Cialis

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Cialis on Prescriptsy

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Cialis is the brand name for tadalafil, a phosphodiesterase type 5 (PDE5) inhibitor licensed in the United Kingdom for the on-demand treatment of erectile dysfunction (ED) in adult men.

Available as 10 mg and 20 mg film-coated tablets, Cialis works by enhancing the natural physiological mechanism of erection during sexual stimulation.

Its defining clinical characteristic is a prolonged duration of action of up to 36 hours after a single dose, substantially longer than the 4 to 6 hour windows associated with sildenafil and vardenafil.

This extended therapeutic window allows greater spontaneity and has established tadalafil as one of the most widely prescribed ED treatments worldwide.

Erectile dysfunction affects an estimated 4.3 million men in the UK and becomes increasingly prevalent with age, affecting approximately 40% of men at age 40 and up to 70% at age 70.

While ED is often multifactorial, the underlying pathophysiology in most cases involves impaired penile blood flow due to endothelial dysfunction, which may be an early marker of cardiovascular disease.

This page provides a comprehensive clinical overview of how Cialis works, correct dosing, clinical evidence, side effects, important safety information, and how to obtain a prescription in the UK.

Important safety information about Cialis

Before reading further, note the following critical safety points. Cialis is a prescription-only medicine (POM) and must not be used without medical supervision.

• Do not take Cialis if you are using organic nitrates (such as GTN spray or isosorbide mononitrate) or recreational nitrates (poppers). The combination can cause a severe, potentially fatal drop in blood pressure.
• Do not take Cialis if you have been advised to avoid sexual activity because of a heart condition.
• If an erection lasts more than 4 hours, seek emergency medical help immediately (call 999 or attend A&E).
• If you experience sudden vision loss or sudden hearing loss, stop taking Cialis and seek urgent medical attention.

What is erectile dysfunction

Erectile dysfunction is defined as the persistent inability to achieve or maintain an erection sufficient for satisfactory sexual performance.

It is a common condition that becomes more prevalent with age but is not an inevitable consequence of ageing.

ED may be caused by vascular disease (the most common organic cause), neurological conditions, hormonal abnormalities, anatomical factors, medication side effects, or psychological factors such as performance anxiety, depression, or relationship difficulties.

In many men, multiple factors contribute.

Risk factors for ED include diabetes mellitus, hypertension, hyperlipidaemia, obesity, smoking, cardiovascular disease, prostate surgery, pelvic radiotherapy, and certain medications including beta-blockers, thiazide diuretics, antidepressants, and antiandrogens.

Because ED and cardiovascular disease share common risk factors, NICE recommends that men presenting with ED should have a cardiovascular risk assessment performed as part of their initial evaluation.

How Cialis works: mechanism of action

During sexual stimulation, the nerve endings and endothelial cells in the corpus cavernosum release nitric oxide (NO).

Nitric oxide activates the enzyme guanylate cyclase, which increases levels of cyclic guanosine monophosphate (cGMP).

Elevated cGMP causes relaxation of smooth muscle in the penile arteries and the trabecular tissue of the corpus cavernosum, allowing increased blood flow into the penis and producing an erection.

Erection is terminated when cGMP is broken down by phosphodiesterase type 5 (PDE5).

Tadalafil selectively inhibits PDE5, preventing cGMP degradation and thereby prolonging and enhancing the erectile response to sexual stimulation.

Importantly, tadalafil has no direct effect on smooth muscle and does not cause erection in the absence of sexual arousal.

Tadalafil is highly selective for PDE5 over other phosphodiesterase isoforms.

It has more than 10,000-fold selectivity for PDE5 over PDE1, PDE2, PDE4, and PDE7, and more than 700-fold selectivity over PDE6 (found in the retina), which accounts for the lower incidence of visual disturbances compared with sildenafil.

Tadalafil also inhibits PDE11, found in skeletal muscle, prostate, and testes, which may explain the back pain and myalgia that are more commonly associated with tadalafil than other PDE5 inhibitors.

Clinical evidence and NICE guidance

The efficacy of tadalafil for ED was established in five pivotal randomised, double-blind, placebo-controlled clinical trials involving over 1,100 patients.

