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Therapeutics Humber > ED and BPH > Flashcards

ED and BPH Flashcards

1
Q

What are 6 risk factors for ED?

(Please hold her darn purse already )

A
  1. Peripheral vascular disease
  2. HTN
  3. HLD
  4. Diabetes
  5. Psychiatric disorders
  6. Age
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2
Q

What are the 3 functioning body systems that are required for an erection?

A
  1. Hormonal
  2. nervous
  3. Vascular
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3
Q

Whats the role of the nervous system in erection?

A
  1. sexual stimulus
  2. parasympathetic activation
  3. outflow of Ach to muscarinic R’s on penile arteries
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4
Q

What’s the role of vascular system in erection?

A
  1. after sexual stimulation , ACh vasodilates the arteries
  2. corpus cavernosum fills with blood
  3. tunica albuginea compresses penile arteries and veins, trapping blood in corpora
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5
Q

What are some conditions that decr testosterone (hypogonadism)? (3)

What are some conditions that decr receptiveness and affect nervous system? (4)

What are some conditions that decr blood flow? (3)

A
  1. Removal of testicles, hypothalamic/pituitary disorders, aging
  2. depression/anxiety, sedation, Alz’s
  3. Periph vascular disease, HTN, Smoking
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6
Q

Describe how Nitric oxide is involved in vascular system that results in erection

A
  1. ACh activates M R’s –> NO production in vasc endothel cells
  2. NO activates guanylate cyclase in vascular smooth muscle cells which converts GTP to cGMP
  3. cGMP acted on by protein kinase G which leads to arterial vasodilation
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7
Q

Role of hormonal system in an erection ?

A

Testosterone produced in leydig cells of testes –> testosterone contributes to Libido

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8
Q

Drugs that cause ED that affect hormonal system? (4)

Vascular system? (5)

Nervous system? (4)

A
  1. Dopamine antags (antipsychotics), estrogens, spirono, digoxin
  2. anticholinergics, alpha2agonists, beta blockers, diuretics, 5alpha reductase inhibs
  3. CNS depressants, alcohol, BZD’s, opioids
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9
Q

What should be tried first for ED?

A

Lifestyle mods

  1. lower cardio risks by exercising, weight loss BMI = 25, healthy diet
  2. avoid tobacco, and excessive alcohol
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10
Q

TX Pathway for ED

  1. what do you start with ?
    a. if effective?
    b. If ineffective? what happens after this step if it is still ineffective? Afterwards if still ineffective?
    c. if CI?
A
  1. PDE5 inhibitor +/- testosterone supplementation if hypogonadism

a. continue

b. ensure tx given at correct time and titrate up dose –> Consider ALPROSTADIL –> Consider penile prosthesis

c. vacuum device

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11
Q

PDE5I MOA ?

A

Blocks PDE5 from breaking down cGMP to GMP –> continued vasodilation!

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12
Q

What are the initial doses for the following?

  1. Sildenafil (Viagra)
  2. Vardenafil ( Levitra)
  3. Vardenafil (Staxyn)
  4. Tadalafil ( Cialis )
  5. Avanafil (Stendra)
A
  1. 50 mg PO prn 1 hour before
    intercourse
  2. 10 mg PO prn 1 hour before
    intercourse
  3. 10 mg dissolved on tongue prn
    1 hour before intercourse
  4. 10 mg PO prn 30 min before
    intercourse
  5. 100 mg PO prn 30 min before
    intercourse
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13
Q

If the initial dose is ineffective after 7-8 trials, what should u do?

A

titrate by doubling dose ! But u should limit that doubled dose to ONCE DAILY dosing only
-vardenafil (staxyn) stays normal at 10 mg once daily dosing

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14
Q

PDE5 I DOsing considerations (KIM LOOK AT CHART)

A

See chart

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15
Q

PDE5I : Monitoring

  1. what are some AE’s
  2. What are some drug interactions to avoid?
A
  1. Sx’s of HYPOtension (Dizzy, light headedness) , HA, flushing, Loss of blue green color discrimination with silden, tadal, avana, priapism lasting >4hr, hearing loss v rare, sudden blindness v rare, QT prolong with varden
  2. ALL drugs should avoid nitrates and grapefruit juice.

with vardenafil, type 1a or type 3 antiarryhthmics (additive QT prolongation)

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16
Q

Patient education :
1. u will still require?
2. take on ___ if silden or varden
3. Max ___ dose daily
4. What do u do if erection lasts > 4 hrs?

A
  1. sexual stimulation
  2. empty stomach
  3. 1
  4. seek emergency care
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17
Q

Testosterone is only indicated if?

