Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
In addition order nimodipine 30mg otc spasms rectal area, new drugs are being introduced in different countries at an explosive pace order nimodipine 30mg overnight delivery muscle relaxant stronger than flexeril. However buy 30 mg nimodipine otc muscle relaxer z, trying to impart all this to a medical student would be counter-productive. One of the important aims of this book is to delineate the essential information about drugs. A ‘prototype’ approach has been followed by describing the representative drug of a class followed by features by which individual members differ from it. Clear-cut guidelines on selection of drugs and their clinical status have been outlined on the basis of current information. Original, simple and self-explanatory illustrations, tables and flow charts have been used with impunity. However, discretion has been used in including only few of the multitude of new drugs not yet available in India. The information and views have been arranged in an orderly sequence of distinct statements. I hope this manageable volume book would serve to dispel awe towards pharmacology from the minds of medical students and provide a concise and uptodate information source for prescribers who wish to remain informed of the current concepts and developments concerning drugs. My sincere thanks are due to my colleagues for their valuable comments and suggestions. Pharmacokinetics: Metabolism and Excretion of Drugs, Kinetics of Elimination 22 4. Antiadrenergic Drugs (Adrenergic Receptor Antagonists) and Drugs for Glaucoma 140 Section 3 Autacoids and Related Drugs 11. Drugs for Cough and Bronchial Asthma 218 Section 5 Hormones and Related Drugs 17a. Drugs Affecting Calcium Balance 335 Section 6 Drugs Acting on Peripheral (Somatic) Nervous System 25. Hypolipidaemic Drugs and Plasma Expanders 634 Section 11 Gastrointestinal Drugs 46. Macrolide, Lincosamide, Glycopeptide and Other Antibacterial Antibiotics; Urinary Antiseptics 752 55. Drug Interactions 928 Appendices Appendix 1: Solution to Problem Directed Study 935 Appendix 2: List of Essential Medicines 957 Appendix 3: Prescribing in Pregnancy 962 Appendix 4: Drugs in Breastfeeding 965 $ Appendix 5: Drugs and Fixed Dose Combinations Banned in India (updated till Dec. The mechanism of Pharmacology action including molecular target of many drugs Pharmacology is the science of drugs (Greek: has been elucidated. In a to prolific growth of pharmacology which forms broad sense, it deals with interaction of exothe backbone of rational therapeutics. It encompasses all aspects of knowledge Pharmacodynamics (Greek: dynamis—power) about drugs, but most importantly those that are —What the drug does to the body. Pharmacodynamic agents these are designed to have pharmacodynamic effects in the recipient. Drug (French: Drogue—a dry herb) It is the single active chemical entity present in a medicine Chemotherapeutic agents these are designed that is used for diagnosis, prevention, treatment/ to inhibit/kill invading parasite/malignant cell and cure of a disease. This disease oriented definition have no/minimal pharmacodynamic effects in the of drug does not include contraceptives or use recipient. It includes collection, identification, or explore physiological systems or pathological purification, isolation, synthesis, standardization states for the benefit of the recipient. The the term ‘drugs’ is being also used to mean large scale manufacture of drugs is called Pharaddictive/abused/illicit substances. It also includes the study of adverse effects of drugs, since the same Pharmacotherapeutics It is the application substance can be a drug or a poison, depending of pharmacological information together with on the dose. This is includes pharmacodynamic and pharmacokinetic cumbersome and not suitable for use in investigation in healthy volunteers and in patients; prescribing. The aim of clinical pharmacology is to (b) Non-proprietary name It is the name accepgenerate data for optimum use of drugs and the ted by a competent scientific body/authority. The nonconsistency of the product in terms of quality proprietary names of newer drugs are kept uniform and bioavailability, etc. After its appearance in the official broughtout by the Government in a country, hold publication, it becomes the official name. In common parlance, the term generic name In addition, some non-official compendia are is used in place of nonproprietary name. Etymolopublished by professional bodies, which are gically this is incorrect: ‘generic’ should be applied supplementary and dependable sources of to the chemical or pharmacological group (or information about drugs. However, this misnomer is widely chemical