What Matters: Atorvastatin for erectile dysfunction

Male sexual dysfunction is a prevalent disorder and a common presenting clinical complaint. It is especially a challenge when simple "fixes" do not work.

The three major forms of male sexual dysfunction are erectile dysfunction (ED), ejaculatory dysfunction, and decreased libido. In my practice, ED is far and away the issue grappled with most, given the heavy representation of men over the age of 40 years with obesity, hypertension, and polypharmacy.

PDE5 inhibitors are an effective, first-line treatment for men presenting with ED. But discontinuation rates approach 50%, with most men citing lack of consistent efficacy as the cause for stopping. And with the amount of money that patients shell out for these drugs, we should not be surprised. Many of us may try other drugs in the same class, which is commonly an exercise in futility.

What else can we do?

Dr. Farid Dadkhah and colleagues published a randomized, controlled clinical trial evaluating the efficacy of atorvastatin among hyperlipidemic men who were "nonresponders" to sildenafil (Int. J. Impot. Res. 2010;22:51-60). In this study, 131 men were randomized to 40 mg of atorvastatin or matching placebo. Men were 18-70 years of age and had an inadequate response to sildenafil 100 mg, LDL cholesterol less than 160 mg/dL, and ED for more than 6 months. Potential subjects were excluded if they were currently using antilipidemics. Patients were asked to have sexual intercourse at least once per week, and they received medication for 12 weeks. Erectile function was assessed using the International Index of Erectile Function (IIEF-5).

The main outcome was improvement in the IIEF-5 total score. A global efficacy question (GEQ) was used that asked, "Did the treatment you were taking improve your erections?"

Atorvastatin was associated with a statistically significant improvement in the mean IIEF-5 score (P = .01) and GEQ (P = .001). Although 37% of subjects improved, none of the patients regained completely normal erectile function as defined by an IIEF-5 score greater than 21.

The study’s authors note that oxidized LDL inhibits vascular smooth-muscle relaxation. Statins decrease the action of oxidized LDL on endothelial cells, which increases the activity of nitrous oxide, the main vasodilator in penile erection. The investigators also remind us that PDE5 inhibitors are palliative, not curative.

But for our men with ED and dyslipidemia, adding atorvastatin to sildenafil can potentially provide both palliation and cure.

Tomado de internalmedicinenews.com

Daily blood tests unnecessary: doctors

Study shows fewer draws do not affect quality of care for critically ill

Intensive care unit doctors at St. Paul's Hospital in Vancouver have done away with daily routine blood tests on patients without affecting the quality of care, simply by challenging a long-held dictum that those who are critically ill need to have blood drawn that frequently.

The prize-winning study of the widely accepted hospital habit shows that the number of tests can be reduced "to lower costs and free up nurses and lab personnel for more important things," according to Dr. Peter Dodek, the intensive care specialist who supervised a group of five internal medicine residents in the study.

The group won a "best team" quality improvement project award from the University of B.C. faculty of medicine. Its results will be presented soon at a medical conference in Philadelphia.

Daily blood testing has, for many decades, been a common hospital practice around the world. Routine blood draws are meant to monitor such things as blood chemistry and red and white blood cell counts. But recent studies here and elsewhere are showing that such tests are often a waste of resources and can even lead to anemia in some patients, who might require blood transfusions as a result.

In addition, every time a patient gets pricked, there's a potential for infection.

The team of internal medicine residents, under the supervision of Dodek, set out to reduce tests by at least 10 per cent, comparing patients before the change and after.

In a sample of about 900 patients, the average age was 58 and most (about two thirds) were male. In the group that received daily blood tests, the ICU death rate was 18 per cent; in the group that didn't receive as many tests, the mortality rate was 20 per cent. The length of stay was 4.3 days for ICU patients in the routine blood test group and 3.7 in the group with fewer tests (the frequency of which varied, depending on need). Dodek said the differences in outcomes between the study groups are not statistically significant. That means that drawing less blood had no negative effect on patients.

"We showed that better stewardship of health care is possible, that there has to be a good reason for every test you do and we can stop doing things we don't need to do. The reason for doing tests shouldn't merely be that it's another day," he said in an interview.

To inform hospital staff about the change, education sessions were held and posters were put up as reminders to reduce unnecessary tests. Forms and checklists were also changed.

Kim Macfarlane, a clinical nurse specialist with responsibility for eight ICUs across the Fraser Health region, said over the past year practices in those hospitals have started changing, too, because of evolving evidence that daily tests aren't necessary.

"We're trying to conserve patients' blood. We know we don't need to collect so frequently because we have non-invasive monitors, which also help us know what's going on," she said, adding smaller collection tubes are also being used.

While baseline blood work on all newly admitted patients is important, tests should only be ordered as conditions and symptoms warrant, Macfarlane said. While Fraser Health hasn't done its own study, the St. Paul's work helps reinforce confidence in the safety of the changes, she said.

Dodek is widely recognized as a leader in quality improvement, said Gavin Wilson, spokesman for Vancouver General Hospital. "Our quality improvement group is looking at Peter's data and is in the process of deciding if the cost/safety balance works for our patients," he said.

Dodek said every blood collection costs at least $10 for materials and lab analysis. So doing 2,220 fewer tests in a year, which is what St. Paul's achieved, meant cost savings of at least $22,000

Tomado de: vancouversun.com/health