The Efficacy of Tadalafil Daily vs on Demand in the Treatment of Erectile Dysfunction: A Systematic Review and Meta-analysis

Therapeutic management of erectile dysfunction: The AFU/SFMS guidelines

CONTEXT

Erectile dysfunction (ED) is a common sexual disorder. In France, recent evidence-based guidelines are lacking.

AIM

To provide practice guidelines on ED therapeutic management.

EVIDENCE ACQUISITION

Publications indexed in PubMed/Medline® between January 1999 and October 2023, were reviewed. For each clinical question, a level of evidence was attributed to the conclusions. These conclusions and the working group arguments were used to develop and grade (A-C) the recommendations.

RECOMMENDATIONS

ED management must be personalized. Phosphodiesterase 5 inhibitors (PDE5I) are recommended as first-line treatment (A). In patients with severe ED, a combination of PDE5I may be proposed as first- or second-line treatment (Expert Agreement, EA). Extra-cavernous or intra-urethral injections of alprostadil may be offered as first-line alternative to PDE5I or as second-line treatment (B). In case of unsatisfactory response to PDE5I or alprostadil alone, the combination of a PDE5I with intra-cavernosal or intra-urethral alprostadil may be proposed (EA). Vacuum therapy can be offered to all patients (B). Low-intensity extracorporeal shockwave therapy may be proposed to patients with mild or moderate ED, alone or in combination with PDE5I (B). Penile implants are indicated for patients with ED who are refractory or intolerant to pharmacological or mechanical treatments, or if they wish a permanent solution (B). Revascularization surgery may be offered to patients without comorbidities following pelvic trauma and ED with isolated arterial insufficiency (B). In addition to pharmaceutical, mechanical and/or surgical treatments, it is suggested to always consider educational interventions and counseling, lifestyle modifications and management of co-morbidities and curable causes.

Long-term tadalafil once daily in Chinese men with erectile dysfunction: a 2-year final analysis of a post-marketing, multicenter, randomized, open-label trial

The long-term safety and effectiveness of once-daily tadalafil is crucial, but limited data are available in Chinese patients with erectile dysfunction (ED). In this post-marketing, multicenter, randomized, open-label trial with 2-year follow-up, 635 ED cases were randomized to receive daily oral tadalafil 2.5 mg or 5 mg for 3 months, of whom 580 continued once-daily tadalafil 5 mg for 21 months. Treatment-emergent adverse events in the 12-month and 24-month period were similar, with the most common being viral upper respiratory tract infection, upper respiratory tract infection, and headache. Significant improvement from baseline in the International Index of Erectile Function-Erectile Function (IIEF-EF) score was detected at month 12 (least squares mean [LSM] change: 7.9, 95% confidence interval [CI]: 7.5-8.4, P < 0.001) and was maintained to month 24 (LSM change: 8.6, 95% CI: 8.1-9.0, P < 0.001). The proportions of patients regaining normal erectile function (IIEF-EF score ≥26) were 43.7% and 48.0% at months 12 and 24, respectively. Global Assessment Questionnaire results showed improved erection function in 97.5% of patients and improved ability to engage in sexual activity in 95.9% of patients at month 12; these values were 96.1% and 95.0% at month 24, respectively. The quality of sexual life score based on the Sexual Life Quality Questionnaire (SLQQ) was increased by 52.2% at month 12 and by 55.3% at month 24 (both P < 0.001). The treatment satisfaction score determined by SLQQ (mean ± standard deviation) was 62.4 ± 21.0 at month 12 versus 65.9 ± 20.2 at month 24. Two-year daily application of tadalafil 5 mg in Chinese men with ED showed a favorable safety profile and durable improvement in sexual performance and satisfaction.

Effects of continuous use of Tadalafil on male sexual function after posterior urethroplasty: A clinical trial

INTRODUCTION

Posterior urethral injuries in men commonly occur following pelvic and perineal trauma. Erectile dysfunction (ED), whether brought on by the severity of the initial trauma or the surgery itself, is one of the complications in these patients.

