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That question can literally apply to any medication, so why don't we take that approach to everything?
What's your threshold for prescribing Viagra?
- Thread starter GoodmanBrown
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Indeed. Within reason, I favor (thoroughly) informed consent as an ideal model for practice. If a drug is likely to cause very significant harm to a person, I can see refusing to provide access to it. If it doesn't cause significant physical harm, then it seems to me that withholding the requested prescription is based in moralizing rather than medicine. I would need there to be some strong reason to refuse to prescribe a relatively benign drug to an adult of sound mind who was seeking it out for a particular effect.
I'm legitimately asking if there are greater risks to Viagra than I've been given to believe. I understand that it can't be combined with nitrates, and that it can even exacerbate erectile dysfunction, particularly if an erection persists to the point of causing ischemic damage. But is that all? Is there more risk to this drug than I know? (And if so, why is it so freely prescribed to older guys who are presumably in worse physical shape?)
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It all comes down to risk/benefit. Even if the risk is very small, if the benefit is smaller you don't prescribe.
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deleted87716
Not inaccurate, and not irrelevant in the context of the OP.
There are plenty of things that are inadvisable, but not illegal. That can still get you into a lot of trouble.
Yep.
PDE5 inhibitors are not benign drugs, and there's a reason they aren't available OTC.
As some have noted previously, combining them with nitrates or alpha-blockers can cause severe hypotension (potentially fatal, in the case of nitrates).
Men with severe heart disease, such as unstable angina, a recent heart attack, arrhythmias, recent stroke, hypotension, uncontrolled hypertension, uncontrolled diabetes, severe heart failure, or retinitis pigmentosa should not take PDE5 inhibitors, or should use them with extreme caution.
There have been reports of fatal heart attacks in a small percentage of men taking sildenafil (Viagra). Intercourse itself involves an increase in physical exertion and a small risk of heart attack for patients with known heart disease or those at risk.
About 2.5% of men who take these drugs develop vision problems that include seeing a blue haze, temporary increased brightness, and even temporary vision loss in a few cases. In a few cases, these drugs have been associated with partial vision loss caused by non-arteritic anterior ischemic optic neuropathy (NAION), related to poor blood flow to optic nerves.
A small number of men have experienced sudden hearing loss in one ear, sometimes accompanied by ringing in the ears and dizziness.
PDE5 inhibitors pose a very low risk for priapism in most men. Exceptions are young men with normal erectile function (emphasis mine.)
PDE5 inhibitors may also interact with certain antibiotics (such as erythromycin), and acid blockers, such as cimetidine (Tagamet).
http://www.nytimes.com/health/guide...blems/oral-medications-(pde5-inhibitors).html
One lawsuit can ruin your whole day...er, career.
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It's a reasonable question, and it boils down to your personal comfort level.
If you feel like you have reasonably laid out all of the risks, and you have appropriately screened the patient (no angina, not a poorly controlled diabetic, not a severe vasculopath) and feel that you have documented this all appropriately, then sure, you can prescribe it. There is nothing stopping you beyond your fear of getting sued, as long as you are within the standard of care.
(BTW, I'm not being facetious in that last sentence. It truly comes down to your comfort level with the patient, your ability to read that patient, and covering yourself as best you can.)
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deleted87716
Which should pretty much eliminate "recreational" use among young men without organic ED.
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Please don't test their testosterone unless they have a true loss of libido.
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Well, not to mention that it falls outside of the standard of care, to prescribe a medication for a patient who doesn't have a true medical issue.
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Some of them don't want to be tested. "No, no, doc, my testosterone is fine...MORE than fine, trust me...I don't NEED it, it just makes sex better."
Eyeroll.
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Sex is an important part of life. I'm not saying that I plan to be a blue pill mill, but I don't see the fact that a patient may enjoy use of the medication to be a reason not to prescribe, all else being satisfactory.
I thought of a different comparison. Would you hesitate to prescribe an H2 blocker or other acid reducing medication to a young, healthy person without structural cause for reflux, when you and they both know that it would abate if they "just" lost 40 pounds and stopped washing down their jalepeno pizzas with big mugs of irish whiskey laced coffee? Life style changes could absolutely solve their problem, but who wants to live without caffeine and spicy food? And while reflux can lead to more serious issues down the line, for many people like my example, it is just an occasional nuisance. So for them, acid reduction is kind of "recreational." Those drugs are not all benign, but they are handed out without any of the qualms that accompany sildenafil.
