ANNEX I
SUMMARY OF PRODUCT CHARACTERISTICS
1.
VIAGRA 25 mg film-coated tablets
2.
Each tablet contains 25 mg of sildenafil(as citrate)
Excipient: Lactose
For a full list of excipients, see section 6.1.
3.
Film-coated tablet.
Blue rounded diamond-shaped tablets, marked “PFIZER” on one side and “VGR 25” on the other.
4.
Treatment of men with erectile dysfunction, which is the inability to achieve or maintain a penile
erection sufficient for satisfactory sexual performance.
In order for VIAGRA to be effective, sexual stimulation is required.
For oral use.
Use in adults:
The recommended dose is 50 mg taken as needed approximately one hour before sexual activity.
Based on efficacy and toleration, the dose may be increased to 100 mg or decreased to 25 mg. The
maximum recommended dose is 100 mg. The maximum recommended dosing frequency is once per
day. If VIAGRA is taken with food, the onset of activity may be delayed compared to the fasted state
(see section 5.2).
Use in the elderly:
Dosage adjustments are not required in elderly patients.
Use in patients with impaired renal function:
The dosing recommendations described in ‘Use in adults’ apply to patients with mild to moderate
renal impairment (creatinine clearance = 30 - 80 ml/min).
Since sildenafil clearance is reduced in patients with severe renal impairment (creatinine clearance
<30 ml/min) a 25 mg dose should be considered. Based on efficacy and toleration, the dose may be
increased to 50 mg and 100 mg.
2
Use in patients with impaired hepatic function:
Since sildenafil clearance is reduced in patients with hepatic impairment (e.g. cirrhosis) a 25 mg dose
should be considered. Based on efficacy and toleration, the dose may be increased to 50 mg and
100 mg.
Use in children and adolescents:
VIAGRA is not indicated for individuals below 18 years of age.
Use in patients using other:
With the exception of ritonavir for which co-administration with sildenafil is not advised (see section
4.4) a starting dose of 25 mg should be considered in patients receiving concomitant treatment with
CYP3A4 inhibitors (see section 4.5).
In order to minimise the potential for developing postural hypotension, patients should be stable on
alpha-blocker therapy prior to initiating sildenafil treatment. In addition, initiation of sildenafil at a
dose of 25 mg should be considered (see sections 4.4 and 4.5).
Hypersensitivity to the active substance or to any of the excipients.
Consistent with its known effects on the nitric oxide/cyclic guanosine monophosphate (cGMP)
pathway (see section 5.1), sildenafil was shown to potentiate the hypotensive effects of nitrates, and
its co-administration with nitric oxide donors (such as amyl nitrite) or nitrates in any form is therefore
contraindicated.
Agents for the treatment of erectile dysfunction, including sildenafil, should not be used in men for
whom sexual activity is inadvisable (e.g. patients with severe cardiovascular disorders such as
unstable angina or severe cardiac failure).
VIAGRA is contraindicated in patients who have loss of vision in one eye because of non-arteritic
anterior ischaemic optic neuropathy (NAION), regardless of whether this episode was in connection
or not with previous PDE5 inhibitor exposure (see section 4.4).
The safety of sildenafil has not been studied in the following sub-groups of patients and its use is
therefore contraindicated: severe hepatic impairment, hypotension (blood pressure <90/50 mmHg),
recent history of stroke or myocardial infarction and known hereditary degenerative retinal disorders
such as
retinitis pigmentosa
(a minority of these patients have genetic disorders of retinal
phosphodiesterases)
.
A medical history and physical examination should be undertaken to diagnose erectile dysfunction
and determine potential underlying causes, before pharmacological treatment is considered.
Prior to initiating any treatment for erectile dysfunction, physicians should consider the
cardiovascular status of their patients, since there is a degree of cardiac risk associated with sexual
activity. Sildenafil has vasodilator properties, resulting in mild and transient decreases in blood
pressure (see section 5.1). Prior to prescribing sildenafil, physicians should carefully consider whether
their patients with certain underlying conditions could be adversely affected by such vasodilatory
effects, especially in combination with sexual activity. Patients with increased susceptibility to
vasodilators include those with left ventricular outflow obstruction (e.g., aortic stenosis, hypertrophic
obstructive cardiomyopathy), or those with the rare syndrome of multiple system atrophy manifesting
as severely impaired autonomic control of blood pressure.
VIAGRA potentiates the hypotensive effect of nitrates (see section 4.3).
3
Serious cardiovascular events, including myocardial infarction, unstable angina, sudden cardiac death,
ventricular arrhythmia, cerebrovascular haemorrhage, transient ischaemic attack, hypertension and
hypotension have been reported post-marketing in temporal association with the use of VIAGRA.
Most, but not all, of these patients had pre-existing cardiovascular risk factors. Many events were
reported to occur during or shortly after sexual intercourse and a few were reported to occur shortly
after the use of VIAGRA without sexual activity. It is not possible to determine whether these events
are related directly to these factors or to other factors.
Agents for the treatment of erectile dysfunction, including sildenafil, should be used with caution in
patients with anatomical deformation of the penis (such as angulation, cavernosal fibrosis or
Peyronie’s disease), or in patients who have conditions which may predispose them to priapism (such
as sickle cell anaemia, multiple myeloma or leukaemia).
The safety and efficacy of combinations of sildenafil with other treatments for erectile dysfunction
have not been studied. Therefore the use of such combinations is not recommended.
Visual defects and cases of non-arteritic anterior ischaemic optic neuropathy have been reported in
connection with the intake of sildenafil and other PDE5 inhibitors. The patient should be advised that
in case of sudden visual defect, he should stop taking VIAGRA and consult a physician immediately
(see section 4.3).
Co-administration of sildenafil with ritonavir is not advised (see section 4.5).
Caution is advised when sildenafil is administered to patients taking an alpha-blocker, as the
coadministration may lead to symptomatic hypotension in a few susceptible individuals (see section
4.5). This is most likely to occur within 4 hours post sildenafil dosing. In order to minimise the
potential for developing postural hypotension, patients should be hemodynamically stable on alpha-
blocker therapy prior to initiating sildenafil treatment. Initiation of sildenafil at a dose of 25 mg
should be considered (see section 4.2). In addition, physicians should advise patients what to do in the
event of postural hypotensive symptoms.
Studies with human platelets indicate that sildenafil potentiates the antiaggregatory effect of sodium
nitroprusside
in vitro
. There is no safety information on the administration of sildenafil to patients
with bleeding disorders or active peptic ulceration. Therefore sildenafil should be administered to
these patients only after careful benefit-risk assessment.
The film coating of the VIAGRA tablet contains lactose. VIAGRA should not be administered to men
with rare hereditary problems of galactose intolerance, Lapp lactase deficiency or glucose-galactose
malabsorption.
VIAGRA is not indicated for use by women.
Effects of other medicinal products on sildenafil
In vitro studies:
Sildenafil metabolism is principally mediated by the cytochrome P450 (CYP) isoforms 3A4 (major
route) and 2C9 (minor route). Therefore, inhibitors of these isoenzymes may reduce sildenafil
clearance.
In vivo studies:
Population pharmacokinetic analysis of clinical trial data indicated a reduction in sildenafil clearance
when co-administered with CYP3A4 inhibitors (such as ketoconazole, erythromycin, cimetidine).
Although no increased incidence of adverse events was observed in these patients, when sildenafil is
administered concomitantly with CYP3A4 inhibitors, a starting dose of 25 mg should be considered.
4
Co-administration of the HIV protease inhibitor ritonavir, which is a
highly potent P450 inhibitor, at
steady state (500 mg twice daily) with sildenafil (100 mg single dose) resulted in a 300% (4-fold)
increase in sildenafil C
max
and a 1,000% (11-fold) increase in sildenafil plasma AUC. At 24 hours, the
plasma levels of sildenafil were still approximately 200 ng/ml, compared to approximately 5 ng/ml
when sildenafil was administered alone. This is consistent with ritonavir’s marked effects on a broad
range of P450 substrates. Sildenafil had no effect on ritonavir pharmacokinetics. Based on these
pharmacokinetic results co-administration of sildenafil with ritonavir is not advised (see section 4.4)
and in any event the maximum dose of sildenafil should under no circumstances exceed 25 mg within
48 hours.
Co-administration of the HIV protease inhibitor saquinavir, a CYP3A4 inhibitor, at steady state
(1200 mg three times a day) with sildenafil (100 mg single dose) resulted in a 140% increase in
sildenafil C
max
and a 210% increase in sildenafil AUC. Sildenafil had no effect on saquinavir
pharmacokinetics (see section 4.2). Stronger CYP3A4 inhibitors such as ketoconazole and
itraconazole would be expected to have greater effects.
When a single 100 mg dose of sildenafil was administered with erythromycin, a specific CYP3A4
inhibitor, at steady state (500 mg twice daily. for 5 days), there was a 182% increase in sildenafil
systemic exposure (AUC). In normal healthy male volunteers, there was no evidence of an effect of
azithromycin (500 mg daily for 3 days) on the AUC, C
max
, t
max
, elimination rate constant, or
subsequent half-life of sildenafil or its principal circulating metabolite. Cimetidine (800 mg), a
cytochrome P450 inhibitor and non-specific CYP3A4 inhibitor, caused a 56% increase in plasma
sildenafil concentrations when co-administered with sildenafil (50 mg) to healthy volunteers.
Grapefruit juice is a weak inhibitor of CYP3A4 gut wall metabolism and may give rise to modest
increases in plasma levels of sildenafil.
Single doses of antacid (magnesium hydroxide/aluminium hydroxide) did not affect the
bioavailability of sildenafil.
Although specific interaction studies were not conducted for all medicinal products, population
pharmacokinetic analysis showed no effect of concomitant medication on sildenafil pharmacokinetics
when grouped as CYP2C9 inhibitors (such as tolbutamide, warfarin, phenytoin), CYP2D6 inhibitors
(such as selective serotonin reuptake inhibitors, tricyclic antidepressants), thiazide and related
diuretics, loop and potassium sparing diuretics, angiotensin converting enzyme inhibitors, calcium
channel blockers, beta-adrenoreceptor antagonists or inducers of CYP450 metabolism (such as
rifampicin, barbiturates).
Nicorandil is a hybrid of potassium channel activator and nitrate. Due to the nitrate component it has
the potential to have serious interaction with sildenafil.
Effects of sildenafil on other medicinal products
In vitro studies:
Sildenafil is a weak inhibitor of the cytochrome P450 isoforms 1A2, 2C9, 2C19, 2D6, 2E1 and 3A4
(IC
50
> 150 μM). Given sildenafil peak plasma concentrations of approximately 1 μM after
recommended doses, it is unlikely that VIAGRA will alter the clearance of substrates of these
isoenzymes.
There are no data on the interaction of sildenafil and non-specific phosphodiesterase inhibitors such
as theophylline or dipyridamole.
In vivo studies:
Consistent with its known effects on the nitric oxide/cGMP pathway (see section 5.1), sildenafil was
shown to potentiate the hypotensive effects of nitrates, and its co-administration with nitric oxide
donors or nitrates in any form is therefore contraindicated (see section 4.3).
5
Concomitant administration of sildenafil to patients taking alpha-blocker therapy may lead to
symptomatic hypotension in a few susceptible individuals. This is most likely to occur within 4 hours
post sildenafil dosing (see sections 4.2 and 4.4). In three specific drug-drug interaction studies, the
alpha-blocker doxazosin (4 mg and 8 mg) and sildenafil (25 mg, 50 mg, or 100 mg) were administered
simultaneously to patients with benign prostatic hyperplasia (BPH) stabilized on doxazosin therapy.
