What's your threshold for prescribing Viagra?

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GoodmanBrown

GoodmanBrown

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PGY-2 IM doc here, hoping to get some advice from other folks working outpatient.

In my clinic, I get a surprising (maybe not?) number of young-ish men (think 30-40) who want Viagra prescribed as a quasi-recreational drug. These are guys that have been married 5-6 years and tell me that they get home a bit more tired than they used to, so they don't want to have sex as often as they used to. They can get an erection, but it's not as hard as it used to be. They used to be able to ejaculate 3 times before losing their erection, now it's only once. For all these reasons, they feel that they need Viagra.

Personally, I don't buy this, and I have never prescribed Viagra for this. Sometimes my attending will get me to test their testosterone, but I don't remember one ever coming back low. These are just men who have normal aging.

At least one dude mentioned to me that he will get it off the street if I don't prescribe it. I told him that was not a great idea, but still didn't prescribe it. Am I naive? Should I just write the damn script already?
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I wouldn't write it. There's no need to order a testosterone in those cases, either.

Don't do stupid stuff just to keep people happy. You don't need those kind of patients, and they don't need that kind of doctor.
 
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This is where I explore psychosocial/stressor-related issues, sleep hygiene, diet, exercise routine....

I'll do a metabolic screen and order a testosterone level, as well. I do agree in that I haven't had any come back abnormally low.
 
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Watch for the viagra need secondary to drug abuse caused erectile dysfunction.
 
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Do you guys find this to be semi-common? I'd say at least 1/10 younger men ask me for it. I hate to throw out generalizations, but it's almost always been black men.
 
A 30 to 40 year old total testosterone is rarely low. Even if you test their Free T it most likely won't be low. Endocrine society would say under 400.

Viagra does not improve sexual desire. It only allows for an erection. It also does not increase duration.

So these guys are trying to play you into giving them some pills because they think it is going to make them a great lover.

You will start to see men over 40 and most likely over 45 complain about ED or less hard of an erection or less desire. They do need T levels and while your at it talk to them about diet, metabolic syndrome and cholesterol. Many men come in for ED issues but have all of the above.

Here is a good sign. If they have a gut, they have to have the talk for the above.
 
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Ericslv said:
A 30 to 40 year old total testosterone is rarely low. Even if you test their Free T it most likely won't be low. Endocrine society would say under 400.

Viagra does not improve sexual desire. It only allows for an erection. It also does not increase duration.

So these guys are trying to play you into giving them some pills because they think it is going to make them a great lover.

You will start to see men over 40 and most likely over 45 complain about ED or less hard of an erection or less desire. They do need T levels and while your at it talk to them about diet, metabolic syndrome and cholesterol. Many men come in for ED issues but have all of the above.

Here is a good sign. If they have a gut, they have to have the talk for the above.
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I do that regardless of age. I talk more prevention with my patients. It's not just middle aged men, I see it a lot in stressed out college kids.
 
Ericslv said:
A 30 to 40 year old total testosterone is rarely low. Even if you test their Free T it most likely won't be low. Endocrine society would say under 400.

Viagra does not improve sexual desire. It only allows for an erection. It also does not increase duration.

So these guys are trying to play you into giving them some pills because they think it is going to make them a great lover.

You will start to see men over 40 and most likely over 45 complain about ED or less hard of an erection or less desire. They do need T levels and while your at it talk to them about diet, metabolic syndrome and cholesterol. Many men come in for ED issues but have all of the above.

Here is a good sign. If they have a gut, they have to have the talk for the above.
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Bingo.

At the risk of oversharing here, during an infertility work up, my testosterone was found to be around 250. This was at age 30. I had no issues in the bedroom whatsoever.

There certainly are the very rare guys who have really bad low testosterone, but they are in the vast minority.
 
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The vast majority of my patients are either Caid/Care or hard working blue collar guys with just ok insurance. As soon as I tell them that their insurance will in all likelyhood not pay for a dime of it and it's $40 a pill, that convo is easily squashed. If they are truly interested in making lifestyle changes which is responsible in the vast majority of cases, then I'll discuss the usual. Good sleep, limiting caffiene, managing stress, eating well and how daily alcohol use is probably not a good idea. Also, when's the last time you and your spouse actually did something fun together?
 
