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OU Module Endo Fall 2018 > ED Pharmacotherapy Exam 3 > Flashcards

ED Pharmacotherapy Exam 3 Flashcards

1
Q

What level of testosterone is usually associated with a hypogonadal state? (not an objective)

A

< 400 ng/dL

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2
Q

Therapy options for ED

A
  • First line: PDE5i
  • Second line: PGEi intraurethral, PGEi intracavernous, Vacuum erection devices (VED)
  • Last line: Penile prosthesis implantation
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3
Q

Sildenafil initial and maintenance dose

A
  • initial: 30 min to 4 hrs

- maintenance: 30 min to 4 hrs

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4
Q

Vardenafil initial and maintenance dose

A
  • initial: 1 hr

- maintenance: 1 hr

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5
Q

Vardenafil initial and maintenance dose

A
  • initial: 1 hr

- maintenance: 1 hr

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6
Q

Tadalafil initial and maintenance dose

A
  • initial: 30 min or once daily

- maintenance: 30 min or once daily

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7
Q

Avanafil initial and maintenance dose

A
  • initial: 15-30 min

- maintenance: 15-30 min

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8
Q

Sildenafil patient population

A
  • Use 25 mg initially in >65 yoa

- Renal dosing and hepatic dosing

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9
Q

Vardenafil patient population

A
  • Start with 5 mg in ≥65 yoa

- no renal dosing

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10
Q

Vardenafil patient population

A
  • No renal dosing

- C/I in hepatic impairment

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11
Q

Tadalafil patient population

A
  • Renal dosing

- C/I in hepatic impairment

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12
Q

Avanafil patient population

A
  • Not recommended: CrCl <30

- severe hepatic impairment

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13
Q

Sildenafil counseling points

A

Take without food

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14
Q

PDE5i drug interactions

A
  • use caution with Caution with alpha blockers and CYP3A4

- C/I in pts taking alpha blockers and CYP3A4 for avanafil

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15
Q

ADE of PDE5i

A
  • Headache
  • Flushing
  • Dyspepsia
  • Nasal congestion
  • Abnormal vision is usually transient (sildenafil, vardenafil, avanafil)
  • Priapism
  • Hypotension
    Acute hearing loss
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16
Q

PDE5i Advantages

A
  • Convenient route of administration
  • Low incidence of serious A/E
  • Effective
  • Discreet use
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17
Q

PDE5i Disadvantages

A

Expensive

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18
Q

PDE5i counseling points

A
  • C/I in pts no short and long acting nitrates
  • increase risk of hypotension
  • may contribute to MI
  • try 5-8 doses before declaring failure
  • avoid alcohol (can cause drowsiness and hypotension)
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19
Q

Alprostadil (Caverject, Edex) population

A

Avoid in patients with sickle cell anemia, multiple myeloma, leukemia, severe coagulopathy, schizophrenia, poor manual dexterity, severe venous incompetence, severe CVD, or Peyronie’s disease

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20
Q

Alprostadil (Caverject, Edex) dosing

A

Titrate dose to achieve results

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21
Q

Alprostadil (MUSE) population

A

anyone can use

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22
Q

MOA of Alprostadi

A
  • induces erection by dilation of arteries in the corpora cavernosa with resulting increased blood flow to the erectile tissue
  • effectiveness increase when used with actis (penile constriction device)
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23
Q

ADE of PGE1

A
  • Intracavernosal: Penile pain, Hematoma at injection site, Fibrotic nodules along penile shaft
  • Intraurethral: Urethral pain or burning, Female partner may experience vaginal pain and burning sensation, Testicular pain
  • Both: Dizziness, Headache, Decreased blood pressure
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24
Q

PGE1 Advantages

A
  • Local application of medication
  • Minimal systemic effects
  • Rarity of drug interactions (only significant one is PDE5i)
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25
Q

PGE1 Disadvantages

A

Patient will require training on proper technique

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26
Q

PGE1 clinical pearls

A
  • intracavernosal route is more effective
  • efficacy is 70-90% for intracavernosal and 65% for intraurethral
  • efficacy is dose related
  • onset is 5-10 minutes and duration 30-60 minutes
27
Q

MOA of VED

A
  • Once pump is activated to produce negative pressure, there is arteriolar blood into the corpora cavernosa
  • Constriction bands can be placed at the base of the penis to prolong the erection
  • Onset is 3-20 minutes
28
Q

ADE of VED

A
  • Penile pain
  • Bruising
  • Penis may feel cold or numb
  • If constriction bands are placed longer than 30 minutes, the penile shaft may turn blue and hurt
29
Q

VED Advantages

A
  • One-time single purchase, reusable device

- Onset 3 to 20 minutes

30
Q

VED Disadvantages

A

Not discreet

31
Q

VED contraindications

A
  • Sickle cell disease
  • History of prolonged erections
  • Patients with severe penile curvature
32
Q

VED precaution

A

patients on warfarin

33
Q

VED clinical pearls

A

Can try in combination with PDE5i or PGE1 before moving to more invasive surgical option

