Endo Exam 1: Lewis ED + Testosterone

Erectile dysfunction is the failure to achieve a penile erection suitable for satisfactory sexual intercourse. Major causes include __________, __________, hormonal, vascular, neurologic, psychogenic, social habits, and medications

Organic ED can result from vascular disease such as PVD, __________, and __________, neurologic disease such as Parkinson's, epilepsy, stroke, or spinal cord injury, and hormonal disease such as low __________.

Psychogenic contributors to ED include anxiety, sedation, Alzheimer’s, hypothyroidism, and mental disorders. Social habits that can contribute include __________ and __________

Organic, secondary, HTN, DM, testosterone, Smoking, alcohol

Drug classes that can cause ED include __________, dopamine antagonists, estrogens/antiandrogens, CNS depressants, agents that decrease penile blood flow, and __________-alpha reductase inhibitors

Anticholinergics, 5

Anticholinergic drugs associated with ED include first-generation __________, __________, and __________.

Antihistamines, TCAs, SSRIs

Drugs that decrease penile blood flow include __________ and beta blockers. Diuretics decrease __________ volume, reducing penile arteriolar flow

Diuretics, intravascular

Beta blockers more implicated in ED include __________, __________, and __________, while __________, __________, and __________ have less potential to cause ED according to the lecture

Propranolol, atenolol, metoprolol, nebivolol, carvedilol, labetalol

High-dose spironolactone can cause __________ effects, which can decrease __________ and contribute to ED

Estrogenic, libido

ACE inhibitors, ARBs, __________, __________, and CCBs are listed as preferred antihypertensive options in patients with ED.

Terazosin, doxazosin

When a medication contributes to ED, address the __________ cause, consider __________ the medication, and check __________ levels when appropriate

Underlying, discontinuing, testosterone

ED treatment generally follows: 1) __________/risk-factor management, 2) __________ inhibitors, 3) vacuum erection device or intracavernosal __________, and 4) __________ only when indicated

Lifestyle, PDE5, alprostadil, testosterone

Lifestyle management includes a heart-healthy lifestyle and addressing __________, __________, __________, __________, __________, and excessive __________ intake

HTN, CAD, dyslipidemia, diabetes, Smoking, alcohol

The first-line pharmacologic therapy for ED is __________ inhibitors

PDE5

FDA-approved PDE5 inhibitors listed in the lecture are __________, __________, __________, and __________

Sildenafil, vardenafil, tadalafil, avanafil

Testosterone should only be used when __________ hypogonadism is confirmed with low serum testosterone, not for isolated ED with __________ testosterone

Symptomatic, normal

PDE5 normally breaks down __________ to inactive GMP. PDE5 inhibitors block this metabolism, prolonging __________ activity and causing penile vasodilation and erection

PDE5 inhibitors require __________ stimulation and do not create an erection without sexual arousal

cGMP, cGMP, Sexual

Sildenafil generally has __________ visual effects than tadalafil or avanafil and should be taken on an __________ stomach because a fatty meal can delay absorption

Vardenafil should NOT be used in patients with __________ prolongation or those taking class __________ or __________ antiarrhythmics. It also has more visual effects than tadalafil or avanafil

More, empty, QT, IA, III

Tadalafil can be taken without regard to __________, is indicated for both ED and __________, and is associated with more __________ pain.

Tadalafil has the __________ half-life among the PDE5 inhibitors, approximately __________ hours, and its effects can last for days

Meals, BPH, back, Longest, 17.5

Avanafil is generally well tolerated and has __________ dyspepsia compared with some other PDE5 inhibitors

Less

Common PDE5 inhibitor adverse effects include __________, flushing, dyspepsia, nasal congestion, dizziness, and __________.

Headache, hypotension

Sildenafil/vardenafil → more __________ effects, tadalafil → more __________/limb pain and myalgia, avanafil → generally better tolerated with less __________.

