organ damage is present
methyldopa / labatolol / nifedipine ER 1st line
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- DM I / II / GDM and pregnancy
o Treatment
ADA diet
Insulin – drug of choice
Regular insulin or NPH
Insulin lispro (Humalog)
Insulin aspart (Novolog)
◦Insulin requirements will increase beginning around 28 weeks gestation and continue to increase due to placental hormones
Increasing data on safety of insulin glargine in pregnancy
Oral agents (metformin / glyburide) 2nd line. Reasonable alternative for women who decline to take, or are unable to comply with, insulin therapy.
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- hypothyroidism and pregnancy
◦Levothyroxine – DOC
◦Attain normal thyrotropin concentrations
◦Women who received thyroid replacement prior to pregnancy can expect an increased dosage requirement of 25-50% during pregnancy
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- depression and depression
o Pregnant patients with severe unipolar major depression who were successfully treated with antidepressants prior to pregnancy should generally receive the same drug during pregnancy. For patients who have not been treated with antidepressants in the past, we suggest selective serotonin reuptake inhibitors (SSRIs) as initial treatment, rather than other antidepressants
o No psychotropic drugs with labeling approved by the FDA for use during pregnancy and lactation
o 1st line – psychotherapy, but not always an option
SSRI’s
◦Avoid paroxetine (D) during first trimester
CV malformations
◦Fluoxetine (C) citalopram (C) sertraline (C) –>Literature is reassuring, best data for use during pregnancy
◦Risk of PPHTN after 20 weeks gestation with SSRI’s
◦Risk of neonatal withdrawal or adaptation syndrome1
d/c 2 weeks before term
TCA’s
◦Literature is reassuring
◦Possible withdrawal symptoms
Atypical antidepressants
◦Limited data
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◦Fluoxetine (C) citalopram (C) sertraline (C) –>Literature is reassuring, best data for use during pregnancy
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- Dyslipidemia and pregnancy
o Women who are on statin therapy and anticipate becoming pregnant should stop statins three months prior to attempting to conceive.
o Maternal consumption of fish and marine omega-3 fatty acid supplement is an active area of investigation because of potential favorable effects on pregnancy and offspring outcome.
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Pharmacotherapy for menopause - hormone therapy remains the most effective treatment for vasomotor symptoms and vulvovaginal atrophy, especially in women with moderate to severe symptoms, provided there is not ____________________________________________________________________.
CHD, significant CHD risk factors or history of breast cancer
___________________ - FDA approved for moderate to severe vasomotor symptoms, vulvovaginal atrophy and prevention of post-menopausal osteoporosis.
Oral Estrogens
Note, ______________ should NOT be used for osteoporosis prevention in the absence of vasomotor symptoms of menopause or for patients with local symptoms ONLY
oral estrogens
_________________ - Used in women with an intact uterus to reduce endometrial hyperplasia and endometrial cancer with estrogen monotherapy.
Oral progestins
NOT necessary s/p hysterectomy .. so check surgical history
Oral p________ (hormones)
Oral progestins
Must be taken minimum of 12-14 days/month
Oral p_________ (hormone)
Oral progestins
Length of therapy - The benefit to risk ratio appears to be best if HT is started close to the time of ____________. Typically can stop 2-3 years after starting. Longer durations may be associated with CHD, stroke, VTE, various cancers etc.
menopause
Strong consideration for __________ in those patients on higher doses of estrogen or long duration.
tapering
Vulvovaginal complications during menopause can range from vaginal dryness to atrophy , dyspareunia (painful coitus) and lower urinary tract symptoms (urge incontinence / OAB)
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o Local or systemic estrogen therapy for symptom relief
Estrogen can help to restore thickness, elasticity, and lubrication
Estrogen can help reduce the risk of recurrent urinary tract infections
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o In the absence of vasomotor symptoms, local/ topical (vaginal) estrogen therapy should be used. There is minimal systemic absorption (with exceptions) and does not require the concomitant administration of a progestin
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Mr. Jackson is a 55 year old male who has been diagnosed with erectile dysfunction. He is wondering what side effects he should be concerned about with his sildenafil prescription. His current diagnoses include, GERD, hypotension, osteoarthritis, and glaucoma. What would be most important to educate him about?
- Risk for exacerbating GERD
- Increasing joint pain
- Drug interaction with glaucoma medications
- Risk of lowering blood pressure
- Risk of lowering blood pressure
One of the risks of sildenafil is that it can lower blood pressure. If he already has issues with hypotension, sildenafil could worsen this issue. He should be educated to stand up slowly and monitor for dizziness when changing positions.
As you review Mr. Stevens medication list, you realize that he has many PRN medications. Which one would be of highest concern with regard to drug interactions with tadalafil?
- Calcium carbonate (Tums) for GERD
- Nitroglycerin for chest pain
- Ibuprofen for pain
- Diphenhydramine for sleep
Nitroglycerin for chest pain
There is a drug interaction with systemic nitrate/nitroglycerin products; advise patients about the potential interaction and the risk of low blood pressure/hypotension.
