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hypotension and syncope. Sildenafil is contraindi- cated in patients taking nitrates. If a man who has taken sildenafil has an acute ischemic syndrome, nitrates should not be prescribed within 24 hours. b.Sildenafil has been associated with myocardial infarction and sudden death. It does not appear to have adverse effects on coronary hemodynamics. Sildenafil is safe for men with stable coronary artery disease who are not taking nitrates. 5.Sildenafil causes blue vision in 3 percent of men, lasting two to three hours. Sildenafil is potentially hazardous in the following: a.Active coronary ischemia (eg, positive exercise test). b.Heart failure and borderline low blood pressure or low volume status. c.Complicated, multidrug, antihypertensive drug regimens. d.Those taking drugs that can prolong the half-life of sildenafil by blocking CYP3A4X. 6.Men who are considering sildenafil should be questioned regarding exercise tolerance. Sildenafil can be considered in men who are participating in aerobic activities. If such activity cannot be documented, exercise treadmill testing should be considered. B.Vardenafil (Levitra) is a phosphodiesterase inhibitor, which is similar to sildenafil. The dosage is 10 mg, taken 60 min before sexual activity. C.Tadalafil (Cialis) is a more selective and more potent phosphodiesterase inhibitor than sildenafil, and it has a more rapid onset of action, and a longer duration of action (36 hours) than sildenafil, allowing for more spontaneity in sexual activity. The dosage is 10-20 mg before sexual activity. D.Penile self-injection 1.Intrapenile injection therapy with alprostadil (prosta- glandin E1, Caverject), papaverine, or alprostadil with papaverine and phentolamine (Tri-Mix) have all been used to induce erection. Firm erection can be expected within a few minutes after intrapenile installation of the drug. 2.Alprostadil (Caverject) injection results in satisfac- tory sexual activity in 87 percent of the men. There is a very high attrition rate. 3.Side effects. The major side effect of intrapenile alprostadil therapy is penile pain, occurring in 50 percent. Priapism, or a prolonged erection lasting more than four to six hours, requires immediate urologic attention to evacuate blood clogged within the corpora cavernosae. Prolonged erections occur in 6 to 11%. E.Intraurethral alprostadil (MUSE) provides a less invasive alternative to intrapenile injection. Two-thirds of men respond to intraurethral alprostadil with an erection sufficient for intercourse. Priapism and penile fibrosis were less common than after alprostadil given by penile injection. F.Vacuum-assisted erection devices utilize vacuum pressure to encourage increased arterial inflow and occlusive rings to discourage venous egress. Patients cannot, however, ejaculate externally because the occlusive rings also compress the penile urethra. Vacuum devices create erections in 67 percent. Satisfaction with vacuum-assisted erections has varies between 25 and 49 percent. G.Penile prostheses. Drug and penile injection therapy has greatly reduced reliance on surgical implants of penile prostheses as a treatment for men with erectile dysfunc- tion. This form of therapy remains an option for those men who do not respond to sildenafil and find penile injection or vacuum erection therapy distasteful. H.Androgen replacement therapy requires either injections of long-acting testosterone esters, one of three available testosterone patches, or testosterone gel (Androgel). One patch (Testoderm) is applied once a day to the scrotum. Androderm and Testoderm TTS are applied daily to the torso or extremities. Androgel is applied as one packet once a day to the upper arm, chest, or abdomen. VII.Premature ejaculation is defined as an inability to control ejaculation so that both partners enjoy sexual intercourse. Approximately 20 percent of men complain of premature ejaculation. Nonpharmacologic therapy such as the "pause and squeeze" technique has achieved variable success, but drug therapy has proved quite useful. A.With Paroxetine (Paxil, 20 mg) three to four hours before planned intercourse, the mean ejaculatory latency time is significantly increased compared with placebo (3.2 versus 0.45 minutes). References: See page 255. Psychiatric Disorders Depression The lifetime prevalence of major depression in the United States is 17 percent. In primary care, depression has a prevalence rate of 4.8 to 8.6 percent. I.Diagnosis A.The Diagnostic and Statistical Manual of Mental Disor- ders (DSM-IV) includes nine symptoms in the diagnosis of major depression. B.These nine symptoms can be divided into two clusters: (1) physical or neurovegetative symptoms and (2) psycho- logic or psychosocial symptoms. The nine symptoms are: depressed mood plus sleep disturbance; interest/pleasure reduction; guilt feelings or thoughts of worthlessness; energy changes/fatigue; concentration/attention impairment; appetite/weight changes; psychomotor disturbances, and suicidal thoughts. Diagnostic Criteria for Major Depression, DSM IV Cluster 1: Physical or neurovegetative symptoms Sleep disturbance Appetite/weight changes Attention/concentration problem Energy-level change/fatigue Psychomotor disturbance Cluster 2: Psychologic or psychosocial symptoms Depressed mood and/or Interest/pleasure reduction Guilt feelings Suicidal thoughts Note: Diagnosis of major depression requires at least one of the first two symptoms under cluster 2 and four of the remain- ing symptoms to be present for at least two weeks. Symp- toms should not be accounted for by bereavement. II.Drug Therapy Characteristics of Common Antidepressants Drug Recommended Comments Dosage Selective Serotonin Reuptake Inhibitors (SSRIs) Escitalopr 10 mg qd am Minimal sedation, activa- (Lexapro) tion, or inhibition of hepatic enzymes, nausea, anorgasmia, headache Citalopra Initially 20 mg qd; [ Pobierz całość w formacie PDF ] |
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