Visual, back, dyspepsia

Sudden __________

Sudden __________ while taking a PDE5 inhibitor requires stopping the medication and seeking medical evaluation while taking a PDE5 inhibitor requires stopping the medication and obtaining medical evaluation

Vision loss, Hearing loss

__________ is an emergency adverse effect of PDE5 inhibitors requiring emergency department evaluation

Priapism

NAION stands for nonarteritic anterior ischemic __________ neuropathy and presents as sudden, unilateral, painless __________ loss that may be irreversible

Optic, vision

If sudden vision loss occurs in one eye while taking a PDE5 inhibitor, evaluate for __________. If present, __________ the PDE5 inhibitor

NAION, stop

Patients at increased risk for NAION include those with glaucoma, macular degeneration, diabetic retinopathy, dyslipidemia, HTN, prior eye surgery/trauma, age ≥__________ years, and __________.

50, smokers

PDE5 inhibitors are contraindicated with organic __________ by any route, whether scheduled or intermittent

Nitrates

Nitrates should be withheld for __________ hours after sildenafil, vardenafil, or avanafil, and __________ hours after tadalafil

Nitrates are __________ donors and PDE5 inhibitors increase __________, so combining them can produce excessive vasodilation and life-threatening __________.

24, 48, NO, cGMP, hypotension

Alpha blockers are not an absolute contraindication, but can cause additive __________. Patients should have stabilized __________, use low alpha-blocker doses, and separate administration when appropriate

Hypotension, BP

Strong CYP3A4 __________ can substantially increase PDE5 exposure and require lower starting doses, while CYP3A4 __________ can reduce exposure and decrease clinical response.

Inhibitors, inducers

PDE5 inhibitors should not be used with __________ because of hypotension risk

Riociguat

__________ should be avoided with PDE5 inhibitors because it inhibits __________ and can increase PDE5 drug exposure

Grapefruit juice, CYP3A4

High-risk/C/I conditions for PDE5 inhibitors include unstable/refractory angina, uncontrolled HTN, __________, severe CHF class __________, recent MI/stroke within __________ weeks, moderate-severe valvular heart disease, high-risk cardiac arrhythmias, and obstructive hypertrophic cardiomyopathy.

AFib, IV, 2

Patients should be told that sexual stimulation is still required and to allow adequate time for effect, sometimes up to __________ hour

Failure should not be declared after one dose. Before escalating therapy, verify correct __________, correct __________, adequate sexual stimulation, enough attempts, and no major food/drug interaction

1, Dose, timing

A patient should generally try the PDE5 inhibitor for at least – doses before declaring treatment failure.

7, 8

Sildenafil and vardenafil should be taken on an __________ stomach, while tadalafil and avanafil can be taken without regard to __________

Empty, meals

Patients should avoid excessive __________ because it can increase hypotension and drowsiness, and they should not __________ doses themselves

Alcohol, increase

At follow-up, assess __________, pulse, adverse effects, and erectile __________

BP, response

When coordinating on-demand therapy is difficult because of timing, __________ once daily may be considered

Tadalafil

For a patient taking an alpha blocker, the lecture notes __________ may be preferred over Staxyn ODT, with careful BP/timing management

Levitra

Revatio = __________, Adcirca = __________, Alyq = __________. These are used for pulmonary arterial __________, not ED.

Sildenafil, tadalafil, tadalafil, hypertension

A vacuum erection device contains a pump, cylinder, and constriction __________. The ring maintains the erection by reducing __________ outflow.

VED onset is approximately – minutes. Use a pop-off safety valve and limit the constriction band to ≤__________ minutes.

VED use can cause penile pain, bruising, numbness, coolness, discoloration, or a __________-like erection.

VEDs are contraindicated in __________ cell disease, history of prolonged erections, or severe penile __________. Use caution with __________ because of bruising risk.

Band/ring, venous, 3, 20, 30, hinge, Sickle, curvature, warfarin

The initial intracavernosal alprostadil dose should be given under healthcare-professional supervision. Typical dose = __________ mcg, usual range – mcg, maximum __________ mcg.

