Tommy is a 48 year old male patient known to your pharmacy. His chronic medical conditions include hypertension and high cholesterol. He has been taking valsartan, hydrochlorothiazide, pravastatin and amlodipine chronically. About a month ago, his physician added sertraline 100 mg once daily. Tommy had lost his job and was suffering from anxiety and depression. He presents to the pharmacy today and informs you that he is having difficulty with sexual performance. This is a new problem for him, which he finds quite upsetting. He can obtain an erection, but cannot achieve orgasm. He is wondering if there is anything he can take for this problem that does not require a prescription. Which medication may be causing Tommy's problem with sexual performance?
C. Blood pressure medications can cause problems with erection, but this patient had difficulty with orgasm.
James is a 59 year-old male patient. His medical conditions are hypertension, dyslipidemia, gout, obesity and erectile dysfunction. His medications include enalapril, nifedipine, allopurinol, atorvastatin and tadalafil. He is currently hospitalized with an acute infection. The infection is being treated with voriconazole (VFEND). Other medications added during the hospital stay are furosemide (Lasix, by injection) and diltiazem. James is complaining of seeing a blue tinge next to objects, and difficulty distinguishing between the colors blue and green. This could be an adverse effect of which of the following medications? (Select ALL that apply.)
B, D. Any of the phosphodiesterase type 5 inhibitors (PDE5 Is) can cause color vision changes, such as seeing a blue tinge (shade) to objects or having difficulty telling the difference between blue and green. Or, blurry vision by itself.
When dispensing a phosphodiesterase type 5 inhibitor the pharmacist must include counseling on the possibility of these possible adverse reactions: (Select ALL that apply.)
A. Sudden decrease in vision in one or both eyes, which may be permanent
B. Sudden loss of hearing, or ringing in the ears and dizziness, which may be permanent
C. Sudden loss of the sense of smell, which may be permanent
A, B, D, E. In rare instances, men taking PDE5 Is have a sudden decrease or loss of vision in one or both eyes. If a patient experiences a sudden decrease or loss of vision, they should stop taking the medicine and contact the doctor right away. The PDE5 Is are thought to rarely cause a sudden loss or decrease in hearing, sometimes with ringing in the ears and dizziness. If this happens, they should stop taking the medicine and contact the doctor right away.
A 74 year-old male patient has presented to his physician with complaints of impotence. He has no other known medical conditions. The physician has written him a prescription for sildenafil 50 mg, 1 hour prior to sexual activity. Is the starting dose appropriate?
A. Yes, the dose is correct.
B. No, he should begin sildenafil at 25 mg, 1 hour prior to sexual activity.
C. No, he should begin sildenafil at 100 mg, 1 hour prior to sexual activity.
D. It would be preferable for him to use the alprostadil injection.
E. It would be preferable for him to use vardenafil.
B. The patient has been started on 50 mg of sildenafil. The 25 mg dose is for use in elderly patients (> 65 years) or with severe liver or kidney impairment or with concurrent use of a potent 3A4 inhibitor.
An elderly man is having difficulty sustaining an erection and finds that when he has an erection he cannot control the ejaculation. He is using many different medications. Which of the following drugs could be contributing to this problem? (Select ALL that apply.)
A, B, D, E. Many medications can cause sexual dysfunction, including a loss of libido or problems with performance.
A patient will begin sildenafil therapy for erectile dysfunction. His only other medical condition is hypertension, for which he uses amlodipine and chlorthalidone. Choose the correct counseling statements. (Select ALL that apply.)
A. Sildenafil is also used for pulmonary arterial hypertension under the name Adcirca; do not use the two medications at the same time, as they are the same drug.
B. This medication can cause you to feel dizzy; be careful standing up until you get used to it.
C. Take sildenafil the morning of the day you plan to have sexual intercourse
D. Sildenafil works best if it is taken with a meal, preferably fatty food.
E. Sildenafil can rarely cause a painful erection that lasts longer than 4 hours; if this happens, you need emergency treatment.
B, E. Sildenafil (Viagra) should be taken about 1 hour before intercourse. It works best when taken on an empty stomach. Fatty food will delay absorption.
Which of the following statements concerning the phosphodiesterase 5 inhibitors are correct? (Select ALL that apply.)
A. The ODT formulation Staxyn contains tadalafil.
B. A benefit to the newer drug Stendra is that it can be taken closer to intercourse (about 30 minutes), with or without food.
C. Sildenafil dosing is 25, 50 and 100 mg (all taken about 1 hour prior to intercourse).
D. If once daily dosing of tadalafil is required the daily dose is 10 mg, taken each morning.
E. It is not possible to cut these medicines as they come in capsules.
B, C. Many patients get the higher dose and cut the tablet; these cost about $30 each and are not covered by many insurance plans. This requires a tablet cutter; the shape is unusual. The newest agent in the class is called avanafil (Stendra). Vardenafil comes in an ODT formulation called Staxyn.
Which of the following statements concerning Cialis dosing are correct? (Select ALL that apply.)
A. The medication comes as 2.5, 5, 10 and 20 mg tablets.
B. A typical daily dose is 2.5, or (if not working well enough), 5 mg.
C. If they are using the medication 2 or more times weekly they should be counseled to consider the daily dose instead.
D. Cialis should not be used at any dose if the creatinine clearance is less than 50 mL/min.
E. Cialis is safe with severe liver impairment; it is renally cleared.
A, B, C. Cialis should not be used at any dose if the creatinine clearance is less than 30 mL/min. If they are using the medication more than two times weekly they should be counseled to consider the daily dose instead.
