What medications can be prescribed for a patient with erectile dysfunction and normal testosterone and FSH (Follicle-Stimulating Hormone)/LH (Luteinizing Hormone) levels?

Medication Management for Erectile Dysfunction with Normal Testosterone and FSH/LH Levels

For patients with erectile dysfunction who have normal testosterone and FSH/LH levels, phosphodiesterase type 5 inhibitors (PDE5i) are the first-line treatment of choice due to their established efficacy and safety profile. 1

First-Line Treatment: PDE5 Inhibitors

• FDA-approved PDE5 inhibitors available in the US include sildenafil, tadalafil, vardenafil, and avanafil 1
• All PDE5 inhibitors have demonstrated similar efficacy in the general ED population, with success rates of approximately 70-88% compared to 26-35% for placebo 1
• PDE5 inhibitors improve both erectile function and successful sexual intercourse rates across various patient populations 1

Selecting the Optimal PDE5 Inhibitor

When choosing between available PDE5 inhibitors, consider:

• Sildenafil 50mg: Highest efficacy but also highest rate of overall adverse events 2
• Tadalafil 10mg: Intermediate efficacy with lowest overall rate of adverse events 2
• Vardenafil 10mg and Avanafil 100mg: Similar adverse event profiles to sildenafil but lower global efficacy 2

Dosing Considerations

• Start with recommended initial doses and titrate as needed for optimal efficacy 1
• Dose-response relationships exist for sildenafil (50mg vs 25mg) and vardenafil (20mg vs 10mg vs 5mg) but not for tadalafil (20mg vs 10mg vs 5mg) 1
• Higher doses are associated with greater efficacy but also increased risk of adverse effects 1

Common Adverse Effects

• Most frequently reported adverse events include headache, flushing, dyspepsia, nasal congestion, back pain, myalgia, visual disturbance, and dizziness 1
• Adverse effect profiles differ slightly between medications:
  • Avanafil: Lowest rates of dyspepsia 1
  • Tadalafil: Lowest rates of flushing 1
  • Vardenafil and avanafil: Lowest rates of myalgia 1
• Most adverse effects follow a dose-response pattern 1

Special Considerations and Contraindications

• Absolute contraindication: Nitrate therapy (risk of severe hypotension) 1
• Use with caution in patients with:
  • Mild to moderate hepatic or renal impairment (start with lower doses) 1
  • Spinal cord injury (start with lower doses) 1
• Not recommended in patients with severe renal or liver disease 1

Maximizing Treatment Success

• Proper medication use is crucial - incorrect use accounts for a large percentage of treatment failures 1
• Provide clear instructions to patients:
  • Sexual stimulation is necessary for medication to work 1
  • Multiple trials may be required to establish efficacy 1
  • Timing relative to meals (especially fatty meals) can affect absorption 1, 3
• Consider dose titration to find optimal balance between efficacy and adverse effects 1

Management of PDE5i Non-Responders

• Approximately 30-40% of patients exhibit little or no response to PDE5i monotherapy 4
• For non-responders, consider:
  • Switching to a different PDE5i 3
  • Chronic low-dose PDE5i treatment (e.g., daily tadalafil) 4
  • Vacuum erection devices (VEDs) as an alternative non-pharmacological option 1

Important Clinical Pearls

• ED is a risk marker for cardiovascular disease - communicate this increased risk to the patient and primary care provider 1
• Since testosterone is normal, testosterone therapy is not indicated and would not be effective as monotherapy for ED 1
• If PDE5i treatment fails despite proper use and dose optimization, specialized testing may be necessary (e.g., nocturnal penile tumescence, intracavernosal injection, penile duplex ultrasound) 1

By following this evidence-based approach to medication selection and management, most patients with erectile dysfunction and normal hormonal profiles can achieve satisfactory treatment outcomes.