(1 of 11)

1 Male patient presents w/ symptoms of erectile dysfunction (ED) for ≥3 months

2 DIAGNOSIS No ALTERNATIVE Does patient’s sexual DIAGNOSIS history confirm ED?

Yes

3 EVALUATION • Identify comorbidities & psychosexual dysfunctions • Evaluate cardiac function

4 RISK STRATIFICATION Intermediate • Do basic cardiovascular (CV) High-risk assessment (usually include a stress test) to classify patient’s • Refer to a CVD risk • Refer for CVD Cardiologist for management further CV • Follow up for No/Low- risk evaluation, treatment of ED assessment & risk once cardiac management status has improved

TREATMENT © MIMSSee next page

B1 © MIMS 2019 ERECTILE DYSFUNCTION B A Pharmacological therapy Pharmacological therapy Non-pharmacological • • • • - Phosphodiesterase inhibitors(PO) Phosphodiesterase - 1st-line ofendocrinopathy w/noevidence forED - Nonspecific therapies forED defi hypogonadism/ by therapy caused forED Endocrine ciency orcause factors risk any medical existing Correct Discontinue offending - Treat factors psychosocial - modifi Lifestyle cation - Patient education &partner © MIMS Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing D B A Surgical intervention Surgical Pharmacological therapy Pharmacological therapy Non-pharmacological • • • Erectile Dysfunction(2of11) • • • • • • • • Penile implants (implanted)Penile devices delivery drug surgery Penile vascular PATIENTS LOW OR W/ NO Intraurethral therapy Intracavernosal inj therapy (PO) (sublingual) (topical) Alprostadil inhibitors(PO) Phosphodiesterase Vacuum constriction devices counselingSexual &education Is patient satisfi ed Is patient satisfiIs patient ed FOLLOWUP FOLLOWUP CVD RISK CVD w/ results? w/ results? C B2 C No No Yes Yes • every 6mth every Follow-up w/patient TREATMENT CONTINUE TREATMENT CONTINUE © MIMS 2019 ERECTILE DYSFUNCTION • • • • • History Sexual • • • • • Symptoms • • • • • • • • &Psychogenic Psychiatric • • • • Endocrine • • • Neurogenic • • • • • • • Arteriogenic identifi should be dysfunction that toerectile contribute factors &risk Comorbidities ed: - tests Lab - examination (DRE) rectal extremity &lower digital characteristics pulse, sexual secondary testicles, Physical penis, Abdomen, exam: -  history &psychosocial medical orough sexual, International eg Function IndexforErectile (IIEF) questionnaires, psychometric validated May use satisfaction Patient consistently or recurrently is unable to maintain/attain an erection that is adequate for sexual partners Inability masturbation related tomaintain private &/orerections during toerotic erection material orother tumescence penile Nocturnal detumescence butearly penetrate can erections ejaculation occurs without Initial penile A patient may complain that erection ofpartial could notattain penetration vaginal isuncommon rigidity ofpenile Complete loss ofage regardless &other factors lifestyle comorbidities dysfunction &sexual &various prostatic hyperplasia, benign tractsymptoms, urinary w/lower associated been has Studies that have dysfunction shown erectile diseases w/cardiovascular as common factors has risk dysfunction Erectile disease vascular peripheral & artery manifestation anearly ofcoronary be can that have dysfunction evidence shown erectile Increasing 3monthsInability forat toattain least performance sexual &maintain enough anerection tohave satisfactory Stress Relationship issues disorders Anxiety Depression Obesity Hyper- &hypothyroidism Hyperprolactinemia defiHypogonadism/testosterone ciency mellitus Diabetes Spinal cord injury Trauma abuse drug Recreational disorders Peripheral vascular smoking Heavy syndrome Hyperlipidemia &the metabolic disease Cardiovascular Hypertension mellitus Diabetes -