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VA Hopeful Dr said:
Bingo.

At the risk of oversharing here, during an infertility work up, my testosterone was found to be around 250. This was at age 30. I had no issues in the bedroom whatsoever.

There certainly are the very rare guys who have really bad low testosterone, but they are in the vast minority.
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At age 30 yes. At age 45 and above much more. The problem is that many people abuse it. they come to get steroids.
 
GoodmanBrown said:
Do you guys find this to be semi-common? I'd say at least 1/10 younger men ask me for it. I hate to throw out generalizations, but it's almost always been black men.
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And yet you throw out generalizations anyway. If you hate to do it. Dont do it.
 
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GoodmanBrown said:
Do you guys find this to be semi-common? I'd say at least 1/10 younger men ask me for it. I hate to throw out generalizations, but it's almost always been black men.
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maybe your demographic is more african american? but sex is sex and viagra and cialis commercials appeal to men of all races and ages

the brain is the biggest sex organ. this is the part of the conversation when you talk with the couples if you can (bring them back for a 15 min follow up strictly for that reason) and discuss expectations/sex therapy/

its usually a good conversation with giggles and lightens up your day.
 
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surrender903 said:
its usually a good conversation with giggles and lightens up your day.
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Indeed. ;)

joe-dator-you-re-healthy-enough-for-sexual-activity-but-not-attractive-enough-new-yorker-cartoon.jpg
 
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Blue Dog said:
Doubtful. Most steroid abusers just get them on the street. No doctor in his/her right mind is going to prescribe anabolic steroids.
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Yeah. What I meant to say was they think of testosterone as a legal steroid and think they can just come in and get it like asprin or something.
 
In a clinic I worked there was an older male that used to come in with "allergies" about once a week -- he knew that one of the docs there would do a decadron/depmedrol combination for that -- interestingly, he was always on his "way to the gym" when this occurred ---- didn't have the heart to correct him...and no, he was told to f/u with his PCP (this was urgent care) with appropriate OTC recs for his complaint....

Also had a buff mid/late 30 y/o hit me up for testosterone and Viagra as the daily sex at home wasn't the same "quality" as it used to be in the late 20s/early 30s --- I was doing locums and did some basic labs and left it for the PCP evidently was doing that sort of stuff.....

How do you manage patient expectations -- seriously -- sorry buddy, you're 45, not 21, get over it...
 
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Damn, guess I should cut back on how much Viagra/Cialis I hand out....
 
I've only rx'ed cialis to one patient, and he was a diabetic who had a stroke several years back.
Otherwise, nah.
 
If a patient has ED and needs it important to help them. It's not a contest to see who can hand out the least amount. In fact it's good medicine to be asking older men if they are having ED issues. You can ask it when talking to them about other health issues.

If he has a gut it time to talk to him about all kinds of issues including ED.
 
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Oddly enough, I think this is another one of those scenarios that isn't "clear" in terms of management unlike for example treating COPD, or HTN

Through residency, I use to have faculty tell me what was indicated to diagnose/treat, appropriately what was published in the AFFP

The AUA actually has a "table/method sequence" for management and evaluation. I've just started to show patients that, and if I do everything, and it comes back negative (obviously it includes H/P, PMHx etc.), than I say they "dont meet criteria" to treat, plain and simple. If they say otherwise, they're going to Urology. No time for BS.
 
septoplasty said:
Oddly enough, I think this is another one of those scenarios that isn't "clear" in terms of management unlike for example treating COPD, or HTN

Through residency, I use to have faculty tell me what was indicated to diagnose/treat, appropriately what was published in the AFFP

The AUA actually has a "table/method sequence" for management and evaluation. I've just started to show patients that, and if I do everything, and it comes back negative (obviously it includes H/P, PMHx etc.), than I say they "dont meet criteria" to treat, plain and simple. If they say otherwise, they're going to Urology. No time for BS.
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I'd like to see what AUA sequence, if you wouldn't mind.
 
Yeah, I had a 32 y/o that was taking Viagra daily (before he came to me)that he bought off the open market -- said he needed it to keep up with his 22 y/o GF -- refused a workup stating he had been worked up before and nothing was wrong, his old doc prescribed Viagra, etc. --- hasta la vista, baby...
 
I think you all have it wrong.

