Nose-bleeds after sildenafil (Viagra)

[Rhinitis medicamentosa]

One type of non-allergic non-infectious rhinitis is represented by a heterogeneous group of rhinitis medicamentosa, which can be divided into several pathogenetic types. The most common rebound nasal congestion associated with the use of topical decongestants. Excessive use of intranasal decongestants leads to a decrease in the number of alpha-adrenoreceptors on the surface of cell membranes and uncoupling their connection with the G-protein and the development of tachyphylaxis. To prevent the development of rebound nasal congestion caused by topical decongestants, it is important to limit the frequency of their use. In most cases, the duration of the use of vasoconstrictor drugs should be limited to 5-7 days, according to Patient information leaflets for the drugs. However, in patients who have had a history of episodes of rebound nasal congestion, which develops including the previously indicated periods, the duration of decongestant therapy should be limited to 3 days. Rhinitis associated with local inflammation is caused by the intake of acetylsalicylic acid (ASA) or other non-steroidal anti-inflammatory drugs. Currently, the so-called "aspirin triad" is well known - a combination of bronchial asthma, rhinosinusitis (often polyposis) and intolerance to ASA. Neurogenic rhinitis develops due to the use of drugs that violate vascular tone, for example, antihypertensive drugs or type 5 phosphodiesterase inhibitors. Drug-induced rhinitis has a significant impact on the patient's quality of life: nasal congestion, rhinorrhea, secondary night apnea, insomnia as a result of nasal breathing disturbances, headaches, irritability, weakness after sleepless nights disturb patients to a large extent. Timely diagnosis and withdrawal of a provocative drug, the use of topical corticosteroids in case of severe rhinitis are the basis of the treatment of rhinitis medicamentosa. In severe cases, there is a need, including surgical treatment, such as, for example, submucosal laser destruction of the lower nasal concha.

Non-allowed Pharmacologically Active Substances in Physical and Sexual Performance Enhancing Products

Background:

Recently, a large amount of physical and sexual performance enhancing products have started to be freely sold mainly on internet web sites as dietary supplements. However, there a high suspicion that pharmacologically active substance, prohibited in these products, can be present to provide the expected effect.

Methods:

A simple and rapid systematic toxicological analysis by gas chromatography-mass spectrometry and liquid chromatography-tandem mass spectrometry has been applied after a liquid-liquid extraction at acidic, neutral and alkaline pH with chloroform-isopropanol (9:1 v/v). The assays were validated in the range from 10 mg to 250 mg/g products showing a good linearity for the calibration curves (r2 ≥0.99). Mean extraction recoveries of analytes from different products were always higher than 90% and intra-assay and inter-assay precision and accuracy were always better than 15%.

Results:

The developed method was applied to the analysis of products with a high percentage of sales in websites and smart and sexy shops. In twelve of eighty supplements, anabolic steroids, anti-estrogenic drugs, psychoactive substances and sildenafil and analogs were identified and quantified.

Conclusion:

Eventual health hazards caused by the hidden presence of pharmacologically active substances in physical and sexual performance enhancing products are reported.

Phosphodiesterase-5 Inhibitor Use: An Under-Reported Cause of Profuse Nasal Bleeding

BACKGROUND

Phosphodiesterase-5 (PDE-5) inhibitors enhance penile erection and have gained popularity not only for erectile dysfunction, but also in recreational settings. Nevertheless, adverse effects have been associated with their use, with nasal bleeding among them. PDE-5 inhibitor action is materialized through the inhibition of the cyclic guanosine monophosphate (cGMP) enzyme. cGMP is present at several sites of the human body in addition to the corpus cavernosum, leading to the adverse effects associated with its nonselective inhibition.

CASE REPORTS

Two male patients with severe epistaxis who were taking PDE-5 inhibitors for erectile dysfunction or recreational purposes are discussed. Surgical intervention was required in both patients to control the nasal hemorrhage. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Nasal bleeding in patients who are taking PDE-5 inhibitors might represent an under-reported cause of epistaxis because of the unwillingness of most male patients to discuss issues pertaining their use without hesitation. Yet such episodes are rather profuse. This is especially true when the venous engorgement caused in the nasal mucosa by the smooth muscle relaxant effect of PDE-5 inhibitors is combined with a second event (e.g., specific drugs or blood dyscrasia). Emergency physicians should be also aware of the possibility that in the coming years the number of such cases might increase because of the increased use of these medications for erectile dysfunction or recreational purposes. It is likely that these patients could not be managed conservatively, but would rather require referral to an Ear, Nose, and Throat Department for surgical intervention.

[Current aspects in epistaxis]

A survey of current literature on the topic of epistaxis revealed only a circumscript number of publications with a high methodologic value. The analysis of these publications showed that there is a controversy on the necessity of routine coagulation tests in epistaxis patients. These tests should only be performed in cases with clinical evidence of a coagulation disorder. Also, there is an ongoing controversy on the value of local cooling with ice or cold packs. Nasal creams and decongestive nose drops have been found to be effective in uncomplicated epistaxis. Rhinoscopically and endoscopically targeted coagulation of bleeding vessels and nasal packing are recommended treatment options. There is a debate on discontinuation of anticoagulant therapy, if INR is within normal limits in Cumadin patients. Intractable epistaxis requires a broad armamentarium of different diagnostic and therapeutic options. Recurrent epistaxis in hereditary syndromes remains to be a challenge, although some advances have been made in diagnosis and symptomatic treatment. Some new medical drugs, as Viagra or Cialis may have nosebleeds as side-effects.

Simultaneous determination of sildenafil, vardenafil and tadalafil as forbidden components in natural dietary supplements for male sexual potency by high-performance liquid chromatography-electrospray ionization mass spectrometry

A high-performance liquid chromatographic method coupled with ultraviolet detection and electrospray ionization mass spectrometry (HPLC-UV-ESI-MS) was developed for simultaneous determination of banned additives-sildenafil, vardenafil and tadalafil in dietary supplements for male sexual potency. The separation was achieved on a C18 column with acetonitrile and aqueous solution (20 mmol ammonium acetate, 0.2% formic acid) as mobile phase at a flow rate of I ml/min with a linear gradient program. UV detection was at 292 nm. Identification of drugs was accomplished using ESI-MS. Good linearity between response (peak area) and concentration was found over a concentration range of 0.8-80 microg/ml for sildenafil; 2.25-225 microg/ml for vardenafil; and 1.1-110 microg/ml for tadalafil, with regression coefficient is better than 0.999. The recovery of the method ranged from 93.3 to 106.1%, and the relative standard deviation varied from 2.0 to 5.6% (n = 6). The method has been successfully applied to the analysis of practical samples of natural dietary supplements.

Recurrent epistaxis after treatment with tadalafil (Cialis)

A 66-year-old male presented to our department with recurrent epistaxis. On examination it was not possible to identify the source of the bleeding, despite various measures. The bleeding stopped spontaneously each time and advice on nose bleeds was given to the patient. During a consultation the patient volunteered that the trigger for the epistaxis appeared to have been energetic sexual activity. To enhance his sexual performance he had taken Viagra; however, on stopping the Viagra and changing to the newer drug Cialis, the episodes of epistaxis continued. We document what we believe to be the first case of epistaxis caused by Cialis.

The rhinological side-effects of systemic drugs

Patients often present to otolaryngologists with nasal symptoms where no cause is apparent. A number of patients seen in outpatient departments are taking medication for other conditions and the adverse affects of these drugs may potentially be the source of these symptoms. In this short review, we present an overview of the more common drugs that may be responsible and outline the possible mechanisms where these are known.