Erectile Dysfunction Management Using PDE5 Inhibitors

Publication: 18/06/2012  --
Last review: 05/09/2019  
Next review: 01/09/2024  
Clinical Guideline
CURRENT 
ID: 2978 
Approved By: Leeds Area Prescribing Committee 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Erectile Dysfunction Management Using PDE5 Inhibitors

Summary - Pathway for Patient Presenting in Primary Care

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Aims

To improve the management of erectile dysfunction in primary care.

To highlight when it is appropriate to refer patients to a secondary care setting.

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Primary Care Investigation

Patient presents to General Practitioner with erectile dysfunction-confirm the diagnosis, assess the patients  
expectations and complete a full history.

Patient History:

  • Identify causative risk factors; 
  • Cardiovascular disease may indicate vascular insufficiency
  • Diabetes (ED may be common) 
  • Neurological disease e.g. multiple sclerosis 
  • Relationship status (current and past) and sexual orientation 
  • Assess  previous erection quality (including erections during sexual relations
  • as well as awakening and masturbatory erections), and concomitant ejaculatory and orgasm dysfunction 
  • Issues with sexual aversion or pain, or issues for  partner (including menopause or vaginal pain) 
  • Lifestyle, including use of alcohol, tobacco, and illicit drugs ( including cannabis) and treatments already tried
  • Energy levels, loss of libido, loss of body hair or spontaneous hot flushes (symptoms of hypogonadism) 

Medication review

Drug therapy may account for erectile dysfunction in a number of presenting cases and may possibly be reversible when the offending agent is stopped, or a suitable alternative is substituted. It is important that a drug related effect is considered at the outset, thus avoiding unnecessary investigation and inappropriate use of specific therapies.

 

Medications which may contribute to erectile dysfunction 

Drug Class

Examples

Diuretics

Thiazides (e.g. bendroflumethiazide) spironolactone

Antihypertensives

Methyldopa, clonidine, beta-blockers (e.g. propranolol, verapamil

Fibrates

Clofibrate, gemfibrozil

Antipsychotics

Phenothiazines (e.g. chlorpromazine), butyrophenones (e.g. haloperidol)

H2 antagonists

Cimetidine, ranitidine

Hormones and hormone modifying drugs

Oestrogens, progesterone, corticosteroids, cyproterone acetate, 5-alpha reductase inhibitors

Cytotoxics

Cyclophosphamide, methotrexate

Anti-arrhythmics and anticonvulsants

Disopyramide

Antidepressants

Tricyclics , SSRIs

Use doxazosin, indoramin, terazosin, prazosin with caution due to increased risk of postural hypotension unless patient has finished alpha-blocker dose titration and are on a stable dose.

 

Examination

  • All men should have measurement of body weight, waist circumference, heart rate and blood pressure
  • Examination of the genitalia may reveal hypogonadism or malformation such as Peyronie’s disease.
  • Check for gynaecomastia and reduced body hair
  • A digital rectal examination is recommended to assess prostate if there are genito-urinary or protracted secondary ejaculation symptoms (e.g. suspected prostate problems)

Investigations

  • Calculate the 10 year cardiovascular risk using Qrisk2.  
  • Erectile dysfunction is part of a spectrum of generalised arteriopathy, and is an early indicator of cardiovascular disease. It may be important to consider preventative treatment (e.g. statins) in those at risk, to reduce morbidity and mortality.
  • Measure serum testosterone in the morning between 8am and 11am. Low testosterone may indicate pituitary disease or testicular failure. If testosterone levels are low repeat the measurement, and also measure follicle-stimulating hormone (FSH), luteinizing hormone (LH) and prolactin levels. Refer patient to urology if patient has two low/borderline test results.
  • For Men with severe cardiovascular disease in whom sexual activity would be unsafe or where PDE5 inhibitors are unsafe, refer to cardiology if appropriate

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Treatment / Management

Primary care management for all patients
Counsel the patient that erectile dysfunction usually responds well to a combination of lifestyle changes and drug treatment.

  • Advise patient to lose weight, stop smoking, reduce alcohol consumption and increase exercise
  • Undertake optimisation of blood pressure, lipid profile and blood sugar
  • Advise men who cycle for more than 3 hours per week to undertake a trial period without cycling to see if erectile function improves
    • If it is not possible for them to stop cycling, preventative measures such as the use of a properly fitted bicycle
      Seat and riding with the seat in a suitable position, may help prevent impairment of erectile function.
  • Advise the man not to take unlicensed herbal remedies for erectile dysfunction as they may contain prescription-only medicines which may be contraindicated or interact with prescribed medication.
  • Advice and support is also available from the Sexual Dysfunction Association www.sda.uk.net
  • After optimisation management the patient should be assessed for suitability for PDE5 inhibitor therapy. If they are suitable they should be trialed on generic sildenafil by their GP as first line.

