Cialis 5 mg

Cialis 5 mg

tadalafil

Manufacturer:

Eli Lilly

Distributor:

Zuellig
Full Prescribing Info
Contents
Tadalafil.
Description
Each film-coated tablet contains 5 mg Tadalafil (Cialis).
Excipient(s) with known effect: Each film-coated coated tablet contains 121 mg lactose (as monohydrate).
Excipients/Inactive Ingredients: Tablet core: Lactose monohydrate, croscarmellose sodium, hydroxypropylcellulose, microcrystalline cellulose, sodium lauryl sulfate, magnesium stearate.
Film-coat:
Lactose monohydrate, hypromellose, triacetin, titanium dioxide (E171), yellow iron oxide (E172), talc.
Action
Pharmacotherapeutic Group: Urologicals, Drugs used in erectile dysfunction. ATC Code: G04BE08.
Pharmacology: Pharmacodynamics: Mechanism of action: Tadalafil (Cialis) is a selective, reversible inhibitor of cyclic guanosine monophosphate (cGMP)-specific phosphodiesterase type 5 (PDE5). When sexual stimulation causes the local release of nitric oxide, inhibition of PDE5 by Tadalafil (Cialis) produces increased levels of cGMP in the corpus cavernosum. This results in smooth muscle relaxation and inflow of blood into the penile tissues, thereby producing an erection. Tadalafil (Cialis) has no effect in the treatment of erectile dysfunction in the absence of sexual stimulation. The effect of PDE5 inhibition on cGMP concentration in the corpus cavernosum is also observed in the smooth muscle of the prostate, the bladder and their vascular supply. The resulting vascular relaxation increases blood perfusion which may be the mechanism by which symptoms of benign prostatic hyperplasia are reduced. These vascular effects may be complemented by inhibition of bladder afferent nerve activity and smooth muscle relaxation of the prostate and bladder.
Pharmacodynamic Effects: Studies in vitro have shown that Tadalafil (Cialis) is a selective inhibitor of PDE5. PDE5 is an enzyme found in corpus cavernosum smooth muscle, vascular and visceral smooth muscle, skeletal muscle, platelets, kidney, lung, and cerebellum. The effect of Tadalafil (Cialis) is more potent on PDE5 than on other phosphodiesterases. Tadalafil (Cialis) is >10,000-fold more potent for PDE5 than for PDE1, PDE2, and PDE4, enzymes which are found in the heart, brain, blood vessels, liver, and other organs. Tadalafil (Cialis) is >10,000-fold more potent for PDE5 than for PDE3, an enzyme found in the heart and blood vessels.
This selectivity for PDE5 over PDE3 is important because PDE3 is an enzyme involved in cardiac contractility. Additionally, Tadalafil (Cialis) is approximately 700-fold more potent for PDE5 than for PDE6, an enzyme which is found in the retina and is responsible for phototransduction.
Tadalafil (Cialis) is also >10,000-fold more potent for PDE5 than for PDE7 through PDE10.
Clinical efficacy and safety: Tadalafil (Cialis) administered to healthy subjects produced no significant difference compared to placebo in supine systolic and diastolic blood pressure (mean maximal decrease of 1.6/0.8 mmHg, respectively), in standing systolic and diastolic blood pressure (mean maximal decrease of 0.2/4.6 mmHg, respectively), and no significant change in heart rate.
In a study to assess the effects of Tadalafil (Cialis) on vision, no impairment of colour discrimination (blue/green) was detected using the Farnsworth-Munsell 100-hue test. This finding is consistent with the low affinity of Tadalafil (Cialis) for PDE6 compared to PDE5. Across all clinical studies, reports of changes in colour vision were rare (<0.1%). Three studies were conducted in men to assess the potential effect on spermatogenesis of Tadalafil (Cialis) 10 mg (one 6-month study) and 20 mg (one 6-month and one 9-month study) administered daily. In two of these studies decreases were observed in sperm count and concentration related to Tadalafil (Cialis) treatment of unlikely clinical relevance. These effects were not associated with changes in other parameters such as motility, morphology and FSH.