Maybe you would hold the line and insist on lifestyle changes rather than medication for my hypothetical glutton, and it isn't that I don't respect that. I just see my role as one of promoting my patients best interests as determined by their wishes for themselves. And I see prescribing for someone determined to use something to "enhance" their sex lives to be harm reduction compared to them going out and buying some herbal crap or counterfeit pills off the internet. At least I can have some opportunity to educate them about alternatives, risks, etc. It is good to hear that there is some room for that kind of judgment call.
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Thanks for your point of view. I think it makes for a good discussion. 
Some thoughts that I have on your post:
At what point do you draw the line? If a patient came to you and said, "I need testosterone. I'm an otherwise healthy 20 year old male, but I want testosterone so I can get big muscles and attract women." He doesn't strictly NEED it. Everything else functions appropriately. But he wants it because he would "enjoy" its use. Now, granted, testosterone carries a lot more risk than Viagra, but a lot of people take it without any issues, so why shouldn't he?
(This is not a hypothetical patient, BTW - I live in Miami Beach and there are a lot of patients here who buy steroids off the internet so that they can "get cut.")
Or, another example that I see frequently in Miami - a woman comes to you, asking for weight loss pills (Phentermine). She has a BMI of 23.5, but she doesn't feel "skinny enough," and is having trouble shedding "the excess weight" through diet and exercise. She doesn't have the money for a personal trainer, and she doesn't have the money to fly to the Dominican Republic or Colombia for cheap liposuction. Do you give her the weight loss pills? She doesn't need it, clearly, but she would certainly enjoy its use.
I don't think that this is a fair analogy, actually. GERD really really fricking hurts, and it actually can be debilitating. You can't sleep, you burp a lot (often during inopportune times, like business meetings), and heartburn really does make you feel like you're having a heart attack.
The patient described in the original scenario CAN have sex. He can have an erection - maybe it's just not as robust as it used to be, but it still works. His refractory time is longer, so he can't have sex as often as he wants, but he can still have sex. It's not like he can't have sex at all, without the medication. There's nothing debilitating about his situation, except for whatever harm it does to his psyche and/or ego.
To be perfectly honest, I will tell you that some of my personal resistance to prescribing Viagra for recreational use is based on my experience with these types of patients. My experience is certainly not universal, but my past experiences with these types of patients have been....irritating. These patients that I have seen have all been either a) very rude (there's no need to call my medical assistant "fat and slow" because she didn't call you back to the room right away) or b) filled with a somewhat misogynistic false bravado that I don't appreciate. ("I certainly don't NEED Viagra....everything works GREAT....but it makes sex better. It keeps all of my women happy....as long as they don't find out about each other, amirite? Hahah! *nudge nudge wink wink*") It also didn't help that whenever I refused to write the script, I was told some variation of "Well, little girl, you clearly don't understand because you clearly have never had sex, but someday you will and you'll understand." I wish I were kidding or exaggerating, but sadly, I am not. It's like 4Chan, come to life.
I think that that's a great goal to have as a physician. I will say, however, that you have to have some boundaries. If you don't, it will be easy to get pushed back, slowly, until you hit some brink of "oh s***, what am I doing?" And an easy boundary to set for yourself is, "Does this patient truly need this medication? What MEDICAL indication am I writing this for?" The ability to have sex 4 times a night instead of just 1 is not really a compelling medical indication.
Some thoughts that I have on your post:
At what point do you draw the line? If a patient came to you and said, "I need testosterone. I'm an otherwise healthy 20 year old male, but I want testosterone so I can get big muscles and attract women." He doesn't strictly NEED it. Everything else functions appropriately. But he wants it because he would "enjoy" its use. Now, granted, testosterone carries a lot more risk than Viagra, but a lot of people take it without any issues, so why shouldn't he?
(This is not a hypothetical patient, BTW - I live in Miami Beach and there are a lot of patients here who buy steroids off the internet so that they can "get cut.")
