Is it safe for an elderly male patient with diabetes, cardiovascular disease, and taking multiple medications including Lisinopril (Angiotensin-Converting Enzyme inhibitor), Atorvastatin (statin), Lantus (Insulin glargine), GlipiZIDE (sulfonylurea), Actos (Pioglitazone), Farxiga (Dapagliflozin), and NexIUM (Esomeprazole) to take Viagra (Sildenafil) for erectile dysfunction?

Sildenafil (Viagra) Safety in This Elderly Patient with Diabetes and Cardiovascular Disease

Sildenafil can be safely prescribed to this patient, as he falls into the low-risk cardiovascular category with controlled hypertension (on Lisinopril 5 mg) and no evidence of unstable cardiac disease, provided he is not taking nitrates and can perform moderate physical activity. 1

Critical Safety Verification Required Before Prescribing

Absolute Contraindications to Rule Out

• Verify the patient is not taking any form of nitrate medication (including sublingual nitroglycerin, isosorbide mononitrate/dinitrate, or recreational nitrates), as co-administration causes potentially fatal hypotension 1, 2
• Confirm no recent myocardial infarction within the past 2 weeks, unstable angina, or high-risk arrhythmias 1

Cardiovascular Risk Assessment

• Ask if the patient can walk 1 mile in 20 minutes or climb 2 flights of stairs without symptoms to confirm adequate cardiovascular fitness for sexual activity 1
• This patient's controlled hypertension on a single low-dose ACE inhibitor (Lisinopril 5 mg) places him in the low-risk category where sildenafil is safe 1
• The American College of Cardiology confirms that patients with controlled hypertension, asymptomatic coronary artery disease with <3 risk factors, and mild stable conditions can safely receive PDE5 inhibitors 1

Drug Interaction Considerations

No Significant Interactions with Current Medications

• Lisinopril (ACE inhibitor): No contraindication; sildenafil causes only modest additional blood pressure reduction (approximately -8/-5.5 mm Hg systolic/diastolic) that is well-tolerated 3, 4
• Atorvastatin: No interaction; statins may actually improve erectile function 5
• Diabetes medications (Lantus, glipizide, Actos, Farxiga): No contraindications; sildenafil remains effective in diabetic patients, though response may be slightly less robust than in non-diabetics 1, 6
• Nexium (esomeprazole): No significant interaction 1
• Antihistamines (cetirizine, hydroxyzine, azelastine-fluticasone): No cardiovascular interactions 1

Important Caveat About CYP3A4 Inhibitors

• If this patient were taking strong CYP3A4 inhibitors (ketoconazole, erythromycin, ritonavir), the starting dose should be reduced to 25 mg, but none of his current medications fall into this category 1

Recommended Prescribing Strategy

Initial Dosing

• Start with sildenafil 50 mg taken approximately 1 hour before sexual activity 1
• The dose-response relationship shows 50 mg is significantly more effective than 25 mg, with minimal additional benefit from increasing to 100 mg 1
• Can titrate to 100 mg if 50 mg is well-tolerated but insufficiently effective, or reduce to 25 mg if side effects occur 1

Defining an Adequate Trial

• Require at least 5 separate attempts at the maximum tolerated dose before declaring treatment failure 1
• Many apparent failures result from inadequate trials, improper timing, lack of sexual stimulation, or heavy alcohol use 1

Patient Counseling Points

• Sexual stimulation is necessary for the medication to work—sildenafil enhances the normal erectile response but does not cause automatic erections 6
• Avoid heavy alcohol use, as it impairs erectile function and increases risk of adverse effects 1
• Take on an empty stomach or after a light meal for optimal absorption 1
• Common side effects include headache, flushing, and dyspepsia, which are generally mild and transient 5, 2

Special Considerations for This Patient

Diabetes and Erectile Dysfunction

• Diabetic patients respond well to sildenafil (69% success rate vs 35.5% placebo), though baseline ED severity may be greater 1
• The patient's multiple diabetes medications (insulin, sulfonylurea, thiazolidinedione, SGLT2 inhibitor) indicate reasonable glycemic control efforts, which supports better erectile function 1

Cardiovascular Safety Profile

• Seven years of postmarketing surveillance data from >28,000 men demonstrate no increased risk of myocardial infarction or cardiovascular death when sildenafil is used according to prescribing guidelines 3
• The Princeton III Consensus confirms no new cardiovascular safety concerns with PDE5 inhibitors 5
• Sexual activity itself carries only a modest metabolic demand (3-5 METs), equivalent to climbing 2 flights of stairs 7

Follow-Up and Monitoring

Periodic Assessment Schedule

• Schedule follow-up between 4 weeks and 6 months to assess efficacy, side effects, cardiovascular status changes, and new medications 1
• Verify that cardiovascular health hasn't deteriorated and review any new medications that might interact 1

When to Reassess or Modify Treatment

• If treatment appears ineffective, systematically evaluate modifiable factors: hormonal abnormalities (consider checking testosterone), timing and frequency of dosing, adequacy of sexual stimulation, heavy alcohol use, and relationship issues 1
• Consider switching to tadalafil if sildenafil fails after an adequate trial, as some patients respond better to one PDE5 inhibitor than another 1

Emergency Protocol

Nitrate Administration After Sildenafil Use

• If the patient requires emergency nitrate administration, wait 24 hours after sildenafil use before giving nitrates, under close medical supervision with continuous monitoring 1
• Instruct the patient to inform emergency personnel that he takes sildenafil if he experiences chest pain 1

Warning Signs Requiring Immediate Medical Attention

• Sudden vision loss in one or both eyes (risk of NAION, though rare) 2
• Sudden hearing loss or decrease, which may be accompanied by tinnitus and dizziness 2
• Erection lasting longer than 4 hours (priapism risk, though uncommon) 2