MATERIALS AND METHODS

In this study, we divided candidates of posterior urethroplasty due to traumatic urethral injury into intervention and placebo groups; the former received continuous treatment with tadalafil (10 mg daily), and the latter received a placebo. Other services were provided equally to both groups. Before and after the intervention, both groups completed the International Index of Erectile Function version 5 (IIEF-5) questionnaire, and the findings were analyzed.

RESULTS

Forty patients were studied in groups of 20 with a mean age of 43.87 ± 15.70 years. The patient's most common cause of urethral injury was a pelvic fracture. Before the intervention, the mean scores of IIEF for patients in the intervention group and placebo group were 14.85 ± 7.39 and 14.77 ± 6.48, respectively with no statistical significance (p = 0.962) and patients of the groups were similar in terms of the severity of ED. The mean IIEF score in the intervention group was 20.12 ± 4.94 and in the placebo group, it was 18.05 ± 4.88 at the three-month follow-up, with no statistically significant difference (p = 0.063). In both the intervention and placebo groups, the IIEF score was significantly increased by 5.27 ± 4.04 (p < 0.001) and 3.27 ± 2.97 (p < 0.001), respectively. The rate of IIEF increase in the intervention group was higher than in the placebo group during the follow-up at 3-month follow-up with statistical significance. (p = 0.022).

CONCLUSION

The findings of this study suggest that tadalafil, in a 3-month treatment course, may improve erectile function in individuals with mild-to-moderate ED, significantly more than placebo. However, more studies, specifically with longer duration of follow-up and larger populations, are necessary for generalizing the current findings.

Analyzing the Clinical Efficacy of a Type 5 Phosphodiesterase Inhibitor Combined With Ziyin Baihuo Granules in the Treatment of Erectile Dysfunction

The study explored the clinical efficacy of a type 5 phosphodiesterase inhibitor (PDE5i) combined with Ziyin Baihuo granules in the treatment of patients suffering from erectile dysfunction (ED) with yin deficiency and fire-hyperactivity syndrome. A total of 163 patients with erectile dysfunction were divided into observation and control groups. The observation group took tadalafil (Cialis) and Ziyin Baihuo granules orally, and the control group took only tadalafil orally, for 12 weeks. An additional 40 healthy people were selected as a normal group for comparison of the sex hormone levels before and after treatment of the participants in the erectile dysfunction group. After treatment, the symptoms of dry throat and tongue, tidal fever and night sweats, liking cold and avoiding heat, and waist pain showed significant improvement in the observation group (p < .05). Compared with before treatment, the clinical indexes of erectile function in the control group and the observation group were improved after treatment (p < .05). After treatment, Ziyin Baihuo granules combined with tadalafil restored the abnormal indexes of blood (p < .05) in the observation group. Our research shows that PDE5i combined with Ziyin Baihuo granules could effectively improve erectile function.

Survey on Sildenafil, Tadalafil, and Vardenafil Concentrations in Food Supplements for Erectile Dysfunction

The aim of the study was to analyze the presence of undeclared sildenafil, tadalafil, and vardenafil in food supplements (FSs) for erectile dysfunction. The presence of sildenafil, tadalafil, and vardenafil was determined using the generated ultraviolet (UV)-spectra and mass-spectrometry (MS)-spectra as well as chromatograms produced by the photodiode array (PDA)-detector and ion trap MS-detector. The results were processed by Xcalibur ver. 2.0.7. Fourteen of the 20 analyzed FSs contained undeclared ingredients. Sildenafil was present in 12 of them. Many violations and discrepancies between the label information and the real composition of the FS were identified. 70% of the samples contained undeclared ingredients of an erectile dysfunction medicinal product. The quantities varied within broad limits from 2 mg per tablet to 116.55 mg per tablet. Sildenafil was present in amounts exceeding 16.55 mg that is the maximum recommended dose, thus creating risk of overdose. Besides that, food supplements adulterated with sildenafil analogues are a health risk for consumer's health as there is no evidence of modified sildenafil toxicity. All analyzed FSs were claimed to be 100% natural, not provoking side effects. No information for any FS contained indications of age limits or risk for interaction with other FSs or medical products.

Selecting an Individualized Treatment Approach: The Predictive Value of Erotic Stimulation and Nocturnal Erections for Efficacy of Tadalafil and Cure in Patients With Erectile Dysfunction

PURPOSE

This study aimed to evaluate two modes of Rigiscan for predicting tadalafil response, and to identify which Rigiscan variables are the most efficient at making these predictions.

