By Benjamin
RyanNBC News
As any sports fan knows, thanks to the relentless pace of Viagra and Cialis commercials during games, mixing erectile dysfunction drugs with nitrates for chest pain can cause a dangerous drop in blood pressure.
Most medical guidelines advise men not to combine the two types of medication.
However, researchers in Denmark and the United States have recently found that significant numbers of men get overlapping prescriptions for both classes of drugs.
But tests suggest they don't seem to suffer negative health outcomes, such as heart attacks, as a result.
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"We were a bit surprised that we didn't find an increased risk," explained Dr Anders Holt, a researcher at Copenhagen University Hospital Herlev-Gentofte.
He is the lead author of a study published Monday in the Annals of Internal Medicine, which identified a sharp escalation in the co-prescription of erectile dysfunction drugs and nitrates among Danish men.
The researchers did not report any conflicting links with the pharmaceutical industry.
So how do men manage to take the drugs safely?
Viagra pill boxes manufactured by the Pfizer company. Christophe Gateau / Alliance via Getty Images
Although the new study couldn't figure out how the men took each medication, Holt suspects that the lack of apparent health consequences is that people with coronary artery disease typically take long-acting nitrate medications in the morning and tend to take medications for erectile dysfunction at night
The length of time could be sufficient to avoid harmful drug interactions.
But medical groups like the American Heart Association advise men to avoid taking nitrates for at least 24 hours after taking shorter-acting erectile dysfunction drugs like Viagra (sildenafil) and Levitra (vardenafil), and within at least 48 hours after taking a longer-acting medication, such as Cialis (tadalafil).
widely used drugs
In 2019, more than 4 million men and women in the United States received prescriptions for the top three nitrates — nitroglycerin, nitrofurantoin and isosorbide — according to the Top 300 list of drugs from drug statistics website ClinCalc.com.
Some 1.4 million men were prescribed Viagra and Cialis.
A 2008 study estimated that 3% of men in the United States experience severe erectile dysfunction, 6% moderate erectile dysfunction, and 26% mild erectile dysfunction.
And a 2020 paper estimated that 2.4 million men age 40 and older have doctor-diagnosed chest pain.
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Both ED drugs and nitrates cause blood vessels to dilate, which can be dramatically increased if the drugs are taken together, potentially causing a sharp drop in blood pressure.
This increases the risk of major cardiovascular problems, such as heart attacks or strokes.
Experts also advise against taking amyl nitrate, known as "poppers" and used as a recreational drug, with erectile dysfunction medications.
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Spacing out doses of erectile dysfunction drugs and nitrates "will decrease the chance of a drug interaction," says Dr. Robert A. Kloner, a professor of medicine at the University of Southern California who led some of the studies. the key studies that established the safety protocol of the American Heart Association.
(Kloner is a paid consultant for Sanofi, which has an agreement with Eli Lilly to sell Cialis in several countries if it becomes an over-the-counter drug.)
Denmark results
In the new Danish study, Holt and colleagues analyzed the medical records of nearly 250,000 Danish men aged 30 to 85 with ischemic heart disease.
About 42,000 of them had stretches during which they received ongoing nitrate prescriptions.
Between 2000 and 2018, the researchers found that the rate of prescription of erectile dysfunction drugs increased tenfold in the entire group, while it shot up twentyfold among those taking nitrates.
In the last five years of the study period, 9% of those in the latter group filled at least one prescription for a drug such as Viagra within three years of starting nitrates.
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The authors analyzed health outcomes during the periods in which the men received prescriptions for both types of drugs and compared them with the results during the periods in which they received only one of those drugs.
The data suggested that the simultaneous prescription of the two drug classes was not associated with any increase in heart health problems, such as cardiac arrest, heart attack or stroke.
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Kloner, who was not involved in the research, explained that the findings suggest "that health care providers are likely to feel more comfortable prescribing these two drug classes despite the guidelines and are at least educating their patients." so they don't take them at the same time."
The study is limited by the fact that the study authors couldn't know for sure when the men actually took each of the drugs.
But when they adjusted their analysis to focus on periods one to four weeks after the men received the new prescriptions for erectile dysfunction drugs, the results held up.
The authors suggest that it is also possible that some men do experience drops in blood pressure from taking both drugs, but that this does not cause health problems significant enough for them to go to an emergency department.
The researchers only had access to the data from the hospitals, not the medical records of the GPs.
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The study also failed to take into account drugs that men obtain on the black market, a common practice among those seeking drugs such as Viagra.
Similar results in the US.
A US study by pharmaceutical company Sanofi, published in August in The Journal of Sexual Medicine, reached similar conclusions.
The drugmaker's researchers analyzed electronic medical records spanning 2012 to 2016 for more than 168,000 American men who had at least one prescription for erectile dysfunction drugs.
Of the 480,000 men who had one or more prescriptions for nitrates, 3,167 received medications from both drug classes during overlapping periods, without any apparent risk of cardiovascular health problems.
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The study also had access to appointment notes from healthcare staff.
Those records indicated that in half of the co-prescribing cases, doctors warned their patients about the dangers of taking the drugs together or instructed them on how to mitigate the risk of drug interactions.
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Holt stressed that men's sexual health and well-being are just as important as the rest of their physical health.
“You can definitely own both drugs,” Holt advised men who are candidates for taking both nitrates and erectile dysfunction drugs.
“But certainly don't take them at the same time.
We have no proof that this is safe."
Raymond Rosen, associate professor of psychiatry and behavioral services at the University of California San Francisco School of Medicine, said, “Erectile dysfunction medications like Viagra have been a boon to many men and their partners who suffer from this common but potentially disturbing male disorder.
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"New evidence," said Rosen, who was not involved in any of the recent studies, "has challenged this long-held belief" that men can't take both nitrates and erectile dysfunction drugs.
Still, he reminded that "men should always check with their doctor or health care provider before making any changes to any of these medications."
