Central nervous system agents in the treatment of erectile dysfunction: how do they work?

The Female Sexual Response: Current Models, Neurobiological Underpinnings and Agents Currently Approved or Under Investigation for the Treatment of Hypoactive Sexual Desire Disorder

How a woman responds to sexual cues is highly dependent on a number of distinct, yet related, factors. Researchers have attempted to explain the female sexual response for decades, but no single model reigns supreme. Proper female sexual function relies on the interplay of somatic, psychosocial and neurobiological factors; misregulation of any of these components could result in sexual dysfunction. The most common sexual dysfunction disorder is hypoactive sexual desire disorder (HSDD). HSDD is a disorder affecting women across the world; a recent in-person diagnostic interview study conducted in the USA found that an estimated 7.4% of US women suffer from HSDD. Despite the disorder's prevalence, it is often overlooked as a formal diagnosis. In a survey of primary care physicians and obstetrics/gynaecology specialists, the number one reason for not assigning an HSDD diagnosis was the lack of a safe and effective therapy approved by the US Food and Drug Administration (FDA). This changed with the recent FDA approval of flibanserin (Addyi™) for the treatment of premenopausal women with acquired, generalized HSDD; there are still, however, no treatments approved outside the USA. HSDD is characterized by a marked decrease in sexual desire, an absence of motivation (also known as avolition) to engage in sexual activity, and the condition's hallmark symptom, marked patient distress. Research suggests that HSDD may arise from an imbalance of the excitatory and inhibitory neurobiological pathways that regulate the mammalian sexual response; top-down inhibition from the prefrontal cortex may be hyperactive, and/or bottom-up excitation to the limbic system may be hypoactive. Key neuromodulators for the excitatory pathways include norepinephrine, oxytocin, dopamine and melanocortins. Serotonin, opioids and endocannabinoids serve as key neuromodulators for the inhibitory pathways. Evolving treatment strategies have relied heavily on these crucial research findings, as many of the agents currently being investigated as treatment options for HSDD target and influence key players within these excitatory and inhibitory pathways, including various hormone therapies and centrally acting drugs, such as buspirone, bupropion and bremelanotide.

Cnidium monnieri: A Review of Traditional Uses, Phytochemical and Ethnopharmacological Properties

Cnidium monnieri (L.) Cuss., an annual plant of the Umbelliferae species is one of the most widely used traditional herbal medicines and its fruits have been used to treat a variety of diseases in China, Vietnam, and Japan. The aim of this review is to provide an up-to-date and comprehensive analysis of the botany, traditional uses, phytochemistry, pharmacology, toxicity and contraindication of Cnidium monnieri (L.) Cuss. and to provide future directions of research on this plant. To date, 350 compounds have been isolated and identified from Cnidium monnieri (L.) Cuss., including the main active constituent, coumarins. In vitro and in vivo studies suggest that osthole and other coumarin compounds possess wide range of pharmacological properties for the treatment of female genitals, male impotence, frigidity, skin-related diseases, and exhibit strong antipruritic, anti-allergic, antidermatophytic, antibacterial, antifungal, anti-osteoporotic effects. Although coumarins have been identified as the main active constituents responsible for the observed pharmacological effects, the molecular mechanisms of their actions are still unknown. Therefore, further studies are still required to reveal the structure-activity relationship of these active constituents. In addition, toxicological and clinical studies are also required to provide further data for pharmaceutical use.

NBM-T-L-BMX-OS01, Semisynthesized from Osthole, Is a Novel Inhibitor of Histone Deacetylase and Enhances Learning and Memory in Rats

NBM-T-L-BMX-OS01 (BMX) was derived from the semisynthesis of osthole, isolated from Cnidium monnieri (L.) Cuss., and was identified to be a potent inhibitor of HDAC8. This study shows that HDAC8 is highly expressed in the pancreas and the brain. The function of HDAC8 in the brain has not been adequately studied. Because BMX enhances neurite outgrowth and cAMP response element-binding protein (CREB) activation, the effect of BMX on neural plasticity such as learning and memory is examined. To examine declarative and nondeclarative memory, a water maze, a passive one-way avoidance task, and a novel object recognition task were performed. Results from the water maze revealed that BMX and suberoylanilide-hydroxamic-acid-(SAHA-) treated rats showed shorter escape latency in finding the hidden platform. The BMX-treated animals spent more time in the target quadrant in the probe trial performance. An analysis of the passive one-way avoidance results showed that the BMX-treated animals stayed longer in the illuminated chamber by 1 day and 7 days after footshock. The novel object recognition task revealed that the BMX-treated animals showed a marked increase in the time spent exploring novel objects. Furthermore, BMX ameliorates scopolamine-(Sco-) induced learning and memory impairment in animals, indicating a novel role of BMX in learning and memory.

