Viagra not working first time

viagra not working first time

Viagra didn’t work? Here are some tips.
So the little blue pill was a big disappointment. You took Viagra (generic name sildenafil) for the first time, and it didn’t give you the erection you were expecting. Don’t get discouraged, though. Certain things can affect how well the drug works for you, including how soon after you take it you try to get an erection, what you ate and drank before you took it, and whether you have the right dosage or medication.
We’ve covered everything you need to know and what you should ask your healthcare provider if it’s still not working.
Treat erectile dysfunction for up to 95% less than the cost of Viagra®
Treat erectile dysfunction for up to 95% less than the cost of Viagra®
How does Viagra work?
To understand why Viagra didn’t work, it’s helpful to understand how it’s supposed to work. Erections happen when you’re aroused, and your brain triggers blood to flow into your penis. Anything that blocks that blood flow, or cuts it short when you’re trying to keep it up, can lead to erectile dysfunction—the inability to get or maintain an erection long enough for satisfying sex.
Things that can disrupt the blood flow include problems with the blood vessels themselves (like plaque buildup in the arteries associated with heart disease, damage to the blood vessels or nerves from high blood sugar associated with diabetes, and more).
So how does Viagra work? Viagra works by keeping the blood in the penis once it gets there. But that’s why the drug doesn’t work as an instant boner pill: You need to be aroused in order for it to work.
Why might your dose not be working for you? These are some things to explore:
How to get better results from Viagra: 8 tips.
If Viagra (generic name sildenafil; see Important Safety Information) isn’t working the way you want it to, there are some simplet things you can try before throwing in the towel. Here are eight strategies.
1. Make sure you’re aroused.
For better or worse, Viagra isn’t a magic pill. It won’t give you an instant erection. You still need to be aroused to get an erection, and Viagra can help strengthen or maintain your erection. If you tried Viagra and the results were underwhelming, maybe your head wasn’t in the game that night, or you were stressed or tired. You might just need to give things another try.
To get the best results from Viagra, make sure you get yourself in the mood. Some people find that trying the medication on their own first is helpful so they can learn how their body responds to it. Also, there’s nothing more arousing than intimacy, so speak to your partner about what you both like to make sure you each get the best shot at having an enjoyable experience.
2. Give it enough time to work (but don’t wait too long)
Using Viagra can require some planning, but don’t let that zap your spontaneity. Aim to take your dose about one hour before you plan to have sex. The drug should remain effective for up to four hours. But keep in mind, if you popped a pill right before heading to bed (or at lunchtime before your 8 pm date) it is less likely to work when you need it to. You might want to try again, ensuring you take Viagra within the proper effectiveness window.
Some people find this inconvenient. Luckily there are other medication choices. Cialis (generic name tadalafil; see Important Safety Information), for example, can be taken daily and stays in your system for up to 36 hours. Some people find that this regimen gives them more flexibility and requires less planning than medication like Viagra.
3. Skip high-fat meals before taking Viagra.
High-fat meals can delay the absorption of Viagra from your digestive system into your bloodstream, meaning that the medication might not be as effective as you expected. If you ate a heavy or high-fat meal before taking Viagra, your erection might come later than expected, be less strong than you expected, or won’t last as long as you would’ve liked. You can try taking the medication on an empty stomach to see how your body responds.
4. Alcohol can make it hard to stay hard.
Alas, Viagra is no cure for “whiskey dick.” Alcohol is a depressant that affects every system in the body, including those that produce an erection. Alcohol, recreational drugs, and marijuana can all worsen the symptoms of ED. And chronic heavy drinking can damage the liver, heart, and nerves and reduce testosterone—all of which can lead to ED. Opt for an alcohol-free beverage at dinner and see if that helps.
5. Maybe a different drug or treatment option is right for you.
Simply put, Viagra might just not be your jam. There are several other strategies you can try for ED, including other oral medications such as Cialis (tadalafil), penis pumps, cock rings, ED drugs delivered by injection (such as alprostadil), and sonic therapy. Speak with your provider about the various treatment options. Some you can explore on your own.
6. Speak with your healthcare provider about a different dose.
Brand name Viagra is available in three dosages: 25 mg, 50 mg, and 100 mg. The most common starting dose is 50 mg, but your healthcare provider will determine the right dose for you based on your medical history, current health, and the medications and supplements you’re taking. If Viagra isn’t working for you, you might need a higher dose. But don’t experiment on your own: Always speak with a healthcare provider about dosage changes and never take more than one dose of Viagra in any 24 hour period.
7. Get treatment for underlying conditions.
The potential causes of ED are numerous and could involve things including depression, stress, or performance anxiety. ED can also sign of several other serious health conditions, including heart disease, high blood pressure, or diabetes. Staying up to date on regular health checkups and keeping your blood sugar and blood pressure in check are important for your overall health. But they can also help you manage your ED. Make sure to check in with your healthcare provider to ensure you don’t have any underlying conditions that might be contributing.
Certain medications can also affect the way your body absorbs Viagra. There’s a special enzyme in your liver called cyp3a4, and it’s involved in breaking down Viagra in your bloodstream. Other medications can sometimes speed up this process, making your Viagra dosage less effective. Medications and supplements that might affect the effectiveness of your Viagra include phenobarbital, phenytoin, rifampicin, St. John’s Wort, and glucocorticoids, among others.
8. Make sure you’re getting enough exercise.
Studies have found that being sedentary is a major risk factor for ED. Studies have found that men who were inactive or moderately active (30 to 149 minutes of physical activity a week) had 40% to 60% higher odds of ED compared to active men who got 150 or more minutes of physical activity weekly (Gerbild, 2018). Why? Viagra works best when you’re healthy, including your heart, so it can effectively pump blood throughout the body—including to the penis. Getting regular exercise is one of the best things you can do to ensure cardiovascular health.
Potential side effects of Viagra.
You might also have experienced a side effect of Viagra that made your sexual experience less than ideal. Common side effects of Viagra include dizziness, headache, flushing, upset stomach or indigestion, increased sensitivity to light, blurred vision, “blue-tinted” vision, a stuffy or runny nose, back pain, insomnia, rash, and muscle pain.
Less common side effects of Viagra include priapism (a prolonged erection that won’t go away), heart attack-like symptoms, eye problems such as sudden vision loss, ringing in ears or hearing loss, seizures, or swelling in the extremities. (If you experience any of those, seek medical attention right away).
If you took Viagra and were disappointed by the results, that’s okay. Don’t throw in the towel. Sometimes our sexual health needs a bit more attention than usual. Consult your healthcare provider about next steps. A healthy sex life is worth it.
Disclaimer.
If you have any medical questions or concerns, please talk to your healthcare provider. The articles on Health Guide are underpinned by peer-reviewed research and information drawn from medical societies and governmental agencies. However, they are not a substitute for professional medical advice, diagnosis, or treatment.
References.
Gerbild, H., Larsen, C. M., Graugaard, C., & Areskoug Josefsson, K. (2018). Physical activity to improve erectile function: a systematic review of intervention studies. Sexual Medicine , 6 (2), 75–89. doi: 10.1016/j.esxm.2018.02.001. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5960035/

Is it safe to take viagra every day?

is it safe to take viagra every day?

Is Viagra safe?
Sildenafil, which is sold under the brand name Viagra, is an oral medication that is used to treat erectile dysfunction (ED). Whilst many people are aware of what Viagra does in relation to erectile behaviour, some people have questions about its safety.
In this article, we are going to aim to address these concerns by looking more closely at how Viagra works, who can take Viagra, how to take it safely and any risks associated with its use.
How does Viagra work?
An erection, which is the hardening of the penis, occurs when the sponge-like tissue in the penis fills with blood. When the brain becomes aroused, signals are sent to the penis, leading to the release of a chemical called cGMP. cGMP relaxes particular muscle cells in the tissue of the penis, and this allows an increase in blood flow to the area.
Erectile dysfunction is the inability to get or maintain an erection. This can be due to a variety of reasons including certain medications, stress, mental health conditions, hormone problems, narrowing of the blood vessels and high blood pressure.
Viagra treats erectile dysfunction by temporarily increasing the blood flow to the penis when sexually excited. It belongs to a group of medicines called phosphodiesterase type 5 (PDE5) inhibitors and works by relaxing the blood vessels in the penis. It does this by reducing the effect of PDE5, which is an enzyme that is released after ejaculation and causes cGMP to break down, leading to the loss of an erection. Viagra stops cGMP from being broken down, meaning that the arteries in the penis stay relaxed, thereby increasing blood flow to the penis.
It usually takes 30-60 minutes for Viagra to take effect so it should be taken at least one hour before you intend to have sex. It stays in your bloodstream for four-six hours, so you should be able to get an erection anytime during that time as long as you are aroused. It will not give you an erection if you are not aroused.
How to take Viagra safely.
Taking Viagra is generally straightforward and once you have taken it for the first time, you’ll likely have a better idea of how your body responds to it. For best results and to reduce the likelihood of any side effects, it is best to follow the following guidelines when taking Viagra:
Only take Viagra once a day Swallow tablets whole with water or juice Ideally, take on an empty stomach Take an hour before you want to have sex Refrain from drinking too much alcohol before taking it Don’t taking Viagra with recreational drugs including, poppers (amyl nitrate), ecstasy, cocaine, and LSD Do not take Viagra if you are taking certain heart medication containing nitrates (e.g. GTN spray, ISMN or ISDN tablets, Nicorandil) or if you are using certain creams to treat anal fissures. Taking this alongside Viagra can cause a fatal reaction.
How much Viagra should I take?
Viagra comes in three different strengths; 25mg, 50mg and 100mg. Viagra connect is the over the counter version of Viagra 50mg.
The standard recommended dose of Viagra is 50mg to be taken as and when you need it. However, some people take different dosages of Viagra following consultation with their GP or pharmacist.
Is Viagra dangerous?
Whilst Viagra is used safely by millions of men across the globe, it can be dangerous if used incorrectly. Viagra can be dangerous if you take more than prescribed, if you have certain medical conditions, or take certain medications. Taking Viagra with recreational drugs, and in particular, poppers can cause collapse due to a sudden, extreme drop in blood pressure.
Can I take Viagra?
Viagra can be used by most men over the age of 18 who are experiencing erectile dysfunction.
When is it not safe to take Viagra?
There are some people that Viagra may not be suitable for. You should speak to your doctor or pharmacist before taking Viagra if you are on any medications that may be causing erectile dysfunction or if you have:
Ever previously reacted to sildenafil or any other medicine Low blood pressure Angina (chest pain) and take nitrates for this A serious liver or heart condition Sickle cell anaemia Multiple myeloma A stomach ulcer Recently had a stroke, heart attack or other heart condition A rare inherited eye disease such as retinitis pigmentosa A penis deformity such as Peyronie’s disease Ever had an erection that has lasted for more than four hours.
You als must not take Viagra or other PDE5 inhibitors if you take or are prescribed any of the following:
Nitrate containing medication to treat or prevent chest pain such as: GTN spray or tablets, isosorbide mononitrate, isosorbide dinitrate, nicorandil GTN cream to treat anal fissures (rectogesic) Certain HIV medications – there are quite a few that interact so please ask your specialist about this Riociguat for the treatment of PAH.
What are the side effects of taking Viagra?
Like all medications, Viagra can cause side effects in some people. Common side effects of Viagra include:
Headaches Dizziness Nausea Flushing, including hot flushes Indigestion Nasal congestion (stuffy nose) Blue tinge to vision or blurred vision.
Serious side effects from Viagra are rare, occurring in less than 1 in 1,000 people. Serious side effects of Viagra include:
Chest pain A prolonged and a painful erection lasting several hours (priapism) An allergic reaction (wheezing, breathing difficulties, or swelling of the eyelids, face, lips, or throat) Serious skin reactions such as skin peeling, swelling, and blistering of the mouth, genitals and around the eyes Fits (seizures) Tightening of the throat Palpitations Sudden decrease or loss of vision Blood in the urine.
So, is it safe to take Viagra?
Generally speaking, yes, Viagra is safe to take for most men over the age of 18. However, it isn’t suitable for everyone as certain conditions and medications can increase the likelihood of dangerous side effects. Even if it’s thought to be safe for you to take Viagra, it might not suit you or cause (serious) side-effects or interact with medication or supplements.
If you are experiencing erectile dysfunction and feel Viagra would be beneficial, you should always consult your doctor, or a pharmacist first and then proceed with their advice and recommended dose. Viagra can be prescribed but it is also available without a prescription in the form of Viagra Connect. This type of Viagra can be purchased over the counter and online.
If you’d like to learn more, why not take a look at our guide to what Viagra does that you may find helpful. You can also request ED treatments discreetly, following a simple online consultation with our clinicians, which comprises of a short medical questionnaire to assess your suitability for medication.
Looking for erectile dysfunction treatment?

The testosterone curse

the testosterone curse

How women have to manage men’s Toxic Testosterone

Former soldier Kevin Godlington on how, unbeknownst to him, his wife had to deal with unwanted attention on a busy train while he sat nearby, and the realisations that came when she revealed why she didn’t tell him about it at the time.

One of the defining and primal differences that separate us men from our women folk is the struggle with testosterone. The delicious hormone rampant in our bodies, rushing though our veins and adrenal system to our perilous detriment and also to our salvation and saviour. It’s the stuff that pre-dates ‘fight of flight’ theories, it is the very basis of our survival and evolution and something that presents as both curse and curiosity.

Testosterone is the key male sex hormone that regulates fertility, muscle mass, fat distribution, and red blood cell production, it is also the stuff that makes us more than a little predisposed to beating the shit out of each other after a few beers. Women also produce the hormone in much smaller amounts. Testosterone, part of a hormone class known as androgens, is produced by the testicles after stimulation by the pituitary gland, which is located near the base of the brain, and it sends signals to a male’s testicles (or to a woman’s ovaries) that spark feelings of sexual desire and aggression. Awesome. Sex and violence, right?

Testosterone plays a significant role in the arousal of these behavioural manifestations in the brain centres involved in aggression and on the development of the muscular system that enables their realization. There is much evidence that testosterone levels are higher in individuals with aggressive behaviour, such as prisoners who have committed violent crimes and soldiers who are trained and motived to be violent.

As a former soldier my testosterone has saved my ass on more than one occasion, and in my younger life I was very happy to embroil myself in mortal pub combat after ten pints. It’s not big, it’s just what it is and that’s that. Most of it was harmless fisticuffs and doesn’t define me, nor does it make me feel particularly proud of my historical misdemeanours.

However, what brought some sobering focus to this issue of testosterone was an event that occurred a few months ago when I was out with my wife and a good male friend – also a soldier, more freshly de-mobbed than I, and only recently reunited with our sceptred isle from Afghanistan – with shall we say, a penchant for short fused interdictions! On the train coming home, I was sat with my mate, chatting about highly intelligent things such as Brexit and Trump whilst to my immediate left my fourteen year old daughter and my wife sat on the two seats to my side, across the aisle, also in deep discussion. Despite my substantial beer intake, I was aware of my environment and surroundings, as every good soldier should be. I’d seen the two young fellas, age circa mid-twenties sat immediately behind my wife and daughter drunkenly minding their own businesses and oblivious to my observational surveillance. The train journey ended and homebound we left. All without incident.

Once home my wife and daughter had a disturbing story to tell: one of these entitled little posh, floppy haired drunken lads had been stroking my wife’s hair, from behind the seat. My daughter and wife had both turned and offered stern and fully focused looks of “stop now or this won’t end well” which evidently, they duly did. Clearly my amazing observational awareness failed owing to copious amounts of ethanol. But what startled me most was my wife’s articulate and detailed explanation as to why she didn’t seek my help and intervention.

“Because you and Doug would have beaten these two idiots up.”

She went on: “men think this is acceptable behaviour when drunk, touching women – but my husband would have ended up in jail for reacting. I feel worried for myself getting touched on a train, but also that I can’t say anything loudly like I wanted to do to this guy, for fear you and Doug would overact: this means the guy got away with being loudly and openly told, NO. He left thinking he had on some way got away with it, that his behaviour was OK.”

I was silent. This shit hit home. She was right, because of my likely predictable aggressive response, this dude actually got away unchecked, clearly the act opposite to what I would have hoped for. It identifies a number of issues here, firstly that some men thinks it ok to stroke my fucking wife’s hair, and secondly, she couldn’t act robustly with this guy for fear of my testosterone infused violent rebuttal.

Freshly equipped with this new information and knowledge, would I react any differently now? Probably, going forward I would let my wife deal with it. Then send Doug in when she’s not looking. (Joking, of course.)

