 |
|
|
|
 |
|
 |
|
|
 |
||
This Month's Questions:
A study by Cameron et al showed that, in many cases, a diagnosis of erectile dysfunction (ED) quickly leads to a diagnosis of other underlying medical conditions. How does the timing of these diagnoses assist clinicians in managing men’s overall health? Response by Raymond A. Costabile, MD, Posted 11/17/06: It has been well established that ED is associated with several other medical conditions, including hypertension, diabetes, hyperlipidemia, depression, benign prostate hypertrophy/lower urinary tract symptoms (BPH/LUTS), and cardiovascular disease To examine this association, Cameron et al conducted a retrospective study that found a correlation between the diagnosis of comorbid conditions in both the 12-month period before the ED diagnosis and the 6-month period after the ED diagnosis.6 More than 80% of the diagnoses of hypertension (81%), diabetes (83%), and BPH/LUTS (82%), and 74% of the diagnoses for CVD were made before the diagnosis of ED,6 indicating that clinicians may be more likely to evaluate sexual function after identifying one of these conditions. Notably, a substantial number of men were diagnosed with these comorbid conditions during the 6 months after their ED diagnosis, with the average time to diagnosis being 2 to 3 months. Approximately 25% of each of the diagnoses of high cholesterol, depression, and CVD were made at approximately 77 days; diabetes, prostate cancer, and BPH/LUTS were identified at approximately 66 days.6 These findings suggest that ED may serve as a marker for previously undetected conditions.1,6,7 The Minority Health Institute Expert Advisory Panel recommends that men aged 25 years and older be queried about their sexual health and function based on the strong evidence indicating that ED is an early clinical manifestation of systemic vascular disease.7 Clinicians may therefore include ED assessment for earlier detection and treatment of comorbid conditions.1,6 ED can be viewed as a window into a patient’s overall health and well-being, particularly in disease states that are frequently “silent” during the early stages. The diagnosis of ED is an opportunity to make positive improvements in a patient’s life. Phosphodiesterase type 5 (PDE5) inhibitors are first-line therapy for managing ED. Because of the common link (via endothelial dysfunction) between risk factors for ED and comorbid conditions, it appears likely that risk modification may improve clinical response to PDE5 inhibitor therapy.8 Treatment of ED with PDE5 inhibitors may improve men’s overall health.
References
Phosphodiesterase type 5 (PDE5) inhibitors can be purchased and distributed via the Internet and the black market for self-prescribed or recreational use. Have alternate means of access to PDE5 inhibitors and inappropriate use resulted in negative consequences? What information can clinicians relay to their patients to explain why such use is harmful and may have negative effects? Response by Irving Fishman, MD, Posted 11/07/06: As with many pharmacotherapeutic agents, PDE5 inhibitors are available through means other than the legal healthcare system pathways, specifically via the Internet and the black market.1 This increased accessibility creates potential problems for men—both those with erectile dysfunction (ED) and those without—taking the drugs outside the established medical framework. Although PDE5 inhibitors are safe and well tolerated when used as directed, men might not be aware of specific contraindications without input from their clinician. Men with ED who self-prescribe PDE5 inhibitors expose themselves to potential negative drug interactions and harmful physical effects. For example, PDE5 inhibitors are contraindicated for patients receiving nitrates because they potentiate the profound, rapid vasodilation caused by nitrates and can cause a dangerous drop in blood pressure.2 Orthostatic hypotension may develop in a patient who takes an α-blocker for the treatment of hypertension or benign prostatic hyperplasia, conditions often comorbid with ED.2,3 Also, when PDE5 inhibitors are administered with drugs metabolized by CYP3A4, the risk for adverse events is increased.3 These scenarios underscore the need for patients to receive medical counseling in conjunction with PDE5 inhibitor use.4 Some healthy men obtain PDE5 inhibitors to enhance their sexual performance in social, recreational settings. Not only are these men susceptible to the same negative consequences described previously, but they run the risk of additional adverse events if they combine PDE5 inhibitors with “club drugs” such as methylenedioxymethamphetamine (“ecstasy”) or amyl and butyl nitrates (“poppers”) as well as antiretroviral drugs and protease inhibitors.1,5-7 To reduce the likelihood of PDE5 inhibitor use with club drugs and the attendant potential health hazards, men should be made aware that a single dose of sildenafil does not improve erections in young healthy men.7 Another concern about recreational use of PDE5 inhibitors involves the possible exacerbation of high-risk sexual practices and the spread of sexually transmitted diseases and human immunodeficiency virus (HIV).5,6 The potential for misuse of PDE5 inhibitors and the subsequent negative consequences highlight the need for clinicians to inquire about sexual health as part of a routine examination so that patients become more comfortable discussing the topic. Many men who experience ED may be embarrassed to discuss this topic with their clinician and may seek alternate sources for treatment.8 Published guidelines are available to assist clinicians in the management of sexual function concerns. Thorough assessment of men seeking treatment for ED is strongly recommended,8 and patients should be discouraged from obtaining PDE5 inhibitors without a prescription and from using them in social or recreational environments.7
References
To view archived responses, click here.
|