structure, molecular weight, physical and accepted and used even in official parlance. One drug may have multiple promanufacturers and regulatory authorities, but not prietary names. Brand Formularies Generally produced in easily names generally differ in different countries. Even the adverse effects and storage of selected drugs that same manufacturer may market the same drug are available for medicinal use in a country. Some In addition, combined formulations have their own rational fixed-dose drug combinations are multiple brand names. Formularies can (b) It should be available in a form in which quality, including be considerably helpful to prescribers. It includes new launches and contains cokinetic properties and local facilities for manufacture and pharmaceutical, pharmacological as well as storage.
Steroids are valuable in the mentation purchase nimodipine overnight muscle relaxant long term use, prednisone can be substituted for cortisol to proven 30 mg nimodipine spasms mouth prevention and treatment of organ transplant rejecavoid ﬂuid retention order nimodipine no prescription muscle relaxant jaw. In Guillainconsidered, since patients with deﬁcient corticotrophin Barré syndrome glucocorticoids reduce the inﬂammasecretion generally do not have abnormal function of tory attack and improve ﬁnal outcome, while in chronic the zona glomerulosa. Since cortisol replacement therinﬂammatory demyelinating polyneuropathy glucocorapy is required for life, adequate assessment of patients ticoids suppress the immune reaction but may not reis critical to avoid the serious long-term consequences tard the progression of the disease. In many cases, the exert a facilitatory action on neuromuscular transmisdoses of glucocorticoid used in replacement therapy are sion that may contribute to their efﬁcacy in certain neuprobably too high. To limit the risk of tor antibodies are responsible for the neuromuscular osteoporosis, replacement therapy should be carefully transmission defect in myasthenia gravis has provided a assessed on an individual basis and overtreatment rationale for exploiting the immunosuppressive effects avoided. Overproduction of androgens causes virilization, particularly frequent and possibly severe in patients accelerated growth, and early epiphysial fusion. Treattreated with steroids, they have been used as short-term ment of this condition requires administration of glucoadjunctive therapy to reduce the severe symptoms assocorticoid in amounts adequate to suppress adrenal anciated with such bacterial infections as acute H. These patients may decystis carinii pneumonia, demyelinating peripheral neuvelop potentially fatal salt-wasting if not treated. Steroids transported by transcortin enter the target cell by diffuLeukemia sion and then form a complex with its cytosolic receptor Steroids are important components in the treatment of protein. Their efﬁcacy in chronic coid receptors containing two subunits of the heat lymphocytic leukemia and multiple myeloma stems shock protein that belong to the 90-kDa family. The from their lympholytic effects to reduce cell proliferaheat shock protein dissociates, allowing rapid nuclear tion, promote cell cycle arrest, and induce cell death by translocation of the receptor–steroid complex. However, the developcalled glucocorticoid response elements in the proment of resistance may limit the effectiveness of steroid moter–enhancer regions of responsive genes (Fig. Because their side effects are thought to be a Prompt intensive treatment with corticosteroids may be consequence of gene induction, glucocorticoids that can lifesaving when an excessive inﬂammatory reaction has repress inﬂammatory genes without inducing gene tranresulted in septic shock. This protective role of steroids may cellular responsiveness are directly proportional to the be due to a direct effect on vascular smooth muscle. A decrease in glucocombination of glucocorticoids and dopamine therapy corticoid receptor number (down-regulation) produced preserves renal blood ﬂow during shock. Downregulation of glucocorticoid receptors also is a potential Congenital Adrenal Hyperplasia mechanism for terminating glucocorticoid-dependent Congenital enzymatic defects in the adrenal biosynresponses and for curtailing excessive cell stimulation thetic pathways lead to diminished cortisol and aldowhen circulating levels of steroids are high. In these conditions, tiveness of glucocorticoids will also be compromised by corticotrophin secretion is increased, and adrenal hythe concomitant administration of other drugs that enperplasia occurs, accompanied by enhanced secretion of hance the clearance of glucocorticoids (ephedrine, steroid intermediates, especially adrenal androgens. However, in