axis, urinary microscopy, necessary urinary as etc axis, lipid profi glucose or HbA1c, Fasting blood hypothalamic-pituitary-gonadal le, testosterone assay to evaluate symptoms ejaculatory secondary orprotracted a genitourinary doneinthe presence butshouldbe of dysfunction inerectile examination isnotmandatory rectal A digital mellitus) diabetes the may fi be dysfunction Erectile condition rst presentation (eg medical hypertension, ofanunderlying serious © MIMSProstate-specifi therapy testosterone during initiating before intervals &atc antigen regular (PSA)ismeasured 1 ERECTILE DYSFUNCTIONERECTILE (ED) Erectile Dysfunction(3of11) 3 2 EVALUATION DIAGNOSIS B3 © MIMS 2019 ERECTILE DYSFUNCTION • • • levels: risk Cardiovascular oftreatment ofthemethod independent activity sexual to infarction (MI)related ofmyocardial the risk in w/asmallincrease associated is disease w/cardiovascular in patients dysfunction Treatment oferectile • • • • • Ot • • Penile Disorders • • • • • • • Drugs • • &Psychogenic (cont'd)Psychiatric identifi should be dysfunction that toerectile contribute factors &risk Comorbidities (Cont'd)ed: hers Low-risk transplant Heart - Recurrent transient ischemic attacks (TIA) - cause Murmur ofunknown - Moderate, stable angina - (excluding gender) (CAD) disease artery forcoronary factors but≥3risk Asymptomatic - III) class (NYHA failure orcongestive ventricular heart dysfunction Left - Recent orcerebrovascular accident infarction myocardial 2-6weeks) the (iewithin last - status ofcardiac receiving treatment before evaluation forfurther referred -Should be Intermediate-risk disease valvular Moderate-severe - &other cardiomyopathies obstructive Hypertrophic - arrhythmias High-risk - Recent orcerebrovascular accident infarction myocardial (CVA) 2weeks the within past - (LVD) ventricular IV) dysfunction class Left (NYHA failure orcongestive heart - pressure (SBP) >180mmHg Systolic blood - Uncontrolled hypertension - angina Unstable/refractory - -Should until notreceive stable condition therapy cardiac High-risk dysfunction becomes forsexual lifestyle Sedentary prostatectomy] radical Pelvic [eg ofthe &prostate prostate surgery transuretheral (TURP), resection Pelvic &prostatic radiation therapy apnea sleep Obstructive Alcohol abuse phimosis Severe Peyronie’s disease Others Tranquillizers Antidepressants Cimetidine Narcotics diuretics) Spironolactone, thiazide Methyldopa, (beta-blockers, Antihypertensives Antiandrogens (eg Finasteride) ofattractionLoss Performance anxiety - Left ventricular dysfunction or congestive heart failure (NYHA class I or II) IorII) class (NYHA failure orcongestive ventricular heart dysfunction Left - disease heart Mildvalvular - infarction Uncomplicated myocardial previous - Post-successful revascularization coronary - treated &/or being evaluated that Mild,stable been angina has - hypertension Controlled - (excluding disease gender) artery forcoronary than factors 3risk Less - disease artery coronary Asymptomatic -

