In 2018, 20 years have passed since the arrival of sildenafil (Viagra), the first accessible and effective treatment against male sexual impotence or erectile dysfunction. This drug, which is administered orally, inhibits the enzyme phosphodiesterase 5 and significantly increases the production of nitric oxide, which is the most potent natural vasodilator known.
Initially, its effects against arterial hypertension, angina pectoris and acute myocardial infarction were investigated, but it soon became clear that its most relevant clinical effect was the improvement that men experienced in their sexual activity. The dilation of the blood vessels that it produces is especially intense in the penis, which enhances the erection.
In what patients is it indicated?
Sildenafil has two indications: in patients with erectile dysfunction and in those suffering from pulmonary arterial hypertension, which is a rare disease. In this second case, what is sought is to expand the artery of the lung to get enough blood.
Regarding the main reason for the use of this drug, Javier Romero-Otero, National Coordinator of the Andrology Group of the Spanish Association of Urology, emphasizes that “every male patient who has an erectile dysfunction should be done a study to find out what the causes are. ”
In most cases, the head of Andrology-Reconstructive Surgery of the University Hospital 12 de Octubre, Madrid, continues, “erectile dysfunction is equal to vascular disease, which means that the cardiovascular risk factors that cause a myocardial infarction or a stroke are the same ones that cause erectile dysfunction. ”
For that reason, nowadays it is considered that this sexual problem “is a window to the cardiovascular health of the male and it is important to diagnose it because often the biggest problem is not that a man can not have sexual relations, but has a vascular disease generalized that can end up triggering a heart attack, a stroke or an ischemia in the lower limbs (obstruction of one of the main arteries responsible for the blood supply to the legs).
What is the most appropriate dose?
Romero-Otero recognizes that the administration of sildenafil “should be initiated -although most of the time it is not done- at the lowest dose, which is 50 mg per day, and if there is no response, it should be increased to 100 mg ” It is also advisable to try to lose to 25 mg when 50 mg is achieved a good result.
The reason why it is usually started with 100 mg daily and then down to 50 mg if the response is adequate is that, being a “relatively expensive drug and not covered by the public health system, many patients who test the dose of 50 and it does not work for them, they do not want to go to 100. ” In short, we opt for the option that most favours the continuity of treatment.
The dose used for the treatment of pulmonary hypertension is 20 mg three times a day.
At what point should it be taken?
Sildenafil should be taken orally with a margin of at least 45 minutes before sexual intercourse and taking into account that its effects last up to 6 hours. Other drugs from the same family can promote erection up to 24 hours after ingestion.
The urologist points out that “it requires stimulation for the erection to occur. This type of drugs potentiate and maintain an erection for a longer time, but they are not capable of initiating it. ”
Can it be taken with alcohol or food?
To achieve an optimal effect and prevent adverse effects, it is important to respect the intake of sildenafil only once a day, as well as not consume it with food or alcoholic beverages, as it interferes with both fats and alcohol.
María Perelló, head of the Medication Information Center of the Official College of Pharmacists of Barcelona (COFB), explains that when taken with food, ” the start of its pharmacological action could be delayed compared to when it is taken on an empty stomach”.
Romero-Otero gives an example of intake: “If one is going to have a romantic dinner, the logical thing is to take the pill an hour and a half before so that it does not interact with the food and is covered before the 6th birthday is served. hours of action. ”
What are the main risks and adverse effects?
The urologist emphasizes that sildenafil is a very safe drug. The main risk is that derived from the consumption of doses higher than those recommended, which produce “a shortage of blood to the heart because vasodilation occurs almost exclusively in the penis and most of the blood accumulates in the skin”. The most serious consequence may be a myocardial infarction.
As for the possible adverse effects, the specialist cites as examples the redness of the face and ears, headache or back pain.
The pharmacist denies a frequent belief about the long-term effects of sildenafil: “There is no evidence that it causes dependence.” It is also not true that it is effective for “the treatment of premature ejaculation “.
Who should not take sildenafil?
The use of sildenafil is contraindicated in patients taking nitroglycerin or other nitrates for the treatment of myocardial infarction. This interaction can be very serious. Those who take nitroglycerin suffer from serious illnesses. “A person with severe heart failure can not breathe, drowns,” stresses Romero-Otero. “To think that these patients do not take sildenafil is common sense”. The same can be applied to those who suffer from severe renal, hepatic or respiratory failure, who are also unable to have an active sex life.
There are other isolated contraindications, such as certain patients with retinitis pigmentosa or uncontrolled hypertension, but the expert states that “they are very specific cases”.
With or without a prescription?
Sildenafil is dispensed in Spain with a prescription, but in the United Kingdom, a non-prescription presentation called Viagra Connect is marketed. In this way, men who do not suffer from erectile dysfunction but want to have more powerful and lasting erections can also consume the pill.
At the moment, this option is not planned in Spain. The urologist considers that it is an interesting debate and believes that the sale without a prescription could be considered “As long as there is a sufficient health education of the population” to control the risks.
However, he believes that if this drug were sold freely, the opportunity could be lost for the doctor to detect those cases in which erectile dysfunction is a symptom of a more serious vascular disease.
Perelló agrees that “erectile dysfunction treatments should be prescribed by a specialist who has established the diagnosis and knows the patient’s clinical history, in a way that allows him to rule out associated pathologies that may be the source of the problem.”
Beware of online sales
Since the beginning of the commercialization of Viagra, known as the blue pill, this drug has been one of the most falsified in the world and most of these copies are sold online.
Romero-Otero warns of the risks of buying Sildenafil on the Internet: “I think it’s nonsense. Who buys it online is putting health at risk. It’s not just that you get the desired response, but it can trigger important side effects.”
The COFB spokeswoman recalls that medicines “must always be purchased through the pharmacy channel. The pharmacist, as a health professional, can guarantee their conditions, in addition to offering health advice. This action is complementary to the previous diagnosis and prescription by the doctor”.
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