In these study populations, mean additional reductions of supine blood pressure of 7/7 mmHg, 9/5
mmHg, and 8/4 mmHg, and mean additional reductions of standing blood pressure of 6/6 mmHg, 11/4
mmHg, and 4/5 mmHg, respectively, were observed. When sildenafil and doxazosin were
administered simultaneously to patients stabilized on doxazosin therapy, there were infrequent reports
of patients who experienced symptomatic postural hypotension. These reports included dizziness and
light-headedness, but not syncope.
No significant interactions were shown when sildenafil (50 mg) was co-administered with
tolbutamide (250 mg) or warfarin (40 mg), both of which are metabolised by CYP2C9.
Sildenafil (50 mg) did not potentiate the increase in bleeding time caused by acetyl salicylic acid
(150 mg).
Sildenafil (50 mg) did not potentiate the hypotensive effects of alcohol in healthy volunteers with
mean maximum blood alcohol levels of 80 mg/dl.
Pooling of the following classes of antihypertensive medication: diuretics, beta-blockers, ACE
inhibitors, angiotensin II antagonists, antihypertensive medicinal products (vasodilator and centrally-
acting), adrenergic neurone blockers, calcium channel blockers and alpha-adrenoceptor blockers,
showed no difference in the side effect profile in patients taking sildenafil compared to placebo
treatment. In a specific interaction study, where sildenafil (100 mg) was co-administered with
amlodipine in hypertensive patients, there was an additional reduction on supine systolic blood
pressure of 8 mmHg. The corresponding additional reduction in supine diastolic blood pressure was
7 mmHg. These additional blood pressure reductions were of a similar magnitude to those seen when
sildenafil was administered alone to healthy volunteers (see section 5.1).
Sildenafil (100 mg) did not affect the steady state pharmacokinetics of the HIV protease inhibitors,
saquinavir and ritonavir, both of which are CYP3A4 substrates.
VIAGRA is not indicated for use by women.
No relevant adverse effects were found in reproduction studies in rats and rabbits following oral
administration of sildenafil.
No studies on the effects on the ability to drive and use machines have been performed.
As dizziness and altered vision were reported in clinical trials with sildenafil, patients should be
aware of how they react to VIAGRA, before driving or operating machinery.
The safety profile of VIAGRA is based on 8691 patients who received the recommended dosing
regimen in 67 placebo-controlled clinical studies. The most commonly reported adverse reactions in
clinical studies among sildenafil treated patients were headache, flushing, dyspepsia, visual disorders,
nasal congestion, dizziness and visual colour distortion.
6
Adverse reactions from post-marketing surveillance has been gathered covering an estimated period
>9 years. Because not all adverse reactions are reported to the Marketing Authorisation Holder and
included in the safety database, the frequencies of these reactions cannot be reliably determined.
In the table below all medically important adverse reactions, which occurred in clinical trials at an
incidence greater than placebo are listed by system organ class and frequency (very common (≥1/10),
common (≥1/100 to <1/10), uncommon (≥1/1,000 to <1/100), rare (≥1/10,000 to <1/1,000).
In addition, the frequency of medically important adverse reactions reported from post-marketing
experience is included as not known.
Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness.
Table 1: Medically important adverse reactions reported at an incidence greater than placebo
in controlled clinical studies and medically important adverse reactions reported through post-
marketing surveillance
System Organ Class
Immune system disorders
Rare
Hypersensitivity reactions
Nervous system disorders
Very common
Headache
Common
Dizziness
Uncommon
Somnolence, Hypoaesthesia
Rare
Cerebrovascular accident, Syncope
Not known
Transient ischaemic attack, Seizure, Seizure recurrence
Eye disorders
Common
Visual disorders, Visual colour distortion
Uncommon
Conjunctival disorders, Eye Disorders, Lacrimation
Disorders, Other Eye Disorders
Not known
Non-arteritic anterior ischaemic optic neuropathy
(NAION), Retinal vascular occlusion, Visual field defect
Ear and labyrinth disorders
Uncommon
Vertigo, Tinnitus
Rare
Deafness*
Vascular disorders
Common
Flushing
Rare
Hypertension, Hypotension
Cardiac disorders
Uncommon Palpitations, Tachycardia
Rare Myocardial infarction, Atrial fibrillation
Not known Ventricular arrhythmia, Unstable angina, Sudden cardiac
death
Respiratory, thoracic and mediastinal disorders
Common
Nasal congestion
Rare
Epistaxis
Gastrointestinal disorders
Common Dyspepsia
Uncommon Vomiting, Nausea, Dry mouth
Skin, subcutaneous and soft tissue disorders
Uncommon Skin rash
Not known Steven Johnson Syndrome (SJS), Toxic Epidermal
Necrolysis (TEN)
Musculoskeletal and connective tissue disorders
Uncommon
Myalgia
7
System Organ Class Adverse Reactions
Reproductive system and breast disorders
Not known Priapism, Prolonged erection
General disorders and administration site conditions
Uncommon
Chest pain, Fatigue
Investigations
Uncommon
Heart rate increased
* Ear disorders: Sudden deafness. Sudden decrease or loss of hearing has been reported in a small
number of post-marketing and clinical trials cases with the use of all PDE5 inhibitors, including
sildenafil.
In single dose volunteer studies of doses up to 800 mg, adverse reactions were similar to those seen at
lower doses, but the incidence rates and severities were increased. Doses of 200 mg did not result in
increased efficacy but the incidence of adverse reactions (headache, flushing, dizziness, dyspepsia,
nasal congestion, altered vision) was increased.
In cases of overdose, standard supportive measures should be adopted as required. Renal dialysis is
not expected to accelerate clearance as sildenafil is highly bound to plasma proteins and not
eliminated in the urine.
5.
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Drugs used in erectile dysfunction. ATC Code: G04B E03.
Sildenafil is an oral therapy for erectile dysfunction. In the natural setting, i.e. with sexual stimulation,
it restores impaired erectile function by increasing blood flow to the penis.
The physiological mechanism responsible for erection of the penis involves the release of nitric oxide
(NO) in the corpus cavernosum during sexual stimulation. Nitric oxide then activates the enzyme
guanylate cyclase, which results in increased levels of cyclic guanosine monophosphate (cGMP),
producing smooth muscle relaxation in the corpus cavernosum and allowing inflow of blood.
Sildenafil is a potent and selective inhibitor of cGMP specific phosphodiesterase type 5 (PDE5) in the
corpus cavernosum, where PDE5 is responsible for degradation of cGMP. Sildenafil has a peripheral
site of action on erections. Sildenafil has no direct relaxant effect on isolated human corpus
cavernosum but potently enhances the relaxant effect of NO on this tissue. When the NO/cGMP
pathway is activated, as occurs with sexual stimulation, inhibition of PDE5 by sildenafil results in
increased corpus cavernosum levels of cGMP. Therefore sexual stimulation is required in order for
sildenafil to produce its intended beneficial pharmacological effects.
Studies
in vitro
have shown that sildenafil is selective for PDE5, which is involved in the erection
process. Its effect is more potent on PDE5 than on other known phosphodiesterases. There is a 10-fold
selectivity over PDE6 which is involved in the phototransduction pathway in the retina. At maximum
recommended doses, there is an 80-fold selectivity over PDE1, and over 700-fold over PDE2, 3, 4, 7,
8, 9, 10 and 11. In particular, sildenafil has greater than 4,000-fold selectivity for PDE5 over PDE3,
the cAMP-specific phosphodiesterase isoform involved in the control of cardiac contractility.
8
Two clinical studies were specifically designed to assess the time window after dosing during which
sildenafil could produce an erection in response to sexual stimulation. In a penile plethysmography
(RigiScan) study of fasted patients, the median time to onset for those who obtained erections of 60%
rigidity (sufficient for sexual intercourse) was 25 minutes (range 12-37 minutes) on sildenafil. In a
separate RigiScan study, sildenafil was still able to produce an erection in response to sexual
stimulation 4-5 hours post-dose.
Sildenafil causes mild and transient decreases in blood pressure which, in the majority of cases, do
not translate into clinical effects. The mean maximum decreases in supine systolic blood pressure
following 100 mg oral dosing of sildenafil was 8.4 mmHg. The corresponding change in supine
diastolic blood pressure was 5.5 mmHg. These decreases in blood pressure are consistent with the
vasodilatory effects of sildenafil, probably due to increased cGMP levels in vascular smooth muscle.
Single oral doses of sildenafil up to 100 mg in healthy volunteers produced no clinically relevant
effects on ECG.
In a study of the hemodynamic effects of a single oral 100 mg dose of sildenafil in 14 patients with
severe coronary artery disease (CAD) (>70% stenosis of at least one coronary artery), the mean
resting systolic and diastolic blood pressures decreased by 7% and 6% respectively compared to
baseline. Mean pulmonary systolic blood pressure decreased by 9%. Sildenafil showed no effect on
cardiac output, and did not impair blood flow through the stenosed coronary arteries.
No clinical relevant differences were demonstrated in time to limiting angina for sildenafil when
compared with placebo in a double blind, placebo controlled exercise stress trial in 144 patients with
erectile dysfunction and chronic stable angina, who were taking on a regular basis anti-anginal
medications (except nitrates).
Mild and transient differences in colour discrimination (blue/green) were detected in some subjects
using the Farnsworth-Munsell 100 hue test at 1 hour following a 100 mg dose, with no effects evident
after 2 hours post-dose. The postulated mechanism for this change in colour discrimination is related
to inhibition of PDE6, which is involved in the phototransduction cascade of the retina. Sildenafil has
no effect on visual acuity or contrast sensitivity. In a small size placebo-controlled study of patients
with documented early age-related macular degeneration (n=9), sildenafil (single dose, 100 mg)
demonstrated no significant changes in visual tests conducted (visual acuity, Amsler grid, colour
discrimination simulated traffic light, Humphrey perimeter and photostress).
There was no effect on sperm motility or morphology after single 100 mg oral doses of sildenafil in
healthy volunteers.
Further information on clinical trials
In clinical trials sildenafil was administered to more than 8000 patients aged 19-87. The following
patient groups were represented: elderly (19.9%), patients with hypertension (30.9%), diabetes
mellitus (20.3%), ischaemic heart disease (5.8%), hyperlipidaemia (19.8%), spinal cord injury (0.6%),
depression (5.2%), transurethral resection of the prostate (3.7%), radical prostatectomy (3.3%). The
following groups were not well represented or excluded from clinical trials: patients with pelvic
surgery, patients post-radiotherapy, patients with severe renal or hepatic impairment and patients with
certain cardiovascular conditions (see section 4.3).
In fixed dose studies, the proportions of patients reporting that treatment improved their erections
were 62% (25 mg), 74% (50 mg) and 82% (100 mg) compared to 25% on placebo. In controlled
clinical trials, the discontinuation rate due to sildenafil was low and similar to placebo.
Across all trials, the proportion of patients reporting improvement on sildenafil were as follows:
psychogenic erectile dysfunction (84%), mixed erectile dysfunction (77%), organic erectile
dysfunction (68%), elderly (67%), diabetes mellitus (59%), ischaemic heart disease (69%),
hypertension (68%), TURP (61%), radical prostatectomy (43%), spinal cord injury (83%), depression
(75%). The safety and efficacy of sildenafil was maintained in long-term studies.
9
5.2 Pharmacokinetic properties
Absorption:
Sildenafil is rapidly absorbed. Maximum observed plasma concentrations are reached within 30 to
120 minutes (median 60 minutes) of oral dosing in the fasted state. The mean absolute oral
bioavailability is 41% (range 25-63%). After oral dosing of sildenafil AUC and C
max
increase in
proportion with dose over the recommended dose range (25-100 mg).
