The medical letter on drugs and therapeutics may 12 2014

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On Drugs and Therapeutics
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IN THIS ISSUE (starts on next page)

Avanafil (Stendra) — Another PDE5 Inhibitor for Erectile Dysfunction .... p 37
Drugs for MRSA Skin and Soft-Tissue Infections ......................................... p 39

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The Medical Letter

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On Drugs and Therapeutics
Published by The Medical Letter, Inc. • 145 Huguenot Street, New Rochelle, NY 10801 • A Nonprofit Publication
Volume 56 (Issue 1442)
May 12, 2014

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Take CME Exams

ALSO IN THIS ISSUE

Table 1. Pharmacology

Drugs for MRSA Skin and Soft-Tissue
Infections.......................................................p 39

Drug class
Route
Formulation
Tmax

Avanafil (Stendra) — Another PDE5
Inhibitor for Erectile Dysfunction

Metabolism

The FDA has approved avanafil (Stendra – Vivus),
an oral phosphodiesterase type-5 (PDE5) inhibitor,

for treatment of erectile dysfunction. It is the fifth
PDE5 inhibitor to be approved for this indication.1
Advertisements on Stendra’s website imply that
it has a faster onset of action than other PDE5
inhibitors.
PDE5 INHIBITORS — There is no convincing
evidence that any one PDE5 inhibitor is safer or
more effective than any other. Their efficacy varies
with the etiology of the erectile dysfunction, but
in placebo-controlled trials in men with various
etiologies, they generally have had an efficacy rate
of 60-70%.2 The PDE5 inhibitors all have similar
onsets of action, but tadalafil has a much longer
duration of action than the other three.1

Elimination
Half-life

Phosphodiesterase type-5 (PDE5) inhibitor
Oral
50, 100, 200 mg tablets
30-45 minutes (delayed 1.12-1.25 hours with a
high-fat meal)
Hepatic, mainly by CYP3A4 and to a lesser extent by
CYP2C
Feces (~62%); urine (~21%)
~5 hours

MECHANISM OF ACTION — Avanafil is a selective
inhibitor of PDE5. Inhibition of PDE5 causes an

increase in cGMP levels in the corpus cavernosum,
which leads to smooth muscle relaxation and inflow
of blood.
CLINICAL STUDIES — A randomized, doubleblind trial in 646 men with mild to severe erectile
dysfunction of various etiologies found that over
a 12-week period the percentages of successful
attempts at sexual intercourse were higher in men
taking avanafil (41% with avanafil 50 mg and 57%
with avanafil 100 mg and 200 mg) than in those
taking placebo (27%). In a post-hoc analysis of
300 sexual attempts made within 15 minutes of
dosing, 64-71% of attempts with avanafil were

Table 2. PDE5 Inhibitors for Erectile Dysfunction
Drug
Avanafil – Stendra (Vivus)
3

Maximum
Daily Dose

Formulations

Usual Dosage

50, 100, 200 mg tabs

100 mg 30 minutes before sexual activity2
2,4

Cost1

200 mg

$24.20

Sildenafil – Viagra (Pfizer)

25, 50, 100 mg tabs

50 mg 1 hour before sexual activity

100 mg

28.40

Tadalafil5 – Cialis (Lilly)

2.5, 5, 10, 20 mg tabs

PRN use: 10 mg at least 30 minutes before
sexual activity
Daily use: 2.5 mg once daily

20 mg

31.70

5 mg

5.40

Vardenafil – Levitra6
(Bayer/GSK)
Staxyn6
(Bayer/GSK)

2.5, 5, 10, 20 mg tabs

10 mg 1 hour before sexual activity2,7

20 mg

27.80

10 mg orally
disintegrating tabs

10 mg 1 hour before sexual activity

10 mg

17.30

1. Approximate wholesale acquisition cost (WAC) of a single tablet at the usual dose. Source: Analy$ource® Monthly (Selected from FDB MedKnowledge™) May 5,
2014. Reprinted with permission by FDB, Inc. All rights reserved. ©2014. www.fdbhealth.com/policies/drug-pricing-policy. Actual retail prices may be higher.
Administration with a high-fat meal may reduce the rate and/or extent of absorption.
Also available as Revatio and generically in 20-mg tablets for treatment of pulmonary arterial hypertension.
Can be taken from 30 minutes to 4 hours before sexual activity. For patients >65 yrs old, the initial dose is 25 mg.
Also available as Adcirca in 20-mg tablets for treatment of pulmonary arterial hypertension.

