Prescribing Guidance: Drugs used in the treatment of Erectile Dysfunction(ED)

Key Points

  • Sildenafil can be prescribed generically on an FP10, it is has been taken off the ‘SLS’ list1
  • All other medications for erectile dysfunction (included branded sildenafil –Viagra®) remain on the ‘SLS’ list and should only be prescribed on a FP10 if the patient is eligible under the Department of Health criteria.
  • Where generic sildenafil is inappropriate/ineffective and the patient does not meet the NHS criteria for drugs other than generic sildenafil, a private prescription should be provided for the brand Viagra®).
  • The Department of Health Treatment of Impotence: Health Service circular 1999/148 2advise that ‘One treatment per week will be appropriate for most patients being treated for ED’ but a prescriber may exercise clinical judgment and prescribe more than one treatment per week if felt to be clinically appropriate and safe.
  • The Revatio brand of sildenafil (20mg tablet, 10mg/ml oral suspension and 800microgram/ml injection) is only licensed for the treatment of pulmonary arterial hypertension. This preparation is RED listed on the Doncaster TLS and should not be prescribed in primary care.

Action

  • Where drug treatment is indicated, generic sildenafil is recommended as the first line option, at the minimum effective dose.

Consider an oral PDE5 (Phosphodiesterase type-5 inhibitor) as first choice

Formulary choice / Drug / Onset of action / Strength / Cost per month
July 2015
First Line Treatment / Sildenafil (generic only ) / 60 minutes / 25 mg
50 mg
100 mg / £1.06 (4 tablets)
£1.16 (4 tablets)
£1.25 (4 tablets)
Second LineTreatment
/ Tadalafil (Cialis®) ‘SLS / 30 minutes / 10 mg
20 mg / £26.99 (4 tablets)
£26.99 (4 tablets)
Vardenafil (Levitra®) ‘SLS’ / 25-60 minutes / 5mg
10mg
20 mg / £7.56 (4 tablets)
£14.08 (4 tablets)
£23.48 (4 tablets)
Avanafil (Spedra®) ‘SLS’ / 25-30minutes / 50 mg
100 mg
200 mg / £10.94 (4 tablets)
£14.08 (4 tablets)
£21.90 (4 tablets)
Third Line
Treatment
Specialist Use / Alprostadil (Vitaros®) 3 mg/g cream ‘SLS’ / topical / £40.00 ( 4 tubes)
Tadalafil (Cialis®) ‘SLS’ Daily / n/a / 2.5 mg
5 mg / £54.99(28 tablets)
£54.99(28 tablets)
  • Although there are some differences between agents the formulary choice is based on cost and erection rigidity6
  • If there is no response to PDE5 treatment, refer patient to Specialist services (Leger Clinic, Urology DBHFT)

SLS Criteria(for all other ED medication including branded Viagra®)4

Author: Karen Jennison Checked by: Osman Ali

Authorised By: Medicines Management CommitteeDate: July 2015

Review Date: July 2017 Version: V1

diabetes

multiple sclerosis

Parkinson’s disease

poliomyelitis

prostate cancer

prostatectomy

radical pelvic surgery

renal failure treated by dialysis or transplant

severe pelvic injury

single gene neurological disease

spinal cord injury

spina bifida

Author: Karen Jennison Checked by: Osman Ali

Authorised By: Medicines Management CommitteeDate: July 2015

Review Date: July 2017 Version: V1

Safety issues5 PDE5 inhibitors are contraindicatedin men:

  • Taking nitrates.
  • In whom vasodilation or sexual activity are inadvisable. with hypotension (resting blood pressure below 90/50 mmHg) or hypertension (resting blood pressure > 170/100 mmHg); stroke, myocardial infarction, life-threatening arrhythmia within the previous 6 months; unstable angina and congestive heart failure New York Heart Association class 2 or greater.
  • With severe hepatic or renal impairment. with a previous history of non-arteritic anterior ischaemic optic neuropathy or known hereditary degenerative retinal disorders

Please note

  • Prescribers are advised to consider the following statement from the Health Service Circular before prescribing:

‘Prescribers may also wish to bear in mind that some treatments for impotence have been found to have a “street value” for men who consider, rightly or wrongly, that these treatments will enhance their sexual performance and that excessive prescribing could therefore lead to unlicensed, unauthorized and possibly dangerous use of these treatments’

References

  1. National Health Service (General Medical Service Contracts) ( Prescription of drugs ect) ( Amendment ) Regulation 2014.
  2. Department of Health. Treatment of impotence. NHS Executive Health Service Circular 1999/148 June 1999.
  3. Department of Health. Treatment of Impotence. NHS Executive Health Service Circular 1999/115 May 1999.
  4. Drug Tariff Part XVIIIB - Drugs, Medicines and Other Substances that may be ordered only in certain circumstances
  5. The Electronic Medicines Compendium (eMC)
  6. NICE guidance for Avanafil
  7. NICE guidance for Alprostadil cream

Author: Karen Jennison Checked by: Osman Ali

Authorised By: Medicines Management CommitteeDate: July 2015

Review Date: July 2017 Version: V1