Ms. Jones has asked about the risks with regard to her birth control. She informs you that she is taking Loestrin which is a combination of estrogen and progestin. You inform her that it can increase the risk of blood clots. Which part of her history would increase the risk of a blood clot?
- 1-2 glasses of wine per week
- She runs marathons a few times per year
- She is currently taking rifampin
- She is a smoker
She is a smoker
Smoking and older age are two major risk factors that will increase the risk for blood clots associated with oral contraceptives. Rifampin may interact with estrogen and progestin combination products, but it would be more likely to reduce drug concentrations and not increase clot risk.
Ms. Linn has recent had the dose of the estrogen component of her birth increased by her provider. What is the likely explanation for this?
- Reduce breakthrough bleeding/spotting
- Reduce blood clot risk
- Improve the nausea adverse effect
- Reduce breast tenderness
Reduce breakthrough bleeding/spotting
In general, increasing the estrogen dose in oral contraceptives will help reduce the frequency and amount of breakthrough bleeding/spotting. Increasing estrogen may increase nausea, breast tenderness, and the risk of blood clots.
Ms. Nelson is a 34-year-old female with a complex medical history. She was asking about drug interactions in relation to her combination birth control of estrogen and progestin. Which of her medications would be most likely to reduce the effectiveness of her birth control and leave her at risk for unintended pregnancy?
- Ibuprofen for rheumatoid arthritis
- Carbamazepine for bipolar disorder
- Quetiapine for bipolar disorder
- Clonazepam for anxiety
Carbamazepine for bipolar disorder
Carbamazepine is an enzyme inducer that would reduce the concentrations of oral contraceptives, leaving the patient at greater risk for unintended pregnancy and birth control failure.
A patient taking oral contraceptives read on the package that it is “monophasic”. What should you tell the patient this means?
- She has to take it at the same time everyday and cannot vary
- She is getting the same amount of hormone in every pill
- She has a lower risk of blood clots with this formulation
- She will not have periods with this type of birth control
She is getting the same amount of hormone in every pill
With monophasic oral contraceptives, the patient will receive the same amount of hormone in each active tablet. With triphasic, the amount of hormone will vary and try to more closely mimic physiologic hormone cycles.
A patient presents to your clinic for their Depo-Provera injection. They receive this injection every three months. Which of the following education should be provided to this patient?
Avoid all alcohol when on this injection and for at least 3 months after stopping
Encourage taking her blood pressure on a weekly basis
Ensure that the patient is taking adequate calcium and vitamin D
Avoid use of acetaminophen while taking this medication
Ensure that the patient is taking adequate calcium and vitamin D
Medroxyprogesterone (Depo-Provera) carries a boxed warning for reduced bone mineral density. Educating about this risk and ensuring adequate calcium and vitamin D intake would be the most important thing to do for this patient given the options listed.
You’re meeting your patient in the clinic for the first time and she reports that she just took an at-home pregnancy test and it was positive. She reports that she is taking Tums, sertraline, lisinopril, and insulin (type 1 diabetes). Which medication should you have the provider address immediately?
- Tums
- Sertraline
- Lisinopril
- Insulin
Lisinopril
ACE inhibitors (lisinopril), ARBs, and aldosterone antagonists for hypertension should absolutely be avoided in pregnancy. They have a high risk of causing birth defects.
What is a potential risk when using estrogen to treat menopausal symptoms like hot flashes?
- Osteoporosis
- Breast cancer
- Bleeding
- Vaginal atrophy
Breast cancer
Hormone replacement therapy (HRT) can increase the risk of breast cancer, blood clots, cardiovascular disease, and stroke. It would be likely to improve bone mineral density and vaginal atrophy.
A 42-year-old patient who presents to the clinic is taking clomiphene 5 days out of the month. What is this likely being used for?
Improve chances of pregnancy
Reduce hot flashes in a patient with early menopause
Reduce spotting and breakthrough bleeding between cycles
Prevention of multiple births (i.e. twins, triplets, etc.)
Improve chances of pregnancy
Clomiphene binds estrogen receptors, which interrupts the normal estrogen negative feedback mechanism that prevents ovulation. It helps to stimulate ovulation and may help improve the chances of the patient becoming pregnant.
Topical _________ products (not transdermal systemic) with limited systemic absorption may be useful for women experiencing vulvovaginal atrophy.
estrogen
For older women, long-term use of _____ for menopause is associated with more overall risk than benefit and should not be used.
HRT
Short-term ___________ therapy can be useful for patients with bothersome vasomotor symptoms, although they should be prescribed at the lowest possible dose and for the shortest possible duration.
hormonal
__________ should not be continued for any other purpose besides bothersome vasomotor symptoms (e.g., prevention of osteoporosis)
HRT
Per the WHI trial: _____ not protective against CHD and increased risks. Increased risk of breast cancer after woman on combo estrogen/progestin for 3 years.
HRT
Women who have an _______ _______ should be prescribed a progestin in addition to estrogen to decrease the risk of endometrial hyperplasia and endometrial cancer.
intact uterus
Women who have had a hysterectomy can do _____.
