Tadalafil, sildenafil and other PDE5 inhibitors combined with any nitrate — including sublingual glyceryl trinitrate kept for angina and isosorbide mononitrate — can cause profound hypotension. Tadalafil's long half-life extends the risk window to about 48 hours after a dose, compared with about 24 hours for sildenafil.
This matters in sexual rehabilitation after prostate cancer treatment, where many men are older and have cardiovascular disease managed elsewhere.
- Ask specifically about GTN sprays or tablets, not only regular nitrates
- Tell men on tadalafil to inform emergency staff of their last dose if they develop chest pain
- Avoid nitrates for 48 hours after tadalafil and 24 hours after sildenafil
- Check for alpha-blocker use and start PDE5 inhibitors at low dose where they are combined
Why it matters
Nitrate interaction is the one PDE5 inhibitor risk that can kill, and as-needed GTN is easy to miss in a medication history.
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