Embargo 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.
Are you taking or have you taken any of the following? Yes No Drugs for osteoporosis such as Fosomax or Boniva List any medications that you are taking. Dental History (circle appropriate answer) Yes No Do you have regular dental checkups? Date of last exam: Yes No Have you had any trouble with previous dental treatment? Explain: Yes No Do you want to keep your own teeth for yo
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
Embargo 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