Staxyn and Levitra are not interchangeable. Staxyn provides higher systemic exposure than a 10-mg tablet of Levitra.
For patients >65 years old, the initial dose is 5 mg.

2.
3.
4.
5.
6.
7.

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37


Table 3. PDE5 Inhibitors in Special Populations
Avanafil (Stendra)
Hepatic impairment, severe
Renal impairment, severe or HD
With an alpha blocker1
With a strong CYP3A4 inhibitor2
With a moderate CYP3A4 inhibitor2

Use not recommended
Use not recommended
Initial dose 50 mg
Use not recommended
Max 50 mg/d

Sildenafil (Viagra)

Hepatic impairment
Renal impairment,
CrCl <30 mL/min
With an alpha blocker1
With a strong CYP3A4 inhibitor2,3

Initial dose 25 mg
Initial dose 25 mg
Initial dose 25 mg
Initial dose 25 mg4

Tadalafil (Cialis)
PRN Use:
Hepatic impairment,
mild or moderate
severe
Renal impairment,
CrCl 30-50 mL/min
CrCl <30 mL/min or HD
With an alpha blocker1
With a strong CYP3A4 inhibitor2
Daily Use:
Hepatic impairment,
mild or moderate
severe
Renal impairment,
CrCl <30 mL/min or HD
With an alpha blocker1
With a strong CYP3A4 inhibitor2

Max 10 mg/d
Use not recommended
Initial 5 mg once/d, max
10 mg q48h
Max 5 mg q72h
Initiate at lowest dose
Max 10 mg q72h

Use with caution
Use not recommended
Use not recommended
Initiate at lowest dose
Max 2.5 mg/d

Vardenafil (Levitra)
Hepatic impairment,
moderate
severe
HD
With an alpha blocker1
With a strong or moderate
CYP3A4 inhibitor2

Initial dose 5 mg,
max 10 mg/d
Use not recommended
Use not recommended
Initial dose 5 mg
Max 2.5 or 5 mg/d5

Vardenafil (Staxyn)
Hepatic impairment,
moderate or severe
HD
With an alpha blocker1
With a strong or moderate
CYP3A4 inhibitor2

Use not recommended
Use not recommended
Use not recommended6
Use not recommended

HD = Hemodialysis
1. When a PDE5 inhibitor is coadministered with an alpha blocker, the patient
should be on stable alpha-blocker therapy before starting the PDE5 inhibitor.
2. Inhibitors and inducers of CYP enzymes and P-glycoprotein. Med Lett Drugs
Ther 2013; 55:e44.
3. Or erythromycin, a moderate CYP3A4 inhibitor.
4. In patients taking ritonavir, maximum dose is 25 mg every 48 hours.
5. Depending on which strong or moderate CYP3A4 inhibitor is used
concomitantly. In patients taking ritonavir, maximum dose is 2.5 mg every
72 hours.
6. Not recommended for initial PDE5 inhibitor therapy in patients taking an
alpha blocker. A lower dose of Levitra should be used initially.