In these studies, tadalafil 20 mg significantly improved erectile function domain scores on the International Index of Erectile Function (IIEF) questionnaire, successful intercourse attempts (measured by the Sexual Encounter Profile diary), and patient-reported global assessment of treatment effect compared with placebo.

The proportion of successful intercourse attempts was approximately 75% with tadalafil 20 mg versus 32% with placebo.

NICE Clinical Knowledge Summary on erectile dysfunction recommends PDE5 inhibitors as first-line pharmacological treatment for ED and notes that the choice between available agents (sildenafil, tadalafil, vardenafil, avanafil) should be based on individual patient preference, anticipated frequency of intercourse, and tolerability profile.

The longer duration of action of tadalafil is highlighted as a potential advantage for men who prefer spontaneity rather than timing medication around sexual activity.

Head-to-head studies comparing tadalafil with sildenafil have found broadly similar efficacy, with patient preference often favouring tadalafil because of its extended duration and lack of food interaction.

The ENDURANCE study found that when given a choice after using both medications, approximately 73% of men preferred tadalafil.

Dosage and administration

The recommended starting dose for on-demand use is 10 mg, taken at least 30 minutes before anticipated sexual activity.

Based on efficacy and tolerability, the dose may be adjusted to a maximum of 20 mg or reduced to 5 mg.

The maximum recommended dosing frequency is once per day. Tablets should be swallowed whole with water and may be taken with or without food.

The onset of action is typically 30 to 45 minutes, with some men reporting effectiveness from as early as 15 minutes.

The therapeutic effect may persist for up to 36 hours. During this window, an erection can be achieved with appropriate sexual stimulation.

Tadalafil does not produce a constant erection and each sexual encounter requires arousal.

For men who plan to use tadalafil frequently (twice per week or more), daily dosing with lower-strength tadalafil (Cialis Once A Day, 2.5 mg or 5 mg) may be considered.

Daily dosing provides continuous readiness without the need to time doses around sexual activity and may also benefit men with concurrent lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH).

Dose adjustments

No dose adjustment is required for mild to moderate renal impairment (creatinine clearance 31 to 80 mL/min).

For severe renal impairment, the maximum on-demand dose is 10 mg, not more frequently than once every 48 hours.

Patients on haemodialysis should not exceed 5 mg daily or 10 mg on-demand no more than every 72 hours.

No dose adjustment is needed for mild hepatic impairment (Child-Pugh A). The maximum recommended dose for moderate hepatic impairment (Child-Pugh B) is 10 mg.

Tadalafil is not recommended in severe hepatic impairment. Age alone does not require dose adjustment, though underlying renal and hepatic function should be considered in elderly patients.

Side effects of Cialis

Common side effects

The most frequently reported adverse effects in clinical trials are headache (14.5% at 20 mg), dyspepsia (12.3%), back pain (6.5%), myalgia (5.7%), nasal congestion (4.3%), and flushing (4.1%).

Back pain and myalgia typically develop 12 to 24 hours after dosing and resolve within 48 hours.

These effects are related to PDE11 inhibition in skeletal muscle and are not indicative of structural damage.

Uncommon and rare side effects

Uncommon side effects include dizziness, blurred vision, eye pain, tinnitus, palpitations, tachycardia, abdominal pain, gastro-oesophageal reflux, rash, and excessive sweating.

Rare but serious side effects include priapism (a prolonged, painful erection lasting more than 4 hours), non-arteritic anterior ischaemic optic neuropathy (NAION), sudden sensorineural hearing loss, hypotension, seizures, transient amnesia, and Stevens-Johnson syndrome.

When to seek medical advice

Contact your GP or call NHS 111 if you experience persistent headache, visual changes, or hearing changes.

Seek emergency care (call 999 or attend A&E) if you experience a prolonged erection lasting more than 4 hours, sudden loss of vision in one or both eyes, sudden hearing loss, chest pain during or after sexual activity, or signs of a severe allergic reaction (swelling of face, lips, tongue, or throat, difficulty breathing).

Report any suspected adverse reactions to the MHRA via the Yellow Card scheme at yellowcard.mhra.gov.uk .