Erectile dysfunction: For Tadalafil (Cialis) on demand, three clinical studies were conducted in 1054 patients in an at-home setting to define the period of responsiveness.
Tadalafil (Cialis) demonstrated statistically significant improvement in erectile function and the ability to have successful sexual intercourse up to 36 hours following dosing, as well as patients' ability to attain and maintain erections for successful intercourse compared to placebo as early as 16 minutes following dosing.
In a 12-week study performed in 186 patients [142 Tadalafil (Cialis), 44 placebo] with erectile dysfunction secondary to spinal cord injury, Tadalafil (Cialis) significantly improved the erectile function leading to a mean per-subject proportion of successful attempts in patients treated with Tadalafil (Cialis) 10 or 20 mg (flexible-dose, on demand) of 48% as compared to 17% with placebo. For once-a-day evaluation of Tadalafil (Cialis) at doses of 2.5, 5, and 10 mg 3 clinical studies were initially conducted involving 853 patients of various ages (range 21-82 years) and ethnicities, with erectile dysfunction of various severities (mild, moderate, severe) and etiologies. In the two primary efficacy studies of general populations, the mean per-subject proportion of successful intercourse attempts were 57 and 67% on Tadalafil (Cialis) 5 mg, 50% on Tadalafil (Cialis) 2.5 mg as compared to 31 and 37% with placebo. In the study in patients with erectile dysfunction secondary to diabetes, the mean per-subject proportion of successful attempts were 41 and 46% on Tadalafil (Cialis) 5 mg and 2.5 mg, respectively, as compared to 28% with placebo. Most patients in these three studies were responder to previous on-demand treatment with PDE5 inhibitors. In a subsequent study, 217 patients who were treatment-naive to PDE5 inhibitors were randomized to Tadalafil (Cialis) 5 mg once a day vs. placebo. The mean per-subject proportion of successful sexual intercourse attempts was 68% for Tadalafil (Cialis) patients compared to placebo.
Benign prostatic hyperplasia: Tadalafil (Cialis) was studied in 4 clinical studies of 12 weeks duration enrolling over 1500 patients with signs and symptoms of benign prostatic hyperplasia. The improvement in the total international prostate symptom score with Tadalafil (Cialis) 5 mg in the four studies were -4.8, -5.6, -6.1 and -6.3 compared to -2.2, -3.6, -3.8 and -4.2 with placebo. The improvements in total international prostate symptom score occurred as early as 1 week. In one of the studies, which also included tamsulosin 0.4 mg as an active comparator, the improvement in total international prostate symptom score with Tadalafil (Cialis) 5 mg, tamsulosin and placebo were -6.3, -5.7 and -4.2 respectively. One of these studies assessed improvements in erectile dysfunction and signs and symptoms of benign prostatic hyperplasia in patients with both conditions. The improvements in the erectile function domain of the international index of erectile function and the total international prostate symptom score in this study were 6.5 and -6.1 with Tadalafil (Cialis) 5 mg compared to 1.8 and -3.8 with placebo, respectively. The mean per-subject proportion of successful sexual intercourse attempts was 71.9% with Tadalafil (Cialis) 5 mg compared to 48.3% with placebo. The maintenance of the effect was evaluated in an open-label extension to one of the studies, which showed that the improvement in total international prostate symptom score seen at 12 weeks was maintained for up to 1 additional year of treatment with Tadalafil (Cialis) 5 mg.
Pharmacokinetics: Absorption: Tadalafil (Cialis) is readily absorbed after oral administration and the mean maximum observed plasma concentration (Cmax) is achieved at a median time of 2 after dosing. Absolute bioavailability of tadalafil following oral dosing has not been determined.
The rate and extent of absorption of Tadalafil (Cialis) are not influenced by food, thus Tadalafil (Cialis) may be taken with or without food. The time of dosing (morning versus evening) had no clinically relevant effects on the rate and extent of absorption.
