cpd 39: erectile dysfunction - irish pharmacy news€¦ · cpd 39: erectile dysfunction erectile...

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Established Products CPD 39: ERECTILE DYSFUNCTION Erectile Dysfunction Supported by 60 Second Summary According to the American Psychiatric Association Diagnositc and Statistical Manual of Mental Disorders IV (DSM-IV), erectile dysfunction can be defined as follows: 1. Persisent or recurrent inablity to attain, or to maintain until completion of the sexual activity, an adequate erection; 2. The disturbance causes marked distress or interpersonal difficulty; 3. The erectile dysfuncion is not better accounted for by another Axis 1 disorder (other than sexual dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g a drug of abuse, medication) or a general medical condition. Erectile dysfunction is highly prevalent, with 5-20% of European men having moderate to severe ED.[ii] In 2002, it was estimated that 152 million men worldwide had an erection problem, but this is expected to reach 322 million by 2025. The primary goal of ED treatment is to ensure that the individual or couple can enjoy a satisfactory sexual experience. This holistic approach incorporates identifying any organic contributor to ED; initiating lifestyle changes and risk factor modification; providing relevant counselling to patients and their partners. ED is a complex, multifactorial condition. Its position as an isolated medical condition is however debatable – anecodotal evidence suggests that the incidence of ED has risen by 250% since the advent of Viagra in 1998. Learning, Evaluation, Accredited, Readers, Network | www.learninpharmacy.ie DEFINITION OF ERECTILE DYSFUNCTION According to the American Psychiatric Association Diagnositc and Statistical Manual of Mental Disorders IV (DSM-IV), erectile dysfunction can be defined as follows: 1.Persisent or recurrent inablity to attain, or to maintain until completion of the sexual activity, an adequate erection; 2.The disturbance causes marked distress or interpersonal difficulty; 3.The erectile dysfuncion is not better accounted for by another Axis 1 disorder (other than sexual dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g a drug of abuse, medication) or a general medical condition The updated DSM-V (2013) sought to improve the definition, and made the following provisions – • To improve precision regarding duration and severity criteria and to reduce the likelihood of over-diagnosis, all of the DSM-V sexual dysfunctions (except substance/medication – induced sexual dysfunction) now require a minimum of approximately six months and more precise sexual difficulties. These changes serve to provide useful thresholds for making a diagnosis and distinguish transient sexual dysfunction from more persistent sexual dysfunction; • Subtypes for all sexual disorders include only ‘lifelong versus acquired’ and ‘generalised versus situational’. The sub-type pertaining to ‘psychological versus combined factors’ has been deleted. • To indicate the presence of and degree of medical and other non-medical correlates, the following features are described in the accompanying text – partner factors; relationship factors; individual vulnerability factors; cultural or religious factors; and medical factors.[i] EPIDEMIOLOGY OF ERECTILE DYSFUNCTION Erectile dysfunction is highly prevalent, with 5-20% of European men having moderate to severe ED.[ii] In 2002, it was estimated that 152 million men worldwide had an erection problem, but this is expected to reach 322 million by 2025.[iii] DIAGNOSIS OF ERECTILE DYSFUNCTION A multi-faceted approach must be taken to obtain a diagnosis of ED, incorporating Medical and Sexual history, physical examination, laboratory tests, and psychosocial examination. [iv] [v] These are described in more detail below: Sexual History - a detailed description of the problem, including the duration of symptoms and original precipitants, should be obtained. Concurrent medical, psychiatric and surgical history should also be recorded, as should the current relationship status, history of previous sexual partners and relationships. Issues of sexual orientation and gender identity should also be identified. Lastly, the subject of smoking, alcohol and recreational drug use should be broached. The diagnostic process can be bolstered by incorporating validated questionnaires, such as The International Index of Erectile Function (IIEF) or the validated shorter version of the SHIM (Sexual Health Inventory for Men). Patients should undergo a full physical examination, recording any genital pain, acute or chronic; deviation of the penis during tumescence; hypogonadism; and any other urological symptoms A digital rectal examination (DRE) of the prostate is not mandatory in ED but should be conducted in the presence of genito-urinary or protracted secondary ejaculatory symptoms. Blood pressure, heart rate, waist circumference and weight should be measured. 1. REFLECT - Before reading this module, consider the following: Will this clinical area be relevant to my practice. 2. IDENTIFY - If the answer is no, I may still be interested in the area but the article may not contribute towards my continuing professional development (CPD). If the answer is yes, I should identify any knowledge gaps in the clinical area. 3. PLAN - If I have identified a knowledge gap - will this article satisfy those needs - or will more reading be required? 4. EVALUATE - Did this article meet my learning needs - and how has my practise changed as a result? Have I identified further learning needs? 5. WHAT NEXT - At this time you may like to record your learning for future use or assessment. Follow the 4 previous steps, log and record your findings. Published by IPN and supported with an unrestricted educational grant from Pfizer Healthcare Ireland. Copies can be downloaded from www.irishpharmacytraining.ie Disclaimer: All material published in CPD and the Pharmacy is copyright and no part of this can be used within any other publication without the permission of the publishers and author. Biography - Paul Knox graduated in 2000 from Trinity College Dublin, and completed his pre-regristration in Unicare Pharmacy, Kilkenny. He the Managing Pharmacist of Cloughjordan Pharmacy from 2001-07 during which time he garnered a higher diploma (in community pharmacy) with distinction from TCD. Paul is currently completing a PhD from TCD, and recently appointed Managing Pharmacist of Coffeys Pharmacy in Roscrea.

