416 Exam 4 ED, HRT

Question 1

MOA of PDE-5 inhibitors

Answer 1

Selective inhibition of phosphodiesterase type 5 isoenzymes

-inhibits catabolism of cGMP

Question 2

PDE-5 inhibitor agents

Answer 2

Sildenafil (Viagra)
Vardenafil (Levitra, Staxyn)
Tadalafil (Cialis)
Avanafil (Stendra)

Question 3

PDE-5 inhibitor DDI

Answer 3

Nitrates
Alpha blockers (terazosin, doxazosin)
3A4 inhibitors

Question 4

PDE-5 inhibitor AE

Answer 4

• HA
• flushing
• congestion
• dyspepsia
• dizziness
• hypotension
• visual effects
• hearing loss
• back/limb pain/myalgia
• priapism

Question 5

Sildenafil dosing

Answer 5

50mg prn

• onset: 30-60min
• duration: 4hrs
• empty stomach
• PDE-6

Question 6

Tadalafil Dosing

Answer 6

10mg prn OR

2. 5-5mg QD
   - onset: 30min-6hr
   - duration: 24-36hrs
   - PDE-11

Question 7

MOA of Alprostadil

Answer 7

Stimulates adenyl cyclase which increases cAMP and leads to enhanced blood flow to the corpora cavernosa

Question 8

Alprostadil dosage forms

Answer 8

Intracevernosal injection (Caverject)
Intraurethral insert (MUSE)

Question 9

AE of intracavernosal Alprostadil

Answer 9

• cavernosal plaques
• penile curvature/pain
• priaprism
• injection site hematoma

Question 10

AE of intraurethral Alprostadil

Answer 10

• urethral injury/pain
• priaprism
• female vaginal burning/pain

Question 11

Primary trt for hyperprolactinemia

Answer 11

Dopamine agonist (cabergoline > bromocriptine)

Question 12

Initial trt for ovulatory dysfunction

Answer 12

Clomiphene

Question 13

MOA of clomiphene

Answer 13

SERM

• competes w/ estradiol for estrogen receptors at the hypothalamus
• blocks estrogen negative feedback at the hypothalamus

Question 14

AE of clomiphene

Answer 14

• hot flashes
• mild abdominal or pelvic discomfort
• vaginal dryness, mood swings
• less frequent: dizziness, fatigue, breast tenderness, HA

Question 15

CI with Clomiphene

Answer 15

• uncontrolled thyroid or adrenal dysfunction
• primary ovarian failure or ovarian cysts
• abnormal uterine bleeding
• hepatic disease
• pregnancy

Question 16

First line trt for polycystic ovary syndrome (PCOS)

Answer 16

Metformin 1500-2000mg/d

Question 17

Risks of HRT

Answer 17

• endometrial CA
• CV disease
• venous thromboembolism
• breast CA
• ovarian CA
• gallbladder disease

Question 18

Endometrial CA

Answer 18

Add progestin for intact uterus

Question 19

Cardiovascular disease

Answer 19

Younger age, closer to MP

Question 20

Venous thromboembolism

Answer 20

Lowest dose (transdermal)

Question 21

Breast CA

Answer 21

Low dose, short duration (<5yrs)

Question 22

Ovarian CA

Answer 22

Short duration use (<5yrs)

Question 23

Gallbladder disease

Answer 23

Transdermal

Question 24

Benefits of HRT

Answer 24

• vasomotor symptom relief
• vaginal symptom relief
• osteoporosis prevention

Question 25

Estrogens approved for

Answer 25

Vasomotor or vaginal menopause symptoms

Question 26

Estrogen AE

Answer 26

- nausea, HA, breast tenderness, uterine bleeding | - may need to taper off when discontinuing

Question 27

ABSOLUTE CI for estrogen therapy

Answer 27

- thromboembolic disease - pregnancy - active liver disease - CAD - CVD or TIA - undiagnosed vaginal bleeding - active breast or endometrial CA

Question 28

Relative CI for estrogen therapy

Answer 28

- HTN - hypertriglyceridemia - impaired liver function - fluid retention - hypothyroidism - ovarian CA - exacerbation of endometriosis - exacerbation of asthma, DM, migraine, SLE, epilepsy - history of breast CA

Question 29

Oral estrogen products

Answer 29

Conjugated equine estrogens (Premarin) Initial/low dose: 0.3-0.45mg Usual dose: 0.3-1.25mg

Question 30

Transdermal estrogen product

Answer 30

Vivelle, Vivelle Dot (apply twice weekly) Initial/low dose: 0.025mg/d Usual dose: 0.025-0.1mg/d

Question 31

Vaginal estrogen product (intravaginally)

Answer 31

Femring (replace q3m)

Question 32

Intravaginal estrogens

Answer 32

Premarin Estring (replace q90d) Vagifem (twice weekly)

Question 33

Progesterone AE

Answer 33

``` Irritability Depression HA Mood swings Bloating Fluid retention Sleep disturbances ```

Question 34

Progesterone products

Answer 34

``` Medroxyprogesterone acetate (Provera) Micronized progesterone (Prometrium) ```

Question 35

Oral combination products

Answer 35

CEE + MPA (Prempro) | Continuous

Question 36

Transdermal combination product

Answer 36

Estradiol + levonorgestrel (Climara Pro) | Continous

Question 37

SERM

Answer 37

Ospemifene (Osphena) 60mg QD

Question 38

SERM combination product

Answer 38

CEE + Bazedoxifene (Duavee) 45/20mg daily

Question 39

Non-hormonal options for vasomotor symptoms

Answer 39

Venlafaxine Paroxetine (approved) Gabapentin Clonidine

Question 40

Male hypogonadism

Answer 40

- reduced libido - depression or dysthymia - decreased spontaneous erections - gynecomastia - loss of auxiliary and pubic hair - small or shrinking testes - infertility - hight, BMD, muscle loss - hot flashes - fatigue, decreased motivation - incomplete sexual development

Question 41

TRT CI

Answer 41

- history of breast or prostate CA (unelevated prostate nodule or PSA >4ng/ml) - hematocrit >50% (epoetin alfa) - untreated severe obstructive sleep apnea - severe lower urinary tract symptoms - uncontrolled/poorly controlled CHF

Question 42

Testosterone transdermal patch

Answer 42

Androderm

Question 43

Testosterone gel

Answer 43

Androgel 1% Testim 1% 5-10g as single dose in the morning and titrate up in 14 day intervals

Question 44

Testosterone transdermal spray

Answer 44

Fortesta 4-7 sprays once daily and titrate dose up at 14-35 day intervals

Question 45

Testosterone transdermal solution

Answer 45

Axiron

Question 46

Benefits of TRT therapy

Answer 46

- decreased body fat and visceral fat - improved libido and sexual function - improved mood - improvements in cognition and vitality - improvement in CV risk factors - improvements in T2DM and metabolic syndrome - increased bone mineral density - increased muscle mass and strength

Question 47

Risks of TRT

Answer 47

- cancers (prostate and breast) - erythrocytosis - gynecomastia - sleep apnea - acne, oily skin - male pattern baldness - liver toxicity - dyslipidemia - increase in CV outcomes