Safety of sildenafil citrate: review of 67 double-blind placebo-controlled trials and the postmarketing safety database

Development and evaluation of sildenafil/glycyrrhizin-loaded nanofibers as a potential novel buccal delivery system for erectile dysfunction

Erectile dysfunction (ED) is a growing health condition that needs safe and effective therapy. One of the main common treatments is sildenafil which is used in clinics for managing erectile dysfunction by enhancing the blood supply to the penis. In the current study, sildenafil was formulated as nanofibers and mixed with the root extract of Glycyrrhiza glabra (glycyrrhizin) as a natural sweetener to be administrated in the buccal cavity for enhanced drug bioavailability, rapid drug absorption and improved patient compliance. The formulated dual-loaded nanofibers were evaluated by measuring diameter, disintegration, drug loading efficiency, drug release profile, and in vitro cell viability assessment. The results showed that the sildenafil/glycyrrhizin-loaded fibers had a diameter of 0.719 ± 0.177 μm and lacked any beads and pores formation on their surfaces. The drug loading and encapsulation efficiency for sildenafil were measured as 52 ± 7 µg/mg and 67 ± 9 %, respectively, while they were 290 ± 32 μg/mg and 94 ± 10 %, respectively, for glycyrrhizin. The release rate of sildenafil and glycyrrhizin demonstrated a burst release in the first minute, followed by a gradual increment until a complete release after 120 min. The in vitro cell viability evaluation exhibited that the application of sildenafil and glycyrrhizin is safe upon 24-hour treatment on human skin fibroblast cells at all used concentrations (i.e., ≤ 1,000 and 4,000 μg/mL, respectively). However, the application of sildenafil-glycyrrhizin combination (in a ratio of 1:4) demonstrated more than 80 % cell viability at concentrations of ≤ 250 and 1000 μg/mL, respectively, following 24-hour cell exposure. Therefore, sildenafil/glycyrrhizin dual-loaded PVP nanofibers showed a potential buccal therapeutic approach for erectile dysfunction management.

Feasibility and Safety of Sildenafil to Repair Brain Injury Secondary to Birth Asphyxia (SANE-01): A Randomized, Double-blind, Placebo-controlled Phase Ib Clinical Trial

OBJECTIVE

To test feasibility and safety of administering sildenafil in neonates with neonatal encephalopathy (NE), developing brain injury despite therapeutic hypothermia (TH).

STUDY DESIGN

We performed a randomized, double-blind, placebo-controlled phase Ib clinical trial between 2016 and 2019 in neonates with moderate or severe NE, displaying brain injury on day-2 magnetic resonance imaging (MRI) despite TH. Neonates were randomized (2:1) to 7-day sildenafil or placebo (2 mg/kg/dose enterally every 12 hours, 14 doses). Outcomes included feasibility and safety (primary outcomes), pharmacokinetics (secondary), and day-30 neuroimaging and 18-month neurodevelopment assessments (exploratory).

RESULTS

Of the 24 enrolled neonates, 8 were randomized to sildenafil and 3 to placebo. A mild decrease in blood pressure was reported in 2 of the 8 neonates after initial dose, but not with subsequent doses. Sildenafil plasma steady-state concentration was rapidly reached, but decreased after TH discontinuation. Twelve percent of neonates (1/8) neonates died in the sildenafil group and 0% (0/3) in the placebo group. Among surviving neonates, partial recovery of injury, fewer cystic lesions, and less brain volume loss on day-30 magnetic resonance imaging were noted in 71% (5/7) of the sildenafil group and in 0% (0/3) of the placebo group. The rate of death or survival to 18 months with severe neurodevelopmental impairment was 57% (4/7) in the sildenafil group and 100% (3/3) in the placebo group.

CONCLUSIONS

Sildenafil was safe and well-absorbed in neonates with NE treated with TH. Optimal dosing needs to be established. Evaluation of a larger number of neonates through subsequent phases II and III trials is required to establish efficacy.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.govNCT02812433.

The relationship between the history of PDE5-inhibitors assumption and melanoma: a systematic review

INTRODUCTION

Phosphodiesterase 5 inhibitors (PDE5-is) are used worldwide as first line therapy for erectile dysfunction (ED). Current literature reported data on the warning association between PDE5-is use and the development of cutaneous melanoma. However, these data are contrasting, thus we aim to summarise evidence regarding this association.

CONTENT

A systematic review of all published articles related to the effects of PDE5-is in the development of cutaneous melanoma was performed. PubMed, EMBASE, and Cochrane library were queried for all the published studies indexed up to the 26th of May 2023. A combination of keywords related to PDE5-is and melanoma were used. Only original studies based on human subjects in the English language were included in the analysis.

SUMMARY AND OUTLOOK

Of 505 articles identified, only eight original articles were considered for further analysis. Overall, five of the selected articles including 657,984 subjects agrees on an increased risk of developing melanoma in PDE5-is users. On the other hand, three original articles based on data regarding 360,915 subjects, disagree with the previous statement declaring any association between PDE5-i use and melanoma. Current literature still reports contrasting data regarding the association between PDE5-is assumption and increased risk of melanoma, but a possible association is described, bringing attention to higher risk melanoma category of patients. More clinical studies are needed to clarify the impact of PDE5-is in the development and progression of melanoma.

A case-control study of phosphodiesterase-5 inhibitor use and Alzheimer's disease and related dementias among male and female patients aged 65 years and older supporting the need for a phase III clinical trial

BACKGROUND

Phosphodiesterase-5 inhibitors (PDE5i) have been evaluated as a novel treatment for Alzheimer's disease and related dementias (ADRD), but two recent cohort studies have offered opposing conclusions.

METHODS

We performed an unmatched case-control study using electronic medical records from a large healthcare system to evaluate the association of PDE5i use and ADRD in patients ≥65 years old.

RESULTS

Odds of PDE5i exposure were 64.2%, 55.7%, and 54.0% lower in patients with ADRD than controls among populations with erectile dysfunction, benign prostatic hyperplasia, and pulmonary hypertension, respectively. We observed odds ratios less than unity among males and females and with exposure to the PDE5i sildenafil (Viagra®) and tadalafil (Cialis®). We also evaluated the odds of exposure to two other common treatments for pulmonary hypertension: endothelin receptor antagonists (ERA) and calcium channel blockers (CCB). The odds of ERA exposure were 63.2% lower, but the odds of CCB exposure were 30.7% higher, in patients with ADRD than controls among the population with pulmonary hypertension.

CONCLUSIONS

Our results reconcile the opposing conclusions from the previous observational studies and support further research into using PDE5i for prevention and treatment of ADRD.

