Pharmacotherapy of ED and BPH Flashcards
(112 cards)
1
Q
What is first line therapy for ED?
A
PDE 5 Inhibitor
2
Q
What is second line therapy for ED?
A
Intracavernosal injections of erectogenic drugs OR intraurethral prostaglandin suppository
3
Q
What is adjunct therapy for ED?
A
TST ONLY for patients with LOW levels
4
Q
What is the function of PDE5i?
A
Selectively inhibits PDE5, enzyme that inactivates cGMP
5
Q
If a patient fails 1 PDE5i what is the next step?
A
Try another PDE5i within the class before considering the entire class as treatment failure
6
Q
Sildenafil Brand Name and Initial Dose?
A
Viagra, 50 mg 30 min-4hrs before intercourse
7
Q
What is the renal and hepatic dosing for >65 for Viagra?
A
25 mg initially
8
Q
What can cause delay absorption fo Viagra and Levitra?
A
High Fat Foods delaying absorption by 1 hr
9
Q
Vardenafil Option 1 Brand Name and Initial Dose?
A
Levitra, 5-10 mg 1hr
10
Q
What is the renal dosing for >65 for Levitra?
A
5 mg initially
caution in hepatic
11
Q
Vardenafil Option 2 Brand Name and Initial Dose?
A
Staxyn, 10 mg 1hr
12
Q
What is the renal dosing for Staxyn?
A
No renal dosing
CI in hepatic
13
Q
What is the counseling pearl for Staxyn?
A
Take without food/liquid
Dissolve tablet on tongue
14
Q
Tadalafil Brand Name and Initial Dose?
A
Cilalis,
10 mg 30 min-36 hr OR
2.5 mg daily
15
Q
What is the renal dosing for Cialis?
A
No renal dosing
CI in hepatic
16
Q
What PDE5i has cautionary use with alpha blockers?
A
Cialis and Stendra
17
Q
Avanafil Brand Name and Initial Dose?
A
Stendra, 100 mg 15-30 min
18
Q
What is the renal dosing for Stendra?
A
AVOID in CrCl ,30 and hepatic
19
Q
What is CI with Stendra?
A
CYP3A4i, avoid large amounts of ethanol = orthostatic hypotension
20
Q
What is onset for Viagra and Levitra?
A
30 mins
21
Q
What is onset for Staxyn?
A
60 mins
22
Q
What is onset for Cialis?
A
45 mins
23
Q
What is onset for Stendra?
A
25-40 mins
24
Q
What is the duration of Cialis?
A
24-36 hrs
25
What are side effects most common in Vardenafil?
HA, Flushing, and Blue Vision
26
Blue Vision is a side effect seen with which PDE5i?
Sildenafil, Vardenafil, and Avanafil
27
What is a common side effect of Tadalafil?
Myalgia and Back Pain
28
When are PDE5i Contraindicated?
In patients taking Nitrates
Isosorbide Mono/Di-nitrate or SL NTG
29
What is the result of PDE5i + Nitrate?
Life threatening HYPOtension
30
If the patient is already on a nitrate, can you prescribe PDE5i?
NO
31
If the patient is on a PDE5i, can you administer nitrates?
Yes IF they have waited the appropriate amount of time
32
How long do you have to wait for Sildenafil before nitrate admin?
24 hrs
33
How long do you have to wait for Vardenafil before nitrate admin?
24 hrs
34
How long do you have to wait for Tadalafil before nitrate admin?
48 hrs
35
If the patient is already on an alpha-blocker (some interaction) what dose of PDE5i do you start the on?
Lowest
36
What are the advantages of PDE5i?
Convenient, low A/E, all equally effective, and discreet use
37
What drug is a Prostaglandin E1?
Alprostadil
38
What is the MOA and Place in therapy for Alprostadil?
Dilates arteries in the corpora cavernosa which thus increases penile blood flow, 2nd line
39
Can Alprostadil be used with TST?
Yes
40
Alprostadil Option 1 Brand and Initial Dose?
Caverject, Edex
2.5 mcg intraCAVERNOSALLY 5-10 min
41
When do you AVOID Alprostadil?
Sickle cell anemia, coagulopathy, venous incompetence, and Peyronie's disease
42
Alprostadil Option 2 Brand and Initial Dose?
MUSE
125-250 mcg intraURETHRALLY 5-10 min
43
What are the AEs of Intracavernosal Caverject/Edex?
Penile Pain
Hematoma
Fibrotic nodules
44
What are the AEs of Intraurethral MUSE?
Urethral pain/burning
Partner experiences burning
Testicular pain
45
What are the general AEs of Alprostadil (no matter which route)?
Dizzy, HA, decreased BP
46
Which route of Alprostadil is more effective?
Intracavernosal 70-90%
65% of intraurethral
47
What are the advantages of PGE1?
Local application
Minimal systemic effects
Rarity of DDI
48
What is the MOA of Testosterone?
Improved libido, sexual function, and mood
Enhances release of NO
49
What is the indication of TST?
Primary Hypogonadism
50
What are the pearls of oral TST?
Less effective than IM and transdermal TST
51
For TST Buccal Mucoadhesive what is the counseling?
Remove before toothbrushing
52
What is the most common form of TST?
IM Injection
53
For renal and hepatic impairment what is the dosing for IM TST?
AVOID/CI
54
Supraphysiologic serum concentrations caused by IM TST can lead to what?
Mood Swings
55
Aveed IM TST has what?
REMs program
56
Why does Aveed need a REMS program?
May cause POME: pulmonary oil micro embolism reaction
57
What is a counseling point for TST Transdermal and Gel?
Avoid swimming showering, or washing for 2 hrs after application
58
What is Virilization of Children and what form of TST is the concern?
