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Loss of vision in one eye due to non-arterial anterior ischemic optic neuropathy (NAPION) (regardless of the connection with the use of PDE5 inhibitors) concomitant use of doxazosin, guanylate cyclase stimulants such as riociguat, and drugs for the treatment of erectile dysfunction.
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Cialis is mainly metabolized with the participation of the CYP3A4 enzyme. Taking ketoconazole, a selective inhibitor of CYP3A4, at a dose of 200 mg per day, increases the effect of the drug (AUC) (10 mg) by 2 times and Cmax by 15% compared with the same indicators with Cialis monotherapy. Taking ketoconazole at a dose of 400 mg per day increases the effect of Cialis (AUC) (20 mg) by 4 times and Cmax by 22%. Ritonavir, a protease inhibitor, 200 mg twice a day, which is an inhibitor of CYP3A4, CYP2C9, CYP2C19 and CYP2D6, doubles the effect of Cialis (20 mg) without changing Cmax. Although specific interactions have not been studied, other protease inhibitors, such as saquinavir, as well as other CYP3A4 inhibitors, such as erythromycin, clarithromycin, itraconazole and grapefruit juice, should be taken with caution in conjunction with Cialis, since an increase in plasma concentrations of the drug can be expected.
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The selective inducer of CYP3A4, rifampin (rifampicin, 600 mg per day), reduces the effect of a single dose of Cialis (AUC) (10 mg) by 88% and Cmax by 46%, relative to AUC and Cmax values with Cialis monotherapy. Reducing the effect of the drug can reduce the effectiveness of Cialis; the magnitude of the decrease in efficiency is unknown. When taking the drug once a day, you can expect a decrease in the effectiveness of Cialis in the case of a joint appointment with rifampin. The simultaneous use of other inducers of CYP3A4, such as phenobarbital, phenytoin and carbamazepine, may also lead to a decrease in the plasma concentration of Cialis.
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Simultaneous administration of antacids (magnesium hydroxide / aluminum hydroxide) and Cialis reduces the absorption rate of the drug without changing the area under the pharmacokinetic curve (AUC) for Cialis.
Cialis does not affect the effect of warfarin in relation to prothrombin time.
An increase in gastric pH as a result of taking the histamine H 2 receptor blocker nizatidine did not affect the pharmacokinetics of Cialis. The safety and efficacy of using Cialis in combination with other PDE5 inhibitors or alternative methods of treating erectile dysfunction have not been studied, therefore the use of such combinations is not recommended.
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There is a potential for drug interactions between Cialis and transport proteins (for example, p-glycoprotein), mediated by inhibition of transporters. It is known that Cialis enhances the hypotensive effect of nitrates. Prescribing Cialis to patients taking any form of organic nitrates is contraindicated. In the event of a life-threatening condition, when the appointment of nitrates is clinically justified, it is necessary to maintain a 48 hour interval after taking the last dose of Cialis. Under these conditions, nitrates should only be used under close medical supervision with appropriate hemodynamic monitoring.
Cialis does not have a clinically significant effect on the clearance of drugs, the metabolism of which occurs with the participation of the cytochrome P450 isoenzyme. Studies have confirmed that Cialis does not inhibit or induce cytochrome P450 isoforms, including CYP3A4, CYP1A2, CYP2D6, CYP2E1, CYP2C9 and CYP2C19.
Cialis has no clinically significant effect on the pharmacokinetics of S-warfarin or R-warfarin.
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Tadalafil has systemic vasodilating properties and can enhance the effect of antihypertensive drugs aimed at lowering blood pressure. In patients with insufficiently controlled arterial hypertension, taking several antihypertensive drugs, in whom there was a more pronounced decrease in blood pressure. In the vast majority of patients, lowering blood pressure was not accompanied by the development of hypotensive symptoms.
Patients receiving treatment with antihypertensive drugs and taking Cialis should be given appropriate clinical recommendations. Patients taking antihypertensive medications should be warned of the possible risk of lowering blood pressure.
When Tadalafil was used by healthy volunteers who took the alpha1-blocker doxazosin (4-8 mg per day), a significant increase in the hypotensive effect of doxazosin was observed. This effect lasts for at least twelve hours and can present with a variety of symptoms, including fainting. The simultaneous use of Cialis and doxazosin is not recommended.
According to the results of two classesIn technical studies, there was no significant decrease in blood pressure when using Cialis by healthy individuals who took selective alpha1-blockers tamsulosin and alfuzosin. Care must be taken when prescribing Cialis to patients taking any alpha-blockers, especially the elderly. Treatment should be started with minimal dosages and adjusted gradually.
In clinical studies, the ability of tadalafil to enhance the hypotensive effect of antihypertensive drugs was studied. The main classes of antihypertensive drugs have been studied, including calcium channel blockers (amlodipine), angiotensin-converting enzyme (ACE) inhibitors (enalapril), beta-adrenergic receptor blockers (metoprolol), thiazide diuretics (bendrofluazide) and receptor blockers (various types of angiotensin and doses taken alone or in combination with thiazides, calcium channel blockers, beta blockers and / or alpha blockers).
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Tadalafil (10 mg, with the exception of interaction studies with angiotensin II receptor blockers and amlodipine, in which a dose of 20 mg was used) did not have a clinically significant interaction with drugs of any of these classes. In a clinical pharmacological study, the interaction of tadalafil (20 mg), taken in combination with several (up to 4) classes of antihypertensive drugs, was studied.
In patients taking multiple antihypertensive drugs, changes in blood pressure measured on an outpatient basis were correlated with measures to regulate pressure. In patients whose blood pressure was under careful drug regulation, its decrease was minimal, and similar to that in healthy study participants.
In patients whose blood pressure was not regulated, its decrease was greater, although this decrease did not lead to the appearance of hypotensive symptoms in most of the observed. In patients receiving co-administered antihypertensive drugs, tadalafil 20 mg can cause a decrease in blood pressure, which (with the exception of alpha-blockers, see above) is usually minimal and most likely does not lead to clinically significant manifestations.
Analysis of the third phase of clinical trials did not show any difference in the occurrence of side effects in patients taking tadalafil in parallel with taking antihypertensive drugs or in isolation. However, it is necessary to warn patients taking antihypertensive drugs about a possible decrease in blood pressure.