Multiple Cerebral Infarctions and Rhabdomyolysis After Sildenafil Citrate (Viagra®) Intoxication: A Case Report

BACKGROUND

Sildenafil citrate (Viagra®) is used to treat male erectile dysfunction; however, little is known about the effects of sildenafil overdose and intoxication. We report a patient who presented with cerebral infarction and rhabdomyolysis after intentional sildenafil intoxication.

CASE REPORT

A 61-year-old man visited the Emergency Department complaining of dysarthria about 1 h after taking more than 30 sildenafil tablets with the intention to commit suicide. Dysarthria and dizziness were observed, but there were no other neurological symptoms. The creatine kinase level was elevated to 3118 U/L, and the patient was diagnosed with rhabdomyolysis. Brain magnetic resonance imaging revealed multiple scattered acute cerebral infarctions in both midbrain artery branches. At 4 h post-intoxication, the dysarthria had improved and we initiated dual antiplatelet therapy for cerebral infarction. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should be able to anticipate and treat complications like cerebral infarction and rhabdomyolysis after sildenafil intoxication.

Does Testosterone Salvage PDE5i Non-Responders? A Scoping Review

Erectile physiology, in order to function normally, requires the complex coordination of endocrine, neurocognitive, neuromuscular and vascular mechanisms. Testosterone (T) influences male sexuality as well as penile erections at multiple levels, including a direct influence on the nitric oxide synthase (NOS)/cGMP/phosphodiesterase 5 pathway in the penis. However, the precise role of testosterone replacement (TRT) to “salvage” men with mixed ED failing phosphdiesterase-5 inhibitors (PDE5i) remains unclear. We conducted a scoping review identifying the rationale for TRT in ED failing PDE5i, and we critically discuss clinical trials that have examined TRT in the setting of PDE5i use. Overall, TRT replacement appears to be well tolerated and may enhance the response to PDE5i and quality of life, particularly for men with mixed ED, and particularly among men with very low levels of testosterone. However, most of the available literature examines concurrent TRT alone or simultaneous TRT + PDE5i usage, without necessarily selecting for PDE5i failure cases. The present studies are limited to heterogenous studies with small sample sizes, without an exact predominant etiologic factor causing ED. Furthermore, studies showing the most benefit are non-placebo-controlled trials; however, the correction of more profound hypogonadism may lead to an improved response to PDE5i. Stronger conclusions would require properly selected patient populations and larger placebo-controlled RCTs.

The Role of Sildenafil in Treating Brain Injuries in Adults and Neonates

Sildenafil is a recognized treatment for patients suffering from erectile dysfunction and pulmonary hypertension. However, new evidence suggests that it may have a neuroprotective and a neurorestorative role in the central nervous system of both adults and neonates. Phosphodiesterase type 5-the target of sildenafil-is distributed in many cells throughout the body, including neurons and glial cells. This study is a comprehensive review of the demonstrated effects of sildenafil on the brain with respect to its function, extent of injury, neurons, neuroinflammation, myelination, and cerebral vessels.

Psychosis beas a rare side effect of sildenafil: a case report

BACKGROUND

Sildenafil citrate is a commonly used medication for the management of erectile dysfunction. Previous studies have described some neuropsychiatric side effects of this medication. So far, however, there has been little discussion about sildenafil-induced psychosis.

CASE PRESENTATION

We here present the case of a 32-year-old Iranian male, without a known psychiatric history, who developed psychotic symptoms following initiation of sildenafil. We also postulate a mechanism by which this may occur.

CONCLUSIONS

This report highlights the importance of watchful observation for the occurrence of this rare but serious side effect. Further studies are needed to clarify the precise mechanism that causes sildenafil-induced psychosis.

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.

Socioeconomic Disparities and Risk Factors in Patients Presenting With Ischemic Priapism: A Multi-Institutional Study

OBJECTIVES

To evaluate contemporary clinical presentations of priapism, their association with socioeconomic characteristics, and the role of prescribing providers in priapism episodes in a large cohort of patients managed at 3 major academic health systems.

METHODS

We identified all consecutive patients presenting with ischemic priapism to the emergency departments of three major academic health systems (2014 -2019). Demographic characteristics, priapism etiologies, and clinical management were evaluated. Univariable and multivariable analyses were used to assess the contribution of socioeconomic characteristics and the role of prescribing providers in priapism episodes.

RESULTS

We identified 102 individuals with a total of 181 priapism encounters. Hispanic race, lower income quartile, sickle-cell disease, and illicit drug use were associated with increased risk of recurrent episodes. Of ICI users, 57% received their prescriptions from non-urological medical professionals (NUMPs); the proportion with recurrent episodes was higher for NUMPs compared to urologists (24% vs 0%, P = 0.06) with no demographic differences identified between patients treated by either group.

CONCLUSION

Socioeconomic disparities exist among patients presenting with recurrent episodes of priapism, potentially highlighting systemic issues with access to care and patient education. With most patients who developed ischemic priapism from ICI being prescribed these medications by NUMPs, further investigation is required to elucidate the prescribing and counseling patterns of these providers. Increased awareness of disparities and complications may improve patient safety.

Erectile Dysfunction as a Cardiovascular Risk Factor: Time to Step Up?

BACKGROUND

Erectile dysfunction (ED) is a major health problem that affects a significant proportion of the general population, and its prevalence is even higher in patients with CV risk factors and/or disease. ED and cardiovascular (CV) disease share several common pathophysiological mechanisms, and thus, the potential role of ED as a predictor of CV events has emerged as a significant research aspect.

OBJECTIVE

The purpose of this review is to present and critically discuss data assessing the relation between ED and CV disease and the potential predictive value of ED for CV events.

METHODS

A comprehensive review of the literature has been performed to identify studies evaluating the association between ED and CV disease.

RESULTS

Several cross-sectional and prospective studies have examined the association between ED and CV disease and found an increased prevalence of ED in patients with CV disease. ED was shown to independently predict future CV events. Importantly, ED was found to precede the development of overt coronary artery disease (CAD) by 3 to 5 years, offering a "time window" to properly manage these patients before the clinical manifestation of CAD. Phosphodiesterase type 5 inhibitors are the first-line treatment option for ED and were shown to be safe in terms of CV events in patients with and without CV disease.

CONCLUSION

Accumulating evidence supports a strong predictive role of ED for CV events. Early identification of ED could allow for the optimal management of these patients to reduce the risk for a CV event to occur.

Perception of the association between erectile dysfunction and cardiovascular disease among Chinese physicians: an online survey

Objective

There is a close association between erectile dysfunction (ED) and cardiovascular disease (CVD). This study aimed to investigate Chinese physicians’ understanding of this association.

Methods

A total of 651 physicians, including 245 cardiologists and 406 urologists, participated in our investigation through WeChat.

