17 PATIENT COUNSELING INFORMATION

Tadalafil is >10,000-fold more potent for PDE5 than for PDE3, an enzyme found in the heart and blood vessels.

Related/similar drugs

CYP3A4 (e.g., Rifampin) — Rifampin (600 mg daily), a CYP3A4 inducer, reduced tadalafil 10-mg single-dose exposure (AUC) by 88% and Cmax by 46%, relative to the values for tadalafil 10 mg alone. Although specific interactions have not been studied, other CYP3A4 inducers, such as carbamazepine, phenytoin, and phenobarbital, would likely decrease tadalafil exposure. The reduced exposure of tadalafil with the coadministration of rifampin or other CYP3A4 inducers can be anticipated to decrease the efficacy of CIALIS for once daily use; the magnitude of decreased efficacy is unknown. Cytochrome P450 Substrates — CIALIS is not expected to cause clinically significant inhibition or induction of the clearance of drugs metabolized by cytochrome P450 (CYP) isoforms. Studies have shown that tadalafil does not inhibit or induce P450 isoforms CYP1A2, CYP3A4, CYP2C9, CYP2C19, CYP2D6, and CYP2E1.

7.2 Potential for Other Drugs to Affect CIALIS

Theophylline) — Tadalafil had no significant effect on the pharmacokinetics of theophylline. When tadalafil was administered to subjects taking theophylline, a small augmentation (3 beats per minute) of the increase in heart rate associated with theophylline was observed. Warfarin) — Tadalafil had no significant effect on exposure (AUC) to S-warfarin or R-warfarin, nor did tadalafil affect changes in prothrombin time induced by warfarin. CIALIS (tadalafil) is not indicated for use in females. There are no data with the use of CIALIS in pregnant women to inform any drug-associated risks for adverse developmental outcomes. Additionally, tadalafil is 700-fold more potent for PDE5 than for PDE6,

which is found in the retina and is responsible for phototransduction.

Adverse effects

The effect of PDE5 inhibition on cGMP concentration in the corpus cavernosum and pulmonary arteries is also observed in the smooth muscle of the prostate, the bladder and their vascular supply. The mechanism for reducing BPH symptoms has not been established. PDE5 is found in the smooth muscle of the corpus cavernosum, prostate, and bladder as well as in vascular and visceral smooth muscle, skeletal muscle, urethra, platelets, kidney, lung, cerebellum, heart, liver, testis, seminal vesicle, and pancreas. In vitro studies have shown that the effect of tadalafil is more potent on PDE5 than on other phosphodiesterases. These studies have shown that tadalafil is >10,000-fold more potent for PDE5 than for PDE1, PDE2, PDE4, and PDE7 enzymes, which are found in the heart, brain, blood vessels, liver, leukocytes, skeletal muscle, and other organs. Tadalafil is 14-fold more potent for PDE5 than for PDE11A1 and 40-fold more

potent for PDE5 than for PDE11A4, two of the four known forms of PDE11. PDE11 is an enzyme found in human prostate, testes, skeletal muscle and in other tissues (e.g., adrenal cortex).

13. Nonclinical Toxicology

In animal reproduction studies, no adverse developmental effects were observed with oral administration of tadalafil to pregnant rats or mice during organogenesis at exposures up to 11 times the maximum recommended human dose (MRHD) of 20 mg/day (see Data). Animal reproduction studies showed no evidence of teratogenicity, embryotoxicity, or fetotoxicity when tadalafil was given orally to pregnant rats or mice at exposures up to 11 times the maximum recommended human dose (MRHD) of 20 mg/day during organogenesis. In a prenatal/postnatal developmental study in rats, postnatal pup survival decreased following maternal exposure to tadalafil doses greater than 10 times the MRHD based on AUC. Signs of maternal toxicity occurred at doses greater than 16 times the MRHD based on AUC. Surviving offspring had normal development and reproductive performance.

What are the most common side effects of tadalafil?

