Patterns of switching phosphodiesterase type 5 inhibitors in the treatment of erectile dysfunction: results from the Erectile Dysfunction Observational Study

The efficacy and safety of tadalafil in the management of erectile dysfunction with diabetes and blood circulation issues

BACKGROUND

Erectile dysfunction (ED) is a common diabetes-related complication.

MATERIALS AND METHODS

This study examined the effect of daily low-dose tadalafil (5 mg) on patients' quality of life (including that of sex life) and blood circulation. Erectile dysfunction questionnaires were administered to 20 patients with type 2 diabetes (T2DM) and ED. The safety and efficacy of tadalafil were evaluated using laboratory tests, and the effect on blood circulation was measured through nail fold capillaroscopy.

RESULTS

Daily tadalafil use by patients with T2DM and ED showed a statistically significant increase in the erectile reliability score from of 1.15 to 3.20 (p < .00012). Capillary blood circulation improvement tests showed a statistically significant increase in apical limb width from 13.1 to 14.64 µm (p = .04829) and flow from 9035 to 11946 μm³/s (p = .04405). Although not significant, increased capillary width and speed (rate of blood flow) confirmed improved blood circulation. There were no significant changes in the cardiac indicators (troponin, prostate-specific antigen, or electrocardiogram tests) before and after tadalafil administration, supporting the safety of its low-dose daily administration.

CONCLUSIONS

A small dose of daily tadalafil was shown to safely improve erectile dysfunction and peripheral blood flow in patients with T2DM, in which peripheral arterial diseases should not be considered separately but rather as complex entities.

Non-invasive Management Options for Erectile Dysfunction When a Phosphodiesterase Type 5 Inhibitor Fails

Phosphodiesterase type 5 inhibitors (PDE5Is) are the drug of choice for medical management of erectile dysfunction (ED). On-demand PDE5Is have an overall efficacy of 60-70% for ED; 30-35% of patients fail to respond to a PDE5I, and 30-50% of non-responders can be salvaged with detailed counseling on proper use and physician follow-up to ensure that the patient has been prescribed an appropriate and full PDE5I clinical trial. True non-responders may be offered intracavernosal injections of erectogenic drugs, intraurethral alprostadil, or surgical insertion of a penile prosthesis. Such options are not discreet and are associated with more adverse effects than PDE5Is. Thus patients may request additional non-invasive medical management options. This review describes published literature on patients who failed to respond to an on-demand PDE5I regimen and were treated with a non-invasive PDEI-based regimen, including switching from one PDE5I to another; increasing the dose of PDE5I above the labeled dosage range; using two PDE5Is concurrently; using a daily PDE5I regimen; or combining a PDE5I with a testosterone supplement, α-adrenergic antagonist, intraurethral or intracavernosal alprostadil, vacuum erection device, or low-intensity shock wave therapy. The limitations of published clinical trials do not allow for sufficient evidence to recommend one option over another. Therefore, in PDE5I-refractory patients, the choice of a specific next step should be individualized based on the preference of the patient and his sexual partner, the advantages and disadvantages of the various options, the concurrent medical illnesses and medications of the patient, and the patient's response to treatment.

Comparative efficacy of tadalafil once daily in men with erectile dysfunction who demonstrated previous partial responses to as-needed sildenafil, tadalafil, or vardenafil

OBJECTIVE

Phosphodiesterase type-5 inhibitors (PDE5Is) are first-line therapies for erectile dysfunction (ED). Sildenafil (SIL) and vardenafil (VAR) are approved for as-needed (PRN) dosing; tadalafil (TAD) is approved for both PRN and once-a-day (OaD) dosing for ED. Recent evidence suggests that TAD-OaD may be effective as therapy in men with an incomplete response to PRN-PDE5I therapy. This study evaluated whether TAD-OaD provides similar efficacy in men with ED who had previously demonstrated a partial response to PRN-PDE5I therapy.

RESEARCH DESIGN AND METHODS

In this randomized, double-blind, placebo-controlled trial, men with a ≥3 month ED history received SIL 100 mg, TAD 20 mg, or VAR 20 mg during a 4 week open-label lead-in period. Those with International Index of Erectile Function - Erectile Function (IIEF-EF) domain scores <26 following lead-in treatment completed a 4 week washout period, then randomized to TAD 2.5 mg up-titrated to 5 mg, TAD 5 mg, or placebo (PBO) OaD for 12 weeks. MAIN OUTCOME MEASURES obtained from patients treated with TAD-OaD were compared to PBO-treated patients. Additionally, results of treatment with TAD-OaD were compared to results obtained from 4 week PRN-PDE5I therapy to determine whether OaD and PRN regimens provided comparable efficacy.

