What is your specialty?

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Cassandra Walters
5 years ago
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1 What is your specialty? A. General practice B. Urology C. Andrology D. Other

2 Do you keep up with news about ED and BPH? A. No B. Yes, weekly or more frequently C. Yes, monthly D. Yes, annually or less frequently

3 Asking the Question News in ED and BPH

4 Overview ED, BPH, Metabolic Syndrome, and CV Risk Guidelines for ED and BPH Lifestyle Modifications Recent Data on PDE5 Inhibitors Cialis 5 mg for Once Daily Use BPH = benign prostatic hyperplasia; CV = cardiovascular; ED = erectile dysfunction, PDE5 = phosphodiesterase type 5.

Dyslipidaemia: 5 years Routine annual exam with general

5 Angelo Barry 56 years of age BPH: 6 years Hypertension: 10 years Routine urology follow-up 45 years of age T2DM: 2 years Dyslipidaemia: 5 years Routine annual exam with general practitioner Note: Hypothetical patient cases. T2DM = type 2 diabetes mellitus.

both parents Coronary artery disease in father Medical History Hypertension, 10 years duration Social History Nonsmoker; social

6 Who is Barry? Reason for Visit Routine follow-up visit for LUTS Reports frequent awakening at night to urinate Family History Hypertension in both parents Coronary artery disease in father Medical History Hypertension, 10 years duration Social History Nonsmoker; social drinker Divorced, 6 years University professor Medications Alpha-1 blocker Angiotensin II receptor blocker Notes Worsening urinary symptoms over the past 6 months Undisclosed ED symptoms Note: Hypothetical patient case. LUTS = lower urinary tract symptoms.

7 Who is Angelo? Medical History T2DM, 2 years duration Dyslipidaemia, 2 years duration Reason for Visit Routine annual visit with primary care physician Social History Past smoker (smoked 1 pack a day for 5 years); quit smoking 3 years ago 1 glass of wine with dinner and 3-4 mixed drinks on weekends Married with 2 children IT consultant; occasionally works late nights Family History T2DM and coronary artery disease in father Medications Metformin 750 mg twice daily Statin Notes Adherent to medications and lifestyle recommendations Concerned about work-related stress Developing ED symptoms Note: Hypothetical patient case.

8 Do you have a patients like Barry or Angelo with undisclosed ED or LUTS? A. No B. I am not sure; I do not always ask if both conditions are present if a patient complains of one of them C. Yes, I have a patient like them D. Yes, I have several patients like them Note: Hypothetical patient cases.

9 What are the risk factors? BMI = body mass index; CVD = cardiovascular disease. 1. Selvin E, et al. Am J Med. 2007;120(2): Ponholzer A, et al. Eur Uro. 2005;47(1): Nicholson TM, et al. Differentiation. 2011;82(4-5): Berger AP, et al. BJU Int. 2005;96(7): Hegarty PK. Curr Urol Rep. 2001;2(4): Patel ND, et al. Indian J Urol. 2014;30(2): Parsons JK. J Urol. 2007;178(2): Meigs JB, et al. J Clin Epidemiol. 2001;54(9): Huri HZ, et al. PLoS One. 2014;9(1):e Ullrich PM, et al. Urology. 2007;70(3): Shih HJ, et al. Prostate. 2018;78(2): Kaur J. Cardiol Res Pract. 2014;2014: Paulhus M, et al. US Pharm. 2014;39(2): Wofford MR, et al. J Clin Hypertens (Greenwich). 2006;8(2): Raheem OA, et al. Am J Mens Health. 2017;11(3): Upadhyay RK. J Lipids. 2015;2015: St. Onge EL. P T. 2009;34(7): Dimsdale JE. J Am Coll Cardiol. 2008;51(13): ED 1-5 BPH 4,6-11 Metabolic Syndrome CVD AGE LIFESTYLE Low physical activity Smoking Alcohol intake High BMI MEDICAL CONDITIONS Diabetes Heart disease Hyperlipidaemia Hormone imbalance Vascular damage Hypertension Inflammation SOME MEDICATIONS PSYCHOLOGICAL STRESS

10 What is the relationship between ED and CVD? Compared to men with no ED, men with ED have 1,2 : 8x HIGHER RISK OF HEART FAILURE A man with ED and no known cardiac disease should be considered a cardiac patient until proven otherwise 1 Risk is closely related to severity of ED ED IS PREDICTIVE OF A CV EVENT IN THE NEXT 3-5 YEARS 1 1. Hackett G, et al. Int J Clin Pract. 2018;72(2):doi: /ijcp Raheem OA, et al. Am J Mens Health. 2017;11(3):

