A comprehensive history of injection therapy for erectile dysfunction, 1982-2023

INTRODUCTION

Although oral phosphodiesterase 5 inhibitors represent a first choice and long-term option for about half of all patients with erectile dysfunction (ED), self-injection therapy with vasoactive drugs remains a viable alternative for all those who are not reacting or cannot tolerate oral drug therapy. This current injection therapy has an interesting history beginning in 1982.

OBJECTIVES

To provide a comprehensive history of self-injection therapy from the very beginnings in 1982 by contemporary witnesses and some members of the International Society for Sexual Medicine's History Committee, a complete history of injection therapy is prepared from eyewitness accounts and review of the published literature on the subject, as well as an update of the current status of self-injection therapy.

METHODS

Published data on injection therapy, as a diagnostic and therapeutic tool for ED, were reviewed thoroughly by PubMed and Medline research from 1982 until June 2023. Early pioneers and witnesses added firsthand details to this historical review. Therapeutic reports of injection therapy were reviewed, and results of side effects and complications were thoroughly reviewed.

RESULTS

The pioneers of the first hours were Ronal Virag (1982) for papaverine, Giles Brindley (1983) for cavernosal alpha-blockade (phentolamine and phenoxybenzamine), Adrian Zorgniotti (1985) for papaverine/phentolamine, and Ganesan Adaikan and N. Ishii (1986) for prostaglandin E1. Moxisylyte (thymoxamine) was originally marketed but later withdrawn. The most common side effect is priapism, with the greatest risk of this from papaverine, which has modified its use for therapy. Currently, prostaglandin E1 and trimixes continue to be the agents of choice for diagnostic and therapeutic use in ED. A recent agent is a mixture of a vasoactive intestinal polypeptide (aviptadil) and phentolamine.

CONCLUSIONS

After 40 years, self-injection therapy represents the medication with the highest efficacy and reliability rates and remains a viable option for many couples with ED. The history of this therapy is rich.

Precision fluid and vasoactive drug therapy for critically ill patients

There are several clinical practice guidelines concerning the use of fluid and vasoactive drug therapies in critically ill adult patients, but the recommendations in these guidelines are often based on low-quality evidence. Further, some were compiled prior to the publication of landmark clinical trials, particularly in the comparison of balanced crystalloid and normal saline. An important consideration in the treatment of critically ill patients is the application of precision medicine to provide the most effective care to groups of patients most likely to benefit from the therapy. Although not currently widely integrated into these practice guidelines, the utility of precision medicine in critical illness is a recognized research priority for fluid and vasoactive therapy management. The purpose of this narrative review was to illustrate the evaluation and challenges of providing precision fluid and vasoactive therapies to adult critically ill patients. The review includes a discussion of important investigations published after the release of currently available clinical practice guidelines to provide insight into how recommendations and research priorities may change future guidelines and bedside care for critically ill patients.

An inquiry into the treatment of sepsis using plasma exchange therapy: A systematic review and meta-analysis

Sepsis is a potentially lethal condition that occurs when the body's response to infection damages tissue and organs. The production of inflammatory mediators typically assists in defending the body against infection; however, an overreaction to inflammation can cause coagulation problems, vascular endothelial damage, and organ hypoperfusion. Blood purification methods, such as plasmapheresis, can effectively remove inflammatory mediators from plasma. The purpose of this meta-analysis was to explore the efficacy of plasma exchange for sepsis treatment as noted in recent studies. The authors searched the Pubmed (Medline), Cochrane Central Register of Controlled Trials (The Cochrane Library), Embase (Ovid), and Scopus databases and included controlled clinical studies that compared plasmapheresis or plasma filtration with conventional treatment in patients with severe sepsis. The Newcastle-Ottawa Scale literature quality assessment tool was used to assess the risk of bias. The primary study outcome was all-cause mortality. The random effects model was adopted for conducting the meta-analysis. Among the 1013 records found, the study included 5 trials, all of which carried a low risk of bias. The use of plasmapheresis was associated with a longer stay in the intensive care unit (odds ratio [OR], 0.85, 95% confidence interval [CI], 0.39-1.32, heterogeneity [I2 ] = 0%), a significant reduction in all-cause mortality (OR, 0.54, 95% CI, 0.33-0.89, I2  = 70%), and reduced mortality (OR, 0.29, 95% CI, 0.13-0.67, I2  = 0%) in adults; the results for children differed from this (OR, 0.79, 95% CI, 0.36-1.72, I2  = 89%). Four trials reported no adverse events; one trial reported an adverse event related to plasma exchange, including an instance of hypotension in one patient. Plasmapheresis appeared to be an effective treatment for patients suffering from sepsis. A large number of additional randomised controlled trials are needed to confirm this finding.