When sildenafil is taken with food, the rate of absorption is reduced with a mean delay in t
max
of 60
minutes and a mean reduction in C
max
of 29%.
Distribution:
The mean steady state volume of distribution (V
d
) for sildenafil is 105 l, indicating distribution into
the tissues. After a single oral dose of 100 mg, the mean maximum total plasma concentration of
sildenafil is approximately 440 ng/ml (CV 40%). Since sildenafil (and its major circulating N-
desmethyl metabolite) is 96% bound to plasma proteins, this results in the mean maximum free
plasma concentration for sildenafil of 18 ng/ml (38 nM). Protein binding is independent of total drug
concentrations.
In healthy volunteers receiving sildenafil (100 mg single dose), less than 0.0002% (average 188 ng) of
the administered dose was present in ejaculate 90 minutes after dosing.
Metabolism:
Sildenafil is cleared predominantly by the CYP3A4 (major route) and CYP2C9 (minor route) hepatic
microsomal isoenzymes. The major circulating metabolite results from N-demethylation of sildenafil.
This metabolite has a phosphodiesterase selectivity profile similar to sildenafil and an
in vitro
potency
for PDE5 approximately 50% that of the parent drug. Plasma concentrations of this metabolite are
approximately 40% of those seen for sildenafil. The N-desmethyl metabolite is further metabolised,
with a terminal half-life of approximately 4 h.
Elimination:
The total body clearance of sildenafil is 41 l/h with a resultant terminal phase half-life of 3-5 h. After
either oral or intravenous administration, sildenafil is excreted as metabolites predominantly in the
faeces (approximately 80% of administered oral dose) and to a lesser extent in the urine
(approximately 13% of administered oral dose).
Pharmacokinetics in special patient groups
Elderly:
Healthy elderly volunteers (65 years or over) had a reduced clearance of sildenafil, resulting in
approximately 90% higher plasma concentrations of sildenafil and the active N-desmethyl metabolite
compared to those seen in healthy younger volunteers (18-45 years). Due to age-differences in
plasma protein binding, the corresponding increase in free sildenafil plasma concentration was
approximately 40%.
Renal insufficiency:
In volunteers with mild to moderate renal impairment (creatinine clearance = 30-80 ml/min), the
pharmacokinetics of sildenafil were not altered after receiving a 50 mg single oral dose. The mean
AUC and C
max
of the N-desmethyl metabolite increased 126% and 73% respectively, compared to
age-matched volunteers with no renal impairment. However, due to high inter-subject variability,
these differences were not statistically significant. In volunteers with severe renal impairment
(creatinine clearance <30 ml/min), sildenafil clearance was reduced, resulting in mean increases in
AUC and C
max
of 100% and 88% respectively compared to age-matched volunteers with no renal
impairment. In addition, N-desmethyl metabolite AUC and C
max
values were significantly increased
79% and 200% respectively.
10
Hepatic insufficiency:
In volunteers with mild to moderate hepatic cirrhosis (Child-Pugh A and B) sildenafil clearance was
reduced, resulting in increases in AUC (84%) and C
max
(47%) compared to age-matched volunteers
with no hepatic impairment. The pharmacokinetics of sildenafil in patients with severely impaired
hepatic function have not been studied.
5.3 Preclinical safety data
Non-clinical data revealed no special hazard for humans based on conventional studies of safety
pharmacology, repeated dose toxicity, genotoxicity, carcinogenic potential, and toxicity to
reproduction.
6.
6.1 List of excipients
Tablet core:
microcrystalline cellulose
calcium hydrogen phosphate (anhydrous)
croscarmellose sodium
magnesium stearate
Film coat:
hypromellose
titanium dioxide (E171)
lactose
triacetin
indigo carmine aluminium lake (E132)
6.2 Incompatibilities
Not applicable.
6.3 Shelf life
5 years.
6.4 Special precautions for storage
Do not store above 30
o
C.
Store in the original package, in order to protect from moisture.
6.5 Nature and content of container
PVC/Aluminium foil blisters in cartons of 2, 4, 8 or 12 tablets.
Not all pack sizes may be marketed.
6.6 Special precautions for disposal and other handling
No special requirements.
11
7.
Pfizer Limited
Sandwich
Kent CT13 9NJ
United Kingdom
EU/1/98/077/002-004
EU/1/98/077/013
9.
Date of first authorisation: 14 September 1998
Date of last renewal: 26 August 2008
Detailed information on this medicinal product is available on the website of the European Medicines
Agency
http://www.ema.europa.eu/
12
1.
VIAGRA 50 mg film-coated tablets
2.
Each tablet contains 50 mg of sildenafil (as citrate)
Excipient: Lactose.
For a full list of excipients, see section 6.1.
3.
Film-coated tablet.
Blue, rounded diamond-shaped tablets, marked “PFIZER” on one side and “VGR 50” on the other.
4.
Treatment of men with erectile dysfunction, which is the inability to achieve or maintain a penile
erection sufficient for satisfactory sexual performance.
In order for VIAGRA to be effective, sexual stimulation is required.
For oral use.
Use in adults:
The recommended dose is 50 mg taken as needed approximately one hour before sexual activity.
Based on efficacy and toleration, the dose may be increased to 100 mg or decreased to 25 mg. The
maximum recommended dose is 100 mg. The maximum recommended dosing frequency is once per
day. If VIAGRA is taken with food, the onset of activity may be delayed compared to the fasted state
(see section 5.2).
Use in the elderly:
Dosage adjustments are not required in elderly patients.
Use in patients with impaired renal function:
The dosing recommendations described in ‘Use in adults’ apply to patients with mild to moderate
renal impairment (creatinine clearance = 30 - 80 ml/min).
Since sildenafil clearance is reduced in patients with severe renal impairment (creatinine clearance
<30 ml/min) a 25 mg dose should be considered. Based on efficacy and toleration, the dose may be
increased to 50 mg and 100 mg.
Use in patients with impaired hepatic function:
Since sildenafil clearance is reduced in patients with hepatic impairment (e.g. cirrhosis) a 25 mg dose
should be considered. Based on efficacy and toleration, the dose may be increased to 50 mg and
100 mg.
13
Use in children and adolescents:
VIAGRA is not indicated for individuals below 18 years of age.
Use in patients using other medicines:
With the exception of ritonavir for which co-administration with sildenafil is not advised (see section
4.4) a starting dose of 25 mg should be considered in patients receiving concomitant treatment with
CYP3A4 inhibitors (see section 4.5).
In order to minimise the potential for developing postural hypotension, patients should be stable on
alpha-blocker therapy prior to initiating sildenafil treatment. In addition, initiation of sildenafil at a
dose of 25 mg should be considered (see sections 4.4 and 4.5).
Hypersensitivity to the active substance or to any of the excipients.
Consistent with its known effects on the nitric oxide/cyclic guanosine monophosphate (cGMP)
pathway (see section 5.1), sildenafil was shown to potentiate the hypotensive effects of nitrates, and
its co-administration with nitric oxide donors (such as amyl nitrite) or nitrates in any form is therefore
contraindicated.
Agents for the treatment of erectile dysfunction, including sildenafil, should not be used in men for
whom sexual activity is inadvisable (e.g. patients with severe cardiovascular disorders such as
unstable angina or severe cardiac failure).
VIAGRA is contraindicated in patients who have loss of vision in one eye because of non-arteritic
anterior ischaemic optic neuropathy (NAION), regardless of whether this episode was in connection
or not with previous PDE5 inhibitor exposure (see section 4.4).
The safety of sildenafil has not been studied in the following sub-groups of patients and its use is
therefore contraindicated : severe hepatic impairment, hypotension (blood pressure <90/50 mmHg),
recent history of stroke or myocardial infarction and known hereditary degenerative retinal disorders
such as
retinitis pigmentosa
(a minority of these patients have genetic disorders of retinal
phosphodiesterases)
.
A medical history and physical examination should be undertaken to diagnose erectile dysfunction
and determine potential underlying causes, before pharmacological treatment is considered.
Prior to initiating any treatment for erectile dysfunction, physicians should consider the
cardiovascular status of their patients, since there is a degree of cardiac risk associated with sexual
activity. Sildenafil has vasodilator properties, resulting in mild and transient decreases in blood
pressure (see section 5.1). Prior to prescribing sildenafil, physicians should carefully consider whether
their patients with certain underlying conditions could be adversely affected by such vasodilatory
effects, especially in combination with sexual activity. Patients with increased susceptibility to
vasodilators include those with left ventricular outflow obstruction (e.g., aortic stenosis, hypertrophic
obstructive cardiomyopathy), or those with the rare syndrome of multiple system atrophy manifesting
as severely impaired autonomic control of blood pressure.
VIAGRA potentiates the hypotensive effect of nitrates (see section 4.3).
Serious cardiovascular events, including myocardial infarction, unstable angina, sudden cardiac death,
ventricular arrhythmia, cerebrovascular haemorrhage, transient ischaemic attack, hypertension and
hypotension have been reported post-marketing in temporal association with the use of VIAGRA.
Most, but not all, of these patients had pre-existing cardiovascular risk factors. Many events were
reported to occur during or shortly after sexual intercourse and a few were reported to occur shortly
14
after the use of VIAGRA without sexual activity. It is not possible to determine whether these events
are related directly to these factors or to other factors.
Agents for the treatment of erectile dysfunction, including sildenafil, should be used with caution in
patients with anatomical deformation of the penis (such as angulation, cavernosal fibrosis or
Peyronie’s disease), or in patients who have conditions which may predispose them to priapism (such
as sickle cell anaemia, multiple myeloma or leukaemia).
The safety and efficacy of combinations of sildenafil with other treatments for erectile dysfunction
have not been studied. Therefore the use of such combinations is not recommended.
Visual defects and cases of non-arteritic anterior ischaemic optic neuropathy have been reported in
connection with the intake of sildenafil and other PDE5 inhibitors. The patient should be advised that
in case of sudden visual defect, he should stop taking VIAGRA and consult a physician immediately
(see section 4.3).
Co-administration of sildenafil with ritonavir is not advised (see section 4.5).
Caution is advised when sildenafil is administered to patients taking an alpha-blocker, as the
coadministration may lead to symptomatic hypotension in a few susceptible individuals (see section
4.5). This is most likely to occur within 4 hours post sildenafil dosing. In order to minimise the
potential for developing postural hypotension, patients should be hemodynamically stable on alpha-
blocker therapy prior to initiating sildenafil treatment. Initiation of sildenafil at a dose of 25 mg
should be considered (see section 4.2). In addition, physicians should advise patients what to do in the
event of postural hypotensive symptoms.
Studies with human platelets indicate that sildenafil potentiates the antiaggregatory effect of sodium
nitroprusside
in vitro
. There is no safety information on the administration of sildenafil to patients
with bleeding disorders or active peptic ulceration. Therefore sildenafil should be administered to
these patients only after careful benefit-risk assessment.
The film coating of the VIAGRA tablet contains lactose. VIAGRA should not be administered to men
with rare hereditary problems of galactose intolerance, Lapp lactase deficiency or glucose-galactose
malabsorption.
VIAGRA is not indicated for use by women.
Effects of other medicinal products on sildenafil
In vitro
studies
:
Sildenafil metabolism is principally mediated by the cytochrome P450 (CYP) isoforms 3A4 (major
route) and 2C9 (minor route). Therefore, inhibitors of these isoenzymes may reduce sildenafil
clearance.