Cialis dosage

cialis dosage

Cialis.
Cialis (tadalafil) is a phosphodiesterase inhibitor used for treating impotence (erectile dysfunction, or ED).
What Are Side Effects of Cialis?
flushing (redness or warmth of the face, neck, or chest), headaches, stomach upset, diarrhea, flu-like symptoms (such as stuffy nose, sneezing, or sore throat), memory problems, muscle or back pain, nausea, low blood pressure, dizziness, blurred vision and changes in color vision, abnormal ejaculation, and prolonged erections (priapism).
Tell your doctor if you have rare but serious side effects of Cialis including:
a painful or prolonged erection lasting 4 or more hours; sudden decreased vision (including permanent blindness, in one or both eyes); a sudden decrease or loss of hearing, sometimes with ringing in the ears and dizziness.
Cialis may cause serious side effects including:
chest pain, pain spreading to the jaw or shoulder, nausea, sweating, vision changes, sudden vision loss, ringing in your ears, sudden hearing loss, and an erection that is painful or lasts longer than 4 hours.
Get medical help right away, if you have any of the symptoms listed above.
Seek medical care or call 911 at once if you have the following serious side effects:
Serious eye symptoms such as sudden vision loss, blurred vision, tunnel vision, eye pain or swelling, or seeing halos around lights; Serious heart symptoms such as fast, irregular, or pounding heartbeats; fluttering in your chest; shortness of breath; and sudden dizziness, lightheartedness, or passing out; Severe headache, confusion, slurred speech, arm or leg weakness, trouble walking, loss of coordination, feeling unsteady, very stiff muscles, high fever, profuse sweating, or tremors.
This document does not contain all possible side effects and others may occur. Check with your physician for additional information about side effects.
Dosage for Cialis.
The recommended dose of Cialis is 5-20 mg per day taken before sexual activity.
What Drugs, Substances, or Supplements Interact with Cialis?
Cialis may interact with rifamycins, antibiotics, antifungals, antidepressants, barbiturates, drugs to treat high blood pressure or a prostate disorder, heart or blood pressure medications, HIV or AIDS medications or seizure medications. Tell your doctor all medications and supplements you use.
Cialis During Pregnancy and Breastfeeding.
Cialis is not approved for use in women and has not been evaluated in women who are breastfeeding.
Additional Information.
Our Cialis Side Effects Drug Center provides a comprehensive view of available drug information on the potential side effects when taking this medication.
DESCRIPTION.
CIALIS (tadalafil) is a selective inhibitor of cyclic guanosine monophosphate (cGMP)-specific phosphodiesterase type 5 (PDE5). Tadalafil has the empirical formula C 22 H 19 N 3 O 4 representing a molecular weight of 389.41. The structural formula is:
The chemical designation is pyrazino[1′;,2′;:1,6]pyrido[3,4-b]indole-1,4-dione, 6-(1,3-benzodioxol-5-yl)2,3,6,7,12,12a-hexahydro-2-methyl-, (6R,12aR)-. It is a crystalline solid that is practically insoluble in water and very slightly soluble in ethanol.
CIALIS is available as almond-shaped tablets for oral administration. Each tablet contains 2.5, 5, 10, or 20 mg of tadalafil and the following inactive ingredients: croscarmellose sodium, hydroxypropyl cellulose, hypromellose, iron oxide, lactose monohydrate, magnesium stearate, microcrystalline cellulose, sodium lauryl sulfate, talc, titanium dioxide, and triacetin.
INDICATIONS.
Erectile Dysfunction.
CIALIS ® is indicated for the treatment of erectile dysfunction (ED).
Benign Prostatic Hyperplasia.
CIALIS is indicated for the treatment of the signs and symptoms of benign prostatic hyperplasia (BPH).
Erectile Dysfunction And Benign Prostatic Hyperplasia.
CIALIS is indicated for the treatment of ED and the signs and symptoms of BPH (ED/BPH).
Limitation Of Use.
If CIALIS is used with finasteride to initiate BPH treatment, such use is recommended for up to 26 weeks because the incremental benefit of CIALIS decreases from 4 weeks until 26 weeks, and the incremental benefit of CIALIS beyond 26 weeks is unknown [see Clinical Studies ] .
DOSAGE AND ADMINISTRATION.
Do not split CIALIS tablets; entire dose should be taken.
CIALIS For Use As Needed For Erectile Dysfunction.
The recommended starting dose of CIALIS for use as needed in most patients is 10 mg, taken prior to anticipated sexual activity. The dose may be increased to 20 mg or decreased to 5 mg, based on individual efficacy and tolerability. The maximum recommended dosing frequency is once per day in most patients. CIALIS for use as needed was shown to improve erectile function compared to placebo up to 36 hours following dosing. Therefore, when advising patients on optimal use of CIALIS, this should be taken into consideration.
CIALIS For Once Daily Use For Erectile Dysfunction.
The recommended starting dose of CIALIS for once daily use is 2.5 mg, taken at approximately the same time every day, without regard to timing of sexual activity. The CIALIS dose for once daily use may be increased to 5 mg, based on individual efficacy and tolerability.
CIALIS For Once Daily Use For Benign Prostatic Hyperplasia.
The recommended dose of CIALIS for once daily use is 5 mg, taken at approximately the same time everyday. When therapy for BPH is initiated with CIALIS and finasteride, the recommended dose of CIALIS for once daily use is 5 mg, taken at approximately the same time every day for up to 26 weeks.
CIALIS For Once Daily Use For Erectile Dysfunction And Benign Prostatic Hyperplasia.
The recommended dose of CIALIS for once daily use is 5 mg, taken at approximately the same time every day, without regard to timing of sexual activity.
Use With Food.
CIALIS may be taken without regard to food.
Use In Specific Populations.
Renal Impairment.
Creatinine clearance 30 to 50 mL/min: A starting dose of 5 mg not more than once per day is recommended ,and the maximum dose is 10 mg not more than once in every 48 hours. Creatinine clearance less than 30 mL/min or on hemodialysis: The maximum dose is 5 mg not more than once in every 72 hours [see WARNINGS AND PRECAUTIONS and Use In Specific Populations ].
Erectile Dysfunction.
Creatinine clearance less than 30 mL/min or on hemodialysis: CIALIS for once daily use is not recommended [see WARNINGS AND PRECAUTIONS and Use In Specific Populations ] .
Benign Prostatic Hyperplasia And Erectile Dysfunction/Benign Prostatic Hyperplasia.
Creatinine clearance 30 to 50 mL/min: A starting dose of 2.5 mg is recommended. An increase to 5 mg maybe considered based on individual response. Creatinine clearance less than 30 mL/min or on hemodialysis: CIALIS for once daily use is not recommended [see WARNINGS AND PRECAUTIONS and Use In Specific Populations ] .
Hepatic Impairment.
Mild or moderate (Child Pugh Class A or B): The dose should not exceed 10 mg once per day. The use ofCIALIS once per day has not been extensively evaluated in patients with hepatic impairment and therefore, caution is advised. Severe (Child Pugh Class Cmax): The use of CIALIS is not recommended [see WARNINGS AND PRECAUTIONS and Use In Specific Populations ] .
Mild or moderate (Child Pugh Class A or B): CIALIS for once daily use has not been extensively evaluate din patients with hepatic impairment. Therefore, caution is advised if CIALIS for once daily use is prescribed to these patients. Severe (Child Pugh Class Cmax): The use of CIALIS is not recommended [see WARNINGS AND PRECAUTIONS and Use In Specific Populations ] .
Concomitant Medications.
Nitrates.
Concomitant use of nitrates in any form is contraindicated [see CONTRAINDICATIONS ] .
Alpha-Blockers.
When CIALIS is coadministered with an alpha-blocker in patients being treated for ED, patients should be stable on alpha-blocker therapy prior to initiating treatment, and CIALIS should be initiated at the lowest recommended dose [see WARNINGS AND PRECAUTIONS , DRUG INTERACTIONS and CLINICAL PHARMACOLOGY ] .
CIALIS is not recommended for use in combination with alpha-blockers for the treatment of BPH [see WARNINGS AND PRECAUTIONS , DRUG INTERACTIONS and CLINICAL PHARMACOLOGY ].
CYP3A4 Inhibitors.
For patients taking concomitant potent inhibitors of CYP3A4, such as ketoconazole or ritonavir, the maximum recommended dose of CIALIS is 10 mg, not to exceed once every 72hours [see WARNINGS AND PRECAUTIONS and DRUG INTERACTIONS ] .
For patients taking concomitant potent inhibitors of CYP3A4, such as ketoconazole or ritonavir, the maximum recommended dose is 2.5 mg [see WARNINGS AND PRECAUTIONS and DRUG INTERACTIONS ] .
HOW SUPPLIED.
Dosage Forms And Strengths.
Four strengths of almond-shaped tablets are available in different sizes and different shades of yellow:
2.5 mg tablets debossed with “C 2 1/2” 5 mg tablets debossed with “C 5” 10 mg tablets debossed with “C 10” 20 mg tablets debossed with “C 20”
Storage And Handling.
CIALIS (tadalafil) is supplied as follows:
2.5 mg tablets debossed with “C 2 1/2” Blisters of 2 x 15 NDC 0002-4465-34 5 mg tablets debossed with “C 5” Bottles of 30 NDC 0002-4462-30 Blisters of 2 x 15 NDC 0002-4462-34 10 mg tablets debossed with “C 10” Bottles of 30 NDC 0002-4463-30 20 mg tablets debossed with “C 20” Bottles of 30 NDC 0002-4464-30.
Four strengths of almond-shaped tablets are available in different sizes and different shades of yellow, and supplied in the following package sizes:
Storage.
Store at 25°C (77°F); excursions permitted to 15-30°C (59-86°F) [see USP Controlled Room Temperature].
Marketed by: Lilly USA, LLC, Indianapolis, IN 46285, USA. Revised Apr 2022.
SIDE EFFECTS.
Clinical Trials Experience.
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
Tadalafil was administered to over 9000 men during clinical trials worldwide. In trials of CIALIS for once daily use, a total of 1434, 905, and 115 were treated for at least 6 months, 1 year, and 2 years, respectively. ForCIALIS for use as needed, over 1300 and 1000 subjects were treated for at least 6 months and 1 year ,respectively.
CIALIS For Use As Needed For ED.
In eight primary placebo-controlled clinical studies of 12 weeks duration, mean age was 59 years (range 22 to88) and the discontinuation rate due to adverse events in patients treated with tadalafil 10 or 20 mg was 3.1%,compared to 1.4% in placebo treated patients.
When taken as recommended in the placebo-controlled clinical trials, the following adverse reactions were reported ( see Table 1) for CIALIS for use as needed:
Table 1: Treatment-Emergent Adverse Reactions Reported by ≥2% of Patients Treated with CIALIS (10or 20 mg) and More Frequent on Drug than Placebo in the Eight Primary Placebo-Controlled ClinicalStudies (Including a Study in Patients with Diabetes) for CIALIS for Use as Needed for ED.
Adverse Reaction Placebo (N=476) Tadalafil 5 mg (N=151) Tadalafil 10 mg (N=394) Tadalafil 20 mg (N=635) Headache 5% 11% 11% 15% Dyspepsia 1% 4% % 10% Back pain 3% 3% 5% 6% Myalgia 1% 1% 4% 3% Nasal congestion 1% 2% 3% 3% Flushing a 1% 2% 3% 3% Pain in limb 1% 1% 3% 3% a The term flushing includes: facial flushing and flushing.
CIALIS For Once Daily Use For ED.
In three placebo-controlled clinical trials of 12 or 24 weeks duration, mean age was 58 years (range 21 to 82)and the discontinuation rate due to adverse events in patients treated with tadalafil was 4.1%, compared to 2.8%in placebo-treated patients.
The following adverse reactions were reported ( see Table 2) in clinical trials of 12 weeks duration:
Table 2: Treatment-Emergent Adverse Reactions Reported by ≥2% of Patients Treated with CIALIS forOnce Daily Use (2.5 or 5 mg) and More Frequent on Drug than Placebo in the Three Primary Placebo-Controlled Phase 3 Studies of 12 weeks Treatment Duration (Including a Study in Patients with Diabetes) for CIALIS for Once Daily Use for ED.
Adverse Reaction Placebo (N=248) Tadalafil 2.5 mg (N=196) Tadalafil 5 mg (N=304) Headache 5% 3% 6% Dyspepsia 2% 4% 5% Nasopharyngitis 4% 4% 3% Back pain 1% 3% 3% Upper respiratory tract infection 1% 3% 3% Flushing 1% 1% 3% Myalgia 1% 2% 2% Cough 0% 4% 2% Diarrhea 0% 1% 2% Nasal congestion 0% 2% 2% Pain in extremity 0% 1% 2% Urinary tract infection 0% 2% 0% Gastroesophageal reflux disease 0% 2% 1% Abdominal pain 0% 2% 1%
The following adverse reactions were reported ( see Table 3) over 24 weeks treatment duration in one placebo-controlled clinical study:
Table 3: Treatment-Emergent Adverse Reactions Reported by ≥2% of Patients Treated with CIALIS forOnce Daily Use (2.5 or 5 mg) and More Frequent on Drug than Placebo in One Placebo-ControlledClinical Study of 24 Weeks Treatment Duration for CIALIS for Once Daily Use for ED.
Adverse Reaction Placebo (N=94) Tadalafil 2.5 mg (N=96) Tadalafil 5 mg (N=97) Nasopharyngitis 5% 6% 6% Gastroenteritis 2% 3% 5% Back pain 3% 5% 2% Upper respiratory tract infection 0% 3% 4% Dyspepsia 1% 4% 1% Gastroesophageal reflux disease 0% 3% 2% Myalgia 2% 4% 1% Hypertension 0% 1% 3% Nasal congestion 0% 0% 4%
CIALIS For Once Daily Use For BPH And For ED And BPH.
In three placebo-controlled clinical trials of 12 weeks duration, two in patients with BPH and one in patients with ED and BPH, the mean age was 63 years (range 44 to 93) and the discontinuation rate due to adverse events in patients treated with tadalafil was 3.6% compared to 1.6% in placebo-treated patients. adverse reactions leading to discontinuation reported by at least 2 patients treated with tadalafil included headache, upper abdominal pain, and myalgia. The following adverse reactions were reported ( see Table 4).
Table 4: Treatment-Emergent Adverse Reactions Reported by ≥1% of Patients Treated with CIALIS forOnce Daily Use (5 mg) and More Frequent on Drug than Placebo in Three Placebo-Controlled ClinicalStudies of 12 Weeks Treatment Duration, including Two Studies for CIALIS for Once Daily Use for BPHand One Study for ED and BPH.
Adverse Reaction Placebo (N=576) Tadalafil 5 mg (N=581) Headache 2.3% 4.1% Dyspepsia 0.2% 2.4% Back pain 1.4% 2.4% Nasopharyngitis 1.6% 2.1% Diarrhea 1.0% 1.4% Pain in extremity 0.0% 1.4% Myalgia 0.3% 1.2% Dizziness 0.5% 1.0%
Across placebo-controlled studies with CIALIS for use as needed for ED, diarrhea was reported more frequently in patients 65 years of age and older who were treated with CIALIS (2.5% of patients) [see Use In Specific Populations ] .
Across all studies with any CIALIS dose, reports of changes in color vision were rare (
Body as a Whole – asthenia, face edema, fatigue, pain, peripheral edema.
Digestive – abnormal liver function tests, dry mouth, dysphagia, esophagitis, gastritis, GGTP increased, loose stools, nausea, upper abdominal pain, vomiting, gastroesophageal reflux disease, hemorrhoidal hemorrhage, rectal hemorrhage.
Musculoskeletal – arthralgia, neck pain.
Nervous – dizziness, hypesthesia, insomnia, paresthesia, somnolence, vertigo.
Renal and Urinary – renal impairment.
Skin and Appendages – pruritus, rash, sweating.
Ophthalmologic – blurred vision, changes in color vision, conjunctivitis (including conjunctival hyperemia),eye pain, lacrimation increase, swelling of eyelids.
Otologic – sudden decrease or loss of hearing, tinnitus.
Urogenital – erection increased, spontaneous penile erection.
Postmarketing Experience.
The following adverse reactions have been identified during post approval use of CIALIS. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. These events have been chosen for inclusion either due to their seriousness, reporting frequency, lack of clear alternative causation, or a combination of these factors.
Cardiovascular And Cerebrovascular.
Serious cardiovascular events, including myocardial infarction, sudden cardiac death, stroke, chest pain, palpitations, and tachycardia, have been reported postmarketing in temporal association with the use of tadalafil. Most, but not all, of these patients had preexisting cardiovascular risk factors. Many of these events were reported to occur during or shortly after sexual activity, and a few were reported to occur shortly after the use of CIALIS without sexual activity. Others were reported to have occurred hours to days after the use of CIALIS and sexual activity. It is not possible to determine whether these events are related directly to CIALIS, to sexual activity, to the patient’s underlying cardiovascular disease, to a combination of these factors, or to other factors [see WARNINGS AND PRECAUTIONS ] .
Body as a Whole – hypersensitivity reactions including urticaria, Stevens-Johnson syndrome, and exfoliative dermatitis.
Nervous – migraine, seizure and seizure recurrence, transient global amnesia.
Ophthalmologic – visual field defect, retinal vein occlusion, retinal artery occlusion.
Non-arteritic anterior ischemic optic neuropathy (NAION), a cause of decreased vision including permanent loss of vision, has been reported rarely postmarketing in temporal association with the use of PDE5 inhibitors, including CIALIS. Most, but not all, of these patients had underlying anatomic or vascular risk factors for development of NAION, including but not necessarily limited to: low cup to disc ratio (“crowded disc”), age over 50, diabetes, hypertension, coronary artery disease, hyperlipidemia, and smoking [see WARNINGS AND PRECAUTIONS ] .
Otologic – Cases of sudden decrease or loss of hearing have been reported postmarketing in temporal association with the use of PDE5 inhibitors, including CIALIS. In some of the cases, medical conditions andother factors were reported that may have also played a role in the otologic adverse events. In many cases, medical follow-up information was limited. It is not possible to determine whether these reported events are related directly to the use of CIALIS, to the patient’s underlying risk factors for hearing loss, a combination of these factors, or to other factors [see WARNINGS AND PRECAUTIONS ] .
Urogenital – priapism [see WARNINGS AND PRECAUTIONS ] .
DRUG INTERACTIONS.
Potential For Pharmacodynamic Interactions With CIALIS.
Nitrates.
Administration of CIALIS to patients who are using any form of organic nitrate, is contraindicated.In clinical pharmacology studies, CIALIS was shown to potentiate the hypotensive effect of nitrates. In a patient who has taken CIALIS, where nitrate administration is deemed medically necessary in a life-threatening situation, at least 48 hours should elapse after the last dose of CIALIS before nitrate administration is considered. In such circumstances, nitrates should still only be administered under close medical supervision with appropriate hemodynamic monitoring [see DOSAGE AND ADMINISTRATION , CONTRAINDICATIONS , and CLINICAL PHARMACOLOGY ] .
Alpha-Blockers.
Caution is advised when PDE5 inhibitors are coadministered with alpha-blockers. PDE5inhibitors, including CIALIS, and alpha-adrenergic blocking agents are both vasodilators with blood-pressure-lowering effects. When vasodilators are used in combination, an additive effect on blood pressure may be anticipated. Clinical pharmacology studies have been conducted with coadministration of tadalafil with doxazosin, tamsulosin or alfuzosin. [see DOSAGE AND ADMINISTRATION , WARNINGS AND PRECAUTIONS , and CLINICAL PHARMACOLOGY ] .
Anti hypertensives.
PDE5 inhibitors, including tadalafil, are mild systemic vasodilators. Clinical pharmacology studies were conducted to assess the effect of tadalafil on the potentiation of the blood-pressure-lowering effects of selected anti hypertensive medications (amlodipine, angiotensin II receptor blockers, bendrofluazide, enalapril, and metoprolol). Small reductions in blood pressure occurred following coadministration of tadalafil with these agents compared with placebo. [see WARNINGS AND PRECAUTIONS and CLINICAL PHARMACOLOGY ] .
Alcohol.
Both alcohol and tadalafil, a PDE5 inhibitor, act as mild vasodilators. When mild vasodilators are taken in combination, blood-pressure-lowering effects of each individual compound may be increased.Substantial consumption of alcohol (e.g., 5 units or greater) in combination with CIALIS can increase the potential for orthostatic signs and symptoms, including increase in heart rate, decrease in standing blood pressure, dizziness, and headache. Tadalafil did not affect alcohol plasma concentrations and alcohol did not affect tadalafil plasma concentrations. [see WARNINGS AND PRECAUTIONS and CLINICAL PHARMACOLOGY ] .
Potential For Other Drugs To Affect CIALIS.
[See DOSAGE AND ADMINISTRATION and WARNINGS AND PRECAUTIONS ] .
Antacids.
Simultaneous administration of an antacid (magnesium hydroxide/aluminum hydroxide) and tadalafil reduced the apparent rate of absorption of tadalafil without altering exposure (AUC) to tadalafil.
H 2 Antagonists (e.g. Nizatidine)
An increase in gastric pH resulting from administration of nizatidine had no significant effect on pharmacokinetics.
Cytochrome P450 Inhibitors.
CIALIS is a substrate of and predominantly metabolized by CYP3A4. Studies have shown that drugs that inhibit CYP3A4 can increase tadalafil exposure.
Ketoconazole (400 mg daily), a selective and potent inhibitor of CYP3A4,increased tadalafil 20 mg single-dose exposure (AUC) by 312% and Cmax by 22%, relative to the values for tadalafil 20 mg alone. Ketoconazole (200 mg daily) increased tadalafil 10-mg single-dose exposure (AUC) by107% and Cmax by 15%, relative to the values for tadalafil 10 mg alone [see DOSAGE AND ADMINISTRATION ] .
Although specific interactions have not been studied, other CYP3A4 inhibitors, such as erythromycin, itraconazole, and grapefruit juice, would likely increase tadalafil exposure.
Ritonavir (500 mg or 600 mg twice daily at steady state), an inhibitor of CYP3A4,CYP2C9, CYP2C19, and CYP2D6, increased tadalafil 20-mg single-dose exposure (AUC) by 32% with a 30%reduction in Cmax , relative to the values for tadalafil 20 mg alone. Ritonavir (200 mg twice daily), increased tadalafil 20-mg single-dose exposure (AUC) by 124% with no change in Cmax , relative to the values for tadalafil 20 mg alone. Although specific interactions have not been studied, other HIV protease inhibitors would likely increase tadalafil exposure [see DOSAGE AND ADMINISTRATION ] .
Cytochrome P450 Inducers.
Studies have shown that drugs that induce CYP3A4 can decrease tadalafil exposure.
Rifampin (600 mg daily), a CYP3A4 inducer, reduced tadalafil 10-mg single-dose exposure (AUC) by 88% and Cmax by 46%, relative to the values for tadalafil 10 mg alone. Although specific interactions have not been studied, other CYP3A4 inducers, such as carbamazepine, phenytoin, and phenobarbital, would likely decrease tadalafil exposure. No dose adjustment is warranted. The reduced exposure of tadalafil with the coadministration of rifampin or other CYP3A4 inducers can be anticipated to decrease the efficacy of CIALIS for once daily use; the magnitude of decreased efficacy is unknown.
Potential For CIALIS To Affect Other Drugs.
Aspirin.
Tadalafil did not potentiate the increase in bleeding time caused by aspirin.
Cytochrome P450 Substrates.
