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IPFC 3 Midterm 2 > Men's health therapeutics > Flashcards

Men's health therapeutics Flashcards

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1
Q

What does health Canada warn about using Testosterone? When should it be used

A

Possible CV problems

Used only if
- Lab tests confirm low testosterone + other possible causes of symptoms excluded if they have non-specific symptoms
- 18+
- Man

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2
Q

What are ABSOLUTE contraindications for testosterone therapy (2)

A
  • Men with known or suspected breast cancer
  • Men with known or suspected prostate cancer
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3
Q

What are RELATIVE contraindications for testosterone therapy (2)

A

men treated for localized prostate cancer with surgery or radiotherapy
- without evidence of active disease
- caution testosterone therapy

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4
Q

What are goals of therapy in testosterone replacement therapies (2)

A
  1. Improvement in symptoms
  2. Achievement of eugonadal testosterone levels
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5
Q

After starting testosterone therapy, what do you do if there is
- improvement
- adverse event NOT related to dose or route of admin

A

Stop treatment

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6
Q

After starting testosterone therapy, what do you do if there is
- improvement
- adverse event related to dose or route of admin

A

Reduce dose or change route
or do both

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7
Q

After starting testosterone therapy, what do you do if there is
- no improvement

A

Measure testosterone again

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8
Q

After starting testosterone therapy, what do you do if there is
- no improvement
- low level of testosterone after testing

A
  • Consider poor compliance
  • consider dose increase
  • consider changing route of admin
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9
Q

After starting testosterone therapy, what do you do if there is
- no improvement
- normal level of testosterone after testing

A
  • consider other diagnosis
    or
    referral to TDS
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10
Q

Monitoring parameter: Symptom response
When to monitor?
What to look for?

A

When to monitor?
- At 3 + 6 months after starting therapy

What to look for?
-psychological and sexual symptoms may improve 1-3 months
- somatic symptoms may take 6-12 months to improve

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11
Q

Monitoring parameter: Testosterone level
When to monitor?
What to look for?

A

When to monitor?
- At 3 + 6 months
- In AM

What to look for?
- change in 30%+ of TT levels between 2 appropriately timed collections

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12
Q

Monitoring parameter: Hematocrit level
When to monitor?
What to look for?

A

When to monitor?
- 3 + 6 months
- then annually

What to look for?
- if 54% over, discontinue therapy
- more likely to clot, VTE, MI = CV risks

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13
Q

Monitoring parameter: PSA level, DRE, BMD
When to monitor?

A

PSA
- 3 + 6 months after therapy
- annually after

DRE
- 6 months after therapy

BMD
- after 1-2 years

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14
Q

When to measure testosterone for the following formulations:
Oral/Intranasal:
Injection:
Transdermal gel:
Transdermal patch:

A

Oral/Intranasal: 2-3 hours after dose

Injection: midpoint of dosing interval

Transdermal gel: anytime after first 1-2 weeks
- then at any time

Transdermal patch: 2-12 hours after application

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15
Q

What are the drug interactions with testosterone (5)

A
  1. Insulin
    - test may decrease BG, lower insulin dose
  2. Anticoagulants
    - warfarin need to lower dose
    - DOAC’s unaffected
  3. Corticosteroids
    - test can enhance edema
    - caution in cardiac, renal, hepatic disease patients
  4. Cyclosporine
    - test can inc risk of nephrotoxicity
  5. Thyroid function tests
    - can increase thyroxin binding globulin -> dec total T4 levels
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16
Q

How can you reduce transdermal patch skin irritations (3)

A
  • topical steroid
  • inhaled steroid
  • put patch on a different spot after each application
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17
Q

When switching to a transdermal gel, when and where can you apply it and can you shower?

A

Apply to shoulder, abdomen, or upper arms

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18
Q

Which minoxidil is more effective? 5% foam or 2% solution

A

5% foam

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19
Q

How long does it take for topical minoxidil to see evident re-growth? Efficacy?

A

2 months or longer
- can take 12 months for patients to notice effect

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20
Q

When do you assess for treatment response with minoxidil?

A

at 6 months

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21
Q

What to expect within the first 2-6 weeks of using minoxidil?

A

Some hair loss may occur
- continue therapy unless hair loss period is greater than 2 weeks

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22
Q

What happens when you stop minoxidil?

A

discontinuation results in loss of effectiveness
- takes 3 months for newly re-grown hair to be lost

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23
Q

What are the adverse effects of minoxidil even though it’s generally well tolerated (3)

A
  1. Dermatitis
    - 5% foam is free of propylene glycol (less irritating to skin)
  2. Hypertrichosis (hair growth) on face
  3. caution is patients with CV disease
    - oral is a potent vasodilator and reduces BP
    - if skin barrier compromised, topical can be systemic
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24
Q

Dosing for 2% solution and 5% foam. How long do you leave on scalp?