In vivo studies:
Population pharmacokinetic analysis of clinical trial data indicated a reduction in sildenafil clearance
when co-administered with CYP3A4 inhibitors (such as ketoconazole, erythromycin, cimetidine).
Although no increased incidence of adverse events was observed in these patients, when sildenafil is
administered concomitantly with CYP3A4 inhibitors, a starting dose of 25 mg should be considered.
Co-administration of the HIV protease inhibitor ritonavir, which is a
highly potent P450 inhibitor, at
steady state (500 mg twice daily) with sildenafil (100 mg single dose) resulted in a 300% (4-fold)
increase in sildenafil C
max
and a 1,000% (11-fold) increase in sildenafil plasma AUC. At 24 hours, the
plasma levels of sildenafil were still approximately 200 ng/ml, compared to approximately 5 ng/ml
when sildenafil was administered alone. This is consistent with ritonavir’s marked effects on a broad
15
range of P450 substrates. Sildenafil had no effect on ritonavir pharmacokinetics. Based on these
pharmacokinetic results co-administration of sildenafil with ritonavir is not advised (see section 4.4)
and in any event the maximum dose of sildenafil should under no circumstances exceed 25 mg within
48 hours.
Co-administration of the HIV protease inhibitor saquinavir, a CYP3A4 inhibitor, at steady state
(1200 mg three times a day) with sildenafil (100 mg single dose) resulted in a 140% increase in
sildenafil C
max
and a 210% increase in sildenafil AUC. Sildenafil had no effect on saquinavir
pharmacokinetics (see section 4.2). Stronger CYP3A4 inhibitors such as ketoconazole and
itraconazole would be expected to have greater effects.
When a single 100 mg dose of sildenafil was administered with erythromycin, a specific CYP3A4
inhibitor, at steady state (500 mg twice daily for 5 days), there was a 182% increase in sildenafil
systemic exposure (AUC). In normal healthy male volunteers, there was no evidence of an effect of
azithromycin (500 mg daily for 3 days) on the AUC, C
max
, t
max
, elimination rate constant, or
subsequent half-life of sildenafil or its principal circulating metabolite. Cimetidine (800 mg), a
cytochrome P450 inhibitor and non-specific CYP3A4 inhibitor, caused a 56% increase in plasma
sildenafil concentrations when co-administered with sildenafil (50 mg) to healthy volunteers.
Grapefruit juice is a weak inhibitor of CYP3A4 gut wall metabolism and may give rise to modest
increases in plasma levels of sildenafil.
Single doses of antacid (magnesium hydroxide/aluminium hydroxide) did not affect the
bioavailability of sildenafil.
Although specific interaction studies were not conducted for all medicinal products, population
pharmacokinetic analysis showed no effect of concomitant medication on sildenafil pharmacokinetics
when grouped as CYP2C9 inhibitors (such as tolbutamide, warfarin, phenytoin), CYP2D6 inhibitors
(such as selective serotonin reuptake inhibitors, tricyclic antidepressants), thiazide and related
diuretics, loop and potassium sparing diuretics, angiotensin converting enzyme inhibitors, calcium
channel blockers, beta-adrenoreceptor antagonists or inducers of CYP450 metabolism (such as
rifampicin, barbiturates).
Nicorandil is a hybrid of potassium channel activator and nitrate. Due to the nitrate component it has
the potential to have serious interaction with sildenafil.
Effects of sildenafil on other medicinal products
In vitro studies:
Sildenafil is a weak inhibitor of the cytochrome P450 isoforms 1A2, 2C9, 2C19, 2D6, 2E1 and 3A4
(IC
50
>150 μM). Given sildenafil peak plasma concentrations of approximately 1 μM after
recommended doses, it is unlikely that VIAGRA will alter the clearance of substrates of these
isoenzymes.
There are no data on the interaction of sildenafil and non-specific phosphodiesterase inhibitors such
as theophylline or dipyridamole.
In vivo studies:
Consistent with its known effects on the nitric oxide/cGMP pathway (see section 5.1), sildenafil was
shown to potentiate the hypotensive effects of nitrates, and its co-administration with nitric oxide
donors or nitrates in any form is therefore contraindicated (see section 4.3).
Concomitant administration of sildenafil to patients taking alpha-blocker therapy may lead to
symptomatic hypotension in a few susceptible individuals. This is most likely to occur within 4 hours
post sildenafil dosing (see sections 4.2 and 4.4). In three specific drug-drug interaction studies, the
alpha-blocker doxazosin (4 mg and 8 mg) and sildenafil (25 mg, 50 mg, or 100 mg) were administered
16
simultaneously to patients with benign prostatic hyperplasia (BPH) stabilized on doxazosin therapy.
In these study populations, mean additional reductions of supine blood pressure of 7/7 mmHg, 9/5
mmHg, and 8/4 mmHg, and mean additional reductions of standing blood pressure of 6/6 mmHg, 11/4
mmHg, and 4/5 mmHg, respectively, were observed. When sildenafil and doxazosin were
administered simultaneously to patients stabilized on doxazosin therapy, there were infrequent reports
of patients who experienced symptomatic postural hypotension. These reports included dizziness and
light-headedness, but not syncope.
No significant interactions were shown when sildenafil (50 mg) was co-administered with
tolbutamide (250 mg) or warfarin (40 mg), both of which are metabolised by CYP2C9.
Sildenafil (50 mg) did not potentiate the increase in bleeding time caused by acetyl salicylic acid
(150 mg).
Sildenafil (50 mg) did not potentiate the hypotensive effects of alcohol in healthy volunteers with
mean maximum blood alcohol levels of 80 mg/dl.
Pooling of the following classes of antihypertensive medication: diuretics, beta-blockers, ACE
inhibitors, angiotensin II antagonists, antihypertensive medicinal products (vasodilator and centrally-
acting), adrenergic neurone blockers, calcium channel blockers and alpha-adrenoceptor blockers,
showed no difference in the side effect profile in patients taking sildenafil compared to placebo
treatment. In a specific interaction study, where sildenafil (100 mg) was co-administered with
amlodipine in hypertensive patients, there was an additional reduction on supine systolic blood
pressure of 8 mmHg. The corresponding additional reduction in supine diastolic blood pressure was
7 mmHg. These additional blood pressure reductions were of a similar magnitude to those seen when
sildenafil was administered alone to healthy volunteers (see section 5.1).
Sildenafil (100 mg) did not affect the steady state pharmacokinetics of the HIV protease inhibitors,
saquinavir and ritonavir, both of which are CYP3A4 substrates.
VIAGRA is not indicated for use by women.
No relevant adverse effects were found in reproduction studies in rats and rabbits following oral
administration of sildenafil.
No studies on the effects on the ability to drive and use machines have been performed.
As dizziness and altered vision were reported in clinical trials with sildenafil, patients should be
aware of how they react to VIAGRA, before driving or operating machinery.
The safety profile of VIAGRA is based on 8691 patients who received the recommended dosing
regimen in 67 placebo-controlled clinical studies. The most commonly reported adverse reactions in
clinical studies among sildenafil treated patients were headache, flushing, dyspepsia, visual disorders,
nasal congestion, dizziness and visual colour distortion.
Adverse reactions from post-marketing surveillance has been gathered covering an estimated period
>9 years. Because not all adverse reactions are reported to the Marketing Authorisation Holder and
included in the safety database, the frequencies of these reactions cannot be reliably determined.
In the table below all medically important adverse reactions, which occurred in clinical trials at an
incidence greater than placebo are listed by system organ class and frequency (very common (≥1/10),
17
common (≥1/100 to <1/10), uncommon (≥1/1,000 to <1/100), rare (≥1/10,000 to <1/1,000). In
addition, the frequency of medically important adverse reactions reported from post-marketing
experience is included as not known. Within each frequency grouping, undesirable effects are
presented in order of decreasing seriousness.
Table 1: Medically important adverse reactions reported at an incidence greater than placebo
in controlled clinical studies and medically important adverse reactions reported through post-
marketing surveillance
System Organ Class
Immune system disorders
Rare
Hypersensitivity reactions
Nervous system disorders
Very common
Headache
Common
Dizziness
Uncommon
Somnolence, Hypoaesthesia
Rare
Cerebrovascular accident, Syncope
Not known
Transient ischaemic attack, Seizure, Seizure recurrence
Eye disorders
Common
Visual disorders, Visual colour distortion
Uncommon
Conjunctival disorders, Eye Disorders, Lacrimation
Disorders, Other Eye Disorders
Not known
Non-arteritic anterior ischaemic optic neuropathy
(NAION), Retinal vascular occlusion, Visual field defect
Ear and labyrinth disorders
Uncommon
Vertigo, Tinnitus
Rare
Deafness*
Vascular disorders
Common
Flushing
Rare
Hypertension, Hypotension
Cardiac disorders
Uncommon Palpitations, Tachycardia
Rare Myocardial infarction, Atrial fibrillation
Not known Ventricular arrhythmia, Unstable angina, Sudden cardiac
death
Respiratory, thoracic and mediastinal disorders
Common
Nasal congestion
Rare
Epistaxis
Gastrointestinal disorders
Common Dyspepsia
Uncommon Vomiting, Nausea, Dry mouth
Skin, subcutaneous and soft tissue disorders
Uncommon Skin rash
Not known Steven Johnson Syndrome (SJS), Toxic Epidermal
Necrolysis (TEN)
Musculoskeletal and connective tissue disorders
Uncommon Myalgia
Reproductive system and breast disorders
Not known Priapism, Prolonged erection
General disorders and administration site conditions
Uncommon
Chest pain, Fatigue
Investigations
Uncommon
Heart rate increased
18
* Ear disorders: Sudden deafness. Sudden decrease or loss of hearing has been reported in a small
number of post-marketing and clinical trials cases with the use of all PDE5 inhibitors, including
sildenafil.
In single dose volunteer studies of doses up to 800 mg, adverse reactions were similar to those seen at
lower doses, but the incidence rates and severities were increased. Doses of 200 mg did not result in
increased efficacy but the incidence of adverse reactions (headache, flushing, dizziness, dyspepsia,
nasal congestion, altered vision) was increased.
In cases of overdose, standard supportive measures should be adopted as required. Renal dialysis is
not expected to accelerate clearance as sildenafil is highly bound to plasma proteins and not
eliminated in the urine.
5.
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Drugs used in erectile dysfunction. ATC Code: G04B E03.
Sildenafil is an oral therapy for erectile dysfunction. In the natural setting, i.e. with sexual stimulation,
it restores impaired erectile function by increasing blood flow to the penis.
The physiological mechanism responsible for erection of the penis involves the release of nitric oxide
(NO) in the corpus cavernosum during sexual stimulation. Nitric oxide then activates the enzyme
guanylate cyclase, which results in increased levels of cyclic guanosine monophosphate (cGMP),
producing smooth muscle relaxation in the corpus cavernosum and allowing inflow of blood.
Sildenafil is a potent and selective inhibitor of cGMP specific phosphodiesterase type 5 (PDE5) in the
corpus cavernosum, where PDE5 is responsible for degradation of cGMP. Sildenafil has a peripheral
site of action on erections. Sildenafil has no direct relaxant effect on isolated human corpus
cavernosum but potently enhances the relaxant effect of NO on this tissue. When the NO/cGMP
pathway is activated, as occurs with sexual stimulation, inhibition of PDE5 by sildenafil results in
increased corpus cavernosum levels of cGMP. Therefore sexual stimulation is required in order for
sildenafil to produce its intended beneficial pharmacological effects.