Distribution: The mean volume of distribution is approximately 63 L, indicating that Tadalafil (Cialis) is distributed into tissues. At therapeutic concentrations, 94% of Tadalafil (Cialis) in plasma is bound to proteins. Protein binding is not affected by impaired renal function. Less than 0.0005% of the administered dose appeared in the semen of healthy subjects.
Biotransformation: Tadalafil (Cialis) is predominantly metabolised by the cytochrome P450 (CYP) 3A4 isoform. The major circulating metabolite is the methylcatechol glucuronide. This metabolite is at least 13,000-fold less potent than Tadalafil (Cialis) for PDE5. Consequently, it is not expected to be clinically active at observed metabolite concentrations.
Elimination: The mean oral clearance for Tadalafil (Cialis) is 2.5 L/h and the mean half-life is 17.5 hours in healthy subjects. Tadalafil (Cialis) is excreted predominantly as inactive metabolites, mainly in the faeces (approximately 61% of the dose) and to a lesser extent in the urine (approximately 36% of the dose).
Linearity/mon-linearity: Tadalafil (Cialis) pharmacokinetics in healthy subjects are linear with respect to time and dose. Over a dose range of 2.5 to 20 mg, exposure (AUC) increases proportionally with dose. Steady-state plasma concentrations are attained within 5 days of once-daily dosing.
Pharmacokinetics determined with a population approach in patients with erectile dysfunction are similar to pharmacokinetics in subjects without erectile dysfunction.
Special populations: Elderly: Healthy elderly subjects (65 years or over), had a lower oral clearance of Tadalafil (Cialis), resulting in 25% higher exposure (AUC) relative to healthy subjects aged 19 to 45 years. This effect of age is not clinically significant and does not warrant a dose adjustment.
Renal insufficiency: In clinical pharmacology studies using single-dose Tadalafil (Cialis) (5 to 20 mg), Tadalafil (Cialis) exposure (AUC) approximately doubled in subjects with mild (creatinine clearance 51 to 80 mL/min) or moderate (creatinine clearance 31 to 50 mL/min) renal impairment and in subjects with end-stage renal disease on dialysis. In haemodialysis patients, Cmax was 41% higher than that observed in healthy subjects. Haemodialysis contributes negligibly to Tadalafil (Cialis) elimination.
Hepatic insufficiency: Tadalafil (Cialis) exposure (AUC) in subjects with mild and moderate hepatic impairment (Child-Pugh Class A and B) is comparable to exposure in healthy subjects when a dose of 10 mg is administered.
There is limited clinical data on the safety of Tadalafil (Cialis) in patients with severe hepatic insufficiency (Child- Pugh Class C). There are no available data about the administration of once-a-day dosing of Tadalafil (Cialis) to patients with hepatic impairment. If Tadalafil (Cialis) is prescribed once-a-day, a careful individual benefit/risk evaluation should be undertaken by the prescribing physician.
Patients with diabetes: Tadalafil (Cialis) exposure (AUC) in patients with diabetes was approximately 19% lower than the AUC value for healthy subjects. This difference in exposure does not warrant a dose adjustment.
Toxicology: Preclinical safety data: Non-clinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity, genotoxicity, carcinogenic potential, and toxicity to reproduction. There was no evidence of teratogenicity, embryotoxicity or foetotoxicity in rats or mice that received up to 1000 mg/kg/day Tadalafil (Cialis). In a rat prenatal and postnatal development study, the no observed effect dose was 30 mg/kg/day.
In the pregnant rat the AUC for calculated free drug at this dose was approximately 18 times the human AUC at a 20 mg dose.
There was no impairment of fertility in male and female rats. In dogs given Tadalafil (Cialis) daily for 6 to 12 months at doses of 25 mg/kg/day [resulting in at least a 3-fold greater exposure (range 3.7-18.6) than seen in humans given a single 20 mg dose] and above, there was regression of the seminiferous tubular epithelium that resulted in a decrease in spermatogenesis in some dogs. See also Pharmacology: Pharmacodynamics under Actions.
Indications/Uses
Treatment of erectile dysfunction in adult males.