4 RISK STRATIFICATION BASED ON CARDIOVASCULAR RISK FACTORS FACTORS RISK CARDIOVASCULAR ON BASED STRATIFICATION RISK © -All1st-line therapies considered may be MIMS Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Erectile Dysfunction(4of11) 3 EVALUATION (CONT'D) EVALUATION B4 © MIMS 2019 ERECTILE DYSFUNCTION • ModifiLifestyle cation • • • • • Patient Education &Partner • • • ofGoals erapy • • • • • • • • • • Vacuum Device Constriction • • • • • • &Education Counseling Sexual • OffDiscontinue Medications ending • • Treat Factors Psychosocial - helpful may factors be risk possible Modifying  echoice together physician, by patient oftreatment decided shouldbe &partner Cultural, taken into shouldbe consideration religious &economic factors &benefi w/patient theDiscuss important risks treatment (ifpossible) &partner options&their associated ts Education may &reassurance causes duetothe failure erectile above help inpreventing further - illness ofserious asign &isnotnecessarily illnesses orchronic isduetoaging, that reassurance function men insexual may decline Some onlyneed &counseling education topatientsProvide &their partners modifi factor Initiate &risk lifestyle cations &treat any dysfunction oferectile curableIdentify causes - - - Side eff ejaculation &slowed bruising petechiae, pain,numbness, include penile ects cumbersome as seen May be onan“on used May be demand” basis &effLow-cost 35-84% from rates satisfaction vary reported ective; disorders oronanticoagulant inpatientsContraindicated w/bleeding therapy therapy patients iscontraindicated by Preferred pharmacological orinwhommedication whodonotwant touse used limiter shouldbe w/ avacuum Only devices Highly eff etiology dysfunction oferectile regardless ininducingerections ective bandplaced at elastic by the inpenis base isretained Blood drawn into tobe the penis causing blood tothepenis pressure isapplied Negative pendulous applicability broad &has itisnoninvasive patients/partners counseling by preferred may because Sexual &education be treatment dysfunction for erectile therapy adjunct toother patient’sUse toaddress as dysfunction erectile totheir reaction need psychological may &individual benefi issues duetopsychologic may drive be sexual Decreased therapy sexual t from fi (eg factors stress work, relationship &correct toaddress issues, used May be family,nances, etc) appropriateMay be forpatient &/orpartner Encompass therapy, sex therapy therapy &marital psychosocial - Many common may medications aff function malesexual ect ofmisinformation education/correction Sexual orsubstanceConfronting abuse depression -

Resolving partner relationship partner issues Resolving  treatment may refuse ey Smoking cessation Reduce alcohol/drug abuse © reported been has rare butskinnecrosis are very events adverse Serious MIMS anti-androgens many &steroids antihypertensives, anti-arrhythmics, antipsychotics, Eg antidepressants, exercise & weightRegular management Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing A NON-PHARMACOLOGICAL THERAPY Erectile Dysfunction(5of11) B5 © MIMS 2019 ERECTILE DYSFUNCTION • Yohimbine (PO) • • • • (sublingual) Apomorphine • • • (topical) Alprostadil • • • • • • • • (PO) Inhibitors Phosphodiesterase-5 Nonspecific  Dysfunction forErectile erapy • • • • Hypogonadism/Testosterone by Defi Caused Dysfunction Erectile ciency • • Alpha - Erectogenic eff administration 20minutes within ofsublingual are usuallyseen ects Works at the agonist central ofthe system; D nervous stimulationSexual isstillrequired - interactionNo drug w/nitrates mellitus patients& diabetes healthy, safeinpatients tobe whoare otherwise Seems undergoing those disease treatment forcardiovascular Topical administration ofintraurethral eliminates the need orintracavernosal ofAlprostadil injection symptoms eff Alprostadil to be topical showed clinical trials II Phase dysfunction in erectile patientsective w/mild to severe counseled onsideeff tobe Patients need &interactions ects toother PDE-5inhibitors ifonefails Consider switching Testosterone replacement w/PDE-5inhibitors used may be apatient anon-responder as classifying before dose maximum It iscurrently that recommended stimulation patients ofaPDE5inhibitorw/sexual receive at 8doses a muscle &enhances smooth inthe cavernosa rigidity relaxation corpora penile Increases - 5,which isfoundinthe tissue penile type phosphodiesterase Works inhibits peripherally; ofpatientssubgroups (eg mellitus whohave men &those w/diabetes hadaprostatectomy) Have proven effi &inspecifi ofmen dysfunction populations w/erectile non-selected inboth &safety cacy c Highlyeff noninvasive ective, - therapy offIf there (PDE5)inhibitorsshouldbe isnocontraindication, oralphosphodiesterase-5 a1st-line as ered Eg Avanafil, Sildenafi l, Tadalafi l, Udenafi l, Vardenafi l other Patient treatment may totry options wish - defi Hormone dysfunction the may forsexual onlycause notbe ciency - If noimprovement 3months after function insexual patient 6-12 months 1-3months within Reassess then every - prostate-specifi Ifprostate [normal isnormal (BPH)] c antigen prostatic hyperplasia (PSA),nobenign - Initiate androgen replacement - months afew oflibidoover loss &progressive dysfunction inerectile Patient increase butsteady slow usuallyhas have males dysfunction erectile Not allhypogonadal Reduce/stop alcohol intake - Treat hyperlipidemia aggressively - antihypertensive medications Optimize - controlled mellitus diabetes glucoseinpoorly Regulate - factors: risk medical any existing Correct - Has been combined w/Trazodone been responsiveness Has toincrease - more eff tobe shown been Has than organic dysfunction erectile dysfunction erectile inpsychologic ective

