Interactions of PDE5 inhibitors – Other medicines

Interactions of PDE5 inhibitors – Other medicines

  1. Introduction:
    PDE5 is used in the clinical environment to treat erectile dysfunction (ED) and lower pulmonary arterial hypertension (PAH), improve exercise tolerance, and increase arterial oxygenation in patients with secondary PAH.

    There have been significant developments in the pharmacologic management of ED in recent years. PDE5i selectively inhibits the PDE5 enzyme’s catalytic site in cavernosal tissue. For patients with ED, PDE5i are a first-line therapeutic choice.

    There are several potent and selective PDE5s, such as Sildenafil, Vardenafil, Tadalafil, and Avanafil. Both the European Medicine Agency (EMEA) and the US Food and Drug Administration (FDA) have authorized these medications for the treatment of ED. In 1998, sildenafil, the first highly selective oral PDE5i drug to be made commercially available, was introduced.

    The diagnosis and management of ED were revolutionized by sildenafil. Tadalafil and vardenafil are now commonly accessible as well. The FDA officially approved avanafil, and it will go on sale in late 2013.

    To understand the mechanism of related drug interactions, it is crucial to comprehend the biochemical effects of PDE5 inhibitors. Nitric oxide (NO), which is produced by endothelial cells of the vasculature, is released during sexual stimulation by nonadrenergic, noncholinergic neurons in the corpus cavernosum, or erectile body, of the penis.

    Cyclic guanosine monophosphate is produced more frequently as a result of nitric oxide’s activation of the guanylate cyclase enzyme (cGMP). In addition, the smooth muscle cells in the sinusoids and blood vessels of the corpus cavernosum relax as a result of cyclic guanosine monophosphate, increasing blood flow to the penis.

  • Interaction of PDE5 inhibitors: 
    In smooth muscle, nitroglycerin is transformed into nitric oxide (NO), which then activates guanylyl cyclase, raising the concentration of cGMP and relaxing the smooth muscle. Vein dilatation reduces venous return to the heart, which lowers left ventricular volume (reduced preload), and lowers the need for myocardial oxygen. Myocardial oxygen requirements are lowered as a result of artery relaxation because it lowers artery resistance (reduced afterload). Additionally, nitroglycerin widens coronary arteries, which enhances myocardial blood flow.

    Vasodilators like nitrates and nitrate-containing substances are used to treat angina and heart failure. Because phosphodiesterase type 5 inhibitors, which are used to treat erectile dysfunction, are also vasodilators, taking them with nitrates may have synergistic effects that strengthen their hypotensive effects. However, PDE5 inhibitors are modest vasodilators, so patients with baseline hypotension, left ventricular outflow blockage, aortic stenosis, congestive heart failure, low blood volume, and other disorders should use caution when using them.

    2.2 Nitrates with PDE5:
    Organic nitrates interact with PDE5 inhibitors like sildenafil and tadalafil to cause a synergistic reduction in blood pressure (BP). Nitric oxide, which is given off by organic nitrates, stimulates guanylate cyclase and causes it to catalyse the synthesis of cyclic guanosine monophosphate (cGMP). Improved erectile function is brought on by cyclic guanosine monophosphate’s reduction of calcium flow into smooth muscle cells, which causes the arteries, arterioles, and sinusoids of the corpus cavernosum to relax. PDE5 stops cGMP from doing its work. When a PDE5 inhibitor is used with a nitric oxide donor, these effects can include a significant increase in cGMP, pronounced vasodilation, and in some people, frank hypotension. Therefore, using organic nitrates continues to be completely against the advice of using PDE5 inhibitors.

    PDE5i therapy has helped a lot of men with ED and a growing number of individuals with PH. PDE5i are mostly metabolized by CYP3A and, to a lesser extent, CYP2C9 in the liver. Therefore, the clearance of these agents may change if these enzymes are inhibited or stimulated.

    3.1 Cytochrome P450 3A Inhibitors
    By increasing exposure to medications with a low therapeutic index, inhibitory drug interactions can be fatal. Plasma concentrations of PDE5i are raised by potent CYP450 inhibitors. In addition, CYP3A inhibitor-induced increases in PDE5i plasma concentrations can hasten the onset and severity of additional PDE5i medication interactions. Never take PDE5i when using nitrates. To prevent negative side effects, it’s crucial to be aware of these possible drug interactions. Simultaneous administration of powerful CYP3A inhibitors like ketoconazole and itraconazole, which are antifungal medications, increases the plasma levels of sildenafil.

    3.2 Cytochrome P450 3A Inducers
    The plasma concentrations of PDE5i are reduced, and their clearance is increased by P4503A inducers. Many other CYP3A4 inducers, such as carbamazepine, phenytoin, and phenobarbital, would probably reduce PDE5i plasma levels, even though not all interactions have been researched. Tadalafil levels in plasma were lowered by rifampin by 88%. When PDE5i are used in conjunction with CYP3A4 inducers, their efficacy may be decreased in some people, necessitating a dose adjustment. For patients using rifampin for an extended period of time, tadalafil (Adcirca®) is not advised. When taken alongside sildenafil, the CYP3A and 2C9 inducer bosentan lowers the amount of sildenafil in the blood. Due to the concurrent drop in sildenafil and increase in bosentan concentration, it’s interesting to note that this drug combination can be described as having a mutual pharmacokinetic interaction.