In another rat prenatal and postnatal development study at doses of 60, 200, and 1000 mg/kg, a reduction in postnatal survival of pups was observed. The no observed effect level (NOEL) for maternal toxicity was 200 mg/kg/day and for developmental toxicity was 30 mg/kg/day. This gives approximately 16 and 10 fold exposure multiples, respectively, of the human AUC for the MRHD of 20 mg. Tadalafil and/or its metabolites cross the placenta, resulting in fetal exposure in rats. CIALIS is not indicated for use in females. In vitro, tadalafil inhibits human recombinant PDE11A1 and, to a

8.2 Lactation

Insufficient data are available for subjects with severe hepatic impairment (Child-Pugh Class C). [see Dosage and Administration (2.6) and Warnings and Precautions (5.8)]. In clinical pharmacology studies using single-dose tadalafil (5 to 10 mg), tadalafil exposure (AUC) doubled in subjects with creatinine clearance 30 to 80 mL/min. In subjects with end-stage renal disease on hemodialysis, there was a two-fold increase in Cmax and 2.7- to 4.8-fold increase in AUC following cialis 5 miligramos single-dose administration of 10 or 20 mg tadalafil. Exposure to total methylcatechol (unconjugated plus glucuronide) was 2- to 4-fold higher in subjects with renal impairment, compared to those with normal renal function.

8.7 Renal Impairment

Hemodialysis (performed between 24 and 30 hours post-dose) contributed negligibly to tadalafil or metabolite elimination. In a clinical pharmacology study (N=28) at a dose of 10 mg, back pain was reported as a limiting adverse event in male patients with creatinine clearance 30 to 50 mL/min. At a dose of 5 mg, the incidence and severity of back pain was not significantly different than in the general population. In patients on hemodialysis taking 10- or 20-mg tadalafil, there were no reported cases of back pain. [see Dosage and Administration (2.6) and Warnings and Precautions (5.7)]. lesser degree, PDE11A4 activities at concentrations within the therapeutic range.

5.11 Combination With Other PDE5 Inhibitors or Erectile Dysfunction Therapies

Single doses up to 500 mg have been given to healthy subjects, and multiple daily doses up to 100 mg have been given to patients. Adverse events were similar to those seen at lower doses. In cases of overdose, standard supportive measures should be adopted as required. Tadalafil has the empirical formula C22H19N3O4 representing a molecular weight of 389.41. It is a crystalline solid that is practically insoluble in water and very slightly soluble in ethanol.

Professional resources

CIALIS is available as almond-shaped tablets for oral administration. Penile erection during sexual stimulation is caused by increased penile blood flow resulting from the relaxation of penile arteries and corpus cavernosal smooth muscle. This response is mediated by the release of nitric oxide (NO) from nerve terminals and endothelial cells, which stimulates the synthesis of cGMP in smooth muscle cells. Cyclic GMP causes smooth muscle relaxation and increased blood flow into the corpus cavernosum. Because sexual stimulation is required to initiate the local release of nitric oxide, the inhibition of PDE5 by tadalafil has no effect in the absence of sexual stimulation. The physiological role and clinical consequence of PDE11 inhibition in humans have not been defined.

17.10 Sexually Transmitted Disease

No adverse effects were observed in a study in which tadalafil was administered orally at doses of 60, 200, and 1000 mg/kg/day to juvenile rats on postnatal days 14 to 90. The highest plasma tadalafil exposures (AUC) achieved were approximately 10-fold that observed at the MRHD. Of the total number of subjects in ED clinical studies of tadalafil, approximately 19 percent were 65 and over, while approximately 2 percent were 75 and over. Of the total number of subjects in BPH clinical studies of tadalafil (including the ED/BPH study), approximately 40 percent were over 65, while approximately 10 percent were 75 and over. In these clinical trials, no overall differences in efficacy or safety were observed between older (>65 and ≥75 years of age) and younger subjects (≤65 years of age).

Who should not use tadalafil?