For an unbiased, evidenced based opinion, I went to LowTcenter.com and here are the important findings from the site.

Energy
"In addition to feeling severe fatigue, men with low testosterone often lose their drive and initiative. Despite getting plenty of sleep, men suffering from low testosterone often find it harder to get motivated to conquer daily activities."

Muscle
"There is a comparative relationship between declining levels of testosterone and reduced muscle mass in men. Testosterone is vital to producing strong and healthy muscles. The hormone binds to receptors in the muscle cells, telling muscles to contract and grow. When the body does not have enough testosterone, it suffers from muscle loss because there is not enough of the hormone to bind to muscle cells."

Which can be all be treated...
"You will then return every 7-10 days to receive your testosterone booster injection. Each subsequent visit takes about 10-15 minutes and you will be on your way. At Low T Center, we are very flexible, as to accommodate your busy schedule."

You are all missing the boat on this problem and need to start treating the Low T epidemic!
 
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TableMD said:
I think you all have it wrong.

For an unbiased, evidenced based opinion, I went to LowTcenter.com and here are the important findings from the site.

Energy
"In addition to feeling severe fatigue, men with low testosterone often lose their drive and initiative. Despite getting plenty of sleep, men suffering from low testosterone often find it harder to get motivated to conquer daily activities."

Muscle
"There is a comparative relationship between declining levels of testosterone and reduced muscle mass in men. Testosterone is vital to producing strong and healthy muscles. The hormone binds to receptors in the muscle cells, telling muscles to contract and grow. When the body does not have enough testosterone, it suffers from muscle loss because there is not enough of the hormone to bind to muscle cells."

Which can be all be treated...
"You will then return every 7-10 days to receive your testosterone booster injection. Each subsequent visit takes about 10-15 minutes and you will be on your way. At Low T Center, we are very flexible, as to accommodate your busy schedule."

You are all missing the boat on this problem and need to start treating the Low T epidemic!
Click to expand...

One thing I would add to this is I had a 40 something guy come in (was doing locums) who was there for "my usual testosterone shot". There really was no paperwork and I had to research who initiated the initial injections. Turns out he had been getting shots for years and years. Anyhow, he started acting weird during the visit, slurring speech and not answering questions correctly, delayed somewhat. Sent him to the ER. He was having a stroke and on lab f/u turned out he had a Protein C or S deficiency which had gone unknown and the testosterone but him over the brink.
 
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cabinbuilder said:
One thing I would add to this is I had a 40 something guy come in (was doing locums) who was there for "my usual testosterone shot". There really was no paperwork and I had to research who initiated the initial injections. Turns out he had been getting shots for years and years. Anyhow, he started acting weird during the visit, slurring speech and not answering questions correctly, delayed somewhat. Sent him to the ER. He was having a stroke and on lab f/u turned out he had a Protein C or S deficiency which had gone unknown and the testosterone but him over the brink.
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Yep.

Here in Miami Beach, it is common to see young men "juicing" with black market testosterone and other steroids.

One kid had an unknown hypercoagulable defect; ended up buying himself a new liver. Yipes.
 
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JustPlainBill said:
Yeah, I had a 32 y/o that was taking Viagra daily (before he came to me)that he bought off the open market -- said he needed it to keep up with his 22 y/o GF -- refused a workup stating he had been worked up before and nothing was wrong, his old doc prescribed Viagra, etc. --- hasta la vista, baby...
Click to expand...

Daily tadalafil 5 mg can also be considered for this patient group.
 
Hi colleagues! I first want to ask whether a prescription is required for PDE5 inhibitors in the US. In Turkey, anyone can buy original products from pharmacy without any prescription. However, PDE5 inhibitors are out of insurance. So with or without prescription, patients have to pay for them.

As an urologist, my threshold is very low. I prescribe or suggest PDE5 inh to every individual for performance anxiety, *subjectively* diminished erectile function, and also for premature ejaculation in a combination therapy. I also suggest daily tadalafil treatment to everyone without complaints but desire to better sexual performance.

Several experimental data available in favor of PDE5 inhibitors in several different clinical events such as stroke, MI, cardiac remodeling etc.
 
mestielest said:
Hi colleagues! I first want to ask whether a prescription is required for PDE5 inhibitors in the US. In Turkey, anyone can buy original products from pharmacy without any prescription. However, PDE5 inhibitors are out of insurance. So with or without prescription, patients have to pay for them.