Or, another example that I see frequently in Miami - a woman comes to you, asking for weight loss pills (Phentermine). She has a BMI of 23.5, but she doesn't feel "skinny enough," and is having trouble shedding "the excess weight" through diet and exercise. She doesn't have the money for a personal trainer, and she doesn't have the money to fly to the Dominican Republic or Colombia for cheap liposuction. Do you give her the weight loss pills? She doesn't need it, clearly, but she would certainly enjoy its use.
I don't think that this is a fair analogy, actually. GERD really really fricking hurts, and it actually can be debilitating. You can't sleep, you burp a lot (often during inopportune times, like business meetings), and heartburn really does make you feel like you're having a heart attack.
The patient described in the original scenario CAN have sex. He can have an erection - maybe it's just not as robust as it used to be, but it still works. His refractory time is longer, so he can't have sex as often as he wants, but he can still have sex. It's not like he can't have sex at all, without the medication. There's nothing debilitating about his situation, except for whatever harm it does to his psyche and/or ego.
To be perfectly honest, I will tell you that some of my personal resistance to prescribing Viagra for recreational use is based on my experience with these types of patients. My experience is certainly not universal, but my past experiences with these types of patients have been....irritating. These patients that I have seen have all been either a) very rude (there's no need to call my medical assistant "fat and slow" because she didn't call you back to the room right away) or b) filled with a somewhat misogynistic false bravado that I don't appreciate. ("I certainly don't NEED Viagra....everything works GREAT....but it makes sex better. It keeps all of my women happy....as long as they don't find out about each other, amirite? Hahah! *nudge nudge wink wink*") It also didn't help that whenever I refused to write the script, I was told some variation of "Well, little girl, you clearly don't understand because you clearly have never had sex, but someday you will and you'll understand." I wish I were kidding or exaggerating, but sadly, I am not. It's like 4Chan, come to life.
I think that that's a great goal to have as a physician. I will say, however, that you have to have some boundaries. If you don't, it will be easy to get pushed back, slowly, until you hit some brink of "oh s***, what am I doing?" And an easy boundary to set for yourself is, "Does this patient truly need this medication? What MEDICAL indication am I writing this for?" The ability to have sex 4 times a night instead of just 1 is not really a compelling medical indication.
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First of all, I thought the sex workers who featured in the article were shemales. As I know, most of the sex workers at the taksim roadside are they.
The headline of the article is very correct. In Turkey, prostitution is legal, barely. However, encouragement to prostitution or bringing an agency service is a matter of violation and will be punished by either 2-4 years of imprisonment or penalty fine up to 3000 days (contemporary Turkish Criminal Code Act 227). Therefore, there is a large and open to subjective interpretation area exist on the issue.
For example, one who works as a prostitute should not be punished due to turkish law. But if he/she brings one of his/her friends to prostitution, then a punishment is possible. Encouragement is also very open to subjective interpretations that can be used to charge in virtually every situation.
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I personally don't put much thought into testosterone prescribing. Given that diagnosis of ED is based on history alone, I think it would be far to taxing to try to discern which patients have "real" ED versus something subclinical of that (whatever that would even mean). As many other posters have pointed out, the medication is not covered by most insurances and is rather expensive. It also has a relatively low side effect profile. This has encouraged me to move towards a more liberal PDE5 inhibitor prescribing practice.
In reading other posts, I found myself making a mental comparison to HRT for post menopausal symptoms. This is another medication that could be viewed as a non-necessary therapy by some but can provide substantial quality of life improvement. For those of us prescribing HRT, we educate patient of the risks and give them information to make an informed decision about taking such treatment. Why should PDE5 inhibitor prescribing be similar. I don't feel its the provider's role to decide the benefits of these types of therapy for the patient as some of the other replies seem to be suggesting. I appreciate the different opinions expressed and interesting discussion.
In reading other posts, I found myself making a mental comparison to HRT for post menopausal symptoms. This is another medication that could be viewed as a non-necessary therapy by some but can provide substantial quality of life improvement. For those of us prescribing HRT, we educate patient of the risks and give them information to make an informed decision about taking such treatment. Why should PDE5 inhibitor prescribing be similar. I don't feel its the provider's role to decide the benefits of these types of therapy for the patient as some of the other replies seem to be suggesting. I appreciate the different opinions expressed and interesting discussion.
