Muse

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alprostadil (intracavernosal, intraurethral)

(al-pross-ta-dil) ,

Caverject

(trade name),

Edex

(trade name),

MUSE

(trade name)

Classification

Therapeutic: erectile dysfunction agents
Pharmacologic: prostaglandins
Pregnancy Category: C

Indications

Diagnosis and treatment of erectile dysfunction.

Action

Relaxes trabecular smooth muscle and dilates cavernosal arteries.

Therapeutic effects

Penile erection sufficient to allow intercourse.

Pharmacokinetics

Absorption: Action is primarily local following intracavernosal injection; after intraurethral use, it is absorbed into the corpora cavernosa.
Distribution: Unknown.
Metabolism and Excretion: Mostly metabolized locally; any systemically absorbed alprostadil is metabolized in the liver.
Half-life: 5–10 min.

Time/action profile (erection)

ROUTEONSETPEAKDURATION
Intracavernosal5–10 minwithin 20 min1 hr
Intraurethral5–10 minwithin 20 min0.5–1 hr

Contraindications/Precautions

Contraindicated in: Penile implants; Penile abnormalities; Balanitis; Men for whom sexual activity is not advisable; Conditions predisposing to priapism (e.g. sickle cell anemia/trait, multiple myeloma, leukemia); Urethritis (suppositories).
Use Cautiously in: Severe coagulation abnormalities or thrombocytopenia; Patients taking anticoagulants or antihypertensive agents.

Adverse Reactions/Side Effects

Central nervous system

  • dizziness
  • headache

Cardiovascular

  • hypertension
  • hypotension

Genitourinary

  • penile pain (most frequent)
  • penile edema
  • penile fibrosis
  • penile rashes
  • priapism

Musculoskeletal

  • back pain

Respiratory

  • cough

Local

  • bleeding
  • ecchymosis (injection)
  • hematomas (injection)
  • irritation

Interactions

Drug-Drug interaction

Increased risk of bleeding at site of intracavernosal injection in patients receiving anticoagulants.Should not be used with other vasoactive agents.Increased risk of bleeding at injection site with anticoagulants.

Route/Dosage

Intracavernosal: (Adults) 1.25–2.5 mcg initially; dose titrated as needed. Should not be used more than 3 times/week. There should be at least 24 hr between doses. Doses > 40 mcg (Edex) or > 60 mcg (Caverject) should not be used.
Intraurethral: (Adults) 125–250 mcg initially; dose titrated as needed. Do not use more than 2 times in 24 hr.

Availability

Powder for injection: 5 mcg vial, 10 mcg vial, 20 mcg vial, 40 mcg vial
Powder for injection (prefilled syringe/cartridge): 10 mcg, 20 mcg, 40 mcgRx (Edex only)
Injection (solution): 500 mcg/mL
Intraurethral pellets: 125 mcg, 250 mcg, 500 mcg, 1000 mcg

Nursing implications

Nursing assessment

  • Monitor for hypotension during in-clinic dosing.

Potential Nursing Diagnoses

Acute pain (Side Effects)

Implementation

  • Intracavernosal Injection: Reconstitute Caverject with 1 mL of bacteriostatic water with benzyl alcohol. For Caverject Impulse and Edex, follow manufacuter's instructions for reconstitution. Do not shake. Use solution immediately; do not freeze or store. Do not administer solutions that are discolored or contain precipitates. A ½-in, 27- to 30-gauge needle is used for injection. Injection must take place under sterile conditions. Injection site is usually along the dorsolateral aspect of the proximal third of the penis. Avoid visible veins. Alternate sides of the penis with each injection. Swab site with alcohol before injection. AutoInjector (PenInject 2.25) is available for self-injection.
  • Intraurethral: System comes with applicator, pellet, and instructions. Store unopened foil pouches in refrigerator.

Patient/Family Teaching

  • Caution patient to report priapism (erection lasting 6 hr or longer) to health care professional immediately. Priapism is a medical emergency that can result in penile tissue damage and permanent loss of potency if not treated promptly.
    • Caution patient that use of alprostadil offers no protection against sexually transmitted diseases (STDs). Injection of alprostadil may cause a small amount of bleeding at injection site, increasing risk of transmission of bloodborne diseases. Advise patient to use protective measures to prevent spread of STDs, including HIV.
  • Intracavernosal Injection: Instruct patient on correct technique for preparation, injection, and disposal of equipment. Caution patient not to reuse or share needle with other persons. Desirable dose is determined with first injection in physician’s office. Advise patient not to increase dose without consulting physician. Injections should be administered no more than 3 times/wk, with 24 hr between injections. Advise patient to notify physician if nodules or hard tissue in the penis; redness, swelling, or tenderness; or curvature of the erect penis occurs.
    • Emphasize the importance of follow-up exams every 3 mo to assess efficacy and safety of therapy and to adjust dose as needed.
  • Intraurethral: Instruct patient on proper technique for administering before self-administration. Patient should urinate before insertion. Stretch penis lengthwise and press at top and bottom. Insert the delivery device into urethra, depress button to release suppository, and hold device upright and immobile for 5 sec to help dissolve suppository. Move penis and device as a unit from side to side to help dissolve suppository and remove device. If uncomfortable or pulling sensation occurs, remove device and repeat procedure if needed. After device is withdrawn, patient should roll penis between the hands for 10 sec to further distribute suppository within walls of urethra and decrease stinging sensation. Sitting, standing, or walking for 10 min while erection is developing promotes blood flow. Patient should not exceed 2 systems in 24 hr. An erection that lasts longer than desired may be relieved by the application of an icepack alternately to each inner thigh for a period no longer than 10 min.
    • Advise patient to use contraception if engaging in sexual intercourse with female of reproductive age. Use a condom if female is pregnant; effects on the fetus are unknown.

Evaluation/Desired Outcomes

  • After intracavernosal injection, an erection should occur within 5–20 min and last no longer than 1 hr.
  • After intraurethral administration, erection should occur within 5–10 min and last 30–60 min.

Muse

A brand name for ALPROSTADIL.
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Mark Musa earned an undergraduate degree at Rutgers University in 1956, where he studied with poet and literary critic John Ciardi, a distinguished translator of Dante, under whose tutelage he translated and published a new version of Dante's Vita Nuova, an edition that has been continuously in print since its appearance in 1961.
Musa is confident CSKA can do that as they face a City side that have also made a disappointing start in the competition.
The oldest minister will be Mihail Cvetkov, 60 years, followed by Musa Xhaferi, born 1959.