Results

Participants with more professional experience, a doctoral/postdoctoral degree, and an intermediate/senior title were significantly more likely to be aware of a close association between ED and CVD. Urologists had a significantly better understanding of the association of severity between both diseases, showed more positive attitudes towards phosphodiesterase type 5 inhibitor application in patients with CVD and systematic treatment, and gave greater consideration to both diseases during follow-up visits than did cardiologists. Men had a significantly better understanding of the associated severity of the two disorders and managed the two diseases together more actively than did women. Department, sex, professional experience, education, and affiliated hospital level significantly affected systematic management of ED and CVD.

Conclusion

Most physicians from cardiology and urology are aware of the association between ED and CVD, but this awareness may be insufficient. Department, sex, professional experience, education background, and professional title are significant factors associated with perception of this association.

Novel Emerging Therapies for Erectile Dysfunction

Currently, several treatments exist for the improvement of erectile dysfunction (ED). These include medical therapies such as phosphodiesterase type 5 inhibitors (PDE5-Is), invasive methods such as intracavernosal injection therapy of vaso-active substances, vacuum erection devices, and penile prosthesis implants. However, the percentage of patients that are unresponsive to available treatments and who drop out from treatments remains high. Current evidence reveals that the pathogenesis of ED is related to multiple factors including underlying comorbidities, previous surgery, and psychological factors. Diverse approaches using novel molecular pathways or new technologies have been tested as potential therapeutic options for difficultto-treat ED populations. Melanocortin receptor agonist, a centrally acting agent, showed promising results by initiating erection without sexual stimulation in non-responders to PDE5-Is. Recent clinical and pre-clinical studies using human tissues suggested that new peripherally acting agents including the Max-K channel activator, guanylate cyclase activator, and nitric oxide donor could be potential therapies either as a monotherapy or in combination with PDE5-Is in ED patients. According to several clinical trials, regeneration therapy using stem cells showed favorable data in men with diabetic or post-prostatectomy ED. Low-intensity shock wave therapy also demonstrated promising results in patients with vasculogenic ED. There are growing evidences which suggest the efficacy of these emerging therapies, though most of the therapies still need to be validated by well-designed clinical trials. It is expected that, should their long-term safety and efficacy be proven, the emerging treatments can meet the needs of patients hitherto unresponsive to or unsatisfied by current therapies for ED.

Phosphodiesterase-5 (PDE-5) Inhibitors and Ototoxicity: A Systematic Review

OBJECTIVE

This study explores the current literature regarding associations between phosphodiesterase-5 (PDE-5) inhibitors and ototoxicity and provides a detailed summary and discussion of the findings.

DATA SOURCES

A comprehensive electronic search of PubMed/MEDLINE, Scopus, and Cochrane Library for studies published from database inception through March 21, 2018.

STUDY SELECTION

Basic science articles, epidemiological studies, randomized controlled trials, cohort studies, case reports, reviews, meta-analyses, press releases, and newsletters were included. The PRISMA search strategy was used to select papers. Search terms are included in the appendix (http://links.lww.com/MAO/A733).

RESULTS

Twenty-two articles met the inclusion criteria. Among case reports, there were a total of nine patients, all male, with an average age of 57.4 years (37-79 years, SD = 13.87 years). Of the cases of hearing loss, 25% (2/8 cases) were bilateral and 75% (6/8) were unilateral; 22% (2/9) were associated with tinnitus; and 33% (3/9) had accompanying vestibular symptoms (including vertigo and dizziness). Among multipatient studies, all prospective studies failed to find a significant association between ototoxicity and PDE-5 inhibitor use. Results of the retrospective studies were also heterogeneous. Many key molecules in the PDE-5 inhibition pathway have been demonstrated to exist in the cochlea. However, mirroring the clinical studies, the basic science mechanisms have suggested both ototoxic and otoprotective effects.

CONCLUSIONS

Currently, the literature is inconclusive regarding the interaction between PDE-5 inhibitor use and ototoxicity. Future study such as a double-blinded placebo controlled randomized trial with audiometric assessment would provide more sound evidence. Similarly, a unified molecular model is necessary.

Established and emerging therapeutic uses of PDE type 5 inhibitors in cardiovascular disease

PDE type 5 inhibitors (PDE5Is), such as sildenafil, tadalafil and vardenafil, are a class of drugs used to prolong the physiological effects of NO/cGMP signalling in tissues through the inhibition of cGMP degradation. Although these agents were originally developed for the treatment of hypertension and angina, unanticipated side effects led to advances in the treatment of erectile dysfunction and, later, pulmonary arterial hypertension. In the last decade, accumulating evidence suggests that PDE5Is may confer a wider range of clinical benefits than was previously recognised. This has led to a broader interest in the cardiovascular therapeutic potential of PDE5Is, in conditions such as hypertension, myocardial infarction, stroke, peripheral arterial disease, chronic kidney disease and diabetes mellitus. Here, we review the pharmacological properties and established licensed uses of this class of drug, along with emerging therapeutic developments and possible future indications.

Do Urologists Really Recognize the Association Between Erectile Dysfunction and Cardiovascular Disease?

INTRODUCTION

Erectile dysfunction (ED) and cardiovascular diseases (CVDs) share many common risk factors. ED could be a strong independent predictive factor of CVDs. Furthermore, the treatment of ED had been shown to be beneficial for cardiovascular diseases. However, the association between ED and CVDs has been reported scarcely in the literature.

AIM

To investigate urologists' perception, diagnosis, and treatment of CVDs in patients with ED.

METHODS

The study was conducted as a prospective study from November 2018 through February 2019, including urologists aged 18-64 years. All participants completed a survey of the knowledge of ED via an online questionnaire platform in 7 WeChat groups of urologists. WeChat is the most popular multipurpose messaging and social media in China.

MAIN OUTCOME MEASURE

The main outcomes were the answers that urologists chose or filled.

RESULTS

449 urologists were included. Most of participants (375, 83.5%) agreed that CVDs are associated with ED. Only 231 participants (51.4%) thought ED was an independent disorder. The awareness of the association between ED and CVDs is significantly higher among male urologists than their female counterparts. Although 378 (83.6%) participants believed that the progression of these 2 diseases was consistent, only 181 (44.9%) would do conjoined assessment of both CVDs and ED. In addition, most urologists only considered conventional treatment, such as psychological intervention (341, 75.4%) and phosphodiesterase type 5 inhibitor (PDE5i) therapy (318, 70.4%) for their patients, whereas 339 urologists (88.3%) claimed that they would treat CVDs in patients with both ED and CVDs. 344 (76.6%) urologists showed some concerns over PDE5is.