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I think its more a combination of 2 factors.
The first, like the OP, is healthy men who don't actually have ED but like to use viagra as a performance enhancer. I'm not writing for that one, period.
The second is those with ED but potentially reversible causes. Those I'll generally write for the drug while trying to fix the problem. Obviously if its just a matter of them being 50 pounds overweight, I don't expect to fix that. But if it is something realistically fixable, why not go for the long-term solution instead of the band-aid solution.
So you would have them wait till they fix the problem before they enjoy life?
By the way how many ED issues are truly fixable? Losing weight, controlling their sugar intake (losing weight), managing DM (losing weight and less sugar), other meds that most of the time are needed or for example HTN meds can be reduced or eliminated by losing weight.
Now count how many of your patients are going to give up their beer and pizza. Give the poor guy some love and prescribe him some Blue pills. Then get him to come back and perhaps he may even decide to take you advice to live healthier.
Regarding your young guy just in for performance. I agree. Get him out of my office.
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There's a reason I said "realistically fixable", most of what you're written doesn't fall into that category if we're honest about 99% of our patients
That's why I wrote it like that? I'm glad you agree. So for those 99% of patients who are not fixable with diet, exercise and tender loving care, give them some T and some V.
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I don't care about PDE5 inhibitor prescriptions and am OK with handing them out, but would say one should be pretty judicious with testosterone prescriptions. What's pretty clear with the testosterone trials published in the last couple years (including the 7 trials published 2 weeks ago) is that the benefits are relatively minimal and the possible harms are significant.
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I just tested a TST and it was rather low. Out of those I've tested (where I felt it was necessary), which has been about 5 since moving to the new job, 1 has been low. As I won't do HRT (risks are way too high), he gets to see urology or endocrinology.
What threshold do you use to test, just wondering?
It's hard (oh ****, no pun intended) to verify symptoms based on what's reported. Some patients have very good stories and their TST is top normal. I feel like testing at this point is flipping a coin.
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If someone describes symptoms OTHER than ED, including some combination of decreased libidos, hot flashes, gynecomastia, or infertility, I start a workup. Or if they have other reason for me to suspect hypogonadism like other pituitary abnormalities. Also osteoporosis in men merits a hypogonadism workup typically. Plus various disorders of puberty, but thankfully they usually get picked up well before the pt gets sent to an adult endocrinologist.
If it's just ED but they have a normal libido, I tell them that the libido is a sign they have a normal testosterone and I don't order the test.
A reasonable workup before being sent to the endocrinologist would be two AM testosterone levels with a free testosterone and an FSH/LH/prolactin ordered with the second one. Stop at 1 if it's normal. If both are low, feel free to send them over. There ARE young hypogonadal men around, just a hell of a lot more who just had inappropriate tests ordered (such as testosterones done in the afternoon only) and/or just want "legal" anabolic steroids.
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deleted87716
Yep. That's pretty much what I do. Low libido is the only reliable diagnosis to use for ordering a serum testosterone level with most insurers, anyway. Ideally, you should repeat it before treating (early AM lab draw).
I concur.
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Thanks for your point of view. I think it makes for a good discussion.
......
I think that that's a great goal to have as a physician. I will say, however, that you have to have some boundaries. If you don't, it will be easy to get pushed back, slowly, until you hit some brink of "oh s***, what am I doing?" And an easy boundary to set for yourself is, "Does this patient truly need this medication? What MEDICAL indication am I writing this for?" The ability to have sex 4 times a night instead of just 1 is not really a compelling medical indication.
You do make some excellent points, and part of the issue here is that I'm just starting 3rd year (as of today - I'm on an odd schedule due to the structure of my program) and so most of my opinions are either academic or drawn from prior experience as a nurse and in other fields. I've yet to meet such douche bros as you describe, at least as patients. I'm sure that a few of them will make me think twice about what I prescribe for them.
I still believe there is a middle ground between being a prescription vending machine and being a paternalistic refusnik, and I think that most physicians do manage to practice somewhere close to that sweet spot. Here's hoping that my idealism gets tempered by experience... but not crushed by it.
I appreciate your input into this discussion. You've given me things to consider. I apologize that my schedule has suddenly become quite full and I will have to spend a little less time here for at least a few weeks. I'm still listening, though.
