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Which drugs should post-MI patients routinely receive?
PATIENTS SHOULD BE PLACED ON THE FOLLOWING MEDICATIONS :
- antiplatelet agents (strength of recommendation [SOR]: A, meta-analysis for aspirin; A, multiple randomized controlled trials [RCTs] for aspirin plus clopidogrel)
- a statin; atorvastatin has the best evidence (SOR: B, a single RCT)
- a beta-blocker (SOR: A, meta-analysis)
- renin-angiotensin-aldosterone system blockers, whether or not the ejection fraction is diminished after myocardial infarction (MI) (SOR: A, meta-analysis for angiotensin-converting enzyme [ACE] inhibitor; B, single RCT for ACE inhibitor plus aldosterone blocker). ( TABLE )
Evidence summary
A systematic review of 9 RCTs demonstrated that aspirin (75-325 mg) started soon after the onset of acute MI significantly reduced mortality, reinfarction, and stroke at 1 month compared with placebo (absolute risk reduction [ARR]=3.8%; number needed to treat [NNT]=26; 95% confidence interval [CI], 23-30).1
One large RCT involving 17,187 patients with suspected acute MI showed that 162 mg aspirin given on the day of the MI resulted in a 2.6% ARR (NNT=38; 95% CI, 29-63) in vascular deaths at 35 days compared with placebo.2 The survival benefit persisted for as long as 10 years. The RCT also found no significant difference between aspirin and placebo in rates of cerebral hemorrhage or bleeding requiring transfusions.
Patients who have had an MI without ST segment elevation should take clopidogrel (75 mg/d) and aspirin (81 mg/d) for 12 months. The combination has been shown to result in a 2.1% ARR (NNT=48) in deaths, recurrent MI, and stroke compared with aspirin alone.3 Patients who have had an ST segment elevation MI should take clopidogrel in combination with aspirin for at least 2 weeks.4
TABLE
Recommended drugs for post-MI patients
| Drug type | Examples | Precautions | Contraindications |
|---|---|---|---|
| Antiplatelet agents | Aspirin 81 mg/d; clopidogrel 75 mg/d | Risk for bleeding; use caution in patients taking warfarin | Active bleeding; hypersensitivity |
| RAAS blockers | Lisinopril 20 mg/d; losartan 50 mg/d; eplerenone 50 mg/d | Hypotension, hyperkalemia, renal failure Use eplerenone only with decreased ejection fraction | Hypersensitivity; systolic blood pressure <90 mm Hg |
| Beta-blockers | Metoprolol 100 mg bid | Hypotension, bradycardia, reactive airways | Systolic blood pressure <90 mm Hg; pulse rate <50 bpm |
| Statins | Atorvastatin 80 mg/d | Elevated AST/ALT, myositis | Active liver disease; pregnancy/nursing |
| ALT, alanine aminotransferase; AST, aspartate aminotransferase; BPM, beats per minute; RAAS, renin-angiotensin-aldosterone system. | |||
Intensive atorvastatin therapy lowers risk of death
The PROVE IT-TIMI 22 trial showed the benefit of early intensive therapy with the hydroxymethyl glutaryl coenzyme A reductase inhibitor atorvastatin to lower low-density lipoprotein <70 mg/dL post-MI.5 At 30 days after the event, atorvastatin 80 mg daily resulted in a 1.2% ARR in death and recurrent acute coronary syndrome (NNT=83; hazard ratio [HR]=0.72; 95% CI, 0.52-0.99). From 6 months to 24 months after the event, the ARR was 2.6% (NNT=38; HR=0.82; 95% CI, 0.69-0.99).
Beta-blockers significantly decrease late mortality
One systematic review of 63 RCTs showed that, in long-term trials, use of a beta-blocker significantly reduced the late mortality rate (NNT=48; odds ratio [OR]=0.77; 95% CI, 0.70-0.85).6 In another review of 82 RCTs, the mortality rate between 6 months and 4 years after MI decreased markedly in patients receiving a beta-blocker (OR=0.77; 95% CI, 0.69-0.85).7
ACE inhibitors decrease overall mortality, sudden cardiac death
An ACE inhibitor should be started regardless of the ejection fraction or the presence or absence of left ventricular systolic dysfunction. One systematic review that compared long-term mortality rates of patients started on an ACE inhibitor within 14 days of acute MI versus placebo found that ACE inhibitors significantly decreased overall mortality and sudden cardiac deaths between 2 and 42 months after the MI (NNT=42; OR=0.83; 95% CI, 0.71-0.97).8
Eplerenone + ACE inhibitor benefit patients with post-MI heart failure
The selective aldosterone blocker eplerenone appears to benefit patients with a decreased ejection fraction post-MI. The EPHESUS study demonstrated that eplerenone, when added to an ACE inhibitor, reduced all-cause mortality (ARR=1.4%; NNT=71; 95% CI, 47-200; RR=0.69; 95% CI, 0.54-0.89) and sudden cardiac death (ARR=0.5%; NNT=200; 95% CI, 125-∞; RR=0.63; 95% CI, 0.40-1.00) up to 30 days in patients with post-MI heart failure. Benefits were also seen after 16 months of treatment.9
Recommendations
The American College of Cardiology (ACC) and American Heart Association (AHA) provide the following recommendations in their joint 2006 Guidelines for Secondary Prevention for Patients with Coronary and Other Atherosclerotic Vascular Disease:10
- Low-dose aspirin should be used, as well as clopidogrel in combination with aspirin for up to 12 months after a non-ST elevation MI
- ACE inhibitors or angiotensin receptor blockers should be considered in all patients, and an aldosterone antagonist should be prescribed for patients with a diminished ejection fraction post-MI
- Beta-blockers should be used in all post-MI patients without contraindications.
The ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non–ST-Elevation Myocardial Infarction recommend the same medication combinations.11 So does the 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction, with the exception that clopidogrel in combination with aspirin is recommended for at least 14 days.12
Similarly, the British National Institute for Clinical Excellence Clinical Guideline 48 recommends that all post-MI patients be offered a combination of an ACE inhibitor, aspirin with clopidogrel, a beta-blocker, and a statin.13
Acknowledgement
The opinions and assertions contained herein are the private views of the authors and should not be construed as official or as reflecting the views of the US Department of the Navy or the Department of Defense.
1. Collaborative overview of randomized trials of antiplatelet therapy: prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of people. Antiplatelet Trialists’ Collaboration. BMJ. 1994;308:81-106.
2. Randomized trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. Second International Study of Infarct Survival (ISIS-2) Collaborative Group. Lancet. 1988;2:349-360.
3. Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001;345:494-502.