CONCLUSION

Urologists' assessment of CVDs in patients with ED was disappointing especially among young and female urologists or those working in underserved areas. Besides, the urologists' treatments of ED were not updated, and their attitudes toward the safety and effectiveness of PDE5is for CVDs were not optimistic. Li D, Li X, Peng A, et al. Do Urologists Really Recognize the Association Between Erectile Dysfunction and Cardiovascular Disease? Sex Med 2020;8:195-204.

Evidence Supporting the Hypothesis That Inflammation-Induced Vasospasm Is Involved in the Pathogenesis of Acquired Sensorineural Hearing Loss

Sensorineural hearing loss is mainly acquired and affects an estimated 1.3 billion humans worldwide. It is related to aging, noise, infection, ototoxic drugs, and genetic defects. It is essential to identify reversible and preventable causes to be able to reduce the burden of this disease. Inflammation is involved in most causes and leads to tissue injury through vasospasm-associated ischemia. Vasospasm is reversible. This review summarized evidence linking inflammation-induced vasospasm to several forms of acquired sensorineural hearing loss. The link between vasospasm and sensorineural hearing loss is directly evident in subarachnoid haemorrhage, which involves the release of vasoconstriction-inducing cytokines like interleukin-1, endothelin-1, and tumour necrosis factor. These proinflammatory cytokines can also be released in response to infection, autoimmune disease, and acute or chronically increased inflammation in the ageing organism as in presbyacusis or in noise-induced cochlear injury. Evidence of vasospasm and hearing loss has also been discovered in bacterial meningitis and brain injury. Resolution of inflammation-induced vasospasm has been associated with improvement of hearing in autoimmune diseases involving overproduction of interleukin-1 from inflammasomes. There is mainly indirect evidence for vasospasm-associated sensorineural hearing loss in most forms of systemic or injury- or infection-induced local vascular inflammation. This opens up avenues in prevention and treatment of vascular and systemic inflammation as well as vasospasm itself as a way to prevent and treat most forms of acquired sensorineural hearing loss. Future research needs to investigate interventions antagonising vasospasm and vasospasm-inducing proinflammatory cytokines and their production in randomised controlled trials of prevention and treatment of acquired sensorineural hearing loss. Prime candidates for interventions are hereby inflammasome inhibitors and vasospasm-reducing drugs like nitric oxide donors, rho-kinase inhibitors, and magnesium which have the potential to reduce sensorineural hearing loss in meningitis, exposure to noise, brain injury, arteriosclerosis, and advanced age-related and autoimmune disease-related inflammation.

Effects of combined extracts of Lepidium meyenii and Allium tuberosum Rottl. on erectile dysfunction

BACKGROUND

Sexual problems are widespread and adversely affect the interpersonal relationships and the quality of life. Currently, synthetic drugs improving sexual function are available, but expenditures for such agents are extremely high. To discover relatively inexpensive, widely available and effective natural drugs, we identified a combined extracts from Lepidium meyenii (maca) root and Allium tuberosum Rottl. (Chinese chive) seed, assessed the effects of this combined extracts on erectile dysfunction, and explored its potential mechanisms.

METHODS

The extracts were obtained via supercritical fluid extraction. Male BALB/c mice received doses of extract from single plant or the combined extracts (200 mg/kg) by gastric gavage for 14 d, and Viagra was used as the positive control drug. Sexual behaviour was observed, and concentrations of serum testosterone, nitric oxide (NO), and cyclic guanosine monophosphate (cGMP) in serum as well as in penis were measured. In addition, weights of genital organs were also measured.

RESULTS

The combined extracts of maca root and Chinese chive seed (1:1, w/w) had a 45-fold increase in macamide content compared with maca extract. It also led to significantly higher ejaculation frequency (P < 0.05) than single extract from maca root or Chinese chive seed, with no corresponding effect on genital indices. In addition, the NO level in serum (P < 0.01) and penis (P < 0.05) increased notably, as well as the level of cGMP in penis (P < 0.05).

CONCLUSIONS

The results indicated that the combined extracts produced better synergistic effects on male sexual function than maca extract or Chinese chive extract alone. These positive effects may involve the upregulation of NO and cGMP concentrations in penis.

Erectile dysfunction in renal failure and transplant patients

Erectile dysfunction (ED) is a prevalent and pertinent condition in the chronic kidney disease (CKD) population. It has a multifactorial etiology, including disruptions of the hypothalamic-pituitary-gonadal axis, the endothelial paracrine signaling system, calcium and vitamin D homeostasis, along with several other factors. Efficacy of treatment of ED in the CKD population is comparable to non-CKD patients across multiple modalities, including PDE5 inhibitors, vacuum erectile devices, intracavernosal injections and penile prostheses. Renal transplant improves the contributing comorbid conditions that lead to ED in CKD patients; thus rates of ED are improved post-transplant. It is important to note that there is a small percentage of patients with persistent ED after renal transplantation.

Psychological Impacts of Male Sexual Dysfunction in Pelvic Cancer Survivorship

INTRODUCTION

A common negative sequela of cancer treatment in men is sexual dysfunction, which can have a significant psychological impact and can contribute to feelings of depression, anxiety, and other mental health issues. Management of cancer survivors' psychological and mental well-being plays an important role in the treatment and recovery process.

AIM

To identify how sexual dysfunction impacts the lives of male cancer survivors and to provide clinicians with treatment recommendations specific to this patient population.

METHODS

A total of 51 peer-reviewed publications related to sexual dysfunction in male cancer survivors were selected for analysis. Sources were chosen based on relevance to current cancer therapies, causes and psychological impacts of sexual dysfunction, and treatment recommendations for clinicians caring for cancer survivors. PubMed search terms included "sexual dysfunction," "cancer survivorship," and "male cancer survivors."

MAIN OUTCOME MEASURES

Measures of sexual dysfunction were based on cancer survivors reporting inadequate erectile capacity for penetrative sexual intercourse, decreased sensitivity of the genitalia, or inability to enjoy sex.

RESULTS AND CONCLUSIONS

Sexual dysfunction was present in male cancer survivors from diverse ages, cancer diagnoses, and treatments of cancer. Many of the men surveyed presented with psychological distress resulting from their posttreatment sexual dysfunction. This had a significant negative impact on their sexual self-esteem, body image, and mental health. Sexual and social development was delayed in survivors of childhood cancer. Healthcare practitioners should initiate conversations with patients regarding the potential for sexual dysfunction at the time of cancer diagnosis and throughout treatment and follow-up. Physical symptoms of sexual dysfunction should be treated, whenever possible, using phosphodiesterase 5 inhibitors or other interventions, and all cancer survivors presenting with psychological distress related to sexual dysfunction should be offered professional counseling. Twitchell DK, Wittmann DA, Hotaling JM, et al. Psychological Impacts of Male Sexual Dysfunction in Pelvic Cancer Survivorship. Sex Med Rev 2019;7:614-626.