A

2% solution
- 1mL = 6 pumps BID
- leave on scalp 4h to maximize absorption

5% foam
- 1/2 capful BID

Do not apply to entire scalp

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25
Finasteride 1mg/day MOA When do you see a clinical difference
Type II 5-alpha-reductase inhibitor - lowers serum and scalp DHT - no affinity for androgen receptor/ does not interfere with testosterone clinical difference may take up to 12 months
26
What happens when you stop finasteride
hair regrowth lost in 6-9 months
27
What are the adverse effects of finasteride? (5)
1. decreased sexual function 2. Reduced sperm count 3. Teratogenic to the child 4. PSA levels might be lower 5. Rare side effects: testicular pain, depression at high doses
28
What is the MOA of of dutasteride
type I and II 5-alpha-reductase inhibitor - 100x more potent for type 1 than finasteride - 3x more potent for type 2 than finasteride - reduces serum DHT by 94%
29
When is dutasteride used?
After failed finasteride 1mg/day for 12 months
30
Which is more superior for hair growth? Finasteride or dutasteride
Dutasteride - however limited number of studies regarding safety therefore we use finasteride
31
Direct comparative effectiveness for: Finasteride 1mg/day vs 5% minoxidil
At 12 months: better response to finasteride 1mg/day
32
Finasteride 1mg/day vs 2% minoxidil
At 3 months: Minoxidil had more hair growth At 12 months: Finasteride had more hair growth
33
Finasteride 1mg/day vs minoxidil 2% vs finasteride + minoxidil vs finasteride + ketoconazole 2% shampoo
At 12 months Finasteride ALONE or finasteride + ketoconazole was significantly more effective
34
What combination therapy works?
Finasteride 1mg/day + topical minoxidil (5% foam) -> may lead to better improvement compared to monotherapies
35
What is the fun wise mneumonic
F frequency U urgency N nocturia W weak stream I intermittency S straining E emptying (sensation of incomplete emptying)
36
Explain boyarsky index
5 questions to assess obstructive symptoms 4 questions to assess irritative symptoms
37
what is the AUA score for BPH severity for MILD? What are the typical signs and symptoms?
7 or under - Asymptomatic - Peak urinary flow rate <10 ml/s - PVR urine volume >25-50 mL
38
what is the AUA score for BPH severity for MODERATE? What are the typical signs and symptoms?
8-19 - all the mild symptoms - obstructive and irritative voiding symptoms
39
what is the AUA score for BPH severity for SEVERE? What are the typical signs and symptoms?
20+ - all moderate + mild symptoms - 1 or more BPH complications
40
What are the goals of therapy with BPH treatment? (5)
1. Reduce LUTS associated with BPH - Minimal clinical important is reduction in 3 points of AUA - increase in urinary flow rate - Normalization of post-void residual less than 50 mL 2. Improve quality of life 3. Reduce the risk of surgical intervention 4. Prevent progression of disease 5. Decrease long-term sequalae of bladder outlet obstruction
41
How to manage if you have mild symptoms of BPH
Watchful waiting
42
How to manage if you have moderate symptoms of BPH WITH ED
- a-adrenergic antagonist - PDE-5 inhibitor OR BOTH
43
How to manage if you have moderate symptoms of BPH WITH small prostate and low PSA
a-adrenergic antagonist
44
How to manage if you have moderate symptoms of BPH WITH large prostate and inc PSA
5-a-reductase inhibitors (finasteride, dutasteride) AND a-adrenergic antagonist
45
How to manage if you have moderate symptoms of BPH WITH predominant irritative voiding symptoms
a-adrenergic antagonist + anticholinergic agent/miragebron
46
How to manage if you have severe symptoms of BPH WITH complications of BPH
Minimally invasive surgery or prostatectomy
47
What are the potential complications of BPH (7)
1. Acute and painful urinary retention (lead to acute renal failure) 2. Gross hematuria 3. Overflow urinary incontinence/unstable bladder 4. Recurrent UTIs 5. Bladder diverticula (out-pouching of bladder) 6. bladder stones 7. chronic renal failure from (long bladder obstruction)
48
What targets the dynamic bladder outlet obstruction
A-adrenergic receptors causes smooth muscle relaxation of: - prostate - bladder neck - prostatic urethra
49
What targets the static bladder outlet obstruction
5a-reductase enzymes - inhibits the conversion of testosterone to DHT
50
Where do the muscarinic receptors work M3 selective M2 non-selective
Bladder lining
51
When doing watchful waiting for mild symptoms for BPH, what/when do you follow up? (4)
- follow up at 6-12 months - standardized questionnaire for symptoms - objective tests to assess urinary flow rate and post-void residual - assess prostate size via DRE +/- digital rectal exam
52
When doing watchful waiting for mild symptoms for BPH, what patient education/lifestyle modification (4)
- Restricting fluids at bedtime - Minimizing caffeine and alcohol intake - frequently emptying bladder - avoiding drugs that can exacerbate voiding symptoms
53
