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Sfcityclinic.org2Embargo Date: May 26, 2005, 5:00 a.m. EST May 26, 2005, The American Journal of Medicine, Volume 118, No. 6 The American Journal of Medicine (2005) 118, 569 –570 EDITORIAL
Viagra: The risks of recreational use
Viagra (Sildenafil) has become one of the most com- Zoloft, and acetaminophen. Since sexual activity is asso- monly prescribed and abused pharmaceuticals available ciated with significant physical exertion, patients with today. More the 600 000 physicians worldwide have pre- marked exercise intolerance should also exercise caution scribed this agent, and more than 16 million patients have used The media talk about the widespread recre- With these reasonable warnings, millions and millions ational use of Viagra. According to the manufacturer’s of patients have taken Sildenafil and its relatives almost Web site for Viagra, the drug induces penile erections in invariably without major incident. However, in this issue 82% of users with erectile dysfunction versus 24% in of the AJM, Swearingen and review reports of Sildenafil abuse that should raise considerable anxiety street” that Sildenafil increases penile size and possibly among physicians and patients. In this report, the author extends the time to ejaculation in individuals without extensively reviewed the medical literature for carefully erectile dysfunction thereby making it a very popular done reports that compared a variety of variables in men agent for abuse. I personally receive multiple e-mail who have sex with men who used Sildenafil compared transmissions each day offering to sell me Viagra cheaply with similar patients who did not use Sildenafil. Among and without a prescription. It seems reasonable to me that the patients who used Sildenafil, there was a worrisome recreational use of Sildenafil may even exceed medical 2- to 5.7-fold increased practice of unsafe sex compared with those patients who did not use Sildenafil. Addition- After ingestion, this agent induces peripheral vasodi- ally, the rate of sexually transmitted diseases (STD) was latation with particular emphasis on erectile tissue in the nearly 2-fold greater in the individuals who used Silde- penis. Viagra has become one of the most mentioned nafil. When I first read this manuscript, I felt strongly that pharmacological agents in the press and on television.
internists, a group that commonly writes prescriptions for Numerous jokes are told that involve Viagra. Less well- Sildenafil in male patients, needed to hear this news so known and less often the butt of humor are the other two that they might give a warning to their patients who use selective type 5 phosphodiesterase inhibitors (PDE5) Sildenafil. After peer review and manuscript revision, I available on the market, Tadalafil (Cialis) and Vardenafil felt strongly that this article needed extra attention and (Levitra). Soon after its approval by the FDA, a strict that is why I chose to feature it in this month’s editorial.
warning was attached to Sildenafil and the other PDE5 Unfortunately, this manuscript raises a number of inhibitors: the drugs should not be used in conjunction troublesome questions in my mind that led me to hope for with nitrate preparations because of the resultant marked more submissions on this topic. For example, is the risk lowering of blood pressure. Initially, there was some of STD and unsafe sex also increased in male heterosex- anxiety about using these agents in patients with coronary ual patients who use Sildenafil? A recent report in the heart disease or heart failure; however, controlled obser- Lancet further raised my public health anxieties: A group of authors from the Aaron Diamond AIDS Re- inhibitors were eventually deemed safe for all but the search Center at the Rockefeller University in New York most severely impaired heart patients. Only patients with City reported on a patient that they recently evaluated.
active myocardial ischemia, congestive heart failure with This individual had a new strain of HIV virus that was low blood volume or low blood pressure, and hyperten- considerably more virulent and progressed more rapidly sive patients on multidrug antihypertensive regimens to AIDS than any HIV virus previously found. The male should avoid Sildenafil. It also is advised that patients patient reported being sexually active with many male receiving drugs that interfere with with Sildenafil’s drug partners over the years–often in conjunction with meth- metabolism should exercise caution in using Sildenafil.
amphetamine abuse. Thus, this patient had been abusing These include erythromycin, diflucan, amiodarone, dilti- both Sildenafil and methamphetamine. The question that azem, losartan, nefidipine, all statin drugs, alprazolam, immediately leaped to mind was: “What effect did the 0002-9343/$ -see front matter 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjmed.2005.03.034 The American Journal of Medicine, Vol 118, No 6, June 2005 combined abuse of these drugs have on the patient?” References
Could this have resulted in the development of the highlyvirulent HIV mutant? Does this combination drug abuse increase the likelihood of STD transmission and/or the 2. Kloner RA. Sex and the patient with cardiovascular risk factors: Focus on sildenafil. Am J Med. 2000;109(9A):13L–21S.
Clearly, this could develop into a major public health 3. Herrmann HC, Chang G, Klugherz BC, Mahoney PD. Hemodynamics problem for the United States. What are the health im- of sildenafil in men with severe coronary artery disease. N Engl J Med.
plications when Sildenafil and illegal drugs are used together recreationally? The answers to these questions 4. Kloner RA. Cardiovascular effects of the 3 phosphodiesterase-5 inhib- itors approved for the treatment of erectile dysfunction. Circulation.
can only be obtained by careful epidemiological and experimental studies. I hope that the article by Swearin- 5. Webster LJ, Michelakis ED, Davis T, Archer SL. Use of sildenafil for gen and Klausner in this issue of the AJM combined with safe improvement of erectile function and quality of life in men with the case report cited above will lead investigators in this New York Heart Association Classes II and III congestive heart failure.
Arch Intern Med. 2004;164:514 –520.
field to explore the multiple implications and questions 6. Katz SD, Parker JD, Glasser DB, et al. Efficacy and safety of sildenafil citrate in men with erectile dysfunction and chronic heart failure. Am JCardiol. 2005;95:36 – 42.
7. Swearingen S, Klausner JD. Sildenafil use, sexual risk behavior, and risk for sexually transmitted diseases, including HIV infection. Am JMed. 2005;118:571–577.
Robert P. and Irene P. Flinn Professor of Medicine, and 8. Markowitz M, Mohri H, Mehandru S, et al. Infection with multidrug Head, Department of Medicine, University of Arizona resistant, dual-tropic HIV-1 and rapid progression to AIDS: a case Health Sciences Center, Tucson, Arizona report. Lancet. 2005;65:1031–1038.
Study on Racial Encounters and Discrimination Experienced by South Asians Executive Summary Background 1. A survey on “Study on Racial Encounters and Discrimination Experienced by South Asians” was commissioned by the Equal Opportunities Commission (EOC) to the Centre for Civil Society and Governance, The University of Hong Kong, and the Policy 21 Limited. Interviews