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Module 1 June 2012

Chronic Pain – assessment and management in primary care

For use by Healthcare Professionals in the Republic of Ireland only© Copyright 2012 Pfizer Healthcare IrelandDate of Preparation: Module 1 June 2012 EPBU/2012/XXX

Established Products

Educational distance learning content for healthcare professionals in Ireland

Objectives

• Describechronicpain,itsprevalenceandconsequencesofinadequatemanagement

• Identifybarriersinprimarycaretoeffectivediagnosisandassessmentofchronicpainanddevelop

strategiestoovercomethesebarriers

• Discussbothpharmacologicandnon-pharmacologictherapeuticoptionsandbenefitsof

multidisciplinarycare

Introduction

Pain is one of the commonest reasons for patients to seek medical attention.1 A recent survey has shown that as many as 8.3 visits per year to primary care physicians in Ireland were due to symptoms of pain.2 A large scale survey carried out in 15 European countries and Israel in 2006, screening 46,394 respondents reported that the prevalence of chronic pain of moderate to severe intensity in adult Europeans was 19%.3

More recent survey data from another study, carried out in 2,019 people with chronic pain and 1,472 primary care physicians across 15 European countries, have demonstrated that chronic pain affects 12-54% of adult Europeans, and its prevalence in Ireland is up to 13%.2 The PRIME (Prevalence, Impact and Cost of Chronic Pain) study, on the other hand, determined the prevalence of chronic pain to be as high as 35.5% in Ireland.4 The PRIME study was designed to investigate the prevalence of chronic pain in Ireland; compare the psychological and physical health profiles of those with and without chronic pain; and explore pain-related disability.4 Responses to survey questions were obtained from 1,204 people.

Despite the magnitude of the problem, chronic pain is both under-recognised and undertreated in primary care.2,5 Indeed, up to 38% of patients reported being inadequately managed in primary care for their pain symptoms.2 In addition, people with chronic pain reported waiting up to 2.2 years between seeking help and diagnosis, and 1.9 years before their pain was adequately managed.2

Sheehan et al reported in 1996 that the estimated cost of pain for 95 patients to the Irish Health Services when added to the amount of Social Welfare payments received and the lost earnings of each patient amounted to 1.9 million pounds at the time of referral.6 The recent data from PRIME survey show that the mean cost per chronic pain patient is estimated at €5,665 per year across all grades of pain, which was extrapolated to €5.34 billion or 2.86% of Irish GDP per year.7 This demonstrates an urgent need for cost effective strategies to manage chronic pain effectively.

Understanding chronic pain

Chronic pain is defined as pain that outlasts normal healing time (usually three to six months), and is most frequently associated with musculoskeletal disorders such as low back pain and arthritis. However, it can also be associated with other disorders such as depression or metabolic disorders or neurologic conditions such as multiple sclerosis.

Pain (acute or chronic) can be categorised as nociceptive or neuropathic. Nociceptive pain is caused by an active illness, injury and/or inflammatory process associated with actual or potential tissue damage i.e. Nociceptive pain results from activity in neural pathways secondary to actual or potential tissue damage. Nociceptive pain is mediated by pain receptors located in skin, musculoskeletal system, bone, and joints.8 Neuropathic pain, on the other hand, results from direct injury to a peripheral or central sensory nerve; the affected nerves do not produce transduction at nociceptors.8 Pain characteristics and associated conditions for both types of pain are shown in Table 1.

CPD 39: ERECTILE DYSFUNCTION

Erectile Dysfunction

Supported by

60 Second SummaryAccording to the American Psychiatric Association Diagnositc and Statistical Manual of Mental Disorders IV (DSM-IV), erectile dysfunction can be defined as follows:

1. Persisent or recurrent inablity to attain, or to maintain until completion of the sexual activity, an adequate erection;

2. The disturbance causes marked distress or interpersonal difficulty;

3. The erectile dysfuncion is not better accounted for by another Axis 1 disorder (other than sexual dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g a drug of abuse, medication) or a general medical condition.

Erectile dysfunction is highly prevalent, with 5-20% of European men having moderate to severe ED.[ii] In 2002, it was estimated that 152 million men worldwide had an erection problem, but this is expected to reach 322 million by 2025.

