Term
| What are the first steps to beginning therapy for ED? |
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Definition
Counseling and a cardio exam
Then PDE5 inhibitors are 1st line
If not working: are they taking it correctly? Maximum dose?
2nd line: prostaglandin analogs |
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Term
| What is the result of PDE5 inhibition? |
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Definition
| In the corpus cavernosa, PDE5 does not inhibit cGMP, leading to incr. NO derived cGMP levels and SM relaxation |
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Term
| When are Sildenafil/Viagra and Vardenafil/Levitra dosed? |
|
Definition
1 hour prior to sexual activity
DO NOT DOSE WITH FATTY MEALS especially viagra. |
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Term
| Why is Tadalafil/Cialis different? |
|
Definition
Can be taken chronically and lasts for 24-72 hours
RENALLY ELIMINATED
no food interactions unlike viagra. |
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Term
| What is Avanafil/Stendra? |
|
Definition
| A new PDE5 inhibitor, taken 30 minutes prior to activity. More selective for PDE5 |
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Term
| What are PDE5 inhibitors contraindicated with? |
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Definition
| Nitrates! Do not give within 24 hours (48 for cialis). |
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Term
| What are AEs of PDE5 inhibitors? |
|
Definition
HA, flushing, visual disturbances
NAION - can be permanant, most often w/ Viagra.
- Muscle pain due to PDE11 (Cialis) |
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Term
| What is characterized as a 'failure' to respond to PDE5 inhibitors? |
|
Definition
| Failure after 8 attempts --> move to alprostadil |
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Term
| What lifestyle modifications are recommended for BPH? |
|
Definition
- Raise HDL, lower LDL
- Stop smoking, stop caffeine (stromal tissue) -- increases alpha1 activation
- Decr body weight in obesity. Adipose has aromatase --> conversion to estradiol
- Increase exercise |
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Term
| What substances contribute to BPH symptoms? |
|
Definition
Decongestants
Anti-cholinergics
Anti-histamines
alcohol |
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Term
| What receptors are upregulated in BPH? |
|
Definition
| Alpha1a in the stromal tissue and 1d in the bladder. Leads to irritation and increased resistance, the DYNAMIC component. |
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Term
| What drugs are alpha1 antagonists? |
|
Definition
- 1st generation: Phentolamine. Not used for BPH
- 2nd generation: Prazosin, Doxazosin, Terazosin, Alfuzosin. Also has cardio effects
- 3rd gen: Tamsulosin and Siludosin: specific for 1a/1d.
**recommended for AUA > 8 |
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Term
| What is specific about 2nd generation alpha blockers? |
|
Definition
- Prazosin - short half life, not used often
- Doxazosin - longer, dosed at bedtime
- Terazosin - longer, dosed at bedtime
- Alfuzosin - better about CV effects |
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Term
| What is the difference between 3rd generation alpha blockers? |
|
Definition
- Tamsulosin/Flomax - interacts w/ food, take on an empty stomach. Extensive 3A4/2D6 metabolism. May cause floppy iris syndrome, stop taking before eye surgery. AE: dizzy, hypotension, ED
- Silodosin/Rapaflo - more potent for alpha1a. Must be renally dosed, 3A4 and p-gp metabolized. Also floppy iris syndrome. |
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Term
| Which drugs are 5alpha-reductase inhibitors and how do they work? |
|
Definition
- Finasteride/Proscar - inhibits type II, lowering DHT. TERATOGENIC.
- Dutasteride/Avodart - inhibits both isoforms, lowering DHT. TERATOGENIC
- BOTH: AE: impotence, libido loss, ED, gynecomastia
** not good drugs for rapid effects or men w/o prostate enlargement. |
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Term
| What is the COMBAT trial? |
|
Definition
| Groups with combo therapy improve over mono-therapy alone. |
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Term
| When can anti-cholinergics be used in BPH? |
|
Definition
Only Tolteridine and Oxybutynin studied
Improve BPH storage symptoms - appropriate as an adjunct in patients WITHOUT post-void residual urine
**patient must be able to void. |
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Term
| When can PDE5 inhibitors be used in BPH? |
|
Definition
Promotes smooth muscle relaxation in bladder neck, urethra, and prostate.
Low dose Tadalafil/Cialis approved, as good as tamsulosin in trials. |
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Term
| When can dietary supplements be used in BPH? |
|
Definition
| Saw palmetto is common, may increase side effects and is not thought to be beneficial. |
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Term
| How is primary or secondary hypogonadism treated? |
|
Definition
| Both treated with testosterone replacement therapy |
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|
Term
| What is the goal of TRT therapy in hypogonadism? |
|
Definition
Goal is NOT to correct testosterone levels
Goal is to alleviate symptoms. Target between 300-1,000 |
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Term
| What are contraindications for TRT? |
|
Definition
- Prostate cancer
- Breast Cancer
- High risk: PSA > 4, Hematocrit > 50, severe LUTS/BPH, uncontrolled CHF |
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Term
| What is monitored in TRT? |
|
Definition
Symptoms: 3 and 6 mo
Serum testosteron - base, 3, and 6 mo
Hct - base, 3, 6, and annually
Bone mineral density
PSA |
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|
Term
|
Definition
Gels - transfer risk, irritation
IM injection - libido fluctuation, pain, erythrocytosis
Patches - irritation
Buccal - gum irritation
Pellets - infection |
|
|
Term
|
Definition
| Taking on male characteristics from testosterone transfer. Avoid contact with women and children. |
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