other tissues glucoMembrane phospholipids corticoids may exert their actions through mineralocorticoid receptors. Several actions of glucocorticoids that are too rapid to be explained by actions on transcription are mediated by effects on membrane receptors. Because glucocorticoids regulate gene expression and Glucocorticoids (induce lipocortin) protein synthesis, there is generally a lag of several hours before their effects are manifest. This may account for the fact that side effects elicited by Arachidonic acid steroids can be minimized by alternate-day therapy. Steroids may exert a primary effect at the inﬂammatory site by inducing the synthesis of a Glucocorticoids group of proteins called lipocortins. Although may also contribute to the antiinﬂammatory effects of the short cosyntropin test is recognized as a valid glucocorticoids. The resulting reduction in the negative feedresidues, the ﬁrst 24 of which are essential for its biologback of cortisol on the hypothalamus and pituitary ical activity. The remainder of the amino acids are also causes an increase in corticotrophin release and in the clinically important, since they may be involved in stimsecretion of precursor 11-deoxysteroids. This is true especially when corticotropin of animal origin is injected into humans. Commercially available Clinical Uses corticotropin is prepared from animal pituitary glands. Metyrapone is used in the differential diagnosis of both adrenocortical insufﬁciency and Cushing’s syndrome Absorption, Metabolism, Excretion (hypercortisolism). The drug tests the functional comCorticotropin is rapidly inactivated by gastrointestinal petence of the hypothalamic–pituitary axis when the proteolytic enzymes and therefore must be administered adrenals are able to respond to corticotrophin; that is, parenterally. It is rapidly removed from the circulation when primary adrenal insufﬁciency has been ruled out. Moreover, if pituitary corticotrophin is suppressed by an autonomously secretthe rationale for using corticotropin instead of pharing adrenal carcinoma, there will be no increase in remacological concentrations of glucocorticoids stems sponse to metyrapone. On the other hand, if pituitary from the fact that corticotropin provides enhanced corticotrophin secretion is maintained, as occurs in adreamounts of all endogenously secreted adrenocortical nal hyperplasia, the inhibition of corticoid synthesis prohormones, including androgens. However, obvious disduced by metyrapone will stimulate corticotrophin secreadvantages are associated with the use of this polypeption and the release of metabolites of precursor urinary tide: (1) It must be given daily parenterally. Metyrapone is now used less frequently in the resistance and hypersensitivity reactions. Corticotropin differential diagnosis of Cushing’s syndrome because of is used as a diagnostic tool for the identiﬁcation of prithe ability to measure plasma corticotrophin directly. However, the compensaAdverse Effects tory rise in corticotrophin levels in response to falling Aside from hypersensitivity and allergic reactions, corcortisol levels tends to maintain adrenal activity. This reticotropin administration has been associated with elecquires that glucocorticoids be administered concomitrolyte disturbances and masculinization in women. Although metyrapone interferes with 11 and 18hydroxylation reactions and thereby inhibits aldosCosyntropin terone synthesis, it may not cause mineralocorticoid deCosyntropin (Cortrosyn) is a polypeptide that consists ﬁciency because of the compensatory increased producsolely of the ﬁrst 24 amino acids of corticotropin. Being a lipid-soluble substance, mitotane remains Side effects associated with the use of metyrapone instored in body tissues for extended periods. This may clude gastrointestinal distress, dizziness, headache, sedaaccount for the marked patient-to-patient variability in tion, and allergic rash. When administered primary adrenal carcinoma when surgery or radiation to pregnant women during the second or third tritherapy is not feasible (see Chapter 56). Its effectivemesters, the drug may impair steroid biosynthesis in the ness in curtailing adrenal activity is due to an action on fetus.
