Cialis, OTC, and Men

I love men.

I mean, I actually went and married one, and I am delighted.

I understand their senses of “maleness” are sometimes a bit more fragile with women challenging them on absolutely every front imaginable.

But they still do quite well.  I absolutely love them.

I may have simply seen more male patients than a lot of psychiatrists.  When I started my psychiatric residency, it was estimated that 70% of all psychiatric patients were female.  The obvious exception was where I spent a fair amount, of my career to date, in the Department of Veterans Affairs medical system.

I still have a deep pain when I see a man cry.  I am sure that they are told somehow when they are growing up (and most particularly, in the military) that this is not something they are supposed to do, for their embarrassment is beyond words.

My attempts to comfort them have always been Herculean.

My success at doing so has always been limited.

I can think of exactly 11 such men I have seen.  They all cried for the same reason.

They had become impotent after a series of events that had started with a medication side effect.  They call it “priapism,” a sustained and painful erection that may not end all by itself.  But the tragedy of this is — after a visit to the emergency room for a treatment to end it — it simply might never happen again.  No more erections – ever!

I remember their faces.  Sometimes even fragments of their names and histories, after, in some cases, many years.

The drug, incidentally, was Trazodone (there are now multiple other brand names), generic name desipramine.

Although it was developed originally as an antidepressant, many doctors (usually general practice or family practice) use smaller doses as a sleeping pill, as it does help some and does not appear to be addictive.  These practitioners are not familiar with the bad side effects – they aren’t trained in psychopharmacology – and think it is generally safe.

It is – for the majority.  But there is a horrible risk for the few.

Although the published risk is “less than 0.1%” – we expect that many people who suffer this side effect don’t report it, or it is treated in a way that doesn’t account for the fault of the medication that caused it.

The VA was sued and plaintiffs won a financial settlement for priapism – which (of course) they are appealing.

Folks the LEAST invasive treatment for this condition is horrible, and it can often lead to a surgical intervention – even penile amputation.

Of my eleven afflicted male patients, the one who has haunted me the most was a much-decorated WWII veteran who cried to me because his wife had done an absolutely stellar job of raising children and now he could not “pleasure” her as she deserved.

I always discuss alternative ways of “pleasuring,” but men seem rarely satisfied.

Okay, so this is a “rare” side effect.  I have seen some side effect lists for this drug on the internet where it is not even mentioned.

I have tried not to start men on this, and told them the details, and still they want it for one or another reason.  I always document that they know because I have told them.

Long ago, this drug was actually used to help promote erections in those who, sometimes as a drug side effect, have difficulty with same.

Here is the truth about this drug.

We don’t much hear about trazodone being prescribed to increase male potency, now that there are drugs on the market for that indication specifically.

Right now, there are three common prescription medications used to treat erectile dysfunction.  They are sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis).

A word to the wise — don’t even think of taking these medications if you take nitrates, which are commonly used for heart problems, or if you have serious blood pressure problems.

Although the “Big Three” are very different molecules, they are all classified as PDE-5  or phosphodiesterase type 5 enzyme inhibitors.

This means on a practical level that they simply produce the desired effect in that most delicate part of the male anatomy by increasing blood flow.

In fact — Viagra was originally developed for heart problems.  In clinical trials back in the 80’s, its ability to promote erections was noted fortuitously, and a whole new category of medications was born.

Cialis has a longer half life than the other two drugs, which someone would generally take only on an “as needed” basis.  It has variable dosing, and may be taken regularly.  All of the television ads for it have played up the spontaneous nature of sexual activity.  It is not uncommon to hear of it as being “good for a whole weekend.”  I have no trouble with these concepts.

Eli Lilly and partner (Sanofi) are trying to sell Cialis over-the counter.

Cialis does have some rare side effects, like making someone go deaf or blind.

I am not as worried about that as I am about priapism.

Here is a nice review of some recent studies on priapism.  There seems to be more of it and nobody seems to know for sure if that has anything to do with the increased use of erectile dysfunction drugs.  I will readily admit that I had a negative visceral reaction when I read about the attempt to sell Cialis over the counter.

This is a trend that is going on with a lot of medications.

Me, I am the one who is compulsive about telling patients the advantages and risks of medications.  Ethically, a doctor should get a signed informed-consent from a patient after discussing these things so the patient won’t be uninformed (and in case the doctor is later sued).

I feel as if the more medications are available over the counter, the less consumers will actually know about the negative side-effects.  These are usually in microscopic print on the packaging (or package insert) and maybe flashed on the screen during TV ads (or horribly speeded up vocally to the pitch of a chipmunk).

And to be honest, there is a bit of wounded pride for us doctors. After all of the time I spent dragging around the world in my attempt to acquire knowledge, I have simply been taken “out of the play.”

I will live with my wounded ego.

But wait — there’s more.

Patients do not take medications as prescribed.  And the promise of sexual supremacy may prove too tempting to expect patients to practice caution.

I am unsure what they do with over the counters, but my bet is they will “double up” or do whatever they have to do to match the prescription strength with the lower, over-the-counter-dose.

Me, I would never judge men on the crazy notion of “sexual performance.”  I cannot count how many men I have attempted to comfort by telling them “It’s not how much you’ve got, but how you use it.”  Such assertions never seem to work quite as well as I would like them to work.  Somebody is judging men on sexual performance, maybe a couple of women — but mostly, I think, men themselves.

Oy!

One thing I am in a position to judge patients, and folks in general about how they listen to the advantages-and-risks discussions from me, or how they read labels on over-the-counters, or how they read the sheets handed out about drugs by pharmacists.

In general, they don’t.

It is especially hard for me to imagine a young man wearing a backwards ball cap with a sports logo reading a label – or worrying about “too much erection.”

Making any prescription drug into an over-the-counter drug runs risks.

Obviously, profit is the motive.  I am not saying that drug companies are any worse than anyone who is in business to make a profit.

I just do not think that they are any better.

Labels on over-the-counters, like package inserts and the articles in the Physicians Desk Reference are basically instruments by which a drug company discharges liability.  With labels they discharge such liability to the consumer.  With package inserts in prescription drugs and articles in the Physicians’ Desk Reference, they discharge it to the physician.

Sometimes drugs are determined not to be safe and pulled from the market after additional data has been collected.  This can be much too late – years after major damage is done.

I read and study as much as I can.  I simply do not have a crystal ball.

Of course, there are natural alternatives to these drugs for the treatment of erectile dysfunction, and they have been studied, although there are very few studies, indeed.

They are nicely summarized on this website, but you do have to wade through some advertisements.

Nevertheless, I would suggest any gentleman with this problem have a doctor’s visit.  The reason is that all kinds of general illness can show up with erectile dysfunction as the first symptom.  Most common in my experience with gentlemen who have this problem has been type II diabetes, as well as problems with circulation.

Take care of yourselves, men.

I really do love and care about all of you.