A 58-year-old man comes to the emergency department due to a persistent, painful erection that has lasted 8 hours. His other medical conditions include ulcerative colitis, kidney stones, depression, insomnia, hypertension, drug-induced diabetes, obesity, and hypercholesterolemia. The patient does not use tobacco, alcohol, or recreational drugs. He takes prednisone, mesalamine, mirtazapine, insulin, trazodone, 6-mercaptopurine, simvastatin, glyburide, and enalapril. He has no known drug allergies. Vital signs are stable. Examination confirms the patient's chief complaint but is otherwise unremarkable. Which of the following medications is the most likely cause of his condition?

Question

A 58-year-old man comes to the emergency department due to a persistent, painful erection that has lasted 8 hours.  His other medical conditions include ulcerative colitis, kidney stones, depression, insomnia, hypertension, drug-induced diabetes, obesity, and hypercholesterolemia.  The patient does not use tobacco, alcohol, or recreational drugs.  He takes prednisone, mesalamine, mirtazapine, insulin, trazodone, 6-mercaptopurine, simvastatin, glyburide, and enalapril.  He has no known drug allergies.  Vital signs are stable.  Examination confirms the patient's chief complaint but is otherwise unremarkable.  Which of the following medications is the most likely cause of his condition?

Quizplus · Accepted Answer

Explanation: Trazodone is a serotonin-modulating antidepressant that is sometimes used off-label in the treatment of insomnia. Priapism is a potentially serious side effect of trazodone that occurs at a rate of <1%. Priapism is defined as a persistent, painful erection that develops without sexual stimulation and has a long duration. It is a medical emergency and requires urgent medical intervention to achieve detumescence and prevent permanent tissue damage. Priapism is often idiopathic (primary). Secondary causes include: Medications: Alpha-1 antagonists (eg, prazosin), some antidepressants (eg, trazodone, selective serotonin reuptake inhibitors), phosphodiesterase inhibitors (eg, sildenafil), stimulants (eg, methylphenidate, cocaine) Medical conditions: Sickle cell disease, leukemia Surgery: Perineal or genital trauma Neurogenic lesions: Cauda equina syndrome (Choice A) 6-mercaptopurine is an immunosuppressant sometimes used in the treatment of autoimmune conditions (eg, ulcerative colitis). Its use is associated with gastrointestinal upset, rash, and malaise but not priapism. (Choice B) Enalapril is an antihypertensive ACE inhibitor that has been associated with impotence but not priapism. (Choice C) Glyburide is a sulfonylurea used in the treatment of diabetes mellitus but is not associated with priapism. (Choice D) Mirtazapine is an alpha-2 antagonist atypical antidepressant used to treat depression. Mirtazapine has not been associated with priapism. (Choice E) Prednisone is a steroid commonly used as an immunosuppressant in autoimmune conditions (eg, ulcerative colitis). Prolonged use of steroids may lead to the development of drug-induced diabetes mellitus, as seen in this patient. Priapism is not associated with prednisone. (Choice F) Simvastatin is used in the treatment of hypercholesterolemia but is not associated with priapism. Educational objective: Priapism refers to an unwanted, persistent, and often painful erection that constitutes a medical emergency. Certain medications (eg, trazodone, prazosin) and medical conditions (eg, sickle cell disease, perineal trauma) may precipitate priapism. References: Off-label trazodone prescription: Evidence, benefits and risks. (http://www.ncbi.nlm.nih.gov/pubmed/26088119) Trazodone for insomnia: A systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/29552421)

A 58-Year-Old Man Comes to the Emergency Department Due to a Persistent