Involvement of the cGMP pathway in the osthole-facilitated glutamate release in rat hippocampal nerve endings

Osthole, an active constituent isolated from Cnidium monnieri (L.) Cusson, has previously been shown to have the capacity to increase depolarization-evoked glutamate release in rat hippocampal nerve terminals. As cGMP-dependent signaling cascade has been found to modulate glutamate release at the presynaptic level, the aim of this study was to further examine the role of cGMP signaling pathway in the regulation of osthole on glutamate release in hippocampal synaptosomes. Results showed that osthole dose-dependently increased intrasynaptosomal cGMP levels. The elevation of cGMP levels by osthole was prevented by the phosphodiesterase 5 inhibitor sildenafil but was insensitive to the guanylyl cyclase inhibitor ODQ. In addition, osthole-induced facilitation of 4-aminopyridine (4-AP)-evoked glutamate release was completely prevented by the cGMP-dependent protein kinase (PKG) inhibitors, KT5823, and Rp-8-Br-PET-cGMPS. Direct activation of PKG with 8-Br-cGMP or 8-pCPT-cGMP also occluded the osthole-mediated facilitation of 4-AP-evoked glutamate release. Furthermore, sildenafil exhibited a dose-dependent facilitation of 4-AP-evoked release of glutamate and occluded the effect of osthole on the 4-AP-evoked glutamate release. Collectively, our findings suggest that osthole-mediated facilitation of glutamate release involves the activation of cGMP/PKG-dependent pathway.

Effect of long-term prazosin and yohimbine administration on c-Fos expression in spinal neurons: inhibitory effect of alpha-1 and alpha-2 adrenoceptors on afferents from the lower urinary tract

INTRODUCTION

To investigate the effects of long-term administration of the α(1)-adrenoceptor antagonist prazosin and the α(2)-adrenoceptor antagonist yohimbine on afferent inputs from the lower urinary tract by evaluating c-Fos expression in the spinal cord.

MATERIALS AND METHODS

Prazosin or yohimbine was administered for 4 weeks in rats using an osmotic pump. Effects of these agents on urodynamic parameters were determined by continuous cystometry in conscious rats. After cystometry, c-Fos expression in the dorsal horn of the L6 spinal cord was measured by immunohistochemistry.

RESULTS

The administration of prazosin (0.12 mg/kg/day) or yohimbine (0.10 mg/kg/day) significantly increased micturition interval and bladder capacity, but did not affect micturition pressure and residual urine volume. The numbers of c-Fos-positive neurons in the dorsal horn were significantly lower in rats that received prazosin than in controls. Yohimbine reduced the number of c-Fos-positive neurons in part of the dorsal horn.

CONCLUSIONS

Long-term administration of prazosin and yohimbine at clinically recommended doses can exert inhibitory effects on afferent pathways from the lower urinary tract during the storage phase. These reductions of the afferent input result in the increased bladder capacity and increased micturition interval.

Future sexual medicine physiological treatment targets

INTRODUCTION

Sexual function in men and women incorporates physiologic processes and regulation of the central and peripheral nervous systems, the vascular system, and the endocrine system. There is need for state-of-the-art information as there is an evolving research understanding of the underlying molecular biological factors and mechanisms governing sexual physiologic functions.

AIM

To develop an evidence-based, state-of-the-art consensus report on the current knowledge of the major cellular and molecular targets of biologic systems responsible for sexual physiologic function.

METHODS

State-of-the-art knowledge representing the opinions of seven experts from four countries was developed in a consensus process over a 2-year period.

MAIN OUTCOME MEASURES

Expert opinion was based on the grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate.

RESULTS

Scientific investigation in this field is needed to increase knowledge and foster development of the future line of treatments for all forms of biological-based sexual dysfunction. This article addresses the current knowledge of the major cellular and molecular targets of biological systems responsible for sexual physiologic function. Future treatment targets include growth factor therapy, gene therapy, stem and cell-based therapies, and regenerative medicine.