The primary goal of ED treatment is to ensure that the individual or couple can enjoy a satisfactory sexual experience. This holistic approach incorporates identifying any organic contributor to ED; initiating lifestyle changes and risk factor modification; providing relevant counselling to patients and their partners.

ED is a complex, multifactorial condition. Its position as an isolated medical condition is however debatable – anecodotal evidence suggests that the incidence of ED has risen by 250% since the advent of Viagra in 1998.

Learning, Evaluation, Accredited, Readers, Network | www.learninpharmacy.ie

DEFINITION OF ERECTILE DYSFUNCTION

According to the American Psychiatric Association Diagnositc and Statistical Manual of Mental Disorders IV (DSM-IV), erectile dysfunction can be defined as follows:

1.Persisent or recurrent inablity to attain, or to maintain until completion of the sexual activity, an adequate erection;

2.The disturbance causes marked distress or interpersonal difficulty;

3.The erectile dysfuncion is not better accounted for by another Axis 1 disorder (other than sexual dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g a drug of abuse, medication) or a general medical condition

The updated DSM-V (2013) sought to improve the definition, and made the following provisions –

• To improve precision regarding duration and severity criteria and to reduce the likelihood of over-diagnosis, all of the DSM-V sexual dysfunctions (except substance/medication – induced sexual dysfunction) now require a minimum of approximately six months and more precise sexual difficulties. These changes serve to provide useful thresholds for making a diagnosis and distinguish transient sexual dysfunction from more persistent sexual dysfunction;

• Subtypes for all sexual disorders include only ‘lifelong versus acquired’ and ‘generalised versus situational’. The sub-type pertaining to ‘psychological versus combined factors’ has been deleted.

• To indicate the presence of and degree of medical and other non-medical correlates, the following features are described in the accompanying text – partner factors; relationship factors; individual vulnerability factors; cultural or religious factors; and medical factors.[i]

EPIDEMIOLOGY OF ERECTILE DYSFUNCTION

Erectile dysfunction is highly prevalent, with 5-20% of European men having moderate to severe ED.[ii] In 2002, it was estimated that 152 million men worldwide had an erection problem, but this is expected to reach 322 million by 2025.[iii]

DIAGNOSIS OF ERECTILE DYSFUNCTION

A multi-faceted approach must be taken to obtain a diagnosis of ED, incorporating Medical and Sexual history, physical examination, laboratory tests, and psychosocial examination.[iv] [v] These are described in more detail below:

Sexual History - a detailed description of the problem, including the duration of symptoms and original precipitants, should be obtained.

Concurrent medical, psychiatric and surgical history should also be recorded, as should the current relationship status, history of previous sexual partners and relationships. Issues of sexual orientation and gender identity should also be identified. Lastly, the subject of smoking, alcohol and recreational drug use should be broached.

The diagnostic process can be bolstered by incorporating validated questionnaires, such as The International Index of Erectile Function (IIEF) or the validated shorter version of the SHIM (Sexual Health Inventory for Men).

Patients should undergo a full physical examination, recording any genital pain, acute or chronic; deviation of the penis during tumescence; hypogonadism; and any other urological symptoms

A digital rectal examination (DRE) of the prostate is not mandatory in ED but should be conducted in the presence of genito-urinary or protracted secondary ejaculatory symptoms.

Blood pressure, heart rate, waist circumference and weight should be measured.

1. REFLECT - Before reading this module, consider the following: Will this clinical area be relevant to my practice.

2. IDENTIFY - If the answer is no, I may still be interested in the area but the article may not contribute towards my continuing professional development (CPD). If the answer is yes, I should identify any knowledge gaps in the clinical area.

3. PLAN - If I have identified a knowledge gap

- will this article satisfy those needs - or will more reading be required?

4. EVALUATE - Did this article meet my learning needs - and how has my practise changed as a result? Have I identified further learning needs?

5. WHAT NEXT - At this time you may like to record your learning for future use or assessment. Follow the 4 previous steps, log and record your findings.

Published by IPN and supported with an unrestricted educational grant from Pfizer Healthcare Ireland. Copies can be downloaded from www.irishpharmacytraining.ie

Disclaimer: All material published in CPD and the Pharmacy is copyright and no part of this can be used within any other publication without the permission of the publishers and author.

Biography - Paul Knox graduated in 2000 from Trinity College Dublin, and completed his pre-regristration in Unicare Pharmacy, Kilkenny. He the Managing Pharmacist of Cloughjordan Pharmacy from 2001-07 during which time he garnered a higher diploma (in community pharmacy) with distinction from TCD. Paul is currently completing a PhD from TCD, and recently appointed Managing Pharmacist of Coffeys Pharmacy in Roscrea.

