Erectile Dysfunction in Class Activity

Erectile Dysfunction in class activity: Scenario 1: You are a pharmacist located in primary care and you were just asked by one of the PCPs to help counsel a patient on the following medication. Patient ED is a 43 year old male who was diagnosed with erectile dysfunction several months ago and is now ready to start a medication. The patient has quit smoking and started exercising since his last evaluation with his PCP 4 weeks ago but is still experiencing problems with sexual dysfunction. • • What are some conditions that could potentially worsen ED? • • Which medications are contraindicated with PDE-5 inhibitors? Nitrates, guanylate cyclase stimulators (ea. Biociguet used for pulmonary HTN). Caution with Alpha blockers (alpha blockers are not absolute contraindication). Which medications could potentially worsen ED? • • CV disease, primary hypogonadism (lack of testosterone)- testes removal, HTN, TDM, trauma, smoking, stroke, CNS tumors, neuropathies Antihypertensives (beta-blockers, clonidine, methyldopa, diuretics), Dopamine antagonists (first generation antipsychotics, meteclempramide), antidepressants/(SSRIs, SNRIs, TCAS), Anticholinergics (antihistamines, antiparkinsonian), BPH drugs (5 alpha reductase: finasteride, dutasteride), opioids (methadone-chronic use), and nicotine (Cigarette smoking) Scenario 2: The doctor agrees to start an erectile dysfunction medication. The following agent listed below is pending in the order queue. Tadalafil 10 mg – 1 tablet PO PRN at least 30 minutes prior to anticipated sexual activity for impotence • There are 2 different types of dosing for tadalafil depending on how the provider/patient decide is best, either PRN or scheduled. What is the difference between the prn and scheduled dosing of tadalafil?  As-needed dosing: Take 10 mg at least 30 minutes prior to anticipated sexual activity as one single dose and not more than once daily. Dose may be adjusted based on tolerability (dosing range: 5 to 20 mg). Note: Erectile function may be improved for up to 36 hours following a single dose (also known as the weekend pil)  Once-daily dosing: 2.5 mg once daily at approximately the same time daily without regard to timing of sexual activity. Dose may be adjusted based on tolerabilty (dosage range: 2.5 to 5 mg/day) Todolafil requires dose odjustment in hepatie and renal impairment • Write down 3 counselling points for the above prescription. • Tadalafil may be taken without regards to food • Tadalafil also known as the weekend pill- duration of action is 24-36 hrs. One pill can be used for multiple sexual intercourse in this time period W ith tadalafil, you m ay experience back pain, flushing, nasal congestion and headache, priapism (erection lasting > 4 hrs) • What are the main differences regarding onset between the PDE5 inhibitors? • Sildenafil and vardenofil should be taken 1 hour before intercourse • Tadalafilshould be taken 30 min prior to anticipated sexual activity (or 2.5-5mg daily- same time every day without regards to timing of sexual activity) • Avanafil should be taken 15-30 minutes before intercourse Scenario #3: It’s 2 months later and the patient reports that he’s tried at least 10 doses of tadalafil 20mg (max dose) PRN for impotence but he is still not able to get an erection. The patient states that one of his friend’s takes MUSE and he’s interested in the medication. The PCP agrees to therapy and enters the order. The following agent listed below is pending in the order queue. Please counsel the patient on the following medication: • Intraurethral alprostadil (Muse)- Insert 125 mcg pellet PRN into urethra 5-10 minutes before intercourse for impotence. Instructor questions (5 min) Describe alprostadil’s unique drug delivery pathway? • • • After administration of the MUSE pellet into the urethra, alprostadil must be absorbed in the corpus spongiosum and then into the corpus cavernosa to exert its effects Alprostadil acts directly on the penile and vascular smooth muscle cells to stimulate the production of CAMP with resulting intracellular calcium sequestration and subsequent smooth muscle relaxation, penile tumescence, and eventual erection. It does not depend on NO or an intact nervous system (appropriate for individuals with NO deficiency) What are the contraindications for MUSE? • Abnormal penile anatomy, ireluding urethral stricture, balanitis (inflammation of the glanshead of the penis), severe hypospadias (hi-pog-SPAY-dee-us) is a birth defect (congenital condition) in which the opening of the urethra is on the underside of the penis instead of at the tip.) and curvature, and acute or chronic urethritis • Pregnant partner unless using condom What is the difference between intraurethral vs intracavernosal alprostadil? Which one is more effective? • Intracavernesal injections are more effective because alprostadil is directly injected at site of action (hence lower strength)