11 What is the relationship between ED and CVD? Up to 26% higher risk of all-cause mortality 1,2 The urologist s role is particularly critical in screening high-risk patients (younger, moderate to severe ED, no diabetes, no prior CV risks) and referring them to cardiology for further evaluation and assessment 2 A question on ED should be included in all CV risk assessments and incorporated into risk assessment guidelines 2 Men without ED Men with ED Up to 48% higher risk of CVD 1,2 Men without ED Men with ED THE RISK OF HEART DISEASE WAS 50x HIGHER IN MEN YEARS OF AGE WITH ED COMPARED TO THOSE WITHOUT ED 3 1. Hackett G, et al. Int J Clin Pract. 2018;72(2):doi: /ijcp Raheem OA, et al. Am J Mens Health. 2017;11(3): Inman BA, et al. Mayo Clin Proc. 2009;84(2):

12 What is the relationship between LUTS and metabolic syndrome? Association Between BPH and MetS 3 N=379 Interconnected physiological, biochemical, clinical, and metabolic factors directly increase risks 1 : CVD T2DM All-cause mortality 95% CI Calculated Prostate Volume (cc) Various definitions of metabolic syndrome exist, but they have commonalities 2 : Central obesity/ increased waist circumference Hyperglycaemia Hypertension Dyslipidaemia Number of MetS Parameters The presence of metabolic syndrome and the number of metabolic syndrome components present is related to LUTS/BPH severity 3,4 Men with BPH are more likely to have metabolic syndrome than men without BPH 4 CI = confidence interval; MetS = metabolic syndrome. 1. Kaur J. Cardiol Res Pract. 2014;2014: Huang PL. Dis Model Mech. 2009;2(5-6): Gacci, et al. BMC Urology. 2017;17(1): DiBello JR, et al. BJU Int. 2016;117(5):

Functional consequences at tissue level Pelvic atherosclerosis ED BPH Comorbidities Steroid hormone imbalance Chronic

13 Why do ED and BPH have so much in common? Common Pathogenic Mechanisms Autonomic hyperactivity Reduced NO-cGMP signalling Increased RhoA-ROCK signalling Functional consequences at tissue level Pelvic atherosclerosis ED BPH Comorbidities Steroid hormone imbalance Chronic inflammation Hypertension Metabolic syndrome Diabetes cgmp = cyclic guanosine monophosphate; NO = nitric oxide; RhoA-ROCK = Rho-associated protein kinase. Gacci M, et al. Eur Urol. 2011;60(4):

14 Visceral fat is an active endocrine organ Hypertension Inflammation TNFα IL-6 Lipoprotein lipase Angiotensinogen FFA Insulin + IGF Atherogenic dyslipidaemia Testosterone Resistin Adipsin (complement D) Leptin Atherosclerosis Adiponectin PAI-1 Lactate T2DM Thrombosis FFA = free fatty acid; IGF = insulin-like growth factor; IL = interleukin; PAI = plasminogen activator inhibitor; TNF = tumour necrosis factor. 1. Ahima RS, et al. Trends Endocrinol Metab. 2000;11(8): Eckel RH, et al. Lancet. 2005;365(9468): Grundy SM. J Clin Endocrinol Metab. 2004;89(6): Lyon CJ, et al. Endocrinology. 2003;144(6): Trayhurn P, et al. Br J Nutr. 2004;92(3):

15 What should I consider if my patient is presenting with symptoms of ED or BPH? Patient presents with symptoms of ED Follow diagnostic guidelines as appropriate Consider a co-diagnosis of BPH Consider a co-diagnosis of ED Patient presents with symptoms of BPH Ask about sexual or urinary health and bother caused by individual symptoms Consider using the IPSS, IIEF, bladder diary, and frequency voiding chart Consider other tests and measurements and possible underlying comorbidities RECOMMENDATION: Patients seeking consultation for one condition should always be screened for the other condition Note: Hypothetical patient cases. IIEF = International Index of Erectile Function; IPSS = International Prostate Symptom Score. Kirby M, et al. Int J Clin Pract. 2013;67(7):

16 When your patients present with ED or LUTS, do you consider doing the necessary investigations to diagnose metabolic syndrome or high CV risk? A. No B. Yes, I refer them to a general practitioner, internist, or specialist C. Yes, I do the investigations myself

17 Who is Barry? Reason for Visit Routine follow-up visit for LUTS Reports frequent awakening at night to urinate Family History Hypertension in both parents Coronary artery disease in father Medical History Hypertension, 10 years duration Social History Nonsmoker; social drinker Divorced, 6 years University professor Medications Alpha-1 blocker Angiotensin II receptor blocker Notes Worsening urinary symptoms over the past 6 months Undisclosed ED symptoms Note: Hypothetical patient case.