CONCLUSIONS

Scientific discovery is critically important for developing new and increasingly effective treatments in sexual medicine. Broad physiologic directions should be vigorously explored and considered for future management of sexual disorders.

Inhibitory and disinhibitory effects of psychomotor stimulants and depressants on the sexual behavior of male and female rats

Drugs of abuse comprise several pharmacological classes, including psychomotor stimulants, such as amphetamine and cocaine, and CNS depressants, such as morphine and alcohol. Few studies have examined the effects of those drugs systematically on human sexual behavior, although substantial clinical and epidemiological literatures suggest that drugs in both classes either inhibit sexual responding or can be "prosexual" in certain situations, thereby increasing the potential of risky sexual activity and the spread of sexually transmitted diseases. This paper reviews original data in rats showing that both classes of drug inhibit or disinhibit sexual behavior depending on the animal's baseline level of sexual responding, hormonal status, whether the drug is given acutely or chronically, and whether the animal has learned to inhibit sexual responding toward nonreceptive partners or in the presence of conditioned olfactory cues that predict sexual nonreward.

Intranasal delivery: physicochemical and therapeutic aspects

Interest in intranasal (IN) administration as a non-invasive route for drug delivery continues to grow rapidly. The nasal mucosa offers numerous benefits as a target issue for drug delivery, such as a large surface area for delivery, rapid drug onset, potential for central nervous system delivery, and no first-pass metabolism. A wide variety of therapeutic compounds can be delivered IN, including relatively large molecules such as peptides and proteins, particularly in the presence of permeation enhancers. The current review provides an in-depth discussion of therapeutic aspects of IN delivery including consideration of the intended indication, regimen, and patient population, as well as physicochemical properties of the drug itself. Case examples are provided to illustrate the utility of IN dosing. It is anticipated that the present review will prove useful for formulation scientists considering IN delivery as a delivery route.

Paullinia pinnata Extracts Rich in Polyphenols Promote Vascular Relaxation via Endothelium-dependent Mechanisms

Paullinia pinnata L. (Sapindaceae) is an African tropical plant whose roots and leaves are used in traditional medicine for many purposes, especially for erectile dysfunction, but its action mechanism is unknown. P. pinnata root and leaf methanolic extracts are rich in phenolic compounds. This study shows that both extracts are highly antioxidative and induce a slight transcriptional activity of peroxisome proliferator activated receptor-alpha. They also increased and decreased endothelial nitric oxide synthase and endothelin-1 mRNA levels in bovine aortic endothelial cells, respectively. In this study P. pinnata methanolic extracts in cumulative doses elicited in a dose-dependent manner the relaxation of phenylephrine precontracted isolated rat aortic rings. N-nitro-L-arginine methyl ester significantly attenuated the capacity of both extracts to induce arterial relaxation, indicating that this arterial relaxation was mediated by endothelial nitric oxide release. It could be suggested that the arterial relaxation induced by both extracts could be mainly linked to their capacities to inhibit nitric oxide oxidation through their antioxidant properties.

The long-lasting improvement of sexual dysfunction in patients with advanced, fluctuating Parkinson's disease induced by pergolide: evidence from the results of an open, prospective, one-year trial

Fourteen male patients suffering from Parkinson's disease, each of whom had been treated with L-DOPA, and in whom additional treatment with oral dopamine agonist (DA) was needed, were followed for a period of one year. Pergolide mesylate (Permax) was given to each patient, and titrated to a total daily dose of 3 mg. All of the patients were taking L-DOPA. The assessments performed before the start of pergolide treatment consisted of neurological examination, unified Parkinson's disease rating scale (UPDRS) III and IV subscales scoring, mini mental state examination (MMSE) scoring, the neuropsychological examination including Zung scale scoring, biochemical and hematological examinations including prolactine serum levels; and a sexological examination during which the patients filled-in the international index of erectile function (IIEF) questionnaire. These examinations were repeated during the control assessments at months 1, 3, 6 and 12. ANOVA, non-parametric Friedmann's ANOVA and Tukey post hoc tests were used for the statistical analysis. There were statistically significant differences between the values of UPDRS III motor subscale and all subscales of IIEF when months 0 and 1 were compared with the results obtained at months 3, 6 and 12. Pergolide mesylate, when added to L-DOPA, significantly improved all sexual functions in younger male Parkinsonian patients who were still interested in sexual activities. The treatment with pergolide in these cases might be more beneficial than with short-acting PDE-5 inhibitor sildenafile. Nevertheless, the relationship between pergolide treatment and incidence of restrictive valvular heart disease must be considered.