CLINICAL TRIAL REGISTRATION

NCT01130532.

MAIN OUTCOME MEASURES

International Index of Erectile Function (IIEF) domain scores; Sexual Encounter Profile (SEP) questions 2-5.

RESULTS

Endpoint data was obtained from 590 men (391 TAD; 199 PBO). RESULTS for all IIEF and SEP measures were significantly better for TAD-OaD (p < 0.001 for all) compared to PBO and were comparable to those observed during PRN-PDE5I treatment. TAD 2.5 mg and TAD 5 mg OaD therapy were safe and generally well tolerated.

CONCLUSION

Tadalafil once daily is a viable alternative to as-needed PDE5I therapy in men with ED. Key limitations include the lack of a PRN PDE5I study group during the double-blind period, and that many more patients took tadalafil than sildenafil or vardenafil during the PRN period.

Decision tree analyses of key patient characteristics in Middle Eastern/North African and Latin American men treated with long-acting and short-acting PDE5 inhibitors for erectile dysfunction

BACKGROUND

Phosphodiesterase type 5 (PDE5) inhibitors have discontinuation rates as high as 60% in men with erectile dysfunction. Treatment satisfaction has been significantly associated with treatment continuation. Understanding key characteristics in terms of treatment preference, relationship, and lifestyle issues could provide direction on how to improve compliance with PDE5 inhibitor treatment globally.

OBJECTIVE

The objective was to identify subgroups of interest in the pooled database of two observational studies conducted in Latin America (LA) and Middle East/North Africa (MENA) exploring patient characteristics and prescription of either a long- or short-acting PDE5 inhibitor at baseline.

METHODS

Two identical prospective, non-interventional, observational, studies in MENA (N = 493) and LA (N = 511) treated men with an 'on demand' (pro re nata, PRN) PDE5 inhibitor (sildenafil, tadalafil, vardenafil, or lodenafil) during 6 months. In this post-hoc meta-analysis of two observational studies with equal design, pooled data were analyzed to determine patient characteristics and PDE5 inhibitor prescribed/used most likely to be associated with patient expectations, satisfaction, self-esteem, and patient-partner relationships. Decision tree analyses, with and without weighting, were used to identify and describe key features.

RESULTS

In each analysis of patient expectations, patient-partner relationship, and self-esteem, we describe the two major subgroups at baseline for each decision tree. Analyses of patient expectations and sexual self-esteem revealed that patients prescribed long-acting PDE5 inhibitors (59%) highlighted the importance of treatment effect duration, second to partner satisfaction with treatment, while patients prescribed short-acting PDE5 inhibitors (32%) placed less importance on treatment effect duration but considerable importance on treatment effect lasting until intercourse completion. Further insights regarding patients, partner relationship characteristics, and treatment expectations were identified.

CONCLUSION

Our analyses have described key characteristics, such as self- and partner perceptions, sexual attitudes, and treatment expectations in relation to the patients' country and prescribed treatment, which might guide treatment decisions in MENA and LA men with ED.

Continuation and effectiveness of tadalafil once daily during a 6-month observational study in erectile dysfunction: the EDATE study

AIMS

This was the first observational study evaluating treatment continuation, effectiveness and tolerability of tadalafil 5 mg once daily (TAD-OaD) in patients who chose and paid for treatment of erectile dysfunction (ED) in routine clinical practice.

METHODS

Men ≥ 18 years with ED, treated previously with phosphodiesterase type 5 (PDE5)-inhibitor on-demand (PRN) or treatment-naïve, were enrolled at 59 sites. For patients prescribed TAD-OaD at baseline (T1), change in erectile function (IIEF-EF and GAQ) was documented after 1-3 (T2) and 4-6 (T3) months. The primary outcome was the probability to switch/discontinue from TAD-OaD, estimated by Kaplan-Meier (KM) product-limit method. Changes in IIEF-EF were evaluated using a mixed model for repeated measures adjusting for patient baseline characteristics.