Children exposed to TST GEL causing unintended AEs
59
How is the Subcutaneous Pellets TST administered?
Implant by healthcare professional, onset 3-4 months
60
What are the disadvantages to the pellet TST?
If there are complications the pellets must be removed surgically
61
What is TST Nasap Spray and the dosing?
Natesto, prime first dose with 10 units, consider alternative therapy is TST <300
62
What are the Cardiovascular AEs of TST?
Increased risk of MI, Stroke, and clots
Do NOT use with 3-6 month history of CVD
63
What are the Genitourinary AEs of TST?
May cause BPH or worsen it
64
What are the Malignancy AEs of TST?
TST dependent tumors (prostate)
65
When do you obtain TST levels usually?
8am
66
When do you check free TST for Oral?
6 hrs after morning dose, 7 days after initiation
67
When do you check free TST for IM Cypionate/Enanthate?
Midpoint
68
When do you check free TST for IM Undecanoate?
Right before 4th dose
69
When do you check free TST Gel?
After 2 wks
70
When do you check free TST Patch?
3-12 hrs after application
71
When do you check free TST SQ Implant?
At end of dosing interval
72
When do you check free TST Buccal?
Before a dose 4-12 weeks in
73
When do you check free TST Nasal?
1 month
74
What are other labs to assess with TST therapy?
1. Hematocrit: increase
2. Hemoglobin: increase
3. Lipids: Increase total and LDL
4. LFT: aggravate liver disease (oral TST)
5. PSA and DRE
75
What schedule are testosterone products?
Schedule III
76
What is Priapism?
Prolonged penile erection >4hrs, soft glands
77
What do you give Rx for in hospital for Priapism?
Intracavernos phenylephrine
78
Is BPH a progressive disease?
Not always
79
What is the first line treatment option for Mild BPH?
Watchful Waiting
80
What are the therapy options for Moderate BPH?
1. With ED = Alpha-1 Blocker +/- PDE5i
2. Small prostate and PSA = Alpha-1 blocker
3. Large prostate and PSA = alpha 1 blocker + Anticholinergic or B3 agonist
81
What are the first gen Alpha 1 Blockers?
Phenoxybenzamine
82
What are the second gen Alpha 1 Blockers?
Terazosin
Doxazosin
Alfuzosin
83
What are the third gen Alpha 1 Blockers?
Tamsulosin
Silodisn
84
Is Prazosin indicated for BPH?
NO
85
Which generation is more selective?
3rd gen, 2nd are mostly non-selective
86
Terazosin Brand and Starting Dose?
Hytrin
1 mg HS QD
87
Doxazosin Brand and Starting Dose?
Cardura
1mg HS QS
4 mg QD AM
88
Alfuxosin Brand and Starting Dose?
Uroxatral
10 mg QD after meal same time
89
What alpha-1 blockers have slow absorption due to food?
Hytrin, Uroxatral, Flomax, and Rapaflo
90
Tamsulosin Brand and Starting Dose?
Flomax
0.4 mg QD 30 min after meal same time
91
Silodosin Brand and Starting Dose?
Rapaflo
8 mg QD after meal
92
Which alpha-1 blockers are CI'd in severe hepatic disease?
Alfuzosin and Sildosin
93
What are the AEs of Alpha-1 Blockers?
1. Orthostatic hypotension/dizzy
2. Lower volume of ejaculate
3. Tachycardia
4. Nasal Congestion
94
What Alpha-1 Blocker are CI'd with ketoconazole, clarithromyxin, and ritonavir?
Alfuzosin, Silodosin, and Tamsulosin
95
What Alpha-1 Blocker are cautioned with ketoconazole, clarithromyxin, and ritonavir?
Doxazosin
96
Which Alpha-1 Blocker has an increased risk for QT prolongation?
Alfuzosin
97
When should tamsulosin be avoided?
Sulfa Allergy
98
If using PDE5i with Alpha-1 Blocker what is the admin?
Wait one week to stabilize Alpha-1 blocker before starting PDE5i
99
What are the clinical pearls of alpha-1 blockers?
Equally effective
Lower AUA by 30-40%
Does NOT alter prostate size
100
If alpha-1 blocker is stopped, what dose do you restart them at?
Initial dose
101
What is the MOA of 5-alpha reductase inhibitors?
Inhibition of 5-alpha reductase to decrease DHT levels
102
What drugs are classified as 5a-reductase inhibitors?
Finasteride and Dutasteride
103
Finasteride Brand and Starting Dose?
Proscar and 5mg QD
104
Dutasteride Brand and Starting Dose?
Avodart and 0.5 mg QD
105
Can you start a patient on 5a-reductase inhibitors alone?
NO, should be prescribed with a-blocker to treat symptoms while 5a-reductase slowly decreases DHT
106
What are the AEs of 5a-reductase inhibitors?
ED
Decreased volume of ejaculate
Decreased libido
Gynecomastia
107
What is the CI of 5a-reductase inhibitors?
Pregnant women should NOT handle the drug or be exposed to the semen of men who are taking it
108
When should you NOT recommend 5a-reductase inhibitors?
Unless Prostate >40 and/or PSA >1.5
109
Alpha-1 Blocker + 5-Alpha Reductase Inhibitor combination is a good option for who?
High risk for progression patients:
1. Men over 50 with low urine flow
2. High PSA
3. Large Prostate >30
110
What PDE5i has an FDA indication for BPH and the approved dosing?
Tadalafil
2.5 mg QD, may increase to 5mg
111
What product is a B3 Agonist Adjunct Therapy?
Mirabegron aka Myrbetriq
112
What is Floppy Iris Syndrome?
Happens during cataract surgery causing pupil constriction and the iris becomes floppy