Studies
in vitro
have shown that sildenafil is selective for PDE5, which is involved in the erection
process. Its effect is more potent on PDE5 than on other known phosphodiesterases. There is a 10-fold
selectivity over PDE6 which is involved in the phototransduction pathway in the retina. At maximum
recommended doses, there is an 80-fold selectivity over PDE1, and over 700-fold over PDE2, 3, 4, 7,
8, 9, 10 and 11. In particular, sildenafil has greater than 4,000-fold selectivity for PDE5 over PDE3,
the cAMP-specific phosphodiesterase isoform involved in the control of cardiac contractility.
Two clinical studies were specifically designed to assess the time window after dosing during which
sildenafil could produce an erection in response to sexual stimulation. In a penile plethysmography
(RigiScan) study of fasted patients, the median time to onset for those who obtained erections of 60%
rigidity (sufficient for sexual intercourse) was 25 minutes (range 12-37 minutes) on sildenafil. In a
separate RigiScan study, sildenafil was still able to produce an erection in response to sexual
stimulation 4-5 hours post-dose.
Sildenafil causes mild and transient decreases in blood pressure which, in the majority of cases, do
not translate into clinical effects. The mean maximum decreases in supine systolic blood pressure
following 100 mg oral dosing of sildenafil was 8.4 mmHg. The corresponding change in supine
diastolic blood pressure was 5.5 mmHg. These decreases in blood pressure are consistent with the
19
vasodilatory effects of sildenafil, probably due to increased cGMP levels in vascular smooth muscle.
Single oral doses of sildenafil up to 100 mg in healthy volunteers produced no clinically relevant
effects on ECG.
In a study of the hemodynamic effects of a single oral 100 mg dose of sildenafil in 14 patients with
severe coronary artery disease (CAD) (>70% stenosis of at least one coronary artery), the mean
resting systolic and diastolic blood pressures decreased by 7% and 6% respectively compared to
baseline. Mean pulmonary systolic blood pressure decreased by 9%. Sildenafil showed no effect on
cardiac output, and did not impair blood flow through the stenosed coronary arteries.
No clinical relevant differences were demonstrated in time to limiting angina for sildenafil when
compared with placebo in a double blind, placebo controlled exercise stress trial in 144 patients with
erectile dysfunction and chronic stable angina, who were taking on a regular basis anti-anginal
medications (except nitrates).
Mild and transient differences in colour discrimination (blue/green) were detected in some subjects
using the Farnsworth-Munsell 100 hue test at 1 hour following a 100 mg dose, with no effects evident
after 2 hours post-dose. The postulated mechanism for this change in colour discrimination is related
to inhibition of PDE6, which is involved in the phototransduction cascade of the retina. Sildenafil has
no effect on visual acuity or contrast sensitivity. In a small size placebo-controlled study of patients
with documented early age-related macular degeneration (n=9), sildenafil (single dose, 100 mg)
demonstrated no significant changes in visual tests conducted (visual acuity, Amsler grid, colour
discrimination simulated traffic light, Humphrey perimeter and photostress).
There was no effect on sperm motility or morphology after single 100 mg oral doses of sildenafil in
healthy volunteers.
Further information on clinical trials
In clinical trials sildenafil was administered to more than 8000 patients aged 19-87. The following
patient groups were represented: elderly (19.9%), patients with hypertension (30.9%), diabetes
mellitus (20.3%), ischaemic heart disease (5.8%), hyperlipidaemia (19.8%), spinal cord injury (0.6%),
depression (5.2%), transurethral resection of the prostate (3.7%), radical prostatectomy (3.3%). The
following groups were not well represented or excluded from clinical trials: patients with pelvic
surgery, patients post-radiotherapy, patients with severe renal or hepatic impairment and patients with
certain cardiovascular conditions (see section 4.3 ).
In fixed dose studies, the proportions of patients reporting that treatment improved their erections
were 62% (25 mg), 74% (50 mg) and 82% (100 mg) compared to 25% on placebo. In controlled
clinical trials, the discontinuation rate due to sildenafil was low and similar to placebo.
Across all trials, the proportion of patients reporting improvement on sildenafil were as follows:
psychogenic erectile dysfunction (84%), mixed erectile dysfunction (77%), organic erectile
dysfunction (68%), elderly (67%), diabetes mellitus (59%), ischaemic heart disease (69%),
hypertension (68%), TURP (61%), radical prostatectomy (43%), spinal cord injury (83%), depression
(75%). The safety and efficacy of sildenafil was maintained in long-term studies.
5.2 Pharmacokinetic properties
Absorption:
Sildenafil is rapidly absorbed. Maximum observed plasma concentrations are reached within 30 to
120 minutes (median 60 minutes) of oral dosing in the fasted state. The mean absolute oral
bioavailability is 41% (range 25-63%). After oral dosing of sildenafil AUC and C
max
increase in
proportion with dose over the recommended dose range (25-100 mg).
When sildenafil is taken with food, the rate of absorption is reduced with a mean delay in t
max
of 60
minutes and a mean reduction in C
max
of 29%.
20
Distribution:
The mean steady state volume of distribution (V
d
) for sildenafil is 105 l, indicating distribution into
the tissues. After a single oral dose of 100 mg, the mean maximum total plasma concentration of
sildenafil is approximately 440 ng/ml (CV 40%). Since sildenafil (and its major circulating N-
desmethyl metabolite) is 96% bound to plasma proteins, this results in the mean maximum free
plasma concentration for sildenafil of 18 ng/ml (38 nM). Protein binding is independent of total drug
concentrations.
In healthy volunteers receiving sildenafil (100 mg single dose), less than 0.0002% (average 188 ng) of
the administered dose was present in ejaculate 90 minutes after dosing.
Metabolism:
Sildenafil is cleared predominantly by the CYP3A4 (major route) and CYP2C9 (minor route) hepatic
microsomal isoenzymes. The major circulating metabolite results from N-demethylation of sildenafil.
This metabolite has a phosphodiesterase selectivity profile similar to sildenafil and an
in vitro
potency
for PDE5 approximately 50% that of the parent drug. Plasma concentrations of this metabolite are
approximately 40% of those seen for sildenafil. The N-desmethyl metabolite is further metabolised,
with a terminal half-life of approximately 4 h.
Elimination:
The total body clearance of sildenafil is 41 l/h with a resultant terminal phase half-life of 3-5 h. After
either oral or intravenous administration, sildenafil is excreted as metabolites predominantly in the
faeces (approximately 80% of administered oral dose) and to a lesser extent in the urine
(approximately 13% of administered oral dose).
Pharmacokinetics in special patient groups
Elderly:
Healthy elderly volunteers (65 years or over) had a reduced clearance of sildenafil, resulting in
approximately 90% higher plasma concentrations of sildenafil and the active N-desmethyl metabolite
compared to those seen in healthy younger volunteers (18-45 years). Due to age-differences in
plasma protein binding, the corresponding increase in free sildenafil plasma concentration was
approximately 40%.
Renal insufficiency:
In volunteers with mild to moderate renal impairment (creatinine clearance = 30-80 ml/min), the
pharmacokinetics of sildenafil were not altered after receiving a 50 mg single oral dose. The mean
AUC and C
max
of the N-desmethyl metabolite increased 126% and 73% respectively, compared to
age-matched volunteers with no renal impairment. However, due to high inter-subject variability,
these differences were not statistically significant. In volunteers with severe renal impairment
(creatinine clearance <30 ml/min), sildenafil clearance was reduced, resulting in mean increases in
AUC and C
max
of 100% and 88% respectively compared to age-matched volunteers with no renal
impairment. In addition, N-desmethyl metabolite AUC and C
max
values were significantly increased
79% and 200% respectively.
Hepatic insufficiency:
In volunteers with mild to moderate hepatic cirrhosis (Child-Pugh A and B) sildenafil clearance was
reduced, resulting in increases in AUC (84%) and C
max
(47%) compared to age-matched volunteers
with no hepatic impairment. The pharmacokinetics of sildenafil in patients with severely impaired
hepatic function have not been studied.
5.3 Preclinical safety data
Non-clinical data revealed no special hazard for humans based on conventional studies of safety
pharmacology, repeated dose toxicity, genotoxicity, carcinogenic potential, and toxicity to
reproduction.
21
6.
6.1 List of excipients
Tablet core:
microcrystalline cellulose
calcium hydrogen phosphate (anhydrous)
croscarmellose sodium
magnesium stearate
Film coat:
hypromellose
titanium dioxide (E171)
lactose
triacetin
indigo carmine aluminium lake (E132)
6.2 Incompatibilities
Not applicable.
6.3 Shelf life
5 years.
6.4 Special precautions for storage
Do not store above 30
o
C.
Store in the original package, in order to protect from moisture.
6.5 Nature and content of container
PVC/Aluminium foil blisters in cartons or secondary heat sealed card packaging of 2, 4, 8 or 12
tablets. Not all pack sizes may be marketed.
6.6 Special precautions for disposal and other handling
No special requirements.
7.
Pfizer Limited
Sandwich
Kent CT13 9NJ
United Kingdom
EU/1/98/077/006-008
EU/1/98/077/014
EU/1/98/077/016-019
22
9.
Date of first authorisation: 14 September 1998
Date of last renewal: 26 August 2008
Detailed information on this medicinal product is available on the website of the European Medicines
Agency
http://www.ema.europa.eu/
23
1.
VIAGRA 100 mg film-coated tablets
2.
Each tablet contains 100 mg of sildenafil (as citrate)
Excipient: Lactose.
For a full list of excipients, see section 6.1.
3.
Film-coated tablet.
Blue, rounded diamond-shaped tablets, marked “PFIZER” on one side and “VGR 100” on the other.
4.
Treatment of men with erectile dysfunction, which is the inability to achieve or maintain a penile
erection sufficient for satisfactory sexual performance.
In order for VIAGRA to be effective, sexual stimulation is required.
For oral use.
Use in adults:
The recommended dose is 50 mg taken as needed approximately one hour before sexual activity.
Based on efficacy and toleration, the dose may be increased to 100 mg or decreased to 25 mg. The
maximum recommended dose is 100 mg. The maximum recommended dosing frequency is once per
day. If VIAGRA is taken with food, the onset of activity may be delayed compared to the fasted state
(see section 5.2).
Use in the elderly:
Dosage adjustments are not required in elderly patients.
Use in patients with impaired renal function:
The dosing recommendations described in ‘Use in adults’ apply to patients with mild to moderate
renal impairment (creatinine clearance = 30 - 80 ml/min).
Since sildenafil clearance is reduced in patients with severe renal impairment (creatinine clearance
<30 ml/min) a 25 mg dose should be considered. Based on efficacy and toleration, the dose may be
increased to 50 mg and 100 mg.
Use in patients with impaired hepatic function:
Since sildenafil clearance is reduced in patients with hepatic impairment (e.g. cirrhosis) a 25 mg dose
should be considered. Based on efficacy and toleration, the dose may be increased to 50 mg and
100 mg.
24
Use in children and adolescents:
VIAGRA is not indicated for individuals below 18 years of age.
Use in patients using other medicines:
With the exception of ritonavir for which co-administration with sildenafil is not advised (see section
4.4) a starting dose of 25 mg should be considered in patients receiving concomitant treatment with
CYP3A4 inhibitors (see section 4.5)
In order to minimise the potential for developing postural hypotension, patients should be stable on
alpha-blocker therapy prior to initiating sildenafil treatment. In addition, initiation of sildenafil at a
dose of 25 mg should be considered (see sections 4.4 and 4.5).
Hypersensitivity to the active substance or to any of the excipients.
Consistent with its known effects on the nitric oxide/cyclic guanosine monophosphate (cGMP)
pathway (see section 5.1), sildenafil was shown to potentiate the hypotensive effects of nitrates, and
its co-administration with nitric oxide donors (such as amyl nitrite) or nitrates in any form is therefore
contraindicated.
