Are nitric oxide supplements and black Maca root capsules safe to take with Tadalafil (tadalafil)?

Safety of Nitric Oxide Supplements and Black Maca Root with Tadalafil

Nitric oxide supplements can be taken with tadalafil without the life-threatening contraindication that exists with pharmaceutical nitrates, though caution is warranted; black Maca root appears safe to combine with tadalafil based on lack of documented interactions.

Critical Distinction: Supplements vs. Pharmaceutical Nitrates

The absolute contraindication applies specifically to pharmaceutical nitrate medications (nitroglycerin, isosorbide dinitrate, isosorbide mononitrate), NOT to dietary nitric oxide supplements 1, 2, 3.

Why Pharmaceutical Nitrates Are Dangerous with Tadalafil:

• Tadalafil inhibits phosphodiesterase-5 (PDE5), preventing breakdown of cyclic guanosine monophosphate (cGMP), which causes vasodilation 3, 4
• When combined with pharmaceutical nitrates, this creates markedly exaggerated and prolonged vasodilation leading to profound hypotension, myocardial infarction, and potentially death 1, 3, 4
• Patients must wait at least 48 hours after taking tadalafil before receiving ANY pharmaceutical nitrate therapy 2, 3, 4

Nitric Oxide Dietary Supplements

These supplements are fundamentally different from pharmaceutical nitrates:

• Common NO supplements contain L-arginine, L-citrulline, or beetroot juice derivatives that modestly increase nitric oxide through physiologic pathways 5
• Research shows these supplements have minimal hemodynamic effects—one study found NO supplements caused only a 6.7% increase in plasma nitrate/nitrite with no changes in blood pressure or heart rate 6
• The small physiologic increases in NO from supplements do not create the dangerous drug interaction seen with pharmaceutical nitrates 6

Practical Safety Considerations:

• NO supplements should still be used cautiously as they may cause mild hypotension in some individuals 5
• Start with lower doses if combining with tadalafil and monitor for dizziness or lightheadedness 5
• Interestingly, tadalafil itself may actually enhance endogenous NO-H2S signaling pathways, suggesting potential synergy rather than danger 7

Black Maca Root

Black Maca root appears safe to combine with tadalafil:

• No documented drug interactions exist between Maca root and PDE5 inhibitors in the medical literature
• Maca works through different mechanisms (hormonal modulation) rather than direct vasodilation
• No guideline or research evidence suggests contraindication or caution with this combination

Common Pitfalls to Avoid

The critical error is confusing dietary NO supplements with prescription nitrate medications:

• Always ask patients specifically about prescription nitroglycerin, Nitro-BID ointment, isosorbide products—these are absolutely contraindicated 1, 3, 4
• Dietary supplements like L-arginine, L-citrulline, and beetroot extracts do not carry this same contraindication 5, 6
• Document carefully which type of nitric oxide product the patient is using to avoid dangerous confusion in emergency situations 4

If a patient on tadalafil develops chest pain requiring emergency care:

• Healthcare providers must know the 48-hour window before nitrates can be given 2, 3
• Alternative anti-ischemic therapies include beta-blockers, calcium channel blockers, or ACE inhibitors 3, 4