Raising More Than Moods: Escitalopram-Associated Priapism

Selective serotonin reuptake inhibitors are a common first choice medication for anxiety and depression treatment, but health care providers should be aware of priapism as a possible adverse effect.

Randomized Controlled Trial of a Leucine-Metformin-Sildenafil Combination (NS-0200) on Weight and Metabolic Parameters

OBJECTIVE

Leucine was previously demonstrated to allosterically activate mammalian sirtuin 1 and synergize with other sirtuin 1/AMP-activated protein kinase/nitric oxide pathway activators to modulate energy metabolism. The objective of this study was to evaluate the effects of a triple combination of leucine, metformin, and sildenafil (NS-0200) on body weight and obesity comorbidities in a phase 2 randomized trial.

METHODS

A total of 91 subjects with obesity were randomized to placebo, low dose (1.1 g leucine/0.5 g metformin/0.5 mg sildenafil), or high dose (1.1 g leucine/0.5 g metformin/1.0 mg sildenafil) twice daily for 16 weeks. Seventy subjects completed the trial and met all a priori compliance criteria. Hypertensive (n = 35) and hypertriglyceridemic (n = 22) subcohorts were also analyzed.

RESULTS

NS-0200 dose-responsively reduced weight; high dose reduced weight by 2.4 and 5.0 kg in the full and high-triglyceride cohorts, respectively (P < 0.0001). High-dose NS-0200 treatment also decreased blood pressure (-5.5 mm Hg diastolic pressure; P = 0.011), with greater effects among hypertensive subjects. NS-0200 also significantly reduced triglycerides and hemoglobin A1c. Significant improvement in ≥ 2 comorbidities was exhibited by 54% of subjects in the high-dose arm versus 5% of placebo subjects (P = 0.0009). Treatment-emergent adverse events did not significantly differ among groups.

CONCLUSIONS

These data support further study of NS-0200 as a therapy for obesity and associated comorbidities.

Sildenafil Administration in Dogs Heterozygous for a Functional Null Mutation in Pde6a: Suppressed Rod-Mediated ERG Responses and Apparent Retinal Outer Nuclear Layer Thinning

This study was designed to assess risk for retinal toxicity associated with administration of high-dose sildenafil citrate to dogs heterozygous for a functionally null mutation in Pde6a over a 4-month period. Three Pde6a +/- dogs were administered 14.3 mg/kg sildenafil per os and two Pde6a +/- dogs placebo once daily for 16 weeks. Three Pde6a +/+ dogs were administered sildenafil for 7 days. Ophthalmic examination, vision testing, and electroretinography (ERG) were regularly performed. At study termination, dogs were euthanized and globes collected. Retinal layer thickness and photoreceptor nuclei counts were determined from plastic sections. In both Pde6a +/- and Pde6a +/+ sildenafil-treated (ST) dogs, elevation of dark-adapted b-wave threshold and unmasking of the scotopic threshold response (STR) were observed. Sildenafil treated Pde6a +/- dogs had significantly thinner ONL (24.90 +/-1.88 μm, p = 0.004) and lower photoreceptor nuclei counts (273.6 +/- 29.3 cells/100 μm, p = 0.008) compared to measurements (35.90 +/- 1.63 μm) and counts (391.5 +/-27.0 cells/100 μm) from archived untreated Pde6a +/- dogs.

Sudden hearing loss after cialis (tadalafil) use: A unique case of cochlear hydrops

We discuss a unique case of sudden sensorineural hearing loss after Cialis (tadalafil) use, a phosphodiesterase 5 (PDE5) inhibitor, and the implication of ipsilateral cochlear hydrops seen on magnetic resonance imaging (MRI). We report a case of a 53-year-old male with unilateral low-frequency sudden sensorineural hearing loss (SSNHL) after ingestion of tadalafil. The SSNHL occurred 1 day after ingestion and was associated with aural fullness and tinnitus. There were no symptoms of vertigo. He received oral prednisone immediately after the onset of hearing loss without improvement. Delayed intravenous contrast-enhanced three-dimensional Fluid-attenuated inversion recovery MRI revealed ipsilateral dilation of the cochlear duct without any hydronic change in the vestibular system. Acetazolamide therapy was initiated, and his symptoms improved. A posttreatment audiogram revealed an increase in threshold of 15 dB. To the best of our knowledge, this is the first case of cochlear hydrops visualized on imaging after a PDE5 inhibitor induced SSNHL. Tadalafil and other PDE5 inhibitors have a known association with SSNHL. Despite several proposed mechanisms, there is inconclusive evidence of a causal relationship. Our presented case suggests that cochlear hydrops may be one possible mechanism of PDE5 inhibitor-associated SSNHL. MRI should be considered in the evaluation of such patients who do not respond to oral steroids as initial treatment. Laryngoscope, 2615-2618, 2018.

Randomised clinical trial: a leucine-metformin-sildenafil combination (NS-0200) vs placebo in patients with non-alcoholic fatty liver disease

BACKGROUND

Sirtuin 1 (Sirt1) is suppressed in non-alcoholic fatty liver disease (NAFLD), while its' stimulation or overexpression results in reduced disease severity in pre-clinical NAFLD models. Leucine allosterically activates Sirt1 and synergise with other Sirt/AMPK/NO pathway activators. We developed a triple combination of leucine, metformin and sildenafil (NS-0200), which was effective in a mouse model of non-alcoholic steatohepatitis (NASH).

AIM

To report the results from a Phase 2, randomised clinical trial of of NS-0200 in 91 subjects with NAFLD (liver fat ≥15% by magnetic resonance imaging-proton-density fat fraction (MRI-PDFF)).

METHODS

Subjects were randomised to placebo, low-dose (1.1 g leucine/0.5 g metformin/0.5 mg sildenafil) or high-dose NS-0200 (1.1 g leucine/0.5 g metformin/1.0 mg sildenafil) b.d. for 16 weeks; change in hepatic fat was assessed via MRI-PDFF, and lipid metabolism was assessed via changes in the lipidomic signature. Seventy subjects completed the trial and met a priori compliance criteria. Analyses were conducted on the full cohort and on those with alanine aminotransferase (ALT) values above median (50 U/L; n = 35).

RESULTS

In the full cohort, active treatments did not separate from placebo. High dose NS-0200 reduced hepatic fat by 15.7% (relative change from baseline) in the high ALT group (P < 0.005) while low dose NS-0200 and placebo did not significantly change hepatic fat. Lipidomic analysis showed dose-responsive treatment effects in both overall and high ALT cohorts, with significant decreases in metabolically active lipids and up-regulation of fatty acid oxidation.

