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Evaluation of erectile dysfunction and BPH should include an appropriate medical assessment and to identify potential underlying causes, as well as treatment options.
Before prescribing Tadalafil (Cialis), it is important to note the following: Cardiovascular: Physicians should consider the cardiovascular status of their patients, since there is a degree of cardiac risk associated with sexual activity. Therefore, treatments for erectile dysfunction, including Tadalafil (Cialis) should not be used in men for whom sexual activity is inadvisable as a result of their underlying cardiovascular status. Patients who experience symptoms upon initiation of sexual activity should be advised to refrain from further sexual activity and seek immediate medical attention.
Physicians should discuss with patients the appropriate action in the event that they experience anginal chest pain requiring nitroglycerin following intake of Tadalafil (Cialis). In such a patient, who has taken Tadalafil (Cialis), where nitrate administration is deemed medically necessary for a life-threatening situation, at least 48 hours should have elapsed after the last dose of Tadalafil (Cialis) before nitrate administration is considered. In such circumstances, nitrates should still only be administered under close medical supervision with appropriate hemodynamic monitoring. Therefore, patients who experience anginal chest pain after taking Tadalafil (Cialis) should seek immediate medical attention (see Contraindications).
Patients with left ventricular outflow obstruction, (e.g., aortic stenosis and idiopathic hypertrophic subaortic stenosis) can be sensitive to the action of vasodilators, including PDE5 inhibitors.
The following groups of patients with cardiovascular disease were not included in clinical safety and efficacy trials for Tadalafil (Cialis), and therefore until further information is available, Tadalafil (Cialis) is not recommended for the following groups of patients: myocardial infarction within the last 90 days; unstable angina or angina occurring during sexual intercourse; New York Heart Association Class 2 or greater heart failure in the last 6 months; uncontrolled arrhythmias, hypotension (<90/50 mmHg), or uncontrolled hypertension; stroke within the last 6 months.
As with other PDE5 inhibitors, tadalafil has mild systemic vasodilatory properties that may result in transient decreases in blood pressure. In a clinical pharmacology study, tadalafil 20 mg resulted in a mean maximal decrease in supine blood pressure, relative to placebo, of 1.6/0.8 mmHg in healthy subjects (see Pharmacology: Pharmacodynamics under Actions). While this effect should not be of consequence in most patients, prior to prescribing Tadalafil (Cialis), physicians should carefully consider whether their patients with underlying cardiovascular disease could be affected adversely by such vasodilatory effects. Patients with severely impaired autonomic control of blood pressure may be particularly sensitive to the actions of vasodilators, including PDE5 inhibitors.
Potential for Drug Interactions When Taking Tadalafil (Cialis) for Once Daily Use: Physicians should be aware that Tadalafil (Cialis) for once daily use provides continuous plasma tadalafil levels and should consider this when evaluating the potential for interactions with medications (e.g., nitrates, alpha-blockers, anti-hypertensives and potent inhibitors of CYP3A4) and with substantial consumption of alcohol (see Interactions).
Prolonged Erection: There have been rare reports of prolonged erections greater than 4 hours and priapism (painful erections greater than 6 hours in duration) for this class of compounds. Priapism, if not treated promptly, can result in irreversible damage to the erectile tissue. Patients who have an erection lasting greater than 4 hours, whether painful or not, should seek emergency medical attention.
Tadalafil (Cialis) should be used with caution in patients who have conditions that might predispose them to priapism (such as sickle cell anemia, multiple myeloma or leukemia) or in patients with anatomical deformation of the penis (such as angulation, cavernosal fibrosis or Peyronie's disease).
Effects on the Eye: Physicians should advise patients to stop use of all phosphodiesterase type 5 (PDE5) inhibitors, including Tadalafil (Cialis), and seek medical attention in the event of a sudden loss of vision in one or both eyes. Such an event may be a sign of non-arteritic anterior ischemic optic neuropathy (NAION), a rare condition and a cause of decreased vision, including permanent loss of vision, that has been reported rarely post-marketing in temporal association with the use of all PDE5 inhibitors. Based on published literature, the annual incidence of NAION is 2.5-11.8 cases per 100,000 in males aged ≥50.
An observational case-crossover study evaluated the risk of NAION when PDE5 inhibitor use, as a class, occurred immediately before NAION onset (within 5 half-lives), compared to PDE5 inhibitor use in a prior time period. The results suggest an approximate 2-fold increase in the risk of NAION, with a risk estimate of 2.15 (95% CI 1.06, 4.34). A similar study reported a consistent result, with a risk estimate of 2.27 (95% CI 0.99, 5.20). Other risk factors for NAION, such as the presence of "crowded" optic disc, may have contributed to the occurrence of NAION in these studies.
Neither the rare post-marketing reports, nor the association of PDE5 inhibitor use and NAION in the observational studies, substantiate a causal relationship between PDE5 inhibitor use and NAION (see Adverse Reactions).
Physicians should consider whether their patients with underlying NAION risk factors could be adversely affected by use of PDE5 inhibitors. Individuals who have already experienced NAION are at increased risk of NAION recurrence. Therefore, PDE5 inhibitors, including Tadalafil (Cialis), should be used with caution in these patients and only when the anticipated benefits outweigh the risks. Individuals with "crowded" optic disc are also considered at greater risk for NAION compared to the general population; however, evidence is insufficient to support screening of prospective users of PDE5 inhibitors, including Tadalafil (Cialis), for this uncommon condition.
Patients with known hereditary degenerative retinal disorders, including retinitis pigmentosa, were not included in the clinical trials, and use in these patients is not recommended.
