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Miller K, May U, Beecken WD, Hatzichristodoulou G, Böhm M, Fink S. Evidence for benefits and risks of tadalafil as a non-prescription medicine: review and evaluation using the Group Delphi technique to achieve consensus amongst clinical experts. Front Pharmacol 2023; 14:1254706. [PMID: 37876727 PMCID: PMC10590875 DOI: 10.3389/fphar.2023.1254706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/19/2023] [Indexed: 10/26/2023] Open
Abstract
An evidence-based consensus meeting was held with urologists, a pharmacist and a cardiologist to perform a structured benefit-risk analysis of reclassifying tadalafil, a phosphodiesterase type 5 (PDE5) inhibitor for treatment of erectile dysfunction (ED), to be available without prescription in Germany. As per the Brass process endorsed by regulatory authorities, an evidence-based Brass value tree was developed, which identified the incremental benefits and risks that should be considered above the safety and efficacy evidence required for prescription medicines. During the Group Delphi consensus meeting, the expert panel rated the likelihood and clinical impact of each benefit and risk on a scale of 0 (none) to 3 (high). Overall attribute scores were calculated from the product of the mean likelihood and mean clinical impact scores giving a possible score of 0-9. The overall benefit attribute scores ranged from 2.8 to 5.4. The overall risk attribute scores ranged from 0.2 to 2.2 though most were 1.0 or less (3 or more is generally considered to be of concern). On balance, the independent meeting scored the benefits of reclassification of tadalafil higher than the risks and considered the risk mitigation strategies of the packaging label and patient information leaflet (PIL) sufficient.
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Affiliation(s)
- Kurt Miller
- Department of Urology, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Uwe May
- Department of Health Economics and Pharmacoeconomics, Fresenius University of Applied Sciences, Wiesbaden, Germany
| | | | | | - Michael Böhm
- Department of Internal Medicine, University of the Saarland, Homburg Saar, Germany
| | - Stefan Fink
- State Pharmacists’ Association of Thuringia, Erfurt, Germany
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von Büren M, Rodler S, Wiesenhütter I, Schröder F, Buchner A, Stief C, Gratzke C, Wülfing C, von Büren J. Digital Real-world Data Suggest Patient Preference for Tadalafil over Sildenafil in Patients with Erectile Dysfunction. Eur Urol Focus 2022; 8:794-802. [PMID: 34006491 DOI: 10.1016/j.euf.2021.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 04/06/2021] [Accepted: 04/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Erectile dysfunction (ED) is a major care problem worldwide. Tadalafil and sildenafil are the two most common phosphodiesterase-5 inhibitors (PDE5is) used to treat ED. OBJECTIVE This study aimed to evaluate patient data of a large online prescription platform (OPP), specifically analyzing preference for tadalafil over sildenafil. DESIGN, SETTING, AND PARTICIPANTS Data from a prospectively collected German OPP were retrospectively analyzed. This dataset included patients with a history of taking one or both substances (n = 26 821). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS ED patient baseline characteristics were derived from medical questionnaires for PDE5i prescriptions between May 2019 and May 2020. Order behavior was analyzed in patients who ordered both substances over time. We applied Kruskal-Wallis tests, χ² tests, and fisher's exact tests for statistical analysis. RESULTS AND LIMITATIONS Baseline characteristics were comparable for both PDE5is in patients with a median age of 49 yr (sildenafil [interquartile range {IQR} 38-57]; tadalafil [IQR 39-56]), a median body mass index (BMI) of 26 kg/m² (sildenafil [IQR 24.54-29.03]; tadalafil [IQR 24.49-28.69]), ED onset time of >12 mo (sildenafil [87%]; tadalafil [88%]), and the presence of morning erections (sildenafil [62%]; tadalafil [61%]). Tadalafil prescriptions increased significantly from 30% (first order) to 80% (last order) in patients who had already tested both drugs. Patients with age ≤40 yr, BMI ≤25 kg/m², and sustained morning erections preferred tadalafil to sildenafil. CONCLUSIONS Using database information from an OPP, preference for tadalafil was shown for patients who had tested both PDE5is. This preference was particularly pronounced in patients with age ≤40 yr, BMI ≤25 kg/m², and sustained morning erections. A well-managed OPP can be used for research on more complex health services. PATIENT SUMMARY Analysis of large online prescription platforms provide the benefit of identifying young treatment-naïve patients with early-stage disease, which is highlighted by the fact that about two-thirds of our patients analyzed still maintained spontaneous morning erections. Patients who had tested tadalafil once developed preference for this drug.