successful, compared to 27% of those with
placebo.3
In a randomized, double-blind 12-week trial in
390 patients with type 1 or 2 diabetes and erectile

dysfunction, the percentage of attempts that resulted

38

in successful intercourse was 34.4% in patients taking avanafil 100 mg, 40.0% in those taking 200 mg,
and 20.5% in those taking placebo.4
Avanafil has also improved erectile dysfunction
following nerve-sparing radical prostatectomy.5
ADVERSE EFFECTS — Headache, flushing, and
back pain were the most common adverse effects of
avanafil in clinical trials. Acute hearing loss, with or
without tinnitus or dizziness, has been reported with
PDE5 inhibitors, but a cause-and-effect relationship
has not been established.
Visual effects, particularly bluish discoloration of
vision, have been reported rarely with all PDE5
inhibitors, including avanafil. Nonarteritic anterior
ischemic optic neuropathy (NAION) has also been
associated rarely with use of a PDE5 inhibitor.
DRUG INTERACTIONS — Like the other PDE5
inhibitors, avanafil is metabolized by CYP3A4.
Inhibitors of CYP3A4 can markedly increase
avanafil concentrations. All PDE5 inhibitors can
increase the hypotensive effects of organic nitrates
such as nitroglycerin and are contraindicated in
patients taking nitrates. They may also potentiate
the antihypertensive effects of alpha blockers, other
antihypertensives, and alcohol.
DOSAGE AND ADMINISTRATION — Avanafil should
be taken as needed about 30 minutes before sexual

activity, but not more than once a day. The drug can be
taken with or without food, but taking it with a high-fat
meal may delay its absorption. The initial dose is 100
mg; the dose may be increased to 200 mg or reduced
to 50 mg based on efficacy and tolerability. Dosage
adjustments for patients also taking an alpha blocker or
a CYP3A4 inhibitor are listed in Table 3.
CONCLUSION — Avanafil (Stendra), like the other
available PDE5 inhibitors, is effective in treating erectile
dysfunction of various etiologies. No head-to-head trials
comparing the efficacy, safety, and speed of onset of
avanafil with those of other PDE5 inhibitors are available. □
1. PDE5 inhibitors for erectile dysfunction revisited. Med Lett Drugs
Ther 2012; 54:10.
2. R Bruzziches et al. An update on pharmacological treatment of
erectile dysfunction with phosphodiesterase type 5 inhibitors. Expert Opin Pharmacother 2013; 14:1333.
3. I Goldstein et al. A randomized, double-blind, placebo-controlled
evaluation of the safety and efficacy of avanafil in subjects with
erectile dysfunction. J Sex Med 2012; 9:1122.
4. I Goldstein et al. Avanafil for the treatment of erectile dysfunction:
a multicenter, randomized, double-blind study in men with diabetes
mellitus. Mayo Clin Proc 2012; 87:843.
5. JP Mulhall et al. A phase 3, placebo-controlled study of the safety
and efficacy of avanafil for the treatment of erectile dysfunction
after nerve-sparing prostatectomy. J Urol 2013; 189:2229.

The Medical Letter • Volume 56 • Issue 1442 • May 12, 2014


Read an updated version of this article by clicking here.

Drugs for MRSA Skin and Soft-Tissue
Infections
Methicillin-resistant Staphylococcus aureus (MRSA),
which was traditionally a nosocomially-acquired
organism but now frequently occurs in the absence
of healthcare exposure, is the predominant cause of
suppurative skin and soft-tissue infections in many parts
of the US.1,2 Community-associated MRSA usually
causes furunculosis, purulent cellulitis, and abscesses,
but necrotizing fasciitis, necrotizing pneumonia, and
sepsis can also occur.
ANTIMICROBIAL SUSCEPTIBILITY — Communityassociated MRSA strains have been susceptible in
vitro to vancomycin, daptomycin, and linezolid, and
usually to clindamycin, trimethoprim/sulfamethoxazole
(TMP/SMX), and tetracyclines.3 Nosocomial strains of
MRSA are often resistant to clindamycin, tetracyclines,
and TMP/SMX. Resistance to uoroquinolones is
common and is increasing in both nosocomial and
community settings.
DRUGS FOR MRSA — Clindamycin – Clindamycin
has the potential advantage over other antimicrobials
of inhibiting bacterial toxin production, but it may
be more likely than other antimicrobials to cause
Clostridium difficile enterocolitis. It should not be used if
the erythromycin-clindamycin D-zone test for inducible
clindamycin resistance is positive.
TMP/SMX – In adequate doses, TMP/SMX appears to
be effective against community-associated MRSA, and
resistance has been rare.

