Cardiovascular Assessment
There is now increasing evidence and knowledge about endothelial dysfunction and NO in both ED and cardiovascular disease, and it has become essential to identify and diagnose patients with ED and assess their cardiovascular status. It is also an important part in counseling patients prior to initiating therapy, as there are some risk factors that make sexual intercourse not advisable. In 2000, the Princeton Consensus Panel came up with a model to stratify patients into low-risk, intermediate-risk, and high-risk and then made decisions about treatment accordingly. The consensus study from the Second Princeton Consensus Conference in 2005 corroborates and clarifies the algorithm and emphasizes the importance of risk factor evaluation and management for all patients with ED. Below are the cardiovascular risk factors and risk categories along with an algorithm for treatment.
The take-home message is that if a patient is in the intermediate or high-risk group, they should be evaluated by a cardiologist prior to treatment for ED and initiation of sexual activity. This is a key component when considering oral pharmacotherapy treatment for ED.
Comparison of PDE-5 Inhibitors
With the available information about the different PDE5 inhibitors, is there any way to know what will be the best option for the patient? Carson and Lue looked at all the different drugs and trials and concluded there is no feasible way to compare sildenafil, vardenafil, and tadalafil with the current data. These drugs have all been shown to be effective in the treatment of ED and are well tolerated. Even in the more difficult to treat patients (diabetic ED, or postprostatectomy) they have the ability to improve erectile function. The Sildenafil Diabetes Study Group showed that over 50% of men with ED and diabetes mellitus had improved erections as compared to placebo. Several studies have shown the benefit of PDE5 inhibitors post prostatectomy, while the best results are in men who have had nerve sparing surgery.
After prescribing a drug for ED, the patient must be followed up and patient preference and partner satisfaction should be evaluated. If the patient is discouraged about lack of effectiveness, there has been data to show that with continued use, the probability of success increases. McCullough et al. showed there is increased success after the first 9–10 attempts with sildenafil canadian pharmacy. There have also been trials to show improvement in erectile function with vardenafil in sildenafil nonresponders. It is advisable to try a different oral therapy if the first one fails.
Even though over 60% of men will respond, there are still reasons men will not be compliant with effective therapy. Klotz et al. looked at 234 patients with successful response to sildenafil and determined that only 161 (69%) refilled their prescription. Of the 73 patients that did not refill the prescription, the most common reason was lack of opportunity or desire for sexual intercourse (45%). Lack of partner interest (23%) was the second most common reason with high cost of medication (12%) and adverse effects (5%) as less prevalent reasons. This information highlights the importance of communication with the patient to meet their goals in treatment for ED.
Аpomorphine. This is a dopamine agonist that acts in the PVN. The peak plasma concentration is reached at 40–60 min and the t ½ is 3 h. Several studies have been done to look at apomorphine versus placebo and other oral agents. Dula et al. showed that apomorphine was better than placebo in attaining firm erections and increasing intercourse rate. However, in men who are diabetic or who have undergone radical prostatectomy, there has been no evidence to show that apomorphine is effective. There are also side effects, including dizziness, nausea, and vomiting that limit patient use. When compared to sildenafil, most patients preferred sildenafil and had better satisfaction scores. Although safe, apomorphine has not been shown to be very effective. Canadian health care mall cialis – cheap tadalafil meds online.
Yohimbine is another centrally acting agent that also works at the peripheral a adrenoreceptors as an antagonist. Yohimbine is a substance from the Corynanthe yohimbe tree, which has been touted as an aphrodisiac.