Which drugs improve storage capacity of bladder? MOA
Relaxes detrusor of muscle bladder - tolterodine - oxybutynin - trospium - solifenacin/darifenacin - fesoterodine - Mirabegron
54
Which drug is associated with floppy iris syndrome although rare?
Tamsulosin
55
What are the non-selective Alpha-1 adrenergic blockers? (3)
Doxazosin Prazosin Terazosin
56
Which non-selective Alpha-1 adrenergic blocker is not associated with orthostatic hypotension?
Prazosin
57
What are the general ADRs associated with non-selective Alpha-1 adrenergic blockers? (6)
- Orthostatic hypotension - Dizziness - headache - asthenia (lack of energy) - nasal congestion - syncope (temporary loss of BP)
58
Which selective Alpha-1 adrenergic blocker has an ADR of orthostatic hypotension
Silodosin
59
Which selective Alpha-1 adrenergic blocker has an ADR of URTI
Alfuzosin
60
What is the first-dose phenomenon in alpha adrenergic blockers? How to prevent it?
Fast and large drop in BP and syncope in first dose - risk is greatest with doxazosin, prazosin, terazosin Prevent by starting with a low dose and titrating up slowly
61
What is the ADR of 5-alpha-reductase inhibitors
Sexual dysfunction, decreased libido, difficulty achieving erection
62
What values do 5-alpha-reductase inhibitors reduce? (2)
Reduce prostate volume by 20-30% 50% reduction in PSA levels after 6 months
63
Which 5-alpha-reductase inhibitors has less drug interactions?
Finasteride
64
What adverse event do you have to be aware with anti-muscarinic
Delerium
65
What other drug class and drug can be used to treat BPH? MOA
Tadalafil (cialis) Relaxes smooth muscle around the prostate 5mg daily
66
What are the drug class & indications for mirabegron important Side effect?
Class: Beta-3 adrenergic agonist Indication: Overactive bladder with symptoms of urgency, incontinence, and frequency Can increase BP--> monitor
67
Desmopressin MOA? indication?
Replacement for endogenous antidiuretic hormone can be useful for problematic nocturia
68
What is the gold standard for surgery?
Prostatectomy
69
Prior to initiating drug therapy for ED? what risk factors should you look at? (6)
- Sexual history - Medical history - DRUG HISTORY - Physical exam - Lab tests
70
Which PDE-5 inhibitor is NOT affected by food? which is?
Tadalafil cialis not affected Sildenifil viagara --> will delay by 60 min
71
What is required for PDE-5 inhibitors to work?
Sexual stimulation to be effective
72
What are the side effects of PDE-5 inhibitor? What properties are they related to?
Headache Flushing Dyspepsia (indigestion) Nasal congestion Vasodilatory properties
73
What are the rare but more serious adverse events of PDE-5 inhibitors (4)
1. Vision changes 2. Nonarteritic anterior ischemic optic neuropathy (NAION) 3. Hearing loss 4. Priapism
74
Explain vision changes in PDE-5 inhibitors
- impairment of blue-green discrimination - light sensitivity, blurred vision - transient, dose-related
75
Explain Nonarteritic anterior ischemic optic neuropathy (NAION) in PDE-5 inhibitors
- rare, sudden, unilateral, painless blindness - higher risk if any comorbidities, smoker - if has any vision loss --> D/C
76
Explain hearing loss in PDE-5 inhibitors
- unilateral - occurs within the first 24 hours of PDE-5 inhibitor use - temporary for 1/3 patients
77
Explain priapism in PDE-5 inhibitors
Erect for 4+ hours without sexual stimulation or desire - more risk with sildenafil and vardenafil due to shorter half-lives
78
What is an absolute contraindication to PDE-5 inhibitors? Why? MOA?
Nitrates Why? - a large drop in blood pressure - increase risk of hypotension and syncope MOA - nitrate inc cGMP + inhibiting PDE-5 inc cGMP = synergistic effect
79
How do you manage PDE-5 inhibitor + nitrate interactions
sildenifil (viagara) = do not administer nitrates within 24 hours Tadalafil (cialis) = do not administer nitrate within 48 hours
80
What do if patient has anginal symptoms and uses a nitrate product?
- Assess how serious is it - Consider beta-block or calcium channel blocker
81
would you wait shorter or longer to adminsiter a nitrate after stopping a PDE-5 inhibitor if a patient had renal or hepatic dysfunction and taking a CYP3A4 inhibitor
Longer
82
Effect of CYP 3A4 inhibitors (erythromycin, ketoconazole) on PDE-5 inhibitors
Drug accumulation inc risk of hypotension, syncope, prolonged erections
83
Effect of CYP 3A4 inducers (rifampin, phenytoin) on PDE-5 inhibitors
More drug cleared - reduces effectiveness of drug
84
What are high risk of CV for patients considering a PDE-5 inhibitor? Management?
- unstable or refractory angina - unctrolled hypertension - Recent MI (<2wk), stroke - Moderate/severe valvular disease Refer for specialized CV management defer treatment
85
What are other options if PDE-5 inhibitors are ineffective?
Alprostadil CAVERJECT (inject Prostaglandin E1) Alprostadil MUSE synthetic PGE1, micro suppositories transurethral

IPFC 3 Midterm 2 (7 decks)

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