Molecular pathophysiology and gene therapy of aging-related erectile dysfunction

Erectile dysfunction (ED) is a major public health problem that seriously affects the quality of life of patients and their partners. ED is mainly associated with vascular disease, diabetes, smoking, and radical prostatectomy, and its prevalence increases significantly with aging. Vasculogenic ED, specifically corporal veno-occlusive dysfunction (CVOD), is caused by the impairment of the relaxation of the smooth muscle in the penile corpora cavernosa and occurs in 2/3 of cases, whereas the less common neurogenic ED is due to a defective nitrergic neurotransmission triggered by the sexual stimulus, either at the central hypothalamic and spinal levels or at the penile nerves. Based on animal and cell studies, neurogenic ED is assumed to be caused mainly by: (a) an insufficient synthesis of nitric oxide (NO) due to a decrease in the levels of the penile neuronal nitric oxide synthase (PnNOS) or the impairment of its regulation by protein effectors (NMDA receptor, protein inhibitor of nNOS: PIN), occurring in the neuronal bodies or nerve terminals, or (b) a loss of the cells themselves by apoptosis caused by the induction of inducible NOS (iNOS) and the production of peroxynitrite. In contrast vasculogenic ED, although may involve endothelial damage and down-regulation of endothelial NOS (eNOS), appears to be mainly caused by the relative loss of smooth muscle cells and replacement by collagen fibers (fibrosis) that impairs tissue compliance. In this case, iNOS induction may not be deleterious, but a defense mechanism preventing excessive collagen deposition. Gene therapy to the penile corpora cavernosa of cDNAs expressing PnNOS or eNOS, or counteracting PIN, has been effective in ameliorating ED in the aging rat model that exhibits both neurogenic ED and CVOD. cDNA constructs for other genes involved in the control of penile erection have also been successfully tested. Gene transfer into the penis may soon translate to the clinic as a therapy aimed to cure the underlying conditions in ED, including fibrosis, as opposed to the facilitation of erection on demand offered by the current oral therapies.

Pergolide mesylate can improve sexual dysfunction in patients with Parkinson's disease: the results of an open, prospective, 6-month follow-up

One of the most disabling problems in males suffering from advanced Parkinson's disease (PD) is complex sexual dysfunction. The effect of dopamine replacement or dopaminergic stimulation on sexual dysfunction has been recently examined and described in patients treated by L-DOPA or apomorphine. Pergolide mesylate is another dopamine agonist with a known high affinity to hD(2S) subtype and a lower affinity to hD(2L) subtype of D2 dopaminergic receptors. It has been repeatedly shown to be a highly effective treatment of the complicated and advanced stages of PD. The current study has been designed to assess its efficacy in the treatment of sexual dysfunction, which frequently accompanies the complicated stage of PD in males. Fourteen male patients suffering from PD, each of whom had been treated with L-DOPA, and in whom additional treatment with peroral dopaminergic agonist (DA) was needed, were followed for a 6-month period. Pergolide mesylate (Permax) was given to each patient, and titrated to a total daily dose of 3 mg. All of the patients were taking L-DOPA. The assessments performed before the start of pergolide treatment consisted of a neurological examination, including Unified Parkinson's Disease Rating Scale (UPDRS) III and IV subscales scoring, Mini Mental State Examination (MMSE) scoring, the neuropsychological examination including Zung scale scoring to exclude depression, biochemical and haematological examinations including the examination of prolactine serum levels; and a sexological examination during which the patients filled-in the International Index of Erectile Function (IIEF) questionnaire. These examinations were repeated during the control assessments at months 1, 3 and 6. To compare the examination results, anova, Friedmann's anova (non-parametric) and Tukey post hoc tests were used. There were statistically significant differences between the values of UPDRS III motor subscale, UPDRS IV (complications of therapy) subscale and all subscales of IIEF when months 0 and 1 were compared with the results obtained at months 3 and 6. The differences between months 0 and 1 and months 3 and 6 (in these items) were virtually insignificant. In conclusion, pergolide substantially improved sexual function in the younger male patients who were still interested in sexual activities. In such cases, the introduction of pergolide might be a better choice than treatment with sildenafile, which usually meets several contraindications in common PD male population.