CIALIS is not expected to cause clinically significant inhibition or induction of the clearance of drugs metabolized by cytochrome P450 (CYP) isoforms. Studies have shown that tadalafil doe snot inhibit or induce P450 isoforms CYP1A2, CYP3A4, CYP2C9, CYP2C19, CYP2D6, and CYP2E1.
Tadalafil had no significant effect on the pharmacokinetics of theophylline.When tadalafil was administered to subjects taking theophylline, a small augmentation (3 beats per minute) of the increase in heart rate associated with theophylline was observed.
Tadalafil had no significant effect on exposure (AUC) to S-warfarin or R-warfarin, nor did tadalafil affect changes in prothrombin time induced by warfarin.
Tadalafil had no significant effect on exposure (AUC) to midazolamor lovastatin.
P-Glycoprotein (e.g. Digoxin)
Coadministration of tadalafil (40 mg once per day) for 10 days did not have a significant effect on the steady-state pharmacokinetics of digoxin (0.25 mg/day) in healthy subjects.
WARNINGS.
Included as part of the “PRECAUTIONS” Section.
PRECAUTIONS.
Evaluation of erectile dysfunction and BPH should include an appropriate medical assessment to identify potential underlying causes, as well as treatment options.
Before prescribing CIALIS, it is important to note the following:
Cardiovascular.
Physicians should consider the cardiovascular status of their patients, since there is a degree of cardiac risk associated with sexual activity. Therefore, treatments for erectile dysfunction, including CIALIS, should not bemused in men for whom sexual activity is inadvisable as a result of their underlying cardiovascular status.Patients who experience symptoms upon initiation of sexual activity should be advised to refrain from further sexual activity and seek immediate medical attention.
Physicians should discuss with patients the appropriate action in the event that they experience anginal chest pain requiring nitroglycerin following intake of CIALIS. In such a patient, who has taken CIALIS, where nitrate administration is deemed medically necessary for a life-threatening situation, at least 48 hours should have elapsed after the last dose of CIALIS before nitrate administration is considered. In such circumstances, nitrates should still only be administered under close medical supervision with appropriate hemodynamic monitoring.
Therefore, patients who experience anginal chest pain after taking CIALIS should seek immediate medical attention. [see CONTRAINDICATIONS and PATIENT INFORMATION ] .
Patients with left ventricular outflow obstruction, (e.g., aortic stenosis and idiopathic hypertrophic subaorticstenosis) can be sensitive to the action of vasodilators, including PDE5 inhibitors.
The following groups of patients with cardiovascular disease were not included in clinical safety and efficacy trials for CIALIS, and therefore until further information is available, CIALIS is not recommended for the following groups of patients:
myocardial infarction within the last 90 days unstable angina or angina occurring during sexual intercourse New York Heart Association Class 2 or greater heart failure in the last 6 months uncontrolled arrhythmias, hypotension ( stroke within the last 6 months.
As with other PDE5 inhibitors, tadalafil has mild systemic vasodilatory properties that may result in transient decreases in blood pressure. In a clinical pharmacology study, tadalafil 20 mg resulted in a mean maximal decrease in supine blood pressure, relative to placebo, of 1.6/0.8 mm Hg in healthy subjects [see CLINICAL PHARMACOLOGY ]. While this effect should not be of consequence in most patients, prior to prescribingCIALIS, physicians should carefully consider whether their patients with underlying cardiovascular disease could be affected adversely by such vasodilatory effects. Patients with severely impaired autonomic control of blood pressure may be particularly sensitive to the actions of vasodilators, including PDE5 inhibitors.
Potential For Drug Interactions When Taking CIALIS For Once Daily Use.
Physicians should be aware that CIALIS for once daily use provides continuous plasma tadalafil levels and should consider this when evaluating the potential for interactions with medications (e.g., nitrates, alpha-blockers, anti-hypertensives and potent inhibitors of CYP3A4) and with substantial consumption of alcohol [see DRUG INTERACTIONS ] .
Prolonged Erection.
There have been rare reports of prolonged erections greater than 4 hours and priapism (painful erections greater than 6 hours in duration) for this class of compounds. Priapism, if not treated promptly, can result in irreversible damage to the erectile tissue. Patients who have an erection lasting greater than 4 hours, whether painful or not, should seek emergency medical attention.
CIALIS should be used with caution in patients who have conditions that might predispose them to priapism (such as sickle cell anemia, multiple myeloma, or leukemia), or in patients with anatomical deformation of the penis (such as angulation, cavernosal fibrosis, or Peyronie’s disease).
Effects On The Eye.
Physicians should advise patients to stop use of all phosphodiesterase type 5 (PDE5) inhibitors, includingCIALIS, and seek medical attention in the event of a sudden loss of vision in one or both eyes. Such an event may be a sign of non-arteritic anterior ischemic optic neuropathy (NAION), a rare condition and a cause of decreased vision, including permanent loss of vision, that has been reported rarely postmarketing in temporal association with the use of all PDE5 inhibitors. Based on published literature, the annual incidence of NAION is2.5-11.8 cases per 100,000 in males aged ≥50.
An observational case-crossover study evaluated the risk of NAION when PDE5 inhibitor use, as a class, occurred immediately before NAION onset (within 5 half-lives), compared to PDE5 inhibitor use in a prior time period. The results suggest an approximate 2-fold increase in the risk of NAION, with a risk estimate of2.15 (95% CI 1.06, 4.34). A similar study reported a consistent result, with a risk estimate of 2.27 (95% CI0.99, 5.20). Other risk factors for NAION, such as the presence of “crowded” optic disc, may have contributed to the occurrence of NAION in these studies.
Neither the rare postmarketing reports, nor the association of PDE5 inhibitor use and NAION in the observational studies, substantiate a causal relationship between PDE5 inhibitor use and NAION [see ADVERSE REACTIONS ] .
Physicians should consider whether their patients with underlying NAION risk factors could be adversely affected by use of PDE5 inhibitors. Individuals who have already experienced NAION are at increased risk ofNAION recurrence. Therefore, PDE5 inhibitors, including CIALIS, should be used with caution in these patients and only when the anticipated benefits outweigh the risks. Individuals with “crowded” optic disc are also considered at greater risk for NAION compared to the general population; however, evidence is insufficient to support screening of prospective users of PDE5 inhibitors, including CIALIS, for this uncommon condition.
Patients with known hereditary degenerative retinal disorders, including retinitis pigmentosa, were not include din the clinical trials, and use in these patients is not recommended.
Sudden Hearing Loss.
Physicians should advise patients to stop taking PDE5 inhibitors, including CIALIS, and seek prompt medical attention in the event of sudden decrease or loss of hearing. These events, which may be accompanied by tinnitus and dizziness, have been reported in temporal association to the intake of PDE5 inhibitors, includingCIALIS. It is not possible to determine whether these events are related directly to the use of PDE5 inhibitors or to other factors [see ADVERSE REACTIONS ] .
Alpha-Blockers And Anti hypertensives.
Physicians should discuss with patients the potential for CIALIS to augment the blood-pressure-lowering effect of alpha-blockers and anti hypertensive medications [see DRUG INTERACTIONS and CLINICAL PHARMACOLOGY ] .
Caution is advised when PDE5 inhibitors are coadministered with alpha-blockers. PDE5 inhibitors, includingCIALIS, and alpha-adrenergic blocking agents are both vasodilators with blood-pressure-lowering effects.When vasodilators are used in combination, an additive effect on blood pressure may be anticipated. In some patients, concomitant use of these two drug classes can lower blood pressure significantly [see DRUG INTERACTIONS and CLINICAL PHARMACOLOGY ] , which may lead to symptomatic hypotension (e.g.,fainting). Consideration should be given to the following:
ED.
Patients should be stable on alpha-blocker therapy prior to initiating a PDE5 inhibitor. Patients who demonstrate hemodynamic instability on alpha-blocker therapy alone are at increased risk of symptomatic hypotension with concomitant use of PDE5 inhibitors. In those patients who are stable on alpha-blocker therapy, PDE5 inhibitors should be initiated at the lowest recommended dose. In those patients already taking an optimized dose of PDE5 inhibitor, alpha-blocker therapy should be initiated at the lowest dose. Stepwise increase in alpha-blocker dose may be associated with further lowering of blood pressure when taking a PDE5 inhibitor. Safety of combined use of PDE5 inhibitors and alpha-blockers may be affected by other variables, including volume depletion and other anti hypertensive drugs.
[see DOSAGE AND ADMINISTRATION and DRUG INTERACTIONS ] .
BPH.
The efficacy of the coadministration of an alpha-blocker and CIALIS for the treatment of BPH has not been adequately studied, and due to the potential vasodilatory effects of combined use resulting in blood pressure lowering, the combination of CIALIS and alpha-blockers is not recommended for the treatment of BPH. [see DOSAGE AND ADMINISTRATION , DRUG INTERACTIONS , and CLINICAL PHARMACOLOGY ] . Patients on alpha-blocker therapy for BPH should discontinue their alpha-blocker at least one day prior to starting CIALIS for once daily use for the treatment of BPH.
Renal Impairment.
CIALIS For Use As Needed.
CIALIS should be limited to 5 mg not more than once in every 72 hours in patients with creatinine clearance less than 30 mL/min or end-stage renal disease on hemodialysis. The starting dose of CIALIS in patients with creatinine clearance 30 – 50 mL/min should be 5 mg not more than once per day, and the maximum dose should be limited to 10 mg not more than once in every 48 hours. [see Use In Specific Populations ] .
CIALIS For Once Daily Use.
Due to increased tadalafil exposure (AUC), limited clinical experience, and the lack of ability to influence clearance by dialysis, CIALIS for once daily use is not recommended in patients with creatinine clearance less than 30 mL/min [see Use In Specific Populations ] .
Due to increased tadalafil exposure (AUC), limited clinical experience, and the lack of ability to influence clearance by dialysis, CIALIS for once daily use is not recommended in patients with creatinine clearance less than 30 mL/min. In patients with creatinine clearance 30 – 50 mL/min, start dosing at 2.5 mg once daily, and increase the dose to 5 mg once daily based upon individual response [see DOSAGE AND ADMINISTRATION , Use In Specific Populations , and CLINICAL PHARMACOLOGY ] .
Hepatic Impairment.
CIALIS For Use As Needed.
In patients with mild or moderate hepatic impairment, the dose of CIALIS should not exceed 10 mg. Because of insufficient information in patients with severe hepatic impairment, use of CIALIS in this group is not recommended [see Use In Specific Populations ] .
CIALIS For Once Daily Use.
CIALIS for once daily use has not been extensively evaluated in patients with mild or moderate hepatic impairment. Therefore, caution is advised if CIALIS for once daily use is prescribed to these patients. Because of insufficient information in patients with severe hepatic impairment, use of CIALIS in this group is not recommended [see Use In Specific Populations ] .
Alcohol.
Patients should be made aware that both alcohol and CIALIS, a PDE5 inhibitor, act as mild vasodilators. When mild vasodilators are taken in combination, blood-pressure-lowering effects of each individual compound maybe increased. Therefore, physicians should inform patients that substantial consumption of alcohol (e.g., 5 units or greater) in combination with CIALIS can increase the potential for orthostatic signs and symptoms, including increase in heart rate, decrease in standing blood pressure, dizziness, and headache [see CLINICAL PHARMACOLOGY ] .
Concomitant Use Of Potent Inhibitors Of Cytochrome P450 3A4 (CYP3A4)
CIALIS is metabolized predominantly by CYP3A4 in the liver. The dose of CIALIS for use as needed should be limited to 10 mg no more than once every 72 hours in patients taking potent inhibitors of CYP3A4 such asritonavir, ketoconazole, and itraconazole [see DRUG INTERACTIONS ] . In patients taking potent inhibitors ofCYP3A4 and CIALIS for once daily use, the maximum recommended dose is 2.5 mg [see DOSAGE AND ADMINISTRATION ] .
Combination With Other PDE5 Inhibitors Or Erectile Dysfunction Therapies.
The safety and efficacy of combinations of CIALIS and other PDE5 inhibitors or treatments for erectile dysfunction have not been studied. Inform patients not to take CIALIS with other PDE5 inhibitors, including ADCIRCA.
Effects On Bleeding.
Studies in vitro have demonstrated that tadalafil is a selective inhibitor of PDE5. PDE5 is found in platelets.When administered in combination with aspirin, tadalafil 20 mg did not prolong bleeding time, relative toaspirin alone. CIALIS has not been administered to patients with bleeding disorders or significant active peptic ulceration. Although CIALIS has not been shown to increase bleeding times in healthy subjects, use in patients with bleeding disorders or significant active peptic ulceration should be based upon a careful risk-benefit assessment and caution.
Counseling Patients About Sexually Transmitted Diseases.
The use of CIALIS offers no protection against sexually transmitted diseases. Counseling patients about the protective measures necessary to guard against sexually transmitted diseases, including HumanImmunodeficiency Virus (HIV) should be considered.
Consideration Of Other Urological Conditions Prior To Initiating Treatment For BPH.
Prior to initiating treatment with CIALIS for BPH, consideration should be given to other urological conditions that may cause similar symptoms. In addition, prostate cancer and BPH may coexist.
Patient Counseling Information.
“See FDA-approved patient labeling ( PATIENT INFORMATION )”
Nitrates.
Physicians should discuss with patients the contraindication of CIALIS with regular and/or intermittent use of organic nitrates. Patients should be counseled that concomitant use of CIALIS with nitrates could cause blood pressure to suddenly drop to an unsafe level, resulting in dizziness, syncope, or even heart attack or stroke.
Physicians should discuss with patients the appropriate action in the event that they experience anginal chest pain requiring nitroglycerin following intake of CIALIS. In such a patient, who has taken CIALIS, where nitrate administration is deemed medically necessary for a life-threatening situation, at least 48 hours should have elapsed after the last dose of CIALIS before nitrate administration is considered. In such circumstances, nitrates should still only be administered under close medical supervision with appropriate hemodynamic monitoring.Therefore, patients who experience anginal chest pain after taking CIALIS should seek immediate medical attention [see CONTRAINDICATIONS and WARNINGS AND PRECAUTIONS ] .
Guanylate Cyclase (GC) Stimulators.
Physicians should discuss with patients the contraindication of CIALIS with any use of a GC stimulator, such asriociguat, for pulmonary arterial hypertension. Patients should be counseled that the concomitant use of CIALISwith GC stimulators may cause blood pressure to drop to an unsafe level.
Cardiovascular Considerations.
Physicians should consider the potential cardiac risk of sexual activity in patients with preexisting cardiovascular disease. Physicians should advise patients who experience symptoms upon initiation of sexual activity to refrain from further sexual activity and seek immediate medical attention [see WARNINGS AND PRECAUTIONS ] .
Concomitant Use With Drugs Which Lower Blood Pressure.
Physicians should discuss with patients the potential for CIALIS to augment the blood-pressure-lowering effect of alpha-blockers, and anti hypertensive medications [see WARNINGS AND PRECAUTIONS , DRUG INTERACTIONS , and CLINICAL PHARMACOLOGY ] .
Potential For Drug Interactions When Taking CIALIS For Once Daily Use.
Physicians should discuss with patients the clinical implications of continuous exposure to tadalafil when prescribing CIALIS for once daily use, especially the potential for interactions with medications (e.g., nitrates, alpha-blockers, anti hypertensives and potent inhibitors of cytochrome P450 3A4) and with substantial consumption of alcohol. [see DOSAGE AND ADMINISTRATION , WARNINGS AND PRECAUTIONS , DRUG INTERACTIONS , CLINICAL PHARMACOLOGY , and Clinical Studies ] .
Priapism.
There have been rare reports of prolonged erections greater than 4 hours and priapism (painful erections greater than 6 hours in duration) for this class of compounds. Priapism, if not treated promptly, can result in irreversible damage to the erectile tissue. Physicians should advise patients who have an erection lasting greater than 4hours, whether painful or not, to seek emergency medical attention.
Sudden Loss Of Vision.
Physicians should advise patients to stop use of all PDE5 inhibitors, including CIALIS, and seek medical attention in the event of a sudden loss of vision in one or both eyes. Such an event may be a sign of non-arteritic anterior ischemic optic neuropathy (NAION), a cause of decreased vision, including possible permanent loss of vision, that has been reported rarely postmarketing in temporal association with the use of all PDE5 inhibitors. Physicians should discuss with patients the increased risk of NAION in individuals who have already experienced NAION in one eye. Physicians should also discuss with patients the increased risk of NAIONamong the general population in patients with a “crowded” optic disc, although evidence is insufficient to support screening of prospective users of PDE5 inhibitors, including CIALIS, for this uncommon condition [see WARNINGS AND PRECAUTIONS and ADVERSE REACTIONS ] .
Sudden Hearing Loss.
Physicians should advise patients to stop taking PDE5 inhibitors, including CIALIS, and seek prompt medical attention in the event of sudden decrease or loss of hearing. These events, which may be accompanied by tinnitus and dizziness, have been reported in temporal association to the intake of PDE5 inhibitors, includingCIALIS. It is not possible to determine whether these events are related directly to the use of PDE5 inhibitors or to other factors [see ADVERSE REACTIONS ] .
Alcohol.
Patients should be made aware that both alcohol and CIALIS, a PDE5 inhibitor, act as mild vasodilators. When mild vasodilators are taken in combination, blood-pressure-lowering effects of each individual compound maybe increased. Therefore, physicians should inform patients that substantial consumption of alcohol (e.g., 5 units or greater) in combination with CIALIS can increase the potential for orthostatic signs and symptoms, including increase in heart rate, decrease in standing blood pressure, dizziness, and headache [see WARNINGS AND PRECAUTIONS , DRUG INTERACTIONS , and CLINICAL PHARMACOLOGY ] .
Sexually Transmitted Disease.
The use of CIALIS offers no protection against sexually transmitted diseases. Counseling of patients about the protective measures necessary to guard against sexually transmitted diseases, including HumanImmunodeficiency Virus (HIV) should be considered.
Recommended Administration.
Physicians should instruct patients on the appropriate administration of CIALIS to allow optimal use.
For CIALIS for use as needed in men with ED, patients should be instructed to take one tablet at least 30minutes before anticipated sexual activity. In most patients, the ability to have sexual intercourse is improved for up to 36 hours.
For CIALIS for once daily use in men with ED or ED/BPH, patients should be instructed to take one tablet at approximately the same time every day without regard for the timing of sexual activity. Cialis is effective at improving erectile function over the course of therapy.
For CIALIS for once daily use in men with BPH, patients should be instructed to take one tablet at approximately the same time every day.
Nonclinical Toxicology.
Carcinogens, Autogenesis, Impairment Of Fertility.
Carcinogens.
Tadalafil was not carcinogenic to rats or mice when administered daily for 2 years at dosesup to 400 mg/kg/day. Systemic drug exposures, as measured by AUC of unbound tadalafil, were approximately10-fold for mice, and 14- and 26-fold for male and female rats, respectively, the exposures in human males given Maximum Recommended Human Dose (MRHD) of 20 mg.
Autogenesis.
Tadalafil was not mutagenic in the in vitro bacterial Ames assays or the forward mutation test in mouse lymphoma cells. Tadalafil was not clastogenic in the in vitro chromosomal aberration test in human lymphocytes or the in vivo rat micronucleus assays.
Impairment Of Fertility.
There were no effects on fertility, reproductive performance or reproductive organ morphology in male or female rats given oral doses of tadalafil up to 400 mg/kg/day, a dose producing AUCsfor unbound tadalafil of 14-fold for males or 26-fold for females the exposures observed in human males given the MRHD of 20 mg. In beagle dogs given tadalafil daily for 3 to 12 months, there was treatment-related non-reversible degeneration and atrophy of the seminiferous tubular epithelium in the testes in 20-100% of the dogs that resulted in a decrease in spermatogenesis in 40-75% of the dogs at doses of ≥10 mg/kg/day. Systemic exposure (based on AUC) at no-observed-adverse-effect-level (NOAEL) (10 mg/kg/day) for unbound tadalafil was similar to that expected in humans at the MRHD of 20 mg.
There were no treatment-related testicular findings in rats or mice treated with doses up to 400 mg/kg/day for 2years.
Use In Specific Populations.
Pregnancy.
Risk Summary.
CIALIS (tadalafil) is not indicated for use in females.
There are no data with the use of CIALIS in pregnant women to inform any drug-associated risks for adverse developmental outcomes. In animal reproduction studies, no adverse developmental effects were observed with oral administration of tadalafil to pregnant rats or mice during organogenesis at exposures up to 11 times the maximum recommended human dose (MRHD) of 20 mg/day ( see Data ).
Data.