    3.3 Oral hypoglycemic medications:
    Sulfonylureas and benzoic acid derivatives are examples of hypoglycemic medications, while biguanides, -glucosidase inhibitors, and thiazolidinediones are examples of anti-hyperglycemic medications. Vardenafil and glyburide have not been found to interact pharmacologically, and there is currently no further relevant research available. However, the treatment of diabetes mellitus-induced-ED has made substantial use of all 3 PDE5i. Recently, Vardi et al. demonstrated that PDE5i are safe and dramatically improved ED in diabetic males in a meta-analysis of double-blind, placebo-controlled studies.

    3.4 PDE5Is and alpha-Blockers:
    Patients with benign prostatic hypertrophy benefit from “uroselective” -blockers (tamsulosin, alfuzosin), which preferentially inhibit 1A and 1D receptors found largely in the prostate. Because of their higher affinity for 1B receptors, which are widely distributed in the peripheral vasculature, some -blockers, such as doxazosin, are used as third-line medicines for hypertension, whereas other -blockers, such as terazosin, are less selective.

    Every -blocker has the potential to cause orthostatic hypotension and vasodilation, and taking PDE5Is concurrently raises the chance of a clinically significant drop in blood pressure. Different PDE5I and -blocker combinations interact to varying degrees. The medications co-administered, the amount of the -blocker, the timing of delivery, and the length or stability of the -blocker therapy all affect the PDE5I—blocker interaction to varying degrees. Less harm to the cardiovascular system is caused by tadalafil than.

    According to studies, patients already taking calcium antagonists, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, diuretics, and PDE5 inhibitors may see minor drops in blood pressure.

    These modest, additive blood pressure drops have often not been considered clinically relevant. PDE5 inhibitors continue to be effective in treating ED in individuals with hypertension who are receiving antihypertensive medications. When PDE5 inhibitors are administered to individuals already taking common antihypertensive medications, the side-effect profile does not worsen.

    These recent trials demonstrate that in individuals already on alpha-blockers, vardenafil at doses of 5, 10, and 20 mg is linked with modest mean maximal incremental decreases in SBP (about 4 to 6 mm Hg). There was no dose response in the decreases in standing blood pressure seen with increasing doses of vardenafil, similar to other PDE5 inhibitors on an alpha-blocker background. Compared to prior research using healthy volunteers who had never taken alpha-blockers, there were smaller orthostatic declines in SBP of 85 mm Hg seen in patients in these more recent investigations using vardenafil.

    According to current labeling, vardenafil should be started at the lowest starting dose, and patients should wait until they are stable on their -blocker dose before beginning PDE5 inhibitor medication. On the other hand, individuals already taking a PDE5 inhibitor at the recommended dosage should take alpha-blockers at the lowest possible dose.

    3.5 Anticoagulant agents
    Initial studies showed that sildenafil increases the inhibitory effects of nitric oxide donors on adenosine diphosphate-dependent platelet aggregation. As a result, PDE3 and PDE5 activities are prominent in platelets. This observation was subsequently verified. On the other hand, in vivo interaction investigations show no discernible interaction between PDE5i and the CYP2C9 substrate warfarin.

    There hasn’t been any evidence of a higher risk of clinically significant bleeding episodes after PDE5i in the trials published thus far or in the current recommendations. However, the potential implications of reduced platelet aggregation under the influence of PDE5i should be considered for the high-risk cardiovascular patient frequently taking various anti-thrombotic regimens or warfarin for systemic anticoagulation. Sildenafil administration to individuals with coagulopathies or active peptic ulcer disorders is also not supported by any safety data.

  • Future Perspective: 
    The success of different PDE5i in treating males with ED of varied syndromes depends on their metabolic characteristics. Sildenafil, tadalafil, and vardenafil are metabolized mostly in the liver by CYP3A, with CYP2C9 serving as a minor metabolic pathway. Some of the most important PDE5i-related medication interactions are caused by this enzyme pathway. Additionally, it is advised to exercise caution when taking strong CYP3A inhibitors like antibiotics with the macrolid class, azole antifungals, or antiviral protease inhibitors. To prevent overdose, therapeutic drug monitoring of PDE5i response must be carried out during new drug therapy.

    There is yet to be long-term safety data for all PDE5i. Studies on how avanafil interacts with CYP3A inducers and inhibitors are also necessary. Other CYP3A inducers, such as carbamazepine, phenytoin, and phenobarbital, may decrease PDE5i plasma levels even if not all interactions have been studied. Some negative effects can be decreased by altering selectivity and pharmacokinetics factors.

    As people get older, ED is more prevalent. The higher likelihood of additional comorbidities and chronic disorders coexisting complicates ED in the elderly. Compared to younger patients, older adults typically consume nearly three times as many prescription medicines, averaging over ten each year. Physicians should be aware that various medications and even non-medical products can interact with PDE5i metabolism, absorption, or mechanism of action in this group of patients, and the younger ones.

    We have a summary of these interactions in this review. The three PDE5i are sufficiently safe overall. The primary contraindication for all 3 continues to be the usage of nitrates.  Vardenafil is likewise not advised for use in individuals who are using type 1A or type 3 antiarrhythmics, while tadalafil and sildenafil have not been associated with any additional significant side effects. If -blockers are being used concurrently when there are strong CYP3A inhibitors present, such as azole antifungals, antiretroviral protease inhibitors, or macrolid antibiotics, caution rather than contraindication is advised. On the other hand, testosterone and statins (but only in hypogonadal patients) appear to work in concert to affect PDE5i results.

    More research is needed on possible interactions between PDE5i and other medicines. It is crucial to titrate doses carefully based on efficacy and the prevalence of hypotension. Pharmacodynamic studies will be necessary for the follow-up analysis to ascertain the ideal exposure window and target medication concentration.