Copyright © 2017, Elsevier Inc. All rights reserved. Chapter 35 Men’s Health Drugs Copyright © 2017, Elsevier Inc. All rights reserved.

Copyright © 2017, Elsevier Inc. All rights reserved. Androgens Testosterone Responsible for normal development and maintenance of primary and secondary male sex characteristics Development of bone and muscle tissue Inhibition of protein catabolism (metabolic breakdown) Retention of various electrolytes Stimulates the production of blood cells Copyright © 2017, Elsevier Inc. All rights reserved.

Copyright © 2017, Elsevier Inc. All rights reserved. Androgens (Cont.) Several synthetic derivatives of testosterone are available Long-term dosage forms can last from 2 to 3 days to 2 to 4 weeks Oral forms have a high first-pass effect Methyltestosterone (Android) Fluoxymesterone (Halotestin) Transdermal forms available Patches and gel Copyright © 2017, Elsevier Inc. All rights reserved.

Copyright © 2017, Elsevier Inc. All rights reserved. Androgens (Cont.) Anabolic steroids Anabolic activity: synthesis of tissue and increasing tissue formation Schedule III, great potential for misuse by athletes Oxymetholone (Anadrol-50) Oxandrolone (Oxandrin) Nandrolone (Deca-Durabolin) Copyright © 2017, Elsevier Inc. All rights reserved.

Copyright © 2017, Elsevier Inc. All rights reserved. Androgens (Cont.) Anabolic steroids: approved indications Adjunctive therapy to promote weight gain after extensive surgery, trauma, chronic diseases, anemia, hereditary angioedema, and metastatic breast cancer Copyright © 2017, Elsevier Inc. All rights reserved.

Copyright © 2017, Elsevier Inc. All rights reserved. Androgens (Cont.) Anabolic steroids: great potential for misuse Bodybuilders and weightlifters Muscle-building properties Serious consequences: sterility, cardiovascular diseases, and liver cancer Schedule III controlled substances by the U.S. Drug Enforcement Administration Misuse of these drugs can lead to psychological or physical dependence or both. Copyright © 2017, Elsevier Inc. All rights reserved.

Copyright © 2017, Elsevier Inc. All rights reserved. Androgens (Cont.) Danazol (Danocrine) Synthetic androgen is danazol (Danocrine). Use: treatment of hereditary angioedema, and, in women, endometriosis and fibrocystic breast disease. Copyright © 2017, Elsevier Inc. All rights reserved.

Androgens: Mechanism of Action Effects are similar to the body’s endogenous androgens Stimulate normal growth and development of the male sex organs Development and maintenance of male secondary sex characteristics Stimulate increased synthesis of body proteins, aiding in the formation of muscular and skeletal proteins Enhanced erythropoiesis Copyright © 2017, Elsevier Inc. All rights reserved.

Copyright © 2017, Elsevier Inc. All rights reserved. Androgen Inhibitors Block the effects of naturally occurring (endogenous) androgens 5-Alpha reductase inhibitors Benign prostatic hyperplasia (BPH) treatment Finasteride Dutasteride Copyright © 2017, Elsevier Inc. All rights reserved.

Finasteride (Propicia) Inhibition of 5-alpha reductase prevents the thinning of hair caused by increased levels of DHT Male pattern baldness Women Not for treatment of female baldness Teratogenic in pregnant women Use in women of any age (pregnant or not) is not recommended. Women need to wear gloves when handling finasteride. Copyright © 2017, Elsevier Inc. All rights reserved.

Alpha1-Adrenergic Blockers Used for symptomatic relief of obstruction caused by BPH Doxazosin (Cardura) Tamsulosin (Flomax) Terazosin (Hytrin) Alfuzosin (Uroxatral) Silodosin (Rapaflo) Copyright © 2017, Elsevier Inc. All rights reserved.

Alpha1-Adrenergic Blockers (Cont.) These drugs have clinical effects of prostate shrinkage immediately. 5-Alpha reductase inhibitors may take up to 6 months of continual therapy for clinical effects of prostate shrinkage. Copyright © 2017, Elsevier Inc. All rights reserved.