Animal reproduction studies showed no evidence of teratogenicity, embryotoxicity, or fetotoxicity when tadalafil was given orally to pregnant rats or mice at exposures up to 11 times the maximum recommended human dose (MRHD) of 20 mg/day during organogenesis. In a prenatal/postnatal developmental study in rats, postnatal pup survival decreased following maternal exposure to tadalafil doses greater than 10 times theMRHD based on AUC. Signs of maternal toxicity occurred at doses greater than 16 times the MRHD based onAUC. Surviving offspring had normal development and reproductive performance.
In another rat prenatal and postnatal development study at doses of 60, 200, and 1000 mg/kg, a reduction in postnatal survival of pups was observed. The no observed effect level (NOEL) for maternal toxicity was200 mg/kg/day and for developmental toxicity was 30 mg/kg/day. This gives approximately 16 and 10 fold exposure multiples, respectively, of the human AUC for the MRHD of 20 mg.
Tadalafil and/or its metabolites cross the placenta, resulting in fetal exposure in rats.
Lactation.
Risk Summary.
CIALIS is not indicated for use in females.
There is no information on the presence of tadalafil and/or metabolites in human milk, the effects on thereat child, or the effects on milk production. Tadalafil and/or its metabolites are present in the milk of lactating rats at concentrations approximately 2.4-fold greater than found in the plasma.
Females And Males Of Reproductive Potential.
Infertility.
Based on the data from 3 studies in adult males, tadalafil decreased sperm concentrations in the study of 10 mg tadalafil for 6 months and the study of 20 mg tadalafil for 9 months. This effect was not seen in the study of 20mg tadalafil taken for 6 months. There was no adverse effect of tadalafil 10 mg or 20 mg on mean concentrations of testosterone, luteinizing hormone or follicle stimulating hormone. The clinical significance of the decreased sperm concentrations in the two studies is unknown. There have been no studies evaluating the effect of tadalafil on fertility in men [see CLINICAL PHARMACOLOGY ] .
Based on studies in animals, a decrease in spermatogenesis was observed in dogs, but not in rats [see Nonclinical Toxicology ] .
Pediatric Use.
CIALIS is not indicated for use in pediatric patients. Safety and efficacy in patients below the age of 18 year shave not been established.
A randomized, double-blind, placebo-controlled trial in pediatric patients (7 to 14 years of age) with Duchennemuscular dystrophy, who received CIALIS 0.3 mg/kg, CIALIS 0.6 mg/kg, or placebo daily for 48 weeks failed to demonstrate any benefit of treatment with CIALIS on a range of assessments of muscle strength and performance.
Juvenile Animal Study.
No adverse effects were observed in a study in which tadalafil was administered orally at doses of 60, 200, and1000 mg/kg/day to juvenile rats on postnatal days 14 to 90. The highest plasma tadalafil exposures (AUC)achieved were approximately 10-fold that observed at the MRHD.
Geriatric Use.
Of the total number of subjects in ED clinical studies of tadalafil, approximately 19 percent were 65 and over, while approximately 2 percent were 75 and over. Of the total number of subjects in BPH clinical studies of tadalafil (including the ED/BPH study), approximately 40 percent were over 65, while approximately 10 percent were 75 and over. In these clinical trials, no overall differences in efficacy or safety were observed between older (>65 and ≥75 years of age) and younger subjects (≤65 years of age). However, in placebo-controlled studies with CIALIS for use as needed for ED, diarrhea was reported more frequently in patients 65years of age and older who were treated with CIALIS (2.5% of patients) [see ADVERSE REACTIONS ] . No dose adjustment is warranted based on age alone. However, a greater sensitivity to medications in some older individuals should be considered. [see CLINICAL PHARMACOLOGY ] .
Hepatic Impairment.
In clinical pharmacology studies, tadalafil exposure (AUC) in subjects with mild or moderate hepatic impairment (Child-Pugh Class A or B) was comparable to exposure in healthy subjects when a dose of 10 mg was administered. There are no available data for doses higher than 10 mg of tadalafil in patients with hepatic impairment. Insufficient data are available for subjects with severe hepatic impairment (Child-Pugh Class Cmax). [see DOSAGE AND ADMINISTRATION and WARNINGS AND PRECAUTIONS ] .
Renal Impairment.
In clinical pharmacology studies using single-dose tadalafil (5 to 10 mg), tadalafil exposure (AUC) doubled in subjects with creatinine clearance 30 to 80 mL/min. In subjects with end-stage renal disease on hemodialysis, there was a two-fold increase in Cmax and 2.7- to 4.8-fold increase in AUC following single-dose administration of 10 or 20 mg tadalafil. Exposure to total methylcatechol (unconjugated plus glucuronide) was 2- to 4-foldhigher in subjects with renal impairment, compared to those with normal renal function. Hemodialysis (performed between 24 and 30 hours post-dose) contributed negligibly to tadalafil or metabolite elimination. Ina clinical pharmacology study (N=28) at a dose of 10 mg, back pain was reported as a limiting adverse event in male patients with creatinine clearance 30 to 50 mL/min. At a dose of 5 mg, the incidence and severity of back pain was not significantly different than in the general population. In patients on hemodialysis taking 10- or 20-mg tadalafil, there were no reported cases of back pain. [see DOSAGE AND ADMINISTRATION and WARNINGS AND PRECAUTIONS ] .
OVERDOSE.
Single doses up to 500 mg have been given to healthy subjects, and multiple daily doses up to 100 mg have been given to patients. Adverse events were similar to those seen at lower doses. In cases of overdose, standard supportive measures should be adopted as required. Hemodialysis contributes negligibly to tadalafil elimination.
CONTRAINDICATIONS.
Nitrates.
Administration of CIALIS to patients who are using any form of organic nitrate, either regularly and/or intermittently, is contraindicated. In clinical pharmacology studies, CIALIS was shown to potentiate the hypotensive effect of nitrates [see CLINICAL PHARMACOLOGY ] .
Hypersensitivity Reactions.
CIALIS is contraindicated in patients with a known serious hypersensitivity to tadalafil (CIALIS orADCIRCA). Hypersensitivity reactions have been reported, including Stevens-Johnson syndrome and exfoliative dermatitis [see ADVERSE REACTIONS ] .
Concomitant Guanylate Cyclase (GC) Stimulators.
Do not use CIALIS in patients who are using a GC stimulator, such as riociguat. PDE5 inhibitors, includingCIALIS, may potentiate the hypotensive effects of GC stimulators.
CLINICAL PHARMACOLOGY.
Mechanism Of Action.
Penile erection during sexual stimulation is caused by increased penile blood flow resulting from the relaxation of penile arteries and corpus cavernosal smooth muscle. This response is mediated by the release of nitric oxide(NO) from nerve terminals and endothelial cells, which stimulates the synthesis of cGMP in smooth muscle cells. Cyclic GMP causes smooth muscle relaxation and increased blood flow into the corpus cavernosum. The inhibition of phosphoresce type 5 (PDE5) enhances erectile function by increasing the amount of cGMP.Tadalafil inhibits PDE5. Because sexual stimulation is required to initiate the local release of nitric oxide, the inhibition of PDE5 by tadalafil has no effect in the absence of sexual stimulation.
The effect of PDE5 inhibition on cGMP concentration in the corpus cavernosum and pulmonary arteries is also observed in the smooth muscle of the prostate, the bladder and their vascular supply. The mechanism for reducing BPH symptoms has not been established.
Studies in vitro have demonstrated that tadalafil is a selective inhibitor of PDE5. PDE5 is found in the smooth muscle of the corpus cavernosum, prostate, and bladder as well as in vascular and visceral smooth muscle, skeletal muscle, urethra, platelets, kidney, lung, cerebellum, heart, liver, testis, seminal vesicle, and pancreas.
In vitro studies have shown that the effect of tadalafil is more potent on PDE5 than on other phosphodiesterases.These studies have shown that tadalafil is >10,000-fold more potent for PDE5 than for PDE1, PDE2, PDE4, andPDE7 enzymes, which are found in the heart, brain, blood vessels, liver, leukocytes, skeletal muscle, and other organs. Tadalafil is >10,000-fold more potent for PDE5 than for PDE3, an enzyme found in the heart and blood vessels. Additionally, tadalafil is 700-fold more potent for PDE5 than for PDE6, which is found in the retina and is responsible for photo transduction. Tadalafil is >9,000-fold more potent for PDE5 than for PDE8, PDE9,and PDE10. Tadalafil is 14-fold more potent for PDE5 than for PDE11A1 and 40-fold more potent for PDE5than for PDE11A4, two of the four known forms of PDE11. PDE11 is an enzyme found in human prostate, testes, skeletal muscle and in other tissues (e.g., adrenal cortex). In vitro , tadalafil inhibits human recombinant PDE11A1 and, to a lesser degree, PDE11A4 activities at concentrations within the therapeutic range. The physiological role and clinical consequence of PDE11 inhibition in humans have not been defined.
Pharmacodynamics.
Effects On Blood Pressure.
Tadalafil 20 mg administered to healthy male subjects produced no significant difference compared to placebo in supine systolic and diastolic blood pressure (difference in the mean maximal decrease of 1.6/0.8 mm Hg, respectively) and in standing systolic and diastolic blood pressure (difference in the mean maximal decrease of0.2/4.6 mm Hg, respectively). In addition, there was no significant effect on heart rate.
Effects On Blood Pressure When Administered With Nitrates.
In clinical pharmacology studies, tadalafil (5 to 20 mg) was shown to potentiate the hypotensive effect of nitrates. Therefore, the use of CIALIS in patients taking any form of nitrates is contraindicated [see CONTRAINDICATIONS ] .
A study was conducted to assess the degree of interaction between nitroglycerin and tadalafil, should nitroglycerin be required in an emergency situation after tadalafil was taken. This was a double-blind, placebo-controlled, crossover study in 150 male subjects at least 40 years of age (including subjects with diabetes mellitus and/or controlled hypertension) and receiving daily doses of tadalafil 20 mg or matching placebo for 7days. Subjects were administered a single dose of 0.4 mg sublingual nitroglycerin (NTG) at pre-specified timepoints, following their last dose of tadalafil (2, 4, 8, 24, 48, 72, and 96 hours after tadalafil). The objective of the study was to determine when, after tadalafil dosing, no apparent blood pressure interaction was observed.In this study, a significant interaction between tadalafil and NTG was observed at each timepoint up to and including 24 hours. At 48 hours, by most hemodynamic measures, the interaction between tadalafil and NTGwas not observed, although a few more tadalafil subjects compared to placebo experienced greater blood-pressure lowering at this timepoint. After 48 hours, the interaction was not detectable ( see Figure 1).
Figure 1: Mean Maximal Change in Blood Pressure (Tadalafil Minus Placebo, Point Estimate with 90% CI)
Therefore, CIALIS administration with nitrates is contraindicated. In a patient who has taken CIALIS, where nitrate administration is deemed medically necessary in a life-threatening situation, at least 48 hours should elapse after the last dose of CIALIS before nitrate administration is considered. In such circumstances, nitrates should still only be administered under close medical supervision with appropriate hemodynamic monitoring [see CONTRAINDICATIONS ] .
Effect On Blood Pressure When Administered With Alpha-Blockers.
Six randomized, double-blinded, crossover clinical pharmacology studies were conducted to investigate the potential interaction of tadalafil with alpha-blocker agents in healthy male subjects [see DOSAGE AND ADMINISTRATION and WARNINGS AND PRECAUTIONS ] . In four studies, a single oral dose of tadalafil was administered to healthy male subjects taking daily (at least 7 days duration) an oral alpha-blocker. In two studies, a daily oral alpha-blocker (at least 7 days duration) was administered to healthy male subjects taking repeated daily doses of tadalafil.
Three clinical pharmacology studies were conducted with tadalafil and doxazosin, an alpha[1]-adrenergic blocker.
In the first doxazosin study, a single oral dose of tadalafil 20 mg or placebo was administered in a 2-period,crossover design to healthy subjects taking oral doxazosin 8 mg daily (N=18 subjects). Doxazosin was administered at the same time as tadalafil or placebo after a minimum of seven days of doxazosin dosing ( see Table 5 and Figure 2).
Table 5: Doxazosin (8 mg/day) Study 1: Mean Maximal Decrease (95% CI) in Systolic Blood Pressure.
Placebo-subtracted mean maximal decrease in systolic blood pressure (mm Hg) Tadalafil 20 mg Supine 3.6 (-1.5, 8.8) Standing 9.8 (4.1, 15.5)
Figure 2: Doxazosin Study 1: Mean Change from Baseline in Systolic Blood Pressure.
Blood pressure was measured manually at 1, 2, 3, 4, 5, 6, 7, 8, 10, 12, and 24 hours after tadalafil or placebo administration. Outliers were defined as subjects with a standing systolic blood pressure of 30 mm Hg at one or more time points. There were nine and three outliers following administration of tadalafil 20 mg and placebo, respectively. Five and two subjects were outliers due to a decrease from baseline in standing systolic BP of >30 mm Hg, while five an done subject were outliers due to standing systolic BP.
In the second doxazosin study, a single oral dose of tadalafil 20 mg was administered to healthy subjects taking oral doxazosin, either 4 or 8 mg daily. The study (N=72 subjects) was conducted in three parts, each a 3-periodcrossover.
In part A (N=24), subjects were titrated to doxazosin 4 mg administered daily at 8 a.m. Tadalafil was administered at either 8 a.m., 4 p.m., or 8 p.m. There was no placebo control.
In part B (N=24), subjects were titrated to doxazosin 4 mg administered daily at 8 p.m. Tadalafil was administered at either 8 a.m., 4 p.m., or 8 p.m. There was no placebo control.
In part Cmax (N=24), subjects were titrated to doxazosin 8 mg administered daily at 8 a.m. In this part, tadalafil or placebo were administered at either 8 a.m. or 8 p.m.
The placebo-subtracted mean maximal decreases in systolic blood pressure over a 12-hour period after dosing in the placebo-controlled portion of the study (part Cmax) are shown in Table 6 and Figure 3 .
Table 6: Doxazosin (8 mg/day) Study 2 (Part C): Mean Maximal Decrease in Systolic Blood Pressure.
Placebo-subtracted mean maximal decrease in systolic blood pressure (mm Hg) Tadalafil 20 mg at 8 a.m. Tadalafil 20 mg at 8 p.m. Ambulatory Blood-Pressure Monitoring (ABPM) 7 8.
Figure 3: Doxazosin Study 2 (Part Cmax): Mean Change from Time-Matched Baseline in Systolic Blood.
Blood pressure was measured by ABPM every 15 to 30 minutes for up to 36 hours after tadalafil or placebo.Subjects were categorized as outliers if one or more systolic blood pressure readings of 30 mm Hg from a time-matched baseline occurred during the analysis interval.
Of the 24 subjects in part C, 16 subjects were categorized as outliers following administration of tadalafil and 6subjects were categorized as outliers following placebo during the 24-hour period after 8 a.m. dosing of tadalafil or placebo. Of these, 5 and 2 were outliers due to systolic BP 30 mm Hg following tadalafil and placebo, respectively.
During the 24-hour period after 8 p.m. dosing, 17 subjects were categorized as outliers following administration of tadalafil and 7 subjects following placebo. Of these, 10 and 2 subjects were outliers due to systolic BP30 mm Hg, following tadalafil and placebo, respectively.
Some additional subjects in both the tadalafil and placebo groups were categorized as outliers in the period beyond 24 hours.
Severe adverse events potentially related to blood-pressure effects were assessed. In the study (N=72 subjects),2 such events were reported following administration of tadalafil (symptomatic hypotension in one subject that began 10 hours after dosing and lasted approximately 1 hour, and dizziness in another subject that began 11hours after dosing and lasted 2 minutes). No such events were reported following placebo. In the period prior to tadalafil dosing, one severe event (dizziness) was reported in a subject during the doxazosin run-in phase.
In the third doxazosin study, healthy subjects (N=45 treated; 37 completed) received 28 days of once per day dosing of tadalafil 5 mg or placebo in a two-period crossover design. After 7 days, doxazosin was initiated at1 mg and titrated up to 4 mg daily over the last 21 days of each period (7 days on 1 mg; 7 days of 2 mg; 7 days of 4 mg doxazosin). The results are shown in Table 7 .
Table 7: Doxazosin Study 3: Mean Maximal Decrease (95% CI) in Systolic Blood Pressure.
Placebo-subtracted mean maximal decrease in systolic blood pressure Tadalafil 5 mg Day 1 of 4 mg Doxazosin Supine 2.4 (-0.4, 5.2) Standing -0.5 (-4.0, 3.1) Day 7 of 4 mg Doxazosin Supine 2.8 (-0.1, 5.7) Standing 1.1 (-2.9, 5.0)
Blood pressure was measured manually pre-dose at two time points (-30 and -15 minutes) and then at 1, 2, 3, 4,5, 6, 7, 8, 10, 12 and 24 hours post dose on the first day of each doxazosin dose, (1 mg, 2 mg, 4 mg), as well ason the seventh day of 4 mg doxazosin administration.
Following the first dose of doxazosin 1 mg, there were no outliers on tadalafil 5 mg and one outlier on placebo due to a decrease from baseline in standing systolic BP of >30 mm Hg.
There were 2 outliers on tadalafil 5 mg and none on placebo following the first dose of doxazosin 2 mg due to a decrease from baseline in standing systolic BP of >30 mm Hg.
There were no outliers on tadalafil 5 mg and two on placebo following the first dose of doxazosin 4 mg due to a decrease from baseline in standing systolic BP of >30 mm Hg. There was one outlier on tadalafil 5 mg and three on placebo following the first dose of doxazosin 4 mg due to standing systolic BP 30 mm Hg in standing systolic blood pressure, and one subject on placebo had standing systolic blood pressure.
In the first tamsulosin study, a single oral dose of tadalafil 10, 20 mg, or placebo was administered in a 3 period, crossover design to healthy subjects taking 0.4 mg once per day tamsulosin, a selective alpha[1A]-adrenergic blocker (N=18 subjects). Tadalafil or placebo was administered 2 hours after tamsulosin following a minimum of seven days of tamsulosin dosing.
Table 8: Tamsulosin (0.4 mg/day) Study 1: Mean Maximal Decrease (95% CI) in Systolic Blood Pressure.
Placebo-subtracted mean maximal decrease in systolic blood pressure (mmHg) Tadalafil 10 mg Tadalafil 20 mg Supine 3.2 (-2.3, 8.6) 3.2 (-2.3, 8.7) Standing 1.7 (-4.7, 8.1) 2.3 (-4.1, 8.7)
Blood pressure was measured manually at 1, 2, 3, 4, 5, 6, 7, 8, 10, 12, and 24 hours after tadalafil or placebo dosing. There were 2, 2, and 1 outliers (subjects with a decrease from baseline in standing systolic blood pressure of >30 mm Hg at one or more time points) following administration of tadalafil 10 mg, 20 mg, and placebo, respectively. There were no subjects with a standing systolic blood pressure.
In the second tamsulosin study, healthy subjects (N=39 treated; and 35 completed) received 14 days of once per day dosing of tadalafil 5 mg or placebo in a two-period crossover design. Daily dosing of tamsulosin 0.4 mg was added for the last seven days of each period.
Table 9: Tamsulosin Study 2: Mean Maximal Decrease (95% CI) in Systolic Blood Pressure.
Placebo-subtracted mean maximal decrease in systolic blood pressure Tadalafil 5 mg Day 1 of 0.4 mg Tamsulosin Supine -0.1 (-2.2, 1.9) Standing 0.9 (-1.4, 3.2) Day 7 of 0.4 mg Tamsulosin Supine 1.2 (-1.2, 3.6) Standing 1.2 (-1.0, 3.5)
Blood pressure was measured manually pre-dose at two time points (-30 and -15 minutes) and then at 1, 2, 3, 4,5, 6, 7, 8, 10, 12, and 24 hours post dose on the first, sixth and seventh days of tamsulosin administration. There were no outliers (subjects with a decrease from baseline in standing systolic blood pressure of >30 mm Hg atone or more time points). One subject on placebo plus tamsulosin (Day 7) and one subject on tadalafil plus tamsulosin (Day 6) had standing systolic blood pressure.
A single oral dose of tadalafil 20 mg or placebo was administered in a 2-period, crossover design to healthy subjects taking once-daily alfuzosin HCl 10 mg extended-release tablets, an alpha[1]-adrenergic blocker (N=17 completed subjects). Tadalafil or placebo was administered 4 hours after alfuzosin following a minimum of seven days of alfuzosin dosing.
Table 10: Alfuzosin (10 mg/day) Study: Mean Maximal Decrease (95% CI) in Systolic Blood Pressure.
Placebo-subtracted mean maximal decrease in systolic blood pressure (mm Hg) Tadalafil 20 mg Supine 2.2 (-0.9,-5.2) Standing 4.4 (-0.2, 8.9)
Blood pressure was measured manually at 1, 2, 3, 4, 6, 8, 10, 20, and 24 hours after tadalafil or placebo dosing.There was 1 outlier (subject with a standing systolic blood pressure 30 mm Hg at one or more time points. No severe adverse events potentially related to blood pressure effects were reported. No syncope was reported.
Effects On Blood Pressure When Administered With Anti hypertensives.
A study was conducted to assess the interaction of amlodipine (5 mg daily) and tadalafil 10 mg.There was no effect of tadalafil on amlodipine blood levels and no effect of amlodipine on tadalafil blood levels. The mean reduction in supine systolic/diastolic blood pressure due to tadalafil 10 mg in subjects taking amlodipine was 3/2 mm Hg, compared to placebo. In a similar study using tadalafil 20 mg, there were no clinically significant differences between tadalafil and placebo in subjects taking amlodipine.
Angiotensin II receptor blockers (with and without other antihypertensives)
A study was conducted to assess the interaction of angiotensin II receptor blockers and tadalafil 20 mg. Subjects in the study were taking any marketed angiotensin II receptor blocker, either alone, as a component of a combination product, or as part of a multiple anti hypertensive regimen. Following dosing, ambulatory measurements of blood pressure revealed differences between tadalafil and placebo of 8/4 mm Hg in systolic/diastolic blood pressure.
A study was conducted to assess the interaction of bendrofluazide (2.5 mg daily) and tadalafil 10 mg. Following dosing, the mean reduction in supine systolic/diastolic blood pressure due to tadalafil10 mg in subjects taking bendrofluazide was 6/4 mm Hg, compared to placebo.
A study was conducted to assess the interaction of enalapril (10 to 20 mg daily) and tadalafil10 mg. Following dosing, the mean reduction in supine systolic/diastolic blood pressure due to tadalafil 10 mg in subjects taking enalapril was 4/1 mm Hg, compared to placebo.
A study was conducted to assess the interaction of sustained-release metoprolol (25 to 200 mg daily) and tadalafil 10 mg. Following dosing, the mean reduction in supine systolic/diastolic blood pressure due to tadalafil 10 mg in subjects taking metoprolol was 5/3 mm Hg, compared to placebo.
Effects On Blood Pressure When Administered With Alcohol.
