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Physicians Section

Difficult To Treat ED Patients

For a patient who failed on PDE5 inhibitors and cannot use a needle to self-inject his penis, TriMix-gel® has been used as an alternative.

Many ED sufferers cannot take PDE5 inhibitors for a variety of reasons. Contraindications include patients on nitrates, certain beta blockers or patients with nonarteritic anterior ischemic optic neuropthy (NAION). Still other patients cannot tolerate the side effects of PDE5's which are numerous and can be harsh.

PDE5 inhibitor side effects have been seen to increase when dosage is increased. At the point PDE5 inhibitors are eliminated as a viable option, of the remaining options, penile injections with vasodilators prevail as the most effective non surgical alternative. Most Primary Care Physicians are not equipped or comfortable enough to encourage or train patients on injection therapy. Furthermore, many patients are not receptive to this alternative because they cannot self-inject their own penis.

Often, ED is secondary to other diseases or conditions such as hyperglycemia, hypertension, hypercholesterolemia, atheroscelorsis or radical prostatectomies.

Current Armamentarium

Currently phosphodiesterese Type 5 Inhibitors (PDE5) are the most popular treatment for ED. Other treatments include but are not limited to yohimbe tablets, penile rings, vacuum erection devices, urethral suppositories, nutriceuticals and penile injections.

The most effective non surgical treatment is penile injection where a compound of vasoactive dilators is injected directly into the corpora cavernosa. “Injection therapy remains on the forefront of treatment options” (Nehra, A. Curr Urol Prp. 2001 Dec;2(6):468-72). A typical injection can result in an erection sufficient for penetration in sexual intercourse of a duration commensurate with the size of the dose, usually between 30 minutes and one and one half hours, but not to exceed four hours. A common objection to penile injection from the patient is the fact the patient must inject a needle into his penis.

Clinical Pharmacology

Trimix in liquid form has been described as a smooth muscle relaxant accompanied by an increase in intracellular cyclic adenosine monophosphate (cAMP) levels. This leads to expansion of the lacunar spaces and entrapment of blood by compressing the venules against the tunica albuginia, a process referred to as the corporal veno-occlusive mechanism.

Combination Therapy

Prostaglandin E/alprostadil, a principle active ingredient in trimix, uses the energy pathway known as cyclic adenosine monophosphate (cAMP). PDE5 inhibitors such as Viagra®, Cialis® and Levitra® use the energy pathway known as cyclic guanosine monophosphate (cGMP). “Combination oral and non-oral (intracavernosal injection and intraurethral application) thereapies have been shown to salvage monotherapy” (Nehra A. Rev Urol. 2007 Summer;9(3):99-105).

For patients who have failed both of these therapies individually in monotherapy, it has been observed this combination of PGE1 (intracavernosal injection or intraurethral application) and oral PDE5 inhibitors such as Viagra®, Cialis® and Levitra® may be a viable alternative.

Prescription Information

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