Erectile Dysfunction Comparison Chart (ED) Treatment Chart 1,2,3,4,5,6,7,8 Canadian 2006 S Downey, B Jensen, L Regier © www.RxFiles.ca June 10 Generic/TRADE Class / Side effects / Contraindications CI √ = therapeutic use / Comments / INITIAL;MAX; $ (Strength & forms) Pregnancy category 9 Drug Interactions DI / Monitor M USUAL DOSE 8 doses 10% 4% 2% √idiopathic, postencephalitic, symptomatic (Option: SSRI induced ED) Sildenafil Oral selective Common: flushing , diarrhea , dizziness , S 25-50mgÆ $99-102 V,S,T V,S >10% <8% (Onset similar: generally 30-60min ; as early as 10-15min ); S&T: pulmonary arterial HTN. VIAGRA =S phosphodiesterase-5 headache ,dyspepsia , blurry vision (visual 100mg x1/24h $109 35 25, 50, 100mg tab χ⊗ PDE5 inhibitor: disturbance > with S,V), myalgia (T=6% ), nasal Peak effect: S &V ~1hr; T ~2hr; Duration: S&V~4-12hr T ≤ 36hr 50-100mg, 10,11,12,13,14 ; approved 1999 congestion & rash 2% esp S ; GI upset dose-related & DI: ↑ hypotension: α-1 blockers (especially in new pt; avoid or space by >4hrs); 30-60min pre-sex -reduce catabolism of ⊗≥ (>10% at dose high (Revatio ), nitrates (CI or caution); antihypertensives (esp. vasodilators) & alcohol 20-80mg tab tid $1050 cGMP resulting in smooth visual disturbance ?(↓smell, →PAH) see QT chart p.17 T 5-10mgÆ $125 per month,new:USAIVform Nitrate washout period V amnesia,hearing loss). [hot flashes if used in ] : S & V~24hr; T ~48hr. :QT muscle relaxation of the ↑ levels of PDE5 by: CYP 3A4 inhibitors (azole antifungals, cimetidine, cipro, erythromycin/ 20mg x1/24h $122 Tadalafil corpus cavernosum and Serious: rare MI & *priapism; QT prolongation –V, juice inhibitors 23 cell crisis macrolides, tacrolimus), doxycycline, grapefruit , isoniazid, protease , 10-20mg 1-2hr very rare cases of NAION ,?seizures, ?sickle Max interval q24h Max interval q72h ↑ blood flow into penis CIALIS =T quinidine, verapamil. (PDE5:use lowest dose; S,V: T: ) pre-sex carbamazepine, phenytoin, phenobarb, rifampin 15,16 (need sexual stimulation to CI: nitrates: ↑↑ hypotensive effect & ↑↑ heart rate 2.5,5,10,20mg tab χ⊗ 31 ↓ effect: enzyme inducers ; ↓S&T by bosentan. 2.5-5mg daily 30days option $132 (Adcirca χ ⊗ produce actual erection) (AVOID within 24h of S,V; 48h of T ); 20-40mgtabod FDA’09; high fat meals may delay and reduce efficacy of S & V. S >25mg ,T,V α-1 blockers (if new pt or if given ≤ 4hrs) glucose, lipid, TSH, testosterone USA is IV form→PAH) -considered FIRST LINE M:S,T= liver & renal fx, V=liver fx tests (Initial workup usually: ) Precautions: anatomical penis deformation; CV dx Vardenafil unless CI, but ~30% of men Dose Adjustments: >65years old: initial; S=25 mg T= by CrCl V=5mg V 5-10mgÆ $102-111 may still not respond to (eg. arrhythmia,recent MI/stroke,uncontrolled HTN, Liver dx: Initial S=25 mg, T=10mg V=5mg 20mg x1 /24h $119 LEVITRA =V PDE5’s monotherapy. coronary ischemia, HF); ↑ risk of priapism* (eg, Renal dx CrCl <30mL/min: Initial S=25 mg T=5mg V= no adjustment 10-20mg, 5,10, 20mg tab χ⊗ sickle cell anemia, multiple myeloma, or leukemia); Daily or 3x/week dosing may be more efficacious for poor responders 36 30-60min pre-sex 17,18,19,20,21,22,23,24,25,26 27 36 B liver dx; multi BP