Alcohol and PDE5 inhibitors, including tadalafil, are mild systemic vasodilators. The interaction of tadalafil with alcohol was evaluated in 3 clinical pharmacology studies. In 2 of these, alcohol was administered at a dose of 0.7 g/kg, which is equivalent to approximately 6 ounces of 80-proof vodka in an 80-kg male, and tadalafil was administered at a dose of 10 mg in one study and 20 mg in another. In both these studies, all patients imbibed the entire alcohol dose within 10 minutes of starting. In one of these two studies, blood alcohol levels of 0.08% were confirmed. In these two studies, more patients had clinically significant decreases in blood pressure on the combination of tadalafil and alcohol as compared to alcohol alone. Some subjects reported postural dizziness, and orthostatic hypotension was observed in some subjects. When tadalafil 20 mg was administered with a lower dose of alcohol (0.6 g/kg, which is equivalent to approximately 4 ounces of 80-proofvodka, administered in less than 10 minutes), orthostatic hypotension was not observed, dizziness occurred with similar frequency to alcohol alone, and the hypotensive effects of alcohol were not potentiated.
Tadalafil did not affect alcohol plasma concentrations and alcohol did not affect tadalafil plasma concentrations.
Effects On Exercise Stress Testing.
The effects of tadalafil on cardiac function, hemodynamics, and exercise tolerance were investigated in a single clinical pharmacology study. In this blinded crossover trial, 23 subjects with stable coronary artery disease and evidence of exercise-induced cardiac ischemia were enrolled. The primary endpoint was time to cardiac ischemia. The mean difference in total exercise time was 3 seconds (tadalafil 10 mg minus placebo), which represented no clinically meaningful difference. Further statistical analysis demonstrated that tadalafil was non-inferior to placebo with respect to time to ischemia. Of note, in this study, in some subjects who received tadalafil followed by sublingual nitroglycerin in the post-exercise period, clinically significant reductions in blood pressure were observed, consistent with the augmentation by tadalafil of the blood-pressure-lowering effects of nitrates.
Effects On Vision.
Single oral doses of phosphodiesterase inhibitors have demonstrated transient dose-related impairment of color discrimination (blue/green), using the Farnsworth-Munsell 100-hue test, with peak effects near the time of peak plasma levels. This finding is consistent with the inhibition of PDE6, which is involved in photo transduction in the retina. In a study to assess the effects of a single dose of tadalafil 40 mg on vision (N=59), no effects were observed on visual acuity, intraocular pressure, or pupilometry. Across all clinical studies with CIALIS, reports of changes in color vision were rare (
Effects On Sperm Characteristics.
Three studies were conducted in men to assess the potential effect on sperm characteristics of tadalafil 10 mg (one 6 month study) and 20 mg (one 6 month and one 9 month study) administered daily. There were no adverse effects on sperm morphology or sperm motility in any of the three studies. In the study of 10 mg tadalafil for 6 months and the study of 20 mg tadalafil for 9 months, results showed a decrease in mean sperm concentrations relative to placebo, although these differences were not clinically meaningful. This effect was not seen in the study of 20 mg tadalafil taken for 6 months. In addition there was no adverse effect on mean concentrations of reproductive hormones, testosterone, luteinizing hormone or follicle stimulating hormone with either 10 or 20 mg of tadalafil compared to placebo.
Effects On Cardiac Electrophysiology.
The effect of a single 100-mg dose of tadalafil on the QT interval was evaluated at the time of peak tadalafil concentration in a randomized, double-blinded, placebo, and active (intravenous ibutilide) -controlled crossover study in 90 healthy males aged 18 to 53 years. The mean change in QT (Fridericia QT correction) for tadalafil, relative to placebo, was 3.5 milliseconds (two-sided 90% CI=1.9, 5.1). The mean change in QT (Individual QTcorrection) for tadalafil, relative to placebo, was 2.8 milliseconds (two-sided 90% CI=1.2, 4.4). A 100-mg dose of tadalafil (5 times the highest recommended dose) was chosen because this dose yields exposures covering those observed upon coadministration of tadalafil with potent CYP3A4 inhibitors or those observed in renal impairment. In this study, the mean increase in heart rate associated with a 100-mg dose of tadalafil compared to placebo was 3.1 beats per minute.
Pharmacokinetics.
Over a dose range of 2.5 to 20 mg, tadalafil exposure (AUC) increases proportionally with dose in healthy subjects. Steady-state plasma concentrations are attained within 5 days of once per day dosing and exposure is approximately 1.6-fold greater than after a single dose. Mean tadalafil concentrations measured after the administration of a single oral dose of 20 mg and single and once daily multiple doses of 5 mg, from a separate study, ( see Figure 4) to healthy male subjects are depicted in Figure 4 .
Figure 4: Plasma tadalafil concentrations (mean ± SD) following a single 20-mg tadalafil dose and single and once daily multiple doses of 5 mg.
Absorption.
After single oral-dose administration, the maximum observed plasma concentration (C) of tadalafil is achieved between 30 minutes and 6 hours (median time of 2 hours). Absolute bioavailability of tadalafil following oral dosing has not been determined.
The rate and extent of absorption of tadalafil are not influenced by food; thus CIALIS may be taken with or without food.
Distribution.
The mean apparent volume of distribution following oral administration is approximately 63 L, indicating that tadalafil is distributed into tissues. At therapeutic concentrations, 94% of tadalafil in plasma is bound to proteins.
Less than 0.0005% of the administered dose appeared in the semen of healthy subjects.
Metabolism.
Tadalafil is predominantly metabolized by CYP3A4 to a catechol metabolite. The catechol metabolite undergoes extensive methylation and glucuronidation to form the methyl catechol and methyl catechol glucuronide conjugate, respectively. The major circulating metabolite is the methyl catechol glucuronide.Methylcatechol concentrations are less than 10% of glucuronide concentrations.
In vitro data suggests that metabolites are not expected to be pharmacologically active at observed metabolite concentrations.
Excretion.
The mean oral clearance for tadalafil is 2.5 L/hr and the mean terminal half-life is 17.5 hours in healthy subjects. Tadalafil is excreted predominantly as metabolites, mainly in the feces (approximately 61% of the dose) and to a lesser extent in the urine (approximately 36% of the dose).
Geriatric.
Healthy male elderly subjects (65 years or over) had a lower oral clearance of tadalafil, resulting in25% higher exposure (AUC) with no effect on Cmax relative to that observed in healthy subjects 19 to 45 years of age. No dose adjustment is warranted based on age alone. However, greater sensitivity to medications winsome older individuals should be considered [see Use In Specific Populations ] .
Patients With Diabetes Mellitus.
In male patients with diabetes mellitus after a 10 mg tadalafil dose, exposure(AUC) was reduced approximately 19% and Cmax was 5% lower than that observed in healthy subjects. No dose adjustment is warranted.
Patients With BPH.
In patients with BPH following single and multiple-doses of 20 mg tadalafil, no statistically significant differences in exposure (AUC and Cmax) were observed between elderly (70 to 85 years) and younger (≤60 years of age) subjects. No dose adjustment is warranted.
Animal Toxicology And/Or Pharmacology.
Animal studies showed vascular inflammation in tadalafil-treated mice, rats, and dogs. In mice and rats, lymphoid necrosis and hemorrhage were seen in the spleen, thymus, and mesenteric lymph nodes at unbound tadalafil exposure of 2- to 33-fold above the human exposure (AUCs) at the MRHD of 20 mg. In dogs, an increased incidence of disseminated arteritis was observed in 1- and 6-month studies at unbound tadalafil exposure of 1- to 54-fold above the human exposure (AUC) at the MRHD of 20 mg. In a 12-month dog study, no disseminated arteritis was observed, but 2 dogs exhibited marked decreases in white blood cells (neutrophils) and moderate decreases in platelets with inflammatory signs at unbound tadalafil exposures of approximately14- to 18-fold the human exposure at the MRHD of 20 mg. The abnormal blood-cell findings were reversible within 2 weeks after stopping treatment.
Clinical Studies.
CIALIS For Use As Needed For ED.
The efficacy and safety of tadalafil in the treatment of erectile dysfunction has been evaluated in 22 clinical trials of up to 24-weeks duration, involving over 4000 patients. CIALIS, when taken as needed up to once per day, was shown to be effective in improving erectile function in men with erectile dysfunction (ED).
CIALIS was studied in the general ED population in 7 randomized, multicenter, double-blinded, placebo-controlled, parallel-arm design, primary efficacy and safety studies of 12-weeks duration. Two of these studies were conducted in the United States and 5 were conducted in centers outside the US. Additional efficacy and safety studies were performed in ED patients with diabetes mellitus and in patients who developed ED status post bilateral nerve-sparing radical prostatectomy.
In these 7 trials, CIALIS was taken as needed, at doses ranging from 2.5 to 20 mg, up to once per day. Patients were free to choose the time interval between dose administration and the time of sexual attempts. Food and alcohol intake were not restricted.
Several assessment tools were used to evaluate the effect of CIALIS on erectile function. The 3 primary outcome measures were the Erectile Function (EF) domain of the International Index of Erectile Function(IIEF) and Questions 2 and 3 from Sexual Encounter Profile (SEP). The IIEF is a 4-week recall questionnaire that was administered at the end of a treatment-free baseline period and subsequently at follow-up visits after randomization. The IIEF EF domain has a 30-point total score, where higher scores reflect better erectile function. SEP is a diary in which patients recorded each sexual attempt made throughout the study. SEPQuestion 2 asks, “Were you able to insert your penis into the partner’s vagina?” SEP Question 3 asks, “Did your erection last long enough for you to have successful intercourse?” The overall percentage of successful attempts to insert the penis into the vagina (SEP2) and to maintain the erection for successful intercourse (SEP3) is derived for each patient.
Results In ED Population In US Trials.
The 2 primary US efficacy and safety trials included a total of 402men with erectile dysfunction, with a mean age of 59 years (range 27 to 87 years). The population was 78%White, 14% Black, 7% Hispanic, and 1% of other ethnicities, and included patients with ED of various severities, etiologies (organic, psychogenic, mixed), and with multiple co-morbid conditions, including diabetes mellitus, hypertension, and other cardiovascular disease. Most (>90%) patients reported ED of at least 1-yearduration. Study A was conducted primarily in academic centers. Study B was conducted primarily in community-based urology practices. In each of these 2 trials, CIALIS 20 mg showed clinically meaningful and statistically significant improvements in all 3 primary efficacy variables ( see Table 11). The treatment effect ofCIALIS did not diminish over time.
Table 11: Mean Endpoint and Change from Baseline for the Primary Efficacy Variables in the TwoPrimary US Trials.
Study A Study B Placebo CIALIS 20 mg Placebo CIALIS 20 mg (N=49) (N=146) p-value (N=48) (N=159) p-value EF Domain Score Endpoint 13.5 19.5 13.6 22.5 Change from baseline -0.2 6.9 0.3 9.3 Insertion of Penis (SEP2) Endpoint 39% 62% 43% 77% Change from baseline 2% 26% 2% 32% Maintenance of Erection (SEP3) Endpoint 25% 50% 23% 64% Change from baseline 5% 34% 4% 44%
Results In General ED Population In Trials Outside The US.
The 5 primary efficacy and safety studies conducted in the general ED population outside the US included 1112 patients, with a mean age of 59 years (range 21 to 82 years). The population was 76% White, 1% Black, 3% Hispanic, and 20% of other ethnicities, and included patients with ED of various severities, etiologies (organic, psychogenic, mixed), and with multiple co-morbid conditions, including diabetes mellitus, hypertension, and other cardiovascular disease. Most (90%)patients reported ED of at least 1-year duration. In these 5 trials, CIALIS 5, 10, and 20 mg showed clinically meaningful and statistically significant improvements in all 3 primary efficacy variables ( see Tables 12 , 13 and 14). The treatment effect of CIALIS did not diminish over time.
Table 12: Mean Endpoint and Change from Baseline for the EF Domain of the IIEF in the General EDPopulation in Five Primary Trials Outside the US.
Placebo CIALIS 5 mg CIALIS 10 mg CIALIS 20 mg Study C Endpoint [Change from baseline] 15.0 [0.7] 17.9 [4.0] 17.9 [4.0] p=.006 p Study D Endpoint [Change from baseline] 14.4 [1.1] 17.5 [5.1] 20.6 [6.0] p=.002 p Study E Endpoint [Change from baseline] 18.1 [2.6] 22.6 [8.1] 25.0 [8.0] p p Study F a Endpoint [Change from baseline] 12.7 [-1.6] 22.8 [6.8] p Study G Endpoint [Change from baseline] 14.5 [-0.9] 21.2 [6.6] 23.3 [8.0] p p a Treatment duration in Study F was 6 months.
Table 13: Mean Post-Baseline Success Rate and Change from Baseline for SEP Question 2 (“Were you able to insert your penis into the partner’s vagina?”) in the General ED Population in Five Pivotal TrialsOutside the US.
Placebo CIALIS 5 mg CIALIS 10 mg CIALIS 20 mg Study C Endpoint [Change from baseline] 49% [6%] 57% [15%] 73% [29%] p=.063 p Study D Endpoint [Change from baseline] 46% [2%] 56% [18%] 68% [15%] p=.008 p Study E Endpoint [Change from baseline] 55% [10%] 77% [35%] 85% [35%] p p Study F a Endpoint [Change from baseline] 42% [-8%] 81% [27%] p Study G Endpoint [Change from baseline] 45% [-6%] 73% [21%] 76% [21%] p p a Treatment duration in Study F was 6 months.
Table 14: Mean Post-Baseline Success Rate and Change from Baseline for SEP Question 3 (“Did your erection last long enough for you to have successful intercourse?”) in the General ED Population in Five Pivotal Trials Outside the US.
Placebo CIALIS 5 mg CIALIS 10 mg CIALIS 20 mg Study C Endpoint [Change from baseline] 26% [4%] 38% [19%] 58% [32%] p=.040 p Study D Endpoint [Change from baseline] 28% [4%] 42% [24%] 51% [26%] p p Study E Endpoint [Change from baseline] 43% [15%] 70% [48%] 78% [50%] p p Study F a Endpoint [Change from baseline] 27% [1%] 74% [40%] p Study G Endpoint [Change from baseline] 32% [5%] 57% [33%] 62% [29%] p p a Treatment duration in Study F was 6 months.
In addition, there were improvements in EF domain scores, success rates based upon SEP Questions 2 and 3,and patient-reported improvement in erections across patients with ED of all degrees of disease severity while taking CIALIS, compared to patients on placebo.
Therefore, in all 7 primary efficacy and safety studies, CIALIS showed statistically significant improvement inpatients’ ability to achieve an erection sufficient for vaginal penetration and to maintain the erection long enough for successful intercourse, as measured by the IIEF questionnaire and by SEP diaries.
Efficacy Results In ED Patients With Diabetes Mellitus.
CIALIS was shown to be effective in treating ED inpatients with diabetes mellitus. Patients with diabetes were included in all 7 primary efficacy studies in the general ED population (N=235) and in one study that specifically assessed CIALIS in ED patients with type 1or type 2 diabetes (N=216). In this randomized, placebo-controlled, double-blinded, parallel-arm design prospective trial, CIALIS demonstrated clinically meaningful and statistically significant improvement in erectile function, as measured by the EF domain of the IIEF questionnaire and Questions 2 and 3 of the SEPdiary ( see Table 15).
Table 15: Mean Endpoint and Change from Baseline for the Primary Efficacy Variables in a Study in EDPatients with Diabetes.
Placebo CIALIS 10 mg CIALIS 20 mg (N=71) (N=73) (N=72) p-value EF Domain Score Endpoint [Change from baseline] 12.2 [0.1] 19.3 [6.4] 18.7 [7.3] Insertion of Penis (SEP2) Endpoint [Change from baseline] 30% [-4%] 57% [22%] 54% [23%] Maintenance of Erection (SEP3) Endpoint [Change from baseline] 20% [2%] 48% [28%] 42% [29%]
Efficacy Results In ED Patients Following Radical Prostatectomy.
CIALIS was shown to be effective in treating patients who developed ED following bilateral nerve-sparing radical prostatectomy. In 1 randomized, placebo-controlled, double-blinded, parallel-arm design prospective trial in this population (N=303), CIALISdemonstrated clinically meaningful and statistically significant improvement in erectile function, as measured by the EF domain of the IIEF questionnaire and Questions 2 and 3 of the SEP diary ( see Table 16).
Table 16: Mean Endpoint and Change from Baseline for the Primary Efficacy Variables in a Study inPatients who Developed ED Following Bilateral Nerve-Sparing Radical Prostatectomy.
Placebo CIALIS 20 mg (N=102) (N=201) p-value EF Domain Score Endpoint [Change from baseline] 13.3 [1.1] 17.7 [5.3] Insertion of Penis (SEP2) Endpoint [Change from baseline] 32% [2%] 54% [22%] Maintenance of Erection (SEP3) Endpoint [Change from baseline] 19% [4%] 41% [23%]
Results In Studies To Determine The Optimal Use Of CIALIS.
Several studies were conducted with the objective of determining the optimal use of CIALIS in the treatment of ED. In one of these studies, the percentage of patients reporting successful erections within 30 minutes of dosing was determined. In this randomized, placebo-controlled, double-blinded trial, 223 patients were randomized to placebo, CIALIS 10, or20 mg. Using a stopwatch, patients recorded the time following dosing at which a successful erection was obtained. A successful erection was defined as at least 1 erection in 4 attempts that led to successful intercourse.At or prior to 30 minutes, 35% (26/74), 38% (28/74), and 52% (39/75) of patients in the placebo, 10-, and 20-mg groups, respectively, reported successful erections as defined above.
Two studies were conducted to assess the efficacy of CIALIS at a given timepoint after dosing, specifically at24 hours and at 36 hours after dosing.
In the first of these studies, 348 patients with ED were randomized to placebo or CIALIS 20 mg. Patients were encouraged to make 4 total attempts at intercourse; 2 attempts were to occur at 24 hours after dosing and 2completely separate attempts were to occur at 36 hours after dosing. The results demonstrated a difference between the placebo group and the CIALIS group at each of the pre-specified timepoints. At the 24-hourtimepoint, (more specifically, 22 to 26 hours), 53/144 (37%) patients reported at least 1 successful intercourse in the placebo group versus 84/138 (61%) in the CIALIS 20-mg group. At the 36-hour timepoint (more specifically, 33 to 39 hours), 49/133 (37%) of patients reported at least 1 successful intercourse in the placebo group versus 88/137 (64%) in the CIALIS 20-mg group.
In the second of these studies, a total of 483 patients were evenly randomized to 1 of 6 groups: 3 different dosing groups (placebo, CIALIS 10, or 20 mg) that were instructed to attempt intercourse at 2 different times(24 and 36 hours post-dosing). Patients were encouraged to make 4 separate attempts at their assigned dose and assigned timepoint. In this study, the results demonstrated a statistically significant difference between the placebo group and the CIALIS groups at each of the pre-specified timepoints. At the 24-hour timepoint, the mean, per patient percentage of attempts resulting in successful intercourse were 42, 56, and 67% for the placebo, CIALIS 10-, and 20-mg groups, respectively. At the 36-hour timepoint, the mean, per-patient percentage of attempts resulting in successful intercourse were 33, 56, and 62% for placebo, CIALIS 10-, and20-mg groups, respectively.
CIALIS For Once Daily Use For ED.
The efficacy and safety of CIALIS for once daily use in the treatment of erectile dysfunction has been evaluate din 2 clinical trials of 12-weeks duration and 1 clinical trial of 24-weeks duration, involving a total of 853patients. CIALIS, when taken once daily, was shown to be effective in improving erectile function in men with erectile dysfunction (ED).
CIALIS was studied in the general ED population in 2 randomized, multicenter, double-blinded, placebo-controlled, parallel-arm design, primary efficacy and safety studies of 12- and 24-weeks duration, respectively.One of these studies was conducted in the United States and one was conducted in centers outside the US. An additional efficacy and safety study was performed in ED patients with diabetes mellitus. CIALIS was taken once daily at doses ranging from 2.5 to 10 mg. Food and alcohol intake were not restricted. Timing of sexual activity was not restricted relative to when patients took Cialis.
Results In General ED Population.
The primary US efficacy and safety trial included a total of 287 patients ,with a mean age of 59 years (range 25 to 82 years). The population was 86% White, 6% Black, 6% Hispanic, and 2% of other ethnicities, and included patients with ED of various severities, etiologies (organic, psychogenic, mixed), and with multiple co-morbid conditions, including diabetes mellitus, hypertension, andother cardiovascular disease. Most (>96%) patients reported ED of at least 1-year duration.
The primary efficacy and safety study conducted outside the US included 268 patients, with a mean age of 56years (range 21 to 78 years). The population was 86% White, 3% Black, 0.4% Hispanic, and 10% of other ethnicities, and included patients with ED of various severities, etiologies (organic, psychogenic, mixed), and with multiple co-morbid conditions, including diabetes mellitus, hypertension, and other cardiovascular disease.Ninety-three percent of patients reported ED of at least 1-year duration.
In each of these trials, conducted without regard to the timing of dose and sexual intercourse, CIALISdemonstrated clinically meaningful and statistically significant improvement in erectile function, as measured by the EF domain of the IIEF questionnaire and Questions 2 and 3 of the SEP diary ( see Table 17). When taken as directed, CIALIS was effective at improving erectile function.
In the 6 month double-blind study, the treatment effect of CIALIS did not diminish over time.
Table 17: Mean Endpoint and Change from Baseline for the Primary Efficacy Variables in the TwoCIALIS for Once Daily Use Studies.
