Viagra and nitrates don’t mix, so how do some men still take both?

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As any sports fan knows, thanks to the incessant drumbeat of Viagra and Cialis commercials while playing, mixing erectile dysfunction drugs with nitrates for chest pain can cause a dangerous drop in blood pressure. Most medical guidelines strongly warn men against taking both types of drugs.

However, researchers in Denmark and the United States have recently found that a significant number of men nevertheless get overlapping prescriptions for both drug classes. But evidence suggests that these men do not appear to suffer from health issues such as heart attacks.

“We were a bit surprised that we didn’t find an increased risk,” said Dr Anders Holt, researcher at Copenhagen University Hospital – Herlev and Gentofte. He is the lead author of a study published Monday in the Annals of Internal Medicine which identified a large increase in the co-prescription of erectile dysfunction drugs and nitrates among Danish men. The researchers reported no conflicting links with the pharmaceutical industry.

So how do men manage to navigate taking these drugs safely?

Although the new study could not determine how the men timed taking each drug, Holt speculated that one possible explanation for the lack of apparent health consequences is that people with coronary heart disease usually take a longer-acting nitrate medication in the morning and tend to take erectile dysfunction medication in the evening. This amount of time could be enough to prevent harmful drug interactions.

But medical groups like the American Heart Association advise men to avoid taking nitrates within 24 hours of taking shorter-acting erectile dysfunction drugs, including Viagra (sildenafil) and Levitra (vardenafil), and within 48 hours of taking a longer-acting drug like Cialis (tadalafil).

Widely used drugs

In 2019, more than 4 million men and women in the United States received prescriptions for the three main nitrates – nitroglycerin, nitrofurantoin and isosorbide – according to The ClinCalc.com list of the top 300 drugs. About 1.4 million men have been prescribed Viagra and Cialis.

A 2008 study estimated that 3% of men in the United States suffer from severe erectile dysfunction, 6% from moderate dysfunction and 26% from mild. And one paper 2020 estimates that 2.4 million men aged 40 and over suffer from doctor-diagnosed chest pain.

Erectile dysfunction drugs and nitrates cause blood vessels to dilate, which can get significantly worse if the drugs are taken in close proximity, potentially causing a sharp drop in blood pressure. This increases the risk of major cardiovascular events such as a heart attack or stroke.

Experts also strongly advise against the consumption of amyl nitrate, known as “poppers” and used as a recreational drug, with erectile dysfunction medications.

Spacing out doses of erectile dysfunction and nitrate drugs “will decrease the chances of drug interactions,” said Dr. Robert A. Kloner, professor of medicine at the University of Southern California., who led some key studies who established the AHA safety protocol. (Kloner is also a paid consultant for Sanofi, which has an agreement with Eli Lilly to sell Cialis in several countries if it becomes an over-the-counter drug.)

Results from Denmark

In the new Danish study, Holt and his colleagues analyzed the medical records of nearly 250,000 Danish men, aged 30 to 85, with ischemic heart disease. About 42,000 of them had periods during which they received continuous prescriptions for nitrates.

From 2000 to 2018, researchers found that the rate at which men received prescriptions for erectile dysfunction drugs increased tenfold across the group as a whole, while increasing twentyfold among those on nitrates. Over the last five years of the study period, 9% of people in the latter group filled at least one prescription for a drug such as Viagra within three years of starting nitrates.

The study authors looked at health outcomes during times when men received prescriptions for both types of drugs and compared them to outcomes during times when they received only one of these drugs. The data suggests that receiving prescriptions for both drug classes at the same time was not associated with increased heart health problems, such as cardiac arrest, heart attack, or stroke.

Kloner, who was not involved in the research, said the results suggest “that health care providers are likely becoming more comfortable with co-prescribing these two drug classes despite guidelines and at least educate their patients about not taking them correctly at the same time.”

The study is limited by the fact that the study authors could not know for sure when the men were actually taking each of the drugs. But when they adjusted their analysis to focus on periods ranging from one to four weeks after the men were given a new prescription for erectile dysfunction drugs, the results held.

The authors of the Danish study suggest that it is also possible some men can actually experience a drop in blood pressure while taking both drugs, but it doesn’t cause serious enough health problems for them to go to the ER. The researchers only had access to hospital data, not the medical records of general practitioners.

The study also could not account for the drugs the men obtained on the black market – a common practice among those seeking drugs like Viagra.

Similar results in the United States

A US study from drugmaker Sanofi, published in The Journal of Sexual Medicine last August, came to similar conclusions. Pharmaceutical researchers analyzed electronic medical records covering the period 2012 to 2016 of more than 168,000 American men who had at least one prescription for erectile dysfunction drugs. Of 480,000 men who had one or more nitrate prescriptions, 3,167 received drugs from both drug classes during an overlapping period, with no apparent increased risk of cardiovascular health problems.

This study also had access to health care provider appointment notes. These records indicated that in perhaps half of co-prescribing cases, physicians cautioned their patients about the dangers of taking these drugs together or instructed men on how to mitigate the risk of drug interactions. .

Holt emphasized that men’s sexual health and well-being are as important as the rest of their physical health.

“You can definitely have both drugs,” Holt advised men who are candidates for both nitrates and erectile dysfunction drugs. “But definitely don’t take them at the same time, we have no evidence it’s safe.”

Raymond Rosen, assistant professor of psychiatry and behavioral services at the University of California, San Francisco School of Medicine, said “erectile dysfunction drugs like Viagra have been a godsend for many men and their partners who suffer from of this common disease, but potentially disruptive male disorder.

“New evidence,” said Rosen, who was not involved in any of the recent studies, “has challenged this long-held belief” that men can’t take both nitrates and anti-inflammatory drugs. erectile dysfunction.

Still, he noted that “men should always consult their doctor or health care provider before changing any of these medications.”

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