Module 1 June 2012

Chronic Pain – assessment and management in primary care

For use by Healthcare Professionals in the Republic of Ireland only© Copyright 2012 Pfizer Healthcare IrelandDate of Preparation: Module 1 June 2012 EPBU/2012/XXX

Established Products

Educational distance learning content for healthcare professionals in Ireland

Objectives

• Describechronicpain,itsprevalenceandconsequencesofinadequatemanagement

• Identifybarriersinprimarycaretoeffectivediagnosisandassessmentofchronicpainanddevelop

strategiestoovercomethesebarriers

• Discussbothpharmacologicandnon-pharmacologictherapeuticoptionsandbenefitsof

multidisciplinarycare

Introduction

Pain is one of the commonest reasons for patients to seek medical attention.1 A recent survey has shown that as many as 8.3 visits per year to primary care physicians in Ireland were due to symptoms of pain.2 A large scale survey carried out in 15 European countries and Israel in 2006, screening 46,394 respondents reported that the prevalence of chronic pain of moderate to severe intensity in adult Europeans was 19%.3

More recent survey data from another study, carried out in 2,019 people with chronic pain and 1,472 primary care physicians across 15 European countries, have demonstrated that chronic pain affects 12-54% of adult Europeans, and its prevalence in Ireland is up to 13%.2 The PRIME (Prevalence, Impact and Cost of Chronic Pain) study, on the other hand, determined the prevalence of chronic pain to be as high as 35.5% in Ireland.4 The PRIME study was designed to investigate the prevalence of chronic pain in Ireland; compare the psychological and physical health profiles of those with and without chronic pain; and explore pain-related disability.4 Responses to survey questions were obtained from 1,204 people.

Despite the magnitude of the problem, chronic pain is both under-recognised and undertreated in primary care.2,5 Indeed, up to 38% of patients reported being inadequately managed in primary care for their pain symptoms.2 In addition, people with chronic pain reported waiting up to 2.2 years between seeking help and diagnosis, and 1.9 years before their pain was adequately managed.2

Sheehan et al reported in 1996 that the estimated cost of pain for 95 patients to the Irish Health Services when added to the amount of Social Welfare payments received and the lost earnings of each patient amounted to 1.9 million pounds at the time of referral.6 The recent data from PRIME survey show that the mean cost per chronic pain patient is estimated at €5,665 per year across all grades of pain, which was extrapolated to €5.34 billion or 2.86% of Irish GDP per year.7 This demonstrates an urgent need for cost effective strategies to manage chronic pain effectively.

Understanding chronic pain

Chronic pain is defined as pain that outlasts normal healing time (usually three to six months), and is most frequently associated with musculoskeletal disorders such as low back pain and arthritis. However, it can also be associated with other disorders such as depression or metabolic disorders or neurologic conditions such as multiple sclerosis.

Pain (acute or chronic) can be categorised as nociceptive or neuropathic. Nociceptive pain is caused by an active illness, injury and/or inflammatory process associated with actual or potential tissue damage i.e. Nociceptive pain results from activity in neural pathways secondary to actual or potential tissue damage. Nociceptive pain is mediated by pain receptors located in skin, musculoskeletal system, bone, and joints.8 Neuropathic pain, on the other hand, results from direct injury to a peripheral or central sensory nerve; the affected nerves do not produce transduction at nociceptors.8 Pain characteristics and associated conditions for both types of pain are shown in Table 1.

CPD 39: ERECTILE DYSFUNCTION

LABORATORY TESTING

• The choice of investigations depends on the individual circumstances of the patient. Serum lipids and fasting plasma glucose should be measured in all patients.

• Hypogonadism is a treatable cause of ED that may render men less responsive, or non- responsive to phosphodiesterase type 5 (PDE5) inhibitors. In this regard, all men with ED should have serum testosterone measured on a blood sample taken in the morning between 8am and 11am.

• Serum prostate specific antigen (PSA) should be considered if clinically indicated. It should certainly be measured before commencing testosterone therapy and at regular intervals during testosterone therapy.

DIAGNOSIS INCORPORATING THE CARDIOVASCULAR SYSTEM

• Coronary heart disease (CHD) is associated with many of the same risk factors as ED. Coronary artery disease (CAD) is often just one affected site in a generalised arteriopathy that is also likely to affect the arterial flow into the corpora cavernosum of the penis.

