Timehost: Good evening! Our chat tonight is about Viagra, the new
miracle cure for male impotence. We're talking with Dr. Gregory Broderick, a urologist and
director of the University of Pennsylvania's Center for the Study of Male
Sexual Dysfunction. We're also joined by Julia Heiman, a psychologist and
director of the University of Washington's Reproductive and Sexual Medicine
Clinic. Welcome to you both.
Both: Thanks.
Timehost: Judging by the brouhaha brewing over this little pill, it
sometimes feels that a major sexual revolution is afoot. Dr. Broderick and
Dr. Heiman, are we actually on the brink of a revolution that would compare
with what the Pill unleashed?
Gregory Broderick: I'll take that one. Rather than a revolution, I think we're allowing the baby
boomers to continue the sexual freedom they grew up with -- meaning, at least for males with erectile dysfunction, we
can turn back the ravages of time with a tablet.
Julia Heiman: I would just add a tiny piece to that. Viagra represents a shift, in that
it does not give an automatic sexual response, as previous
treatments have done, it potentiates the possibility of an erection. So
that's not exactly a revolution, but it's certainly unique.
Sero34 asks: Is demand 10, 30, 199 or 1000 times greater than expected?
How profitable will it be for Pfizer?
Gregory Broderick: I saw an interesting cartoon in the Philadelphia Inquirer. It started with the words "oooh, ooh, ahh,
ahh, yes, yes" and the next frame showed an elderly couple saying how glad
they were that Viagra worked for their investment strategy. In all
sincerity, it's very clear that a lot of the media interest is being fueled
by people wanting to do financial speculation in the pharmaceutical
industry. I really appreciate anything that brings the subject of male
sexual dysfunction to the forefront of the public's attention, nonetheless.
Timehost: That said, what's the chance of a Viagra black market
emerging... or of a boom in Viagra look-alikes overseas?
Julia Heiman: There's already been some problem with that .I've heard that Pfizer's working very hard to make sure
that that doesn't happen. I don't know how likely that is, but there are two
reasons that it might happen: One, it's a sex drug. Two, the cost per pill
is quite high. I think the aspect of Viagra that may make that less likely
to happen is that it is not, per se, an aphrodisiac.
Gregory Broderick: I am aware of one copycat that's already been advertised. One of my own patients brought in a mailing that he had
received at home for Vaegra, an herbal preparation.
For 90 dollars the marketers promised to send you a one-month supply. As far
as I know, Pfizer has moved very quickly with a legal injunction claiming a
patent infringement, and rightly so. I've also been told by the Pfizer reps
in Philadelphia that some of the preparation is showing up on the streets,
and is being sold at 14 dollars a pill. So they are very aware of the
potential for alternative markets, and seem to be doing everything possible
to stop non-prescription use and copycats.
Lequs asks: Will most insurance companies pay for this treatment, if
it is prescribed?
Julia Heiman: Not to my knowledge, at least not yet -- at least not in my
state.
Gregory Broderick: Some of the insurers in Pennsylvania are paying for the drug. There are some significant
holdouts, though, and I've heard some very appropriate complaints from
women's health advocates that if insurers are going to pay for Viagra, they
should also pay for women's birth control pills on their plans.
Svad asks: What would be the potential effects/side effects if a
person without impotency takes this drug?
Gregory Broderick: The side effect profile should be similar to the side effect profile that was demonstrated in
clinical trials. Those side effects included, headache, facial flushing, gastrointestinal upset -- and they generally occurred in fewer than 10 to 15 percent of men. Notably,
there was no occurrence of priapism, which is a significant drawback for any normal man who might consider
using a penile injection of Caverject, or MUSE. Whether it will actually make a normal man have longer
lasting or stiffer erections remains to be seen. I personally think that if
a ball is round, you can't make it any rounder.
Julia Heiman: (Laughs) I would just add, given that there have only been trials of
this drug for a year and a half or two, that I think that anyone who doesn't genuinely need it should
be very hesitant about using it.
Gregory Broderick: I have to agree with that. 40,000 prescriptions for Viagra were written in the first
two weeks since its release, and only 3,000 to 4,000 men participated in the
clinical trials.
larryguest_15a040024 asks: Is Viagra effective for someone who has
problems with performance anxiety?