Tetracyclines – Minocycline and doxycycline have
greater antistaphylococcal activity than other oral
tetracyclines and have been effective clinically for
treatment of community-associated MRSA skin and
soft-tissue infections.
Linezolid – Even though it is not bactericidal against
staphylococci, linezolid appears to be as effective as
vancomycin for serious MRSA infections. It may have
the advantage over vancomycin of inhibiting bacterial
toxin production.
Vancomycin – Despite increasing reports of clinical
failures, IV vancomycin is generally still the drug of
choice for hospitalized patients with complicated MRSA
skin and soft-tissue infections. Vancomycin-resistant
MRSA isolates have been reported rarely.4
Daptomycin – Only available parenterally, daptomycin
is bactericidal for MRSA in vitro and appears to be as
effective as vancomycin for treatment of MRSA skin
and soft-tissue infections.

Ceftaroline fosamil – A broad-spectrum parenteral
cephalosporin, ceftaroline is effective in treating MRSA
skin and skin structure infections. It is the rst betalactam approved by the FDA for such use.5
Telavancin – A lipoglycopeptide derivative of vancomycin, parenteral telavancin appears to be as effective
as vancomycin in treating MRSA skin infections, but it
causes more adverse effects.
Tigecycline – A broad-spectrum parenteral derivative
of minocycline, tigecycline is active against MRSA,
but the FDA has warned about an increased risk of
death associated with its use for treatment of serious

infections, including skin and skin structure infections.6
Fluoroquinolones – Most healthcare-associated
MRSA strains are resistant to uoroquinolones.
Community-associated MRSA may be susceptible to
uoroquinolones in vitro, but resistance can emerge
during treatment.
New Drugs – Two new drugs, dalbavancin and tedizolid,
are currently being considered for approval by the FDA
for treatment of acute bacterial skin and skin structure
infections. They will be reviewed in a future issue.
RECOMMENDATIONS — For small simple abscesses
and other less serious MRSA skin and soft-tissue
infections, incision and drainage alone is usually
effective.7 When it is not, oral TMP/SMX, minocycline,
doxycycline, clindamycin, or linezolid is recommended.8
Table 1. Oral Drugs for MRSA Skin and Soft-Tissue
Infections1
Usual Dosage2

Cost3

Clindamycin4 – generic

300-450 mg q8h5

$43.10

Doxycycline6 – generic
Vibramycin (P zer)

100 mg q12h7

61.90
120.20

Linezolid – Zyvox
(P zer)

600 mg q12h8

2560.40

Minocycline6 – generic
Minocin (Onset
Dermatologics)

200 mg x 1, then
100 mg q12h9

TMP/SMX – generic
Bactrim DS (AR Scienti c)

1-2 DS tablets q12h10

Drug

31.20
246.20
1.10
52.00

TMP/SMX = Trimethoprim/sulfamethoxazole
1. If coverage for both MRSA and ß-hemolytic streptococci is desired, a ß-lactam
(e.g., amoxicillin) should be added to TMP/SMX, minocycline, or doxycycline.
2. Five to 10 days of treatment is recommended. Dosage adjustment may be
needed for renal or hepatic impairment.
3. Approximate wholesale acquisition cost (WAC) for 10 days’ oral treatment with
the lowest daily dosage. Source: Analy$ource® Monthly (Selected from FDB
MedKnowledge™) May 5, 2014. Reprinted with permission by FDB, Inc. All
rights reserved. ©2014. www.fdbhealth.com/policies/drug-pricing-policy. Actual
retail prices may be higher.
4. Clindamycin should not be used if the erythromycin-clindamycin D-zone test for
inducible resistance is positive.
5. Pediatric dosage is 10-13 mg/kg q6-8h.
6. Not recommended for children <8 years old.
7. Dosage for children ≥8 years old is 2 mg/kg q12h.
8. Dosage for children ≥12 years old is 10 mg/kg q12h and for those <12 years old
is 10 mg/kg q8h.
9. Dosage for children ≥8 years old is 4 mg/kg x1, then 2 mg/kg q12h.
10. Pediatric dosage is 4-6 mg/kg TMP q12h.