• ED in an otherwise asymptomatic man may be a marker for underlying CAD. All men with unexplained ED should have a thorough evaluation and any risk factors for CHD that are identified should be addressed. In fact, a man with ED should be considered a cardiac patient until proven otherwise.5

• Current NICE guidance recommends that all men with type 2 diabetes be asked annually about ED, assessed, and offered oral treatment with the medication with the lowest acquisition cost.[vi]

The NICE guidelines also provide for those who may require specialised investigations –

1. Young patients who have always had difficulty in obtaining and/or sustaining an erection;

2. Patients with a history of trauma;

3. Where a genital abnormality is evident upon examination;

4. Patients unresponsive to medical therapies.

PSYCHOGENIC ERECTILE DYSFUNCTION

ARTERIOGENIC, NEUORGENIC, AND ENDOCRINE CAUSES OF ED

Arteriogenic causes of ED

1. Hypertension

2. Smoking

3. Diabetes

4. Peripheral vascular disease

5. Blunt perineal or pelvic trauma

6. Pelvic irradiation

Neurogenic causes of ED

• Lesions of medial preoptic nucleus, paraventicular nucleus, hippocampus

• Spinal trauma

• Myelodisplasia (Spina bifida)

• Pelvic surgery/radiotherapy

• Multiple Sclerosis

• Intervertebral disc lesion

• Peripheral neuropathies – alcohol, diabetes, and HIV in particular

Endocrine causes of ED

• Hypogonadism – Low testosterone; raised sex hormone-binding globulin (SHBG); raised prolactin

• Thyroid disease

DRUGS ASSOCIATED WITH ED

Table 1 – Drugs associated with ED

DRUGS ASSOICATED WITH ED

Anti-hypertsivesives

• Thiazides

• Beta-Blockers

• Centrally acting drugs

Antidepressants

o Tricyclics

o MAO inhibitors

o SSRIs

Anticholinergics

• Atropine

Antipsychotics

• Phenothiazines

Anxiolytics

• Benzodiazepines

Psychotropic Drugs

• Alcohol

• Opiates

• Amphetamines

• Cocaine

TREATMENT OF ED

The primary goal of ED treatment is to ensure that the individual or couple can enjoy a satisfactory sexual experience. This holistic approach incorporates identifying any organic contributor to ED; initiating lifestyle changes and risk factor modification; providing relevant counselling to patients and their partners.5

Lifestyle modifications can greatly reduce the risk of ED, and should accompany any specific pharmacotherapy or psychological therapy. However, pharmacotherapy should not be withheld on the basis that lifestyle changes have not been made.

Psychosexual therapy should also be considered, taking the following into account

1.Regardless of the cause of ED, the patient will develop psychosexual issues that will contribute to performance anxiety.

2.Sensate focus exercises may be employed[viii], in accordance with

3.Relationship counselling

CONTEMPORARY PHARMACOTHERAPY FOR ED

First-line treatment

PDE5 Inhibitors (Phosphodiesterase type 5 inhibitors)

Part of the physiological process of erection involves the release of nitric oxide (NO) in the vasculature of the corpus cavernosum as a result of sexual stimulation. NO activates the enzyme guanylate cyclase that results in increased levels of cyclic guanosine monophosphate (cGMP), leading to smooth muscle relaxation in blood vessels supplying the corpus cavernosum, resulting in increased blood flow and an erection.[ix]

PDE5 inhibitors inhibit the degradation of cGMP by phosphodiesterase type 5 (PDE5), increasing blood flow to the penis during sexual stimulation.

This mode of action infers that PDE5 inhibitors are ineffective without sexual stimulation.5 It is currently recommended that patients should receive eight doses of a PDE5 inhibitor with sexual stimulation at maximum dose before classifying a patient as a non-responder.

Learning, Evaluation, Accredited, Readers, Network | www.learninpharmacy.ieSupported by

THE CAUSES OF ERECTILE DYSFUNCTION

The contributory factors to erectile dysfunction can be categorised as psychogenic or oragnic[vii]

Psychogenic Organic

Sudden onset Gradual Onset

Situational All situations

Normal waking and nocturnal erections Reduced or absent waking and nocturnal erections

Normal erection with masturbation No erection with masturbation

Relationship factors Penile pain

Life event

Anxiety, fear and depression

Module 1 June 2012

Chronic Pain – assessment and management in primary care

For use by Healthcare Professionals in the Republic of Ireland only© Copyright 2012 Pfizer Healthcare IrelandDate of Preparation: Module 1 June 2012 EPBU/2012/XXX

Established Products

Educational distance learning content for healthcare professionals in Ireland

Objectives

• Describechronicpain,itsprevalenceandconsequencesofinadequatemanagement

• Identifybarriersinprimarycaretoeffectivediagnosisandassessmentofchronicpainanddevelop

strategiestoovercomethesebarriers

• Discussbothpharmacologicandnon-pharmacologictherapeuticoptionsandbenefitsof

multidisciplinarycare

Introduction

Pain is one of the commonest reasons for patients to seek medical attention.1 A recent survey has shown that as many as 8.3 visits per year to primary care physicians in Ireland were due to symptoms of pain.2 A large scale survey carried out in 15 European countries and Israel in 2006, screening 46,394 respondents reported that the prevalence of chronic pain of moderate to severe intensity in adult Europeans was 19%.3

More recent survey data from another study, carried out in 2,019 people with chronic pain and 1,472 primary care physicians across 15 European countries, have demonstrated that chronic pain affects 12-54% of adult Europeans, and its prevalence in Ireland is up to 13%.2 The PRIME (Prevalence, Impact and Cost of Chronic Pain) study, on the other hand, determined the prevalence of chronic pain to be as high as 35.5% in Ireland.4 The PRIME study was designed to investigate the prevalence of chronic pain in Ireland; compare the psychological and physical health profiles of those with and without chronic pain; and explore pain-related disability.4 Responses to survey questions were obtained from 1,204 people.

