ED treatments: PDE5 inhibitors, injections and vacuum devices

Transcription

1 ED treatments: PDE5 inhibitors, injections and vacuum devices Martin Steggall Clinical Nurse Specialist (Erectile Dysfunction and Premature Ejaculation) Barts Health NHS Trust; Associate Dean, Director of Undergraduate Studies, City University London

2 Treatment options (ED) Talk to your partner Phosphodiesterase Type 5 (PDE5Is) inhibitors Medicated Urethral System for Erections (Alprostadil pellets) Intracavernosal injections Vacuum devices Surgery Psychosexual counselling 12/09/2014 O:ED Study Day 2

3 Talking Sexual activity is concerned with communication and intimacy Poor communication and poor intimacy = sexual dysfunction 1 st line therapy is always communication Do you have time for your sex lives? What s the priority? Everything has an opportunity cost Bodies form patterns very quickly do you have a pattern that is unhelpful for your sex life? Is sexual activity the last thing you do before you go to bed? Try sensate focus what do you like; what do you not like? 12/09/2014 O:ED Study Day 3

4 Phosphodiesterase Type 5 Inhibitors* (prn) Sildenafil Citrate (Viagra)/Generic Sildenafil 25, mg Takes an hour to work (best on an empty stomach), lasts for 4 hours Tadalafil (Cialis) mg od or 10-20mg prn Takes 30 minutes to work, lasts for 36 hours (check use of alphablockers) Vardenafil (Levitra) similar to Sildenafil, minute onset of action, lasts for 5 hours All have similar efficacy rates 12/09/2014 O:ED Study Day 4

5 Mode of action PDE5Is block the action of PDE5, which causes cyclic GMP to degrade. Blocking this enzyme allows relaxation of the smooth muscles, resulting in erection Only work if there is sexual stimulation 12/09/2014 O:ED Study Day 5

6 Once daily Tadalafil 5-7 days to reach steady plasma concentrations If you miss a day back to baseline Use for those who have had success with PDE5Is where prn dosing is problematic (high demands for sexual activity) Also licensed for BPH 12/09/2014 O:ED Study Day 6

7 Contraindications/cautions/Side effects Cannot be taken with nitrates (ISMN, GTN, etc.) care with Nicorandil (hypotensive effect), antibiotics ( -azoles) and grapefruit juice Side effects Headache Nasal congestion Facial flushing Muscle pain (Cialis) No increased incidence of priapism Visual changes; permanent change in vision? 12/09/2014 O:ED Study Day 7

8 How often should medication be taken? If, intimacy present, and if possible: Prescribe 8 doses (max. dose) take Mon, Wed, Fri, etc. If good erection after 4 doses, try a drug holiday on the 5 th occasion If erections return, leave medication, if not, try ½ dose. If ½ dose successful, use as maintenance, try another drug holiday after a further 4 doses If failing at ½ dose go back up to max dose Failure continues try alternative PDE5I/refer for advice Finally, know your patient s culture - choice is not always the answer 12/09/2014 O:ED Study Day 8

9 Treatment rationale Titrating up will exacerbate failures High expectation that medication works first time - it s unlikely Patients disengage from treatment quickly One dose per week will cause performance anxiety because conditions for good sex will not be met Prescribing guidelines are not exceeded It will be more expensive to treat in the long-term 12/09/2014 O:ED Study Day 9

10 Dosing guidance from DoH 1 dose per week Based on survey in 1998 Number of occasions the year old age group had sexual activity was once per week Does not account for the duration of the problem, or pressure to perform, or conditions for sexual activity 12/09/2014 O:ED Study Day 10

11 Guidelines What do the guidelines actually say? HSC 1999/177 Treatment for Impotence: patients with severe distress HSC 1999/148 Treatment for Impotence Estimated cost of treatment for ED in 1999/2000 was 20 million (Primary Care NHS costs) 12/09/2014 O:ED Study Day 11

12 Eligibility criteria Condition Diabetes mellitus Multiple sclerosis Parkinson s disease Poliomyelitis Prostate cancer Radical pelvic surgery Renal failure treated by dialysis or transplant Severe pelvic injury Single gene neurological disease Spinal cord injury Spina bifida Additional circumstances Men who were receiving a course of NHS treatment for erectile dysfunction on or before 14 th September 1998 Treatment included Sildenafil citrate (Viagra) Tadalafil (Cialis) Vardenafil (Levitra) Medicated Urethral System for Erections (MUSE) Viridal Duo or Caverject Dual chamber Vacuum devices 12/09/2014 O:ED Study Day 12

13 Other options (specialist clinics) MUSE Intracavernosal Injections Vacuum Devices Combination therapy (PDE5I plus MUSE or ICI or Vacuum) Prostheses Psychosexual Counselling 12/09/2014 O:ED Study Day 13

14 Alprostadil (PGE 1 )* Medicated Urethral System for Erections μg (efficacy of up to 50%) Test dose of µg Patients need time and training for best efficacy 12/09/2014 O:ED Study Day 14

15 Side effects of MUSE Urethral burning Hypotension If BP /60mmHg don t give However, generally well tolerated Can be effective Can combine effectively with PDE5Is although are not licensed for this Costs are approximately 10 per dose 12/09/2014 O:ED Study Day 15

16 Intracavernosal injections (ICI) µg (efficacy of up to 90%) Test dose of 5µg (depending on duration of ED and whether early morning tumescence) Excellent results, but.the man has to give himself an erection each time he wants intercourse 12/09/2014 O:ED Study Day 16

17 Side effects of ICI Bleeding Infection risk increases (??safe sex) Needle phobia Hypotension If BP /60mmHg don t give 12/09/2014 O:ED Study Day 17