Julia Heiman: It definitely could be helpful for someone with performance
anxiety. The issue is, unless they want to rely on the pill
forever, they may want to consider short-term therapy to deal with the
performance anxiety, either in addition to or separately from taking Viagra.
Gregory Broderick: I agree, and would like to point out that premature
ejaculation can now be treated with oral medications, but that the effectiveness of those drugs is considerably
enhanced when patients have psychosexual therapy in addition.
Timehost: Back to the side effects for a moment...
Pedro_co asks: Have side effects been spotted different on diabetic men?
Gregory Broderick: I'm not aware that there is a different risk profile for
diabetics.
Julia Heiman: There is a significantly different rate of effectiveness of
the medication for diabetics than for men with erectile dysfunction without
any organic base.
Gregory Broderick: The more severe the organic erectile dysfunction, the more
difficult the problem is to treat, and that there will be some men who wont respond to Viagra. If you had to describe a patient profile for non-response,
you would certainly have to list among those characteristics, severe
insulin-dependent diabetes, which is often associated with both peripheral
vascular disease and nerve damage, known as neuropathy.
Julia Heiman: It's just a little bit curious that in spite of that, men
with spinal injury have an effectiveness level that is comparable to men with no organic basis to their erectile
dysfunction, which is good news for men with spinal cord injury, since they
are often young men.
Thunderbirdie asks: What happens when Viagra doesn't work the first
time?
Heiman: That's a great question. The thing to do would be to try several times. The first
time one tries there may be lots of expectancies or pressure which does not
help the sexual response.
Gregory Broderick: I think it's a great question also, and it's one I've
already had to deal with several times. And you really have to ask the patient the question: what
were the particular circumstances. We know that the patient who takes the drug on an empty stomach will begin to
have blood levels of Viagra in 45 to 60 minutes. We also know that the blood
levels will be sustained for 4 to 6 hours after the pill is taken. There is some pharmacologic data that says your peak blood
levels are actually delayed if you take the pill with a fatty meal. So my
advice is: sex is better on an empty stomach.
Julia Heiman: Another thing I think we don't know about is the interaction
of various amounts of alcohol with Viagra.
Great_Root_Bearess asks: Is it a lifelong pill?
Gregory Broderick: In the past, patients used to ask me whether or not they
would need to use penile injections for the rest of their life. Eight years ago, I used to tell patients that the alternative
would be a surgical implant. I never dreamed at that time that management of
erectile dysfunctions would ever become as easy as management of high blood
pressure with a tablet. There is some speculation in the research community
that good erections, whether they're initiated by a shot or a tablet have the
beneficial effect on the smooth muscle of the penis. And indeed one out of five
men on chronic injection therapy begins to develop better spontaneous
erections.
Timehost: We've had several questions from people wondering what
Viagra means for women....
Jennypoolqueen asks: Do you think this pill can help women? If so,
how?
Julia Heiman: Well, we don't know yet. It' s likely that it will have some effect on women
because women also have smooth muscle tissue in their clitoral area as well
as their vaginal area. So it's likely that the drug will some effect on
increasing blood flow to the area. What we don't know is what difference this
will make to women subjectively. There's no currently described clinical
problem that consists precisely of the problem of blood flow to the
genitals for women. So we have to guess that it could impact on a woman's sense of
being aroused, and that it may impact lubrication in the genital area. What we still don't know however, is the degree that blood
flow completely overlaps with lubrication. There is data suggesting that
some women don't lubricate very well, though they have adequate blood flow. One other point about this, is that we are not sure
whether increased blood flow to the genitals is always an increased positive
feeling for women. From my experience in treating non-orgasmic women, there
is a subgroup of these women who find these sensations of genital response
uncomfortable. Therefore, there are a lot of things to be studied in this
area.
Gregory Broderick: The physiology of the clitoris is
similar to the physiology of the smooth muscle inside the penis. We've done animal studies to show that the tissues react
in the same fashion to the same drugs. But I would have to agree that the
female sexual response is a lot more complex than clitoral engorgement. So
that I think the thing that all women should be asking themselves before
they take the drug, is just how important clitoral engorgement is to their
own personal sexual response. If the answer is no, then let somebody else
take the pill, and wait to read about it.
Ladyopus asks: Could Viagra be harmful to females?