Agents for the treatment of erectile dysfunction, including sildenafil, should not be used in men for
whom sexual activity is inadvisable (e.g. patients with severe cardiovascular disorders such as
unstable angina or severe cardiac failure).
VIAGRA is contraindicated in patients who have loss of vision in one eye because of non-arteritic
anterior ischaemic optic neuropathy (NAION), regardless of whether this episode was in connection
or not with previous PDE5 inhibitor exposure (see section 4.4).
The safety of sildenafil has not been studied in the following sub-groups of patients and its use is
therefore contraindicated: severe hepatic impairment, hypotension (blood pressure <90/50 mmHg),
recent history of stroke or myocardial infarction and known hereditary degenerative retinal disorders
such as
retinitis pigmentosa
(a minority of these patients have genetic disorders of retinal
phosphodiesterases)
.
A medical history and physical examination should be undertaken to diagnose erectile dysfunction
and determine potential underlying causes, before pharmacological treatment is considered.
Prior to initiating any treatment for erectile dysfunction, physicians should consider the
cardiovascular status of their patients, since there is a degree of cardiac risk associated with sexual
activity. Sildenafil has vasodilator properties, resulting in mild and transient decreases in blood
pressure (see section 5.1). Prior to prescribing sildenafil, physicians should carefully consider whether
their patients with certain underlying conditions could be adversely affected by such vasodilatory
effects, especially in combination with sexual activity. Patients with increased susceptibility to
vasodilators include those with left ventricular outflow obstruction (e.g., aortic stenosis, hypertrophic
obstructive cardiomyopathy), or those with the rare syndrome of multiple system atrophy manifesting
as severely impaired autonomic control of blood pressure.
VIAGRA potentiates the hypotensive effect of nitrates (see section 4.3 ).
Serious cardiovascular events, including myocardial infarction, unstable angina, sudden cardiac death,
ventricular arrhythmia, cerebrovascular haemorrhage, transient ischaemic attack, hypertension and
hypotension have been reported post-marketing in temporal association with the use of VIAGRA.
Most, but not all, of these patients had pre-existing cardiovascular risk factors. Many events were
25
reported to occur during or shortly after sexual intercourse and a few were reported to occur shortly
after the use of VIAGRA without sexual activity. It is not possible to determine whether these events
are related directly to these factors or to other factors.
Agents for the treatment of erectile dysfunction, including sildenafil, should be used with caution in
patients with anatomical deformation of the penis (such as angulation, cavernosal fibrosis or
Peyronie’s disease), or in patients who have conditions which may predispose them to priapism (such
as sickle cell anaemia, multiple myeloma or leukaemia).
The safety and efficacy of combinations of sildenafil with other treatments for erectile dysfunction
have not been studied. Therefore the use of such combinations is not recommended.
Visual defects and cases of non-arteritic anterior ischaemic optic neuropathy have been reported in
connection with the intake of sildenafil and other PDE5 inhibitors. The patient should be advised that
in case of sudden visual defect, he should stop taking VIAGRA and consult a physician immediately
(see section 4.3).
Co-administration of sildenafil with ritonavir is not advised (see section 4.5).
Caution is advised when sildenafil is administered to patients taking an alpha-blocker, as the
coadministration may lead to symptomatic hypotension in a few susceptible individuals (see section
4.5). This is most likely to occur within 4 hours post sildenafil dosing. In order to minimise the
potential for developing postural hypotension, patients should be hemodynamically stable on alpha-
blocker therapy prior to initiating sildenafil treatment. Initiation of sildenafil at a dose of 25 mg
should be considered (see section 4.2). In addition, physicians should advise patients what to do in the
event of postural hypotensive symptoms.
Studies with human platelets indicate that sildenafil potentiates the antiaggregatory effect of sodium
nitroprusside
in vitro
. There is no safety information on the administration of sildenafil to patients
with bleeding disorders or active peptic ulceration. Therefore sildenafil should be administered to
these patients only after careful benefit-risk assessment.
The film coating of the VIAGRA tablet contains lactose. VIAGRA should not be administered to men
with rare hereditary problems of galactose intolerance, Lapp lactase deficiency or glucose-galactose
malabsorption.
VIAGRA is not indicated for use by women.
Effects of other medicinal products on sildenafil
In vitro studies:
Sildenafil metabolism is principally mediated by the cytochrome P450 (CYP) isoforms 3A4 (major
route) and 2C9 (minor route). Therefore, inhibitors of these isoenzymes may reduce sildenafil
clearance.
In vivo studies:
Population pharmacokinetic analysis of clinical trial data indicated a reduction in sildenafil clearance
when co-administered with CYP3A4 inhibitors (such as ketoconazole, erythromycin, cimetidine).
Although no increased incidence of adverse events was observed in these patients, when sildenafil is
administered concomitantly with CYP3A4 inhibitors, a starting dose of 25 mg should be considered.
Co-administration of the HIV protease inhibitor ritonavir, which is a
highly potent P450 inhibitor, at
steady state (500 mgtwice daily) with sildenafil (100 mg single dose) resulted in a 300% (4-fold)
increase in sildenafil C
max
and a 1,000% (11-fold) increase in sildenafil plasma AUC. At 24 hours, the
plasma levels of sildenafil were still approximately 200 ng/ml, compared to approximately 5 ng/ml
26
when sildenafil was administered alone. This is consistent with ritonavir’s marked effects on a broad
range of P450 substrates. Sildenafil had no effect on ritonavir pharmacokinetics. Based on these
pharmacokinetic results co-administration of sildenafil with ritonavir is not advised (see section 4.4)
and in any event the maximum dose of sildenafil should under no circumstances exceed 25 mg within
48 hours.
Co-administration of the HIV protease inhibitor saquinavir, a CYP3A4 inhibitor, at steady state
(1200 mg three times a day) with sildenafil (100 mg single dose) resulted in a 140% increase in
sildenafil C
max
and a 210% increase in sildenafil AUC. Sildenafil had no effect on saquinavir
pharmacokinetics (see section 4.2). Stronger CYP3A4 inhibitors such as ketoconazole and
itraconazole would be expected to have greater effects.
When a single 100 mg dose of sildenafil was administered with erythromycin, a specific CYP3A4
inhibitor, at steady state (500 mg twice daily for 5 days), there was a 182% increase in sildenafil
systemic exposure (AUC). In normal healthy male volunteers, there was no evidence of an effect of
azithromycin (500 mg daily for 3 days) on the AUC, C
max
, t
max
, elimination rate constant, or
subsequent half-life of sildenafil or its principal circulating metabolite. Cimetidine (800 mg), a
cytochrome P450 inhibitor and non-specific CYP3A4 inhibitor, caused a 56% increase in plasma
sildenafil concentrations when co-administered with sildenafil (50 mg) to healthy volunteers.
Grapefruit juice is a weak inhibitor of CYP3A4 gut wall metabolism and may give rise to modest
increases in plasma levels of sildenafil.
Single doses of antacid (magnesium hydroxide/aluminium hydroxide) did not affect the
bioavailability of sildenafil.
Although specific interaction studies were not conducted for all medicinal products, population
pharmacokinetic analysis showed no effect of concomitant medication on sildenafil pharmacokinetics
when grouped as CYP2C9 inhibitors (such as tolbutamide, warfarin, phenytoin), CYP2D6 inhibitors
(such as selective serotonin reuptake inhibitors, tricyclic antidepressants), thiazide and related
diuretics, loop and potassium sparing diuretics, angiotensin converting enzyme inhibitors, calcium
channel blockers, beta-adrenoreceptor antagonists or inducers of CYP450 metabolism (such as
rifampicin, barbiturates).
Nicorandil is a hybrid of potassium channel activator and nitrate. Due to the nitrate component it has
the potential to have serious interaction with sildenafil.
Effects of sildenafil on other medicinal products
In vitro studies:
Sildenafil is a weak inhibitor of the cytochrome P450 isoforms 1A2, 2C9, 2C19, 2D6, 2E1 and 3A4
(IC
50
>150 μM). Given sildenafil peak plasma concentrations of approximately 1 μM after
recommended doses, it is unlikely that VIAGRA will alter the clearance of substrates of these
isoenzymes.
There are no data on the interaction of sildenafil and non-specific phosphodiesterase inhibitors such
as theophylline or dipyridamole.
In vivo studies:
Consistent with its known effects on the nitric oxide/cGMP pathway (see section 5.1), sildenafil was
shown to potentiate the hypotensive effects of nitrates, and its co-administration with nitric oxide
donors or nitrates in any form is therefore contraindicated (see section 4.3).
Concomitant administration of sildenafil to patients taking alpha-blocker therapy may lead to
symptomatic hypotension in a few susceptible individuals. This is most likely to occur within 4 hours
post sildenafil dosing (see sections 4.2 and 4.4). In three specific drug-drug interaction studies, the
27
alpha-blocker doxazosin (4 mg and 8 mg) and sildenafil (25 mg, 50 mg, or 100 mg) were administered
simultaneously to patients with benign prostatic hyperplasia (BPH) stabilized on doxazosin therapy.
In these study populations, mean additional reductions of supine blood pressure of 7/7 mmHg, 9/5
mmHg, and 8/4 mmHg, and mean additional reductions of standing blood pressure of 6/6 mmHg, 11/4
mmHg, and 4/5 mmHg, respectively, were observed. When sildenafil and doxazosin were
administered simultaneously to patients stabilized on doxazosin therapy, there were infrequent reports
of patients who experienced symptomatic postural hypotension. These reports included dizziness and
light-headedness, but not syncope.
No significant interactions were shown when sildenafil (50 mg) was co-administered with
tolbutamide (250 mg) or warfarin (40 mg), both of which are metabolised by CYP2C9.
Sildenafil (50 mg) did not potentiate the increase in bleeding time caused by acetyl salicylic acid
(150 mg).
Sildenafil (50 mg) did not potentiate the hypotensive effects of alcohol in healthy volunteers with
mean maximum blood alcohol levels of 80 mg/dl.
Pooling of the following classes of antihypertensive medication: diuretics, beta-blockers, ACE
inhibitors, angiotensin II antagonists, antihypertensive medicinal products (vasodilator and centrally-
acting), adrenergic neurone blockers, calcium channel blockers and alpha-adrenoceptor blockers,
showed no difference in the side effect profile in patients taking sildenafil compared to placebo
treatment. In a specific interaction study, where sildenafil (100 mg) was co-administered with
amlodipine in hypertensive patients, there was an additional reduction on supine systolic blood
pressure of 8 mmHg. The corresponding additional reduction in supine diastolic blood pressure was
7 mmHg. These additional blood pressure reductions were of a similar magnitude to those seen when
sildenafil was administered alone to healthy volunteers (see section(see section 5.1).
Sildenafil (100 mg) did not affect the steady state pharmacokinetics of the HIV protease inhibitors,
saquinavir and ritonavir, both of which are CYP3A4 substrates.
VIAGRA is not indicated for use by women.
No relevant adverse effects were found in reproduction studies in rats and rabbits following oral
administration of sildenafil.
No studies on the effects on the ability to drive and use machines have been performed.
As dizziness and altered vision were reported in clinical trials with sildenafil, patients should be
aware of how they react to VIAGRA, before driving or operating machinery.
The safety profile of VIAGRA is based on 8691 patients who received the recommended dosing
regimen in 67 placebo-controlled clinical studies. The most commonly reported adverse reactions in
clinical studies among sildenafil treated patients were headache, flushing, dyspepsia, visual disorders,
nasal congestion, dizziness and visual colour distortion.
