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# Tadalafil (Cialis)
## Overview
Tadalafil is a phosphodiesterase type 5 (PDE5) inhibitor used to treat erectile dysfunction (ED), benign prostatic hyperplasia (BPH), and pulmonary arterial hypertension (PAH). It increases blood flow to specific areas of the body.
## Primary Indications
* Erectile Dysfunction (ED)
* Benign Prostatic Hyperplasia (BPH)
* Pulmonary Arterial Hypertension (PAH)
## Adult Dosing
* **ED:**
* **On-demand:** 10 mg orally once daily, taken at least 30 minutes before sexual activity. May be increased to 20 mg or decreased to 5 mg based on efficacy and tolerability. Maximum dose is 20 mg per day.
* **Daily:** 5 mg orally once daily, taken at the same time each day, regardless of sexual activity. May be decreased to 2.5 mg based on tolerability.
* **BPH:** 5 mg orally once daily, taken at the same time each day.
* **PAH:** 40 mg orally once daily.
## Pediatric Dosing
Tadalafil is not typically recommended for pediatric patients. No established pediatric dosing.
## Dose Adjustments
* **Hepatic Impairment:**
* For ED and BPH: Maximum dose is 10 mg once daily for patients with mild to moderate hepatic impairment. Use with caution in severe hepatic impairment.
* For PAH: Data is limited; use with caution.
* **Renal Impairment:**
* For ED and BPH:
* Mild to moderate impairment: No dose adjustment needed for on-demand therapy. For daily therapy, 2.5 mg once daily is recommended.
* Severe impairment: Maximum on-demand dose is 10 mg every 72 hours. Maximum daily dose is 2.5 mg once daily.
* For PAH:
* Mild to moderate impairment: Maximum dose is 20 mg once daily.
* Severe impairment: Use with caution; no specific dose adjustments provided.
## Contraindications
* Concomitant use of nitrates (e.g., nitroglycerin, isosorbide mononitrate/dinitrate) due to the risk of severe hypotension.
* In patients who have lost vision in one eye because of non-arteritic anterior ischemic optic neuropathy (NAION), regardless of whether this episode was associated with prior PDE5 inhibitor use.
* Hypersensitivity to tadalafil or its excipients.
* Use in women for ED.
## Adverse Effects
* **Common:** Headache, dyspepsia, back pain, myalgia, nasal congestion, flushing, pain in extremities.
* **Serious:** Priapism (erection lasting > 4 hours), sudden vision loss (NAION), sudden hearing decrease or loss, severe hypotension.
## Key Drug Interactions
* **Nitrates:** Contraindicated. Potentially life-threatening hypotension.
* **Alpha-blockers (e.g., tamsulosin, prazosin):** Use with caution. Increased risk of symptomatic hypotension. Administer cautiously, considering timing and dose.
* **CYP3A4 inhibitors (e.g., ketoconazole, ritonavir):** Can increase tadalafil exposure. May require dose reduction.
* **CYP3A4 inducers (e.g., rifampin, carbamazepine):** Can decrease tadalafil exposure. May require dose increase.
* **Antihypertensives:** Tadalafil can further lower blood pressure; monitor closely.
## Monitoring
* Efficacy: Improvement in ED, BPH symptoms, or PAH symptoms.
* Adverse effects: Monitor for headache, visual disturbances, hearing changes, and signs of priapism.
* Blood pressure: Especially when used with antihypertensives or alpha-blockers.
## Clinical Pearls
* Tadalafil has a longer half-life (17.5 hours) compared to sildenafil (4 hours), allowing for a longer window of opportunity for sexual activity for on-demand dosing.
* The daily dosing option for ED provides spontaneity.
* Tadalafil is the only PDE5 inhibitor approved for daily treatment of BPH.
* Patients should be advised to seek immediate medical attention if they experience sudden vision or hearing loss, or an erection lasting more than 4 hours.
**Disclaimer:** This information is intended for healthcare professionals. Always refer to the most current prescribing information and consult with a healthcare provider before making any treatment decisions.