The effects of vasopressors with and without dobutamine on haemodynamics, metabolism and gut injury during endotoxic shock in rabbits. A controlled study

INTRODUCTION

Vasopressors increase arterial pressure but they may have deleterious effects on mesenteric blood flow. We aimed to evaluate the response of gut biomarkers and superior mesenteric blood flow to different vasopressors with and without dobutamine.

MATERIAL AND METHODS

Thirty New Zealand rabbits were included and randomly allocated to 5 groups: group A - sham group; group B - norepinephrine; group C - norepinephrine plus dobutamine; group D - vasopressin; and group E - vasopressin plus dobutamine. Mean arterial pressure (MAP) target was greater than 60 mmHg. Endotoxic shock was induced by intra-venous injection of lipopolysaccharide (LPS) in four of the five groups. Aortic blood flow (Qao), superior mesenteric artery flow (QSMA) and lactate were measured after LPS injection. Enterocyte damage was evaluated by measurements of serum citrulline and intestinal fatty acid-binding protein (I-FABP) after 4 h.

RESULTS

The largest reduction in Qao occurred in group D (64 ± 17.3 to 38 ± 7.5 mL min-1; P = 0.04). QSMA also declined significantly in groups D and E and remained lower than in the other groups over 4 h (group D - baseline: 65 ± 31; 1 h: 37 ± 10; 2 h: 38 ± 10; 3 h: 46 ± 26; and 4 h: 48 ± 15 mL min-1; P < 0.005; group E - baseline: 73 ± 14; 1 h: 28 ± 4.0; 2 h: 37 ± 6.4; 3 h: 40 ± 11; and 4 h: 48 ± 11; P < 0.005; all in mL min-1). Serum citrulline was significantly lower in groups D (P = 0.014) and E (P = 0.019) in comparison to group A. The fluid administration regimen was similar in all groups.

CONCLUSIONS

Vasopressin seems to negatively impact gut enterocyte function during endotoxic shock despite the association of an inodilator and adequate fluid replacement.

Transjugular intrahepatic portosystemic shunt in patients treated with a balloon tamponade for variceal hemorrhage without response to high doses of vasoactive drugs: A real-world multicenter retrospective study

OBJECTIVE

To evaluate the efficacy of transjugular intrahepatic portosystemic shunt (TIPS) and non-TIPS therapy (endoscopy and/or nonselective beta-blockers [NSBB]) in patients with cirrhosis and active variceal hemorrhage who did not respond to high-dose vasoactive drugs and required balloon tamponade for hemostasis.

METHODS

Medical records of cirrhotic patients who did not respond to high-dose vasoactive drugs and required balloon tamponade for hemostasis at five university hospitals in China between January 2011 and December 2018 were reviewed. Treatment outcomes were compared between the TIPS and the non-TIPS groups.

RESULTS

Treatment failure of variceal hemorrhage within 5 days was reported in six patients of the non-TIPS group (N = 70) and none of the TIPS group (N = 66) (P = .028). The TIPS group had a higher 1-year variceal rebleeding-free rate compared with the non-TIPS group (95.5% vs 60.0%, P < .001). One patient treated with TIPS and nine with non-TIPS therapy experienced rebleeding within 5 days and 6 weeks after the intervention (P = .009). The cumulative 1-year survival rate was higher in the TIPS group than in the non-TIPS group (93.9% vs 78.6%, P = .01). The TIPS group had a higher incidence of hepatic encephalopathy within one year compared with the non-TIPS group (18.2% vs 4.3%, P = .026).

CONCLUSION

For patients with cirrhosis and active variceal bleeding who do not respond to high-dose vasoactive agents and require a balloon tamponade for hemostasis, TIPS may be an appropriate treatment choice.