Study H a Study I b Placebo CIALIS 2.5 mg CIALIS 5 mg Placebo CIALIS 5 mg (N=94) (N=96) (N=97) p-value (N=54) (N=109) p-value EF Domain Score Endpoint 1.6 19.1 20.8 15.0 22.8 Change from baseline 1.2 6.1 c 7.0 c 0.9 9.7 c Insertion of Penis (SEP2) Endpoint 51% 65% 71% 52% 79% Change from baseline 5% 24% c 26% c 11% 37% c Maintenance of Erection (SEP3) Endpoint 31% 50% 57% 37% 67% Change from baseline 10% 31% c 35% c 13% 46% c a Twenty-four-week study conducted in the US. b Twelve-week study conducted outside the US. c Statistically significantly different from placebo.
Efficacy Results In ED Patients With Diabetes Mellitus.
CIALIS for once daily use was shown to be effective in treating ED in patients with diabetes mellitus. Patients with diabetes were included in both studies in the general ED population (N=79). A third randomized, multicenter, double-blinded, placebo-controlled, parallel-arm design trial included only ED patients with type 1 or type 2 diabetes (N=298). In this third trial, CIALISdemonstrated clinically meaningful and statistically significant improvement in erectile function, as measured by the EF domain of the IIEF questionnaire and Questions 2 and 3 of the SEP diary ( see Table 18).
Table 18: Mean Endpoint and Change from Baseline for the Primary Efficacy Variables in a CIALIS forOnce Daily Use Study in ED Patients with Diabetes.
Placebo CIALIS 2.5 mg CIALIS 5 mg (N=100) (N=100) (N=98) p-value EF Domain Score Endpoint 14.7 18.3 17.2 Change from baseline 1.3 4.8 a 4.5 a Insertion of Penis (SEP2) Endpoint 43% 62% 61% Change from baseline 5% 21% a 29% a Maintenance of Erection (SEP3) Endpoint 28% 46% 41% Change from baseline 8% 26% a 25% a a Statistically significantly different from placebo.
CIALIS 5 mg For Once Daily Use For Benign Prostatic Hyperplasia (BPH)
The efficacy and safety of CIALIS for once daily use for the treatment of the signs and symptoms of BPH was evaluated in 3 randomized, multinational, double-blinded, placebo-controlled, parallel-design, efficacy and safety studies of 12 weeks duration. Two of these studies were in men with BPH and one study was specific to men with both ED and BPH [see CIALIS 5 mg For Once Daily Use For ED And BPH ] . The first study (Study J) randomized 1058 patients to receive either CIALIS 2.5 mg, 5 mg, 10 mg or 20 mg for once daily use or placebo. The second study (Study K) randomized 325 patients to receive either CIALIS 5 mg for once daily use or placebo. The full study population was 87% White, 2% Black, 11% other races; 15% was of Hispanic ethnicity. Patients with multiple co-morbid conditions such as diabetes mellitus, hypertension, and other cardiovascular disease were included.
The primary efficacy endpoint in the two studies that evaluated the effect of CIALIS for the signs and symptoms of BPH was the International Prostate Symptom Score (IPSS), a four week recall questionnaire that was administered at the beginning and end of a placebo run-in period and subsequently at follow-up visits after randomization. The IPSS assesses the severity of irritative (frequency, urgency, nocturia) and obstructive symptoms (incomplete emptying, stopping and starting, weak stream, and pushing or straining), with scores ranging from 0 to 35; higher numeric scores representing greater severity. Maximum urinary flow rate (Qmax),an objective measure of urine flow, was assessed as a secondary efficacy endpoint in Study J and as a safety endpoint in Study K.
The results for BPH patients with moderate to severe symptoms and a mean age of 63.2 years (range 44 to 87)who received either CIALIS 5 mg for once daily use or placebo (N=748) in Studies J and K are shown in Table19 and Figures 5 and 6 , respectively.
In each of these 2 trials, CIALIS 5 mg for once daily use resulted in statistically significant improvement in the total IPSS compared to placebo. Mean total IPSS showed a decrease starting at the first scheduled observation(4 weeks) in Study K and remained decreased through 12 weeks.
Table 19: Mean IPSS Changes in BPH Patients in Two CIALIS for Once Daily Use Studies.
Study J Study K Placebo CIALIS 5 mg Placebo CIALIS 5 mg (N=205) (N=205) p-value (N=164) (N=160) p-value Total Symptom Score (IPSS) Baseline 17.1 17.3 16.6 17.1 Change from Baseline to Week12 -2.2 -4.8 -3.6 -5.6.
Figure 5: Mean IPSS Changes in BPH Patients by Visit in Study J.
Figure 6: Mean IPSS Changes in BPH Patients by Visit in Study K.
In Study J, the effect of CIALIS 5 mg once daily on maximum urinary flow rate (Qmax) was evaluated as a secondary efficacy endpoint. Mean Qmax increased from baseline in both the treatment and placebo groups(CIALIS 5 mg: 1.6 mL/sec, placebo: 1.2 mL/sec); however, these changes were not significantly different between groups.
In Study K, the effect of CIALIS 5 mg once daily on Qmax was evaluated as a safety endpoint. Mean Qmax increased from baseline in both the treatment and placebo groups (CIALIS 5 mg: 1.6 mL/sec, placebo:1.1 mL/sec); however, these changes were not significantly different between groups.
Efficacy Results In Patients With BPH Initiating CIALIS And Finasteride.
CIALIS for once daily use initiated together with finasteride was shown to be effective in treating the signs and symptoms of BPH in men with an enlarged prostate (>30 cc) for up to 26 weeks. This additional double-blinded, parallel-design study of 26 weeks duration randomized 696 men to initiate either CIALIS 5 mg with finasteride 5 mg or placebo with finasteride 5mg. The study population had a mean age of 64 years (range 46-86). Patients with multiple co-morbid conditions such as erectile dysfunction, diabetes mellitus, hypertension, and other cardiovascular disease were included.
CIALIS with finasteride demonstrated statistically significant improvement in the signs and symptoms of BPHcompared to placebo with finasteride, as measured by the total IPSS at 12 weeks, the primary study endpoint( see Table 20). Key secondary endpoints demonstrated improvement in total IPSS starting at the first scheduled observation at week 4 (CIALIS -4.0, placebo -2.3: p.
Table 20: Mean Total IPSS Changes in BPH Patients in a CIALIS for Once Daily Use Study Together with Finasteride.
Placebo and finasteride 5mg CIALIS 5mg and finasteride 5 mg Treatment difference n (N=350) a n (N=345) a p-value b Total Symptom Score (IPSS) Baseline c 349 17. 344 17.1 Change from Baseline to Week4 b 30 -2.3 330 -4.0 -1.7 Change from Baseline to Week12 b 318 -3.8 317 -5.2 -1.4 .001 Change from Baseline to Week26 b 295 -.5 308 -5.5 -1.0 .022 a Overall ITT population. b Mixed model for repeated measurements. c Unadjusted mean.
Figure 7: Mean Total IPSS Changes By Visit in BPH Patients Taking CIALIS for Once Daily Use.
In the 404 patients who had both ED and BPH at baseline, changes in erectile function were assessed as key secondary endpoints using the EF domain of the IIEF questionnaire. CIALIS with finasteride (N=203) was compared to placebo with finasteride (N=201). A statistically significant improvement from baseline(CIALIS/finasteride 13.7, placebo/finasteride 15.1) was observed at week 4 (CIALIS/finasteride 3.7,placebo/finasteride -1.1; p.
CIALIS 5 mg For Once Daily Use For ED And BPH.
The efficacy and safety of CIALIS for once daily use for the treatment of ED, and the signs and symptoms ofBPH, in patients with both conditions was evaluated in one placebo-controlled, multinational, double-blind, parallel-arm study which randomized 606 patients to receive either CIALIS 2.5 mg, 5 mg, for once daily use or placebo. ED severity ranged from mild to severe and BPH severity ranged from moderate to severe. The full study population had a mean age of 63 years (range 45 to 83) and was 93% White, 4% Black, 3% other races;16% were of Hispanic ethnicity. Patients with multiple co-morbid conditions such as diabetes mellitus, hypertension, and other cardiovascular disease were included.
In this study, the co-primary endpoints were total IPSS and the Erectile Function (EF) domain score of theInternational Index of Erectile Function (IIEF). One of the key secondary endpoints in this study was Question3 of the Sexual Encounter Profile diary (SEP3). Timing of sexual activity was not restricted relative to when patients took CIALIS.
The efficacy results for patients with both ED and BPH, who received either CIALIS 5 mg for once daily use or placebo (N=408) are shown in Tables 21 and 22 and Figure 8 .
CIALIS 5 mg for once daily use resulted in statistically significant improvements in the total IPSS and in the EFdomain of the IIEF questionnaire. CIALIS 5 mg for once daily use also resulted in statistically significant improvement in SEP3. CIALIS 2.5 mg did not result in statistically significant improvement in the total IPSS.
Table 21: Mean IPSS and IIEF EF Domain Changes in the CIALIS 5 mg for Once Daily Use Study inPatients with ED and BPH.
Placebo CIALIS 5 mg p-value Total Symptom Score (IPSS) (N=193) (N=206) Baseline 18.2 18.5 Change from Baseline to Week 12 -3.8 -6.1 EF Domain Score (IIEF EF) (N=188) (N=202) Baseline 15.6 16.5 Endpoint 17.6 22.9 Change from Baseline to Week 12 1.9 6.5.
Table 22: Mean SEP Question 3 Changes in the CIALIS 5 mg for Once Daily Use Study in Patients withED and BPH.
Placebo CIALIS 5 mg (N=187) (N=199) p-value Maintenance of Erection (SEP3) Baseline 36% 43% Endpoint 48% 72% Change from Baseline to Week 12 12% 32%
CIALIS for once daily use resulted in improvement in the IPSS total score at the first scheduled observation (week 2) and throughout the 12 weeks of treatment ( see Figure 8).
Figure 8: Mean IPSS Changes in ED/BPH Patients by Visit in Study L.
In this study, the effect of CIALIS 5 mg once daily on Qmax was evaluated as a safety endpoint. Mean Qmax increased from baseline in both the treatment and placebo groups (CIALIS 5 mg: 1.6 mL/sec, placebo:1.2 mL/sec); however, these changes were not significantly different between groups.
PATIENT INFORMATION.
CIALIS ® (See-AL-iss) (tadalafil) tablets.
Read this important information before you start taking CIALIS and each time you get a refill. There may be new information. You may also find it helpful to share this information with your partner. This information doe snot take the place of talking with your healthcare provider. You and your healthcare provider should talk aboutCIALIS when you start taking it and at regular checkups. If you do not understand the information, or have questions, talk with your healthcare provider or pharmacist.
What Is The Most Important Information I Should Know About CIALIS?
CIALIS can cause your blood pressure to drop suddenly to an unsafe level if it is taken with certain other medicines. You could get dizzy, faint, or have a heart attack or stroke. Never take CIALIS with any nitrate orguanylate cyclase stimulator medicines.
Do not take CIALIS if you take any medicines called “nitrates.” Nitrates are commonly used to treat angina.Angina is a symptom of heart disease and can cause pain in your chest, jaw, or down your arm.
Medicines called nitrates include nitroglycerin that is found in tablets, sprays, ointments, pastes, or patches.Nitrates can also be found in other medicines such as isosorbide dinitrate or isosorbide mononitrate. Some recreational drugs called “poppers” also contain nitrates, such as amyl nitrite and butyl nitrite.
Do not take CIALIS if you take medicines called guanylate cyclase stimulators which include:
Ask your healthcare provider or pharmacist if you are not sure if any of your medicines are nitrates or guanylatecyclase stimulators, such as riociguat.
Tell all of your healthcare providers that you take CIALIS. If you need emergency medical care for a heart problem, it will be important for your healthcare provider to know when you last took CIALIS.
After taking a single tablet, some of the active ingredient of CIALIS remains in your body for more than 2 days. The active ingredient can remain longer if you have problems with your kidneys or liver, or you are taking certain other medications (see “ Can Other Medicines Affect CIALIS? ”).
Stop sexual activity and get medical help right away if you get symptoms such as chest pain, dizziness, or nausea during sex. Sexual activity can put an extra strain on your heart, especially if your heart is already weak from a heart attack or heart disease.
See also “ What Are The Possible Side Effects Of CIALIS? ”
CIALIS is a prescription medicine taken by mouth for the treatment of:
ED is a condition where the penis does not fill with enough blood to harden and expand when a man is sexually excited, or when he cannot keep an erection. A man who has trouble getting or keeping an erection should see his healthcare provider for help if the condition bothers him. CIALIS helps increase blood flow to the penis and may help men with ED get and keep an erection satisfactory for sexual activity. Once a man has completed sexual activity, blood flow to his penis decreases, and his erection goes away.
Some form of sexual stimulation is needed for an erection to happen with CIALIS.
cure ED increase a man’s sexual desire protect a man or his partner from sexually transmitted diseases, including HIV. Speak to your healthcare provider about ways to guard against sexually transmitted diseases. serve as a male form of birth control.
CIALIS is only for men over the age of 18, including men with diabetes or who have undergone prostatectomy.
CIALIS for the Treatment of Symptoms of BPH.
BPH is a condition that happens in men, where the prostate gland enlarges which can cause urinary symptoms.
CIALIS for the Treatment of ED and Symptoms of BPH.
ED and symptoms of BPH may happen in the same person and at the same time. Men who have both ED and symptoms of BPH may take CIALIS for the treatment of both conditions.
CIALIS must be used only under a healthcare provider’s care.
take any medicines called “nitrates”. use recreational drugs called “poppers” like amyl nitrite and butyl nitrite. (See “ What Is The MostImportant Information I Should Know About CIALIS? ”) take any medicines called guanylate cyclase stimulators, such as riociguat. are allergic to CIALIS or ADCIRCA ® , or any of its ingredients. See the end of this leaflet for a complete list of ingredients in CIALIS. Symptoms of an allergic reaction may include: rash hives swelling of the lips, tongue, or throat difficulty breathing or swallowing.
Call your healthcare provider or get help right away if you have any of the symptoms of an allergic reaction listed above.
What Should I Tell My Healthcare Provider Before Taking CIALIS?
CIALIS is not right for everyone. Only your healthcare provider and you can decide if CIALIS is right for you. Before taking CIALIS, tell your healthcare provider about all your medical problems, including if you:
have heart problems such as angina, heart failure, irregular heartbeats, or have had a heart attack. Ask your healthcare provider if it is safe for you to have sexual activity. You should not take CIALIS if your healthcare provider has told you not to have sexual activity because of your health problems. have pulmonary hypertension have low blood pressure or have high blood pressure that is not controlled have had a stroke have liver problems have kidney problems or require dialysis have retinitis pigmentosa , a rare genetic (runs in families) eye disease have ever had severe vision loss, including a condition called NAION have stomach ulcers have a bleeding problem have a deformed penis shape or Peyronie’s disease have had an erection that lasted more than 4 hours have blood cell problems such as sickle cell anemia, multiple myeloma, or leukemia.
Tell your healthcare provider about all the medicines you take including prescription and non-prescription medicines, vitamins, and herbal supplements. CIALIS and other medicines may affect each other. Always check with your healthcare provider before starting or stopping any medicines. Especially tell your healthcare provider if you take any of the following*:
medicines called nitrates (see “ What Is The Most Important Information I Should Know AboutCIALIS? ”) medicines called guanylate cyclase stimulators, such as riociguat (Adempas ® ), used to treat pulmonary hypertension medicines called alpha blockers. These include Hytrin ® (terazosin HCl), Flomax ® (tamsulosin HCl),Cardura ® (doxazosin mesylate), Minipress ® (prazosin HCl), Uroxatral ® (alfuzosin HCl), Jalyn ® (dutasteride and tamsulosin HCl) or Rapaflo ® (silodosin). Alpha-blockers are sometimes prescribed for prostate problems or high blood pressure. If CIALIS is taken with certain alpha blockers, your blood pressure could suddenly drop. You could get dizzy or faint. other medicines to treat high blood pressure (hypertension) medicines called HIV protease inhibitors, such as ritonavir (Norvir ® , Kaletra ® ) some types of oral antifungals such as ketoconazole (Nizoral ® ), itraconazole (Sporano ® x) some types of antibiotics such as clarithromycin (Biaxin ® ), telithromycin (Ketek ® ), erythromycin (several brand names exist. Please consult your healthcare provider to determine if you are taking this medicine). other medicines or treatments for ED. CIALIS is also marketed as ADCIRCA for the treatment of pulmonary arterial hypertension. Do not take both CIALIS and ADCIRCA. Do not take sildenafil citrate (Revatio ® ) with CIALIS.
Take CIALIS exactly as your healthcare provider prescribes it. Your healthcare provider will prescribe the dose that is right for you. Some men can only take a low dose of CIALIS or may have to take it less often, because of medical conditions or medicines they take. Do not change your dose or the way you take CIALIS without talking to your healthcare provider. your healthcare provider may lower or raise your dose, depending on how your body reacts to CIALIS and your health condition. CIALIS may be taken with or without meals. If you take too much CIALIS, call your healthcare provider or emergency room right away.
How Should I Take CIALIS for Symptoms of BPH?
For symptoms of BPH, CIALIS is taken once daily.
Do not take CIALIS more than one time each day. Take one CIALIS tablet every day at about the same time of day. If you miss a dose, you may take it when you remember but do not take more than one dose per day.
For ED, there are two ways to take CIALIS – either for use as needed OR for use once daily.
Do not take CIALIS more than one time each day. Take one CIALIS tablet before you expect to have sexual activity. You may be able to have sexual activity at 30 minutes after taking CIALIS and up to 36 hours after taking it. You and your healthcare provider should consider this in deciding when you should take CIALIS before sexual activity. Some form of sexual stimulation is needed for an erection to happen with CIALIS. Your healthcare provider may change your dose of CIALIS depending on how you respond to the medicine, and on your health condition.
CIALIS for once daily use is a lower dose you take every day.
Do not take CIALIS more than one time each day. Take one CIALIS tablet every day at about the same time of day. You may attempt sexual activity at anytime between doses. If you miss a dose, you may take it when you remember but do not take more than one dose per day. Some form of sexual stimulation is needed for an erection to happen with CIALIS. Your healthcare provider may change your dose of CIALIS depending on how you respond to the medicine, and on your health condition.
How Should I Take CIALIS for Both ED and the Symptoms of BPH?
For both ED and the symptoms of BPH, CIALIS is taken once daily.
Do not take CIALIS more than one time each day. Take one CIALIS tablet every day at about the same time of day. You may attempt sexual activity at anytime between doses. If you miss a dose, you may take it when you remember but do not take more than one dose per day. Some form of sexual stimulation is needed for an erection to happen with CIALIS.
What Should I Avoid While Taking CIALIS?
Do not use other ED medicines or ED treatments while taking CIALIS. Do not drink too much alcohol when taking CIALIS (for example, 5 glasses of wine or 5 shots of whiskey).Drinking too much alcohol can increase your chances of getting a headache or getting dizzy, increasing your heart rate, or lowering your blood pressure.
What Are The Possible Side Effects Of CIALIS?
See “ What Is The Most Important Information I Should Know About CIALIS? ”
The most common side effects with CIALIS are : headache, indigestion, back pain, muscle aches, flushing, and stuffy or runny nose. These side effects usually go away after a few hours. Men who get back pain and muscle aches usually get it 12 to 24 hours after taking CIALIS. Back pain and muscle aches usually go away within 2 days.
Call your healthcare provider if you get any side effect that bothers you or one that does not go away.
An erection that won’t go away (priapism). If you get an erection that lasts more than 4 hours, get medical help right away. Priapism must be treated as soon as possible or lasting damage can happen to your penis, including the inability to have erections.
Color vision changes, such as seeing a blue tinge (shade) to objects or having difficulty telling the difference between the colors blue and green.
In rare instances, men taking PDE5 inhibitors (oral erectile dysfunction medicines, including CIALIS) reported sudden decrease or loss of vision in one or both eyes. It is uncertain whether PDE5 inhibitors directly cause the vision loss. If you experience sudden decrease or loss of vision, stop taking PDE5 inhibitors, includingCIALIS, and call a healthcare provider right away.
Sudden loss or decrease in hearing, sometimes with ringing in the ears and dizziness, has been rarely reported in people taking PDE5 inhibitors, including CIALIS. It is not possible to determine whether these events are related directly to the PDE5 inhibitors, to other diseases or medications, to other factors, or to a combination of factors. If you experience these symptoms, stop taking CIALIS and contact a healthcare provider right away.
These are not all the possible side effects of CIALIS. For more information, ask your healthcare provider or pharmacist.
Store CIALIS at room temperature between 59° and 86°F (15° and 30°C).
Keep CIALIS and all medicines out of the reach of children.
Medicines are sometimes prescribed for conditions other than those described in patient information leaflets. Do not use CIALIS for a condition for which it was not prescribed. Do not give CIALIS to other people, even if they have the same symptoms that you have. It may harm them.
This is a summary of the most important information about CIALIS. If you would like more information, talk with your healthcare provider. You can ask your healthcare provider or pharmacist for information aboutCIALIS that is written for health providers. For more information you can also visit www.cialis.com , or call 1-877-CIALIS1 (1-877-242-5471).
What Are The Ingredients In CIALIS?
Inactive Ingredients: croscarmellose sodium, hydroxypropyl cellulose, hypromellose, iron oxide, lactose monohydrate, magnesium stearate, microcrystalline cellulose, sodium lauryl sulfate, talc, titanium dioxide, contraception.
This Patient Information has been approved by the U.S. Food and Drug Administration.