The Medical Letter • Volume 56 • Issue 1442 • May 12, 2014

39


Table 2. Some IV Drugs for MRSA Skin and SoftTissue Infections
Drug

Usual Dosage1

Ceftaroline fosamil –
Teflaro (Forest)

600 mg q12h3

Cost2
$126.30

3

Daptomycin –
Cubicin (Cubist)

4 mg/kg q24h

Linezolid –
Zyvox (Pfizer)

600 mg q12h4

Telavancin –
Vibativ (Theravance)

10 mg/kg q24h3

Tigecycline5 –
Tygacil (Pfizer)

100 mg x 1, then

50 mg q12h3

Vancomycin – generic

15-20 mg/kg (max 2 g)
q8-12h6

Coming Soon in Treatment Guidelines:
Adult Immunizations

336.20
263.40

The Medical Letter

®

299.00
191.20
17.80

1. A total of 7-14 days’ treatment (IV followed by PO) is recommended. Dosage
adjustment may be needed for renal or hepatic impairment.
2. Approximate wholesale acquisition cost (WAC) for 1 day’s treatment of a 70kg patient with the lowest dosage. Source: Analy$ource® Monthly (Selected
from FDB MedKnowledge™) May 5, 2014. Reprinted with permission by FDB,
Inc. All rights reserved. ©2014. www.fdbhealth.com/policies/drug-pricingpolicy. Actual retail prices may be higher.
3. Not FDA-approved for use in children.
4. Dosage for children <12 years old is 10 mg/kg q8h and for those >12 years
old is 10 mg/kg q12h.
5. May be associated with an increased risk of death when used to treat serious

infections. Other antibiotics are preferred.
6. Initial pediatric dose is 15 mg/kg q6h.

Patients with more complicated skin and soft-tissue
infections suspected to be caused by MRSA should be
treated empirically with IV vancomycin. Parenteral linezolid,
daptomycin, and ceftaroline fosamil are alternatives.3,8
CONCLUSION — Patients with complicated MRSA skin
and soft-tissue infections should be hospitalized and
treated with intravenous vancomycin. For less serious
community-associated MRSA skin or soft-tissue infections,
incision and drainage alone may be effective. When it is not,
use of oral trimethoprim/sulfamethoxazole, minocycline,
doxycycline, or clindamycin is usually recommended.
Linezolid is an expensive alternative. □
1. DA Talan et al. Comparison of Staphylococcus aureus from skin
and soft-tissue infections in US emergency department patients,
2004 and 2008. Clin Infect Dis 2011; 53:144.
2. R Dantes et al. National burden of invasive methicillin-resistant
Staphylococcus aureus infections, United States, 2011. JAMA Intern Med 2013; 173:1970.
3. Drugs for bacterial infections. Treat Guidel Med Lett 2013; 11:65.
4. F Rossi et al. Transferable vancomycin resistance in a communityassociated MRSA lineage. N Engl J Med 2014; 370:1524.
5. Ceftaroline fosamil (Teflaro) - a new IV cephalosporin. Med Lett
Drugs Ther 2011; 53:5.
6. FDA Drug Safety Communication: FDA warns of increased risk
of death with IV antibacterial Tygacil (tigecycline) and approves
new boxed warning. Available at www.fda.gov/drugs/drugsafety/
ucm369580.htm. Accessed May 5, 2014.
7. AJ Singer and DA Talan. Management of skin abscesses in the era
of methicillin-resistant Staphylococcus aureus. N Engl J Med 2014;

370:1039.
8. C Liu et al. Clinical practice guidelines by the Infectious Diseases
Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children: executive summary. Clin Infect Dis 2011; 52:285.