men who have some residual erectile function &inyounger patientsmen function whohave erectile residual some effiBest for &maybetter inpatients perhaps be dysfunction w/mild-moderate erectile reported was cacy manufacturers still advise to be cautious when used w/nitrate) cautious when used manufacturers tobe stilladvise inhibitorsduetonitrate (however, use takephosphodiesterase anoption formen whocannot May be oralcohol) anxiety toandrogen are unlikely torespond replacement events, or acutemedical (eg surgery after functioning axis inhypothalamic-pituitary-gonadal decrease Patients whohave atemporary 2 ©-adrenergic antagonist MIMS Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing B PHARMACOLOGICAL THERAPY Erectile Dysfunction(6of11) B6 1 &D 2 postsynaptic receptors fordopamine receptors postsynaptic © MIMS 2019 ERECTILE DYSFUNCTION • • • • • • Penile Implants • Devices (Implanted) Penile Delivery Drug • Penile Vascular Surgery • • • • • • • • • • Intraurethral erapy • • • • • • • • • •  Injection Intracavernosal erapy Surgical approaches &infrapubic include penoscrotal Available implants ofpenile are infl classes atable (2-&3-piece) &malleable devices May have complication surgical failure &mechanical w/highrate ofpatient satisfaction associated been surgeon has experienced by When performed &highlyinvasive Irreversible other treatments fiConsidered forpatients whohave failed nal treatment patients reserved &shouldbe dysfunction forerectile inj w/pharmacological ispossible standard iferection before implants are used tried May be disease occlusion inthe arterial absence vascular ofageneralized due toafocal considered onlyinhealthy shouldbe surgery men reconstructive w/recently Arterial acquired dysfunction erectile a diff w/other therapies more invasive inhibitororproceed dysfunction forerectile erent phosphodiesterase are modifi factors above inhibitor(after A patient ofphosphodiesterase initialtrial whofails given may be ed) Timing ofdosing &frequency - Food interference w/absorption - interactions Drug - abnormalities Hormonal - dueto: inhibitormay be Failure tophosphodiesterase torespond health) including medications changerelevant intheir health status cardiovascular (especially ofeffi inhibitorsmust have follow-up regular Patients receiving phosphodiesterase cacy, sideeff &any ects eff tobe shown Intraurethral been has Alprostadil in60-70%ofpatientsective more effi studies tobe some by shown been inhibitors has alone Alprostadil over cacious  ororalphosphodiesterase w/either constriction ecombination device apenile suppositories ofAlprostadil ofthe ofsyncope risk ofphysician because under given the must supervision be dose Initial trial for the saiddrug inhibitorsorare notcandidates w/oralphosphodiesterase results inpatientsConsider whohave unsatisfactory Transfer urethra from directly tothe cavernosa ofdrug corpora invasive Less - Alternative tointracavernosal therapy injection this route via administered isAlprostadil Drug ofaction,highlyeffRapid onset ective muscle actiononthe smooth Direct corporal treatment planbeforehand Physician forurgent prepared must be patient &inform treatment erections prolonged ofthis ofpossible patientInform ofthe erection potential ofprolonged event onlyonce a24-hourperiod within used Should be ofphysician under given the must supervision be dose Initial trial therapyInvasive &therefore trainingofpatient proper inintracavernosal isnecessary injection effMost forpriapism risk highest treatment buthas nonsurgical ective dysfunction forerectile tooraldrugs inpatientsIndicated notresponding this route via administered are Alprostadil, Drugs & © MIMS Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not B Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing PHARMACOLOGICAL THERAPY (CONT’D) D Erectile Dysfunction(7of11) SURGICAL INTERVENTION C FOLLOW-UP B7 Patient’s relationship w/hispartner - alcohol use Heavy - stimulation ofadequate sexual Lack -