Androgen Receptor Blockers Block the activity of androgen hormones at target tissue (prostate) receptors Used in the treatment of prostate cancer Flutamide (Eulexin) Nilutamide (Nilandron) Bicalutamide (Casodex) Copyright © 2017, Elsevier Inc. All rights reserved.

Gonadotropin-Releasing Hormone Analogs Used to treat prostate cancer Action: inhibit the secretion of pituitary gonadotropin, which eventually leads to a decrease in testosterone production Goserelin (Zoladex) Leuprolide (Lupron) Triptorelin (Trelstar) Copyright © 2017, Elsevier Inc. All rights reserved.

Drugs to Treat Erectile Dysfunction Phosphodiesterase (PDE) inhibitors are used in the treatment of erectile dysfunction (ED). Sildenafil (Viagra) First oral drug for treatment of ED Causes relaxation of the smooth muscle in the corpora cavernosa (erectile tubes) of the penis and permits the inflow of blood Copyright © 2017, Elsevier Inc. All rights reserved.

Drugs to Treat Erectile Dysfunction (Cont.) Vardenafil (Levitra) Tadalafil (Cialis) Similar to sildenafil (Viagra) but longer duration of action Sildenafil and tadalafil are also used to treat pulmonary hypertension. Copyright © 2017, Elsevier Inc. All rights reserved.

Drugs to Treat Erectile Dysfunction (Cont.) Avanagil (Stendra): newest PDE inhibitor approved for ED Copyright © 2017, Elsevier Inc. All rights reserved.

Drugs to Treat Erectile Dysfunction (Cont.) Alprostadil (Caverject) Prostaglandin Administered by injecting it directly into the erectile tissue of the penis or pushing a suppository form of the drug into the urethra Copyright © 2017, Elsevier Inc. All rights reserved.

Audience Response System Question A 48-year-old man asks the nurse practitioner for a prescription for sildenafil (Viagra). He is currently taking transdermal nitroglycerin, hydrochlorothiazide, and potassium supplements for cardiac problems, as well as a multivitamin with iron. Which medication would be a cause for concern if taken with the sildenafil? Transdermal nitroglycerin Hydrochlorothiazide Potassium Multivitamin with iron Correct answer: A Rationale: Taking drugs such as sildenafil with nitrates may lead to dangerous hypotensive episodes. Copyright © 2017, Elsevier Inc. All rights reserved.

Men’s Health Drugs: Indications Primary use: replacement therapy Other uses vary with the specific drug Copyright © 2017, Elsevier Inc. All rights reserved.

Men’s Health Drugs: Contraindications Known androgen-responsive tumors Sildenafil, vardenafil, tadalafil and avanafil: contraindicated in men with major cardiovascular disorders, especially if they use nitrate medications such as nitroglycerin Use of finasteride is contraindicated in women (especially pregnant women) and children. Copyright © 2017, Elsevier Inc. All rights reserved.

Men’s Health Drugs: Adverse Effects Androgens cause fluid retention. Anabolic steroids Peliosis of the liver Hepatic neoplasms (liver cancer) Cholestatic hepatitis Jaundice Abnormal liver function Copyright © 2017, Elsevier Inc. All rights reserved.

Men’s Health Drugs: Adverse Effects (Cont.) Priapism: abnormally prolonged penile erection Relatively uncommon Possible adverse effect of both the ED drugs and the androgens Medical emergency that warrants urgent medical attention Caused by an excessive therapeutic drug response Copyright © 2017, Elsevier Inc. All rights reserved.

Men’s Health Drugs: Adverse Effects (Cont.) PDE inhibitors: can cause unexplained visual loss. Copyright © 2017, Elsevier Inc. All rights reserved.

Men’s Health Drugs: Adverse Effects (Cont.) Finasteride: loss of libido, loss of erection, ejaculatory dysfunction, hypersensitivity reactions, gynecomastia, severe myopathy, and a 50% decrease in prostate-specific antigen (PSA) concentrations Copyright © 2017, Elsevier Inc. All rights reserved.