What are some signs of hypogonadism? (4)

A

Hypogonadism is present

  1. serum testost < 300 ng/dL measured in early morning with repeat 4 wks later for confirmation
  2. small testicles
  3. decr body hair
  4. gynecomastia
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18
Q

Testosterone Dosing

  1. Testost patch (androderm)
  2. Testost Gel 1% (AndroGel)
  3. Testosterone Cypionate IM injection (Depo-Testosterone)
A
  1. 4 mg applied to upper arm, back, abdomen, or thigh qHS
  2. 5-10 gm of gel applied to shoulder, upper arm, or abdomen qAM
  3. 100-200 mg IM q2-4 wks
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19
Q

Therapeutic Dose Monitoring

  1. If gel or patch collect trough level when?
  2. If injection collect trough level when ?
  3. Incr dose if trough serum testosterone is ?
  4. Decr dose if trough serum testosterone is ??
A
  1. prior to week 2 dose
  2. prior to 4th dose
  3. <450 ng/dL
  4. > 600 ng/dL
20
Q

What’s the dosing range for the following :

  1. Testosterone patch
  2. Testost gel 1%
  3. Testost cypionate IM injection
A
  1. 2-6 mg
  2. 5-10 gm
  3. 200-400 mg
21
Q

Testosterone Monitoring :

  1. what are the 4 ae’s ?
  2. Which 3 scenarios should u be cautious to use Testost in ?
A
  1. sodium retention, HLD, mood swings, hepatotoxicity
  2. hf, hx of myocard infarction or stroke , avoid in untreated prostate cancer
22
Q

Testost Gel Patient education :

  1. Cover application site to avoid?
  2. Who should avoid contact with unwashed area?
  3. After using u should?
  4. Avoid ___ and ___ for ___ after application

Testost Patch
1. how often should u rotate application site?
2. avoid __ and ___ for 3 hrs after application

A
  1. inadvertent transfer to others
  2. women and children
  3. wash hands
  4. swimming, showering, 3hrs
  5. every 7 days
  6. swimming, showering
23
Q

Alprostadil (PGE1) : MOA ?

Available dosage forms? (2)

A

It activates EP2 receptor in vascular smooth muscle cells which can act on Adenylate cyclase to convert ATP to cAMP which acts on protein kinase A –> arterial vasodilation

Intracavernosal injection, intraurethral pill

24
Q

Alprostadil Dosing

  1. Alprostadil Intracavernosal injection (Caverject)
  2. Alprostadil Intraurethral pill (Muse)
A
  1. 10 mcg injected 5-10 min
    prior to intercourse
  2. 250 mcg intraurethrally 5-
    10 min prior to intercourse
25
Q

Titration :

For injection , increase by ___ every ___ to achieve a firm erection for ___ (performed in physicians office)

For intraurethral, incr by ___ on separate occasions until firm erection for 1 hr (Initial dose should be done in ? )

A

2.5 mcg increments, 30 min , 1 hr

250 mcg increments, physician office

26
Q

Dose Range
1. Carverject?
2.Muse?

A
  1. 60 mcg, max once per day and 3x per week with a 24-hr interval
    between doses
  2. 1000 mcg, max 2 doses per day
27
Q

Alprostadil AE’s ? (5)

A
  1. Hematoma at site of injection (caverject)
  2. Infection with caverject
  3. hypotension, dizzy (uncommon)
  4. Priapism (rare)
  5. pain at site of injection or insertion
28
Q

Injection Patient Education
1. Inject into shaft at what degree angle?
2. For penile pain, use ?
3. Prior to use u should ?
4. AFter injection what should u do to reduce risk of hematoma?

Intraurethral (Muse) Pt education
1. To moisten the urethra?
2. After insertion do what?

A
  1. 90 degree
  2. tylenol
  3. wash hands
  4. apply pressure for 5 mins
  5. void
  6. massage penis to enhance drug dissolution
29
Q

BPH is characterized by ?

  1. what are the DHT mediated effects?
  2. Adrenergic tone mediated effects?
A

enlargement of the prostate

1.Testost –> 5alphareductase –> DHT –> prostatic growth

  1. incr adrenergic tone (with NE) –> Alpha1 R on smooth muscle cells of prostate –> prostatic contraction around urethra
30
Q

Which meds exacerbate BPH? (3)

A
  1. Anticholinergics (Diphenhydramine , TCA) –> prevent contraction of bladder detrusor muscles (Urinary retention)
  2. Alpha agonists like pseudoephedrine
  3. Testost replacement
31
Q

Obstructive Sxs of BPH (3)

Irritative sx’s ? (2)

Signs? (4)

A
  1. diminished urinary flow rate, straining to urinate, suprapubic pain
  2. incr urinary frequency, incr urinary urgency
  3. enlargement based on digital rectal exam >20 gm , possible serum prostate specific antigen > 1.5 ng/mL , possible elevated Scr and BUN

-AUA sx score.
<=7 is mild
8-19 mod
>= 20 severe

32
Q

What are some recc lifestyle mods?
What should pt’s avoid?

