T2 L4 (COWART) (ED)

T/F: Diseases that compromise vascular flow to the corpora cavernosum are associated with ED.

True

What vascular disease is most commonly associated with ED?

A. PVD

B. Hyperlipidemia

C. Metabolic syndrome

D. Atherosclerosis

D. Atherosclerosis

T/F: Uncontrolled diabetes has no effect on the penile vasculature.

False

Medication classes which can contribute to ED? (five)

1. Anticholinergics

2. Dopamine antagonists

3. Estrogens or drugs with antiandrogenic effects

4. CNS depressants

5. Agents that decrease penile blood flow

Diagnostic criteria for ED includes? (four)

1. Validated questionnaires

2. Medical history

3. Physical exam

4. Labs

When is medication warranted for the treatment of ED?

3 month period of reported problems

Goal of medication therapy in treatment of ED? (two big and general ones)

Improve quality & quantity of penile erections suitable for sexual intercourse (usually assessed following after 3 wks therapy)

Avoidance of adverse drug reactions, drug-drug interactions, drug-disease interactions

First line pharmacotherapeutic agent in treatment of ED? (one class)

PDE-5 inhibitor

Alternative treatments (second line) for treatment of ED? (two classes)

Prostaglandin E1 (Alprostadil)

Testosterone supplements

Starting PRN dose for sildenafil?

50 mg

Starting PRN dose for vardenafil?

10 mg

Starting PRN dose for avanafil?

100 mg

Starting PRN dose for tadalafil?

10 mg

Which PDE-5 inhibitor is the only thus-far FDA approved ED medication for daily use?

Tadalafil

Which of the following PDE-5 inhibitors should be taken ~1hr prior to intercourse?

A. Sildenafil

B. Vardenafil

C. Avanafil

D. Tadalafil

A. Sildenafil

B. Vardenafil

Which of the following PDE-5 inhibitors should be taken 15-30 minutes prior to intercourse?

A. Sildenafil

B. Vardenafil

C. Avanafil

D. Tadalafil

C. Avanafil

Which of the following PDE-5 inhibitors should be taken ~2hr prior to intercourse?

A. Sildenafil

B. Vardenafil

C. Avanafil

D. Tadalafil

D. Tadalafil

Duration of action for sildenafil?

Up to 12 hr

Duration of action for vardenafil?

Up to 10 hr

Duration of action for avanafil?

Up to 6 hr

Duration of action for tadalafil?

Up to36 hr (weekend pill)

T/F: Avanafil is the only PDE-5 inhibitor not metabolized by CYP3A4.

False; all of them are.

Dose-response of PDE-5 inhibitors is __________ and _______

A. linear, profound

B. non-linear, profound

C. linear, small

D. non-linear, small

D. non-linear, small

Why do we start low when considering PDE-5 inhibitors?

Stronger dose-response patterns observed for adverse effects

An adequate trial of a PDE-5 inhibitor requires the use of at least how many doses?

at least 5-8 doses

Characteristics which put a patient in the "intermediate" risk category (needs assessment to be prescribed a PDE-5 inhibitor)? (five)

1. Has 3 or more risk factors for CVD

2. Mild or moderate, stable angina

3. Recent MI or stroke within the past 2-8 weeks

4. Moderate CHF (NYHA Class III)

5. History of stroke, TIA or peripheral artery disease

Characteristics which put a patient in the "high" risk category (PDE-5 inhibitor contraindicated)? (seven)

1. Unstable or refractory angina, despite treatment

2. Uncontrolled HTN

3. Severe CHF (NYHA Class IV)

4. Recent MI or stroke (past 2 weeks)

5. Moderate or severe valvular heart disease

6. High-risk cardiac arrythmias

7. Obstructive hypertrophic cardiomyopathy

Characteristics which put a patient in the "low" risk category (patient can be started on a PDE-5 inhibitor)? (five)

1. Asymptomatic CVD with <3 risk factors for CVD

2. Well-controlled HTN

3. Mild CHF (NYHA class I or II)

4. Mild valvular heart disease

5. History of MI

How should we manage an "intermediate" risk patient who is being considered for PDE-5 inhibitor therapy?

Refer to cardio

How should we manage a "high" risk patient who is being considered for PDE-5 inhibitor therapy?

PDE-5 inhibitor contraindicated, should probably go see cardio

Major contraindication associated with PDE-5 inhibitors?

NITRATES

Not even daily nitrates (BiDil, transdermal)

Must hold ~48 hours nitrate therapy if planning to take PDE-5 inhibitor

Describe nonarteritic anterior ischemic optic neuropathy

Sudden, unilateral painless blindness - can be irreversible

Can develop 6hr later or years later

Risk increased in glaucoma, macular degeneration, diabetic retinopathy, HLD, HTN, past eye trauma, age >50 years, smokers

Potential adverse effect associated with PDE-5 inhibitors

Steps to take if a patient appears to have risk factors like glaucoma, macular degeneration, diabetic retinopathy, etc. prior to consideration for PDE-5 inhibitor therapy?

Refer to ophthalmology for assessment

Most common adverse effects associated with PDE-5 inhibitors? (four)

Headache, facial flushing, dyspepsia, priapism

Drug-drug interactions associated with PDE-5 inhibitors? (four)

Alpha blockers (hypotension) (in this situation, switch to tamsulosin)

Potent CYP3A4 inhibitors (azoles, clarithromycin, erythromycin, ritonavir, GFJ, etc.)

Vardenafil specifically should be used cautiously with drugs that prolong QT interval

Nitrates bad just generally

Treatment pathway for ED?

Treat underlying, d/c meds that can contribute, remove risk factors, add test. if pt hypogonadism --->

PDE5 inhibitor --->

If not working, make sure optimized, dose titrated --->

If not working, inject --->

If not working, unlucky

If a patient has BPH and ED, which PDE-5 inhibitor should they get?

Tadalafil