Early Enteral Nutrition Tolerance in Patients With Cardiogenic Shock Requiring Mechanical Circulatory Support

Background: Enteral nutrition (EN) is recommended within the first 24-48 h for patients with hemodynamic stability, following admission to an intensive care unit (ICU). However, for patients with approximate stable hemodynamics requiring mechanical circulatory support and vasoactive drugs, the application of early EN remains controversial. We sought to evaluate the tolerance of early EN in patients with cardiogenic shock who required vasoactive drugs and mechanical circulatory support after cardiac surgery. Methods: This single-center, prospective observational study included patients with cardiogenic shock, requiring vasoactive drugs and mechanical circulatory support after cardiac surgery, undergoing EN. The primary endpoint was EN tolerance and secondary endpoints were mortality, length of mechanical ventilation, and length of ICU stay. Results: From February 2019 to December 2020, 59 patients were enrolled, of which 25 (42.37%) developed intolerance within 3 days of starting EN. Patients in the EN intolerant group had a longer median length of mechanical ventilation (380 vs. 128 h, p = 0.006), a longer median ICU stay (20 vs. 11.5 days, p = 0.03), and a higher proportion of bloodstream infections (44 vs. 14.71%, p = 0.018). The median EN calorie levels for all patients in the first 3 days of EN were 4.00, 4.13, and 4.28 kcal/kg/day, respectively. Median protein intake levels of EN in the first 3 days were 0.18, 0.17, and 0.17 g/kg/day, respectively. No significant difference was observed in the median dose of vasoactive drugs between the groups (0.035 vs. 0.05 μg/kg/min, p = 0.306). Conclusions: Patients with cardiogenic shock after cardiac surgery had a high proportion of early EN intolerance, and patients with EN intolerance had a worse prognosis, but no significant correlation was identified between EN tolerance and the dose of vasoactive drugs.

Does Inhaled Milrinone Facilitate Weaning From Cardiopulmonary Bypass in Children with Congenital Heart Diseases Complicated with Pulmonary Arterial Hypertension?

Objective

The aim of the present study was to evaluate the efficacy of inhaled milrinone in controlling pulmonary arterial hypertension (PAH) in paediatric cardiac surgery and its effect on weaning from cardiopulmonary bypass (CPB).

Methods

A total of 40 patients with congenital heart diseases complicated by PAH submitted to cardiac surgery requiring CPB were included in the present study and were randomly classified into the control group (n=20) who received intravenous milrinone 0.5 μg kg⁻¹ min⁻¹ and the inhaled group (n=20) who received inhaled milrinone 50 μg kg⁻¹ before initiation and just before weaning off CPB. Mean pulmonary artery pressure (mPAP), mean systemic arterial pressure (MAP), heart rate (HR), MAP/mPAP ratio, vasoactive drug requirements and time needed to wean the patients from CPB were collected.

Results

mPAP and HR were significantly lower, and MAP and MAP/mPAP ratio were significantly higher in the inhaled group than in the control group. Vasoactive drug requirements were significantly lesser, and the time needed to wean the patients was significantly shorter in the inhaled group than in the control group.

Conclusion

Milrinone inhalation facilitated the weaning from CPB as it significantly reduced mPAP and maintained MAP with subsequently less needs for vasoactive drugs.

Impact of the use of vasoactive drugs in cardiac death donors on the early postoperative renal function and related complications in renal transplant recipients

Background

To explore the impact of the use of vasoactive drugs in donation after cardiac death (DCD) donors on graft function, with an attempt to guide the clinical practices of organ preservation and DCD kidney transplantation.

Methods

The clinical data of 187 DCD donors and 304 recipients who were operated on in our center from February 2018 to May 2019 were retrospectively analyzed. Based on whether vasoactive drugs were used for maintaining blood pressure in DCD donors, the renal donors and recipients were divided into a high-dose group (norepinephrine ≥1.3 µg/kg/min or in combination with dopamine), a low-dose group (norepinephrine <1.3 µg/kg/min or in conjunction with dopamine), and a no-medication group (without the use of vasoactive drugs). The clinical features, post-transplant renal function, and complications were compared among these three groups.