Review of the antihypertensive drugs Like epilepsy 30mg nimodipine with amex muscle relaxant 16, hypertension is characterized by a deregulation of interactive functions discount nimodipine 30 mg spasms in chest. The four different classes of antihypertensives that were described affect the pathologically increased interactive functions in hypertension from different angles buy nimodipine 30 mg on-line spasms lower right abdomen. The calcium channel blockers increase integrative functions to block the excess interactive qualities. Thus, interactive qualities in general are inhibited by integrative qualities, consume vegetative qualities, and cause an increase in physical qualities, when they use up regenerative vegetative functions. We can formulate the differentiated way in which the four qualities of the framework interact to make our therapeutic aim more explicit. Conclusion In this Companion we have found that a framework with four characteristic qualities that has been derived from our study of the healthy organism helps us fnd more coherence in studying pharmacological compounds, because compounds tend to affect one of the four qualities more than others. We have seen how this framework may assist us in understanding disease processes and the way our drugs work on them. We have begun to see how the four qualities of the framework interact in the organism and how we can formulate explicit therapeutic goals with them. In the future, we will try to show how disease processes and therapeutic goals can be further understood by using this framework. Giftbildung und Eiweisszerfall im Nervensystem als Grundlage von Wachbewusstsein und Vorstellungstaetigkeit. Monograph of a roundtable discussion that took place in New York City on October 26, 2001. Can we find answers for work in organs unique for organisms the questions that satisfy both head How can the many processes be these questions that satisfy both our and limited to biological activity? Can we find a scientific basis to How these quetions are answered of a unique organism? How these questions are answered research the coherence between depends on the scientific method the scope of the answers to these depends on the scientific method we organ systems? In this publication two methods By enhancing the current scientific method to learn about biological combination of the current scientific are used: the current scientific method with phenomenological facts and the phenomenological method and a phenomenological method to learn about anatomical points of view we can find meaning method to understand more about method developed specifically to facts and the phenomenological in the facts and understand them the meaning of these facts. Nearly all of us scientifc method applied in systems system functions as one organ? Companions that studies the have had some experience with biology and phenomenology. In it, we respiratory disease, given that ordering in four biological levels that functions? It is easy to loose oneself in asthma and pneumonia from own to an individualized treatment of the approach, the factual knowledge the countless details included in the experience and will readily recognize patient, tailored to his or her specifc obtained through reductionism is descriptions of this process. The phenomenological method of the experience with these patients restoring the defcient forces of selfthe concept that is presented in systems biology makes it possible leads us through a study of airway healing. This innovative avenues of treatment for approach, as well as a variety of case Goethe in his phenomenological results in a characterization of the respiratory disorders in general. This also includes the various phases of the wound healing Our research has alerted us to the this model can aid diagnosis and acquisition of insight into the holistic process. Rhythm, consequently, regular and integral treatment then be seen as an expression of the leads for medical practice. For ways to order the Companions see inside of front cover or check our website: Pharmacology is a changeable subject, depending on the needs and knowledge of the time. Can we find an inner coherence in the manifold ways compounds influence organisms? Can we formulate a framework that can be used in the study of pharmacology that will promote such a coherent view? We can enhance the scope of the answers to these questions by using a combination of the current scientific method and a phenomenological method. The specific phenomenological method employed here was developed to comprehend the cohterence within living organisms. It illuminates the known facts about the activity of compounds in organisms, and provides the means to find their significance. What emerges is a new grasp of the interrelations between pharmacological and biological processes, and consciousness, psychology, and behavior. This leads to a more rational understanding of the effect of compounds in health and disease. This is a small but dynamic family with new members and pharmacological data being added when reported in the literature Information on immune checkpoint proteins. This family consolidates existing GtoPdb targets with new family members in a single place for easy user access