As an urologist, my threshold is very low. I prescribe or suggest PDE5 inh to every individual for performance anxiety, *subjectively* diminished erectile function, and also for premature ejaculation in a combination therapy. I also suggest daily tadalafil treatment to everyone without complaints but desire to better sexual performance.

Several experimental data available in favor of PDE5 inhibitors in several different clinical events such as stroke, MI, cardiac remodeling etc.
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In the US, PDE 5 inhibitors do require a prescription, but insurances also often do not cover them.
 
VenusinFurs said:
In the US, PDE 5 inhibitors do require a prescription, but insurances also often do not cover them.
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Thanks :thumbup: So, may I run an internet company that ships PDE5 inhibitors to the US, without any prescription? :hijacked:
 
mestielest said:
Thanks :thumbup: So, may I run an internet company that ships PDE5 inhibitors to the US, without any prescription? :hijacked:
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Seems like a legitimate business proposal. Alot of the other families are moving in on PDE5.

However, if I back you in this venture, what percentage will go to the Tattaglia family?

 
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Blue Dog said:
I'm going to assume you're joking, as SDN prohibits discussion of illegal activities on their forums.

See section 4(i): https://www.studentdoctor.net/online-service-agreement/
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It isn't necessarily illegal if it is permitted where he is to operate such a business. Assuming that isn't a scheduled drug, it *may* not even be illegal for the US resident to order it from abroad, with a lot of caveats that I don't care to list.

However, if the poster thinks that they have any hope of breaking into the online viagra sales market, they are about a decade too late to get a foothold. Spammers have already staked out that whole market and poisoned the well (literally!) with mass shipments of counterfeit blue painted placebos.
 
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Blue Dog said:
I'm going to assume you're joking, as SDN prohibits discussion of illegal activities on their forums.

See section 4(i): https://www.studentdoctor.net/online-service-agreement/
Click to expand...

To be honest, first time I took a look to SDN Forum Terms of Service with the occasion of the issue. Thanks for the reference :bow:

Anyway, I think my post did not violate the forum rules, as it contains a question on whether an activity can be carried out or not. It did not request any info regarding illegal activities.
 
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Promethean said:
It isn't necessarily illegal if it is permitted where he is to operate such a business. Assuming that isn't a scheduled drug, it *may* not even be illegal for the US resident to order it from abroad, with a lot of caveats that I don't care to list.

However, if the poster thinks that they have any hope of breaking into the online viagra sales market, they are about a decade too late to get a foothold. Spammers have already staked out that whole market and poisoned the well (literally!) with mass shipments of counterfeit blue painted placebos.
Click to expand...

Yep, I missed the "blue" boat :beat:

Anyway, I think selling original product PDE5 inhibitor from a registered pharmacy via shipping to the US may not be a violation of the legislations. It is not different from flying to Turkey, buying the medicine from the airport pharmacy, drinking a coffee, and return to the US.
 
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Blue Dog said:
Doesn't matter. Prostitution is legal in Turkey. That doesn't make it legal in the US.
Click to expand...

Inaccurate and irrelevant example aside, the point is that importing small quantities (30 day supply? Maybe 90?) of non-scheduled (so, Viagra is okay, Xanax isn't) prescription drugs for personal use is not illegal in the US, provided the drug is FDA approved. I am not a lawyer, and it has been a few years since I've needed to know the specifics of those regulations, but the point is that the practice, although inadvisable, is not actually illegal.
 
Back on topic... is there a great reason to withhold a Viagra prescription if, after educating the patient on risks, benefits, and alternatives, the patient continues to want it? I don't appreciate that it has nearly as much potential to harm the patient as many other drugs that are asked for by name. It doesn't cause respiratory depression or habit forming euphoria. Not everyone is going to be successful with recommended lifestyle changes. If you are cool with providing antihypertensives to patients who have caused their own problem through obesity / poor diet / sedentary lifestyle... why not be willing to treat other sequelae of those behaviors/choices?

I'm really asking. Yes, Viagra, like all drugs, has potential side effects and interactions, and those should be fully discussed with the patient. But if they are willing to accept those risks, why not prescribe?
 
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