From the Guidelines
For a patient on nitro glycerin, phosphodiesterase-5 (PDE5) inhibitors are absolutely contraindicated due to the risk of severe, potentially fatal hypotension, as stated in the 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guideline 1. When considering treatment options for erectile dysfunction in patients on nitroglycerin, it is crucial to prioritize alternatives that do not interact with nitrates.
- Vacuum erection devices are a safe and effective first-line option, creating negative pressure to draw blood into the penis and maintaining erection with a constriction ring.
- Alprostadil is another viable option, available as either urethral suppositories (MUSE) at doses of 125-1000 mcg or as intracavernosal injections (5-40 mcg), as it works through a mechanism that does not interact with nitrates.
- Testosterone replacement therapy may be considered if low testosterone is confirmed through blood testing, providing a potential solution for patients with hormonal imbalances contributing to their erectile dysfunction.
- Psychological counseling can also be beneficial, particularly if erectile dysfunction has psychological components, addressing the mental health aspects of the condition. These alternatives are recommended because they avoid the dangerous blood pressure drop that occurs when PDE5 inhibitors are combined with nitroglycerin, as highlighted in the guideline 1. It is essential for the patient to discuss these options with their healthcare provider to determine the most appropriate treatment based on their specific health status and preferences, ensuring the chosen treatment prioritizes their morbidity, mortality, and quality of life.
From the FDA Drug Label
Do not take nitroglycerin sublingual tablets with drugs for erectile dysfunction, like VIAGRA® (sildenafil citrate), CIALIS® (tadalafil), or LEVITRA® (vardenafil hydrochloride), as this may lead to extreme lowering of your blood pressure
- Erectile dysfunction treatment is not recommended with nitroglycerin due to the risk of extreme lowering of blood pressure.
- Patients on nitroglycerin should not take drugs for erectile dysfunction like VIAGRA®, CIALIS®, or LEVITRA®.
- The use of these medications together may lead to severe hypotension 2.
From the Research
Treatment Options for Erectile Dysfunction
- Erectile dysfunction (ED) has several treatment options available, including oral medications, injection therapies, and vacuum constriction devices 3.
- For patients who are taking nitroglycerin, such as Nitro-Glucoside, phosphodiesterase type 5 (PDE5) inhibitors are contraindicated due to the risk of hypotension 3, 4.
- In such cases, alternative treatment options may be considered, including:
- Intracavernosal injections of alprostadil alone or in combination with other vasoactive agents 3, 5.
- Vacuum constriction devices, which may be used in combination with other treatments, such as PDE5 inhibitors, as salvage therapy in non-responders 6.
- Topical alprostadil, which has been approved for use in some countries and may be an option for patients who cannot use oral medications 5.
Combination Therapy
- Combination therapy, such as the use of a vacuum erection device (VED) and PDE5 inhibitors, may be effective as salvage therapy in patients who do not respond to PDE5 inhibitors alone 6.
- This combination therapy has been shown to improve erectile function and patient satisfaction in clinical studies 6.
Patient-Centered Approach
- A patient-centered approach is necessary for the management of ED, taking into account the patient's needs, preferences, and medical history 3, 4.
- The clinician should educate the patient and provide a supportive environment for shared decision making, and the management strategy should be supplemented by careful follow-up to identify changes in patient health and relationship/emotional status that may necessitate treatment optimization 3.