A new study published this week in the Journal of the American College of Cardiology highlights the potential dangers of concurrently using erectile dysfunction (ED) drugs like Viagra or Cialis together with nitrate medications often prescribed for patients with angina chest pain. Researchers found the combination was associated with an increased risk of early death.
Study Finds Combination Doubles Mortality Risk
The research team analyzed health data on over 6 million adult male veterans over a 12 year period. Out of this group, around 43,000 men had taken PDE5 inhibitor ED treatments such as sildenafil (Viagra) or tadalafil (Cialis) together with nitrate drugs used for chest pain like nitroglycerin or isosorbide mononitrate.
When comparing survival rates, the analysis showed:
- Men taking both types of medications had double the risk of early death compared to men taking nitrates alone
- The risk of death was even greater for those with heart disease using the combination
Dr. Nastaran Khalili, cardiologist at Western University and lead investigator expressed, “The results show that the combined use of ED medications and nitrates is associated with significantly increased risk of early death in individuals with and without coronary artery disease.”
She cautioned, “Given the widespread utilization of nitrate therapy to treat angina and ED medications for erectile dysfunction, further research is needed to evaluate whether the increased risk we found is directly due to medication use or linked to other factors.”
How Nitrates and PDE5 Inhibitors Interact
Nitrate drugs like nitroglycerin work by relaxing and dilating blood vessels, making it easier for blood to flow through arteries and veins. This improves oxygen circulation and can relieve chest pain symptoms in patients with heart disease.
On the other hand, PDE5 inhibitors treat erectile dysfunction by enhancing the effects of nitric oxide, which also relaxes muscle tissues in the penis allowing increased blood flow.
Experts speculate these two drug classes may have an amplified impact in lowering blood pressure when used concurrently, possibly to dangerous levels in some patients.
Dr. John Osborne, cardiologist at State University summarized, “Both these medication classes essentially work by increasing nitric oxide availability and promoting vasodilation through different pathways. We hypothesize their effects could be additive, potentially causing severe hypotension when used together.”
Previous Safety Concerns and Advice
The possible interaction between nitrates and ED drugs has been flagged in the past. Current guidelines warn about co-administering the medications due to risks of life-threatening drops in blood pressure.
For example, Viagra labeling carries this warning:
“Patients should not use VIAGRA if sex is inadvisable due to cardiovascular status or any other reason…Concomitant use of VIAGRA and nitrates is contraindicated as it may potentially result in life-threatening hypotension.”
However, Dr. Khalili pointed out, “Despite safety recommendations, our study suggests concurrent use of ED medications and nitrates remains common, indicating a need for greater awareness and caution among clinicians prescribing these drugs.”
Implications for Patients
Patients using nitrate chest pain drugs should inform their doctor about any erectile dysfunction treatments they are taking. Combining these medications puts people at considerably higher risk of complications.
For men seeking help with sexual performance issues, speak to your provider about alternative ED options if you have a history of heart problems and take nitrate prescriptions. Identifying safer alternatives is important.
Dr. Sarah Taylor, family physician and sexual health specialist suggests, “For patients on nitrates with angina who seek erectile dysfunction treatment, options like Cialis daily or other PDE5 inhibitor regimens not contraindicated with nitrate use may be preferable. Weighing potential benefits and harms of any therapy is vital.”
Calls for More Research into Safety
While this study identified a mortality link between the two drug classes, the underlying mechanisms are still unclear.
Researchers emphasized the need for more rigorous clinical trials to determine if the life-threatening risks are directly pharmacological or related to other underlying factors. Safety may depend on variables like patient age, dosage levels, specific medications combined, and timing of administration.
Dr. Khalili concluded, “We hope increased recognition of this issue will lead to additional studies that further evaluate the roots of the safety signal we observed and determine best practices for patients requiring both nitrate and ED treatments.”
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