40

Coming Soon in The Medical Letter:
Esomeprazole Strontium for GERD
Apremilast (Otezla) for Psoriatic Arthritis
Eslicarbazepine (Aptiom) for Epilepsy

On Drugs and Therapeutics
EDITOR IN CHIEF: Mark Abramowicz, M.D.
EXECUTIVE EDITOR: Gianna Zuccotti, M.D., M.P.H., F.A.C.P., Harvard Medical School
EDITOR: Jean-Marie Pflomm, Pharm.D.
ASSISTANT EDITORS, DRUG INFORMATION: Susan M. Daron, Pharm.D.,
Corinne Z. Morrison, Pharm.D., Michael P. Viscusi, Pharm.D.
CONSULTING EDITORS: Brinda M. Shah, Pharm.D., F. Peter Swanson, M.D.
CONTRIBUTING EDITORS:
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Vanessa K. Dalton, M.D., M.P.H., University of Michigan Medical School
Eric J. Epstein, M.D., Albert Einstein College of Medicine
Jane P. Gagliardi, M.D., M.H.S., F.A.C.P Duke University School of Medicine
Jules Hirsch, M.D., Rockefeller University
David N. Juurlink, BPhm, M.D., Ph.D., Sunnybrook Health Sciences Centre
Richard B. Kim, M.D., University of Western Ontario
Hans Meinertz, M.D., University Hospital, Copenhagen
Sandip K. Mukherjee, M.D., F.A.C.C., Yale School of Medicine
Dan M. Roden, M.D., Vanderbilt University School of Medicine
Esperance A.K. Schaefer, M.D., M.P.H., Harvard Medical School

F. Estelle R. Simons, M.D., University of Manitoba
Neal H. Steigbigel, M.D., New York University School of Medicine
Arthur M. F. Yee, M.D., Ph.D., F.A.C.R., Weill Medical College of Cornell University
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The Medical Letter • Volume 56 • Issue 1442 • May 12, 2014


The Medical Letter

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To take CME exams and earn credit, go to:

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Issue 1442 Questions
(Correspond to questions #55-60 in
Comprehensive Exam #70, available July 2014)
Avanafil (Stendra) — Another PDE5 Inhibitor for Erectile Dysfunction
1.

Compared to the other available PDE5 inhibitors for treatment of
erectile dysfunction, avanafil:
a. is more effective
b. causes fewer serious adverse effects
c. has a longer duration of action
d. none of the above

2.

A 62-year-old man comes into your office and tells you that he has seen
ads on TV that have convinced him he should start taking Stendra for
erectile dysfunction. His current medications are prazosin for urinary
symptoms of prostate enlargement and metoprolol for hypertension.
Before you give him a prescription for Stendra, you should tell him that:
a. taking Stendra with prazosin might cause a drop in
blood pressure
b. taking Stendra with metoprolol might cause a drop in
blood pressure
c. you would recommend a starting dose of 50 mg of Stendra
d. all of the above

3.

In the clinical study in men with erectile dysfunction due to various
etiologies, the percentage of successful sexual attempts in men taking
avanafil 100 mg was:
a. about 20%
b. about 40%
c. about 60%
d. about 80%

Drugs for MRSA Skin and Soft-Tissue Infections
4.

Which of the following could be used for empiric outpatient treatment
of skin and soft tissue infections caused by methicillin-resistant
Staphylococcus aureus?
a. linezolid
b. clindamycin
c. doxycycline
d. all of the above

5.

A 43-year-old woman was admitted to the hospital with a serious
suppurative skin and soft-tissue infection that progressed on
dicloxacillin as an outpatient. Which of the following would be the
best antibiotic choice in this patient?
a. IV tigecycline
b. PO tetracycline
c. IV vancomycin
d. PO clindamycin

6.