Audience Response System Question When assessing a patient taking testosterone, which laboratory value is most important for the nurse to review? Hemoglobin A1C Triglycerides Potassium Lactate dehydrogenase (LDH) Correct answer: D Rationale: Assess the patient for liver disease because formation of blood-filled cavities may occur. This condition, also called peliosis, is associated with long-term therapy and may be life threatening. Perform liver function studies (e.g., LDH, CPK, and bilirubin levels) as ordered to monitor for the possible adverse effect of abnormal liver function and jaundice. Copyright © 2017, Elsevier Inc. All rights reserved.

Copyright © 2017, Elsevier Inc. All rights reserved. Interactions Androgens, when used with oral anticoagulants, can significantly increase or decrease anticoagulant activity. Androgens with cyclosporine increases the risk of cyclosporine toxicity. Sildenafil, vardenafil, tadalafil, and avanafil may cause severe hypotension when given together with nitrates such as nitroglycerin, isosorbide mononitrate, or isosorbide dinitrate. Copyright © 2017, Elsevier Inc. All rights reserved.

Copyright © 2017, Elsevier Inc. All rights reserved. Interactions (Cont.) Alpha blockers: additive hypotension when given with other drugs that lower blood pressure Effects of tamsulosin may be increased when it is taken with azole antifungal drugs, erythromycin and clarithromycin, cardiac drugs such as propranolol and verapamil, and protease inhibitors. Copyright © 2017, Elsevier Inc. All rights reserved.

Herbal Products: Saw Palmetto Serenoa repens, Sabal serrulata Used for treatment of BPH and alopecia Adverse effects Gastrointestinal upset Headache Back pain Dysuria Copyright © 2017, Elsevier Inc. All rights reserved.

Audience Response System Question A patient tells the nurse that he takes saw palmetto because he thinks his prostate gland is enlarged. The patient informs the nurse of the medications he takes on a regular basis. Which medication will be of most concern to the nurse? Calcium with vitamin D Acetaminophen (Tylenol) St. John’s wort Ibuprofen (Motrin) Correct answer: D Rationale: The nurse should be most concerned about concurrent use of saw palmetto with the nonsteroidal antiinflammatory drug ibuprofen (Motrin) because of the potential for drug interactions. Copyright © 2017, Elsevier Inc. All rights reserved.

Copyright © 2017, Elsevier Inc. All rights reserved. Nursing Implications Assessment should include complete history, including medication history, urinary elimination problems, and potential contraindications. Obtain baseline vital signs, weight, height, and serum electrolyte levels. Copyright © 2017, Elsevier Inc. All rights reserved.

Nursing Implications (Cont.) Assess renal and liver function. Assess PSA level and perform digital rectal examination before beginning any drugs for treatment of prostate disease. Assess current medications for potential interactions. Copyright © 2017, Elsevier Inc. All rights reserved.

Nursing Implications (Cont.) Follow exact instructions for sublingual, buccal, and oral forms. Transdermal Testoderm patches are applied to the scrotal skin. Transdermal Androderm patches are applied to the skin on the body, never to scrotal skin. Copyright © 2017, Elsevier Inc. All rights reserved.

Audience Response System Question A patient has been prescribed Testoderm transdermal patches for hypogonadism. The nurse should teach the patient to apply the patch to the upper arm. apply the patch to clean, dry scrotal skin that has been shaved for optimal skin contact. shave the skin of the calf and apply the patch. discontinue use of the patch if the skin is uncomfortable. Correct answer: B Rationale: Testoderm transdermal patches for the treatment of hypogonadism should be applied to clean, dry scrotal skin that has been shaved for optimal skin contact. Patients should not be advised to discontinue any medication without consulting the prescriber. Copyright © 2017, Elsevier Inc. All rights reserved.

Nursing Implications (Cont.) Pregnant women should not touch crushed or broken hormone drugs. Educate patients on proper administration techniques for each drug. Monitor for therapeutic responses. Monitor for adverse effects. Copyright © 2017, Elsevier Inc. All rights reserved.

Audience Response System Question A patient has been prescribed AndroGel. When providing patient teaching, the nurse will instruct the patient that the gel may be applied to all of the following areas EXCEPT the abdomen. shoulders. arms. thighs. Correct answer: D Rationale: AndroGel is to be applied to the shoulders, arms, or abdominal skin as ordered. Copyright © 2017, Elsevier Inc. All rights reserved.