What do you need to know before starting Erectile Dysfunction (ED) medication?

Essential Evaluation Before Starting Erectile Dysfunction Medication

Before starting erectile dysfunction medication, patients must undergo a thorough cardiovascular assessment, medical history review, physical examination, and laboratory testing to ensure safety and identify underlying causes. 1, 2

Comprehensive Evaluation Required

Medical History Assessment

• Obtain detailed medical history focusing on:
  • Cardiovascular disease and risk factors (hypertension, diabetes, hyperlipidemia)
  • Current medications, especially nitrates (absolute contraindication) 3
  • Psychological factors (anxiety, depression, relationship issues) 1
  • Substance use (alcohol, tobacco, recreational drugs) 1
  • Onset, progression, and nature of erectile dysfunction symptoms 1
  • Prior surgeries, especially pelvic or urological procedures 1

Physical Examination

• Measure vital signs, including blood pressure and heart rate 1
• Perform genital examination to assess for anatomical abnormalities or Peyronie's disease 1
• Evaluate secondary sexual characteristics 2
• Examine chest for gynecomastia 1
• Check for peripheral vascular disease signs 1

Laboratory Testing

• Essential laboratory tests:
  • Morning serum total testosterone (mandatory) 1, 2
  • Fasting glucose or HbA1c 2
  • Lipid profile 2
  • PSA if testosterone therapy is being considered 1, 2

Cardiovascular Risk Assessment

• Assess cardiovascular status and exercise capacity 1, 3
• Determine if patient can perform exercise equivalent to walking 1 mile in 20 minutes or climbing 2 flights of stairs in 20 seconds 1
• High-risk patients should be referred to a cardiologist before ED treatment 1, 4
• ED may be an early marker of cardiovascular disease 1, 4

Contraindications and Special Considerations

Absolute Contraindications

• Use of nitrates in any form (risk of severe hypotension) 3
• Severe aortic stenosis or hypertrophic obstructive cardiomyopathy 4
• Unstable angina or recent myocardial infarction (within 90 days) 3
• Stroke within the last 6 months 3

Medication Interactions

• Review all current medications for potential interactions:
  • Alpha-blockers require dose adjustments and careful monitoring 3
  • CYP3A4 inhibitors (ketoconazole, ritonavir) require dose reduction of PDE5 inhibitors 3
  • Antihypertensives may cause additive blood pressure effects 3

Renal and Hepatic Function

• Assess renal function, as dose adjustments are needed for creatinine clearance <50 mL/min 3
• Evaluate hepatic function, as severe impairment may contraindicate certain ED medications 3

Treatment Selection Considerations

• Validated questionnaires (Sexual Health Inventory for Men) help assess ED severity and guide treatment 1, 2
• Consider psychological factors that may require concurrent mental health referral 1
• Discuss all treatment options, including lifestyle modifications, oral medications, injections, and devices 1, 5
• PDE5 inhibitors are first-line therapy for most men without specific contraindications 5

Common Pitfalls to Avoid

• Failing to measure testosterone levels 2
• Not screening for cardiovascular disease before starting treatment 4
• Overlooking psychological factors contributing to ED 1, 2
• Neglecting to discuss potential side effects before prescribing 2
• Not advising patients about counterfeit medications from unauthorized sources 5

By following this comprehensive evaluation approach, clinicians can safely prescribe ED medications while identifying and addressing underlying causes, ultimately improving patient outcomes related to morbidity, mortality, and quality of life.