Julia Heiman: We don't know, though I do expect that at some point in the next year,
Pfizer will come out with safety data for women, because they are currently
testing that.
Timehost: We have several questions on safe procedures for
prescribing Viagra. Here're two of them....
Bilscriba asks: Does the doctor have to be a urologist to prescribe
Viagra?
Cybelle_501 asks: I hear Viagra is flying off the shelves. Isn't it
for people with serious problems only? It sounds as though it is being used
and prescribed frivolously
Gregory Broderick: I'll handle the first question. For years, the experts in male sexual dysfunction have
been the urologists, and that's been principally because the therapies have
been rather invasive, injections and surgery. But clearly, the National Institute of Health recognized
in 1992 that erectile dysfunction is an aging phenomena, that's worsened by common medical problems like high blood
pressure, elevated cholesterol, coronary artery disease, diabetes, and
smoking. I think the fact that Viagra is a non-invasive therapy, so
far without major side effect, that it's going to put the impotent male patient back into his primary caregiver's office, and that
urologists will be consulted only when he does not respond to the pill.
Julia Heiman: It's not clear who will end up giving out the most Viagra,
but I would guess that it's shifting away from the urologist and to the primary care specialist. My concern is that Viagra will be prescribed without
taking a broader look at the patient, given the amount of time that doctors
are able to spend with patients in the current health care climate. Take the example of one patient who came to see me, and who was drinking a minimum of 20 large alcoholic drinks a week, was 40, and who's parents had major
coronary problems. To simply have given this patient Viagra without pursuing
treatment or the suggestion of treatment for heavy alcohol intake, would not
have been responsible.
Falcon53 asks: Do you expect the price of Viagra to drop soon? How
about generics?
Gregory Broderick: I think the price is actually competitive when you look at
the dollar costs of the other therapies. If you don't have a prescription plan you end up paying $15
to $25 for every applications of MUSE, or injections of Caverject. What
will drive the price down before the patent expires would be the FDA
approval of another tablet for impotence. And I really believe that over the next two years, we may
see a variety of drugs introduced for the management of impotence.
rscmdcguest_cb941089 asks: My husband has had severe problems for 15
to 20 years, he has used the vacuum as well as the injection...neither have
been good in that he has not responded well..will Viagra help him?
Julia Heiman: It's difficult to say with this little information. We would also want to know his age, illnesses, overall
health, any medical conditions he might have, and the severity, as well as
any medications, to know what might be the picture that's contributing to his
non-responsiveness. I suppose there would be no harm in trying Viagra, since
the other alternatives are to adapt to the non-responsiveness of the
treatments or to an implant. Not knowing more, this might be a rather good
case to refer to a urologist, if he hasn't been referred already, which I would imagine has already happened, to see
what the urologist believes is the cause of the problem, such as vascular or
nerve damage.
Gregory Broderick: Dr. Heiman is right. This is exactly the type of patient who should be seeing a
specialist. And this is exactly the type of case where objective testing
would be important. One of the evaluations I perform is an injection of
Caverject at a dosage that is specific for the patient's age. I evaluate that patient's response both visually by how strong that
erection becomes, but also with Doppler ultrasound. That gives us a
clear evaluation of both the strength and quality of the erection in terms of its
stiffness, but we can also see below the surface of the penis to
diagnose arterial disease or diseases of the veins, or a combination of the
two.
Timehost: We have had several questions from people wondering when
Viagra will be available overseas - namely, in Australia and Canada. Very
quickly...any information on that front?
Julia Heiman: It's currently undergoing the approval process in Europe, and
there it's still likely to take several months. Every country has its own approval process.
Timehost: Any closing thoughts from either of you before we end the
chat?
Julia Heiman: Viagra is an interesting and relatively safe drug. However I
would caution people not to take a prescription from someone who does not ask questions
about their current medical condition and their medical history.
Broderick: That's an excellent observation. I'm pleased that Viagra has stirred up such an interest in
male sexual function, and hopefully it will get couples talking about their
intimacy, and that when they do, they'll seek out the appropriate
consultation from a physician.
Timehost: Unfortunately, that looks like all the time we have left
for tonight. Thank you both very much for joining us.
Julia Heiman: It's been a pleasure.
Gregory Broderick: Thank you.
