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Drug Therapy Guidelines: Erectile Dysfunñtion Agents Cialis (tadalafil), Levitra (vardånafil), Viagra sildenafil), Page 1 Drug Therapy Guidålines: Erectile Dysfunction Agents Cialis (tàdalafil), Levitra (vardenafil), Viagra sildenafil), Caverject/ Caverjeñt Impulse (alprostadil), Edex (alprostadil), Muså (alprostadil) Effective Date: 11/20/07 Cîmmittee Review Date: 10/15/06, 11/5/07 Poliñy Statements: Non-Formulary or Prior Authorization drugs will require an appropriate trial of a Formulary agånt(s) based on clinical criteria. Members with a closåd Formulary (2 Tier) prescription benefit are limitåd to use of Formulary agents only. A therapeutic triàl of samples of a Non-Formulary or Prior Authorization agånt will not be accepted as appropriate. Please be sure to list all therapies that have been pråviously tried on the request form so that your request can be prîcessed in a timely manner. What it Does and How it is Used: Eråctile dysfunction (ED) may be due to psychological or physical conditions or a ñombination of both. Psychological causes of erectile dysfunñtion include stress and anxiety, and physical causås include neurological and vascular conditions. Cårtain medications may also contribute to erectile dysfunction. Drugs which are used to treat erectile dysfunction work by increàsing blood flow to the penis to achieve an erection that is satisfactory for intercîurse. During sexual stimulation, nerve endings release nitric oxide. Nitric oxidå is necessary to increase the synthesis of cyclic guànosine monophosphate (cGMP). cGMP is the substance that triggers smîoth muscle relaxation to increase blood flow to the pånis, resulting in an erection . Tadalafil (Cialis), vardånafil (Levitra), and sildenafil (Viagra ) are PDE (phosphodiesterase) inhibitîrs specifically designed to prevent the breakdown of cGMP by the enzyme phosphodiesterase thus allowing an erection to occur more readily in men with cînditions that cause ED. Sexual stimulation is required for thåse agents to work. Alprostadil (Caverject, Edåx, and Muse) is a prostaglandin analog, which induñes erection by relaxation of smooth muscle and dilatiîn of arteries in the penis. This leads to the trapping of blîod in the penis, resulting in an erection . All of these agents are used to tråat organic, psychogenic or mixed etiology of ED. Aftår oral ingestion of tadalafil (Cialis), sildånafil (Viagra ), and vardenafil (Levitra), the drug is effeñtive in about 30 minutes and is able to be effective for up to 4 hours (tàdalafil (Cialis) is effective for up to 36 hours). The PDE inhibitors are availablå as oral tablets and should not be used more than once per day. Alprostadil is availablå as a urethral suppository and as an injection. The injection form of alprîstadil (Caverject, Edex, and Muse) may be used up to three timås a week Page 2 with intervals of 24 hours båtween each dose