Adverse reactions from post-marketing surveillance has been gathered covering an estimated period
>9 years. Because not all adverse reactions are reported to the Marketing Authorisation Holder and
included in the safety database, the frequencies of these reactions cannot be reliably determined.
28
In the table below all medically important adverse reactions, which occurred in clinical trials at an
incidence greater than placebo are listed by system organ class and frequency (very common (≥1/10),
common (≥1/100 to <1/10), uncommon (≥1/1,000 to <1/100), rare (≥1/10,000 to <1/1,000). In
addition, the frequency of medically important adverse reactions reported from post-marketing
experience is included as not known. Within each frequency grouping, undesirable effects are
presented in order of decreasing seriousness.
Table 1: Medically important adverse reactions reported at an incidence greater than placebo
in controlled clinical studies and medically important adverse reactions reported through post-
marketing surveillance
System Organ Class
Immune system disorders
Rare
Hypersensitivity reactions
Nervous system disorders
Very common
Headache
Common
Dizziness
Uncommon
Somnolence, Hypoaesthesia
Rare
Cerebrovascular accident, Syncope
Not known
Transient ischaemic attack, Seizure, Seizure recurrence
Eye disorders
Common
Visual disorders, Visual colour distortion
Uncommon
Conjunctival disorders, Eye Disorders, Lacrimation
Disorders, Other Eye Disorders
Not known
Non-arteritic anterior ischaemic optic neuropathy
(NAION), Retinal vascular occlusion, Visual field defect
Ear and labyrinth disorders
Uncommon
Vertigo, Tinnitus
Rare
Deafness*
Vascular disorders
Common
Flushing
Rare
Hypertension, Hypotension
Cardiac disorders
Uncommon Palpitations, Tachycardia
Rare Myocardial infarction, Atrial fibrillation
Not known Ventricular arrhythmia, Unstable angina, Sudden cardiac
death
Respiratory, thoracic and mediastinal disorders
Common
Nasal congestion
Rare
Epistaxis
Gastrointestinal disorders
Common Dyspepsia
Uncommon Vomiting, Nausea, Dry mouth
Skin, subcutaneous and soft tissue disorders
Uncommon Skin rash
Not known Steven Johnson Syndrome (SJS), Toxic Epidermal
Necrolysis (TEN)
Musculoskeletal and connective tissue disorders
Uncommon Myalgia
Reproductive system and breast disorders
Not known Priapism, Prolonged erection
General disorders and administration site conditions
Uncommon
Chest pain, Fatigue
Investigations
Uncommon
Heart rate increased
29
* Ear disorders: Sudden deafness. Sudden decrease or loss of hearing has been reported in a small
number of post-marketing and clinical trials cases with the use of all PDE5 inhibitors, including
sildenafil.
In single dose volunteer studies of doses up to 800 mg, adverse reactions were similar to those seen at
lower doses, but the incidence rates and severities were increased. Doses of 200 mg did not result in
increased efficacy but the incidence of adverse reactions (headache, flushing, dizziness, dyspepsia,
nasal congestion, altered vision) was increased.
In cases of overdose, standard supportive measures should be adopted as required. Renal dialysis is
not expected to accelerate clearance as sildenafil is highly bound to plasma proteins and not
eliminated in the urine.
5.
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Drugs used in erectile dysfunction. ATC Code: G04B E03.
Sildenafil is an oral therapy for erectile dysfunction. In the natural setting, i.e. with sexual stimulation,
it restores impaired erectile function by increasing blood flow to the penis.
The physiological mechanism responsible for erection of the penis involves the release of nitric oxide
(NO) in the corpus cavernosum during sexual stimulation. Nitric oxide then activates the enzyme
guanylate cyclase, which results in increased levels of cyclic guanosine monophosphate (cGMP),
producing smooth muscle relaxation in the corpus cavernosum and allowing inflow of blood.
Sildenafil is a potent and selective inhibitor of cGMP specific phosphodiesterase type 5 (PDE5) in the
corpus cavernosum, where PDE5 is responsible for degradation of cGMP. Sildenafil has a peripheral
site of action on erections. Sildenafil has no direct relaxant effect on isolated human corpus
cavernosum but potently enhances the relaxant effect of NO on this tissue. When the NO/cGMP
pathway is activated, as occurs with sexual stimulation, inhibition of PDE5 by sildenafil results in
increased corpus cavernosum levels of cGMP. Therefore sexual stimulation is required in order for
sildenafil to produce its intended beneficial pharmacological effects.
Studies
in vitro
have shown that sildenafil is selective for PDE5, which is involved in the erection
process. Its effect is more potent on PDE5 than on other known phosphodiesterases. There is a 10-fold
selectivity over PDE6 which is involved in the phototransduction pathway in the retina. At maximum
recommended doses, there is an 80-fold selectivity over PDE1, and over 700-fold over PDE2, 3, 4, 7,
8, 9, 10 and 11. In particular, sildenafil has greater than 4,000-fold selectivity for PDE5 over PDE3,
the cAMP-specific phosphodiesterase isoform involved in the control of cardiac contractility.
Two clinical studies were specifically designed to assess the time window after dosing during which
sildenafil could produce an erection in response to sexual stimulation. In a penile plethysmography
(RigiScan) study of fasted patients, the median time to onset for those who obtained erections of 60%
rigidity (sufficient for sexual intercourse) was 25 minutes (range 12-37 minutes) on sildenafil. In a
separate RigiScan study, sildenafil was still able to produce an erection in response to sexual
stimulation 4-5 hours post-dose.
Sildenafil causes mild and transient decreases in blood pressure which, in the majority of cases, do
not translate into clinical effects. The mean maximum decreases in supine systolic blood pressure
following 100 mg oral dosing of sildenafil was 8.4 mmHg. The corresponding change in supine
30
diastolic blood pressure was 5.5 mmHg. These decreases in blood pressure are consistent with the
vasodilatory effects of sildenafil, probably due to increased cGMP levels in vascular smooth muscle.
Single oral doses of sildenafil up to 100 mg in healthy volunteers produced no clinically relevant
effects on ECG.
In a study of the hemodynamic effects of a single oral 100 mg dose of sildenafil in 14 patients with
severe coronary artery disease (CAD) (>70% stenosis of at least one coronary artery), the mean
resting systolic and diastolic blood pressures decreased by 7% and 6% respectively compared to
baseline. Mean pulmonary systolic blood pressure decreased by 9%. Sildenafil showed no effect on
cardiac output, and did not impair blood flow through the stenosed coronary arteries.
No clinical relevant differences were demonstrated in time to limiting angina for sildenafil when
compared with placebo in a double blind, placebo controlled exercise stress trial in 144 patients with
erectile dysfunction and chronic stable angina, who were taking on a regular basis anti-anginal
medications (except nitrates).
Mild and transient differences in colour discrimination (blue/green) were detected in some subjects
using the Farnsworth-Munsell 100 hue test at 1 hour following a 100 mg dose, with no effects evident
after 2 hours post-dose. The postulated mechanism for this change in colour discrimination is related
to inhibition of PDE6, which is involved in the phototransduction cascade of the retina. Sildenafil has
no effect on visual acuity or contrast sensitivity. In a small size placebo-controlled study of patients
with documented early age-related macular degeneration (n=9), sildenafil (single dose, 100 mg)
demonstrated no significant changes in visual tests conducted (visual acuity, Amsler grid, colour
discrimination simulated traffic light, Humphrey perimeter and photostress).
There was no effect on sperm motility or morphology after single 100 mg oral doses of sildenafil in
healthy volunteers.
Further information on clinical trials
In clinical trials sildenafil was administered to more than 8000 patients aged 19-87. The following
patient groups were represented: elderly (19.9%), patients with hypertension (30.9%), diabetes
mellitus (20.3%), ischaemic heart disease (5.8%), hyperlipidaemia (19.8%), spinal cord injury (0.6%),
depression (5.2%), transurethral resection of the prostate (3.7%), radical prostatectomy (3.3%). The
following groups were not well represented or excluded from clinical trials: patients with pelvic
surgery, patients post-radiotherapy, patients with severe renal or hepatic impairment and patients with
certain cardiovascular conditions (see section 4.3).
In fixed dose studies, the proportions of patients reporting that treatment improved their erections
were 62% (25 mg), 74% (50 mg) and 82% (100 mg) compared to 25% on placebo. In controlled
clinical trials, the discontinuation rate due to sildenafil was low and similar to placebo.
Across all trials, the proportion of patients reporting improvement on sildenafil were as follows:
psychogenic erectile dysfunction (84%), mixed erectile dysfunction (77%), organic erectile
dysfunction (68%), elderly (67%), diabetes mellitus (59%), ischaemic heart disease (69%),
hypertension (68%), TURP (61%), radical prostatectomy (43%), spinal cord injury (83%), depression
(75%). The safety and efficacy of sildenafil was maintained in long-term studies.
5.2 Pharmacokinetic properties
Absorption:
Sildenafil is rapidly absorbed. Maximum observed plasma concentrations are reached within 30 to
120 minutes (median 60 minutes) of oral dosing in the fasted state. The mean absolute oral
bioavailability is 41% (range 25-63%). After oral dosing of sildenafil AUC and C
max
increase in
proportion with dose over the recommended dose range (25-100 mg).
When sildenafil is taken with food, the rate of absorption is reduced with a mean delay in t
max
of 60
minutes and a mean reduction in C
max
of 29%.
31
Distribution:
The mean steady state volume of distribution (V
d
) for sildenafil is 105 l, indicating distribution into
the tissues. After a single oral dose of 100 mg, the mean maximum total plasma concentration of
sildenafil is approximately 440 ng/ml (CV 40%). Since sildenafil (and its major circulating N-
desmethyl metabolite) is 96% bound to plasma proteins, this results in the mean maximum free
plasma concentration for sildenafil of 18 ng/ml (38 nM). Protein binding is independent of total drug
concentrations.
In healthy volunteers receiving sildenafil (100 mg single dose), less than 0.0002% (average 188 ng) of
the administered dose was present in ejaculate 90 minutes after dosing.
Metabolism:
Sildenafil is cleared predominantly by the CYP3A4 (major route) and CYP2C9 (minor route) hepatic
microsomal isoenzymes. The major circulating metabolite results from N-demethylation of sildenafil.
This metabolite has a phosphodiesterase selectivity profile similar to sildenafil and an
in vitro
potency
for PDE5 approximately 50% that of the parent drug. Plasma concentrations of this metabolite are
approximately 40% of those seen for sildenafil. The N-desmethyl metabolite is further metabolised,
with a terminal half-life of approximately 4 h.
Elimination:
The total body clearance of sildenafil is 41 l/h with a resultant terminal phase half-life of 3-5 h. After
either oral or intravenous administration, sildenafil is excreted as metabolites predominantly in the
faeces (approximately 80% of administered oral dose) and to a lesser extent in the urine
(approximately 13% of administered oral dose).
Pharmacokinetics in special patient groups
Elderly:
Healthy elderly volunteers (65 years or over) had a reduced clearance of sildenafil, resulting in
approximately 90% higher plasma concentrations of sildenafil and the active N-desmethyl metabolite
compared to those seen in healthy younger volunteers (18-45 years). Due to age-differences in
plasma protein binding, the corresponding increase in free sildenafil plasma concentration was
approximately 40%.