34
Q

testosterone effects

A
  • improved libido, sexual function and mood
  • Enhances release of nitric oxide from the endothelium inside the walls of the blood vessels supplying the corpora cavernosa
35
Q

Methyltestosterone (Android, Testred, Methitest) pearls

A
  • oral once daily

- Extensive first pass hepatic catabolism and risk of hepatotoxicity

36
Q

Fluoxymesterone (Androxy) pearls

A
  • oral once daily
  • Risk of hepatotoxicity
  • C/I in severe renal or hepatic impairment
37
Q

Testosterone buccal (Striant) pearls

A
  • buccal twice daily
  • Remove before toothbrushing, place above incisor tooth on both sides of the mouth and hold in place for 30 seconds to adhere
38
Q

Testosterone cypionate (DepoTestosterone) pearls

A
  • IM injection q 2-4/6 wks
  • C/I in severe renal or hepatic impairment and serious cardiac disease
  • may occur leading to mood swings if levels are high
39
Q

Testosterone enanthate (Delatestryl) pearls

A
  • IM injection q 2-4/6 wks
  • Avoid in severe renal or hepatic impairment
  • may occur leading to mood swings if levels are high
40
Q

Testosterone undecanoate (Aveed) pearls

A
  • IM injection; one dose at day 1, week 4, then Q10 wks
  • REMS
  • Patients must be monitored for at least 30 minutes after each injection for the duration of therapy
  • may cause anaphylaxis or a POME reaction
41
Q

POME

A
  • pulmonary oil microembolism
  • cased by Aveed
  • caused when tiny droplets of oil travel to the lung
  • characterized by difficulty breathing and chest pain
42
Q

Testosterone Transdermal patch (Androderm) pearls

A
  • transdermal QHS
  • Caution in patients with renal or hepatic impairment
  • Application sites: upper arm, back, abdomen, and thigh.
  • Rotate site every 7 days.
  • Avoid swimming, showering or washing for 3 hrs after application
43
Q

Testosterone Transdermal Spray (Fortesta) pearls

A
  • sprays once daily, titrate 14-35d interval
  • Cover site to avoid transfer.
  • Avoid swimming, showering or washing for 2 hrs
  • Sites: front and inner thigh
44
Q

Testosterone Transdermal Solution (Axiron) pearls

A
  • one axilla daily; rotate; titrate 35d interval
  • apply deodorant first
  • Avoid swimming, showering, or washing for 2 hrs
45
Q

Testosterone Gel (Androgel 1%, Testim 1%) pearls

A
  • AM dose, titrate q14d
  • Cover site to avoid transfer
  • Avoid swimming, shower, or washing for 2 hrs
  • Application sites: shoulders, upper arms, or abdomen.
  • Available in premeasured dose packets or from pump dispenser
46
Q

Testosterone Gel (Androgel 1.6%) pearls

A
  • AM dose, titrate 14-28d
  • Apply to shoulder and upper arms
  • Avoid swimming, shower, or washing for 2 hrs
47
Q

Testosterone Gel disadvantages

A

Virilization of children exposed to testosterone gel secondarily may occur.

48
Q

Testosterone Subcutaneous Pellet (Testopel) pearls

A
  • q3-6 months

- Onset is delayed 3-4 months after initial dose

49
Q

Testosterone Subcutaneous Pellet (Testopel) advantages

A

compliance

50
Q

Testosterone Subcutaneous Pellet (Testopel) disadvantages

A

in the case of complications, the pellets would have to be removed with a surgical procedure (local excision and removal)

51
Q

ADE of Testosterone

A
  • Sodium and water retention
  • Hyperlipidemia
  • Increased hematocrit
  • Gynecomastia
  • Sleep apnea
  • Mood swings
  • Oligospermia
  • Hepatotoxicity
  • Prostate enlargement
  • POME with Aveed
52
Q

Testosterone contraindications

A
  • Breast cancer

- Prostate cancer

53
Q

Normal Testosterone range

A

300 to 1100 ng/dL

54
Q

When to check Free Testosterone levels after oral tablets?

A

2-3 hours after dose

55
Q

When to check Free Testosterone levels after IM injection (cypionate, enanthate)?

A

Midpoint of dosing interval

56
Q

When to check Free Testosterone levels after IM injection (undecanoate)?

A

Right before the 4th dose

57
Q

When to check Free Testosterone levels after gel?

A

Anytime after the first 1-2 weeks of continued use

58
Q

When to check Free Testosterone levels after patch?

A

3-12 hours after patch application

59
Q

When to check Free Testosterone levels after subQ implant?

A

1-4 months after implantation

60
Q

When to check Free Testosterone levels after buccal?

A

Before a dose

61
Q

When should free testosterone levels be checked?

A

between 8-11am

62
Q

Testosterone monitoring parameters

A
  • Hematocrit
  • Hemoglobin
  • Lipid
  • Liver function tests
  • rostate-specific antigen (PSA)
  • digital rectal examination (DRE)
63
Q

Surgery for ED

A
  • Semi-rigid or inflatable prostheses

- These devices produce an unnatural erection and there is a risk for infection

OU Module Endo Fall 2018 (27 decks)

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