Sudden Hearing Loss: Physicians should advise patients to stop taking PDE5 inhibitors, including Tadalafil (Cialis), and seek prompt medical attention in the event of sudden decrease or loss of hearing. These events, which may be accompanied by tinnitus and dizziness, have been reported in temporal association to the intake of PDE5 inhibitors, including Tadalafil (Cialis). It is not possible to determine whether these events are related directly to the use of PDE5 inhibitors or to other factors (see Adverse Reactions).
Alpha-blockers and Antihypertensives: Physicians should discuss with patients the potential for Tadalafil (Cialis) to augment the blood-pressure-lowering effect of alpha-blockers and antihypertensive medications (see Interactions and Pharmacology: Pharmacodynamics under Actions).
Caution is advised when PDE5 inhibitors are co-administered with alpha-blockers. PDE5 inhibitors, including Tadalafil (Cialis), and alpha-adrenergic blocking agents are both vasodilators with blood-pressure-lowering effects. When vasodilators are used in combination, an additive effect on blood pressure may be anticipated. In some patients, concomitant use of these two drug classes can lower blood pressure significantly (see Interactions, Pharmacology: Pharmacodynamics under Actions), which may lead to symptomatic hypotension (e.g., fainting). Consideration should be given to the following: ED: Patients should be stable on alpha-blocker therapy prior to initiating a PDE5 inhibitor. Patients who demonstrate hemodynamic instability on alpha-blocker therapy alone are at increased risk of symptomatic hypotension with concomitant use of PDE5 inhibitors.
In those patients who are stable on alpha-blocker therapy, PDE5 inhibitors should be initiated at the lowest recommended dose.
In those patients already taking an optimized dose of PDE5 inhibitor, alpha-blocker therapy should be initiated at the lowest dose. Stepwise increase in alpha-blocker dose may be associated with further lowering of blood pressure when taking a PDE5 inhibitor.
Safety of combined use of PDE5 inhibitors and alpha-blockers may be affected by other variables, including intravascular volume depletion and other antihypertensive drugs. (See Interactions.)
BPH: The efficacy of the coadministration of an alpha-blocker and Tadalafil (Cialis) for the treatment of BPH has not been adequately studied, and due to the potential vasodilatory effects of combined use resulting in blood pressure lowering, the combination of Tadalafil (Cialis) and alpha-blockers is not recommended for the treatment of BPH. (See Interactions, Pharmacology: Pharmacodynamics under Actions.)
Patients on alpha-blocker therapy for BPH should discontinue their alpha-blocker at least one day prior to starting Tadalafil (Cialis) for once daily use for the treatment of BPH.
Alcohol: Patients should be made aware that both alcohol and Tadalafil (Cialis), a PDE5 inhibitor, act as mild vasodilators. When mild vasodilators are taken in combination, blood-pressure-lowering effects of each individual compound may be increased. Therefore, physicians should inform patients that substantial consumption of alcohol (e.g. 5 units or greater) in combination with Tadalafil (Cialis) can increase the potential for orthostatic signs and symptoms, including increase in heart rate, decrease in standing blood pressure, dizziness, and headache (see Pharmacology: Pharmacodynamics under Actions).
Concomitant Use of Potent Inhibitors of Cytochrome P450 3A4 (CYP3A4): Tadalafil (Cialis) is metabolized predominantly by CYP3A4 in the liver (see Interactions).
Combination with Other PDE5 Inhibitors or Erectile Dysfunction Therapies: The safety and efficacy of combinations of Tadalafil (Cialis) and other PDE5 inhibitors or treatments for erectile dysfunction have not been studied. Inform patients not to take Tadalafil (Cialis) with other PDE5 inhibitors.
Effects on Bleeding: Studies in vitro have demonstrated that tadalafil is a selective inhibitor of PDE5. PDE5 is found in platelets. When administered in combination with aspirin, tadalafil 20 mg did not prolong bleeding time, relative to aspirin alone. Tadalafil (Cialis) has not been administered to patients with bleeding disorders or significant active peptic ulceration. Although Tadalafil (Cialis) has not been shown to increase bleeding times in healthy subjects, use in patients with bleeding disorders or significant active peptic ulceration should be based upon a careful risk-benefit assessment and caution.
Counseling Patients about Sexually Transmitted Diseases: The use of Tadalafil (Cialis) offers no protection against sexually transmitted diseases. Counseling patients about the protective measures necessary to guard against sexually transmitted diseases, including Human Immunodeficiency Virus (HIV) should be considered.
Consideration of Other Urological Conditions Prior to Initiating Treatment for BPH: Prior to initiating treatment with Tadalafil (Cialis) for BPH, consideration should be given to other urological conditions that may cause similar symptoms. In addition, prostate cancer and BPH may coexist.
Renal Impairment: ED: Due to increased tadalafil exposure (AUC), limited clinical experience, and the lack of ability to influence clearance by dialysis, Tadalafil (Cialis) for once daily use is not recommended in patients with creatinine clearance less than 30 mL/min (see Use in Specific Populations under Dosage & Administration).
BPH and ED/BPH: Due to increased tadalafil exposure (AUC), limited clinical experience, and the lack of ability to influence clearance by dialysis, Tadalafil (Cialis) for once daily use is not recommended in patients with creatinine clearance less than 30 mL/min. (See Use in Specific Populations under Dosage & Administration, Pharmacology: Pharmacokinetics under Actions.)
Hepatic Impairment: Tadalafil (Cialis) for once daily use has not been extensively evaluated in patients with mild or moderate hepatic impairment. Therefore, caution is advised if Tadalafil (Cialis) for once daily use is prescribed to these patients. Because of insufficient information in patients with severe hepatic impairment, use of Tadalafil (Cialis) in this group is not recommended (see Use in Specific Populations under Dosage & Administration).