Results

The early renal function 1 and 7 days after surgery was significantly superior in the high-dose group and no-medication group (P<0.05) but showed no significant difference between the low-dose group and the no-medication group (P>0.05). Blood urea nitrogen (BUN) on the 1st postoperative days was significantly higher in the high-dose group than in the low-dose group and the no-medication group (P<0.05). Renal function indicators, including serum creatinine (CRE), BUN, and blood uric acid (UA) on the 30th postoperative day, showed no significant difference among these three groups (P>0.05). The incidence of delayed graft function (DGF) after renal transplantation was significantly higher in the high-dose group than in the low-dose group and the no-medication group (P<0.05), whereas there was no significant difference between the groups in the incidences of graft rejection and infections (P>0.05).

Conclusions

The use of vasoactive drugs in DCD donors can affect the early recovery of renal function in renal transplant recipients, particularly for those donors who are administered a high dose of vasoactive drugs. Therefore, donor maintenance should be performed cautiously with vasoactive drugs.

Is additional 5-day vasoactive drug therapy necessary for acute variceal bleeding after successful endoscopic hemostasis?: A systematic review and meta-analysis

BACKGROUND

Vasoactive drugs and endoscopic therapy have been widely used in the management of acute variceal bleeding of cirrhosis patients. The current standard regimen of vasoactive drugs is in combination with endoscopic therapy and continues for up to 5 days; however, the necessity of vasoactive drugs after endoscopic hemostasis was still controversial. Therefore, we conducted a systematic review and meta-analysis to evaluate the efficacy and optimal duration of adjuvant vasoactive drugs after hemorrhage control by endoscopic therapy.

METHODS

A search was conducted of PubMed, EMBASE, and Cochrane Library databases until June, 2018. Lan DeMets sequential monitoring boundary was constructed to assess the reliability and conclusiveness of our major results.

RESULTS

Seven studies (639 patients) and 4 studies (435 patients) were included in the analyses to evaluate the efficacy and optimal duration of adjuvant vasoactive drugs therapy, respectively. Our analyses showed that adjuvant vasoactive drugs facilitated endoscopic hemostasis and reduced very early re-bleeding rate both in sclerotherapy (risk ratio [RR] 0.51, 95% confidence interval [CI] 0.34-0.78, P = .23, I = 31%) and band ligation (RR 0.48, 95% CI 0.27-0.83, P = .07, I = 62%). However, the 3 to 5-day therapy duration was not superior to a shorter course in very early re-bleeding rate and mortality rate in 42 days (RR 1.77, 95% CI 0.64-4.89, P = .70, I = 0%; RR 0.95, 95% CI 0.43-2.13, P = .81, I = 0%, respectively).

CONCLUSION

Additional 5-day vasoactive drug after endoscopic hemostasis may significantly ameliorate very early re-bleeding rate, However, the 3 to 5 days' adjuvant regimen was not superior to a shorter course.

The Pathogenesis of Nonocclusive Mesenteric Ischemia: Implications for Research and Clinical Practice

Nonocclusive mesenteric ischemia (NOMI) is a condition that can encompass ischemia, inflammation, and infarction of the intestinal wall. In contrast to most patients with acute mesenteric ischemia, NOMI is distinguished by patent arteries and veins. The clinical presentation of NOMI is often insidious and nonspecific, resulting in a delayed diagnosis. Patients most at risk are those with severe acute and critical disease, including major surgery and trauma. Nonocclusive mesenteric ischemia is part of a spectrum, from mild, asymptomatic, and an unexpected finding on CT scanning, through to those exhibiting abdominal distension and peritonitis. Severe NOMI is associated with a significant mortality rate. This review of NOMI pathophysiology was conducted to document current concepts and evidence, to examine the implications for diagnosis and treatment, and to identify gaps in knowledge that might direct future research. The key pathologic mechanisms involved in the genesis of NOMI represent an exaggerated normal physiological response to maintain perfusion of vital organs at the expense of mesenteric perfusion. A supply-demand mismatch develops in the intestine due to the development of persistent mesenteric vasoconstriction resulting in reduced blood flow and oxygen delivery to the intestine, particularly to the vulnerable superficial mucosa. This mismatch can be exacerbated by raised intra-abdominal pressure, enteral nutrition, and the use of certain vasoactive drugs, ultimately resulting in the development of intestinal ischemia. Strategies for prevention, early detection, and treatment are urgently needed.

