References

Blaber A, Harris G Assessment skills for paramedics.Berkshire: Open University Press; 2011

Boyle M A dramatic drop in blood pressure following prehospital GTN administration. Emerg Med J. 2007; 24:(3)225-226

Braun M, Wassmer G, Klotz T, Reifenrath B, Mathers M, Engelmann U Epidermiology of erectile dysfunction: results of the Cologne Male Survey [Internet]. Intl J Impotence Res. 2000; 12:(6)305-311

British Heart Foundation. BHF CVD Statistics compendium 2017. 2017. http://tinyurl.com/y986j43u (cited 2017 Oct 11)

Capogrosso P, Colicchia M, Ventimiglia E, Castagna G, Clementi M C, Suardi N, Salonia A One patient out of four with newly diagnosed erectile dysfunction is a young man—worrisome picture from the everyday clinical practice. The J Sexl Med. 2013; 10:(7)1833-1841

Sildenafil (Viagra) and the heart [Internet]. 2001. http://www.ncbi.nlm.nih.gov/pubmed/23008645 (cited 2017 Jun 3)

Chao H, Hwang T Contemporary management of erectile dysfunction. Urological Sci. 2013; 24:(2)35-40

Crowley A, Muirhead G, Gillies H, Osterloh I Interaction between glyceryl trinitrate and sildenafil citrate (viagraS) may last less than 4 hours. Am J Hypertension. 2004; 17:(5)

Engelberg S, Singer A, Moldashel J, Sciammarella J, Thode H, Henry M Effects of prehospital nitroglycerin on hemodynamics and chest pain intensity. Prehosp Emerg Care. 2000; 4:(4)290-293

Feldman H, Goldstein I, Hatzichristou D, Krane R, McKinlay J Impotence and its medical and psychosocial correlates: results of the Massachusetts male aging study. J Urology. 1994; 151:(1)54-61

Ghandi M, Lampe F, Wood D Incidence, clinical characteristics and short-term prognosis of angina pectoris. Br Heart J. 1995; 73:(2)193-198

Goldstein H, Lue T, Padma-Nathan H Oral sildenafil in the treatment of erectile dysfunction. N Engl J Med. 1998; 338:1397-1404

Greenland P Glyceryl trinitrate (Anginine) use in a cardiovascular emergency [Internet]. Contemp Nurs: J for Aus Nursing Prof. 2006; 22:(1)91-96

Health and Care Professions Council (HCPC). Standards of conduct, performance and ethics. 2008. http://www.hpc-uk.org/assets/documents/10002367finalcopyofscpejuly2008.pdf (cited 2017 Jun 30)

Health and Care Professions Council (HCPC). Standards of proficiency - Paramedics. 2014. http://tinyurl.com/y83ealnx (cited 2017 Jun 30)

Jackson G Sexual intercourse and stable angina pectoris. Am J Cardiology. 2000; 86:35-37

Jackson G, Gillies H, Osterloh I Past, present and future: a 7-year update of Viagra (sildenafil citrate). Intl J Clinical Pract. 2005; 59:(6)680-691

Jeremy J, Ballard S, Naylor A, Miller M, Angelini G Effects of sildenafil, a type-5 cGMP phosphodiesterase inhibitor, and papaverine on cyclic GMP and cyclic AMP levels in the rabbit corpus cavernosum in vitro. Br J Urology. 1997; 79:(6)958-963

UK ambulances services: clinical practice guidelines, 2016.Bridgewater: Class Professional Publishing; 2016

Moreland R, Goldstein I, Traish A Sildenafil, a novel inhibitor of phosphodiesterase type 5 in human corpus cavernosum smooth muscle cells. Life Science. 1998; 62:309-318

National Institute for Health and Care Excellence. Erectile dysfunction: avanafil. 2014a. http://tinyurl.com/ybm5ez45 (cited 201 Jun 9)

National Institute for Health and Care Excellence. Clinical knowledge summaries: erectile dysfunction. Revised December 2014. 2014b. https://cks.nice.org.uk/erectile-dysfunction#!topicsummary (cited 2017 Jun 9)

Oliver J, Kerr D, Webb D Time-dependent interactions of the hypotensive effects of sildenafil citrate and sublingual glyceryl trinitrate. Br J Clinical Pharmacology. 2009; 67:(4)403-412

Parker J Nitrate therapy for stable angina oectoris. New England J Med. 1998; 338:(8)520-531

Coronary heart disease statistics: morbidity supplement 2001 edition [Internet]. 2001. http://tinyurl.com/ycd2ch3k

Taylor RW, Griffiths MJ, Evans TW Low-dose inhaled nitric oxide in patients with acute lung injury; a randomised controlled trial [Internet]. JAMA. 2004; 291:(13)

Webb D, Freestone S, Allen M, Muirhead G Sildenafil citrate and blood-pressure-lowering drugs: results of drug interaction studies with an organic nitrate and a calcium antagonist. Am J Cardiology. 1999; 83:21-218

Webb D, Muirhead G, Wulff M, Sutton J, Levi R, Dinsmore W Sildenafil citrate potentiates the hypotensive effects of nitric oxide donor drugs in male patients with stable angina. J Am Col Cardiology. 2000; 36:(1)25-31

Wylie K Male sexual dysfunction. Psychiatry. 2007; (3)99-104

Zitkus B Assessing chest pain accurately. Cardiac Insider. 2010; 40:(1)1-6

medication
patient care
patient safety

‘Have you had Viagra within the past 24 hours?’

02 November 2017
Features
02 November 2017
Volume 9 · Issue 11

Abstract

Rapid drug-induced vasodilation is essential in treating coronary medical emergencies. Through oral or sublingual administration of glyceryl trinitrate (GTN), changes occur in cyclic guanosine monophosphate (cGMP) levels, as well as a reduction in blood pressure. Patients who require GTN treatment may also take vasodilatory medication for other medical conditions, including erectile dysfunction (ED). Current guidance in the UK contraindicates GTN use alongside sildenafil (commercially known as Viagra) and other related drugs, owing to the likelihood of life-threatening hypotension. Therefore, it is essential that paramedics and emergency responders establish whether patients have taken sildenafil within the past 24 hours before administering GTN. This article identifies the action mechanisms of both drugs, and provides an evidence-based explanation for co-administration outcomes; a dramatic drop in blood pressure which can potentially be fatal. This article also reflects on the challenges faced by paramedics when considering administration of GTN to determine whether sildenafil has been taken within the past 24 hours.

Sildenafil, commercially known as Viagra, is the most effective first-line treatment for erectile disfunction (ED) in the UK (Chamsi-Pasha, 2001; National Institute for Health and Care Excellence (NICE), 2014a). ED is estimated to affect more than 100 million men worldwide (Chamsi-Pasha, 2001), with one in four patients seeking help for the onset of ED being younger than 40 years (Capogrosso et al, 2013). However, its prevalence varies greatly. It is estimated to affect more than 30% of the population subgroup of men aged between 30 and 70 years worldwide (Feldman, 1994). A German study identified 19.2% of men aged between 30 and 80 years with this condition (Braun et al, 2000). This data should be treated with caution however, as it could potentially be an underestimation. For example, there are men who, for various reasons (e.g. embarrassment), do not report ED issues.

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NO-cGMP pathway
Sildenafil
GTN
Paramedic
Pre-hospital
Contraindication