meds; ↓ renal fx; NAION ; < 5% of Non-responders will respond to a different PDE-5 inhibitor Frequently as adulterants in herbs: Acai Berry products, Actra-Sx,STDs; Adam retinitisFree, Armstong pigmentosa/ Natural, Aspire36retinal & Aspire abnormalities LIte, Aspire T preferred Lite,. Axcil, 4Everon, Actra-Rx, Blue Steel, China Vigour, Chong Cao Ju Wang , Chongcaoliubian Jiaonang, Darling Caps, Dali Caps, Deguozhanjiang, Deguozonghengtianxia, Desirin, Dr. Life, Ehanix New Extra Men's Formula, Encore tabs for Men, Energy Max, Erextra, Excite, Firm Dose, Granite Rooster, Herb Vigour, Hero, HS Joy of Love, Jia Yi Jian, Jolex, Jiu Bian Wang, Kang Da, King Power Oral Soln, Lady Shangai, Libidfit, Libidus, Libimax, Libipower Plus, Liviro3, Max V& Rhino, Lover Liquid Nutriment, Lu Quan, Meng Rong, Nangen Zengzhangsu, Nasutra, Naturalë Super Plus, NaturalUp, Natural Vigour, Neophase,Once More, Onyo, Oyster Plus, Platinum Power 58 Extra, Power 58, Power 1 Walnut, Powertabs, Power Up, Santi Scalper Penis Erection, Rize 2 The Occasion Caps, Rockhard Weekend, Rose 4 Her Capsules, Sanbianwan,Satis 60hr Ever Lasting, Shangai Regular & Ultra & X, Spanish Fly ,Stamina Rx, Steam, Stiff Nights, Stretch Up, Strong Testis, Super Shangai, Super X, Sweet Energizer Vitality, Tian Li, Tian Huang Gu Shen Dan, Top Gun for Men Herbal Extracts,True Man, Ultimates, Urat Madu, Valentino, for men Vigoureux, VG, Vigor-25, Vigorect, Viril-ity Power vpxl No1, Yilishen, Yixinjiaonang, Xiadafil VIP, XOX , XP Tongkat Ali Supreme, Viapro, Viril-Ity -Power, Wodibo, Zencore & Plus, Zhong Guo Shen Fang , Zhong Hua Niu Bian, Zhuang Yao Gu Shen, Zhuang Tjar Gere, Zui Xian Dan Gon g Shi Z, Zimaxx etc.. Ch C Neurogenic ED: Alprostadil χ⊗ 7% 14% √ vasculogenic, psychogenic, neurogenic & mixed $248 Prostaglandin E Common: ↓ HR , dizziness, fever , headache, Titrate from 1 ug CAVERJECT, 4% 37% 3% Onset = rapid Duration= <1hr 10 doses -activates cAMP which hypotension , penile pain , penile fibrosis , Usual: 2-5ug 20 ug vial (powder) 3% CAVERJECT tachycardia , urethral burning, vaginal itch (in Initial dosage/titration should occur under medical supervision (due to risk of Vascular ED: intracavernosal inj. relaxes smooth muscle and partner with transurethral systems) syncope). Pts receiving intracavernosal inj should be assessed by Dr. q12months Titrate from 4ug produces vasodilation 28 33 MUSE 4% <4% Vascular ED requires larger doses (>20ug) vs neurogenic ED (2-5ug) Usual: 5-20ug (also inhibition of platelet Serious: seizures , priapism* , HF, second degree 250, 500, 1000 ug Injection: no more than 3 doses/week (with 24 hours between doses) Severe: 40-60ug $200 aggregation and gastric heart block, supraventricular tachycardia, ventricular Inject 10-30mins urethral supp <1% Suppositories: no more than 2 within 24 hours 8 doses secretion, stimulation of fibrillation , disseminated intravascular pre-sex (refrigerate; otherwise 1% MUSE intestinal smooth muscle, coagulation & cortical proliferation of long bones ↓ dose if erection lasts greater than one hour with either system 125-250ug; 14days at RT) 29,30,31 uterine smooth muscle) CI: anatomical penis deformation, penile implant, 1000ug x1/24h Seek