Information on Fc epsilon receptors. This family is included because these receptors are crucial in the development of allergic reactions, although specific pharmacology is sparse Information on pattern recognition receptors. This family consolidates existing GtoPdb targets across different target classes, with new family members, in a single place for easy user access Bryant et al. Tto enlisting experts in pharmacology to provide Reﬁned Focus: In this edition, we chose to focus a textbook that is up-to-date and comprehensive. Demore on drug classes rather than on individual drugs, signed to be used during a single semester, the book foeliminate unnecessary detail such as chemical struccuses on the clinical application of drugs within a contures, and maintain emphasis on structure–activity relatext of the major principles of pharmacology. With these revisions, we hope we have provided a this edition includes a number of new or updated feabook that is readable, up-to-date, comprehensive but tures that further enhance the appeal of the text. States Medical Licensing Examination guidelines) with detailed answers to help students test their knowledge Charles R. Stitzel Case Studies: Appearing at the end of each chapter, case studies present students with real-life examples of Table of Contents I. Contemporary Bioethical Issues in Pharmacology and Pharmacology 281 Pharmaceutical Research 73 Charles R.
Benign exertional headache/benign sexual headache: a disorder of myogenic cerebrovascular autoregulaBibliography tion? J Neurol quency order 30mg nimodipine mastercard back spasms 6 weeks pregnant, characteristics and the relationship with the Neurosurg Psychiatr 1991; 54: 417–421 discount nimodipine 30mg free shipping spasms movie. Clinical features Vaga˚ ˚study of headache epidemiHeadaches precipitated by cough buy line nimodipine muscle relaxant wpi 3968, prolonged exerology. Primary headaches associated with sexual activity – some observations in Indian 4. Headache associated exertional, cough and sneeze headache responciated with sexual activity: demography, clinical feasive to medical therapy. Follow-up of ciated with sexual activity: prognosis and treatment idiopathic thunderclap headache in general practice. A prospective follow-up of thunderclap J Neurol Neurosurg Psychiatr 1976; 39: 1226–1230. Recurrent thunderclap imaging ﬁndings and outcomes of headache assoheadache associated with reversible intracerebral ciated with sexual activity. Cephalalgia study; epidemiology of headache I: the prevalence of 2001; 21: 230–235. Field testing primary tions: comparative characteristics in a series of 72 stabbing headache criteria according to the 3rd patients. The classiﬁcation of chronic daily headache in adolescents – a comparison between the second edition of the international classiﬁcation of headache 4. J Neurol Neurosurg Psychiatr 2002; 72(Suppl tics and therapeutic options in hypnic headache. Hypothalamic gray of new daily persistent headache in the general matter volume loss in hypnic headache. The clinical characteristics of new clinical features, therapeutic options and outcomes. What incites new daily persistent headache in somnography and outcome in patients with hypnic children? Curr Pain Headache Rep 2009; headache syndrome: a benign headache disorder of 13: 47–51. Potential headache: clinical and serological characteristics in a therapeutic use of melatonin in migraine and other retrospective study. Postinfectious new daily perchronic daily headache and its subtypes in adolessistent headache may respond to intravenous methylcents and adults. Cephalalgia 2004; joint hypermobility: a possible predisposing factor 24: 955–959. New daily-persistent painful lymphadenopathy in extracranial or sysheadache: the switched-on headache. Headache or facial pain attributed to disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structure 12. International Headache Society 2018 62 Cephalalgia 38(1) Introduction to the secondary B. Another disorder scientiﬁcally documented to be 1 able to cause headache has been diagnosed headaches C. Evidence of causation demonstrated by at least 2 When a patient has headache for the ﬁrst time, or a new two of the following : headache type, and at the same time develops a brain 1. In causative disorder other words, a de novo headache occurring with b) headache has signiﬁcantly improved in another disorder recognized to be capable of causing parallel with improvement of the preit is always diagnosed as secondary. When a new headache occurs for the ﬁrst time in solid evidence exists from published scientiﬁc studies close temporal relation to another disorder that is that the disorder speciﬁed in criterion B is capable of known to cause headache, or