4. Chen ZM, Jiang LX, Chen YP, et al. Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet. 2005;366:1607-1621.
5. Ray KK, Cannon CP, McCabe CH, et al. Early and late benefits of high-dose atorvastatin in patients with acute coronary syndromes: results from the PROVE IT-TIMI 22 trial. J Am Coll Cardiol. 2005;46:1405-1410.
6. Yusuf S, Peto R, Lewis J, et al. Beta-blockade during and after myocardial infarction: an overview of the randomized trials. Prog Cardiovasc Dis. 1985;27:335-371.
7. Freemantle N, Cleland J, Young P, et al. Beta blockade after myocardial infarction: systematic review and meta regression analysis. BMJ. 1999;318:1730-1737.
8. Domanski MJ, Exner DV, Borkowf CB, et al. Effect of angiotensin converting enzyme inhibition on sudden cardiac death in patients following acute myocardial infarction. A meta-analysis of randomized clinical trials. J Am Coll Cardiol. 1999;33:598-604.
9. Pitt B, White H, Nicolau J, et al. Eplerenone reduces mortality 30 days post-randomization following acute myocardial infarction in patients with left ventricular systolic dysfunction and heart failure. J Am Coll Cardiol. 2005;46:425-431.
10. Smith SC, Jr, Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and Blood Institute. Circulation. 2006;113:2363-2372.
11. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction. J Am Coll Cardiol. 2007;50:e1-e157.
12. Antman EM, Hand M, Armstron PW, et al. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2008;51:210-247.
13. National Institute for Health and Clinical Excellence (NICE). Clinical guideline 48. Secondary prevention in primary and secondary care for patients following a myocardial infarction. London: NICE; 2007. Available at: http://guidance.nice.org.uk/CG48. Accessed March 7, 2010.
PATIENTS SHOULD BE PLACED ON THE FOLLOWING MEDICATIONS :
- antiplatelet agents (strength of recommendation [SOR]: A, meta-analysis for aspirin; A, multiple randomized controlled trials [RCTs] for aspirin plus clopidogrel)
- a statin; atorvastatin has the best evidence (SOR: B, a single RCT)
- a beta-blocker (SOR: A, meta-analysis)
- renin-angiotensin-aldosterone system blockers, whether or not the ejection fraction is diminished after myocardial infarction (MI) (SOR: A, meta-analysis for angiotensin-converting enzyme [ACE] inhibitor; B, single RCT for ACE inhibitor plus aldosterone blocker). ( TABLE )
Evidence summary
A systematic review of 9 RCTs demonstrated that aspirin (75-325 mg) started soon after the onset of acute MI significantly reduced mortality, reinfarction, and stroke at 1 month compared with placebo (absolute risk reduction [ARR]=3.8%; number needed to treat [NNT]=26; 95% confidence interval [CI], 23-30).1
One large RCT involving 17,187 patients with suspected acute MI showed that 162 mg aspirin given on the day of the MI resulted in a 2.6% ARR (NNT=38; 95% CI, 29-63) in vascular deaths at 35 days compared with placebo.2 The survival benefit persisted for as long as 10 years. The RCT also found no significant difference between aspirin and placebo in rates of cerebral hemorrhage or bleeding requiring transfusions.
Patients who have had an MI without ST segment elevation should take clopidogrel (75 mg/d) and aspirin (81 mg/d) for 12 months. The combination has been shown to result in a 2.1% ARR (NNT=48) in deaths, recurrent MI, and stroke compared with aspirin alone.3 Patients who have had an ST segment elevation MI should take clopidogrel in combination with aspirin for at least 2 weeks.4
TABLE
Recommended drugs for post-MI patients
| Drug type | Examples | Precautions | Contraindications |
|---|---|---|---|
| Antiplatelet agents | Aspirin 81 mg/d; clopidogrel 75 mg/d | Risk for bleeding; use caution in patients taking warfarin | Active bleeding; hypersensitivity |
| RAAS blockers | Lisinopril 20 mg/d; losartan 50 mg/d; eplerenone 50 mg/d | Hypotension, hyperkalemia, renal failure Use eplerenone only with decreased ejection fraction | Hypersensitivity; systolic blood pressure <90 mm Hg |
| Beta-blockers | Metoprolol 100 mg bid | Hypotension, bradycardia, reactive airways | Systolic blood pressure <90 mm Hg; pulse rate <50 bpm |
| Statins | Atorvastatin 80 mg/d | Elevated AST/ALT, myositis | Active liver disease; pregnancy/nursing |
| ALT, alanine aminotransferase; AST, aspartate aminotransferase; BPM, beats per minute; RAAS, renin-angiotensin-aldosterone system. | |||
Intensive atorvastatin therapy lowers risk of death
The PROVE IT-TIMI 22 trial showed the benefit of early intensive therapy with the hydroxymethyl glutaryl coenzyme A reductase inhibitor atorvastatin to lower low-density lipoprotein <70 mg/dL post-MI.5 At 30 days after the event, atorvastatin 80 mg daily resulted in a 1.2% ARR in death and recurrent acute coronary syndrome (NNT=83; hazard ratio [HR]=0.72; 95% CI, 0.52-0.99). From 6 months to 24 months after the event, the ARR was 2.6% (NNT=38; HR=0.82; 95% CI, 0.69-0.99).
Beta-blockers significantly decrease late mortality
One systematic review of 63 RCTs showed that, in long-term trials, use of a beta-blocker significantly reduced the late mortality rate (NNT=48; odds ratio [OR]=0.77; 95% CI, 0.70-0.85).6 In another review of 82 RCTs, the mortality rate between 6 months and 4 years after MI decreased markedly in patients receiving a beta-blocker (OR=0.77; 95% CI, 0.69-0.85).7
ACE inhibitors decrease overall mortality, sudden cardiac death
An ACE inhibitor should be started regardless of the ejection fraction or the presence or absence of left ventricular systolic dysfunction. One systematic review that compared long-term mortality rates of patients started on an ACE inhibitor within 14 days of acute MI versus placebo found that ACE inhibitors significantly decreased overall mortality and sudden cardiac deaths between 2 and 42 months after the MI (NNT=42; OR=0.83; 95% CI, 0.71-0.97).8
Eplerenone + ACE inhibitor benefit patients with post-MI heart failure
The selective aldosterone blocker eplerenone appears to benefit patients with a decreased ejection fraction post-MI. The EPHESUS study demonstrated that eplerenone, when added to an ACE inhibitor, reduced all-cause mortality (ARR=1.4%; NNT=71; 95% CI, 47-200; RR=0.69; 95% CI, 0.54-0.89) and sudden cardiac death (ARR=0.5%; NNT=200; 95% CI, 125-∞; RR=0.63; 95% CI, 0.40-1.00) up to 30 days in patients with post-MI heart failure. Benefits were also seen after 16 months of treatment.9
Recommendations
The American College of Cardiology (ACC) and American Heart Association (AHA) provide the following recommendations in their joint 2006 Guidelines for Secondary Prevention for Patients with Coronary and Other Atherosclerotic Vascular Disease:10
- Low-dose aspirin should be used, as well as clopidogrel in combination with aspirin for up to 12 months after a non-ST elevation MI
- ACE inhibitors or angiotensin receptor blockers should be considered in all patients, and an aldosterone antagonist should be prescribed for patients with a diminished ejection fraction post-MI
- Beta-blockers should be used in all post-MI patients without contraindications.
The ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non–ST-Elevation Myocardial Infarction recommend the same medication combinations.11 So does the 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction, with the exception that clopidogrel in combination with aspirin is recommended for at least 14 days.12
Similarly, the British National Institute for Clinical Excellence Clinical Guideline 48 recommends that all post-MI patients be offered a combination of an ACE inhibitor, aspirin with clopidogrel, a beta-blocker, and a statin.13
Acknowledgement
The opinions and assertions contained herein are the private views of the authors and should not be construed as official or as reflecting the views of the US Department of the Navy or the Department of Defense.
PATIENTS SHOULD BE PLACED ON THE FOLLOWING MEDICATIONS :
- antiplatelet agents (strength of recommendation [SOR]: A, meta-analysis for aspirin; A, multiple randomized controlled trials [RCTs] for aspirin plus clopidogrel)
- a statin; atorvastatin has the best evidence (SOR: B, a single RCT)
- a beta-blocker (SOR: A, meta-analysis)
- renin-angiotensin-aldosterone system blockers, whether or not the ejection fraction is diminished after myocardial infarction (MI) (SOR: A, meta-analysis for angiotensin-converting enzyme [ACE] inhibitor; B, single RCT for ACE inhibitor plus aldosterone blocker). ( TABLE )
Evidence summary
A systematic review of 9 RCTs demonstrated that aspirin (75-325 mg) started soon after the onset of acute MI significantly reduced mortality, reinfarction, and stroke at 1 month compared with placebo (absolute risk reduction [ARR]=3.8%; number needed to treat [NNT]=26; 95% confidence interval [CI], 23-30).1
One large RCT involving 17,187 patients with suspected acute MI showed that 162 mg aspirin given on the day of the MI resulted in a 2.6% ARR (NNT=38; 95% CI, 29-63) in vascular deaths at 35 days compared with placebo.2 The survival benefit persisted for as long as 10 years. The RCT also found no significant difference between aspirin and placebo in rates of cerebral hemorrhage or bleeding requiring transfusions.
Patients who have had an MI without ST segment elevation should take clopidogrel (75 mg/d) and aspirin (81 mg/d) for 12 months. The combination has been shown to result in a 2.1% ARR (NNT=48) in deaths, recurrent MI, and stroke compared with aspirin alone.3 Patients who have had an ST segment elevation MI should take clopidogrel in combination with aspirin for at least 2 weeks.4
TABLE
Recommended drugs for post-MI patients
| Drug type | Examples | Precautions | Contraindications |
|---|---|---|---|
| Antiplatelet agents | Aspirin 81 mg/d; clopidogrel 75 mg/d | Risk for bleeding; use caution in patients taking warfarin | Active bleeding; hypersensitivity |
| RAAS blockers | Lisinopril 20 mg/d; losartan 50 mg/d; eplerenone 50 mg/d | Hypotension, hyperkalemia, renal failure Use eplerenone only with decreased ejection fraction | Hypersensitivity; systolic blood pressure <90 mm Hg |
| Beta-blockers | Metoprolol 100 mg bid | Hypotension, bradycardia, reactive airways | Systolic blood pressure <90 mm Hg; pulse rate <50 bpm |
| Statins | Atorvastatin 80 mg/d | Elevated AST/ALT, myositis | Active liver disease; pregnancy/nursing |
| ALT, alanine aminotransferase; AST, aspartate aminotransferase; BPM, beats per minute; RAAS, renin-angiotensin-aldosterone system. | |||
Intensive atorvastatin therapy lowers risk of death
The PROVE IT-TIMI 22 trial showed the benefit of early intensive therapy with the hydroxymethyl glutaryl coenzyme A reductase inhibitor atorvastatin to lower low-density lipoprotein <70 mg/dL post-MI.5 At 30 days after the event, atorvastatin 80 mg daily resulted in a 1.2% ARR in death and recurrent acute coronary syndrome (NNT=83; hazard ratio [HR]=0.72; 95% CI, 0.52-0.99). From 6 months to 24 months after the event, the ARR was 2.6% (NNT=38; HR=0.82; 95% CI, 0.69-0.99).
Beta-blockers significantly decrease late mortality
One systematic review of 63 RCTs showed that, in long-term trials, use of a beta-blocker significantly reduced the late mortality rate (NNT=48; odds ratio [OR]=0.77; 95% CI, 0.70-0.85).6 In another review of 82 RCTs, the mortality rate between 6 months and 4 years after MI decreased markedly in patients receiving a beta-blocker (OR=0.77; 95% CI, 0.69-0.85).7
ACE inhibitors decrease overall mortality, sudden cardiac death
An ACE inhibitor should be started regardless of the ejection fraction or the presence or absence of left ventricular systolic dysfunction. One systematic review that compared long-term mortality rates of patients started on an ACE inhibitor within 14 days of acute MI versus placebo found that ACE inhibitors significantly decreased overall mortality and sudden cardiac deaths between 2 and 42 months after the MI (NNT=42; OR=0.83; 95% CI, 0.71-0.97).8
Eplerenone + ACE inhibitor benefit patients with post-MI heart failure
The selective aldosterone blocker eplerenone appears to benefit patients with a decreased ejection fraction post-MI. The EPHESUS study demonstrated that eplerenone, when added to an ACE inhibitor, reduced all-cause mortality (ARR=1.4%; NNT=71; 95% CI, 47-200; RR=0.69; 95% CI, 0.54-0.89) and sudden cardiac death (ARR=0.5%; NNT=200; 95% CI, 125-∞; RR=0.63; 95% CI, 0.40-1.00) up to 30 days in patients with post-MI heart failure. Benefits were also seen after 16 months of treatment.9
Recommendations
The American College of Cardiology (ACC) and American Heart Association (AHA) provide the following recommendations in their joint 2006 Guidelines for Secondary Prevention for Patients with Coronary and Other Atherosclerotic Vascular Disease:10
- Low-dose aspirin should be used, as well as clopidogrel in combination with aspirin for up to 12 months after a non-ST elevation MI
- ACE inhibitors or angiotensin receptor blockers should be considered in all patients, and an aldosterone antagonist should be prescribed for patients with a diminished ejection fraction post-MI
- Beta-blockers should be used in all post-MI patients without contraindications.
The ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non–ST-Elevation Myocardial Infarction recommend the same medication combinations.11 So does the 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction, with the exception that clopidogrel in combination with aspirin is recommended for at least 14 days.12
Similarly, the British National Institute for Clinical Excellence Clinical Guideline 48 recommends that all post-MI patients be offered a combination of an ACE inhibitor, aspirin with clopidogrel, a beta-blocker, and a statin.13
Acknowledgement
The opinions and assertions contained herein are the private views of the authors and should not be construed as official or as reflecting the views of the US Department of the Navy or the Department of Defense.
1. Collaborative overview of randomized trials of antiplatelet therapy: prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of people. Antiplatelet Trialists’ Collaboration. BMJ. 1994;308:81-106.
2. Randomized trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. Second International Study of Infarct Survival (ISIS-2) Collaborative Group. Lancet. 1988;2:349-360.
3. Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001;345:494-502.
4. Chen ZM, Jiang LX, Chen YP, et al. Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet. 2005;366:1607-1621.
5. Ray KK, Cannon CP, McCabe CH, et al. Early and late benefits of high-dose atorvastatin in patients with acute coronary syndromes: results from the PROVE IT-TIMI 22 trial. J Am Coll Cardiol. 2005;46:1405-1410.
6. Yusuf S, Peto R, Lewis J, et al. Beta-blockade during and after myocardial infarction: an overview of the randomized trials. Prog Cardiovasc Dis. 1985;27:335-371.
7. Freemantle N, Cleland J, Young P, et al. Beta blockade after myocardial infarction: systematic review and meta regression analysis. BMJ. 1999;318:1730-1737.
8. Domanski MJ, Exner DV, Borkowf CB, et al. Effect of angiotensin converting enzyme inhibition on sudden cardiac death in patients following acute myocardial infarction. A meta-analysis of randomized clinical trials. J Am Coll Cardiol. 1999;33:598-604.
9. Pitt B, White H, Nicolau J, et al. Eplerenone reduces mortality 30 days post-randomization following acute myocardial infarction in patients with left ventricular systolic dysfunction and heart failure. J Am Coll Cardiol. 2005;46:425-431.
10. Smith SC, Jr, Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and Blood Institute. Circulation. 2006;113:2363-2372.
11. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction. J Am Coll Cardiol. 2007;50:e1-e157.
12. Antman EM, Hand M, Armstron PW, et al. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2008;51:210-247.
13. National Institute for Health and Clinical Excellence (NICE). Clinical guideline 48. Secondary prevention in primary and secondary care for patients following a myocardial infarction. London: NICE; 2007. Available at: http://guidance.nice.org.uk/CG48. Accessed March 7, 2010.
1. Collaborative overview of randomized trials of antiplatelet therapy: prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of people. Antiplatelet Trialists’ Collaboration. BMJ. 1994;308:81-106.
2. Randomized trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. Second International Study of Infarct Survival (ISIS-2) Collaborative Group. Lancet. 1988;2:349-360.
3. Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001;345:494-502.
4. Chen ZM, Jiang LX, Chen YP, et al. Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet. 2005;366:1607-1621.
5. Ray KK, Cannon CP, McCabe CH, et al. Early and late benefits of high-dose atorvastatin in patients with acute coronary syndromes: results from the PROVE IT-TIMI 22 trial. J Am Coll Cardiol. 2005;46:1405-1410.
6. Yusuf S, Peto R, Lewis J, et al. Beta-blockade during and after myocardial infarction: an overview of the randomized trials. Prog Cardiovasc Dis. 1985;27:335-371.
7. Freemantle N, Cleland J, Young P, et al. Beta blockade after myocardial infarction: systematic review and meta regression analysis. BMJ. 1999;318:1730-1737.
8. Domanski MJ, Exner DV, Borkowf CB, et al. Effect of angiotensin converting enzyme inhibition on sudden cardiac death in patients following acute myocardial infarction. A meta-analysis of randomized clinical trials. J Am Coll Cardiol. 1999;33:598-604.
9. Pitt B, White H, Nicolau J, et al. Eplerenone reduces mortality 30 days post-randomization following acute myocardial infarction in patients with left ventricular systolic dysfunction and heart failure. J Am Coll Cardiol. 2005;46:425-431.
10. Smith SC, Jr, Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and Blood Institute. Circulation. 2006;113:2363-2372.
11. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction. J Am Coll Cardiol. 2007;50:e1-e157.
12. Antman EM, Hand M, Armstron PW, et al. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2008;51:210-247.
13. National Institute for Health and Clinical Excellence (NICE). Clinical guideline 48. Secondary prevention in primary and secondary care for patients following a myocardial infarction. London: NICE; 2007. Available at: http://guidance.nice.org.uk/CG48. Accessed March 7, 2010.
Evidence-based answers from the Family Physicians Inquiries Network
What’s the best drug treatment for premature ejaculation?
Antidepressants—specifically clomipramine, fluoxetine, paroxetine, and sertraline—are best and have been shown to improve symptoms of premature ejaculation (strength of recommendation [SOR]: A, meta-analysis of randomized controlled trials [RCTs]). The topical application of prilocaine-lidocaine cream (trade name EMLA) improves intravaginal ejaculatory latency time (IELT), but penile numbness and loss of erection may occur (SOR: B, based on several small RCTs).
There is no evidence that phosphodiesterase type 5 (PDE5) inhibitors—such as sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis)—decrease instances of premature ejaculation in otherwise healthy men. There is limited evidence, however, that PDE5 inhibitors reduce symptoms of premature ejaculation for men with concomitant erectile dysfunction (SOR: B, systematic review of RCTs of variable quality).
Overcome any reluctance to discuss premature ejaculation
Vincent Lo, MD
San Joaquin Family Medicine Residency, French Camp, Calif
Family physicians should be comfortable diagnosing and treating premature ejaculation because of their unique and long-term relationship with the patient. But that’s not always the case. Premature ejaculation is underdiagnosed and undertreated because of a reluctance to discuss it, by both patient and physician.
A thorough medical history, including pertinent sexual history and physical examination, can often establish the diagnosis of premature ejaculation. Effective treatments can improve sexual satisfaction and quality of life for both the men and their partners.