Patients  presenting in secondary care who are  suitable for primary care treatment (Appendix 1) or have had an incomplete trial of PDE5 inhibitors will be referred back to their primary care provider.

Patients suitable for primary care treatment
Patient should be trialed on generic sildenafil as a first line oral agent. If this fails follow the treatment pathway.

Provide the patients with suitable information regarding PDE5 inhibitor therapy.

Patient information leaflets can be found at www.medicines.org.uk

Contraindications to PDE5 inhibitor therapy can be checked at www.medicines.org.uk

NHS Choices has useful information on Erectile dysfunction
https://www.nhs.uk/conditions/erection-problems-erectile-dysfunction/

The British Association of Urological Surgeons (BAUS) has produced an information leaflet on Erectile dysfunction.
http://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Erectile%20dysfunction.pdf
         
How do PDE5 inhibitors work?

Normal physiological mechanism responsible for erection involves the release of nitric oxide (NO) in the corpus cavernosum during sexual stimulation. The nitric oxide then activates guanylate cyclase which is an enzyme that causes increase levels of cyclic guanosine monophosphate(cGMP), producing smooth muscle relaxation and allowing blood flow.

Phosphodiesterase type 5 (PDE5) is responsible for degradation of cGMP. Inhibition of PDE5 by PDE5 inhibitors results in increased levels of cGMP in the corpus cavernosum leading to erection. As NO/cGMP pathway is only activated in the presence of sexual stimulation, PDE5 inhibitors for ED have no effect in the absence of sexual stimulation.

A brief summary of dosing is shown below.

 

Sildenafil  (Viagra® )

Tadalafil (Cialis®)

Vardenafil (Levitra®)

Recommended
starting dose

50mg (Dose can be
titrated to 100mg or reduced
to 25mg depending on
tolerability)

10mg (usual dose range
10-20mg)

10mg (usual dose
range 10-20mg)

Time to take
before sexual
activity

60 minutes

30 minutes to 12 hours

25 to 60 minutes

Time to max
plasma conc.

Mean 1 hour (30-120 minutes). Delayed by 60 minutes if Delayed by 60minutes if
taken with taken with food.

Mean 2 hours, range 30
minutes to 12 hours.
Unaffected by food.

30-120 minutes. 15
minutes in some cases.
High fat meal may
delay absorption.

Half life

3-5hours

17.5 hours

4-5 hours

Duration of
action

Up to 4 hours

Up to 24 hours

Up to 5 hours

Special
Populations

Consider starting dose of
25mg in patients
with reduced renal and
hepatic function

Maximum dose of 10mg in
eGFR<30 and hepatic
impairment

Consider starting
Dose of 5 mg in
those with mild
moderate hepatic
or
severe renal
 impairment

Patients should be prescribed 12 doses of a PDE5 inhibitor and planned for follow up review after 3 months.
If treatment is successful it is up to the primary care providers discretion of how to provide further repeat prescriptions to the patient. Primary care providers should not add PDE5 inhibitors on to repeat prescription until a 3 month review has taken place.

Discussion at follow up reviews

  • Where possible, involve the man's partner in follow-up appointments (bearing in mind the sensitive nature of the condition).
  • Ask about the effectiveness of treatment.
  • If treatment has not been satisfactorily effective:
    • Counsel about the appropriate use of phosphodiesterase-5 (PDE-5) inhibitors. Ensure that the man is aware that PDE-5 inhibitors are not initiators of erection but require sexual stimulation in order to facilitate erection.
    • Reconsider comorbidities and treat where possible. In particular, consider the possibility of hypogonadism (which makes PDE-5 inhibitors ineffective).
    • Consider increasing to the maximum dose, or switching to an alternative PDE-5 inhibitor.

PDE5 inhibitors are not licensed for those under the age of 18 years.

Interaction of the PDE5 inhibitors with food, particularly fatty food, is greatest with sildenafil and least with tadalafil.

Use of nitrates (e.g. isosorbide mononitrate or dinitrate, nitroglycerine (GTN), nicorandil including recreational drugs such as amyl nitrates (poppers) in conjunction with PDE5 inhibitors can lead to excessive hypotension and vasodilation. Hence use of nitrates is an absolute contradiction with PDE5 inhibitors.

