Is Saxagliptin safe to use with Viagra (Sildenafil)?

Saxagliptin and Viagra (Sildenafil) Interaction: Safety Considerations

Saxagliptin should be used with caution when combined with sildenafil (Viagra) due to potential increased risk of hypotension, particularly in patients with pre-existing cardiovascular disease.

Cardiovascular Concerns with Saxagliptin

Saxagliptin has been associated with specific cardiovascular risks that warrant consideration when combining with sildenafil:

• The SAVOR-TIMI 53 trial demonstrated that saxagliptin was associated with a 27% increased risk of hospitalization for heart failure compared to placebo 1
• Patients treated with saxagliptin were more likely to be hospitalized for heart failure than those given placebo (3.5% vs. 2.8%) 1
• The American Heart Association and Heart Failure Society of America specifically note that saxagliptin has been associated with increased risk of heart failure hospitalization 1

Sildenafil's Hemodynamic Effects

Sildenafil has vasodilatory properties that could potentially interact with saxagliptin:

• Sildenafil causes moderate vasodilation resulting in modest reductions in blood pressure 2
• The most common adverse events of sildenafil (headache, flushing, hypotension) result from its vasodilating properties 3
• Concomitant use of sildenafil with antihypertensive medications may lead to additive blood pressure decreases 3

Specific Recommendations

1. Patient Risk Assessment:

   • Evaluate cardiovascular risk status before prescribing this combination
   • Use with particular caution in patients with:
     • History of heart failure
     • Unstable blood pressure
     • Recent cardiovascular events

2. Monitoring Requirements:

   • Monitor blood pressure closely when initiating this combination
   • Watch for symptoms of hypotension (dizziness, lightheadedness)
   • Consider lower starting doses of sildenafil (25mg) when used with saxagliptin

3. Absolute Contraindications:

   • Do NOT use this combination with nitrates under any circumstances 4
   • Use extreme caution in patients taking alpha-blockers 2

Important Precautions

• While the combination is not absolutely contraindicated, patients should be informed about potential additive hypotensive effects
• The risk appears to be highest in patients with pre-existing cardiovascular disease or those taking multiple antihypertensive medications
• Patients with stable cardiovascular status without heart failure concerns can likely use this combination with appropriate monitoring

Alternative Considerations

If there are significant concerns about this combination, especially in patients with heart failure risk:

• Consider switching from saxagliptin to another DPP-4 inhibitor like linagliptin, which has not shown increased heart failure risk in the CARMELINA trial 1
• For patients with established heart failure with reduced ejection fraction, SGLT2 inhibitors would be preferred over DPP-4 inhibitors for diabetes management 1

While the combination of saxagliptin and sildenafil is not absolutely prohibited, the potential for additive hypotensive effects and saxagliptin's known association with increased heart failure hospitalization warrants careful clinical consideration, especially in patients with cardiovascular risk factors.