In order for Tadalafil (Cialis) to be effective for the treatment of erectile dysfunction, sexual stimulation is required.
Treatment of the signs and symptoms of benign prostatic hyperplasia in adult males.
Treatment of erectile dysfunction and the signs and symptoms of benign prostatic hyperplasia in adult males.
Dosage/Direction for Use
Posology: Erectile dysfunction in adult men: Once a Day Dosing: The recommended dose is 5 mg taken once a day at approximately the same time of day. The dose may be decreased to 2.5 mg once a day based on individual tolerability. The appropriateness of continued use of the daily regimen should be reassessed periodically.
Benign prostatic hyperplasia in adult men: The recommended dose is 5 mg, taken at approximately the same time every day with or without food.
Erectile Dysfunction and Benign prostatic hyperplasia in adult men: For adult men being treated for both benign prostatic hyperplasia and erectile dysfunction the recommended dose is also 5 mg taken at approximately the same time every day. Patients who are unable to tolerate Tadalafil (Cialis) 5 mg for the treatment of benign prostatic hyperplasia should consider an alternative therapy as the efficacy of Tadalafil (Cialis) 2.5mg for the treatment of benign prostatic hyperplasia has not been demonstrated.
Special populations: Elderly men: Dose adjustments are not required in elderly patients.
Men with renal impairment: Dose adjustments are not required in patients with mild to moderate renal impairment.
Once-a-day dosing of 2.5 or 5 mg Tadalafil (Cialis) both for the treatment of erectile dysfunction or benign prostatic hyperplasia is not recommended in patients with severe renal impairment. (see Precautions and Pharmacology: Pharmacokinetics under Actions).
Men with hepatic impairment: Once-a-day dosing of Tadalafil (Cialis) both for the treatment of erectile dysfunction and benign prostatic hyperplasia has not been evaluated in patients with hepatic impairment; therefore, if prescribed, a careful individual benefit/risk evaluation should be undertaken by the prescribing physician. (see Precautions and Pharmacology: Pharmacokinetics under Actions).
Men with diabetes: Dose adjustments are not required in diabetic patients.
Paediatric population: There is no relevant use of Tadalafil (Cialis) in the paediatric population with regard to the treatment of erectile dysfunction.
Overdosage
Single doses of up to 500 mg have been given to healthy subjects, and multiple daily doses up to 100 mg have been given to patients. Adverse events were similar to those seen at lower doses. In cases of overdose, standard supportive measures should be adopted as required. Haemodialysis contributes negligibly to Tadalafil (Cialis) elimination.
Contraindications
Hypersensitivity to tadalafil or to any of the excipients of Cialis.
In clinical studies, Tadalafil (Cialis) was shown to augment the hypotensive effects of nitrates. This is thought to result from the combined effects of nitrates and Tadalafil (Cialis) on the nitric oxide/cGMP pathway. Therefore, administration of Tadalafil (Cialis) to patients who are using any form of organic nitrate is contraindicated (see Interactions).
Tadalafil (Cialis) must not be used in men with cardiac disease for whom sexual activity is inadvisable. Physicians should consider the potential cardiac risk of sexual activity in patients with pre-existing cardiovascular disease.
The following groups of patients with cardiovascular disease were not included in clinical trials and the use of Tadalafil (Cialis) is therefore contraindicated: Patients with myocardial infarction within the last 90 days, patients with unstable angina or angina occurring during sexual intercourse, patients with New York Heart Association class ≥2 heart failure in the last 6 months, uncontrolled arrhythmias, hypotension (<90/50 mmHg), or uncontrolled hypertension, and patients with a stroke within the last 6 months.
Tadalafil (Cialis) is contraindicated in patients who have loss of vision in one eye because of non-arteritic anterior ischaemic optic neuropathy (NAION), regardless of whether this episode was in connection or not with previous PDE5 inhibitor exposure (see Precautions).
Special Precautions
Before treatment with Tadalafil (Cialis): A medical history and physical examination should be undertaken to diagnose erectile dysfunction or benign prostatic hyperplasia and determine potential underlying causes, before pharmacological treatment is considered.