The testosterone issue has been beat to death in here. I disagree because the studies were of poor quality. Others don't agree with me. Harvard urologist that have done many of the comprehensive studies agree with me and lecture on it several times a year.
Thats the short version so we don't have to drag it out again.
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Was going to post the same thing! Revatio! Just have them take 3 tabs and it's a rough equivalent dose to the traditional 50mg starting dose for Viagra.
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Must be the roid rage causing it
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So I totally thought about doing this when I was on my family rotation for a patient with ED 2/2 T2DM, but I never thought to ask if there're any issues with prescribing it to someone without pulmonary HTN? Does it just mean that insurance wouldn't cover it without the indicated diagnosis?
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deleted87716
If you have to resort to generic sildenafil 20mg, they're paying out-of-pocket, so insurance is a non-issue.
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I'd buy him a sandwich and tell him to come meet me at the squat rack at 4:30 am.
Honestly, I'd have a talk about diet, training, and the risks of performance enhancing drugs. I've had these conversations before and they can be productive.
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I am a resident so please excuse my stupid question..... but are there many dangerous side effects or other concerns with viagra? I have yet to prescribe the drug but what should you be on the look out for? Can it be abused like opioids or benzos?
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deleted87716
Read the whole thread, esp. post #54.
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Virtually anything you will prescribe has potential side effects. I would say "dangerous side effects" are few and extremely rare with PDE5 inhibitors. As with many Rx utilized that are considered dangerous, I think that there are OTC meds that have far more common and significant risk (NSAIDs).
Viagra and class equivalents are not thought to be habit forming like opioids or benzodiazepines. Certainly they are abused but not in the same guise as other performance enhancing or habit forming substances.
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It'd be nice if they taught commonly used anabolic steroids (trenbolone, anadrol, dianabol, winstrol, deca, etc.) to physicians. I'd be surprised if any doc outside of endos knows about trenbolone for example yet every serious bodybuilder they encounter is on it. The side effect profile is endless as its putting these teenagers BPs in the 170/110 range, skyrocketing their AST/ALT etc etc. The risks/side effects apply to each steroid and can vary quite a bit.
Lot of doctors are only familiar with testosterone but don't realize that the patient using something like winstrol for example is at major risk of LVH. Or the tamoxifen he's using once he's done his cycle... and so on.
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Why should they make this part of the standard curriculum?
A) You hardly need to be a rocket scientist to realize that injecting yourself with hormones bought off the black market might be a bad idea.
B) It's also not that hard to study on your own. You can't expect medical school to teach you everything; it's called Continuing Medical Education for a reason.
C) Most physicians outside endo and primary care (and maybe EM) have little need to know this stuff.
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And how many things in the curriculum are infinitely more useless for almost everyone in the class? I could go on all day.
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Sure you could
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Read through the posts regarding prescribing the generic (which is probably very useful in the residency office setting).
Preparing for a patient population with better insurance, I have noticed that the insurance companies will only cover 5-6 tabs/month. Is this everyone else's experience?
Preparing for a patient population with better insurance, I have noticed that the insurance companies will only cover 5-6 tabs/month. Is this everyone else's experience?
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That's about right. Most I've ever seen was 10, but that was unusual.
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If that. My personal experience has been that 9 times out of 10, vit C/V come back with a PA.
As an aside, I have actually had a patient ask me to write an "estrogen blocker" for the current cycle he was on. I wanted to instead discuss going up on his Seroquel but he wasn't interested.
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Give the people what they want. You'll never make bank in FM otherwise.
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deleted87716
:troll:
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Why did you ban him. I thought the pic was funny. ??? Come on get a sense of humor.
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It was a mod pretending to be a banned poster for April Fool's Day
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deleted87716
Um...I can't ban anybody. I'm not a moderator.
Riiiiight.
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deleted87716
Seriously, what...? All of the moderators are designated as such.
I've been in here a long time. Not always signed in or signed up. Come on man. It's ok, I just thought his post was funny. You've made gestures like that yourself in the past. It's important to keep it light.
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deleted87716
Whatever, man. If you'd have been paying attention, you'd know that he was a planted troll for an April Fool's prank. Kinda obvious now, less so initially. Regardless, I still can't ban anyone. Be glad.
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