18 Who is Angelo? Medical History T2DM, 2 years duration Dyslipidaemia, 2 years duration Reason for Visit Routine annual visit with primary care physician Social History Past smoker (smoked 1 pack a day for 5 years); quit smoking 3 years ago 1 glass of wine with dinner and 3-4 mixed drinks on weekends Married with 2 children IT consultant; occasionally works late nights Family History T2DM and coronary artery disease in father Medications Metformin 750 mg twice daily Statin Notes Adherent to medications and lifestyle recommendations Concerned about work-related stress Developing ED symptoms Note: Hypothetical patient case.

19 How can I quantify my patient s CV risk? Several CV risk calculators are available, modelled on different patient populations (eg, QRISK 3 Calculator). Most calculators will have similar variables, such as: Blood pressure Family history of CV disease ED is increasingly included in calculations (eg, QRISK increases risk calculations by 25% for men with ED) Age Height Personal history Sex Weight Smoking CV disease Diabetes Chronic kidney disease Treatment for hypertension Cholesterol (eg, total, HDL, LDL) HDL = high-density lipoprotein; LDL = low-density lipoprotein. 1. QRISK risk calculator. Accessed 17 April Hippisley-Cox J, et al. BMJ 2017;357:j2099.

0 mmol/l LDL 3.5 mmol/l 135 mg/dl HDL 1.0 mmol/l 39 mg/dl 2.0 mmol/l Triglycerides 2.

20 What is Barry s CV risk? Age: 56 years Weight: 80 kg Height: 170 cm BMI: 27.7 kg/m 2 History: Treatment for hypertension Coronary artery disease in father, 58 years of age ED BP LIPID PROFILE With modifications: Total cholesterol 6.0 mmol/l 232 mg/dl 4.0 mmol/l LDL 3.5 mmol/l 135 mg/dl HDL 1.0 mmol/l 39 mg/dl 2.0 mmol/l Triglycerides 2.5 mmol/l 221 mg/dl HEART AGE 130/90 mmhg 120/80 mmhg with modifications 72 YEARS 61 YEARS with modifications RISK OF MI OR STROKE in next 10 years: 18,9% 6,2% 9,0% Note: Hypothetical patient case. BP = blood pressure; MI = myocardial infarction. QRISK risk calculator. Accessed 17 April Healthy patient Current state With modifications

8 mmol/l 108 mg/dl HDL 0.9 mmol/l 35 mg/dl 2.0 mmol/l Triglycerides 2.

21 What is Angelo s CV risk? Age: 45 years Weight: 87 kg; 78 kg with modifications Height: 170 cm BMI: 30.1 kg/m 2 ; 27.0 kg/m 2 with modifications History: T2DM Former smoker ED BP LIPID PROFILE With modifications: Total cholesterol 5.0 mmol/l 193 mg/dl 4.0 mmol/l LDL 2.8 mmol/l 108 mg/dl HDL 0.9 mmol/l 35 mg/dl 2.0 mmol/l Triglycerides 2.6 mmol/l 230 mg/dl HEART AGE 136/88 mmhg 120/80 mmhg with modifications 66 YEARS 55 YEARS with modifications RISK OF MI OR STROKE in next 10 years: 12,3% 2,4% 5,4% Note: Hypothetical patient case. QRISK risk calculator. Accessed 17 April Healthy patient Current state With modifications

22 Why is sexual activity important? Longer life 1 Improved quality of life 7 Lower BP 2 Lower pulse rate 3 Less risk of heart attacks and strokes 4,5 Less likely to divorce 6 Longer marriage 6 Note: Hypothetical patient cases. 1. Smith GD, et al. BMJ. 1997;315(7123): Brody S. Biol Psychol. 2006;71(2): Brody S, et al. Biol Psychol. 2000;52(3): Ebrahim S, et al. J Epidemiol Community Health. 2002;56(2): Corona G, et al. Andrology. 2013;1(6): Kornrich S, et al. Am Sociol Rev. 2013;78(1): Robinson JG, et al. J Gerontol Nurs. 2007;33(3):19-27.

23 What are the guidelines for treatment of ED? Provide education and counselling to patient (and partner, if available) Intracavernous injections Vacuum device Intraurethral and topical alprostadil Treatment of ED Change lifestyle and address modifiable risk factors Identify patient needs and expectations Share decision-making Offer conjoint psychosexual and medical/physical treatment Assess therapeutic outcomes Erectile response Side effects Treatment satisfaction Assess adequate use of treatment options Provide new instructions and counselling Retry therapies Consider alternative or combination therapy Identify and treat curable causes of ED PDE5 inhibitors Inadequate treatment outcome Inadequate treatment outcome Consider penile prostheses Hatzimouratidis, K. European Association of Urology