CONCLUSION

These data support further evaluation of high-dose NS-0200 for treating NASH, especially in those with elevated ALT (NCT 02546609).

Predictors of Erectile Function Normalization in Men With Erectile Dysfunction Treated With Placebo

BACKGROUND

Clinical study and practice data have shown sildenafil improves sexual function in men with erectile dysfunction (ED). However, some men treated with placebo in double-blind, placebo-controlled sildenafil studies also report improved erectile function as measured by International Index of Erectile Function (IIEF)-Erectile Function Domain (EFD) scores.

AIM

This analysis estimated the relationship between post-baseline IIEF-EFD scores and demographic variables, including co-morbidities, in men with ED receiving placebo in flexible-dose sildenafil studies.

METHODS

Placebo-treated participants in the intent-to-treat population of 42 double-blind, placebo-controlled, flexible-dose, sildenafil studies were included. A participant was classified as a placebo responder if the IIEF-EFD score was ≥26 at the last visit.

OUTCOMES

Variables assessed were age (<45, 45-64, ≥65 years), race, body mass index, co-morbidities (cardiovascular disease/hypertension, diabetes mellitus, depression), date the last study dose was taken, study completion date, ED etiology (psychogenic, organic, mixed), history of cigarette smoking, ED duration, baseline IIEF-EFD score (≤10, 11-16, ≥17), and treatment duration. Stepwise multivariate logistic regression models assessed the odds of being a responder vs a non-responder for each variable.

RESULTS

A total of 4,360 men were included; 13.5% were responders. Odds estimates indicated the largest likelihood of placebo response occurred in men who were black (odds = 20.2, P < .0001), were younger than 45 years (odds = 7.3, P < .0001), had mild ED (baseline IIEF-EFD ≥17; odds >100, P < .0001), and did not have diabetes (odds = 4.5, P < .0001). The likelihood of a placebo response decreased as ED duration increased (odds = 0.74, P < .0001). The frequency of common adverse events was similar between placebo responders and non-responders.

CLINICAL TRANSLATION

These findings contribute to the improved understanding of predictors of placebo response in sildenafil clinical studies. Elucidation of these factors may contribute to the development of further interventions and treatment strategies and best practices for clinical trials.

STRENGTHS AND CONCLUSIONS

Strengths of this analysis include the large and diverse population and the duration of follow-up. Limitations include those associated with retrospective analyses and the inability to ascertain to what extent other demographic factors might have contributed to the placebo responses or how these placebo responses might be related to the natural course of ED.

CONCLUSIONS

Certain demographics, co-morbidities, and condition characteristics predicted the odds of a placebo response in sildenafil clinical studies of ED. Underlying reasons behind a placebo response warrant further evaluation. Mulhall JP, Carlsson M, Stecher V, et al. Predictors of Erectile Function Normalization in Men With Erectile Dysfunction Treated With Placebo. J Sex Med 2018;15:866-872.

Utero-placental perfusion Doppler indices in growth restricted fetuses: effect of sildenafil citrate

OBJECTIVE

To assess efficacy and tolerability of sildenafil citrate on utero-placental blood flow and fetal growth in pregnancies complicated by fetal growth restriction (FGR).

METHODS

From March 2015, a randomized controlled trial of 54 patients at 24 weeks or more complicated by FGR and abnormal Doppler indices were randomly allocated 1:1 into an intervention arm (receive sildenafil citrate, 50 mg) or a control arm (receive placebo). The primary outcomes were changes occurred in the Doppler parameters 2 h following drug administration.

RESULTS

Baseline characteristics were similar between groups. Significant difference was observed in the Delta uterine and umbilical Doppler indices among sildenafil group as compared to placebo group (p < 0.001). Middle cerebral Doppler indices, however, decreased significantly after sildenafil, which could be the result of shifting more blood to improve the utero-placental perfusion. No difference regarding Delta cerebro-placental ratio among both groups (p = 0.979). Sildenafil was also associated with pregnancy prolongation (p = .0001), increased gestational age at delivery (p = .004), improved neonatal weight (p = .0001), and less admission to neonatal intensive care unit (p = .03). No adverse effects reported in both treatment arms.

CONCLUSION

Sildenafil citrate, by its vasodilator effect, can improve utero-placental blood flow in pregnancies complicated by FGR and abnormal Doppler.

CLINICAL TRIAL

gov Registry: NCT02362399.

Phosphodiesterase-5 inhibitors and the heart: compound cardioprotection?

Novel cardioprotective agents are needed in both heart failure (HF) and myocardial infarction. Increasing evidence from cellular studies and animal models indicate protective effects of phosphodiesterase-5 (PDE5) inhibitors, drugs usually reserved as treatments of erectile dysfunction and pulmonary arterial hypertension. PDE5 inhibitors have been shown to improve contractile function in systolic HF, regress left ventricular hypertrophy, reduce myocardial infarct size and suppress ischaemia-induced ventricular arrhythmias. Underpinning these actions are complex but increasingly understood cellular mechanisms involving the cyclic GMP activation of protein kinase-G in both cardiac myocytes and the vasculature. In clinical trials, PDE5 inhibitors improve symptoms and ventricular function in systolic HF, and accumulating epidemiological data indicate a reduction in cardiovascular events and mortality in PDE5 inhibitor users at high cardiovascular risk. Here, we focus on the translation of underpinning basic science to clinical studies and report that PDE5 inhibitors act through a number of cardioprotective mechanisms, including a direct myocardial action independent of the vasculature. We conclude that future clinical trials should be designed with these mechanisms in mind to identify patient subsets that derive greatest treatment benefit from these novel cardioprotective agents.

Risk of sudden sensorineural hearing loss in adults using phosphodiesterase type 5 inhibitors: Population-based cohort study

PURPOSE

The objective of the study was to determine the risk of sudden sensorineural hearing loss (SNHL) associated with use of phosphodiesterase type 5 (PDE5) inhibitors.

METHODS

We conducted a retrospective cohort study in the MarketScan Commercial Claims and Encounters Database including adult men who initiated a PDE5 inhibitor (n = 377,722) and 1,957,233 nonusers between 1998 and 2007. Periods of drug exposure were assessed on a weekly basis based on pharmacy billing records, assuming use of 1 dose per week (current use). Incident sudden SNHL was defined based on inpatient or outpatient visits with International Classification of Diseases, Ninth Revision, Clinical Modification codes 389.1x, 389.2x, or 388.2 plus ≥2 procedure codes for audiometric hearing testing within ±30 days of sudden SNHL diagnosis. We used age- and propensity score-adjusted Cox proportional hazards model to evaluate the risk of sudden SNHL during periods of current or recent use compared with that of nonuse. We conducted sensitivity analyses by varying the assumed drug utilization frequency and sudden SNHL case definition.