Causes of erectile dysfunction

Erectile dysfunction (ED) arises as a result of a collision of circumstances among any of a number of factors (e.g., risk factors, causes, probable associations), each with its own primary power to affect the outcome. Furthermore, each of the components has its own timing as part of a complex effort of compensation and adjustment that often obscures the individual details. In the end, ED results from a failure of local tissues or systemic supply and control structures. The power of any individual "cause" to degrade erectile function is an important but as-yet unquantified property. The power of a small abnormality over a long or critical period (e.g., organogenesis), or many small contributions, or multiple risk factors will certainly be greater than the sum of the individual elements. Without a full quantitation of pathways and their potential influence, one can compare the importance of causative factors only in limited ways. Not surprisingly, it is the presence of a multiplicity of unidentified or poorly understood causative factors that accounts in large measure for the current inability to cure and prevent ED. There are two other important properties of a putatively causative factor for ED--reversibility and preventability--and these are strongly influenced by the time of onset and the duration of impact. Thus, a critical understanding that comes from recognizing the importance of the temporal associations of component factors is that the causes of ED in an individual may be guessed at but cannot be fully disclosed by an analysis of a "snapshot" of the disease taken at the time of diagnosis.

Clinical Experience With Apomorphine Hydrochloride: The First 107 Patients

PURPOSE

We assessed the efficacy and safety of apomorphine hydrochloride in patients with erectile dysfunction.

MATERIALS AND METHODS

A total of 107 patients who had consultations because of erectile dysfunction between July and November 2001 were assessed. The sample was randomly selected.

RESULTS

Response to apomorphine hydrochloride was assessed in 107 patients complaining of erectile dysfunction, randomly selected at the office. With the 2 mg initial dose the response amounted to 23.5%, with 3 mg it amounted to 28.5% and the global response to the drug amounted to 26.1%. Positive response was obtained in 18.5% of those in whom the dose was increased from 2 to 3 mg. Obtaining an erection with enough rigidity to enable coitus satisfactory for the patient was accepted as a positive response. According to the clinical presentation of the erectile dysfunction, the highest efficacy was found in those cases with early detumescence, and the lowest one in those cases with complete affection. The overall incidence of adverse effects was 8.4%, with nausea being the most frequently reported.

CONCLUSIONS

Apomorphine hydrochloride is the first central action erection inducing drug. Its use is encouraged by high tolerability, low rate of adverse effects and virtually nonexistent interaction with other drugs usually administered to patients with erectile dysfunction.

Neuroprotective, anti-apoptotic effects of apomorphine

There is increasing experimental and clinical evidence that oxidation plays a pivotal role in causing neurodegeneration in general and Parkinson's disease in particular. The protective role of antioxidants in such conditions has not been fully examined, but certain neuroprotective agents that have antioxidant action are now being credited with an ability to prevent oxidation-induced neuronal dysfunction. One such agent is the dopamine agonist apomorphine, which is already in clinical use, providing symptomatic relief in Parkinson's disease patients. Far from having simple antioxidants properties, apomorphine is described as a pluripotent agent that can also afford neuroprotection through mechanisms independent of its antioxidant actions. It can, for example, salvage dopaminergic receptors and terminals, upregulate expression of neurotrophic factors, limit the rate of neuronal loss by interfering with several steps of apoptotic cascades, reduce excitotoxicity by modulating nitric oxide metabolism, and reverse ubiquitine-proteasome dependent pathology. This paper reviews the wide range of apomorphine's neuroprotective benefits, suggesting that it is a promising agent with regards to its potential to prevent, reduce, and retard age-related neurodegeneration.

Herb use in critical care: what to watch for

The use of herbal remedies for well-being and treatment of illness has occurred for thousands of years. Although herbal remedies frequently are misconceptually considered to be safe because they are natural, herbal medicines can cause severe or toxic effects if not used appropriately. This article discusses implications that healthcare providers need to consider when patients are admitted to critical care units due to herbal interactions or when patients and families request to maintain patients' herbal regimens during a critical illness.