Despite the magnitude of the problem, chronic pain is both under-recognised and undertreated in primary care.2,5 Indeed, up to 38% of patients reported being inadequately managed in primary care for their pain symptoms.2 In addition, people with chronic pain reported waiting up to 2.2 years between seeking help and diagnosis, and 1.9 years before their pain was adequately managed.2

Sheehan et al reported in 1996 that the estimated cost of pain for 95 patients to the Irish Health Services when added to the amount of Social Welfare payments received and the lost earnings of each patient amounted to 1.9 million pounds at the time of referral.6 The recent data from PRIME survey show that the mean cost per chronic pain patient is estimated at €5,665 per year across all grades of pain, which was extrapolated to €5.34 billion or 2.86% of Irish GDP per year.7 This demonstrates an urgent need for cost effective strategies to manage chronic pain effectively.

Understanding chronic pain

Chronic pain is defined as pain that outlasts normal healing time (usually three to six months), and is most frequently associated with musculoskeletal disorders such as low back pain and arthritis. However, it can also be associated with other disorders such as depression or metabolic disorders or neurologic conditions such as multiple sclerosis.

Pain (acute or chronic) can be categorised as nociceptive or neuropathic. Nociceptive pain is caused by an active illness, injury and/or inflammatory process associated with actual or potential tissue damage i.e. Nociceptive pain results from activity in neural pathways secondary to actual or potential tissue damage. Nociceptive pain is mediated by pain receptors located in skin, musculoskeletal system, bone, and joints.8 Neuropathic pain, on the other hand, results from direct injury to a peripheral or central sensory nerve; the affected nerves do not produce transduction at nociceptors.8 Pain characteristics and associated conditions for both types of pain are shown in Table 1.

Learning, Evaluation, Accredited, Readers, Network | www.learninpharmacy.ie

CPD 39: ERECTILE DYSFUNCTION

Supported by

FIGURE 1 - METHOD OF ACTION OF PDE5 INHIBITORS

TABLE 2 - LIST OF ORAL THERAPIES LICENSED FOR ED

TABLE 3 - PDE5 CONTRAINDICATIONS AND DRUG-INTERACTIONS

SEXUAL INQUIRY

CLINICAL EVALUATION

INTERMEDIATE RISK

CARDIOVASCULAR ASSESSMENT

RISK FACTORS AND CHD EVALUATION, TREATMENT AND FOLLOW-UP FOR ALL PATIENTS WITH ED

LOW RISK HIGH RISK

MANAGE ED IN PRIMARY CARE SETTING

SEXUAL ACTIVITY DEFERRED UNTIL CARDIAC

Drug

Sildenafil (Viagra) 25mg, 50mg, 100mg

Tadalafil (Ciails) 10mg, 20mg

Tadalafil (Cialis) 5mg

Vardenafil (Levitra) 5mg, 10mg, 20mg

Half-life

4 hours

17 hours

17 hours

4 hours

When taken

1 hour before sexual activity 30 minutes before sexual activity

May be taken daily

30-60 minutes before sexual activity

Window for sexual activity

4-6 hour window

36 hour window

n/a

4-6 hour window

Absorption considerations

Absorption delayed by a fatty meal.

Absorption not affected by food.

Absorption not affected by food

Absorption delayed by a fatty meal.

Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002

SIDE EFFECTS OF PDE5 INHIBITORS

• Facial flushing

• Headache

• Nasal Congestion

• Dizziness

• Dyspepsia

• Visual disturbance

• Priapism

• Non-arteritic anterior ischaemic optic neuropathy7

PDE5 Contraindications

Recent cardiovascular event

Nitrate treated angina

Hypotension Anatomical deformity • Angulation, cavernosal fibrosis, Peyronie’s disease Predispostion to prolonged erection • Sickle cell disease • Multiple myeloma • Leukemia

PDE5 Drug Interactions

Nitrates • Glyceryl trinitrate, isorbide mono or dinitrate • Chest pain after taking sildenafil/vardenafil no nitrates for 24 hours, taldalfil 48 hour interval • Recreational amyl nitrate

CyP450 inhibitors • Protease kinase inhibitors – Ritonavir • Cimetidine, Ketoconazole, Erythromycin, grapefruit juice