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Cialis Daily (Tadalafil)
Cialis Daily is an expensive brand name drug to treat Erectile Dysfunction. Unlike other ED meds, there’s no planning required allowing you to be spontaneous and ready anytime. For a cheaper and equally effective option, get the generic version. Get Cialis Daily prescribed by a Lemonaid doctor or nurse practitioner and shipped to your door.
52% of men experience some kind of erectile dysfunction throughout their life.
Cialis Daily – what is it?
Cialis Daily is a popular brand-name ED medicine approved by the FDA for erectile dysfunction. The active ingredient is Tadalafil. Brand-name Cialis is made by Lilly. Generic Tadalafil or Generic Cialis Daily is also approved by the FDA to treat ED and is much more affordable. Generic Cialis has exactly the same active ingredient and is just as effective.
What are the benefits of Cialis Daily over other ED meds?
Cialis Daily allows you to be spontaneous and ready to have sex anytime in a way that other ED medicines don’t. If that’s as important to you as it is to many other men, then Cialis Daily can be a great option.
How to take Cialis Daily.
Cialis Daily is a 5mg tadalafil pill that you take every day. Because it’s a daily pill, it’s a lower dose than Cialis 10mg or Ciails 20mg which men take as needed. By taking the pill every day, you constantly have a sufficient quantity of tadalafil in your body that it should help with your erection whenever you have sex.
By comparison, you need to take other ED medicines – including Cialis 10mg and 20mg – before sex, so in that sense they require a level of planning that isn’t necessary with Cialis Daily.
Is Cialis Daily effective?
Cialis Daily tends to be effective. But like any prescription medicine it’s not guaranteed to work, and how it works for you will depend upon a number of factors. If it doesn’t work the way you want it to, you shouldn’t give up hope but instead message our medical team for advice.
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PDE5 drug that lasts in your system for 4 – 6 hours.
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*Offer valid for new patients only. Starting from $60 per shipment after the first treatment. Prescription products require completion of an independent medical consultation through Lemonaid Health platform. Additional terms and conditions also apply. See www.lemonaidhealth.com to learn more. Services and products available in all 50 states and the District of Columbia, subject to local laws.
*Offer valid for new patients only. $95 after first month of treatment. Prescription products require completion of an independent medical consultation through Lemonaid Health platform. Additional terms and conditions also apply. See www.lemonaidhealth.com to learn more. Services and products available in all 50 states and the District of Columbia, subject to local laws.
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Can I Take 40 mg of Tadalafil (Cialis) for ED?
Cialis is a brand-name version of tadalafil, a popular medication for treating erectile dysfunction (ED). Taking the medication helps you get the maximum effect while avoiding side effects.
Reasons not to take 40 milligrams (mg) of Cialis include how the drug works and its duration. Increasing the dose could result in side effects.
If you feel your current dosage isn’t working, there may be options to consider. Let’s look at Cialis, why to avoid taking too much, and more.
Taking 40 mg of Cialis could be dangerous and raise the risk of side effects such as a sudden drop in blood pressure and priapism. The typical dose is 10 mg for occasional use and 2.5 or 5 mg for daily use. The typical maximum dose of Cialis for ED is 20 mg once a day.
If a doctor has prescribed Cialis for pulmonary arterial hypertension, you may be advised to take two 20-mg doses a day. But taking that much of the medication should be done only under a doctor’s guidance.
It changes more than your penis.
While Cialis works for ED by affecting the PDE5 enzyme in the penis, it also affects other PDE enzymes in tissues and cells in other areas of the body. For example, PDE5 is found in tissues in the lungs, kidneys, liver, brain, and platelets.
Cialis also affects PDE11, which is found in tissues in the heart, pancreas, pituitary, skeletal muscles, testes, and corpus cavernosum.
It increases your chances of side effects.
Doubling the maximum dose of Cialis to 40 mg can increase the chances of experiencing side effects, which include:
It may also cause priapism, an erection lasting longer than 4 hours, damaging the penile tissue. An urgent medical evaluation is needed to prevent long-term damage if this occurs.
It’s in your system for a while and clears slowly.
Another reason not to double your dose is the long lasting effects of Cialis.
The effects of Cialis last much longer (up to 36 hours) than other PDE5 inhibitors like Viagra (4 to 5 hours). So, Cialis stays in your body and clears slowly. This can increase the risk of side effects if you add doses on top of what’s already in your system.
How does Cialis work?
Cialis is a phosphodiesterase type 5 (PDE5) inhibitor. It limits the effect of the PDE5 enzyme in the penis, allowing blood vessels in your penis to relax so blood can flow into the penis, helping to get or keep an erection. Keep in mind that Cialis won’t work unless you’re stimulated or aroused.

