From the Guidelines
Propranolol is not contraindicated with tadalafil, but caution should be exercised when using these medications together. The 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guideline for the management of patients with chronic coronary disease 1 does not explicitly mention a contraindication between propranolol and tadalafil. However, it does highlight the potential for severe hypotension when phosphodiesterase type 5 inhibitors, such as tadalafil, are used concomitantly with nitrate medications. Although propranolol is not a nitrate, its beta-blocking effects can lower blood pressure, and the combined use with tadalafil may potentially cause additive hypotensive effects.
When considering the use of propranolol and tadalafil together, it is essential to weigh the benefits against the potential risks. The guideline suggests that patients on long-acting nitrate therapy who want to use a phosphodiesterase type 5 inhibitor should have their treatment guided by the need for continued nitrate therapy versus other alternative options available to the treating clinician 1. Similarly, patients taking propranolol and tadalafil should be monitored for symptoms of low blood pressure, such as dizziness, lightheadedness, or fainting, especially when initiating therapy or adjusting doses.
Key considerations when using propranolol and tadalafil together include:
- Monitoring for symptoms of low blood pressure
- Maintaining adequate hydration
- Avoiding excessive alcohol consumption
- Regularly reviewing and adjusting medication doses as needed
- Ensuring patients with cardiovascular disease are particularly cautious and discuss this combination with their healthcare provider to ensure appropriate monitoring and dosing.
From the Research
Contraindications and Precautions
- The use of tadalafil with any nitric oxide donor is contraindicated due to the risk of significant arterial hypotension 2, 3, 4.
- Caution is needed when using tadalafil with alpha-blocking agents, as this combination may lead to larger declines in blood pressure and cause orthostatic hypotension 2, 3, 4.
- The concomitant use of tadalafil with beta blockers, such as propranolol, is not explicitly contraindicated in the provided studies.
- However, it is essential to note that patients with erectile dysfunction may have underlying cardiovascular conditions, and the use of tadalafil with other medications, including beta blockers, should be carefully evaluated on a case-by-case basis 3, 5.
Hemodynamic Effects
- Tadalafil has been shown to have a mild effect on blood pressure, with a reduction in blood pressure that is generally not of clinical concern 3, 5.
- The additive effect of tadalafil with one or multiple antihypertensive drugs, including beta blockers, is modest 4, 5.
- The incidence of cardiovascular events, including hypotension and syncope, is comparable between patients taking tadalafil and those taking placebo, even in patients receiving concomitant antihypertensive therapy 5.
Drug-Drug Interactions
- The use of tadalafil with other medications, including beta blockers, should be carefully evaluated due to the potential for drug-drug interactions 6.
- Precaution is suggested when using tadalafil with potent CYP3A inhibitors, such as azole antifungals, antiretroviral protease inhibitors, or macrolid antibiotics, as tadalafil is metabolized mainly via the CYP3A4 pathway 6.