© MIMS 2019 ERECTILE DYSFUNCTION 1 Methyltestosterone & Testosterone the combinations forspecifi latest MIMS see are available. Please c formulations. undecanoate Testosterone propionate Testosterone enanthate Testosterone cypionate Testosterone 100mg 8hrly 10mgPO Testosterone 10mg/cap 25mg/tab 5-20mg/day PO Methyltestosterone 5mg/tab Mesterolone Fluoxymesterone Dihydrotestosterone Yohimbine Drug Drug Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All © MIMS 4 mL inj 1,000 mg/ 40 mg/cap inj 25 mg/mL inj depot 250 mg/mL inj 100 mg/mL implant 2.5% gel 8 hrly 5.4 mgPO Available Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Strength Dosage Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing ALPHA Erectile Dysfunction(8of11) to aminof6wk reduced may be 1st inj interval 10-14wk IMevery 1,00 mgslow 40-120 mg/day PO dose: Maintenance x2-3wk PO 120-160mg/day dose: Initial 25 mgIM intervals at 6-8wkcourses 4wk Repeat 2-3wk. 50-100 mgIMevery : dose climacteric Male wk IMevery3-6 mg 250 dose: Maintenance 2-3 wk 250mgIMevery dose: Initial 2-4wk 50-400 mgIMevery physiologic rangefor4-5mth testosterone levelsw/innormal usuallymaintains mg 600 requirementon individual 100-600 mgimplanted SCbased 50mg/day dose: Max 25-50 mg/day PO dose: Maintenance 8hrly Initial dose:25mgPO Apply 5-10 g topically daily g Apply 5-10 • Instructions Special • Reactions Adverse • Dosage Guidelines 2 -ADRENERGIC ANTAGONIST Contraindicated in patientsContraindicated w/renal &hepatic failure in patients w/uncontrolled BP anxiety, inBPmay occur insomnia, increase dizziness, Headaches, w/inthe 1st4wkoftherapy usuallybe itwill If apatient responds, ANDROGENS Dosage B8 1 Remarks • • • Instructions Special • Reactions Adverse • Administration >4 hr immediately lasts iferection assistance medical seek to Patient informed should be BPH or erythrocytosis apnea, sleep fl by aggravated uid retention, orotherDM conditions impairment, epilepsy, migraine, renal orhepatic disorders, CV Use w/ caution inpatients w/ - Examine prostate regularly Examine - orprostate cancerbreast inmenContraindicated w/ prostatic hyperplasia (LFTs), tests function abnormal patients, susceptible apnea in induce sleep may GIbleed, depression, fi activity,brinolytic headache, &increased hematocrit, increased LDL-C, increased impaired glucosetolerance, ofthe skin, vascularity increased hypercalciuria, hypercalcemia, edema, nitrogen, Na&water retention, volume, ejaculatory decreased stimulation, oligospermia, Priapism, excessive sexual buttocks wall, abdominal lower relative little movement eg SCinto w/ Insert area Implant:

