What is the recommended medication for erectile dysfunction (ED) in the elderly?

From the Guidelines

Phosphodiesterase type 5 (PDE5) inhibitors are the first-line medication recommended for erectile dysfunction in elderly patients, with sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra) being the most commonly prescribed options. For elderly patients, starting with a lower dose is advisable - sildenafil 25mg, tadalafil 5mg, or vardenafil 5mg - which can be adjusted based on response and tolerability 1. Tadalafil may be particularly suitable for elderly patients due to its longer duration of action (up to 36 hours) and once-daily dosing option (2.5-5mg), which eliminates the need to time medication before sexual activity. These medications work by enhancing blood flow to the penis by relaxing smooth muscle in blood vessels. Important considerations for elderly patients include potential drug interactions, especially with nitrates (which are absolutely contraindicated) and alpha-blockers (which require careful dosing separation) 1. Reduced hepatic and renal function in elderly patients may necessitate dose adjustments. Side effects to monitor include headache, flushing, dyspepsia, and visual disturbances. Before starting treatment, underlying causes of ED should be addressed, including diabetes management, hypertension control, and medication review, as many commonly prescribed medications in the elderly can contribute to erectile dysfunction 1.

Some key points to consider when prescribing PDE5 inhibitors to elderly patients include:

• Starting with a lower dose and adjusting as needed
• Monitoring for potential drug interactions, especially with nitrates and alpha-blockers
• Adjusting doses based on hepatic and renal function
• Monitoring for side effects such as headache, flushing, and dyspepsia
• Addressing underlying causes of ED, including diabetes management and medication review 1.

It's also important to note that the American College of Physicians recommends that clinicians initiate therapy with a PDE-5 inhibitor in men who seek treatment for erectile dysfunction and who do not have a contraindication to PDE-5 inhibitor use 1. Additionally, the choice of a specific PDE-5 inhibitor should be based on individual preferences, including ease of use, cost of medication, and adverse effects profile 1.

From the FDA Drug Label

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 (greater than 65 and greater than or equal to75 years of age) and younger subjects (less than or equal to 65 years of age) However, in placebo-controlled studies with tadalafil for use as needed for ED, diarrhea was reported more frequently in patients 65 years of age and older who were treated with tadalafil (2.5% of patients) [see Adverse Reactions (6. 1)]. 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 (12.3)].

Tadalafil is recommended for erectile dysfunction (ED) in the elderly, as no overall differences in efficacy or safety were observed between older and younger subjects in clinical trials 2. However, a greater sensitivity to medications in some older individuals should be considered.

From the Research

Medication for Erectile Dysfunction in the Elderly

The recommended medication for erectile dysfunction (ED) in the elderly includes:

• Phosphodiesterase type 5 (PDE5) inhibitors, which are considered the first-line treatment for ED 3
• Sildenafil, a PDE5 inhibitor that has been shown to be effective in improving erectile function in elderly patients with ED of broad-spectrum etiology and in those with ED and diabetes 4, 5
• Tadalafil, another PDE5 inhibitor that has been found to be effective in treating ED in elderly patients, with a prolonged action of 36 hours 6
• Vardenafil, a PDE5 inhibitor that has a similar efficacy and safety profile to sildenafil and tadalafil 3, 7

Dosage and Administration

The dosage of these medications may need to be adjusted in elderly patients, with lower doses recommended for those with hepatic or renal impairment or receiving certain medications, such as cytochrome P450 enzyme CYP3A4 inhibitors 4

• Sildenafil: dosages usually begin at 50mg taken when needed, with a maximum dose of 100mg once daily, and lower doses (e.g. 25mg) may be used in elderly patients 4
• Tadalafil: dosages range from 5mg to 20mg taken as needed, with a maximum dose of 20mg once daily 6
• Vardenafil: dosages range from 5mg to 20mg taken as needed, with a maximum dose of 20mg once daily 3

Efficacy and Safety

These medications have been shown to be effective in improving erectile function in elderly patients, with a good safety profile 4, 3, 6, 7, 5

• Common adverse events associated with these medications include headache, flushing, dyspepsia, nasal congestion, and abnormal vision, which are usually mild or moderate and transient 4, 3, 6, 7, 5