Alpha Blockers

Learning, Evaluation, Accredited, Readers, Network | www.learninpharmacy.ie

CPD 39: ERECTILE DYSFUNCTION

Module 1 June 2012

Chronic Pain – assessment and management in primary care

For use by Healthcare Professionals in the Republic of Ireland only© Copyright 2012 Pfizer Healthcare IrelandDate of Preparation: Module 1 June 2012 EPBU/2012/XXX

Established Products

Educational distance learning content for healthcare professionals in Ireland

Objectives

• Describechronicpain,itsprevalenceandconsequencesofinadequatemanagement

• Identifybarriersinprimarycaretoeffectivediagnosisandassessmentofchronicpainanddevelop

strategiestoovercomethesebarriers

• Discussbothpharmacologicandnon-pharmacologictherapeuticoptionsandbenefitsof

multidisciplinarycare

Introduction

Pain is one of the commonest reasons for patients to seek medical attention.1 A recent survey has shown that as many as 8.3 visits per year to primary care physicians in Ireland were due to symptoms of pain.2 A large scale survey carried out in 15 European countries and Israel in 2006, screening 46,394 respondents reported that the prevalence of chronic pain of moderate to severe intensity in adult Europeans was 19%.3

More recent survey data from another study, carried out in 2,019 people with chronic pain and 1,472 primary care physicians across 15 European countries, have demonstrated that chronic pain affects 12-54% of adult Europeans, and its prevalence in Ireland is up to 13%.2 The PRIME (Prevalence, Impact and Cost of Chronic Pain) study, on the other hand, determined the prevalence of chronic pain to be as high as 35.5% in Ireland.4 The PRIME study was designed to investigate the prevalence of chronic pain in Ireland; compare the psychological and physical health profiles of those with and without chronic pain; and explore pain-related disability.4 Responses to survey questions were obtained from 1,204 people.

Despite the magnitude of the problem, chronic pain is both under-recognised and undertreated in primary care.2,5 Indeed, up to 38% of patients reported being inadequately managed in primary care for their pain symptoms.2 In addition, people with chronic pain reported waiting up to 2.2 years between seeking help and diagnosis, and 1.9 years before their pain was adequately managed.2

Sheehan et al reported in 1996 that the estimated cost of pain for 95 patients to the Irish Health Services when added to the amount of Social Welfare payments received and the lost earnings of each patient amounted to 1.9 million pounds at the time of referral.6 The recent data from PRIME survey show that the mean cost per chronic pain patient is estimated at €5,665 per year across all grades of pain, which was extrapolated to €5.34 billion or 2.86% of Irish GDP per year.7 This demonstrates an urgent need for cost effective strategies to manage chronic pain effectively.

Understanding chronic pain

Chronic pain is defined as pain that outlasts normal healing time (usually three to six months), and is most frequently associated with musculoskeletal disorders such as low back pain and arthritis. However, it can also be associated with other disorders such as depression or metabolic disorders or neurologic conditions such as multiple sclerosis.

Pain (acute or chronic) can be categorised as nociceptive or neuropathic. Nociceptive pain is caused by an active illness, injury and/or inflammatory process associated with actual or potential tissue damage i.e. Nociceptive pain results from activity in neural pathways secondary to actual or potential tissue damage. Nociceptive pain is mediated by pain receptors located in skin, musculoskeletal system, bone, and joints.8 Neuropathic pain, on the other hand, results from direct injury to a peripheral or central sensory nerve; the affected nerves do not produce transduction at nociceptors.8 Pain characteristics and associated conditions for both types of pain are shown in Table 1.

Supported by

VACUUM ERECTION DEVICES

These are highly effective in inducing erections regardless of the aetiology of the ED. They exert their effect by trapping blood in the intra-corporal and extra-corporal compartments of the penis.7 An erection can be maintained for a maximum of 30 minutes with varying satisfaction rates of 35-85%; anecdotal evidence suggests that if a man is satisfied with a vacuum pump, he will continue to use it on a long term basis. Adverse effects of vacuum devices include bruising, cyanosis, oedema, local pain and failure to ejaculate. Partners sometimes complain that the penis feels cold.5 Serious side effects such as skin necrosis have been reported, but are rare.

SECOND LINE TREATMENT

Prostaglandin E1 (PGE1), Alprostadil, intracavernosal injection – Caverject, Viridal

• Works independently of intact nervous system

• Administration requires manual dexterity, adequate vision, and training

• Contraindications include bleeding disorders, sickle cell anaemia, multiple myeloma, and leukemia.

• The side effects include penoscrotal pain, hematoma, fibrosis tat injuection site and priapism.

Papaverine, phentolamine, aviptadil (vaso-intestinal peptide) have been used as sole agents or in combination with Alprostadil

Alprostadil Intraurethral devices

Muse (125mg, 250mg, 500mg, 1g)

This requires administration of a pellet into the urethra using an applicator. The penis is subsequently massaged to aid absorption. Side effects include penile pain, dizziness and priapism.