Jon is a 58 year-old male with dyslipidemia, type 2 diabetes, hypertension and coronary heart disease. His medications include insulin glargine 40 units QHS, metformin 1 gram BID, lisinopril-HCT 20-12.5 mg daily, vardenafil 10 mg as-needed, clopidogrel 75 mg daily and aspirin 81 mg EC daily. He went to his doctor with several medical complaints, including a dry, intermittent cough. The physician discontinued the lisinopril-HCT and gave him prescriptions for valsartan-HCT, Restasisand nitroglycerin SL 0.4 mg, as instructed. Which of the following action should the pharmacist take?
A. Do not fill valsartan-HCT.
B. Do not fill Restasis.
C. Do not fill nitroglycerin SL.
D. Change the nitroglycerin SL tablets to Nitrolingual spray.
E. Change the Restasis to Timoptic.
C. The patient has received prescriptions for an ARB-HCTZ combination to replace the ACE I-HCTZ combination. This was likely due to the dry, intermittent cough. He has received a prescription for cyclosporine eye drops (Restasis), which are used for dry eyes. The third prescription is for nitroglycerin, which is contraindicated in this patient due to the use of vardenafil.
The phosphodiesterase type 5 inhibitors are contraindicated with the following drugs: (Select ALL that apply.)
C, D, E. The last 3 choices are nitrate formulations.
Which of the following side effects are possible from the use of Cialis? (Select ALL that apply.)
A. Hearing loss
B. Urinary incontinence
D. Vision loss
E. Blurry vision
A, C, D, E. Indigestion is written in the RxPrep Text as "dyspepsia" -- patients might describe this as heartburn, burping, or upset stomach.
Tadalafil is approved for the following indications: (Select ALL that apply.)
A. Benign prostatic hyperplasia, with or without erectile dysfunction
B. Erectile dysfunction
C. Pulmonary arterial hypertension (PAH)
D. Floppy Iris Syndrome
A, B, C. The doses used for PAH and BPH are enough to treat ED if it is concurrent; PAH is 40 mg daily (a high dose) and BPH is 5 mg daily.
A patient gave the pharmacist a prescription for Levitra 10 mg 1 tablet an hour before sexual intercourse. Which of the following is an appropriate generic substitution for Levitra?
Select the correct brand names for the different formulations of tadalafil. (Select ALL that apply.)
Select the correct brand names for the different formulations of sildenafil. (Select ALL that apply.)
John had an extramarital affair, which made him lose sexual interest in his wife. He has anger towards his wife as he perceives that she is preventing him from a relationship with his new, "true love." He does not want his wife to find out about the affair and does not wish to get separated, but is plainly no longer interested in his wife sexually and when he tried to have sex with her he could not sustain an erection. He has no problem getting an erection, however, with his new girlfriend. He has asked the doctor for help, and the doctor gave him a prescription for Levitra. John is planning to take aLevitra tablet this evening prior to bed so that he is more interested in having sex with his wife. Choose the correct statement:
A. Levitra will help him to have an erection with his wife.
B. Levitra is not likely to help with the erectile dysfunction he has with his wife.
C. Stendra would have been a better option, since it has a faster onset than the other agents in this class.
D. Viagra would be a better option than Levitra.
E. The pharmacist should call the physician to change the medication to Caverject.
B. All the PDE-5 Is require some form of sexual stimulation in order to have an erection. We do not know what will help this man, but it is not a problem solved by drug therapy.
Which of the following are correct starting doses of the designated PDE5-Inhibitor for a 50 year old overweight male with no other known medical conditions: (Select ALL that apply.)
A. Sildenafil 100 mg
B. Vardenafil 10 mg
C. Tadalafil 5 mg
D. Sildenafil 50 mg
E. Tadalafil 10 mg
B, D, E. Use these starting doses, unless you need to begin lower (organ disease, elderly, 3A4 inhibitors, use of alpha blockers).
Many classes of medications can cause sexual dysfunction, which may be a significant issue to patients and have a negative impact on quality of life and treatment adherence. Which of the following drugs contribute to sexual dysfunction? (Select ALL that apply.)
B, C, D, E. Zyban is a formulation of bupropion, which does not cause sexual dysfunction.
Jack is a 55 year-old male who has been using sildenafil therapy about 3-4 times weekly. He states that he takes the sildenafil with lunch but often finds that he is not "ready" when he wants. What could be the problem causing a delayed reaction to the drug?
A. The sildenafil should be taken in the morning.
B. The sildenafil should be taken with fatty food an hour before intercourse.
C. The sildenafil should be taken on an empty stomach an hour prior to intercourse.
D. The sildenafil should be taken with a full glass of regular milk.
E. Sildenafil often does not work when needed.
C. Both sildenafil and vardenafil are taken ~1 hour prior to sexual intercourse. Sildenafil is taken on an empty stomach (for a more predictable onset), without fatty food. Vardenafil is taken with or without food, but the food should not be fatty.
A patient gave the pharmacist a prescription for Viagra 50 mg 1 tablet an hour before sexual intercourse. Which of the following is an appropriate generic substitution for Viagra?
C. Sildenafil is the generic name for Viagra.
Vardenafil comes in an oral tablet and an orally disintegrating tablet (ODT). What is the most likely reason the manufacturer felt there might be a market for the ODT formulation?
A. Elderly men might cheek the tablet and spit it in the toilet.
B. They may have dysphagia.
C. They prefer to crush their medications.
D. It comes in nicer packaging.
E. The ODT is easier to handle without breaking the tablet.
B. ODT's crumble easily and the hands should be dry when handling.