Female cialis

Cialis for Women: Can Women Take Tadalafil?
Does Cialis (tadalafil) work for women?
The drug known as Cialis is used to treat men who suffer from symptoms of erectile dysfunction (ED). This well-known brand name medication, also sold as tadalafil, a generic, non-branded version, is designed to help men achieve and maintain an erection firm enough for sex. Due to the effectiveness and positive reviews of tadalafil, many women have wondered if taking Cialis might increase their libido. Tadalafil tablets work by increasing blood flow to the penis for men that struggle with getting and keeping an erection, despite their desire to perform sexually. Contrary to popular belief, the drug has no effect on the level of a man’s sexual desire. Hence, women who take Cialis will not have an improved sex drive, making the treatment ineffective. Whilst the medication is commonly dispensed for men in the UK, Cialis and tadalafil are not currently licensed for women. This article will examine why women should not take ED medication like Cialis, and detail how this drug works for men by enabling an erection hard enough for sex.
What is Cialis (tadalafil)?
There are a few major players in the ED space. You may be familiar with brand names like Viagra and Levitra that, much like tadalafil, work by increasing blood flow to the penis. Cialis belongs to the same class of drugs, known as phosphodiesterase type 5 (PDE5) inhibitors. Cialis is available in four different strengths; 2.5mg, 5mg, 10mg and 20mg. The lower strengths of 2.5mg and 5mg are known as ‘Cialis Daily’ and have a continuous effect. They are recommended for individuals who have more than 2 sexual encounters per week. The 10mg and 20mg strengths should be taken around half an hour before sex, and can last up to 36 hours, earning them the nickname ‘the weekend pill.’ Many men star by taking Cialis 10mg in order to determine its effectiveness. As outlined by UK national guidelines, if you’re a man beginning treatment, you should try taking ED tablets on 8 separate occasions, before increasing the dose or trying another medication. It can take time for you to get used to the idea of using a tablet to help with ED. As previously mentioned, these guidelines are not intended for women, as the drug doesn’t increase the state of arousal necessary to facilitate stimulation of the sexual organs.
How does Cialis work?
PDE5 is a chemical which is present in the penis. It helps the penis to become flaccid after an erection. However, excess levels of PDE5 can also make it difficult to get an erection. Cialis blocks the action of PDE5, which helps blood vessels to relax. By ‘relaxing’ the blood vessels, they essentially widen, which in turn enables more blood to flow freely to the penis, causing an erection.
Does Cialis work for women?
Many women have wondered how taking an ED medication like tadalafil would affect them. During sexual stimulation, a woman’s clitoris engorges with blood. So, in theory, tadalafil should work for women. So, here’s why tadalafil does not work for women. Tadalafil encourages blood flow to the penis, by blocking the action of PDE5. In women, PDE5 does not prevent blood flow to the genitals, to the same extent as it does in men. This means that it is unlikely to have much of an effect on women. Furthermore, women do not rely on blood flow as much as men, in order to have sex. During sexual excitement, the vagina secretes fluid, lubricating the area. In order to achieve this state, a degree of sexual excitement is required. As tadalafil has no effect on sexual arousal, it will not help women. Tadalafil for women is not licensed because of this. Women taking Cialis are not likely to see an improvement in sexual performance, and it can be harmful.
What will happen if a woman takes Cialis?
Taking Cialis may increase blood flow to the clitoris, facilitating a sexual response mechanism. This effect – combined with the clitoris becoming engorged with blood – has a pronounced visual effect and may result in the vagina experiencing a ‘pounding’ or ‘tingling’ sensation. In order for the vagina to lubricate and contract, sexual stimulation is required. As noted, the effects of tadalafil have nothing to do with impacting a woman’s sexual desire, making the increased blood flow an effect unattributed to the body’s natural sexual response. As Cialis is a vasodilator, women can expect to experience a drop in blood pressure, and other side effects associated with tadalafil, such as dizziness, headache, facial flushing, and an upset stomach. If you’re a woman who is considering the benefits of a drug like Cialis in order to help increase your sex drive, consult your doctor to determine the best course of action before taking any ED medication. Tadalafil for women is not licensed and can be harmful to your health.
Is there a female version of Cialis or Viagra?
In the same way that female Cialis is not licensed for use, Viagra for women is not licensed either. Women are not likely to experience problems having intercourse, as a result of reduced blood flow. Most of the issues that arise with women having sex, is caused by female sexual dysfunction (FSD). The main causes of FSD are lack of sexual arousal, or painful sex. Cialis will not help to treat FSD. Treatments for FSD can include psychotherapy, pelvic floor exercises, hormone therapy and lifestyle changes. Whilst all of our content is written and reviewed by healthcare professionals, it is not intended to be substituted for or used as medical advice. If you have any questions or concerns about your health, please speak to your doctor.
FAQ:
Why has my libido dropped?
In the event that you notice a significant decrease in arousal, consult your doctor or healthcare provider in order to determine the best course of action. FSD is a treatable condition and can be overcome by following the right protocol.
Is low sex drive permanent?
No, you do not have to live with a low sex drive forever. Whilst age and certain other factors can contribute to diminished feelings of arousal, there are treatments available that are designed to help you regain a healthy sexual appetite. The first and most important step is to recognise if you’re feeling this way, and talk to a licensed medical professional for help in determining the best course of action.
How can I increase my sex drive naturally?
When it comes to increasing your libido naturally, nothing beats the combination of rest, exercise, and a healthy diet. Deploying a routine that includes plenty of sleep, lots of physical activity and good food can work wonders for naturally boosting sex hormones, and offsetting the stress that can trigger a decrease in sex drive. You should be wary of companies which sell products such as “natural Viagra” or libido enhancers, as these are not proven to work, and may contain harmful substances. For more tips on how to boost your sexual desire, and remember that communicating your feelings to a healthcare provider – or even your partner – can go a long ways towards recovering your libido.
Whilst all of our content is written and reviewed by healthcare professionals, it is not intended to be substituted for or used as medical advice. If you have any questions or concerns about your health, please speak to your doctor.

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Can you take cialis and viagra together?

Efficacy and safety of long-term tadalafil 5 mg once daily combined with sildenafil 50 mg as needed at the early stage of treatment for patients with erectile dysfunction.
This study aimed to evaluate the efficacy and safety of long-term and low-dose tadalafil combined with sildenafil as needed at the early stage of treatment for erectile dysfunction (ED). We enrolled 180 patients with ED 1 : 1 to tadalafil 5 mg once daily or once-a-day tadalafil 5 mg combined with sildenafil 50 mg as needed. The efficacy measures included the 5-item version of the International Index of Erectile Function (IIEF-5) and the Sexual Encounter Profile (SEP). The safety was assessed by observing drug tolerability and adverse events. Total IIEF-5 scores of patients with severe ED in combined medication group were significantly higher than in tadalafil alone group. Question 2 scores of IIEF-5 of patients with moderate and severe ED in combined medication group were significantly higher than in tadalafil alone group. The significant improvement in question 3 scores of IIEF-5 existed only in patients with severe ED receiving combined medication. The percentage of ‘yes’ responses to SEP4, SEP5 and partner’s SEP3 were improved significantly in combined medication group. There was no difference between two groups in the incidence of adverse events. Our results suggest that combined medication can better improve erectile function, especially for patients with severe ED.
Keywords: Combination therapy; erectile dysfunction; safety; tadalafil.
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