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Affiliation(s)
- Moritz von Büren
- Department of Urology, University of Freiburg, Freiburg, Germany.
| | - Severin Rodler
- Department of Urology, University of Munich, Munich, Germany
| | - Isabell Wiesenhütter
- Munich University Institute for Psychological Psychotherapy Training (MUNIP), Munich, Germany
| | | | | | - Christian Stief
- Department of Urology, University of Munich, Munich, Germany
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Domes T, Najafabadi BT, Roberts M, Campbell J, Flannigan R, Bach P, Patel P, Langille G, Krakowsky Y, Violette PD, Brock GB, Yafi FA. Canadian Urological Association guideline: Erectile dysfunction. Can Urol Assoc J 2021; 15:310-322. [PMID: 34665713 DOI: 10.5489/cuaj.7572] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Erectile dysfunction (ED) impacts the wellness and quality of life of millions of Canadians. An evaluation focused on the identification of reversible and irreversible underlying factors is recommended for patients presenting with ED. Through a shared decision-making model framework, the goal of ED treatment is to improve functional outcomes and enhance sexual satisfaction while minimizing adverse effects associated with treatment. Given that ED is assessed and treated by multiple different types of health practitioners, the purpose of this guideline is to provide the best available evidence to facilitate care delivery through a Canadian lens. After a narrative review of ED assessment and treatment for general readership, five key clinical questions relating to priority areas of ED are assessed using the GRADE and evidence-to-decision-making frameworks.
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Affiliation(s)
- Trustin Domes
- Division of Urology, Department of Surgery, University of Saskatchewan, Saskatoon, SK, Canada
| | - Borna Tadayon Najafabadi
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Matthew Roberts
- Division of Urology, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Jeffrey Campbell
- Division of Urology, Department of Surgery, Western University, London, ON, Canada
| | - Ryan Flannigan
- Department of Urological Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Phil Bach
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Premal Patel
- Division of Urology, Department of Surgery, University of Manitoba, Winnipeg, MB, Canada
| | | | - Yonah Krakowsky
- Division of Urology, Women's College Hospital & Sinai Health System, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Philippe D Violette
- Department of Surgery, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Gerald B Brock
- Professor Emeritus, Western University, London, ON, Canada
| | - Faysal A Yafi
- Department of Urology, University of California Irvine, Irvine, CA, United States
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Efficacy and safety of oral phosphodiesterase 5 inhibitors for erectile dysfunction: a network meta-analysis and multicriteria decision analysis. World J Urol 2020; 39:953-962. [PMID: 32388784 DOI: 10.1007/s00345-020-03233-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 04/27/2020] [Indexed: 10/24/2022] Open
Abstract
PURPOSE To quantitatively assess the benefit-risk ratio on the efficacy and safety of all phosphodiesterase type 5 inhibitors (PDE5i) in men with erectile dysfunction. METHODS A systematic review with network meta-analysis, surface under the cumulative ranking analysis and stochastic multicriteria acceptability analyses were performed. Searches were conducted in Pubmed, Scopus, Web of Science without limits for time-frame or language. Randomized controlled trials evaluating the efficacy or safety of any PDE5i compared to a placebo or to other PDE5i in males with erectile disfunction were included. RESULTS Overall, 184 articles representing 179 randomized controlled trials (50,620 patients) were included. All PDE5i were significantly more efficient than placebo. Sildenafil 25 mg was statistically superior to all interventions in enhancing IIEF (with a 98% probability of being the most effective treatment), followed by sildenafil 50 mg (80% of probability). Taladafil 10 mg and 20 mg also presented good profiles (73% and 76%, respectively). Avanafil and lodenafil were less effective interventions. Mirodenafil 150 mg was the treatment that caused more adverse events, especially flushing and headaches. Sildenafil 100 mg was more related to visual disorders, while vardenafil and udenafil were more prone to cause nasal congestion. CONCLUSION Sildenafil at low doses and tadalafil should be the first therapeutic options. Avanafil, lodenafil and mirodenafil use are hardly justified given the lack of expressive efficacy or high rates of adverse events.