HRT
Risks of HRT include: _____, _____, _____
CVD, breast cancer, VTE
Benefits of HRT include: _______, ______, ________. _______________
vasomotor symptoms, vulvovaginal atrophy, secondary osteoporosis prevention, and improvement of well-being and mood.
Contraindications of HRT: ________, ________, _____________, ____________, ________, _________, __________
History of thromboembolic disease, CHD, breast cancer, estrogen-dependent neoplasm, pregnancy, liver disease, or undiagnosed vaginal bleeding.
_______ _________ therapy is not to be used for the prevention or treatment of CVD, cerebrovascular disease, or dementia.
hormone replacement
__________ is the only ABT to date that has been reported to reduce plasma estrogen concentrations. Oral contraceptives cannot be relied upon for birth control while taking __________. This ABT makes it easier to get pregnant.
Rifampin
________ is a CHD risk factor.
Diabetes
What signs and symptoms are associated with menopause?
Vasomotor symptoms, sleep disturbances, mood swings, vaginal dryness, depression.
Less common: fatigue, irritability, migraine, arthralgia, myalgia, and decreaed libido.
Risks of contraceptive use:
STIs, CV events, HTN, VTE, gallbladder disease exacerbation, benign hepatic tumors, cervical cancer (especially in women who test positive for HPV).
_________ is only indicated in patients who also have documented low serum testosterone levels.
ED is an off-label use.
Testosterone
All PDE51s have comparable efficacy for ____.
ED
Non-pharm for ED include:
lifestyle modifications
psychotherapy
vacuum erection devices
prostheses
The four category “X” anticonvulsants:
- P__________
- V__________
- C__________
- P__________
Phenytoin, valproic acid, carbamazepine, phenobarbitol.
M_____________ (GI med for ulcer prohylaxis) is category “X” and causes uterine contractines.
Misoprostol
Don’t use _________ in the 3rd trimester. Safe in 1st and 2nd trimester.
NSAIDs
What medications can contribute to the development and/or worsening of BPH/ED and could be reasonably stopped or substituted?
Anticholinergics and caffeine could be more easily stopped. Replacement depends on what the patient is being treated for. BZDs could be switched out for the shortest-acting one. Thiazide diuretics’ increased urination stabilizes after 2 weeks., whereas loop diuretic never do. TCAs could be switched to SSRIs or SNRIs or others depending on what the disease is.
SSRIs are a potential cause of ED. A reasonable replacement or addition (to offset the ED) might be ____________ (assuming no contraindications).
Bupropion.
d_____steride (for BPH) is a common cause of ED. Tardenafil as a replacement for or in combination with a 5-alpha reductase inhibitor might be reasonable (assuming no contraindications)
Dutasteride
PDE51s + nitrates =
severe hypotension
In an emergent situation, a patient who has taken s_____________ (ED med) may be given a nitrate after 24 hours; for t___________ (ED med), after 48 hours. Vardenafil does not have a suggested time interval, but blood pressure and heart rate did not change when the drug was taken 24 hours before nitrate administration. These suggested intervals are a direct correlation to half-life and duration of action
sildenafil, tadalafil
Behavior modification for BPH:
Behavior modification includes restricting fluids close to bedtime, minimizing caffeine, sweetened drinks and alcohol intake, frequent emptying of the bladder during waking hours (to avoid overflow incontinence and urgency), and avoiding drugs that could exacerbate voiding symptoms (e.g. antihistamines, decongestants).
Reduce prostate size (and PSA) and thus outlet obstruction
5a________ / 5A__s (DM drug class)
5 alpha reductase inhibitors
fairly rapid onset (2-4 weeks) with relatively rapid symptom resolution , durable effect (years) with AUA symptom index (AUASI) improving 30-45%. No effect on prostate size (PSA) or disease progression.
(a_______ b________s)
Alpha blockers
One significant DI regarding PDE5Is is prolongation of QT interval, especially v__________ (ED med)
Vardenafil
_________ (ED drug class) can cause severe CV events, and so should not be used in patients with poor cardiac status.
PDE5Is
5ARIs
5 alpha reductase inhibitors
finasteride
dutasteride
- Management of moderate to severe BPH in patients with enlarged prostate glands.
- Management of patients who desire medical therapy but cannot tolerate alpha-1-adrenergic antagonists and do not have predominately irritant symptoms or concomitant erectile dysfunction (Symptoms are non-bothersome, so the delay in onset would not interfere with Qol)
- Reduce prostate size (and PSA) and thus outlet obstruction
5ARIs (5 alpha reductase inhibitors)
finasteride
dutasteride
o Concomitant use of P450 enzyme inducers (rifampin, phenytoin, carbamazepine, phenobarbital) may result in decreased ________________ ____________.
contraceptive efficacy
Regarding VTE / Thromboembolism:
___________ (hormone) - increase hepatic production of factor VII, factor X, and fibrinogen in the coagulation cascade, therefore increasing the risk of thromboembolic events
Estrogens
__________ Only oral contraceptives - indicated in Breastfeeding (post-partum phase), older women, and women who cannot take estrogen
Progestin
Alpha blocker drugs (“-zosin”):
D____________
P____________
T____________
Doxazosin (Cardura)
Prazosin (Minipress)
Terazosin.