fulﬁls other criteria for causing headache. Scientiﬁc evidence can come from causation by that disorder, the new headache is large clinical studies observing close temporal relacoded as a secondary headache attributed to the tionships between the disorder and headache outcausative disorder. This remains true even when comes after treatment of the disorder, or from the headache has the characteristics of a primary smaller studies using advanced scanning methods, headache (migraine, tension-type headache, cluster blood tests or other paraclinical tests, even if these headache or one of the other trigeminal autonomic are not readily available to the diagnosing physician cephalalgias). When a pre-existing primary headache becomes methods that are not useful in routine use of the chronic or is made signiﬁcantly worse (usually meaning diagnostic criteria may nonetheless be useful for a twofold or greater increase in frequency and/or establishing general causal relationships as the severity) in close temporal relation to such a causative basis of criterion B. There are a few secondary headaches for which evidence of General diagnostic criteria for secondary causation depends very heavily upon onset in temheadaches poral relation to the presumed cause. Any headache fulﬁlling criterion C brospinal ﬂuid pressure, which are usually orthostatic! In such ache and the location of a presumed causative discases, criterion D is of particular importance. An example is very sudden (thunderclap) onset of headache features (such as intensity) and markers headache in 6. The characterchanges on neuroimaging, or in other laboratory istics (if any) must be speciﬁed for each secondary measures [such as erythrocyte sedimentation headache. Headache attributed to trauma or diagnostic criteria, although the term persistent has been adopted in place of chronic. Consequently, traumatic injury to the head their diagnosis is largely dependent upon the close tem5. The general rules moderate or severe traumatic injury to the head and for attribution to another disorder apply to 5. Headache may occur as an isolated symptom following trauma or injury or as one of a constellation of 1.
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It is ap200 mg/day buy nimodipine 30 mg with mastercard muscle relaxant in surgeries, testosterone biosynthesis in both the adreproved for the treatment of benign prostatic hyperplanal and testis is completely abolished by doses of 800 to generic nimodipine 30mg on-line muscle relaxant neuromuscular junction sia buy nimodipine overnight delivery muscle relaxant voltaren. This drug is used most commonly for of the prostate gland following administration of ﬁnaslarge virilizing adrenal tumors that cannot be surgically teride, clinical response may take 6 to 12 months. The prinAndrogen Receptor Antagonists cipal adverse effects of ﬁnasteride are impotence, decreased libido, and decreased volume of ejaculate. The Spironolactone (Aldactone) is a compound originally compound is generally well tolerated in men. However, at high doses spironolactone binds to the Gonadotropin-Releasing Hormone androgen receptor. These compounds are inhaled, inshould be checked within 1 month of starting the medjected subcutaneously, or implanted subcutaneously. They are used in males in the treatment of precocious Flutamide (Eulexin) is a nonsteroidal androgen repuberty and carcinoma of the prostate. Because of the toxicity of the oral Flutamide may eventually be used for the treatment of preparations and the inconvenience of the injectable hirsutism and male pattern baldness in women if a topforms, the transdermal gels have been a major clinical ical preparation is developed. The serum level of testosterone in males from ado(C) A decline in the metabolic clearance rate of lescence through the ﬁfth decade of life is a primatestosterone rily a consequence of (D) An increase in the metabolic clearance rate of (A) A relatively constant level of testicular testostestosterone terone production (E) A sharp drop in urinary 17-ketosteroid levels (B) A signiﬁcant decline in testosterone produc2. Which of the following is mostly likely to be found tion in a male who lacks functional 5 -reductase? The enzyme 5 -reductase catalyzes the forma(B) Elevated serum levels of dihydrotestosterone tion of dihydrotestosterone from testosterone. In (C) Highly depressed protein anabolic activity in normal accessory sex gland tissues, such as the skeletal muscle, bone, and kidney prostate, most of the direct androgen effect is due (D) Elevated serum levels of testosterone with subto dihydrotestosterone rather than testosterone. In the Leydig cell the rate-limiting step in testosterone is considered the biosynthetic