However, in placebo-controlled studies with CIALIS for use as needed for ED, diarrhea was reported more frequently in patients 65 years of age and older who were treated with CIALIS (2.5% of patients) [see Adverse Reactions (6.1)]. No dose adjustment is warranted based on age alone. However, a greater sensitivity to medications in some older individuals should be considered. In clinical pharmacology studies, tadalafil exposure (AUC) in subjects with mild or moderate hepatic impairment (Child-Pugh Class A or B) was comparable to exposure in healthy subjects when a dose of 10 mg was administered. There are no available data for doses higher than 10 mg of tadalafil in patients with hepatic impairment. Tadalafil 20 mg administered to healthy male subjects produced no significant difference compared

• Cialis was part of a class of drugs known as PDE5 inhibitors.
• These drugs revolutionized the treatment of erectile dysfunction.
• Lilly invested heavily in development and patent protection for Cialis.
• The medication is generally safe when used as prescribed.
• Cialis use should be avoided if heart conditions preclude sexual activity.
• The medication can have interactions with certain medications like alpha-blockers.
• Men often seek Cialis consultations to improve sexual confidence.
• Treatments like Cialis allow restoration of intimacy in relationships.
• Physician follow-up ensures optimal dosing and safety monitoring.
• Cialis’s approval marked a significant advancement in sexual medicine.
• The drug’s marketing often includes education about ED causes.
• Cialis remains a subject of scientific and clinical interest.

to placebo in supine systolic and diastolic blood pressure (difference in the mean

• Tadalafil is chemically distinct from sildenafil, the active ingredient in Viagra.
• Cialis is often known as the "weekend pill" due to its long effect.
• The medication’s efficacy depends on adequate sexual arousal.
• Drug comparisons show Cialis’s side effect profile is favorable.
• Lilly’s patient assistance programs can reduce cost barriers.
• Daily low-dose Cialis may improve endothelial function in some patients.
• The drug is contraindicated with nitrates used for chest pain.
• Care should be taken when driving or performing tasks after taking Cialis.
• Cialis does not cause immediate permanent changes in sexual function.
• The medication's role in female sexual dysfunction remains unclear.
• Cialis has changed perceptions of male sexual health treatments.
• Safety reviews continue as new data emerge internationally.

maximal decrease of 1.6/0.8 mm Hg, respectively) and in standing systolic and diastolic

• Cialis was approved for daily use for ED in 2008.
• The drug’s long duration allows for more natural sexual experiences.
• Daily Cialis dosage is usually 2.5 or 5 mg per day.
• Lifestyle changes may enhance Cialis effectiveness.
• Men with diabetes may benefit from Cialis for ED.
• Cialis can also improve exercise capacity in pulmonary hypertension patients.
• Typical adverse reactions resolve quickly with dose adjustments.
• Cialis clinical data show improvement in men with spinal cord injuries.
• Cialis does not cure ED but manages symptoms effectively.
• Patient counseling is crucial for safe Cialis use.
• Lilly promotes Cialis as part of sexual health awareness.
• Cialis use requires prior medical evaluation to rule out contraindications.

blood pressure (difference in the mean maximal decrease of 0.2/4.6 mm Hg, respectively).

Medical uses

There is no information on the presence of tadalafil and/or metabolites in human milk, the effects on the breastfed child, or the effects on milk production. Tadalafil and/or its metabolites are present in the milk of lactating rats at concentrations approximately 2.4-fold greater than found in the plasma. Based on the data from 3 studies in adult males, tadalafil decreased sperm concentrations in the study of 10 mg tadalafil for 6 months and the study of 20 mg tadalafil for 9 months. This effect was not seen in the study of 20 mg tadalafil taken for 6 months. The clinical significance of the decreased sperm concentrations in the two studies is unknown.

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There have been no studies evaluating the effect of tadalafil on fertility in men [see Clinical Pharmacology (12.2)]. Based on studies in animals, a decrease in spermatogenesis was observed in dogs, but not in rats [see Nonclinical Toxicology (13.1)]. CIALIS is not indicated for use in pediatric patients. Safety and efficacy in patients below the age generic brand cialis of 18 years have not been established. A randomized, double-blind, placebo-controlled trial in pediatric patients (7 to 14 years of age) with Duchenne muscular dystrophy, who received CIALIS 0.3 mg/kg, CIALIS 0.6 mg/kg, or placebo daily for 48 weeks failed to demonstrate any benefit of treatment with CIALIS on a range of assessments of muscle strength and performance.