Prior to initiating any treatment for erectile dysfunction, physicians should consider the cardiovascular status of their patients, since there is a degree of cardiac risk associated with sexual activity. Tadalafil (Cialis) has vasodilator properties, resulting in mild and transient decreases in blood pressure (see Pharmacology: Pharmacodynamics under Actions) and as such potentiates the hypotensive effect of nitrates (see Contraindications).
Prior to initiating treatment with Tadalafil (Cialis) for benign prostatic hyperplasia patients should be examined to rule out the presence of carcinoma of the prostate and carefully assessed for cardiovascular conditions (see Contraindications).
The evaluation of erectile dysfunction should include a determination of potential underlying causes and the identification of appropriate treatment following an appropriate medical assessment. It is not known if Tadalafil (Cialis) is effective in patients who have undergone pelvic surgery or radical non-nerve-sparing prostatectomy.
Cardiovascular: Serious cardiovascular events, including myocardial infarction, sudden cardiac death, unstable angina pectoris, ventricular arrhythmia, stroke, transient ischemic attacks, chest pain, palpitations and tachycardia, have been reported either post marketing and/or in clinical trials. Most of the patients in whom these events have been reported had pre-existing cardiovascular risk factors. However, it is not possible to definitively determine whether these events are related directly to these risk factors, to Tadalafil (Cialis), to sexual activity, or to a combination of these or other factors.
In patients receiving concomitant antihypertensive medicinal products, Tadalafil (Cialis) may induce a blood pressure decrease. When initiating daily treatment with Tadalafil (Cialis), appropriate clinical considerations should be given to a possible dose adjustment of the antihypertensive therapy.
In patients who are taking alpha1 blockers, concomitant administration of Tadalafil (Cialis) may lead to symptomatic hypotension in some patients (see Interactions). The combination of Tadalafil (Cialis) and doxazosin is not recommended.
The combination of tadalafil and guanylate cyclase stimulators, such as riociguat, is not recommended because it may lead to symptomatic hypotension.
Vision: Visual defects and cases of NAION have been reported in connection with the intake of Tadalafil (Cialis) and other PDE5 inhibitors. The patient should be advised that in case of sudden visual defect, he should stop taking Tadalafil (Cialis) and consult a physician immediately (see Contraindications).
Renal and hepatic impairment: Due to increased Tadalafil (Cialis) exposure (AUC), limited clinical experience and the lack of ability to influence clearance by dialysis, once-a-day dosing of Tadalafil (Cialis) is not recommended in patients with severe renal impairment.
There are limited clinical data on the safety of single-dose administration of Tadalafil (Cialis) in patients with severe hepatic insufficiency (Child-Pugh Class C). Once-a-day administration either for the treatment of erectile dysfunction or benign prostatic hyperplasia has not been evaluated in patients with hepatic insufficiency. If Tadalafil (Cialis) is prescribed, a careful individual benefit/risk evaluation should be undertaken by the prescribing physician.
Priapism and anatomical deformation of the penis: Patients who experience erections lasting 4 hours or more should be instructed to seek immediate medical assistance. If priapism is not treated immediately, penile tissue damage and permanent loss of potency may result.
Tadalafil (Cialis), should be used with caution in patients with anatomical deformation of the penis (such as angulation, cavernosal fibrosis or Peyronie's disease), or in patients who have conditions which may predispose them to priapism (such as sickle cell anaemia, multiple myeloma or leukaemia).
Use with CYP3A4 inhibitors: Caution should be exercised when prescribing Tadalafil (Cialis) to patients using potent CYP3A4 inhibitors (ritonavir, saquinavir, ketoconazole, itraconazole, and erythromycin) as increased Tadalafil (Cialis) exposure (AUC) has been observed if the medicinal products are combined (see Interaction).
Tadalafil (Cialis) and other treatments for erectile dysfunction: The safety and efficacy of combinations of Tadalafil (Cialis) and other PDE5 inhibitors or other treatments for erectile dysfunction have not been studied. The patients should be informed not to take Tadalafil (Cialis) in such combinations.