Evidence summary
Premature ejaculation is the most common male sexual dysfunction, but there is no universally accepted definition or validated screening instrument. The pathophysiology and etiology remain incompletely understood.1 Based on surveys, prevalence rates for premature ejaculation are approximately 20% to 30%.1
Studies in male rats have demonstrated that serotonin with various 5-HT receptor subtypes are involved in the ejaculatory process.2 Based on these studies, it’s been suggested that lifelong premature ejaculation is a neurobiological phenomenon related to decreased central serotonergic neurotransmission, 5-HT2c receptor hyposensitivity, or 5-HT1a receptor hypersensitivity.3
Antidepressants delay ejaculation
The introduction of selective serotonin reuptake inhibitors (SSRIs) revolutionized the treatment of premature ejaculation.4 In 1994, the first study of SSRIs in men with premature ejaculation demonstrated a delaying effect with paroxetine (Paxil).5 Since that time, SSRIs have been repeatedly investigated for their propensity to delay ejaculation. Certain SSRIs and the tricyclic antidepressant clomipramine (Anafranil) have become the agents of choice for the treatment of premature ejaculation.6
A meta-analysis6 of 35 treatment studies with serotonergic antidepressants from 1943 to 2003 shows that, despite major differences in design and drug dosing, clomipramine, fluoxetine (Prozac), paroxetine, and sertraline (Zoloft) significantly delay ejaculation compared with placebo. The percentage increase in IELT was the primary outcome measured. The rank order of efficacy was:
- paroxetine (1492% IELT increase; 95% confidence interval [CI], 918–2425)
- sertraline (790% IELT increase; 95% CI, 532–1173)
- clomipramine (512% IELT increase; 95% CI, 234–1122)
- fluoxetine (295% IELT increase; 95% CI, 172–506).6
Of the 35 studies used in the previous meta-analysis, 8 studies (N=263) were prospective, double-blind, real-time stopwatch studies that were separately analyzed in a subsequent meta-analysis. These 8 studies evaluated clomipramine, fluoxetine, paroxetine, sertraline, citalopram (Celexa), fluvoxamine (Luvox), mirtazapine (Remeron), and nefazodone (Serzone) against placebo. Paroxetine (783% IELT increase, 95% CI, 499–1228), clomipramine (360% IELT increase, 95% CI, 200–435), sertraline (313%, 95% CI, 161–608), and fluoxetine (295%, 95% CI, 200–435) exerted a significant delay in the IELT compared with placebo.6
EMLA cream: “Improvement” and “cure” seen
EMLA cream, a topical anesthetic, has been evaluated as a treatment option for premature ejaculation. One double-blinded RCT7 (N=29) showed significant improvement in the IELT (measured by stopwatch by the subject’s partner) from baseline compared with placebo (8.45 min vs 1.95 min; P<.001) at 2 months.
Another RCT8 (N=84) compared EMLA cream applied 15 minutes prior to intercourse, sildenafil 50 mg orally 45 minutes prior to intercourse, EMLA cream plus sildenafil, and placebo. In the sildenafil-plus-EMLA group, 32% of the patients reported “improvement” and 54% reported “cure,” which was defined as ejaculation delayed until the patient wished it. In the EMLA-only group, 27% of the patients reported “improvement” and 50% reported “cure.” This was a statistically significant difference when compared with the placebo and sildenafil-only groups (number needed to treat [NNT]=3). There was no significant difference in reports of “improvement” or “cure” between the placebo and sildenafil-only groups.
One small RCT9 (N=24) compared placebo with the application of EMLA cream 20, 30, and 45 minutes prior to sexual intercourse. Improvement was seen in IELT in the 20- and 30-minute group, but penile numbness and erection loss increased in the 30- and 45-minute group.
PDE5 inhibitors: No convincing evidence
A review10 of 14 clinical trials concluded that there is no convincing evidence for PDE5 inhibitors in the treatment of men with lifelong premature ejaculation and normal erectile function. One RCT11 found no increase in IELT from baseline in men taking sildenafil when compared with placebo, although patients reported overall sexual satisfaction and confidence based on a questionnaire.
However, a study by Li et al12 treated 45 men with premature ejaculation and comorbid erectile dysfunction with sildenafil. Eighty-nine percent reported improved erectile function, and 60% reported decreased severity of premature ejaculation.
Recommendations from others
The American Urological Association13 recommends antidepressants as first-line systemic therapy for premature ejaculation, specifically the SSRIs fluoxetine, paroxetine, sertraline, and the tricyclic clomipramine. Topical EMLA cream is also recommended, but the reduction of penile sensation may limit the acceptability of this treatment option.
The British Association for Sexual Health and HIV Special Interest Group for Sexual Dysfunction14 also recommends SSRIs and clomipramine as they have the strongest evidence for their efficacy. The group emphasizes the importance of combining behavioral and pharmacologic therapies as the management approach should be tailored to the individual patient.
Acknowledgments
The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the US Government.
1. Althof SE. Prevalence, characteristics and implications of premature ejaculation/rapid ejaculation. J Urol 2006;175(3 pt 1):842-848.
2. Ahlenius S, Larsson K, Svensson L, et al. Effects of a new type of 5-HT receptor agonist on male rat sexual behavior. Pharmacol Biochem Behav 1981;15:785-792.
3. Waldinger MD, Berendsen HH, Blok BF, Olivier B, Holstege G. Premature ejaculation and serotonergic antidepressants-induced delayed ejaculation: the involvement of the serotonergic system. Behav Brain Res 1998;92:111-118.
4. Waldinger MD, Olivier B. Utility of selective serotonin reuptake inhibitors in premature ejaculation. Curr Opin Investig Drugs 2004;5:743-747.
5. Waldinger MD, Hengeveld MW, Zwinderman AH. Paroxetine treatment of premature ejaculation: a double-blind, randomized, placebo-controlled study. Am J Psychiatry 1994;151:1377-1379.
6. Waldinger MD, Zwinderman AH, Schweitzer DH, Olivier B. Relevance of methodological design for the interpretation of efficacy of drug treatment of premature ejaculation: a systematic review and meta-analysis. Int J Impot Res 2004;16:369-381.
7. Busato W, Galindo CC. Topical anaesthetic use for treating premature ejaculation: a double-blind, randomized, placebo-controlled study. BJU Int 2004;93:1018-1021.
8. Atan A, Basar MM, Tuncel A, Ferhat M, Agras K, Tekdogan U. Comparison of efficacy of sildenafil-only, sildenafil plus topical EMLA cream, and topical EMLA-cream-only in treatment of premature ejaculation. Urology 2006;67:388-391.
