Tadalafil Contraindications and Precautions

Absolute Contraindications

• The American College of Cardiology and American Heart Association recommend that any form of organic nitrate use is an absolute contraindication to tadalafil, due to the risk of profound hypotension, myocardial infarction, and potentially death, with a Class III (harm) recommendation 1, 2, 3
• The mechanism of this contraindication involves tadalafil's inhibition of phosphodiesterase-5 (PDE5), which prevents degradation of cyclic GMP, and when combined with nitrates, causes markedly exaggerated and prolonged vasodilation 3, 4
• At least 48 hours must elapse after the last dose of tadalafil before any nitrate therapy can be administered, according to the American College of Cardiology and American Heart Association guidelines 1, 2, 3, 4

Relative Contraindications and High-Risk Conditions

• The European Association of Urology guidelines list cardiac disease, hypotension, poorly controlled blood pressure, or recent stroke (<6 months) as contraindications for tadalafil use 5, 6
• Significant hepatic or renal insufficiency is also listed as a contraindication in European Association of Urology guidelines 5, 6
• Patients who report sudden loss of vision due to anterior ischemic optic neuropathy after previous PDE5 inhibitor use are contraindicated for tadalafil 5, 6

Critical Drug Interactions Requiring Dose Adjustment

• No relevant facts with citations.

Alternative Anti-Ischemic Therapies When Tadalafil Precludes Nitrate Use

• The American College of Cardiology recommends beta-blockers as first-line anti-ischemic therapy when nitrates are contraindicated due to recent tadalafil use 3, 4
• Calcium channel blockers (non-dihydropyridine preferred) can be used for recurrent ischemia, according to the American College of Cardiology guidelines 3, 4
• ACE inhibitors provide blood pressure control and cardioprotection, as recommended by the American College of Cardiology 3, 4