RESULTS

Of 975 men enrolled (median age 56.8 years, 33.7% with previous PDE5-inhibitor use), 778 were prescribed TAD-OaD, 135 TAD-PRN and 62 sildenafil or vardenafil PRN. During the 6-month longitudinal observation, 107 patients (13.8% of 778) switched or discontinued TAD-OaD-treatment. KM-rates (95%CI) for continuing TAD-OaD at 2, 4 and 6 months were 94.0% (92.3, 95.7), 88.3% (85.9, 90.6) and 86.3% (83.7, 88.9), respectively. The 25th percentile of time to switch/discontinuation of TAD-OaD was estimated as 31.1 weeks (lower 95%CI 30.3 weeks). At T3, IIEF-EF scores had increased by 7.1 (LSmean; 95%CI 5.8, 8.5) points; 91.3% of patients reported improved erections. The most frequently reported AE was headache (10 patients; 1.3%); no new/unexpected safety signals were observed.

CONCLUSION

Under routine conditions, and when patients were involved in treatment decision-making, more than 86% of men starting/switching to tadalafil once daily (OaD) at baseline continued tadalafil OaD treatment for ≥ 6 months.

Preference for erectile dysfunction treatments: Assessment by means of consumers preference analysis techniques

INTRODUCTION

Patient preference for erectile dysfunction (ED) treatments is of great importance for satisfaction and adherence. We have assessed the usefulness of the main technique for assessing consumer preferences (conjoint analysis) to analyze preferences towards these treatments. We also assessed the influence of age, frequency of sexual intercourse, co-morbidities, ED severity or having testosterone deficiency syndrome (TDS).

MATERIAL AND METHOD

Observational, cross-sectional, multicenter study in 626 men aged ≥18 years that had recently taken at least two different PDE5i, one being vardenafil orodispersible (ODT). Seven selected features of ED treatments were tested. Different series of scenarios (cards) were created by combining these features: two series of 4 features (9 cards), another one series of 7 (16 cards). Short series were tested in Primary Care, and the long series in Urology/Andrology offices. Influences were tested by rank ordered logistic regression analysis.

RESULTS

The feature «administration form» was consistently given the most relative importance; the ODT form was given the greatest utility. Consensus towards the most and least preferred treatment was achieved only in one of the short series tested. Only severity of TDS symptoms, or having the most frequent symptoms, influenced treatment preference. Influence was mild.

CONCLUSIONS

Conjoint analysis is a valid method for assessing preferences for ED treatments. A short series of highly selected attributes is advisable. Easiness and convenience of administration are of great importance for users. TDS symptomatology mildly affects preference.

Psychosocial outcomes after initial treatment of erectile dysfunction with tadalafil once daily, tadalafil on demand or sildenafil citrate on demand: results from a randomized, open-label study

Initiation of ED treatment with a particular PDE5I may influence treatment-adherence and other outcomes. In this multicenter, open-label study, men with ED, naïve to PDE5I, were randomized to tadalafil 5 mg once-a-day (OaD; N=257), 10 mg on demand (PRN; N = 252) or sildenafil-citrate (sildenafil) 50 mg PRN (N = 261) for 8 weeks (dose adjustments allowed), followed by 16 weeks of pragmatic treatment (switching between PDE5I allowed). Primary outcomes (treatment-adherence) were reported previously. Here, we report effects on: Psychological and Interpersonal Relationship Scales, Self-Esteem and Relationship (SEAR) questionnaire, ED Inventory of Treatment Satisfaction (EDITS), International Index of Erectile Function (IIEF), Sexual Encounter Profile (SEP) and Global Assessment Questions (GAQ). Mixed-model for repeated measures and analysis of covariance were used to analyze changes from baseline; GAQ-responses were evaluated by logistic regression. Analyses were adjusted for treatment, country, ED-severity, baseline and baseline-by-treatment interaction. Patients randomized to tadalafil OaD or PRN reported greater improvement (least-square mean (s.e.) change) in Sexual Self-Confidence (OaD +0.90 (0.048), PRN +0.93 (0.050), vs +0.73 (0.049); P=0.006 and P=0.001) and Spontaneity (OaD +0.11 (0.035), PRN +0.13 (0.035), vs +0.02 (0.035); P = 0.044 and P = 0.010) compared with sildenafil. Improvements in GAQ and SEP responses, IIEF-EF, orgasmic function, sexual desire, overall satisfaction domains, SEAR and EDITS scores did not differ significantly between treatment groups.