medical assistance if tx results in erection that lasts >4 hr. $55-85 Prostaglandin χ⊗ predisposition to priapism* (sickle cell anemia or trait, DI: heparin (↑ partial thromboplastin time & thrombin time); ↑ risk of 250-500ug -most efficacious of pre-sex 32 leukemia, myeloma), Peyronie's disease symptomatic hypotension, syncope with vasodilators, antihypertensives, alcohol 10-30mins 5ml vial E1 (PGE1) = E1 injectable agents Precautions: concurrent anticoagulant, vasoactive (dose depends on 0.5-1ml/dose inj corpora cavernosa; X M: *priapism (erection lasting >4hr) tx=needle aspiration of penile blood; agents or bleeding abnormalities venous anatomy compounded transurethral gel intracavernosal inj phenyleprhine 200ug q5min up to 500ug if needed) 34 not ED etiology) Common: abdominal discomfort, anorexia, Papaverine = Pv Vasodilator √ idiopathic, postencephalitic & symptomatic (not FDA indication) 30 mg constipation, diarrhea, nausea, vomiting, 30mg/ml inj. soln (non-selective PDE 2,3,4 Papaverine in any ischemic type condition is not recommended. $40 drowsiness, headache, vertigo, hypertension, 60mg (2ml vials) χ⊗ inhibitor) Do not use more than 3 times weekly or 2 days in succession. 30mg-60mg 10x2ml tachycardia, pruritis, rash & blurred vision? Combos: -0.5-1 mg phentolamine intracavernosal; -produces generalized intracavernosal vials Serious: acidosis, ↑intercranial pressure, phentolamine & alprostadil by intracavernosal inj arteriolar dilation & over 1-2 min smooth muscle relaxation hepatotoxicity & priapism* Consult Dr. if erection lasts more than 4 hours after self inj -can be combined with CI: complete atrioventricular block T½= 0.5-2hr Compounded Products Precautions: glaucoma, liver dx, recent MI, stroke, prostaglandin &/or C DI: levodopa (↓ levodopa affect), ginkgo (↑ SE of papaverine) Bi-mix inj = Pt + Pv phentolamine Parkinsonism & sickle cell anemia M: intraocular pressure in glaucoma patients, liver fx 6ml vial = $60 3% Phentolamine χ⊗ Alpha-Adrenergic Common: chest pain, diarrhea, dizziness , √ idiopathic, postencephalitic & symptomatic (not FDA indication) 0.5-1ml/dose 3% 2% 10% = Pt Blocker headache , hypotension , nasal congestion , Take one hour prior to sexual activity Tri-Mix inj =Pt + Pv + E1 nausea, palpitations1%, ↑HR1-7% & vomiting in 3 strengths -antagonizes anti-erectile Peak activity: 30-60min Onset of action: 30-40min Duration: 5-7hr Rogitine, generic Serious: arrhythmia $60-80 per 5ml vial 5mg lypholized sympathetic tone, ↑perfusion Compounded mixes may ↑ efficacy and ↓ pain associated with prostaglandin CI: myocardial infarction, CAD, angina pectoris, 0.2-1ml per dose powder for injection - poor efficacy alone so DI: ↑ hypotension: beta blockers, tadalafil & vardenafil; disulfiram like rx with hypersensitivity to phentolamine or mannitol, renal TriMix also available in usually combined with impairment, coronary or cerebral arteriosclerosis alcohol; ↓ effect with ephedrine (OTC cough/cold products, diet & “wake-up” pills) Transurethral gel As adulterants in: prostaglandin &/or Desire Precautions: arrhythmia, cerebral vascular spasm M: blood pressure changes, heart rate $40-120 / 5x1ml syr papaverine C or occlusion,