Which of the following is not recommended for treatment of MRSA skin and
soft-tissue infections because of resistance?
a. telavancin
b. ciprofloxacin
c. linezolid
d. trimethoprim/sulfamethoxazole

ACPE UPN: Per Issue Exam: 0379-0000-14-442-H01-P; Release: May 12, 2014, Expire: May 12, 2015
Comprehensive Exam 70: 0379-0000-14-070-H01-P; Release: July 2014, Expire: July 2015

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(0.1 CEU). The comprehensive exam is acceptable for 13.0 hour(s) of knowledge-based continuing education
credit (1.3 CEU).
The American Academy of Nurse Practitioners (AANP) and the American Academy of Physician Assistants
(AAPA) accept AMA Category 1 credit for the Physician’s Recognition Award from organizations accredited by the
ACCME.
This activity, being ACCME (AMA) approved, is acceptable for Category 2-B credit by the American Osteopathic
Association (AOA).
Physician Assistants: The National Commission on Certification of Physician Assistants (NCCPA) accepts AMA
PRA Category 1 Credit(s)™ from organizations accredited by ACCME. NCCPA also accepts AAFP Prescribed credits
for recertification. The Medical Letter is accredited by both ACCME and AAFP.
Physicians in Canada: Members of The College of Family Physicians of Canada are eligible to receive Mainpro-M1
credits (equivalent to AAFP Prescribed credits) as per our reciprocal agreement with the American Academy of Family
Physicians.
Physicians, nurse practitioners, pharmacists, and physician assistants may earn 1 credit with this exam.
MISSION:

The mission of The Medical Letter’s Continuing Medical Education Program is to support the professional development
of healthcare professionals including physicians, nurse practitioners, pharmacists, and physician assistants by providing
independent, unbiased drug information and prescribing recommendations that are free of industry influence. The program
content includes current information and unbiased reviews of FDA-approved and off-label uses of drugs, their mechanisms
of action, clinical trials, dosage and administration, adverse effects, and drug interactions. The Medical Letter delivers
educational content in the form of self-study material.
The expected outcome of the CME Program is to increase the participant’s ability to know, or apply knowledge into
practice after assimilating, information presented in materials contained in The Medical Letter.
The Medical Letter will strive to continually improve the CME program through periodic assessment of the program and
activities. The Medical Letter aims to be a leader in supporting the professional development of healthcare professionals
through Core Competencies by providing continuing medical education that is unbiased and free of industry influence.
The Medical Letter is supported solely by subscription fees and accepts no advertising, grants, or donations.
GOAL:
Through this program, The Medical Letter expects to provide the healthcare community with unbiased, reliable, and
timely educational content that they will use to make independent and informed therapeutic choices in their practice.
LEARNING OBJECTIVES:
Activity participants will read and assimilate unbiased reviews of FDA-approved and off-label uses of drugs and
other treatment modalities. Activity participants will be able to select and prescribe, or confirm the appropriateness
of the prescribed usage of, the drugs and other therapeutic modalities discussed in The Medical Letter with specific
attention to clinical trials, pathophysiology, dosage and administration, drug metabolism and interactions, and patient
management. Activity participants will make independent and informed therapeutic choices in their practice.
Upon completion of this program, the participant will be able to:
1. Review the efficacy and safety of avanafil (Stendra) for treatment of erectile dysfunction.
2. Discuss the treatment of skin and soft-tissue infections caused by methicillin-resistant Staphylococcus aureus.
Privacy and Confidentiality: The Medical Letter guarantees our firm commitment to your privacy. We do not sell any
of your information. Secure server software (SSL) is used for commerce transactions through VeriSign, Inc. No credit
card information is stored.
IT Requirements: IT Requirements: Windows XP/Vista/7/8, Mac OS X+; current versions of Microsoft IE, Mozilla
Firefox, Google Chrome, Safari or any other compatible Web browser. High-speed connection.
Have any questions? Call us at 800-211-2769 or 914-235-0500 or e-mail us at: