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Erectile dysfunction treatment in aviators

Erectile dysfunction treatment in aviators. Grossman A M.D. ¹, Barenboim E M.D. MHA¹² , Azaria B M.D.¹, Goldstein L M.D. MHA². ¹The IAF AeroMedical center, ²The IAF Surgeon General HQ, ISRAEL. Background. 150 million men worldwide suffer from erectile dysfunction (ED)

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Erectile dysfunction treatment in aviators

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  1. Erectile dysfunction treatment in aviators Grossman A M.D.¹, Barenboim E M.D. MHA¹² , Azaria B M.D.¹, Goldstein L M.D. MHA². ¹The IAF AeroMedical center, ²The IAF Surgeon General HQ, ISRAEL.

  2. Background • 150 million men worldwide suffer from erectile dysfunction (ED) • This population will more than double in the next 25 years • Associated with other vascular phenomena • Phosphodiesterase 5 (PDE5) inhibitors- common in use in the general population • Increasing use in aviators (civil aviation)

  3. objectives • To review: PDES inh side effects Regulation Aero medical issues

  4. PDE5 inhibitors- mechanism • Widely distributed throughout the body • 11 families identified in human tissues • PDE5- responsible for degradation of cGMP in cavernosal tissue • PDE5 inhibitors increase cellular cGMP concentrations in the corpora cavernosa • This amplifies smooth muscle relaxation and cavernosal vasodilatation

  5. Sildenafil (Viagra) • The first of the PDE5 inhibitors • Recommended dose-50 mg, up to 100 mg Should be taken 1 hour before intercourse • Improves both the ability to attain and the ability to maintain an erection • 4 hour half-life • Affinity for PDE 6

  6. Tadalafil (Cialis) • Effective up to 36 hours • Dosing- 2.5-25 mg • Significant improvement in erectile function as compared with placebo

  7. Vardenafil (Levitra, Nuviva) • Effective for approximately 24 hours • Dosing- 5-20 milligram • Efficacy- dose-dependant

  8. Side effects • Depend on the selective inhibition of PDE5 and affinity to PDE6 • Dose-related with vardenafil • Hepatic metabolism-CYP3A4 system- macrolide, itraconazole • Hepatotoxicity (Am J Gastroenterol-8/05)

  9. Cardiovascular side effects SystolicBP(7%) • Preserved hemodynamic response to exercise • QT- insignificant increase • PDE5 inh + nitrates BP = CI • Association with ischemic events? Diastolic BP (10%) Rt Atr P (28%) Pul Art P (28%) Cardiac Output (7%)

  10. PDE5 Inh & ischemic events • Evaluation of acute risk for myocardial infarction in men treated with sildenafil citrate. • Mittleman et al, Am J Cardiol. 2005 Aug • In conclusion, these data indicate that sildenafil was not associated with short-term risk for MI and are consistent with the growing body of evidence that sildenafil use is not associated with an increased risk for cardiovascular events • Sexual intercourse is a rare trigger of acute myocardial infarction (MI).

  11. ED and ischemic heart disease • Sexual dysfunction and cardiac risk (the second princeton consensus conference). Kostis et al Am J Cardiol Jul 2005 • Relation between ED and CVS • importance of risk factor evaluation and management for all patients with ED • ED + 50-59y IHD risk Speel et al • ED sus IHD treat risk factors – life style intervention

  12. Visual side effects • Inhibition of retinal PDE6 involved in phototransduction • PDE5 Inh do not affect visual acuity, visual fields, and contrast sensitivity • All agents cause mild transient difficulty in discriminating blue-green hue (peak levels) • Pt’s reported abnormal vision • Sildenafil (3%) compared with tadalafil (0.1%) or vardenafil (0.1-1%)

  13. Side effects

  14. Aeromedical considerations • Headaches • Rhinitis (sildenafil> tadalafil or vardenafil) • Dyspepsia- (G forces)

  15. Aeromedical considerations • Visual complaints-significance unknown • Hypotension • Sildenafil- short half time Vs side effects • Vardenafil-intermediate side effect profile • Tadalafil- longer half-life better side effect profile

  16. Aeromedical regulations • FAA- 6 hours grounding sildenafil and vardenafil Tadalafil- not authorized • NOMI- sildenafil is prohibited (CD) • US ARMY- sildenafil 12 hours grounding

  17. Summary • Increased use of PDE5 inhibitors • Rule out IHD • Visual problems and nasal congestion- hazardous • 6 hours grounding - sildenafil and vardenafil • Tadalafil- side effect profile Vs long effective period (1/1000!) Do we need further studies to determine it’s safety?

  18. Questions?

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