9. Atikeler MK, Gecit I, Senol FA. Optimum usage of prilocaine-lidocaine cream in premature ejaculation. Andrologia 2002;34:356-359.
10. McMahon CG, McMahon CN, Leow LJ, Winestock CG. Efficacy of type-5 phosphodiesterase inhibitors in the drug treatment of premature ejaculation: a systematic review. BJU Int 2006;98:259-272.
11. McMahon CG, Stuckey BG, Andersen M, et al. Efficacy of sildenafil citrate (Viagra) in men with premature ejaculation. J Sex Med 2005;2:368-375.
12. Li X, Zhang SX, Cheng HM, Zhang WD. Clinical study of sildenafil in the treatment of premature ejaculation complicated by erectile dysfunction [in Chinese]. Zhonghua Nan Ke Xue 2003;9:266-269.
13. Montague DK, Jarow J, Broderick GA, et al. AUA Erectile Dysfunction Guideline Update Panel. AUA guideline on the pharmacologic management of premature ejaculation. J Urol 2004;172:290-294.
14. Richardson D, Goldmeier D, Green J, Lamba H, Harris , JR. BASHH Special Interest Group for Sexual Dysfunction. Recommendations for the management of premature ejaculation: BASHH Special Interest Group for Sexual Dysfunction. Int J STD AIDS 2006;17:1-6.
Antidepressants—specifically clomipramine, fluoxetine, paroxetine, and sertraline—are best and have been shown to improve symptoms of premature ejaculation (strength of recommendation [SOR]: A, meta-analysis of randomized controlled trials [RCTs]). The topical application of prilocaine-lidocaine cream (trade name EMLA) improves intravaginal ejaculatory latency time (IELT), but penile numbness and loss of erection may occur (SOR: B, based on several small RCTs).
There is no evidence that phosphodiesterase type 5 (PDE5) inhibitors—such as sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis)—decrease instances of premature ejaculation in otherwise healthy men. There is limited evidence, however, that PDE5 inhibitors reduce symptoms of premature ejaculation for men with concomitant erectile dysfunction (SOR: B, systematic review of RCTs of variable quality).
Overcome any reluctance to discuss premature ejaculation
Vincent Lo, MD
San Joaquin Family Medicine Residency, French Camp, Calif
Family physicians should be comfortable diagnosing and treating premature ejaculation because of their unique and long-term relationship with the patient. But that’s not always the case. Premature ejaculation is underdiagnosed and undertreated because of a reluctance to discuss it, by both patient and physician.
A thorough medical history, including pertinent sexual history and physical examination, can often establish the diagnosis of premature ejaculation. Effective treatments can improve sexual satisfaction and quality of life for both the men and their partners.
Evidence summary
Premature ejaculation is the most common male sexual dysfunction, but there is no universally accepted definition or validated screening instrument. The pathophysiology and etiology remain incompletely understood.1 Based on surveys, prevalence rates for premature ejaculation are approximately 20% to 30%.1
Studies in male rats have demonstrated that serotonin with various 5-HT receptor subtypes are involved in the ejaculatory process.2 Based on these studies, it’s been suggested that lifelong premature ejaculation is a neurobiological phenomenon related to decreased central serotonergic neurotransmission, 5-HT2c receptor hyposensitivity, or 5-HT1a receptor hypersensitivity.3
Antidepressants delay ejaculation
The introduction of selective serotonin reuptake inhibitors (SSRIs) revolutionized the treatment of premature ejaculation.4 In 1994, the first study of SSRIs in men with premature ejaculation demonstrated a delaying effect with paroxetine (Paxil).5 Since that time, SSRIs have been repeatedly investigated for their propensity to delay ejaculation. Certain SSRIs and the tricyclic antidepressant clomipramine (Anafranil) have become the agents of choice for the treatment of premature ejaculation.6
A meta-analysis6 of 35 treatment studies with serotonergic antidepressants from 1943 to 2003 shows that, despite major differences in design and drug dosing, clomipramine, fluoxetine (Prozac), paroxetine, and sertraline (Zoloft) significantly delay ejaculation compared with placebo. The percentage increase in IELT was the primary outcome measured. The rank order of efficacy was:
- paroxetine (1492% IELT increase; 95% confidence interval [CI], 918–2425)
- sertraline (790% IELT increase; 95% CI, 532–1173)
- clomipramine (512% IELT increase; 95% CI, 234–1122)
- fluoxetine (295% IELT increase; 95% CI, 172–506).6
Of the 35 studies used in the previous meta-analysis, 8 studies (N=263) were prospective, double-blind, real-time stopwatch studies that were separately analyzed in a subsequent meta-analysis. These 8 studies evaluated clomipramine, fluoxetine, paroxetine, sertraline, citalopram (Celexa), fluvoxamine (Luvox), mirtazapine (Remeron), and nefazodone (Serzone) against placebo. Paroxetine (783% IELT increase, 95% CI, 499–1228), clomipramine (360% IELT increase, 95% CI, 200–435), sertraline (313%, 95% CI, 161–608), and fluoxetine (295%, 95% CI, 200–435) exerted a significant delay in the IELT compared with placebo.6
EMLA cream: “Improvement” and “cure” seen
EMLA cream, a topical anesthetic, has been evaluated as a treatment option for premature ejaculation. One double-blinded RCT7 (N=29) showed significant improvement in the IELT (measured by stopwatch by the subject’s partner) from baseline compared with placebo (8.45 min vs 1.95 min; P<.001) at 2 months.
Another RCT8 (N=84) compared EMLA cream applied 15 minutes prior to intercourse, sildenafil 50 mg orally 45 minutes prior to intercourse, EMLA cream plus sildenafil, and placebo. In the sildenafil-plus-EMLA group, 32% of the patients reported “improvement” and 54% reported “cure,” which was defined as ejaculation delayed until the patient wished it. In the EMLA-only group, 27% of the patients reported “improvement” and 50% reported “cure.” This was a statistically significant difference when compared with the placebo and sildenafil-only groups (number needed to treat [NNT]=3). There was no significant difference in reports of “improvement” or “cure” between the placebo and sildenafil-only groups.
One small RCT9 (N=24) compared placebo with the application of EMLA cream 20, 30, and 45 minutes prior to sexual intercourse. Improvement was seen in IELT in the 20- and 30-minute group, but penile numbness and erection loss increased in the 30- and 45-minute group.
PDE5 inhibitors: No convincing evidence
A review10 of 14 clinical trials concluded that there is no convincing evidence for PDE5 inhibitors in the treatment of men with lifelong premature ejaculation and normal erectile function. One RCT11 found no increase in IELT from baseline in men taking sildenafil when compared with placebo, although patients reported overall sexual satisfaction and confidence based on a questionnaire.