during treatmentduring Remarks © MIMS 2019 ERECTILE DYSFUNCTION Papaverine ( E Alprostadil Drug 1 Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products ) placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All © MIMS Usual dose: 30mg/inj dose: Usual penis injintocorpuscavernosaof mg 2.5-37.5 not >3inj/wk & Not>1inj ina24hrperiod dose: Max inj technique on &trained Patient instructed shouldbe Once eff achieved: been has dose ective 60mcg dose: Max >1 hr for intercourse notlasting isachieved, until suitable erection dose previous from 5-10mcgincrements onwards: 3rd inj 7.5 mcgifnoresponse or response 5mcgifpartial 2nd inj: inj intracavernosal direct 2.5mcgby 1st inj: dysfunction: erectile etiology ormixed Vasculogenic, psychogenic 60mcg dose: Max hr achieved, notlasting>1 until suitable erection forintercourse is 5mcg 3rd inj: 2.5mcg 2nd inj: injernosal intracav- direct 1.25mcgby 1st inj: dysfunction: erectile Neurogenic w/in1hr may nextdose give no response if dose, nexttitrated administering before 1day ismadewait response If partial 1hr exceed suitable forintercourse not &does Follow is titration until response erectile supervision: medical under titration Dose Followed additional5mcgincrements by Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not INTRACAVERNOSAL INJECTIONTHERAPY Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Erectile Dysfunction(9of11) Dosage Dosage Guidelines B9 • • Instructions Special • Reactions Adverse • • • Instructions Special • Reactions Adverse erection lasts >4hr lasts erection assistance immediately if medical toseek Patient informed should be effto increase ectiveness combined w/Phentolamine been Has conc aminotransferase inserum increase fiPriapism, corporal occasional brosis, erection lasts >4hr lasts erection assistance immediately if medical toseek Patient informed shouldbe 7 days under refrigeration orw/in in 48hrat temp room (<25°C) w/ Once used reconstituted, shouldbe patients deformities w/penile sickleto priapism cell eg anemia, Use w/caution inpatients predisposed orfi edema penile hypotension brosis, ecchymosis at inj rash, site,penile priapism, erection, prolonged Penile pain,hematoma at inj site, Remarks © MIMS 2019 ERECTILE DYSFUNCTION A potdlApply contents ofunitdose Alprostadil Avanafi l Sildenafi l Drug Drug Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed 24-hr period 2administrations per dose: Max erection until the patient an achieves manner inastepwise decreased or increased may be Dose 125mcgor250 dose: Initial tointercourse10-15 minprior tourethralcream opening day, 100mg/dose 1dose/ dose: Max patient response on 50 mgbased to mg ordecrease 200 to dose May increase intercourse tosexual prior min 15-30 mg PO 100 day, 100mg/dose 1dose/ dose: Max patient response on 25 mgbased to mg ordecrease 100 to dose May increase intercoursesexual to 1hrprior PO 25mg impairment: orrenal hepatic elderly (>65yr), for dose Initial intercoursesexual to 1hrprior PO 50mg dose: Initial & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All © MIMS Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Dosage PHOSPHODIESTERASE INHIBITORS(ORAL) Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Dosage Erectile Dysfunction(10of11) INTRAURETHRAL THERAPY Dosage Guidelines • • • • • • • • • • Instructions Special • Reactions Adverse immediately if erection lasts >4hr immediately lasts iferection assistance medical toseek Patient informed shouldbe °enerativeangina disorders retinal recent hypotension, stroke severe orMI,unstable dialysis, renal hepatic failure, requiring patients failure w/severe Ritonavir, in Contraindicated Indinavir &Erythromycin. Itraconazole, Ketoconazole, 3A4inhibitors; potent CYP450 Vardenafi inpatient’s adjustment isnecessary l: Dose taking ulcer problems oractivepeptic uncontrolled bleeding DM, 6months, w/inthe last hemorrhage/infarction, stroke, MI,CABG impaired autonomic control ofBP, patients w/cerebral in patients ventricular outfl w/left orw/severely obstruction ow Use w/caution failure). heart severe (eg unstable angina, disease Udenafi inpatientsl: Contraindicated whohave underlying CV hepatic impairmentpatients