Lactose: Tadalafil (Cialis) contains lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicinal product.
Effects on the ability to drive and use machines: Tadalafil (Cialis) has negligible influence on the ability to drive or use machines. Although the frequency of reports of dizziness in placebo and Tadalafil (Cialis) arms in clinical trials was similar, patients should be aware of how they react to Tadalafil (Cialis), before driving or using machines.
Use In Pregnancy & Lactation
Tadalafil (Cialis) is not indicated for use by women.
Pregnancy:
There are limited data from the use of Tadalafil (Cialis) in pregnant women. Animal studies do not indicate direct or indirect harmful effects with respect to pregnancy, embryonal/foetal development, parturition or postnatal development (see Pharmacology: Toxicology: Preclinical Safety Data under Actions). As a precautionary measure, it is preferable to avoid the use of Tadalafil (Cialis) during pregnancy.
Breastfeeding: Available pharmacodynamic/toxicological data in animals have shown excretion of Tadalafil (Cialis) in milk. A risk to the suckling child cannot be excluded. Tadalafil (Cialis) should not be used during breast feeding.
Fertility: Effects were seen in dogs that might indicate impairment of fertility. Two subsequent clinical studies suggest that this effect is unlikely in humans, although a decrease in sperm concentration was seen in some men (see Pharmacology: Pharmacodynamics and Toxicology: Preclinical Safety Data under Actions).
Adverse Reactions
Summary of the safety profile: The most commonly reported adverse reactions in patients taking Tadalafil (Cialis) for the treatment of erectile dysfunction or benign prostatic hyperplasia were headache, dyspepsia, back pain and myalgia, in which the incidences increase with increasing dose of Cialis.
The adverse reactions reported were transient and generally mild or moderate. The majority of headaches reported with Cialis once-a-day dosing are experienced within the first 10 to 30 days of starting treatment.
Tabulated summary of adverse reactions: The following table lists the adverse reactions observed from spontaneous reporting and in placebo-controlled clinical trials (comprising a total of 7116 patients on Cialis and 3718 patients on placebo) for on-demand and once-a-day treatment of erectile dysfunction and the once-a-day treatment of benign prostatic hyperplasia.
Frequency convention: Very common (≥1/10), common (≥1/100 to <1/10), uncommon (≥1/1,000 to <1/100), rare (≥1/10,000 to <1/1,000) and very rare (<1/10,000) and not known (cannot be estimated from the available data). (See table.)

Click on icon to see table/diagram/image

Description of selected adverse reactions: A slightly higher incidence of ECG abnormalities, primarily sinus bradycardia, has been reported in patients treated with Tadalafil (Cialis) once a day as compared with placebo. Most of these ECG abnormalities were not associated with adverse reactions.
Other special populations: Data in patients over 65 years of age receiving Tadalafil (Cialis) in clinical trials, either for the treatment of erectile dysfunction or the treatment of benign prostatic hyperplasia, are limited. In clinical trials with Tadalafil (Cialis) 5 mg taken once a day for the treatment of benign prostatic hyperplasia, dizziness and diarrhoea were reported more frequently in patients over 75 years of age.
Drug Interactions
Interaction studies were conducted with 10 mg and/or 20 mg Tadalafil (Cialis), as indicated as follows. With regard to those interaction studies where only the 10 mg Tadalafil (Cialis) dose was used, clinically relevant interactions at higher doses cannot be completely ruled out.