However, a study by Li et al12 treated 45 men with premature ejaculation and comorbid erectile dysfunction with sildenafil. Eighty-nine percent reported improved erectile function, and 60% reported decreased severity of premature ejaculation.
Recommendations from others
The American Urological Association13 recommends antidepressants as first-line systemic therapy for premature ejaculation, specifically the SSRIs fluoxetine, paroxetine, sertraline, and the tricyclic clomipramine. Topical EMLA cream is also recommended, but the reduction of penile sensation may limit the acceptability of this treatment option.
The British Association for Sexual Health and HIV Special Interest Group for Sexual Dysfunction14 also recommends SSRIs and clomipramine as they have the strongest evidence for their efficacy. The group emphasizes the importance of combining behavioral and pharmacologic therapies as the management approach should be tailored to the individual patient.
Acknowledgments
The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the US Government.
Antidepressants—specifically clomipramine, fluoxetine, paroxetine, and sertraline—are best and have been shown to improve symptoms of premature ejaculation (strength of recommendation [SOR]: A, meta-analysis of randomized controlled trials [RCTs]). The topical application of prilocaine-lidocaine cream (trade name EMLA) improves intravaginal ejaculatory latency time (IELT), but penile numbness and loss of erection may occur (SOR: B, based on several small RCTs).
There is no evidence that phosphodiesterase type 5 (PDE5) inhibitors—such as sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis)—decrease instances of premature ejaculation in otherwise healthy men. There is limited evidence, however, that PDE5 inhibitors reduce symptoms of premature ejaculation for men with concomitant erectile dysfunction (SOR: B, systematic review of RCTs of variable quality).
Overcome any reluctance to discuss premature ejaculation
Vincent Lo, MD
San Joaquin Family Medicine Residency, French Camp, Calif
Family physicians should be comfortable diagnosing and treating premature ejaculation because of their unique and long-term relationship with the patient. But that’s not always the case. Premature ejaculation is underdiagnosed and undertreated because of a reluctance to discuss it, by both patient and physician.
A thorough medical history, including pertinent sexual history and physical examination, can often establish the diagnosis of premature ejaculation. Effective treatments can improve sexual satisfaction and quality of life for both the men and their partners.
Evidence summary
Premature ejaculation is the most common male sexual dysfunction, but there is no universally accepted definition or validated screening instrument. The pathophysiology and etiology remain incompletely understood.1 Based on surveys, prevalence rates for premature ejaculation are approximately 20% to 30%.1
Studies in male rats have demonstrated that serotonin with various 5-HT receptor subtypes are involved in the ejaculatory process.2 Based on these studies, it’s been suggested that lifelong premature ejaculation is a neurobiological phenomenon related to decreased central serotonergic neurotransmission, 5-HT2c receptor hyposensitivity, or 5-HT1a receptor hypersensitivity.3
Antidepressants delay ejaculation
The introduction of selective serotonin reuptake inhibitors (SSRIs) revolutionized the treatment of premature ejaculation.4 In 1994, the first study of SSRIs in men with premature ejaculation demonstrated a delaying effect with paroxetine (Paxil).5 Since that time, SSRIs have been repeatedly investigated for their propensity to delay ejaculation. Certain SSRIs and the tricyclic antidepressant clomipramine (Anafranil) have become the agents of choice for the treatment of premature ejaculation.6
A meta-analysis6 of 35 treatment studies with serotonergic antidepressants from 1943 to 2003 shows that, despite major differences in design and drug dosing, clomipramine, fluoxetine (Prozac), paroxetine, and sertraline (Zoloft) significantly delay ejaculation compared with placebo. The percentage increase in IELT was the primary outcome measured. The rank order of efficacy was:
- paroxetine (1492% IELT increase; 95% confidence interval [CI], 918–2425)
- sertraline (790% IELT increase; 95% CI, 532–1173)
- clomipramine (512% IELT increase; 95% CI, 234–1122)
- fluoxetine (295% IELT increase; 95% CI, 172–506).6
Of the 35 studies used in the previous meta-analysis, 8 studies (N=263) were prospective, double-blind, real-time stopwatch studies that were separately analyzed in a subsequent meta-analysis. These 8 studies evaluated clomipramine, fluoxetine, paroxetine, sertraline, citalopram (Celexa), fluvoxamine (Luvox), mirtazapine (Remeron), and nefazodone (Serzone) against placebo. Paroxetine (783% IELT increase, 95% CI, 499–1228), clomipramine (360% IELT increase, 95% CI, 200–435), sertraline (313%, 95% CI, 161–608), and fluoxetine (295%, 95% CI, 200–435) exerted a significant delay in the IELT compared with placebo.6
EMLA cream: “Improvement” and “cure” seen
EMLA cream, a topical anesthetic, has been evaluated as a treatment option for premature ejaculation. One double-blinded RCT7 (N=29) showed significant improvement in the IELT (measured by stopwatch by the subject’s partner) from baseline compared with placebo (8.45 min vs 1.95 min; P<.001) at 2 months.
Another RCT8 (N=84) compared EMLA cream applied 15 minutes prior to intercourse, sildenafil 50 mg orally 45 minutes prior to intercourse, EMLA cream plus sildenafil, and placebo. In the sildenafil-plus-EMLA group, 32% of the patients reported “improvement” and 54% reported “cure,” which was defined as ejaculation delayed until the patient wished it. In the EMLA-only group, 27% of the patients reported “improvement” and 50% reported “cure.” This was a statistically significant difference when compared with the placebo and sildenafil-only groups (number needed to treat [NNT]=3). There was no significant difference in reports of “improvement” or “cure” between the placebo and sildenafil-only groups.
One small RCT9 (N=24) compared placebo with the application of EMLA cream 20, 30, and 45 minutes prior to sexual intercourse. Improvement was seen in IELT in the 20- and 30-minute group, but penile numbness and erection loss increased in the 30- and 45-minute group.
PDE5 inhibitors: No convincing evidence
A review10 of 14 clinical trials concluded that there is no convincing evidence for PDE5 inhibitors in the treatment of men with lifelong premature ejaculation and normal erectile function. One RCT11 found no increase in IELT from baseline in men taking sildenafil when compared with placebo, although patients reported overall sexual satisfaction and confidence based on a questionnaire.
However, a study by Li et al12 treated 45 men with premature ejaculation and comorbid erectile dysfunction with sildenafil. Eighty-nine percent reported improved erectile function, and 60% reported decreased severity of premature ejaculation.
