AAFP Endorses ACP Clinical Guideline for Treatment of ED

The Academy has endorsed a clinical practice guideline on the appropriate diagnosis and treatment of erectile dysfunction (scroll down to the list of AAFP-endorsed guidelines), or ED, that was developed by the American College of Physicians, or ACP. Among the chief recommendations included in the guideline is that physicians should consider initiating phosphodiesterase-5, or PDE-5, inhibitor therapy in men who seek treatment for ED and have no contraindications to PDE-5 inhibitor use.

The ED guideline endorsement is the latest completed since the AAFP Board of Directors approved a process for endorsing clinical practice guidelines developed by external organizations in February 2009.

Defined as the inability to achieve or maintain penile erection for sexual performance, ED affected more than 152 million men worldwide in 1995, according to the ACP. By 2025, it is predicted that 322 million men worldwide will have experienced ED. The condition affects all age groups but is particularly common among men who are older and/or have diabetes, vascular disease, mental disorders or hypogonadism.

It's a problem frequently seen -- and managed -- by family physicians, according to Valerie King, M.D., M.P.H., of Portland, Ore., chair of the Commission on Health of the Public and Science's Subcommittee on Clinical Practice Guidelines.

"ED is a common problem, but there is a lot of advertising and promotion of both drugs and hormonal testing," she told AAFP News Now. "We felt that this topic was one where a good evidence-based guideline would be particularly useful to our membership."

Current pharmacologic therapies available for the treatment of ED are PDE-5 inhibitors and hormonal treatment. Use of PDE-5 inhibitors has shown clinical benefit in treating ED, regardless of its cause or severity. Current PDE-5 inhibitors include sildenafil, vardenafil, tadalafil, mirodenafil and udenafil.

Based on an evidence report (770-page PDF; About PDFs) developed by the University of Ottawa Evidence-based Practice Center for the Agency for Healthcare Research, as well as a systematic review and meta-analysis (22-page PDF) published in the Annals of Internal Medicine, the guideline recommends initiating therapy with a PDE-5 inhibitor in men seeking treatment for ED who do not have a contraindication to PDE-5 inhibitor use. In addition, the guideline recommends basing the choice of a specific PDE-5 inhibitor on individual patient preferences, including ease of use, cost and side effects. The document does not advise for or against the use of hormonal treatment for ED because of insufficient evidence.

According to Michelle Jeffcott-Pera, senior clinical sciences assistant in the AAFP Health of the Public and Science Division, the Academy's endorsement decision comes only after a rigorous review process designed to ensure the guideline complies with the AAFP's evidence-based approach to all clinical recommendations.

"Prior to February 2009, the AAFP endorsed a guideline only if a representative of the AAFP participated in the development of the guideline by being on the panel," Jeffcott-Pera told AAFP News Now. "However, the Commission on Health of the Public and Science realized that it could be beneficial to members for us to review guidelines relevant to family medicine and rate them according to a priori criteria even if we were not involved in the guideline development."

The process of reviewing and approving guidelines can be lengthy, taking anywhere from three to nine months to complete, according to Jeffcott-Pera.

"The subcommittee regularly examines a list of published guidelines and prioritizes the topics they believe to be of higher relevance and importance in family medicine," she explained. "Staff (members) then solicit reviewers for guidelines, beginning with the guideline that has been rated the most important."

At least three family physician reviewers well-versed in evidence-based medicine, one of whom is a member of the commission, are selected to read and evaluate the guideline selected. Each reviewer is asked to rate various aspects of the guideline (5-page PDF; About PDFs) as "good," "fair" or "poor" according to numerous criteria and come up with a recommendation -- to endorse, endorse with reservations or not endorse the guideline --based on those ratings.

Only after an extensive process of reaching agreement on a course of action among the reviewers and the subcommittee, followed, in turn, by securing the commission's thumbs-up, is a recommendation forwarded for approval by the AAFP Board. If approved, the guideline is published on the AAFP website as either endorsed as Academy policy, endorsed with reservations or not endorsed.

As for what Academy members can expect from this work going forward: "This is a time-consuming process, and so we are fairly judicious about the number of guidelines we take on for rating," King explained. "I would estimate that with current resources, we are able to evaluate 8-12 guidelines per year at the most."

The entire process sprang largely from AAFP members' comments that they didn't always know when a newly released guideline merited their attention, according to King. "They also said they felt that they were often being asked to adhere to poor-quality guidelines and wanted the AAFP to help them by specifically giving guidelines a 'not endorsed' rating, as well as by endorsing good-quality, applicable guidelines for their use."

For those reasons, "we would really like to hear from the membership about this new service," King noted. "Feedback about specific guidelines, nominations for guidelines members would like us to evaluate and any other comments can be directed to the subcommittee."