Effects of other substances on Tadalafil (Cialis): Cytochrome P450 inhibitors: Tadalafil (Cialis) is principally metabolised by CYP3A4. A selective inhibitor of CYP3A4, ketoconazole (200 mg daily), increased Tadalafil (Cialis) exposure (AUC) 2-fold and Cmax by 15%, relative to the AUC and Cmax values for Tadalafil (Cialis) alone. Ketoconazole (400 mg daily) increased Tadalafil (Cialis) (20 mg) exposure (AUC) 4-fold and Cmax by 22%. Ritonavir, a protease inhibitor (200 mg twice daily), which is an inhibitor of CYP3A4, CYP2C9, CYP2C19, and CYP2D6, increased Tadalafil (Cialis) (20 mg) exposure (AUC) 2-fold with no change in Cmax. Although specific interactions have not been studied, other protease inhibitors, such as saquinavir, and other CYP3A4 inhibitors, such as erythromycin, clarithromycin, itraconazole and grapefruit juice should be co-administered with caution as they would be expected to increase plasma concentrations of Tadalafil (Cialis) (see Precautions). Consequently the incidence of the adverse reactions listed might be increased.
Transporters: The role of transporters (for example p-glycoprotein) in the disposition of Tadalafil (Cialis) is not known. Therefore there is the potential of drug interactions mediated by inhibition of transporters.
Cytochrome P450 Inducers: A CYP3A4 inducer, rifampicin, reduced Tadalafil (Cialis) AUC by 88%, relative to the AUC values for Tadalafil (Cialis) alone (10 mg). This reduced exposure can be anticipated to decrease the efficacy Tadalafil (Cialis); the magnitude of decreased efficacy is unknown. Other inducers of CYP3A4 such as phenobarbital, phenytoin and carbamazepine, may also decrease the plasma concentrations of Tadalafil (Cialis).
Effects of Tadalafil (Cialis) on Other Medicinal Products: Nitrates: In clinical studies, Tadalafil (Cialis) (5, 10 and 20 mg) was shown to augment the hypotensive effects of nitrates. Therefore, administration of Tadalafil (Cialis) to patients who are using any form of organic nitrate is contraindicated (see Contraindications). Based on the results of a clinical study in which 150 subjects receiving daily doses of Cialis 20 mg for 7 days and 0.4 mg sublingual nitroglycerin at various times, this interaction lasted for more than 24 hours and was no longer detectable when 48 hours had elapsed after the last Tadalafil (Cialis) dose. Thus, in a patient prescribed any dose of CIALIS (2.5 mg-20 mg), where nitrate administration is deemed medically necessary in a life-threatening situation, at least 48 hours should have elapsed after the last dose of CIALIS before nitrate administration is considered. In such circumstances, nitrates should only be administered under close medical supervision with appropriate hemodynamic monitoring.
Anti-hypertensives (including calcium channel blockers): The co-administration of doxazosin (4 and 8 mg daily) and Tadalafil (Cialis) (5 mg daily dose and 20 mg as a single dose) increases the blood pressure-lowering effect of this alpha-blocker in a significant manner. This effect lasts at least twelve hours and may be symptomatic, including syncope. Therefore this combination is not recommended (see Precautions). In interaction studies performed in a limited number of healthy volunteers, these effects were not reported with alfuzosin or tamsulosin. However, caution should be exercised when using Tadalafil (Cialis) in patients treated with any alpha-blockers, and notably in the elderly. Treatments should be initiated at minimal dosage and progressively adjusted. In clinical pharmacology studies, the potential for Tadalafil (Cialis) to augment the hypotensive effects of antihypertensive medicinal products was examined. Major classes of antihypertensive medicinal products were studied, including calcium channel blockers (amlodipine), angiotensin converting enzyme (ACE) inhibitors (enalapril), beta-adrenergic receptor blockers (metoprolol), thiazide diuretics (bendrofluazide), and angiotensin II receptor blockers (various types and doses, alone or in combination with thiazides, calcium channel blockers, beta-blockers, and/or alpha-blockers).