METHODS

All patients received at least two rounds of nocturnal penile tumescence and rigidity (NPTR) testing and/or audiovisual sexual stimulation (AVSS), then completed the International Index of Erectile Function-5 (IIEF-5) questionnaire, followed by oral 5 mg tadalafil daily for 4 weeks. After a 4-week washout period, all respondents underwent an the IIEF-5 questionnaire again. ED patients were then categorized into tadalafil responders and tadalafil non-responders, who were then further divided into cured patients and uncured patients.

RESULTS

When predicting tadalafil responders, the area under the curve (AUC) of NPTR was superior to that of AVSS (0.68~0.84 VS 0.69~0.73), and the predicted optimal cut-off values were DOEE60≥17.75 min in NPTR, compared to other parameters regardless of AVSS or NPTR (P<0.05). When predicting which patients would be cured, the AUC of AVSS was superior to NPTR parameters (0.77~0.81 vs 0.61~0.76), and the determined best diagnostic cut-off values were DOEE≥4.125min in AVSS, compared to other parameters regardless of AVSS or NPTR (P < 0.05).

CONCLUSION

Rigiscan was able to predict the efficacy of daily tadalafil accurately and efficiently. Its diagnostic value was at maximum when DOEE60 ≥17.75 min of NPTR in tadalafil responders and DOEE ≥ 4.125 min of AVSS in cured patients.

Screening sexual performance enhancing compounds and their analogues in counterfeit and illicit erectile dysfunction drugs by high-performance liquid chromatography and liquid chromatography-tandem mass spectrometry

The growth of the counterfeit and illicit drugs market is attributable in part to phosphodiesterase type-5 inhibitor (PDE-5is) medications for erectile dysfunction (ED). PDE-5is and their analogues are being increasingly supplied as counterfeit and illicit drugs marketed to enhance sexual performance. Herein, we screened and confirmed a total of 181 such counterfeit and illicit drugs used to date to enhance sexual performance by high-performance liquid chromatography (HPLC) and liquid chromatography-tandem mass spectrometry (LC-MS/MS). Out of 181 samples, PDE-5is and their analogues were detected in 156 samples, with 49.4% containing two or more components in a single sample. Sildenafil, tadalafil, and miscellaneous group were detected a rates of 64.1%, 34.4%, and 1.5% times and concentrations of 0.04-496 mg/g, 0.02-147 mg/g, and 0.54-16.4 mg/g, respectively with multiple compound groups also detected in single samples. Overdosing on these drugs can lead to adverse effects, the toxicities of combined administrations have not been researched, and administering multiple components in a single sample can be fatal. We recommend that counterfeit and illicit drugs for enhancing sexual performance be continuously controlled and supervised for the protection of public health, and more studies into toxicity and side effects are required.

Should All Men with Type 2 Diabetes Be Routinely Prescribed a Phosphodiesterase Type 5 Inhibitor?

Important health problems in men such as type 2 diabetes (T2DM), insulin resistance, erectile dysfunction, benign prostatic hyperplasia and depression have been shown to have to share common pathological processes, such as endothelial dysfunction and inflammation. This paper discusses the role of phosphodiesterase type 5 (PDE5) inhibitors, through beneficial effects on endothelial function and mediators of chronic inflammation and the possibility to treat or preventing these common conditions. We explore possible barriers to this approach, namely the lack of multiple product licences to treat each of these conditions and how these can be overcome by involving the patient in personalised decisions. We also discuss how opportunities are lost by patients with multiple medical conditions being referred to specialists, primarily interested in one specific problem, with little motivation to treat or prevent conditions outside their remit. We explore how these problems might be related to time and financial restraints or simply a lack of awareness of evidence published in journals related to other specialities. As specialists, we often pride ourselves on providing "personalised" or "patient centred" care, but we can only truly be doing so if we assess the specific needs of the patient across a range of conditions. As part of personalised care in T2DM, we routinely prescribe statins, angiotensin converting enzyme inhibitors and metformin, often with poor compliance. In this paper we explore whether the licensed daily PDE5 inhibitor tadalafil should be added routinely to this list as it will potentially improve and prevent bothersome symptoms and improve compliance with other medications.