A
  1. Void before bedtime, exercise, restrict fluids before bedtime, healthy diet
  2. excessive caffeine, excessive alc
33
Q

TX PATHWAY FOR BPH

  1. What happens if they have BPH with MILD AUA score?
  2. SEVERE AUA score + complications OR unresponsive to therapy?
  3. MODERATE-SEVERE AUA score AND
    a. prostate < 40 gm and PSA < 1.4 ng/mL
    b. Prostate > 40 gm OR PSA > 1.4 ng/mL
    c. They have ED
    d. Predom irritative voiding sx’s
A
  1. wait and see
  2. Surgery

a. alpha 1 antag

b. Alpha 1 antag PLUS 5alphareductase inhib

c. PDE5I +/- Alpha1 antag

d. anticholinergic PLUS alpha 1 antag ORRRR Mirabegron PLUS alpha1 antag

34
Q

What can alpha 1 blockers do to ameliorate BPH pt’s?

This MOA will relax SM cells to allow better ___ BUT DOES NOT ___

A

They block Alpha 1 receptor so that there’s no prostatic contraction around the urethra.

urine flow, reduce prostate size

35
Q

ALPHA 1 ANTAGS DOSING, TITRATION, MAX DOSE : KIM SEE CHART

A

See chart

36
Q

Which alpha 1 antags are uroselective and preferentially block alpha 1 r’s resulting in less ___ risk?

A

HYPOTENSION

-Tamsulosin, and Silodosin

37
Q

Alpha1 Antags : AE’s ?

CI for Alfuzosin? Silodosin?

DDI’s for silodosin?

A

sx’s of hypotension mainly w/nonuroselective agents (dizzy)
-floppy iris syndrome
-retrograde ejaculation mainly w/uroselective agents

1.Mod-severe hepatic impairment

  1. Severe hepatic impairment or ClCr < 30

Need to avoid strong 3A4 inhibitors with silodosin

38
Q

5Alpha Reductase inhibitors will result in decreased ___ over the course of ___

A

prostate size, 6-12 months

39
Q

5Alpha Reductase Inhibs Dosing

  1. Finasteride (proscar)
  2. Dutasteride (Avodart)

AE’s ? (3)
CI?

PSA (prostate specific antigen) should decrease by ___ by ___ months. If it doesnt , evaluate for ?

When should u see the full effects of the drug?

A
  1. 5 mg PO daily
  2. 0.5 mg PO daily
  3. ED, decr libido, gynecomastia
  4. Preg category X. preg females or females wanting to become preg should avoid handling the drug , should also avoid contact with semen of men on the drug

50%, 6, Prostate cancer

6-12 months to see full effects

40
Q

PDE5 Inhibs used for BPH

  1. Tadalafil Dosing?
  2. if ClCr 30-50?
  3. Avoid if?
  4. Avoid if?
  5. AE’s and Drugs to avoid refer to card for ED
A
  1. 5 mg PO daily
  2. 2.5 mg daily
  3. ClCr <30
  4. severe hepatic impairment
41
Q

Anticholinergics MOA ?

Irritative sx’s in BPH are a result of?

A

Blocks M3 receptor –> no contraction of detrusor muscle preventing irritative sx’s

overactive bladder

42
Q

Anticholinergics : Dosing

  1. Use only if pt has irritative sx’s and has a post void residual urine volume of ?
  2. what are the 2 drugs?
  3. Dosing Solifenacin (Vesicare) , if ClCr < 30 or mod hepa impair, avoid in?
  4. Dosing Tolterodine (Detrol) , if ClCr < 30 or mod hepatic impairment ?
A
  1. < 100-150 mL
  2. Solifenacin and Tolterodine
  3. 5-10 mg PO daily
    - limit to 5 mg daily
    -severe hepatic impairment
  4. 1-2 mg PO BID
    -limit to 1 mg BID
43
Q

Anticholinergic ae’s ? (6)

Drug interactions with Solifenacin?

A
  1. Blurry vision
  2. urinary retention,
  3. dry mouth
  4. constipation
  5. drowsiness
  6. tachycardia

if on strong 3A4 inhibs, limit to 5 mg daily

44
Q

Beta 3 Agonists

  1. what are the 2 drugs?
  2. what’s their MOA?
  3. Unlike anticholinergics, beta3 agonists dont cause?
  4. Use ONLY IF pt has?
A
  1. Mirabegron, vibegron
  2. Acts on B3 R to relax detrusor muscle!
  3. urinary retention
  4. Irritative sx’s
45
Q

Beta3 Agonists : Dosing

  1. Mirabegron (Myrbetriq)
    -if ClCr 15-30 or mod hepatic impairment?
    -Avoid in ?
  2. Vibegron (Gemtesa) Dosing
    -Avoid in ClCr < ?? or ???
A
  1. 25-50 mg PO DAILY
    - limit to 25 mg daily
    - ClCr < 15 or severe hepatic impairment
  2. 75 mg PO DAILY
    -<15, severe hepatic impairment
46
Q

Beta 3 Agonists : Monitoring

  1. AE’s ?
A
  1. For myrbetriq –> small incr in BP

for all –> MILD HA, dry mouth, N/D

47
Q

Follow up timeline?

When to check PSA?

Annual ___ exam?

A

Minimum 6-12 weeks after starting therapy, assess AUA score for improvement

at 6 months if on 5alpha reductase inhib

Digital rectal

Therapeutics Humber (14 decks)

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