Tadalafil (Cialis) (10 mg except for studies with angiotensin II receptor blockers and amlodipine in which a 20 mg dose was applied) had no clinically significant interaction with any of these classes. In another clinical pharmacology study Tadalafil (Cialis) (20 mg) was studied in combination with up to4 classes of antihypertensives. In subjects taking multiple antihypertensives, the ambulatory-blood- pressure changes appeared to relate to the degree of blood-pressure control. In this regard, study subjects whose blood pressure was well controlled, the reduction was minimal and similar to that seen in healthy subjects. In study subjects whose blood pressure was not controlled, the reduction was greater although this reduction was not associated with hypotensive symptoms in the majority of subjects. In patients receiving concomitant antihypertensive medicinal products, Tadalafil (Cialis) 20 mg may induce a blood pressure decrease, which [with the exception of alpha blockers (see previous information)] is, in general, minor and not likely to be clinically relevant. Analysis of phase 3 clinical trial data showed no difference in adverse events in patients taking Tadalafil (Cialis) with or without antihypertensive medicinal products. However, appropriate clinical advice should be given to patients regarding a possible decrease in blood pressure when they are treated with antihypertensive medicinal products.
5-alpha reductase inhibitors: In a clinical trial that compared Tadalafil (Cialis) 5 mg coadministered with finasteride 5 mg to placebo plus finasteride 5 mg in the relief of BPH symptoms, no new adverse reactions were identified. However, as a formal drug-drug interaction study evaluating the effects of Tadalafil (Cialis) and 5-alpha reductase inhibitors (5-ARIs) has not been performed, caution should be exercised when Tadalafil (Cialis) is co-administered with 5-ARIs.
CYP1A2 substrates (e.g. theophylline): When Tadalafil (Cialis) 10 mg was administered with theophylline (a non-selective phosphodiesterase inhibitor) in a clinical pharmacology study, there was no pharmacokinetic interaction. The only pharmacodynamic effect was a small (3.5 bpm) increase in heart rate. Although this effect is minor and was of no clinical significance in this study, it should be considered when co-administering these medicinal products.
Ethinylestradiol and terbutaline: Tadalafil (Cialis) has been demonstrated to produce an increase in the oral bioavailability of ethinylestradiol; a similar increase may be expected with oral administration of terbutaline, although the clinical consequence of this is uncertain.
Alcohol: Alcohol concentrations (mean maximum blood concentration 0.08 %) were not affected by co-administration with Tadalafil (Cialis) (10 mg or 20 mg). In addition, no changes in Tadalafil (Cialis) concentrations were seen 3 hours after co-administration with alcohol. Alcohol was administered in a manner to maximise the rate of alcohol absorption (overnight fast with no food until 2 hours after alcohol). Tadalafil (Cialis) (20 mg) did not augment the mean blood pressure decrease produced by alcohol (0.7 g/kg or approximately 180 mL of 40% alcohol [vodka] in an 80-kg male) but in some subjects, postural dizziness and orthostatic hypotension were observed. When Tadalafil (Cialis) was administered with lower doses of alcohol (0.6 g/kg), hypotension was not observed and dizziness occurred with similar frequency to alcohol alone. The effect of alcohol on cognitive function was not augmented by Tadalafil (Cialis) (10 mg).
Cytochrome 450 metabolized medicinal products: Tadalafil (Cialis) is not expected to cause clinically significant inhibition or induction of the clearance of medicinal products metabolised by CYP450 isoforms. Studies have confirmed that Tadalafil (Cialis) does not inhibit or induce CYP450 isoforms, including CYP3A4, CYP1A2, CYP2D6, CYP2E1, CYP2C9 and CYP2C19.
CYP2C9 substrates (e.g. R-warfarin): Tadalafil (Cialis) (10 mg and 20 mg) had no clinically significant effect on exposure (AUC) to S-warfarin or R-warfarin (CYP2C9 substrate), nor did Tadalafil (Cialis) affect changes in prothrombin time induced by warfarin.
Aspirin: Tadalafil (Cialis) (10 mg and 20 mg) did not potentiate the increase in bleeding time caused by acetyl salicylic acid.
Antidiabetic medicinal products: Specific interaction studies with antidiabetic medicinal products were not conducted.
Caution For Usage
Incompatibilities: Not applicable.
Storage
Store in original package to protect from moisture. Store at temperatures between 30°C.
ATC Classification
G04BE08 - tadalafil ; Belongs to the class of drugs used in erectile dysfunction.
Presentation/Packing
FC tab 5 mg (light yellow, almond-shaped and marked "C5" on one side) x 28's.
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