Two Birds with One Stone: Regular Use of PDE5 Inhibitors for Treating Male Patients with Erectile Dysfunction and Cardiovascular Diseases

Patients with cardiovascular disease (CVD) frequently have erectile dysfunction (ED) because the two conditions have similar risk factors and potential mechanisms. The therapeutic effect of CVD is strongly dependent upon long-term management of the condition. Patients with CVD tend to have poor medication compliance, and the coexistence of ED often discourages patients with CVD from continuing their long-term CVD management, thus worsening CVD treatment compliance. The two major reasons for poor compliance are that (i) the adverse effects of cardiovascular medications on erectile function drive people to reduce the prescribed dosage or even stop taking the medications to obtain satisfactory sexual arousal and (ii) a worsening mental state due to ED reduces medication compliance. The regular administration of phosphodiesterase-5 inhibitors (PDE5is) guarantees that the prescribed medication dosages are easy to comply with and that they improve the mental status of patients by enhancing their erectile function, resulting in improved long-term management of CVD through medication compliance. PDE5is themselves also play a role in reducing cardiovascular events and improving the prognosis. We recommend prescribing PDE5is for ED and suggest that PDE5i administration is a promising strategy to improve the long-term management of patients with both ED and CVD.

Meta-Analysis of the Long-Term Efficacy and Tolerance of Tadalafil Daily Compared With Tadalafil On-Demand in Treating Men With Erectile Dysfunction

Background

Erectile dysfunction (ED) is highly prevalent in aging men. Tadalafil daily and on-demand are widely used for the treatment of ED.

Aim

We performed a meta-analysis to evaluate the efficacy and safety of tadalafil daily compared with tadalafil on-demand in treating men with ED after at least 24 weeks of long-term treatment.

Methods

Randomized controlled trials of tadalafil daily vs on-demand in treating men with ED were searched using MEDLINE, EMBASE, and the Cochrane Controlled Trials Register. Systematic review was carried out using the Preferred Reporting Items for Systematic Reviews and Meta-analyses. The data was calculated by RevMan version 5.3.0. The references of related articles were also searched.

Outcomes

International Index of Erectile Function-Erectile Function domain, sexual encounter profile question 2 (SEP2), SEP question 3 (SEP3), any treatment-emergent adverse event (AE), discontinuation due to AEs, myalgia, back pain, headache, dyspepsia, and nasopharyngitis.

Results

4 articles, including 1,035 participants were studied. The analysis found that tadalafil daily had a greater improvement than tadalafil on-demand in terms of International Index of Erectile Function-Erectile Function (mean difference (MD) 1.24; 95% CI 0.03−2.44; P = .04), SEP2 (MD 10.08; 95% CI 9.15−11.01; P < .00001) and SEP3 (MD 8.19; 95% CI 2.09−14.29; P = .009) in treating ED after at least 24 weeks treatment cycle. For safety, tadalafil on-demand had a higher incidence of any treatment-emergent AE (odds ratio 0.73; 95% CI 0.56−0.96; P = .02) compared with tadalafil daily, but for other aspects, including discontinuation due to AEs, myalgia, back pain, headache, dyspepsia, and nasopharyngitis, there were no significant difference between the 2 treatments.

Clinical Implications

Tadalafil daily may offer a better effect for ED than on-demand for long-term treatment.

Strengths and Limitations

From the perspective of evidence-based medicine, we evaluated the efficacy and safety of tadalafil daily compared with tadalafil on-demand in treating men with ED after a long-term treatment. The quality of these studies included is flawed, primarily in difference in tadalafil doses and severity of the ED.

Conclusion

Tadalafil daily provides a preferable therapeutic effect for ED with a lower incidence of treatment-emergent side effects relative to tadalafil on-demand after at least 24 weeks of long-term treatment.

Zhou Z, Chen H, Wu J, et al. Meta-Analysis of the Long-Term Efficacy and Tolerance of Tadalafil Daily Compared With Tadalafil On-Demand in Treating Men With Erectile Dysfunction. J Sex Med 2019;7:282–291.