Annals
Established in 1927 by the American College of Physicians

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20 October 2009 Annals of Internal Medicine Tip Sheet

Annals of Internal Medicine is published by the American College of Physicians on the first and third Tuesday of every month. These highlights are not intended to substitute for articles as sources of information. For a copy of an article, call 1-800-523-1546, ext. 2656, or 215-351-2656, or visit www.annals.org. Past highlights are accessible as well.

Early Releases:

1. For Patients with Erectile Dysfunction, Treatment with Oral Medications Demonstrates Significant Improvements in Sexual Intercourse and Erectile Function

ACP issues clinical practice guideline on the benefits and risks of PDE-5 inhibitor drugs used to treat patients with ED

The American College of Physicians issued recommendations for the treatment of erectile dysfunction (ED). ACP strongly recommends that physicians initiate therapy with an oral phosphodiesterase type 5 (PDE-5) inhibitor in men who seek treatment for ED unless they have a contraindication to PDE-5 inhibitors, such as nitrate therapy. As for which PDE-5 inhibitor to use, ACP recommends that physicians base the choice on the individual preferences of patients including ease of use, cost of medication, and adverse effects profile.

"The evidence is insufficient to compare the effectiveness or adverse effects of different PDE-5 inhibitors for the treatment of ED because there were only a few head-to-head trials," explained the lead author of the guideline, Amir Qaseem, MD, PhD, MHA, FACP, senior medical associate at the American College of Physicians.

The guideline authors analyzed evidence gathered from 130 randomized controlled trials that evaluated oral PDE-5 inhibitors alone or combined. Treatment with a PDE-5 inhibitor resulted in statistically significant and clinically relevant improvements in sexual intercourse and erectile function in patients with ED, regardless of the cause (e.g., diabetes, depression, prostate cancer) or baseline severity.

Overall, the evidence showed that PDE-5 inhibitors were relatively well-tolerated and were associated with mild or moderate adverse effects, such as headaches, flushing, upset stomach, and runny nose.

ACP does not recommend for or against routine hormonal blood tests or treatment in the management of patients with ED because the evidence is inconclusive about the effectiveness in patients with low testosterone levels. Physicians should individualize decisions to measure hormone levels based on the clinical symptoms (e.g., decreased libido, premature ejaculation, fatigue, etc.) and physical findings (for example, testicular atrophy, muscle atrophy) that suggest hormonal abnormality.

2. Adding ACE Inhibitors to Standard Care Improves Outcomes for Stable Ischemic Heart Disease Patients; Adding ARBs Does Not Help, Increases Harms

Ischemic heart disease (IHD) is the leading cause of death of both men and women in the United States. IHD is the lack of blood supply to the heart muscle caused by coronary artery disease and heart attacks. Traditionally, IHD is treated with aspirin, beta-blockers, and aggressive modification of risk factors. Angiotension-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) are introduced when patients have heart failure or a heart attack with ventricular dysfunction. However, these treatments typically are not used on patients with preserved ventricular function. Researchers reviewed 41 published studies to compare the benefits and harms of using ACE inhibitors, ARBs, or a combination of these treatments in adults with stable IHD and preserved ventricular function. The researchers found that adding ACE inhibitors to standard treatment improves clinical outcomes in these types of patients. A combination of ACE inhibitors and ARBs appeared no better than ACE inhibitor therapy alone and increased harms. The researchers recommend future trials to more clearly define the role for ARBs in this population.

In this Issue:

3. HPV Vaccination Not Cost Effective for Women Older in their 30s and 40s

Most cases of cervical cancer are caused by certain strains of a common sexually transmitted virus called the human papillomavirus, or HPV. Physicians typically screen women for cervical cancer using a Pap smear, sometimes with HPV testing, every one to three years. A vaccine to prevent infection with the strains of HPV that cause cervical cancer is available and is recommended for girls and women between the ages of 11 and 26. The value of the vaccine in older women is questionable because exposure to the virus is likely to have occurred in many women. Researchers modeled a cost-effectiveness analysis to assess the health and economic outcomes of HPV vaccination in older women in the U.S. participating in a screening program. The researchers found that adding HPV vaccination for women aged 35 to 45 years cost from $116,950 to $381,590 per quality-adjusted life-year gained, which is more than the current United States health care system is generally willing to pay for preventive care interventions. The research suggests that current cervical cancer screening interventions are the more economically favorable strategy for reducing cervical cancer deaths among older women.