What are the treatment options for erectile dysfunction in a patient taking Imdur (isosorbide mononitrate) and nitroglycerine?

From the Guidelines

If you are taking Imdur (isosorbide mononitrate) or nitroglycerin, you should not use erectile dysfunction medications like Viagra (sildenafil), Cialis (tadalafil), or Levitra (vardenafil) due to the risk of severe hypotension, as stated in the 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guideline for the management of patients with chronic coronary disease 1. This combination can cause a dangerous and potentially life-threatening drop in blood pressure. Instead, discuss alternative treatments with your doctor such as:

• Vacuum erection devices
• Penile injections (like alprostadil)
• Penile implants These mechanical or local treatments don't interact with nitrates and can be effective options. In some cases, your cardiologist might consider whether you could temporarily discontinue the nitrate medication under close supervision to allow safe use of ED medications, but this requires careful medical evaluation, as phosphodiesterase type 5 inhibitors should not be used concomitantly with nitrate medications 1. The reason for this dangerous interaction is that both nitrates and ED medications work by increasing nitric oxide, which relaxes blood vessels, and when combined, they can cause severe hypotension that may lead to heart attack or stroke, highlighting the importance of informing all healthcare providers about all medications taken to avoid dangerous drug interactions. According to the American College of Physicians, 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, but this does not apply when nitrates are involved due to the contraindication 1. Always prioritize your safety and the safety of your treatment plan under the guidance of your healthcare provider.

From the FDA Drug Label

Information for Patients Physicians should discuss with patients the contraindication of LEVITRA with regular and/or intermittent use of organic nitrates Patients should be counseled that concomitant use of LEVITRA with nitrates could cause blood pressure to suddenly drop to an unsafe level, resulting in dizziness, syncope, or even heart attack or stroke

The use of vardenafil (LEVITRA) is contraindicated with organic nitrates, such as nitroglycerine (Imdur). Patients taking nitrates should not use LEVITRA due to the risk of severe hypotension and potentially life-threatening complications, including heart attack or stroke 2.

From the Research

Erectile Dysfunction Treatment with Imdur Nitroglycerine

• Patients taking Imdur (isosorbide mononitrate) or other nitrates for angina should not take phosphodiesterase 5 inhibitors (PDE5is) like sildenafil due to the risk of severe hypotension 3.
• The combination of PDE5is and nitrates can cause a significant decrease in blood pressure, which can be dangerous for patients with certain medical conditions 3, 4.
• Alternative treatments for erectile dysfunction (ED) may be considered for patients taking Imdur, such as:
  • Nutraceutical interventions like L-Arginine and propionyl L-carnitine (PLC) + acetyl L-carnitine (ALC) in combination with PDE5is 5.
  • Other PDE5is like vardenafil or tadalafil, which may have different interactions with nitrates 6, 7.
• It is essential to consult a healthcare professional before starting any new medication, especially for patients with pre-existing medical conditions or taking multiple medications 3, 6, 4, 7.