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Elbardisy B, Galal S, Abdelmonsif DA, Boraie N. Intranasal Tadalafil nanoemulsions: formulation, characterization and pharmacodynamic evaluation. Pharm Dev Technol 2019; 24:1083-1094. [PMID: 31215307 DOI: 10.1080/10837450.2019.1631846] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This study aims at improving the bioavailability of a poorly soluble phosphodiesterase-5 inhibitor; tadalafil (TD) via developing intranasal (IN) nanoemulsions (NEs). Optimum NE ingredients were selected based on solubility studies, emulsification tests, and phase diagram construction. Both o/w and w/o NEs were selected based on their drug loading capacity. Optimum formulations were subjected to physicochemical characterization and were assessed for nasal toxicity through biochemical analysis of tumor necrosis factor-α (TNF-α) and caspase-3 in rat nasal tissues. Pharmacodynamic study was performed via biochemical analysis of cyclic guanosine monophosphate (cGMP) in rat penis 2-h post-treatment and compared with oral suspension of Cialis® tablets. Optimum o/w and w/o NEs were successfully prepared using different ratios of Capmul-MCM-EP, Labrasol:Transcutol-HP (1:1) and water. Optimized formulations exhibited more than 4000-fold increase in TD solubility compared with its aqueous solubility. Both formulations were optically isotropic with the majority of globules in the nanometric-size range. Nasal toxicity study revealed no significant difference in values of TNF-α and caspase-3 between the NE-treated groups and the control group. Both TD-NEs succeeded to achieve a significant enhancement in cGMP levels. Our findings suggested that IN administration of the developed TD-NEs could provide a safe and effective alternative to TD oral delivery.
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Affiliation(s)
- Bassant Elbardisy
- Department of Pharmaceutics, Faculty of Pharmacy, Alexandria University , Alexandria , Egypt
| | - Sally Galal
- Department of Pharmaceutics, Faculty of Pharmacy, Alexandria University , Alexandria , Egypt
| | - Doaa A Abdelmonsif
- Department of Medical Biochemistry, Faculty of Medicine, Alexandria University , Alexandria , Egypt
| | - Nabila Boraie
- Department of Pharmaceutics, Faculty of Pharmacy, Alexandria University , Alexandria , Egypt
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Zhou Z, Chen H, Wu J, Wang J, Zhang X, Ma J, Cui Y. Meta-Analysis of the Long-Term Efficacy and Tolerance of Tadalafil Daily Compared With Tadalafil On-Demand in Treating Men With Erectile Dysfunction. Sex Med 2019; 7:282-291. [PMID: 31307951 PMCID: PMC6728809 DOI: 10.1016/j.esxm.2019.06.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/10/2019] [Accepted: 06/17/2019] [Indexed: 12/04/2022] Open
Abstract
Background Erectile dysfunction (ED) is highly prevalent in aging men. Tadalafil daily and on-demand are widely used for the treatment of ED. Aim We performed a meta-analysis to evaluate the efficacy and safety of tadalafil daily compared with tadalafil on-demand in treating men with ED after at least 24 weeks of long-term treatment. Methods Randomized controlled trials of tadalafil daily vs on-demand in treating men with ED were searched using MEDLINE, EMBASE, and the Cochrane Controlled Trials Register. Systematic review was carried out using the Preferred Reporting Items for Systematic Reviews and Meta-analyses. The data was calculated by RevMan version 5.3.0. The references of related articles were also searched. Outcomes International