erectile dysfunction

Buprenorphine Post
compchat57
Posts: 35

Postby compchat57 » Thu Jan 22, 2009 9:33 am

drpasser,

Why would a patient require a dosage of 16 mgs but at six months ? My understanding is that withdrawl sx generally don't start until around 2 mg or less ? Thoughts ?

crmark
Posts: 38

Postby crmark » Thu Jan 22, 2009 9:33 am

AMEN Dr. Passer!! And thank you!

drpasser
Posts: 1404

Postby drpasser » Thu Jan 22, 2009 9:33 am

Do you know what helps with libido? Losing weight! I therefore try and promote weight reduction as first line for low T, as well as striving for a lower dose of bupe, as is clinically indicated. I have Rxed testosterone supplements, but rarely and I try and avoid such. Also, checking TFTs can be important and helpful.

Often, reducing or stopping other agents is more helpful than adding T. As is the case above, I would try and eliminate the Cymbalta if possible, as well as to decrease the bupe. 24 mgs/day is not a low dose. IMO-many men on 24 mgs of bupe/day will have no sex drive, regardless of what else is done.

Doesn't it often make more sense to try and take some agents away or at least reduce them, before adding more to counteract side effects from the offending agent? There can be no end to Rxing for side-effects. I try to keep it simple.

My prediction, a reduction from 24-16 mgs of bupe/day will increase libido by about 50%. In many cases, it isn't particularly difficult to reduce from 24 to 16 mgs of bupe/day. I only have a hand full of pts taking more than 16 mgs/day.

I do agree, one size does not fit all, but still I try to get pts down to 16 mgs of bupe or less within 3-6 months of starting tx with me.

:-)

MChaplin
Posts: 183

Postby MChaplin » Thu Jan 22, 2009 9:33 am

back to the original post- Cymbalta can cause ED- usually it is similar to what you see with SSRIs namely prolonged time to orgasm rather than failure to get an erection.

miket
Posts: 15

Postby miket » Thu Jan 22, 2009 9:33 am

Controversy still surrounds HRT with T and goes back to Lyle Alzado as best as I can recall. My issue has always been that T is converted by aromitization to E2. I continue to prefer injectable Test Cypionate over compounded creams as patients just don't care for the cream as much and state their energy and generalized feeling of well being is less. Good point Mack regarding the relationship between the T and E2. The problem I have with antiestrogens is they block down Estrogen too much even at low dosage. I prefer using a selective estrogen receptor modulator ( Tamoxifen), to keep some E2 on board. I also supplement with Low dose progesterone 5 mg and 7 Keto DHEA to reestablish the intermediates that are shut down through negative feedback loop ( and both are natural anti-aromatizers..Ther DHEA can aromatize but less so by adding the 7 Keto group). The low dose progesterone is an excellent sleep aid as well so I have them take the compounded caps at bedtime.. The literature on negative side effects of Testosterone is seriously outdated and continues to need further study..I also check female hormone levels frequently and have a lot of success with bioidenticals including very low dose T which I compound based on their symptoms and levels..

edibill
Posts: 101

Postby edibill » Thu Jan 22, 2009 9:33 am

"And with small frequent doses they can use insulin syringes, does not have to be deep IM. Its a thick liquid, though, so requires a little patience."

Great idea. Thanks for that tip.

mack86
Posts: 70

Postby mack86 » Thu Jan 22, 2009 9:33 am

Good summary, Dave. Yes, you should check levels. However, I think the cut-off levels in the JAMA article are too low. Most men don't feel well with total testosterone levels under 700, so if they are symptomatic I will treat.

When you supplement testosterone, you need to follow estradiol levels, as testosterone is aromatized to E2, more in some men than others. Need to order high sensitivity E2 level, the regular test for E2 is made for women and is not accurate at low (male) levels. If E2 is elevated, it easily controlled with low dose anastrozole - I never give more than 1 mg a week - you don't want to drop it too low because of cognitive effects.

I have seen men who have E2 higher than testosterone - sometimes all you need to do is block aromatization and their testosterone comes up.

I have not found the commercial topical testosterone products useful, you have to keep increasing the dose and the men end up slathering tons all over and run out of skin to put it on before you get therapeutic. A compounding pharmacist can make up a more concentrated dose and its much cheaper. Or you can do injections. If you do injections, its better to give small doses frequently rather than the traditional every 2 weeks- that ends up with high peaks and more aromatization. And with small frequent doses they can use insulin syringes, does not have to be deep IM. Its a thick liquid, though, so requires a little patience.

MChaplin
Posts: 183

Postby MChaplin » Thu Jan 22, 2009 9:33 am

This week's JAMA has an editorial on T supplementation- it seems to be saying that more research needs to be done to establish the risk.benefit but at a minimum docs should be checking levels (two low levels needed to treat) to establish diagnosis and then again to establish efficacy- and that CV risk should be monitored....

Dave
Posts: 187

Postby Dave » Thu Jan 22, 2009 9:33 am

I've never had a patient who could lose weight easily and many fail completely. Some go on a diet and when they quit dieting, they gain it all back and then some. Eating habits must be changed permanently. It is hard enough to stop one habit at a time, but working on two or more at once would be nearly impossible for most people. A joke about breaking habits for the highly addictive tobacco habit goes something like this, "It's easy to stop smoking, I've done it at least a dozen times." God is omnipotent, but we human beings are frail creatures subject to many problems.

Testosterone administered correctly in proper doses with blood level monitoring works very well with few unpleasant side effects, except perhaps in those who already have cardiovascular disease. Generally mood and quality of life improve along with libido. T decreases low density lipoprotein cholesterol (LDL) and increases HDL, the 'good' cholesterol. When T is misused in large doses in building massive muscles, major problems can occur in the cardiovascular system.

This Medscape summary is a good example of some of the controversy that still exists http://www.medscape.com/viewarticle/819766 There is an increased risk of cardiovascular mortality and overall mortality in men with low T. Low T is correlated with increasing age and increasing prostate size. Increasing T could only be beneficial except in those people who already have cancer of the prostate, and even that is controversial. T decreases fat mass, increases muscle power, and improves bone mineral density. It reduces insulin resistance and improves the lipid profile. The recent VA study was flawed by at least the fact that most of the old men already had cardiovascular disease.

drpasser
Posts: 1404

Postby drpasser » Thu Jan 22, 2009 9:33 am

Testosterone has lots of side effects. Wt control only has benefits. Yes, it's hard to get pts to lose wt and stop smoking. Since when do we just do easy stuff?

If you try it, you can do it. Don't give up until you try. Perseverance is omnipotent :-)

It's hard to quit drugs too.

Pts say, one thing at a time. I say, why not do everything at once?

Best
Kevin


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