Alprostadil should be injected using __________ technique over – seconds. Do not exceed one injection/day or __________ injections/week and maintain a __________-hour interval.

Alprostadil can cause penile pain, hematoma, hypotension, priapism, and rarely __________ nodules. Avoid/use caution in sickle cell disease, leukemia, multiple myeloma, severe coagulopathy, severe CV disease, and poor manual __________

2.5, 5, 40, 60, Aseptic, 5, 10, 3, 24, Fibrotic, dexterity

Testosterone replacement is indicated for symptomatic primary, secondary, or mixed __________ confirmed with low serum __________.

Testosterone should NOT be used for isolated ED when serum testosterone is __________.

Hypogonadism, testosterone, Normal

Diagnosis requires compatible __________/signs plus confirmed low testosterone. Obtain __________ total testosterone measurements on separate occasions, both in the __________.

Symptoms, 2, morning

The lecture/AUA guideline uses total testosterone <__________ ng/dL as a reasonable cutoff supporting low testosterone.

When total testosterone is borderline, approximately – ng/dL in the lecture, measure __________ testosterone.

300, 200, 300/400, free

Primary hypogonadism = low T with __________ gonadotropins. Secondary = low T with __________-normal gonadotropins. Mixed = low T with __________ gonadotropins

Elevated, low, variable

Oral testosterone products include testosterone __________ such as Kyzatrex, Jatenzo, Tlando, and Undecatrex. They are absorbed through the intestinal __________ system, bypassing the liver

Undecanoate, lymphatic

Oral testosterone products are __________ substitutable and some oral products carry a warning for increased __________

Not, BP

IM testosterone products include testosterone cypionate, __________, and __________. Common dosing strategies include 75–100 mg weekly or 150–200 mg every __________ weeks.

IM testosterone can produce __________ testosterone concentrations during part of the dosing interval, which has been associated with __________ swings

Enanthate, undecanoate, 2, Supraphysiologic, mood

Testosterone undecanoate injection carries a boxed warning for pulmonary oil __________ (POME), including cough, shortness of breath, chest pain, and __________

IM testosterone undecanoate requires __________ administration and patients must be monitored for at least __________ minutes after injection

Microembolism, anaphylaxis, REMS, 30

SQ testosterone enanthate can be administered __________ weekly. Testosterone pellets contain __________ mg each, with 2–6 pellets inserted every – months.

Once, 75, 3, 6

Testosterone pellets can cause pellet extrusion, __________, and __________ and are not routinely recommended.

Infection, fibrosis

Natesto is testosterone nasal gel administered as __________ pump in each nostril __________ times daily

A major adverse effect of nasal testosterone is nasal irritation, including __________, rhinorrhea, and nasopharyngitis.

1, 3, Nosebleeds

Topical testosterone is available as pump gels, tubes, and __________ applied to the __________

Topical testosterone is noninvasive and allows relatively easy onset/reversal, but the major limitation is risk of __________ to other people

Apply topical testosterone in the __________, cover the application site with __________, and wash hands after application to prevent secondary exposure.

Solution, axillae, Transference, Morning, clothing

Secondary exposure to topical testosterone can cause __________ in children, so patients must cover the application site and prevent contact with women and children

Virilization

Topical Testosterone Washing RestrictionAvoid swimming, showering, or washing the administration site for approximately – hours after application

2, 5

Testosterone solution is applied to the __________. Deodorant/antiperspirant should be applied at least __________ minutes before testosterone

Axillae, 2

Before using testosterone pump products, the pump should be __________.

Primed

Application sites and doses of topical testosterone products __________ substitutable

are not

Testosterone is contraindicated in men with __________ cancer or __________ cancer and in pregnancy

Prostate, breast

Do not initiate testosterone when PSA is >__________ ng/mL or >__________ ng/mL in a patient at high risk for prostate cancer

Do not initiate testosterone when baseline hematocrit is >% or >% at high altitude.