ratetestosterone synthesis is the enzymatic cleavage of limiting step? Skeletal muscle cells use the androgen receptor (B) Cholesterol to bind testosterone that promotes the anabolic ef(C) Androstenediol fect of this hormone. Finasteride is a 5 -reductase inhibitor, which es(E) Progesterone sentially makes dihydrotestosterone unavailable to 4. Normal skeletal muscle cells the prostate but does not reduce serum testosterone (A) Typically lack androgen receptors and thus levels. The decreased prostatic levels of dihyare not affected by high concentrations of testosdrotestosterone frequently result in a size regresterone sion of the prostate, while the relatively normal (B) Respond more readily to dihydrotestosterone testosterone levels minimize a depressed libido. Upon examination, a 68-year-old married man was self-reported aggressive behaviors in hypogonadal found to have a greatly enlarged prostate. J Clin Endocrinol Metab one of the following drugs is most likely to suppress 1997;82:2433–2438. The male sex accessory tisduction dramatically rises from prepuberal levels sues: structure, androgen action, and physiology. Anabolic steroids in the serum testosterone is seen in the relative constant athlete. Effects of testosterone replacement in testosterone, from the second to the ﬁfth decade of hypogonadal men. He compounds typically use 100 to 200 times the noris a good athlete who would like to get a college mal dose and will cycle or stack multiple anabolic scholarship and thinks that if he can increase his compounds together in an effort to enhance the bimuscle strength, he will get better and win a scholological effect. He knows of some other athletes who are Common endocrine side effects of these comusing anabolic steroids and requests your help. Surveys inhepatotoxicity, suppression of high-density lipoprodicate that in the United States 6% of high school tein cholesterol, increased cardiovascular risk, inathletes, 20% of college athletes, and more than sulin resistance, and decreased thyroid hormone 50% of professional athletes in certain sports use or production. However, it compounds does result in increased muscle mass, is important to educate him about the risk–beneﬁt strength, and endurance. Several classes of drugs have been associated with aging, but that is not entirely accurate. It has a shorter onset of action and can be used dal artery, and three major sets of veins, superﬁcial, inin smaller doses than sildenaﬁl. The pudendal nerve is the major sothe pharmacological agents useful in this disorder may matic pathway innervating the male genitalia. Such a classiﬁcation system takes into acripheral nerves, central neural pathways are involved in count the mode of drug action, the route of administrathe process. These central mechanisms interact during tion, and the means by which target organ selectivity is normal sexual activity and require complex coordinaachieved. A therapeutic taxonomy of treatment for erectile dysfunction:An evolutional imperative. The injection does not appear to produce plications were frequently required for satisfactory any long-term side effects on penile smooth muscle. Compounds with relatively short dura(alprostadil urethral suppository or medicated urethral tion of action were found to be less than satisfactory in system for erection) is also an effective therapeutic maintaining penile erections. The intracavto take advantage of the differing onset and duration of ernosal injection of alprostadil. Dopamine appears to have an imporexerts a number of effects, including systemic vasodilatant role in normal erectile function. Apomorphine is a tion, inhibition of platelet aggregation, and stimulation D1-like, D2-like dopamine receptor agonist. Apomorphine can be the drug of choice in depends on its being injected intracavernosally or adpatients with coexisting benign prostatic hyperplasia ministered transurethrally or intraurethrally. Attempts to buffer papaverine to render it more suitable for intracaverAndrogens: Testosterone nosal injection have not been entirely satisfactory, and Androgen deﬁciency can lead to decreases in nocturnal such delivery may still lead to intracorporeal scarring. Hypogonadism is associated with impotence, yet erection in response to visual stimulaPhentolamine tion is preserved in men with hypogonadism, suggesting that androgens are not essential for erection. Phentolamine (Vasomax) is a nonselective couraged unless the cause is clearly related to hypogoadrenoceptor blocking agent (see Chapter 11), and like nadism. Androgen replacement regimens for treating tration, phentolamine has a plasma half-life of about 30 male hypogonadism include long-acting intramuscular minutes and a duration of action of 2 to 4 hours.