Index of Erectile Function-Erectile Function domain, sexual encounter profile question 2 (SEP2), SEP question 3 (SEP3), any treatment-emergent adverse event (AE), discontinuation due to AEs, myalgia, back pain, headache, dyspepsia, and nasopharyngitis. Results 4 articles, including 1,035 participants were studied. The analysis found that tadalafil daily had a greater improvement than tadalafil on-demand in terms of International Index of Erectile Function-Erectile Function (mean difference (MD) 1.24; 95% CI 0.03−2.44; P = .04), SEP2 (MD 10.08; 95% CI 9.15−11.01; P < .00001) and SEP3 (MD 8.19; 95% CI 2.09−14.29; P = .009) in treating ED after at least 24 weeks treatment cycle. For safety, tadalafil on-demand had a higher incidence of any treatment-emergent AE (odds ratio 0.73; 95% CI 0.56−0.96; P = .02) compared with tadalafil daily, but for other aspects, including discontinuation due to AEs, myalgia, back pain, headache, dyspepsia, and nasopharyngitis, there were no significant difference between the 2 treatments. Clinical Implications Tadalafil daily may offer a better effect for ED than on-demand for long-term treatment. Strengths and Limitations From the perspective of evidence-based medicine, we evaluated the efficacy and safety of tadalafil daily compared with tadalafil on-demand in treating men with ED after a long-term treatment. The quality of these studies included is flawed, primarily in difference in tadalafil doses and severity of the ED. Conclusion Tadalafil daily provides a preferable therapeutic effect for ED with a lower incidence of treatment-emergent side effects relative to tadalafil on-demand after at least 24 weeks of long-term treatment. Zhou Z, Chen H, Wu J, et al. Meta-Analysis of the Long-Term Efficacy and Tolerance of Tadalafil Daily Compared With Tadalafil On-Demand in Treating Men With Erectile Dysfunction. J Sex Med 2019;7:282–291.
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Affiliation(s)
- Zhongbao Zhou
- Binzhou Medical University, Yantai, Shandong, China; Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Hongyan Chen
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Jitao Wu
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Jipeng Wang
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Xuebao Zhang
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Jiajia Ma
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Yuanshan Cui
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China.
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The Efficacy of Tadalafil Daily vs on Demand in the Treatment of Erectile Dysfunction: A Systematic Review and Meta-analysis. Urology 2017; 112:6-11. [PMID: 28882778 DOI: 10.1016/j.urology.2017.08.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 08/12/2017] [Accepted: 08/18/2017] [Indexed: 11/23/2022]
Abstract
We present a review comparing the use of tadalafil daily vs on-demand for erectile dysfunction. We examined randomized controlled trials and observational studies that examined the use of tadalafil for at least 8 weeks of follow-up with the primary outcome of International Index for Erectile Dysfunction-Erectile Function domain. Eight studies that examined the desired dosing regimens were identified. Of these, 6 studies included the primary end point of 12 weeks. Those patients taking tadalafil daily for 12 weeks scored on average 1.82 points higher in International Index for Erectile Dysfunction-Erectile Function domain scores, although the difference may not be clinically significant (Fig. 1).
