Nitrates Phosphodiesterase type-5 inhibitors

As long as the couple are not stressed by the sexual position they use, there is no evidence of increased cardiac stress to a man or woman. Man on top, woman on top, side to side, oral sex, and masturbation are cardiologically equivalent. In homosexual relationships, other than casual, anal intercourse is not associated with increased cardiac stress provided proper lubrication is used and amyl nitrate ( poppers ) are not used in the presence of a phosphodiesterase type-5 (PDE-5) inhibitor by the patient or partner. 

ED and vascular disease commonly coexist. They share the same risk factors and endothelial dysfunction is the common denominator. ED may develop in an otherwise asymptomatic male and be an important predictor of subsequent acute or chronic cardiac events. ED may therefore offer an opportunity for risk assessment and therapeutic intervention to reduce the chance of a subsequent cardiac presentation. Cardiac patients with ED need a careful assessment to judge the safety of sexual activity and suitability for ED treatment. Properly assessed and counselled patients can safely enjoy sexual activity. ED therapy with phosphodiesterase type five inhibitors is safe and effective providing the patient and partner are advised on their use and the importance of avoiding drug interactions, especially with nitrates. 

Jackson G, Martin E, McGing E, etal. Successful withdrawal of oral long-acting nitrates to facilitate phosphodiesterase Type 5 Inhibitor use in stable coronary disease patients with erectile dysfunction. J Sex Med 2005 2 513-516. 

PHOSPHODIESTERASE TYPE 5 INHIBITORS NITRATES Risk of severe 1 BP and precipitation of myocardial infarction Additive effect Avoid co-administration... 

The combination of organic nitrates and sildenafil citrate (Viagra) can precipitate life-threatening hypotension in patients with angina (112). Sildenafil is a selective inhibitor of cyclic GMP-specific phosphodiesterase type 5, which causes smooth muscle relaxation and vasodilatation, and is an effective treatment for male erectile dysfunction. More than 3.6 million prescriptions have been issued as of August 1998, and so far there have been 69 deaths, 12 of which were attributable to the interaction with nitrates, as reported to the FDA. 

Phosphodiesterase type-5 inhibitors Aipha biockers Antihypertensives Nitrates... 

The use of phosphodiesterase inhibitors (e.g. sildenafil, tadaiafil and var-denafil) with sodium nitroprusside is contraindicated by the manufacturers, due to the risk of severe hypotension. See also Phosphodiesterase type-5 inhihitors +Nitrates , p.l272. A case report describes the therapeutic use of sildenafil to enhance the hypotensive effect of sodium nitroprusside and other antihypertensives in a patient with a hypertensive crisis. ... 

No clinically relevant interactions appear to occur between sildenafil, tadalafil or vardenafil and most antihypertensive drugs. The exceptions may be diltiazem and verapamil. The potentially serious interactions of sildenafil, tadalafil and vardenafil with the alpha blockers and nitrates are discussed elsewhere. See Phosphodiesterase type-5 inhibitors + Alpha blockers , p.l268 and Phosphodiesterase type-5 inhibitors -I- Nitrates , p.l272. 

The phosphodiesterase type-5 inhibitors potentiate the hypotensive effects of nitrates in a proportion of patients, which might re-suit in potentiaiiy serious hypotension or even precipitate myocardiai infarction. Therefore, the concurrent use of sildenafil, tadalafil or vardenafil with organic nitrates (glyceryl trinitrate (nitroglycerin), isosorbide dinitrate, isosorbide mononitrate, etc.) is contraindicated. The concurrent use of nicorandil and all phosphodiesterase type-5 inhibitors is also contraindicated. 

The interaction between phosphodiesterase type-5 inhibitors and nitrates is established, clinically important, potentially serious and even possibly fatal. Sildenafil and organic nitrates of any form are contraindicated both for erectile dysfunction (within 24 hours of each other ) and for pulmonary hypertension because of the risk of precipitating serious hypotension, or even myocardial infarction. The ACC/AHA Expert consensus document provides a useful list of many of the organic nitrates available, whieh inelude glyeeryl trinitrate (nitroglycerin), isosorbide mononitrate, isosorbide dinitrate and illicit substances such as amyl nitrite. ... 

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