severe w/impaired renal function, recent hypotension, stroke severe orMI, disorders, CV severe inpatients Contraindicated mild-moderate hepatic failure. w/ Tadalafi safeinpatients appears w/ l: 10mgdose recenthypotension, stroke orMI,degenerative disorders retinal hepatic orrenal impairment, severe severe disorders, Avanafil &Sildenafi CV inpatientsl: Contraindicated w/severe deformities w/ penile sickle topriapism cell eg patients anemia, patients predisposed in factors, risk Use w/caution inpatients CV w/preexisting inhibitors ofphosphodiesterase may doses require theDiabetics max Administer w/caution inpatients onα-adrenergic blocker Coadministration w/nitrates iscontraindicated eff tobe stimulationSexual fordrugs isrequired ective congestion, priapism nasal transient color altered dizziness, vision), flHeadache, disturbances visual (eg stomach upset, ushing, B10 • • • Instructions Special • Reactions Adverse infarction ororthostatic hypotension infarction Use w/caution inpatients cardiac w/preexisting patients intercourse inwhomsexual isinadvisable cell patients deformities), w/penile anemia, Avoid topriapism (eg sickle inpatients predisposed pregnant orlactating women &fororalsex intercourseUse condom forsexual barrier w/ at applicationredness site fullness, penile Urethral pain,urethral burning, Remarks Remarks © MIMS 2019 ERECTILE DYSFUNCTION Vardenafi l Udenafi l Tadalafi l Drug Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly PHOSPHODIESTERASE INHIBITORS(ORAL)(CONT'D) All dosage recommendations are for non-pregnant & non-breastfeeding women, are for & non-breastfeeding non-pregnant All recommendations dosage © MIMS 20 mg/dose 1dose/day, dose: Max on patient response to5mgbased or decrease to20mg dose May increase activity tosexual 25-60 minprior 10mgPO &elderly: Adults 200 mg/dose 1dose/day, dose: Max reactions adverse &tolerance to response onpatient 200 mgbased to dose May increase activity tosexual 30 min-12hrprior PO 100mg &elderly: Adults 1dose/day dose: Max 24 hrly at sametimedaily 5mgPO use: frequent Patients whoanticipate response ontheir own based Patient may adjust timing intercourse tosexual prior 30min-36hr 10-20 mgPO &elderly: Adults Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Please see the end of this section for the reference list. reference the for section this of end the see Please Dosage Erectile Dysfunction(11of11) Dosage Guidelines B11 • • • • • • • • • Instructions Special • Reactions Adverse assistance immediately if erection lasts >4hr assistance immediately lasts iferection medical toseek Patient informed should be °enerativeunstable angina disorders retinal recent hypotension, stroke severe orMI, dialysis, renal hepatic failure, requiring failure severe inpatients Contraindicated w/ & Erythromycin. Itraconazole,Ketoconazole, Ritonavir, Indinavir patient’s 3A4inhibitors; takingpotent CYP450 Vardenafi in adjustment isnecessary l: Dose ulcer problems oractivepeptic bleeding uncontrolled 6months, w/inthe DM, last CABG cerebral hemorrhage/infarction, stroke, MI, impaired autonomic control ofBP, patients w/ ventricular outfl orw/severely obstruction ow Use w/caution failure). inpatients w/left heart severe (eg unstable angina, disease underlying CV Udenafi inpatientsl: Contraindicated whohave impairment hepatic severe impaired renal function, recenthypotension, stroke orMI,patients w/ severe disorders, CV in patients w/severe Contraindicated mild-moderate hepatic failure. Tadalafi safeinpatients appears w/ l: 10mgdose MI, degenerative disorders retinal recent hypotension, impairment, stroke severe or hepatic orrenal severe disorders, CV w/ severe Avanafil &Sildenafi inpatientsl: Contraindicated sickle cell patients deformities w/penile anemia, topriapism eg inpatients predisposed factors, risk Use w/caution inpatients CV w/preexisting inhibitors phosphodiesterase of may doses require theDiabetics max Coadministration w/nitrates iscontraindicated eff ective tobe stimulationSexual fordrugs isrequired congestion, priapism nasal dizziness, disturbances (eg transient color altered vision), flHeadache, visual stomach upset, ushing, Remarks © MIMS 2019