Reversible cerebral vasoconstriction syndrome secondary to caffeine withdrawal

We describe a 39-year-old man who developed thunderclap headaches during a hospital admission for accidental superficial burns. His magnetic resonance brain imaging was normal expect for diffuse segmental vasoconstriction. Prior to admission, he was consuming excessive amounts of caffeine which was restarted and slowly tapered and stopped over weeks. Repeat magnetic resonance angiogram showed resolution of segmental vasoconstriction. The implications of prescribed and non-prescribed drugs on cerebral vasculature have been discussed.

Improving the management of gastrointestinal bleeding in patients with cirrhosis

Gastrointestinal bleeding remains a major cause of mortality in patients with cirrhosis. The most common source of bleeding is from gastroesophageal varices but non-variceal bleeding from peptic ulcer disease also carries a significant risk in patients with liver disease. The prognosis is related to the severity of the underlying liver disease, and deaths often occur due to liver failure, infection or renal failure. Optimal management should therefore not only achieve haemostasis but address these complications as well. The management of gastrointestinal bleeding in patients with cirrhosis includes a range of medical, endoscopic and radiological interventions. This article updates the recent developments in this area and highlights topics where further research is still required.

Impact of the implementation of vasoactive drug protocols on safety and efficacy in the treatment of critically ill patients

WHAT IS KNOWN AND OBJECTIVE

The correct management of high-alert medications is a priority issue in expert recommendations for improving the clinical safety of patients. Objectives were to assess the impact of the implementation of vasoactive drug (VAD) protocols on safety and efficacy in the treatment of critically ill patients.

METHODS

A prospective before-and-after study on the implementation of different VAD protocols, comparing medication errors (MEs) rates, mean intensive care unit (ICU) stay, mean blood pressure (MAP), heart rate (HR) and oxygen saturation.

RESULTS AND DISCUSSION

The study included 432 patients. There was a statistically significant decrease in prescribing errors (55·9%), validation errors (68·1%) and medication administration records (MAR) errors (78·8%). No differences were found between the two phases in ICU stay, MAP, HR and oxygen saturation.

WHAT IS NEW AND CONCLUSION

Implementation of protocols decreases variability in clinical practice, reduces the incidence of MEs and maintains the effectiveness of VAD therapy in critically ill patients.

Comparative safety and efficacy of vasopressors for mortality in septic shock: A network meta-analysis

INTRODUCTION

Septic shock is a life-threatening condition requiring vasopressor agents to support the circulatory system. Several agents exist with choice typically guided by the specific clinical scenario. We used a network meta-analysis approach to rate the comparative efficacy and safety of vasopressors for mortality and arrhythmia incidence in septic shock patients.

METHODS

We performed a comprehensive electronic database search including Medline, Embase, Science Citation Index Expanded and the Cochrane database. Randomised trials investigating vasopressor agents in septic shock patients and specifically assessing 28-day mortality or arrhythmia incidence were included. A Bayesian network meta-analysis was performed using Markov chain Monte Carlo methods.

RESULTS

Thirteen trials of low to moderate risk of bias in which 3146 patients were randomised were included. There was no pairwise evidence to suggest one agent was superior over another for mortality. In the network meta-analysis, vasopressin was significantly superior to dopamine (OR 0.68 (95% CI 0.5 to 0.94)) for mortality. For arrhythmia incidence, standard pairwise meta-analyses confirmed that dopamine led to a higher incidence of arrhythmias than norepinephrine (OR 2.69 (95% CI 2.08 to 3.47)). In the network meta-analysis, there was no evidence of superiority of one agent over another.

CONCLUSIONS

In this network meta-analysis, vasopressin was superior to dopamine for 28-day mortality in septic shock. Existing pairwise information supports the use of norepinephrine over dopamine. Our findings suggest that dopamine should be avoided in patients with septic shock and that other vasopressor agents should continue to be based on existing guidelines and clinical judgement of the specific presentation of the patient.