The Prescribing and Dispensing of Phosphodiesterase Type 5 Inhibitors in South Korea: A Questionnaire Survey of Patient Discomfort

Purpose

This study was performed to investigate the discomfort reported by patients taking phosphodiesterase type 5 inhibitors (PDE5Is) in clinical practice.

Materials and Methods

From September 2011 to March 2012, we surveyed patients who were prescribed PDE5Is for erectile dysfunction (ED). The questionnaire elicited information concerning: patient characteristics, medication counseling received and inconveniences experienced in hospitals and at pharmacies, effects of PDE5Is, and the separation of the prescribing and the dispensing of PDE5Is.

Results

A total of 237 patients completed the questionnaire (mean age: 58.81±9.14 years). Among the 62 patients (26.0%) who reported having encountered some inconveniences in hospitals, the most frequently expressed concerns 'assistant staff,' including nurses (38.7%), 'testing procedures' (27.4%), and 'the issuing of prescriptions' (22.6%). Of the 137 patients (57.8%) who noted inconveniences in obtaining medications from pharmacies, 60.6% cited 'self-consciousness' as the most common reason, followed by 'insufficient medication counseling' (22.6%), and 'absence of consultation' (11.6%). In contrast, 82% of the patients were satisfied with the medication counseling that they had received in hospitals, covering drug usage, side effects, and precautions regarding PDE5Is; this proportion was only 30% for pharmacies. Further, most patients (89%) indicated that they preferred to obtain their prescriptions and medications for ED from the hospital at the same time.

Conclusions

Treatment of ED is a highly private matter. According to the survey, ED patients more often felt that obtaining medication from pharmacies was inconvenient. The sociocultural aspects of ED necessitate that exceptions to separating the prescribing and the dispensing of medication be considered.

Health-related characteristics and unmet needs of men with erectile dysfunction: a survey in five European countries

INTRODUCTION

Data suggest that ED is still an underdiagnosed and undertreated condition. In addition, it seems that men with ED are unsatisfied about their relationship with their physician and with the available drugs.

AIM

The study aims to identify health-related characteristics and unmet needs of patients suffering from erectile dysfunction (ED) in big 5 European Union (EU) nations (France, Germany, Italy, Spain, and UK).

METHODS

Data were collected from the 2011 5EU National Health and Wellness-Survey on a population of 28,511 adult men (mean age: 47.18; SD 16.07) and was focused on men (5,184) who self-reported ED in the past 6 months. In addition, the quality of life (QoL) and work productivity/activity were explored.

MAIN OUTCOME MEASURES

Health-related QoL (HRQoL) and work productivity were measured with SF-12v2 and WPAI validated psychometric tools.

RESULTS

One in every 20 young men (age 18-39) across 5EU experienced ED in the past 6 months. About half of men (2,702/5,184; [52%]) with ED across all ages did not discuss their condition with their physician. Interestingly, among those men who did discuss their condition with their physician, 68% (1,668/2,465) do not currently use medication. These findings were more evident in the age group of 18-39 years. Only 48% (2,465/5,184) had a closer relationship with their physician, suggesting that this quality of relationship may be unsatisfactory. Compared with controls, ED patients have a significantly higher intrapsychic and relational psychopathological comorbid burden and relevant decreasing in HRQoL, with a significantly higher impairment on work productivity/activity.

CONCLUSION

Data suggest that there is a need for a new therapeutic paradigm in ED treatment which images the achievement of a new alliance between physician and patient. Hence, alternative drug delivery strategies may reduce the psychological and social impact of this disease.

Couples' reasons for adherence to, or discontinuation of, PDE type 5 inhibitors for men with erectile dysfunction at 12 to 24-month follow-up after a 6-month free trial

INTRODUCTION

The history of treatments for erectile dysfunction (ED) has involved a repeated pattern of uptake, followed by abandonment of the various therapies in the medium term. Even effective and simple to use medications are not necessarily continued; discontinuation rates range between 15% and 60%. Despite the association between partner sexual function and men's use of PDE5, no previous studies have reported any contact with partners of men taking PDE5 for their ED. This study involved both partners in couples followed up at least 1 year after treatment of ED.