Warnings and precautions

Contraindications

Cialis is absolutely contraindicated in men taking organic nitrates (glyceryl trinitrate, isosorbide mononitrate or dinitrate, sodium nitroprusside), recreational nitrates (amyl nitrite, known as "poppers"), or guanylate cyclase stimulators (riociguat).

The concurrent vasodilatory effects can produce severe hypotension, syncope, myocardial infarction, or death.

Cardiovascular considerations

Sexual activity carries a degree of cardiac risk. Men who have been advised to avoid sexual activity due to cardiovascular status should not use Cialis.

Specific contraindications include myocardial infarction within the past 90 days, unstable angina or angina during intercourse, NYHA class II or higher heart failure in the past 6 months, uncontrolled arrhythmias, uncontrolled hypertension (above 170/100 mmHg), hypotension (below 90/50 mmHg), and stroke within the past 6 months.

A cardiovascular risk assessment is recommended for all men presenting with ED.

Alpha-blocker interaction

Concurrent use of tadalafil with alpha-adrenergic blocking agents (tamsulosin, doxazosin, alfuzosin) may cause symptomatic hypotension in some patients. Haemodynamic stability on the alpha-blocker should be established before prescribing tadalafil, and the lowest dose of tadalafil should be used initially.

Visual and auditory safety

Rare cases of NAION have been temporally associated with PDE5 inhibitor use.

NAION causes sudden, painless loss of vision in one eye and is more common in men over 50 with diabetes, hypertension, hyperlipidaemia, smoking history, or a crowded optic disc.

Men who have previously experienced NAION should not use PDE5 inhibitors. Sudden sensorineural hearing loss, sometimes accompanied by tinnitus and dizziness, has also been reported.

Patients should stop tadalafil and seek immediate medical advice if either event occurs.

Cialis versus other PDE5 inhibitors

Four PDE5 inhibitors are currently available in the UK: sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra), and avanafil (Spedra).

All share the same mechanism of action but differ in pharmacokinetics, selectivity, and side effect profiles.

Tadalafil has the longest half-life (17.5 hours versus approximately 4 hours for sildenafil and vardenafil, and 6 to 17 hours for avanafil), providing the longest therapeutic window of up to 36 hours.

Tadalafil is not affected by food, whereas sildenafil absorption is delayed by high-fat meals.

Back pain and myalgia are more common with tadalafil due to PDE11 cross-reactivity, whereas visual disturbances (blue tint, increased brightness) are more common with sildenafil due to PDE6 cross-reactivity.

The choice between agents is based on individual preference, frequency of intercourse, tolerability, and cost.

How to get a Cialis prescription in the UK

Cialis is classified as a prescription-only medicine (POM) in the United Kingdom.

It can be prescribed by your GP, at an NHS sexual health clinic, or by an authorised online prescriber following a clinical assessment including cardiovascular risk evaluation, medication review, and discussion of treatment expectations.

Following patent expiry, generic tadalafil is widely available and is typically less expensive than branded Cialis. Generic tadalafil meets the same regulatory standards for quality, safety, and bioequivalence.

Your prescriber may prescribe generically, allowing the pharmacy to dispense any licensed tadalafil product.

The standard NHS prescription charge in England is currently 9.90 pounds per item; prescriptions are free in Scotland, Wales, and Northern Ireland.

Lifestyle considerations and ED management

Whilst pharmacological treatment with Cialis or other PDE5 inhibitors is effective for most men, lifestyle modification is an important component of ED management.

Smoking cessation, regular aerobic exercise, weight loss in overweight or obese men, moderation of alcohol intake, and optimisation of cardiovascular risk factors (blood pressure, lipids, blood glucose) have all been shown to improve erectile function.

Psychological approaches including cognitive behavioural therapy and psychosexual counselling may benefit men with a significant psychological component to their ED.

A combined approach addressing both organic and psychological factors typically produces the best outcomes.

Sources

• Cialis 10 mg Film-coated Tablets, Summary of Product Characteristics (EMC)
• Tadalafil, British National Formulary (BNF)
• NICE CKS: Erectile Dysfunction
• Erectile dysfunction (impotence), NHS
• MHRA Yellow Card Scheme