24 What are the guidelines for treatment of BPH? Yes Education + lifestyle advice with or without vasopressin analogue Yes Nocturnal polyuria predominant? Yes Education + lifestyle advice with or without muscarinic receptor antagonist/β-3 agonist Male LUTS (without indications for surgery) Bothersome symptoms? No Storage symptoms predominant? No Yes Prostate volume >40 ml? Long-term treatment? No Yes Education + lifestyle advice with or without 5α-reductase inhibitor ± α 1 -blocker/pde5 inhibitor Add muscarinic receptor antagonist/β-3 agonist No No Education + lifestyle advice with or without α 1 - blocker/pde5 inhibitor Residual storage symptoms Watchful waiting with or without education + lifestyle advice Gravas S, et al. European Association of Urology

25 Do you emphasise to your patients the importance of lifestyle modifications in reducing ED and BPH symptoms? A. No B. Yes

26 What is the biggest challenge you face when talking to your patients about lifestyle modifications? A. Patients do not wish to change their lifestyles B. Patients do not understand the benefits they may gain C. Patients have heard it all before and do not take lifestyle counselling seriously D. Other

27 How can lifestyle modifications improve ED and BPH? Lifestyle risk factors common in ED and BPH 1 Low physical activity Psychological stress Alcohol intake Smoking Obesity Why should I emphasise lifestyle modifications with my patients? 2 First-line intervention Significant benefits leading to: Reduced risk of CVD and diabetes Improved erectile function and testosterone levels What modifications can be made? 2 Alter diet Lose weight Increase physical activity Stop smoking Moderate alcohol intake Manage stress Lifestyle changes should precede or accompany any pharmacological treatment 1. Kirby M, et al. Int J Clin Pract. 2013;67(7): Kirby M. Sex Med Rev. 2015;3(3):

28 How can physicians help patients modify their lifestyle? 1 Monitor and manage reversible risk factors Consider smoking cessation support Emphasise importance of a healthy diet, physical activity, and smoking cessation Consider sexual counselling Use motivational interviewing techniques to encourage lifestyle changes Deliver message at every contact in a sincere and nonjudgmental way Move patients from contemplation to action 1. Kirby M. Sex Med Rev. 2015;3(3):

29 What are some recent data on PDE5 inhibitors? 2016: PDE5 inhibitor use in patients with T2DM is associated with a reduction in all-cause mortality (N=5956) 1 Controlled for: age; egfr; smoking status; prior cerebrovascular accident; hypertension; prior MI; systolic blood pressure; use of statins, metformin, aspirin, and beta-blockers 46% less risk of all-cause mortality over 7.5 years With PDE5 inhibitor Without PDE5 inhibitor 38% less risk of all-cause mortality over mean 3.3 years With PDE5 inhibitor 2017: ED treatment with PDE5 inhibitor after a first MI had a reduced risk of mortality (N=43,145) 2 Without PDE5 inhibitor Less risk of heart failure, MACE, non-cvd death, and CVD death MACE = major adverse cardiac events. 1. Anderson SG, et al. Heart. 2016;102(21): Andersson DP, et al. Heart. 2017;103(16):

30 If my patient and I decide that he may benefit from a PDE5 inhibitor, why might Cialis 5 mg for daily use be a good choice? Round-the-clock efficacy 1 Confidence because of freedom 3 Helps patients feel normal 2 Indicated for treatment of ED and treatment of the signs and symptoms of BPH 1 Preferred to as-needed options 4 Note: Hypothetical patient cases. 1. Cialis [Summary of Product Characteristics]. Utrecht, the Netherlands: Eli Lilly Nederland B.V.; Kim ED, et al. J Sex Med. 2014;11(3): Seftel AD, et al. Int J Impot Res. 2009;21(4): Rubio-Aurioles E, et al. J Sex Med. 2012;9(5):

31 What are some things I should remember? If physicians don t ask, patients won t tell Patients with symptoms of ED or BPH should be asked about symptoms of both conditions at first contact Patients with ED or BPH should be assessed for CV risk and metabolic syndrome Management of ED and BPH is not only about prescribing effective medication; lifestyle modifications and managing comorbidities are also important Modifiable risk factors should be assessed and addressed in order to treat the patient holistically Effective treatment for one condition can improve the other; however, only by assessing comorbidities for both conditions can therapy achieve the desired outcome for the patient and his partner Cialis 5 mg for once daily use may be a good choice for patients with ED and/or BPH

32 How many people are watching this webcast at your location? A. 1 (only me) B C D. >50

33 Barry Q&A Angelo Note: Hypothetical patient cases.

34 Has this presentation influenced your views on the associations among ED, LUTS, metabolic syndrome, and CV risk? A. No B. Yes Note: Hypothetical patient cases.

Cardiovascular Complications of Diabetes

VBWG Cardiovascular Complications of Diabetes Nicola Abate, M.D., F.N.L.A. Professor and Chief Division of Endocrinology and Metabolism The University of Texas Medical Branch Galveston, Texas Coronary