AIM

The study sought clarification of factors influencing adherence to, or discontinuation of, oral ED medications from couples. We hypothesized that many factors contribute to decision making about ED medication use at >12 months.

MAIN OUTCOME MEASURES

The main outcome measures of this article were interviews and International Index of Erectile Function-erectile function domain.

METHODS

A total of 155 interviews were conducted seeking details of frequency of usage and preference for the drugs available; reasons for that choice, or for discontinuation of use, were also sought.

RESULTS

Of men interviewed, 71% were using PDE5 at 18 months. Most men interviewed were using the oral medications either 1-2x/week or 1-2x/month. Forty-four percent of men who had decreased their use of the medications reported less need for them. Thirty-four men said the main reason they were using less medication was cost. "Partner issues" from the men's perspective were seldom reported in this study. However, for a number of women, "partner issues" meant a range of problems from separation to alcohol abuse, lack of communication, and lack of confidence, or fear of failure.

CONCLUSIONS

This is the first study to ask couples why they decided to continue or stop using PDE5 when followed up. Female partners provided a different perspective on "partner issues" often cited as reasons for discontinuing PDE5 use. It was also clear that discontinuation did not mean couples were no longer sexually active.

Erectile dysfunction and lower urinary tract

During the last decades it turned out that the NO/cGMP signaling cascade is one of the most prominent regulators of a variety of physiological and pathophysiological processes in a broad range of mammalian tissues. Thus cGMP is a key second messenger and targeting this pathway by increasing intracellular cGMP levels is a very successful approach in pharmacology as shown for nitrates, PDE5 inhibitors and more recently for stimulators of the guanylate cyclase. Besides the beneficial effects of cGMP elevation in cardiac, vascular, pulmonary, renal or liver disorders the launch of PDE5 inhibitors for the treatment of erectile dysfunction 10 years ago, has directed a lot of attention to the NO/cGMP signaling in the lower urinary tract. Triggered by the use of PDE5 inhibitors in ED it turned out that cGMP is a common regulatory mechanism for lower urinary tract function also beyond ED. In recent years intense research and development efforts were undertaken to elucidate the role of the NO/cGMP and to fully exploit the therapeutic implications of cGMP elevation in urological disorders in ED and beyond. Therefore we have summarized the effects of cGMP elevation for treatment of erectile dysfunction in males and in females. We have also reviewed the recent pre-clinical and clinical lines of evidence for treatment options of benign prostatic hyperplasia and lower urinary tract symptoms in male patients and overactive bladder and urinary incontinence in female patients. In addition we also touch more speculative concepts using cGMP elevating drugs for the treatment of premature ejaculation, peyornies disease and stone disease.

Therapeutic response after first month of tadalafil treatment predicts 12 months treatment continuation in patients with erectile dysfunction: results from the DETECT study

INTRODUCTION

The DETECT study is a prospective, 12-month, European, multicenter, observational study of patients with erectile dysfunction (ED) initiating or changing treatment to tadalafil in routine clinical practice.

AIM

To determine the effectiveness of tadalafil and the factors associated with the continuation of treatment for ED at 12 months.

METHODS

The DETECT study included 1,900 men aged 18 years and older with a history of ED and who were initiating or changing treatment to tadalafil.

MAIN OUTCOME MEASURES

Sexual function at baseline, 1, 6, and 12 months was assessed using the International Index of Erectile Function-erectile function (IIEF-EF) domain. Factors associated with treatment continuation at 12 months were evaluated using multivariate regression analysis.

RESULTS

At 12 months, 1,319 (84%) of 1,567 patients who completed the questionnaire reported continued use of tadalafil. Among these patients, tadalafil was highly effective: 94%, 95%, and 71% with severe, moderate, and mild ED at baseline, respectively, improved by at least one IIEF-EF category and 65% had normal EF. Five factors were associated with tadalafil continuation at 12 months: (i) ED severity at 1 month (based on IIEF-EF domain score); (ii) tolerance to treatment at 1 month; (iii) age younger than 60 years; (iv) number of sexual attempts in the first month; and (v) no history of pelvic surgery. Patient and partner factors at baseline were not significantly associated with continued tadalafil use.

CONCLUSIONS

Tadalafil is an effective treatment for ED in routine clinical practice. The therapeutic response and treatment tolerance after 1-month treatment are the most important factors influencing tadalafil continuation.