Table of Contents
This is the best review I have seen on the subject.
Abstract
Phosphodiesterase type 5 inhibitors (PDE5-i) have become first-line therapy for the treatment of erectile dysfunction. Most initial prescriptions for PDE5-i are by primary care practitioners.
Urologists must now routinely manage the patient who has failed initial therapy with PDE5-i. Lifestyle modifications can be of benefit to patients. Patient education and optimization of the PDE5-i can result in a successful response. Interestingly, there are reports of up to 60% salvage after changing the PDE5-i utilized. Daily PDE5-i have shown benefit, and treatment of hypogonadism can enhance response to PDE5-i.
We review the management of PDE5-i failures with emphasis on noninvasive approaches to gaining improved erectile response to these medications. An algorithm based on the reviewed strategies is proposed to guide clinicians in the treatment of erectile dysfunction.
Conclusion
Between 30 and 40% of patients fail initial attempts to manage erectile dysfunction with PDE5-i. Many of these patients can be salvaged with further noninvasive management. Specific patient instruction regarding timing of medication dosing and effect of food and alcohol are often inadequate at the time of initial prescribing. Patients should expect that it may take up to eight attempts prior to achieving the benefit of a PDE5-i.
Lifestyle changes improve erectile response and overall health. Pelvic floor exercises have been shown to increase erectile responsiveness. Daily dosing of a PDE5-i may provide benefit for up to 41% of men. Switching the PDE5-i has been shown to provide response rates between 12% and 61% in patients failing a previous PDE5-i.
Finally, treatment of hypogonadism and treatment with pioglitazone, doxazosin, or bremelanotide have been shown to improve PDE5-i responsiveness in small clinical studies but remain to be substantiated. High dose PDE5-i treatment carries increased rates of adverse effects, and patient drop-out increases.
Finally, the authors recommend a ‘personalized medicine’ approach be taken when counseling patients initially failing PDE5-i, as not all patients will be tolerant of the trials necessary to achieve success with a noninvasive approach.
Further trials are necessary to determine which patient characteristics lend to a poor response regardless of the PDE5-i used, in order to direct these patients to a more effective therapy.
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