The combination of sildenafil with ritonavir should be avoided.

Caution should be used in patients taking CYP3A4 inhibitors e.g. erythromycin, azole antifungals, protease inhibitors-

Co-administration of PDE5 inhibitors with antihypertensive agents may result in a small additive drop in blood pressure.

 

Non responders

  • Approximately 25% of patients do not respond to PDE5 inhibitors
  • Patients should be exposed to preferably 8 doses of the highest tolerated dose  of three drugs (taken sequentially not concurrently) with adequate sexual stimulation
  • So called failure may be due to sub-optimal counseling at the initial consultation, which should aim to ensure that the patient understands how to take the medication correctly.

Several methods are described in the literature to salvage patients who are clearly identified as non responders;

  • Counsel again on proper use
  • Optimise treatment of concurrent diseases and frequently evaluate for new risk factors.
  • Consider if the patient needs to be treated for hypogonadism
  • Remember that patients may respond to one drug when another has failed

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Provenance

Record: 2978
Objective:

 

To provide evidence-based recommendations for appropriate diagnosis, investigation and management of 
erectile dysfunction.

To provide evidence-based recommendations for appropriate diagnosis, investigation and management of erectile dysfunction.

 

Clinical condition:

Erectile dysfunction

Target patient group: Patients aged over 18 years
Target professional group(s): Primary Care Nurses
Primary Care Doctors
Secondary Care Doctors
Secondary Care Nurses
Pharmacists
Adapted from:

Evidence base

Drug Tariff
https://www.nhsbsa.nhs.uk/pharmacies-gp-practices-and-appliance-contractors/drug-tariff

Erectile Dysfunction Management produced by NHS Clinical knowledge Summaries
http://cks.nice.org.uk/erectile-dysfunction

Guidelines on the Management of Erectile Dysfunction produced by British Society for Sexual Medicine accessed 8/9/16
http://www.bssm.org.uk/downloads/BSSM_ED_Management_Guidelines_2013.pdf

Therapeutic Class Summaries - Oral Therapy For Erectile Dysfunction produced by the UK Medicines Information Pharmacist Group accessed 24/05/18 UKMi PDE5i

Type 2 Diabetes - The Management of Type 2 Diabetes in Adults NICE Clinical Guideline NG28 - produced by National Institute for Health and Clinical Excellence accessed 8/9/16 https://www.nice.org.uk/guidance/NG28

Items which should not be routinely prescribed in primary care NHSE webpage https://www.england.nhs.uk/medicines/items-which-should-not-be-routinely-prescribed/ Accessed July 2018

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Approved By

Leeds Area Prescribing Committee

Document history

LHP version 2.0

Related information

Appendix 1

Department of Health  Health Service Circular 1999/148 Health Service Circular NHS criteria for erectile dysfunction Pharmacotherapy  (excluding generic sildenafil which can be prescribed on the NHS to any patient with erectile dysfunction regardless of cause, where this is clinically appropriate).

Patients suffering from any of the following;

  • Diabetes
  • Multiple sclerosis
  • Parkinson’s disease
  • Poliomyelitis
  • Prostate cancer
  • Severe pelvic injury
  • Single gene neurological disease
  • Spina bifida
  • Spinal cord injury·
  • Patients receiving treatment for renal failure by dialysis

Patients who have had the following surgery

  • Prostatectomy
  • Radical pelvic surgery
  • Kidney transplant·

Patients who were receiving NHS prescriptions for alprostadil, apomorphine, moxisylyte, sildenafil, tadalafil or thymoxamine HCL on 14th September 1998·

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Appendix 2

If a GP believes a patient may be suffering from erectile dysfunction with complications and considered inappropriate to be
managed in primary care, they should refer the patient for assessment and advice as per local specialist service.
Reasons for specialist referral may include:

  • Priapism (patients to seek urgent medical advice if erection lasting longer than 4 hours).
  • Underlying cause of erectile dysfunction suspected to be psychogenic. - refer to psychosexual specialist
  • Hypogonadism (abnormal testosterone, follicle-stimulating hormone, luteinizing hormone, or prolactin levels).
  • Severe cardiovascular disease that would make sexual activity unsafe or contraindications to PDE5 use.
  • Recent history of stroke or myocardial infarction
  • Patients with unstable angina or angina suffered during intercourse
  • Patients with New York Heart Association Class 2 or greater heart failure in the last 6 months known hereditary degenerative retinal disorders such as retinitis pigmentosa
  • End stage renal disease requiring dialysis - (for Vardenafil)

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