Benefits of smart pumps for automated changeovers of vasoactive drug infusion pumps: a quasi-experimental study

BACKGROUND

Manual changeover of vasoactive drug infusion pumps (CVIP) frequently lead to haemodynamic instability. Some of the newest smart pumps allow automated CVIP. The aim of this study was to compare automated CVIP with manual 'Quick Change' relays.

METHODS

We performed a prospective, quasi-experimental study, in a university-affiliated intensive care unit (ICU). All adult patients receiving continuous i.v. infusion of vasoactive drugs were included. CVIP were successively performed manually (Phase 1) and automatically (Phase 2) during two 6-month periods. The primary endpoint was the frequency of haemodynamic incidents related to the relays, which were defined as variations of mean arterial pressure >15 mm Hg or heart rate >15 bpm. The secondary endpoints were the nursing time dedicated to relays and the number of interruptions in care because of CVIP. A multivariate mixed effects logistic regression was fitted for analytic analysis.

RESULTS

We studied 1329 relays (Phase 1: 681, Phase 2: 648) from 133 patients (Phase 1: 63, Phase 2: 70). Incidents related to CVIP decreased from 137 (20%) in Phase 1 to 73 (11%) in Phase 2 (P<0.001). Automated relays were independently associated with a 49% risk reduction of CVIP-induced incidents (adjusted OR=0.51, 95% confidence interval 0.34-0.77, P=0.001). Time dedicated to the relays and the number of interruptions in care to manage CVIP were also significantly reduced with automated relays vs manual relays (P=0.001).

CONCLUSIONS

These results demonstrate the benefits of automated CVIP using smart pumps in limiting the frequency of haemodynamic incidents related to relays and in reducing the nursing workload.

Pulmonary hypertension in COPD

Pulmonary hypertension (PH) is a common consequence of COPD. It has been speculated that patients showing serious PH and vascular remodeling without severe airway obstruction might benefit from vasoactive treatment. There is no approved drug available for COPD-induced PH. Most trials assessing the efficacy of vasoactive drugs in PH have had a follow-up of 12-16 weeks. We report on 4 subjects with COPD and PH. Pulmonary arterial hypertension associated diseases and pulmonary embolism were ruled out. PH persisted despite optimized treatment of underlying COPD and comorbidities, so bosentan was started in all 4 subjects. With bosentan the mean pulmonary artery pressure improved. The average gains in 6-min walk distance at 2-3 months and 8-9 months were 36 m and 145 m, respectively. The maximum gains in 6-min walk distance of the individual subjects were at the 9th, 13th, and 18th month. Oxygenation was stable, and no side effects were observed. We suggest from this experience that in clinical trials of PH in COPD, a follow-up of 16 weeks might cause underestimation of the treatment effects.

Outcomes of patients on multiple vasoactive drugs for shock

INTRODUCTION

Vasoactive drugs are routinely used in critically ill patients with shock to optimize the hemodynamic state while evaluating and treating potentially reversible causes. Limited data exist on the use of multiple vasoactive drugs in the intensive care unit. We hypothesize that the use of 3 or more vasoactive drugs is associated with worse outcomes.

METHODS

We retrospectively examined the outcome in patients, at least 18 years of age, in whom 3 or more vasoactive drugs were administered simultaneously. We included patients admitted between November 2007 and August 2009. Vasoactive drugs included dopamine, dobutamine, epinephrine, norepinephrine, phenylephrine, and vasopressin. The primary end point was survival to hospital discharge.

RESULTS

Sixty-six patients received 3 or more vasoactive drugs simultaneously. Nine patients (14%) survived to ICU discharge and 6 patients (9%) survived to hospital discharge. There was a significant difference in mean Simplified Acute Physiology Score II between survivors (32.3 ± 28.6) and nonsurvivors (72.1 ± 30.4), P = .003. Five of the 6 survivors had an acute cardiac procedure, either percutaneous cardiac intervention or heart transplantation. The 1 patient with septic shock who survived had surgery for a bowel perforation. All patients who survived received inotropic therapy (dobutamine). None of the patients who received 4 or more vasoactive drugs survived.

CONCLUSION

Patients requiring 3 or more vasoactive drugs rarely survive in the absence of an intervention aimed at correcting the underlying cause such as revascularization or source control surgery.