Recommendations from others
The American Urological Association13 recommends antidepressants as first-line systemic therapy for premature ejaculation, specifically the SSRIs fluoxetine, paroxetine, sertraline, and the tricyclic clomipramine. Topical EMLA cream is also recommended, but the reduction of penile sensation may limit the acceptability of this treatment option.
The British Association for Sexual Health and HIV Special Interest Group for Sexual Dysfunction14 also recommends SSRIs and clomipramine as they have the strongest evidence for their efficacy. The group emphasizes the importance of combining behavioral and pharmacologic therapies as the management approach should be tailored to the individual patient.
Acknowledgments
The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the US Government.
1. Althof SE. Prevalence, characteristics and implications of premature ejaculation/rapid ejaculation. J Urol 2006;175(3 pt 1):842-848.
2. Ahlenius S, Larsson K, Svensson L, et al. Effects of a new type of 5-HT receptor agonist on male rat sexual behavior. Pharmacol Biochem Behav 1981;15:785-792.
3. Waldinger MD, Berendsen HH, Blok BF, Olivier B, Holstege G. Premature ejaculation and serotonergic antidepressants-induced delayed ejaculation: the involvement of the serotonergic system. Behav Brain Res 1998;92:111-118.
4. Waldinger MD, Olivier B. Utility of selective serotonin reuptake inhibitors in premature ejaculation. Curr Opin Investig Drugs 2004;5:743-747.
5. Waldinger MD, Hengeveld MW, Zwinderman AH. Paroxetine treatment of premature ejaculation: a double-blind, randomized, placebo-controlled study. Am J Psychiatry 1994;151:1377-1379.
6. Waldinger MD, Zwinderman AH, Schweitzer DH, Olivier B. Relevance of methodological design for the interpretation of efficacy of drug treatment of premature ejaculation: a systematic review and meta-analysis. Int J Impot Res 2004;16:369-381.
7. Busato W, Galindo CC. Topical anaesthetic use for treating premature ejaculation: a double-blind, randomized, placebo-controlled study. BJU Int 2004;93:1018-1021.
8. Atan A, Basar MM, Tuncel A, Ferhat M, Agras K, Tekdogan U. Comparison of efficacy of sildenafil-only, sildenafil plus topical EMLA cream, and topical EMLA-cream-only in treatment of premature ejaculation. Urology 2006;67:388-391.
9. Atikeler MK, Gecit I, Senol FA. Optimum usage of prilocaine-lidocaine cream in premature ejaculation. Andrologia 2002;34:356-359.
10. McMahon CG, McMahon CN, Leow LJ, Winestock CG. Efficacy of type-5 phosphodiesterase inhibitors in the drug treatment of premature ejaculation: a systematic review. BJU Int 2006;98:259-272.
11. McMahon CG, Stuckey BG, Andersen M, et al. Efficacy of sildenafil citrate (Viagra) in men with premature ejaculation. J Sex Med 2005;2:368-375.
12. Li X, Zhang SX, Cheng HM, Zhang WD. Clinical study of sildenafil in the treatment of premature ejaculation complicated by erectile dysfunction [in Chinese]. Zhonghua Nan Ke Xue 2003;9:266-269.
13. Montague DK, Jarow J, Broderick GA, et al. AUA Erectile Dysfunction Guideline Update Panel. AUA guideline on the pharmacologic management of premature ejaculation. J Urol 2004;172:290-294.
14. Richardson D, Goldmeier D, Green J, Lamba H, Harris , JR. BASHH Special Interest Group for Sexual Dysfunction. Recommendations for the management of premature ejaculation: BASHH Special Interest Group for Sexual Dysfunction. Int J STD AIDS 2006;17:1-6.
1. Althof SE. Prevalence, characteristics and implications of premature ejaculation/rapid ejaculation. J Urol 2006;175(3 pt 1):842-848.
2. Ahlenius S, Larsson K, Svensson L, et al. Effects of a new type of 5-HT receptor agonist on male rat sexual behavior. Pharmacol Biochem Behav 1981;15:785-792.
3. Waldinger MD, Berendsen HH, Blok BF, Olivier B, Holstege G. Premature ejaculation and serotonergic antidepressants-induced delayed ejaculation: the involvement of the serotonergic system. Behav Brain Res 1998;92:111-118.
4. Waldinger MD, Olivier B. Utility of selective serotonin reuptake inhibitors in premature ejaculation. Curr Opin Investig Drugs 2004;5:743-747.
5. Waldinger MD, Hengeveld MW, Zwinderman AH. Paroxetine treatment of premature ejaculation: a double-blind, randomized, placebo-controlled study. Am J Psychiatry 1994;151:1377-1379.
6. Waldinger MD, Zwinderman AH, Schweitzer DH, Olivier B. Relevance of methodological design for the interpretation of efficacy of drug treatment of premature ejaculation: a systematic review and meta-analysis. Int J Impot Res 2004;16:369-381.
7. Busato W, Galindo CC. Topical anaesthetic use for treating premature ejaculation: a double-blind, randomized, placebo-controlled study. BJU Int 2004;93:1018-1021.
8. Atan A, Basar MM, Tuncel A, Ferhat M, Agras K, Tekdogan U. Comparison of efficacy of sildenafil-only, sildenafil plus topical EMLA cream, and topical EMLA-cream-only in treatment of premature ejaculation. Urology 2006;67:388-391.
9. Atikeler MK, Gecit I, Senol FA. Optimum usage of prilocaine-lidocaine cream in premature ejaculation. Andrologia 2002;34:356-359.
10. McMahon CG, McMahon CN, Leow LJ, Winestock CG. Efficacy of type-5 phosphodiesterase inhibitors in the drug treatment of premature ejaculation: a systematic review. BJU Int 2006;98:259-272.
11. McMahon CG, Stuckey BG, Andersen M, et al. Efficacy of sildenafil citrate (Viagra) in men with premature ejaculation. J Sex Med 2005;2:368-375.
12. Li X, Zhang SX, Cheng HM, Zhang WD. Clinical study of sildenafil in the treatment of premature ejaculation complicated by erectile dysfunction [in Chinese]. Zhonghua Nan Ke Xue 2003;9:266-269.
13. Montague DK, Jarow J, Broderick GA, et al. AUA Erectile Dysfunction Guideline Update Panel. AUA guideline on the pharmacologic management of premature ejaculation. J Urol 2004;172:290-294.
14. Richardson D, Goldmeier D, Green J, Lamba H, Harris , JR. BASHH Special Interest Group for Sexual Dysfunction. Recommendations for the management of premature ejaculation: BASHH Special Interest Group for Sexual Dysfunction. Int J STD AIDS 2006;17:1-6.
Evidence-based answers from the Family Physicians Inquiries Network