RESULTS

We evaluated 1233 sudden SNHL cases, resulting in an incidence of 4.35, 5.58, and 2.38 per 10,000 person-years for current, recent, and nonuse of PDE5 inhibitors, respectively. Compared with nonuse, the adjusted hazard ratio was 1.25 (1.01-1.55) for current use with a risk difference of 1.97 (1.12-2.82) per 10,000 person-years. For recent use, the adjusted hazard ratio was 1.60 (1.33-1.94) and risk difference was 3.19 (2.24-4.14). Estimates were consistent across the sensitivity analyses.

CONCLUSIONS

Use of PDE5 inhibitors is associated with a small but significantly increased risk of sudden SNHL.

Sexual Dysfunction: Behavioral, Medical, and Surgical Treatment

Sexual dysfunction affects both men and women and is responsible for 1 in 5 visits to urologist and/or gynecologists. It is important that treating providers use a logical and methodical approach to the diagnosis and treatment of this disorder. Behavioral therapy, coupled with oral medications, are very successful in treating erectile dysfunction. Complex and invasive therapies are used for more severe cases of sexual dysfunction and are best deployed by specialists.

Erectile Dysfunction and Ischaemic Heart Disease

Erectile dysfunction (ED) is a common disorder that affects the quality of life of many patients. It is prevalent in more than half of males aged over 60 years. Increasing evidence suggests that ED is predominantly a vascular disorder. Endothelial dysfunction seems to be the common pathological process causing ED. Many common risk factors for atherosclerosis such as diabetes, hypertension, smoking, obesity and hyperlipidaemia are prevalent in patients with ED and so management of these common cardiovascular risk factors can potentially prevent ED. Phosphodiesterase type 5 inhibitors provide short-term change of haemodynamic factors to help initiate and maintain penile erection. They have been shown to be an effective and safe treatment strategy for ED in patients with heart disease, including those with ischaemic heart disease and hypertension.

The blue pill (sildenafil) and its descendants: an overview

An increasing number of men around the world suffer from erectile dysfunction (ED). Indeed, according to the sexuality study conducted by Professor Izdebski, 1 out of 10 men in Poland suffers from ED. The problem is found among men of any age, however, 60% of all patients are between 40 and 60 years old, thus in their prime, and who still want to fully enjoy life. Not only do the effects of ED affect a man, but they have influence on his relationship and partner as well. In spite of a growing awareness within society, the problem remains perceived as embarrassing, which leads patients to treat themselves on their own, delaying a visit to their doctors. Meanwhile, in many cases, ED may be the first symptom of more serious diseases, such as diabetes, or result from the sideeffects of applied drugs. A breakthrough in the oral medication treatment of ED was observed when a new phosphodiesterase type 5 inhibitor (PDE-5-inhibitor) - sildenafil citrate (Viagra®) - was introduced. Nowadays, 5 active substances from this group are being applied. The current medical guidelines recommend PDE-5 inhibitors as the firstline therapy for most men with ED, irrespective of the cause and severity of the disease. Recently, sildenafil at the dose of 25 mg came into the market without prescription. This paper presents an overview and update of the PDE-5 inhibitors.

Effect of Linear Low-Intensity Extracorporeal Shockwave Therapy for Erectile Dysfunction-12-Month Follow-Up of a Randomized, Double-Blinded, Sham-Controlled Study

INTRODUCTION

Short-term data on the effect of low-intensity extracorporeal shockwave therapy (Li-ESWT) on erectile dysfunction (ED) have been inconsistent. The suggested mechanisms of action of Li-ESWT on ED include stimulation of cell proliferation, tissue regeneration, and angiogenesis, which can be processes with a long generation time. Therefore, long-term data on the effect of Li-ESWT on ED are strongly warranted.

AIM

To assess the outcome at 6 and 12 months of linear Li-ESWT on ED from a previously published randomized, double-blinded, sham-controlled trial.

METHODS

Subjects with ED (N = 126) who scored lower than 25 points in the erectile function domain of the International Index of Erectile Function (IIEF-EF) were eligible for the study. They were allocated to 1 of 2 groups: 5 weekly sessions of sham treatment (group A) or linear Li-ESWT (group B). After a 4-week break, the 2 groups received active treatment once a week for 5 weeks. At baseline and 6 and 12 months, subjects were evaluated by the IIEF-EF, the Erectile Hardness Scale (EHS), and the Sexual Quality of Life in Men.

MAIN OUTCOME MEASURES

The primary outcome measure was an increase of at least 5 points in the IIEF-EF (ΔIIEF-EF score). The secondary outcome measure was an increase in the EHS score to at least 3 in men with a score no higher than 2 at baseline. Data were analyzed by linear and logistic regressions.

RESULTS

Linear regression of the ΔIIEF-EF score from baseline to 12 months included 95 patients (dropout rate = 25%). Adjusted for the IIEF-EF score at baseline, the difference between groups B and A was -1.30 (95% CI = -4.37 to 1.77, P = .4). The success rate based on the main outcome parameter (ΔIIEF-EF score ≥ 5) was 54% in group A vs 47% in group B (odds ratio = 0.67, P = .28). Improvement based on changes in the EHS score in groups A and B was 34% and 24%, respectively (odds ratio = 0.47, P = .82).

CONCLUSION

Exposure to 2 cycles of linear Li-ESWT for ED is not superior to 1 cycle at 6- and 12-month follow-ups. Fojecki GL, Tiessen S, Osther PJS. Effect of Linear Low-Intensity Extracorporeal Shockwave Therapy for Erectile Dysfunction-12-Month Follow-Up of a Randomized, Double-Blinded, Sham-Controlled Study. Sex Med 2018;6:1-7.

Update on the Safety of Phosphodiesterase Type 5 Inhibitors for the Treatment of Erectile Dysfunction

INTRODUCTION

Phosphodiesterase type 5 inhibitors (PDE5Is) have demonstrated efficacy in the treatment of erectile dysfunction (ED). Although historically found to have limited drug-related adverse events, emerging data have suggested that PDE5Is might be associated with melanoma or recurrence of prostate cancer after radical prostatectomy.

AIM

To summarize the literature on the safety of PDE5Is.

METHODS

A literature review was performed through PubMed from 1990 through 2016 regarding ED. Keywords used for the search were erectile dysfunction, phosphodiesterase type 5 inhibitors, sildenafil, vardenafil, tadalafil, avanafil, safety, side effects, and adverse events, among others.