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Gong B, Ma M, Xie W, Yang X, Huang Y, Sun T, Luo Y, Huang J. Direct comparison of tadalafil with sildenafil for the treatment of erectile dysfunction: a systematic review and meta-analysis. Int Urol Nephrol 2017; 49:1731-1740. [PMID: 28741090 PMCID: PMC5603624 DOI: 10.1007/s11255-017-1644-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 06/26/2017] [Indexed: 12/17/2022]
Abstract
Aims Erectile dysfunction (ED) is a major care problem worldwide. Tadalafil and sildenafil are the two most common phosphodiesterase 5 inhibitors used to treat ED. This systematic review and meta-analysis were conducted to directly compare tadalafil with sildenafil for the treatment of ED. Methods We designed a strategy for searching the PubMed, Embase, EBSCO, Web of Science and Cochrane library databases; the reference lists of the retrieved studies were also investigated. A literature review was performed to identify all published randomized or non-randomized controlled trials that compared tadalafil with sildenafil for the treatment of ED and to assess the quality of the studies. Two investigators independently and blindly screened the studies for inclusion. The meta-analysis was performed using RevMan 5.0. Results A total of 16 trials that compared tadalafil with sildenafil for the treatment of ED were included in the meta-analysis. In the meta-analysis, tadalafil and sildenafil appeared to have similar efficacies and overall adverse event rates. However, compared with sildenafil, tadalafil significantly improved psychological outcomes. Furthermore, the patients and their partners preferred tadalafil over sildenafil, and no significant difference was found in the adherence and persistence rates between tadalafil and sildenafil. Additionally, the myalgia and back pain rates were higher and the flushing rate was lower with tadalafil than with sildenafil. Conclusion Tadalafil shares a similar efficacy and safety with sildenafil and significantly improves patients’ sexual confidence. Furthermore, patients and their partners prefer tadalafil to sildenafil. Hence, tadalafil may be a better choice for ED treatment.
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Affiliation(s)
- Binbin Gong
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, 330000, Jiangxi Province, China
| | - Ming Ma
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, 330000, Jiangxi Province, China.
| | - Wenjie Xie
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, 330000, Jiangxi Province, China
| | - Xiaorong Yang
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, 330000, Jiangxi Province, China
| | - Yongming Huang
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, 330000, Jiangxi Province, China
| | - Ting Sun
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, 330000, Jiangxi Province, China.
| | - Yanping Luo
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, 330000, Jiangxi Province, China
| | - Jiao Huang
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, 330000, Jiangxi Province, China
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Kucuk EV, Tahra A, Bindayi A, Onol FF. Erectile dysfunction patients are more satisfied with penile prosthesis implantation compared with tadalafil and intracavernosal injection treatments. Andrology 2016; 4:952-6. [DOI: 10.1111/andr.12237] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 05/17/2016] [Indexed: 11/30/2022]
Affiliation(s)
- E. V. Kucuk
- Urology, Umraniye Training & Research Hospital; Health Sciences University; Istanbul Turkey
| | - A. Tahra
- Umraniye Training & Research Hospital; Health Sciences University; Istanbul Turkey
| | - A. Bindayi
- Umraniye Training & Research Hospital; Health Sciences University; Istanbul Turkey
| | - F. F. Onol
- Umraniye Training & Research Hospital; Health Sciences University; Istanbul Turkey
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Abstract
Many therapies for erectile dysfunction (ED) after prostate cancer treatment improve erectile firmness, yet, most couples stop using aids within 1-2 years. Patients and partners who expect immediate and complete success with their first ED treatment can be demoralized when they experience treatment failure, which contributes to reticence to explore other ED aids. Comprehensive patient education should improve sustainability and satisfaction with ED treatments. Pre-emptive and realistic information should be provided to couples about the probability of recovering natural erections. Beginning intervention early and using a couple-based approach is ideal. Recommendations are provided about the timing of ED treatment, the order of aid introduction, and combination therapies. Renegotiation of sexual activity is an essential part of sexual adaptation. From the outset of therapy, couples should be encouraged to broaden their sexual repertoire, incorporate erection-independent sexual activities, and continue to be sexual despite ED and reduced libido.
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