THIRD LINE TREATMENT

Penile prosthesis

This form of treatment should be offered to those patients who are unresponsive to, or unwilling to consider first or second line treatments. All patients and their partners should be counselled pre-operatively, have access to inspect all the available devices and, where appropriate, engage with other patients who have undergone the procedure. This treatment is particularly suitable for those with severe organic ED, especially if the cause is Peyronie’s Disease. All patients should be given a choice of either a malleable or inflatable prosthesis. The risks of this approach include – infection; compromise or destruction of the corpora cavernosa; erosion and extrusion; and mechanical failure.7

ERECTILE DYSFUNCION AND MASCULINITY

Erectile dysfunction or impotence, as it was perjoratively known, has been affecting men since time immemorial. Angus McLaren in his book, Two Millennea of Impotence Cures charts ED cures through the ages, from Anicent Rome and Greece (leek, asparagus and, not surpisingly perhaps, the genitalia of various animals) to the 13th century (a roasted wolf penis), all the way to the revolutionary viagra in

1998. What is without question is how indelibly linked ED is to the masuclinity and self esteem of the man. A season 1 episode of Friends in 1994 has the character Joey reveal that being impotent was a fate worse than death - “If little-Joey is dead, then I’ve got no reason to live.” Such melodrama aside, there is conflicting evidence that ED can precipitate depression, but it can certainly exacerbate depression;[iii] and new evidence has suggested that the emasculating effect of ED can be slightly overstated. A European study of 30,000 men confounds the stereotype of men’s perception of masculinity. Men reported that being seen as ‘honourable, self-reliant and respected by friends’ were the most important determinants of self-perceived masculinity – having an active sex life was seen as an important construct of masuculinty by only 3% of participants, regardless of whether they reported erectile difficulties.[iv] The study also highlighs that ED may matter to the man because of the impact on the valued partnered relationship, rather than any predicted, perceived personal slight.

ED AND SOCIETY

ED is a complex, multifactorial condition. Its position as an isolated medical condition is however debatable – anecodotal evidence suggests that the incidence of ED has risen by 250% since the advent of Viagra in 1998. Never before has a drug seeped into the public consciousness, achieved such market penetration, or become so synonymous with a medical condition, than Viagra. However, the positive impact of the drug is far reaching. Men with comorbidities requiring polypharmacy simply require one more tablet to alleviate an embarrassing, and in some cases, debilitating function of their illness. While the drug is open to abuse, this does not seem to be prevalent, and PDE5 inhibitors have ensured that almost no man is deprived a healthy sex life.

CONCLUSION

ED is a worldwide, indiscriminate condition, affecting hundreds of million of men. It has many components and is rarely seen without other comorbidites. The advent of PDE5 inhibitors have offered a short-term treatment for the condition but further investigation for an underlying cause, psychogenic or organic must be undertaken.

REFERENCES

1 Highlights of Changes from DSM-IV-TR to DSM-5” (PDF). American Psychiatric Association. May 17, 2013

2 Hatzimouratidis K et al Guidelines on male sexual dysfunction: erectile dysfunction and premature ejaculation Eur Urol 2010, doi 10.1016/jeururo2010.02.02

3 Mc Vary KT Erectile Dysfunction New England Journal of Medicine; 357: 2472-814 The American Urological Foundation Diagnosing Erectile Dysfunction 2009 Fact Sheet Press Release

4 British Society for Sexual Medicine Guidelines on the management of erectile dysfunction 2009: 279-283

5 NICE guidelines – Erectile Dysfunction updated July 2013

6 Ewan J “Erectile Dysfunction” Powerpoint Presentation uploaded October 2012

7 Van Hasselt, Vincent B.; Michel Hersen (1996). Sourcebook of psychological treatment manuals for adult disorders. Springer. pp. 348–351

8 Ning, Hongxiu et al. “Effects of icariin on phosphodiesterase-5 activity in vitro and cyclic guanosine monophosphate level in cavernous smooth muscle cells”. Urology 2006; 68 (6): 1350–4

9 Tsertsvadze A et al. “Diagnosis and treatment of erectile dysfunction” Agency for Healthcare Research and Quality (US) 2009: 1-9

10 Harte C, Meston C “Recreational use of erectile dysfunction medications in undergraduate men in the US: characteristics and associated risk factors.” Archives of Sexual Behaviour 2011; 40: 597-606

11 Harte C, Meston C “Recreational use of erectile dysfunctions and its adverse effects on erectile function in young healthy men: the mediating role of confidence in erectile abilty.” Journal of Sexual Medicine 2012; 9(7): 1852-9

12 Seidman S et al. “The relationship between depression and erectile dysfunction.” Current Psychiatry Reports 2000; 2: 201-205

13 Sand MS et al. “Erectile dysfunction and constructs of masculinity an quality of life in the Multinational Men’s Attitude to Life Events and Sexuality (MALES) study.” Journal of Sexual Medicine 2008; 5: 583-594