MAIN OUTCOME MEASURES

Visual, auditory, cardiovascular, renal, hepatic, priapic, and oncologic outcomes associated with the intake of PDE5Is for the treatment of ED, in addition to drug interactions, abuse, overdose, and the phenomenon of counterfeit medications.

RESULTS

PDE5Is are safe drugs for the management of ED. Although recent studies have shown an increased risk of non-arteritic ischemic optic neuropathy with PDE5Is, the magnitude of that risk is small. The possibility that PDE5Is cause sensorineural hearing loss remains uncertain. PDE5Is display a safe cardiovascular profile if used according to the Princeton III Consensus guidelines. There appears to be an association between PDE5I use and melanoma but the absence of a mechanism of causation raises doubt that the association is cause and effect. PDE5Is do not increase the risk of biochemical recurrence after prostate cancer management. PDE5I abuse and use of counterfeit medications present serious global health concerns.

CONCLUSION

Current data strongly support the efficacy, tolerability, and overall safety of PDE5Is for the treatment of ED. PDE5Is probably cause a small increase in the risk of non-arteritic ischemic optic neuropathy. Evidence on increased rates of melanoma and prostate cancer recurrence is weak and controversial. PDE5Is should still be considered first-line therapy for the treatment of most etiologies of ED. Yafi FA, Sharlip ID, Becher EF. Update on the Safety of Phosphodiesterase Type 5 Inhibitors for the Treatment of Erectile Dysfunction. Sex Med Rev 2018;6:242-252.

Quality of erections by age group in men with erectile dysfunction

AIMS

The aim of this study was to assess erection quality with sildenafil vs placebo and adverse events (AEs) according to age (≤45, 46-55 and ≥56 years) in 997 men with erectile dysfunction (ED) using pooled data from four randomized, double-blind, placebo-controlled, flexible-dose trials.

METHODS

The trials included 6- to 10-week treatment periods. The starting sildenafil dose was 50 mg, taken ~1 hour before sexual activity but not more than once daily, with subsequent adjustment to 100 or 25 mg based on efficacy and safety. Exclusion criteria included blood pressure <90/50 or >170/110 mmHg, taking nitrate therapy or nitric oxide donors, severe cardiac failure/unstable angina or recent stroke or myocardial infarction. Changes from baseline in Quality of Erection Questionnaire (QEQ), International Index of Erectile Function (IIEF) and Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) scores were analysed.

RESULTS

Improvements in QEQ scores with sildenafil vs placebo were significant (P<.0001) for the overall sample (33.7 sildenafil; 8.1 placebo) and each age group (≤45 years: 38.5 sildenafil, 13.9 placebo; 46-55 years: 34.9 sildenafil, 5.8 placebo; ≥56 years: 26.9 sildenafil, 4.9 placebo). IIEF Erectile Function domain (P<.0001), question 3 (achieving erection; P<.003), and question 4 (maintaining erection; P<.001) scores also improved significantly for the overall sample and each age group. Treatment satisfaction was significantly greater (P<.0001) with sildenafil vs placebo for the overall sample and each age group. The most common AEs with sildenafil were headache, flushing and nasal congestion in all age groups.

CONCLUSIONS

Sildenafil significantly improved erection quality across all age groups of men with ED. Efficacy improvements with sildenafil were consistent with the QEQ, IIEF, and EDITS. AEs were comparable across age groups. ClinicalTrials.gov ID: NCT00159900, NCT00147628, NCT00301262, NCT00343200.

Medical treatment of erectile dysfunction: too many medical prescriptions?

Erectile dysfunction (ED) is a worldwide commonly reported condition; epidemiological data showed a prevalence ranging from 2.3 to 53.4% within different population subsets. In this context, the advent of phosphodiesterase type 5 inhibitors (PDE5is) in the second mid of 1990s has deeply changed the treatment scenario of this bothersome condition. Being user-friendly compounds with an excellent overall safety profile, PDE5is emerged as the first-line treatment for ED, thus overcoming topical alprostadil and intracavernous injections (ICIs). However, available data on treatment-utilization patterns and medical prescriptions of PDE5is showed a range of as wide as 22-78% of patients reporting to purchase PDE5is even without a proper medical prescription. Moreover, an increase in the recreational use of PDE5is among young men has been observed in the last decades, with a worrisome diffusion of potential health-risky behaviours associated with this habit. Indeed, treatment of ED should carefully follow internationally based clinical guidelines to avoid inappropriate drug prescriptions, which may eventually expose treated patients to drug-related side effects. Thereof, a careful assessment of the so-called modifiable and reversible ED risk factors along with a patient-tailored screening for potential contraindications to the treatment itself should be performed in every case. Lastly, although conclusive data still lack, the potential association between life-risky PDE5is side effects (i.e. cardiovascular adverse events, melanoma skin cancer and worsening of prostate cancer outcomes) should be carefully taken into account when counselling patients for ED treatment.

Efficacy and Safety of Sildenafil by Age in Men With Erectile Dysfunction

INTRODUCTION

Sildenafil, an oral phosphodiesterase type 5 inhibitor, has been extensively investigated for the treatment of erectile dysfunction in randomized controlled trials.

AIM

To assess the efficacy and safety of sildenafil vs placebo according to age subgroups (<65, 65-74, and ≥75 years) in 11,364 men with erectile dysfunction using pooled data from 48 randomized, double-blinded, placebo-controlled, parallel-group, flexible-dose trials.

METHODS

Most trials had a 12-week treatment duration. The starting sildenafil dose was 50 mg, taken 1 hour before sexual activity, with subsequent adjustment to 100 or 25 mg based on efficacy and safety. Men taking nitrate therapy or nitric oxide donors and men with severe cardiac failure, unstable angina, or recent stroke or myocardial infarction were excluded. Efficacy analyses included all subjects with baseline and at least one postrandomization evaluation. Safety analyses included subjects who received study medication.

MAIN OUTCOME MEASURES

The International Index of Erectile Function and a global assessment question ("Did the treatment improve your erections?").

RESULTS

Mean International Index of Erectile Function scores for question 3 (frequency of penetration), question 4 (maintenance of erections after penetration), and the erectile function domain were statistically significantly improved with sildenafil vs placebo for each age subgroup; orgasmic function, intercourse satisfaction, sexual desire, and overall satisfaction domain scores also were statistically significantly improved with sildenafil vs placebo. The percentage of men reporting improved erections on the global assessment question was statistically significantly higher with sildenafil vs placebo for all age subgroups; the percentage with sildenafil tended to decrease with increasing age (<65 years, 80%; 65-74 years, 69%; ≥75 years, 59%). The most common adverse events with sildenafil were headache and flushing in each age subgroup.

CONCLUSION

Sildenafil is an effective and well-tolerated treatment for erectile dysfunction regardless of patient age, including men at least 75 years old.