4, 3, 48, 50

Do not initiate testosterone in severe __________ symptoms, erythrocytosis, untreated severe __________ apnea, uncontrolled __________ failure, recent MI/stroke within 6 months, or a hypercoagulable state.

LUTS, obstructive sleep, heart

The lecture lists age-related hypogonadism as a product-specific contraindication for __________, __________, and __________. Depo-Testosterone is contraindicated in serious cardiac, hepatic, or __________ disease.

Tlando, Undecatrex, Kyzatrex, renal

Important precautions include hypercalcemia especially in cancer patients, depression, hepatic/renal impairment, __________ apnea, and age >__________ years.

Sleep, 65

Potential adverse effects include low sperm count, increased __________, worsening __________/LUTS, fluid retention, increased BP, worsening HF, hyperlipidemia, increased LFTs, __________, gynecomastia, and secondary exposure.

Testosterone can increase __________, leading to increased hematocrit.

Testosterone can cause fluid retention → increased __________ and worsening __________.

At very high doses, testosterone may increase __________ and decrease __________.

PSA, BPH, polycythemia, Polycythemia, BP, HF, TGs, HDL-C

Formulation-specific effects include dermatologic irritation with topical products, __________ irritation with nasal products, oral cavity irritation with oral products, peak/trough variability with __________ injections, and hematoma/infection with __________

Nasal, IM, pellets

Testosterone can increase __________ sensitivity, improve glycemic __________, increase lean/muscle mass, decrease __________ fat, increase bone density, and stimulate __________

Very high doses of testosterone can increase __________ and decrease __________

Insulin, control, subcutaneous, libido, TGs, HDL-C

Before initiating testosterone, obtain __________ levels, __________, CBC/hematocrit, liver function, __________, and BP.

Testosterone, PSA, lipids

At approximately 3 months, monitor testosterone level according to the __________, PSA, CBC/hematocrit, liver function, lipids, BP, symptoms of low T, and medication __________ .

Product/formulation, adverse effects

Once stable, monitor every – months with testosterone levels according to formulation, CBC/hematocrit, PSA as appropriate for age, liver function, lipids, BP, symptoms, and adverse effects

Discontinue testosterone if hematocrit reaches >__________%.

6, 12, 54

Discontinue testosterone if PSA increases by >__________ ng/mL from baseline or is >__________ ng/mL, or if there is substantial worsening of __________ symptoms.

1.4, 4.0, LUTS

Testosterone may be discontinued for clinically important __________, laboratory abnormalities, or failure of symptoms to improve despite normalization of testosterone

Adverse effects

Testosterone replacement is usually __________ term, but cessation should be discussed after approximately – months if testosterone normalizes without improvement in symptoms

Long, 3, 6

For oral testosterone, the lecture recommends measuring the __________ level approximately – hours after the dose for peak assessment.

Peak, 2, 3

For testosterone cypionate, check testosterone at the / of the dosing interval, before the __________ dose according to the lecture

Midpoint, trough, 4th

For testosterone undecanoate, measure testosterone just before each injection or approximately halfway between the __________-week dosing intervals

10

For testosterone gel, timing depends on the formulation. Check just before the __________ dose 2–4 weeks after initiation/dose adjustment, and obtain at least __________ levels. Do not draw the lab from the same __________ used for application.

Morning, 2, arm

Natesto and Tlando should be discontinued if total serum testosterone is consistently __________ the normal range

Outside

Before prescribing testosterone: 1) confirm __________, 2) assess for __________, 3) initiate therapy if appropriate and monitor within – months.

Hypogonadism, contraindications, 1, 3

Testosterone doses should be adjusted __________ or __________ based on the product, dose, serum testosterone, clinical response, and adverse effects

Up, down

The goal of testosterone therapy is generally to achieve testosterone concentrations in the __________-normal range while considering patient preference, pharmacokinetics, formulation-specific AEs, treatment burden, and __________.

Mid, cost