Renal insufficiency:
In volunteers with mild to moderate renal impairment (creatinine clearance = 30-80 ml/min), the
pharmacokinetics of sildenafil were not altered after receiving a 50 mg single oral dose. The mean
AUC and C
max
of the N-desmethyl metabolite increased 126% and 73% respectively, compared to
age-matched volunteers with no renal impairment. However, due to high inter-subject variability,
these differences were not statistically significant. In volunteers with severe renal impairment
(creatinine clearance <30 ml/min), sildenafil clearance was reduced, resulting in mean increases in
AUC and C
max
of 100% and 88% respectively compared to age-matched volunteers with no renal
impairment. In addition, N-desmethyl metabolite AUC and C
max
values were significantly increased
79% and 200% respectively.
Hepatic insufficiency:
In volunteers with mild to moderate hepatic cirrhosis (Child-Pugh A and B) sildenafil clearance was
reduced, resulting in increases in AUC (84%) and C
max
(47%) compared to age-matched volunteers
with no hepatic impairment. The pharmacokinetics of sildenafil in patients with severely impaired
hepatic function have not been studied.
32
5.3 Preclinical safety data
Non-clinical data revealed no special hazard for humans based on conventional studies of safety
pharmacology, repeated dose toxicity, genotoxicity, carcinogenic potential, and toxicity to
reproduction.
6.
6.1 List of excipients
Tablet core:
microcrystalline cellulose
calcium hydrogen phosphate (anhydrous)
croscarmellose sodium
magnesium stearate
Film coat:
Hypromellose
titanium dioxide (E171)
lactose
triacetin
indigo carmine aluminium lake (E132)
6.2 Incompatibilities
Not applicable.
6.3 Shelf life
5 years.
6.4 Special precautions for storage
Do not store above 30
o
C.
Store in the original package, in order to protect from moisture.
6.5 Nature and content of container
PVC/Aluminium foil blisters in cartons of 2, 4, 8 or 12 tablets. Not all pack sizes may be marketed.
6.6 Special precautions for disposal and other handling
No special requirements.
7.
Pfizer Limited
Sandwich
Kent CT13 9NJ
United Kingdom
33
EU/1/98/077/010-012
EU/1/98/077/015
9.
Date of first authorisation: 14 September 1998
Date of last renewal: 26 August 2008
Detailed information on this medicinal product is available on the website of the European Medicines
Agency
http://www.ema.europa.eu/
34
ANNEX II
A.
MANUFACTURING AUTHORISATION HOLDER
RESPONSIBLE FOR BATCH RELEASE
B.
CONDITIONS OF THE MARKETING AUTHORISATION
35
A.
MANUFACTURING AUTHORISATION HOLDER RESPONSIBLE FOR BATCH
RELEASE
Name and address of the manufacturer responsible for batch release
Pfizer PGM
Zone Industrielle,
29 route des Industries
37530 Pocé-sur-Cisse
France
B. CONDITIONS OF THE MARKETING AUTHORISATION
Medicinal product subject to medical prescription
CONDITIONS OR RESTRICTIONS WITH REGARD TO THE SAFE AND
EFFECTIVE USE OF THE MEDICINAL PRODUCT
Not applicable.
36
ANNEX III
LABELLING AND PACKAGE LEAFLET
37
A. LABELLING
38
PARTICULARS TO APPEAR ON THE OUTER PACKAGING
OUTER PACKAGING /CARTON
1.
VIAGRA 25 mg film-coated tablets
Sildenafil
2.
STATEMENT OF ACTIVE SUBSTANCE(S)
25 mg sildenafil (as citrate)
3.
LIST OF EXCIPIENTS
Contains lactose.
See package leaflet for further information
4.
2 film-coated tablets
4 film-coated tablets
8 film-coated tablets
12 film-coated-tablets
5.
METHOD AND ROUTE(S) OF ADMINISTRATION
For oral use.
Read the package leaflet before use
6.
SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT
OF THE REACH AND SIGHT OF CHILDREN
Keep out of the reach and sight of children.
7.
OTHER SPECIAL WARNING(S), IF NECESSARY
Sealed Pack
Do not use if box has been opened
8.
EXPIRY DATE
EXP:
39
9.
SPECIAL STORAGE CONDITIONS
Do not store above 30C.
Store in the original package in order to protect from moisture.
10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS
OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF
APPROPRIATE
Marketing Authorisation Holder:
Pfizer Limited
Sandwich
Kent CT13 9NJ
United Kingdom
EU/1/98/077/013 (2 film-coated tablets)
EU/1/98/077/002 (4 film-coated tablets)
EU/1/98/077/003 (8 film-coated tablets)
EU/1/98/077/004 (12 film-coated tablets)
13. BATCH NUMBER
Batch:
14. GENERAL CLASSIFICATION FOR SUPPLY
Medicinal product subject to medical prescription.
15. INSTRUCTIONS ON USE
16.
INFORMATION IN BRAILLE
VIAGRA 25mg
40
PARTICULARS TO APPEAR ON THE OUTER PACKAGING
OUTER PACKAGING /CARTON
1.
VIAGRA 50 mg film-coated tablets
Sildenafil
2.
STATEMENT OF ACTIVE SUBSTANCE(S)
50 mg sildenafil (as citrate)
3.
LIST OF EXCIPIENTS
Contains lactose
See package leaflet for further information
4.
2 film-coated tablets
4 film-coated tablets
8 film-coated tablets
12 film-coated tablets
5.
METHOD AND ROUTE(S) OF ADMINISTRATION
For oral use.
Read the package leaflet before use.
6.
SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT
OF THE REACH AND SIGHT OF CHILDREN
Keep out of the reach and sight of children.
7.
OTHER SPECIAL WARNING(S), IF NECESSARY
Sealed Pack
Do not use if box has been opened
8.
EXPIRY DATE
EXP:
41
9.
SPECIAL STORAGE CONDITIONS
Do not store above 30C.
Store in the original package in order to protect from moisture.
10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS
OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF
APPROPRIATE
Marketing Authorisation Holder:
Pfizer Limited
Sandwich
Kent CT13 9NJ
United Kingdom
EU/1/98/077/014 (2 film-coated tablets)
EU/1/98/077/006 (4 film-coated tablets)
EU/1/98/077/007 (8 film-coated tablets)
EU/1/98/077/008 (12 film-coated tablets)
13. BATCH NUMBER
Batch:
14. GENERAL CLASSIFICATION FOR SUPPLY
Medicinal product subject to medical prescription.
15. INSTRUCTIONS ON USE
16.
INFORMATION IN BRAILLE
VIAGRA 50mg
42
PARTICULARS TO APPEAR ON THE OUTER PACKAGING
OUTER PACKAGING /SECONDARY HEAT SEALED CARD PACKAGING
1.
VIAGRA 50 mg film-coated tablets
Sildenafil
2.
STATEMENT OF ACTIVE SUBSTANCE(S)
50 mg sildenafil (as citrate)
3.
LIST OF EXCIPIENTS
Contains lactose
See package leaflet for further information
4.
2 film-coated tablets
4 film-coated tablets
8 film-coated tablets
12 film-coated tablets
5.
METHOD AND ROUTE(S) OF ADMINISTRATION
For oral use.
Read the package leaflet before use.
6.
SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT
OF THE REACH AND SIGHT OF CHILDREN
Keep out of the reach and sight of children.
7.
OTHER SPECIAL WARNING(S), IF NECESSARY
Sealed Pack
Do not use if box has been opened
8.
EXPIRY DATE
EXP:
43
9.
SPECIAL STORAGE CONDITIONS
Do not store above 30C.
Store in the original package in order to protect from moisture.
10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS
OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF
APPROPRIATE
Marketing Authorisation Holder:
Pfizer Limited
Sandwich
Kent CT13 9NJ
United Kingdom
EU/1/98/077/016 (2 film-coated tablets)
EU/1/98/077/017 (4 film-coated tablets)
EU/1/98/077/018 (8 film-coated tablets)
EU/1/98/077/019 (12 film-coated tablets)
13. BATCH NUMBER
Batch:
14. GENERAL CLASSIFICATION FOR SUPPLY
Medicinal product subject to medical prescription.
15. INSTRUCTIONS ON USE
16.
INFORMATION IN BRAILLE
VIAGRA 50mg
44
PARTICULARS TO APPEAR ON THE OUTER PACKAGING
OUTER PACKAGING /CARTON
1.
VIAGRA 100 mg film-coated tablets
Sildenafil
2.
STATEMENT OF ACTIVE SUBSTANCE(S)
100 mg sildenafil (as citrate)
3.
LIST OF EXCIPIENTS
Contains lactose
See package leaflet for further information
4.
2 film-coated tablets
4 film-coated tablets
8 film-coated tablets
12 film-coated tablets
5.
METHOD AND ROUTE(S) OF ADMINISTRATION
For oral use.
Read the package leaflet before use.
6.
SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT
OF THE REACH AND SIGHT OF CHILDREN
Keep out of the reach and sight of children.
7.
OTHER SPECIAL WARNING(S), IF NECESSARY
Sealed Pack
Do not use if box has been opened
8.
EXPIRY DATE
EXP:
45
9.
SPECIAL STORAGE CONDITIONS
Do not store above 30C.
Store in the original package in order to protect from moisture.
10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS
OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF
APPROPRIATE
Marketing Authorisation Holder:
Pfizer Limited
Sandwich
Kent CT13 9NJ
United Kingdom
EU/1/98/077/015 (2 film-coated tablets)
EU/1/98/077/010 (4 film-coated tablets)
EU/1/98/077/011 (8 film-coated tablets)
EU/1/98/077/012 (12 film-coated tablets)
13. BATCH NUMBER
Batch:
14. GENERAL CLASSIFICATION FOR SUPPLY
Medicinal product subject to medical prescription.
15. INSTRUCTIONS ON USE
16.
INFORMATION IN BRAILLE
VIAGRA 100mg
46
MINIMUM PARTICULARS TO APPEAR ON BLISTERS OR STRIPS
PRIMARY PACKAGING/BLISTER
1.
VIAGRA 25 mg tablets
Sildenafil
2.
Pfizer
3.
EXPIRY DATE
EXP:
4.
BATCH NUMBER
Batch:
5.
OTHER
47
MINIMUM PARTICULARS TO APPEAR ON BLISTERS OR STRIPS
PRIMARY PACKAGING/BLISTER
1.
VIAGRA 50 mg tablets
Sildenafil
2.
Pfizer
3.
EXPIRY DATE
EXP:
4.
BATCH NUMBER
Batch:
5.
OTHER
48
MINIMUM PARTICULARS TO APPEAR ON BLISTERS OR STRIPS
PRIMARY PACKAGING/BLISTER
1.
VIAGRA 100 mg tablets
Sildenafil
2.
Pfizer
3.
EXPIRY DATE
EXP:
4.
BATCH NUMBER
Batch:
5.
OTHER
49
B. PACKAGE LEAFLET
50
PACKAGE LEAFLET: INFORMATION FOR THE USER
VIAGRA 25 mg film-coated tablets
Sildenafil citrate
Read all of this leaflet carefully before you start taking this medicine.
Keep this leaflet. You may need to read it again.
If you have any further questions, please ask your doctor or pharmacist.
This medicine has been prescribed for you. Do not pass it on to others. It may harm them, even
if their symptoms are the same as yours.
If any of the side effects get serious, or you notice any side effects not listed in this leaflet,
please tell your doctor or pharmacist.
In this leaflet:
1.
What VIAGRA is and what it is used for
2.
Before you take VIAGRA
3.
How to take VIAGRA
4.
Possible side effects
5.
How to store VIAGRA
6.
Further information
1.
WHAT VIAGRA IS AND WHAT IT IS USED FOR
VIAGRA belongs to a group of medicines called phosphodiesterase type 5 (PDE5) inhibitors. It
works by helping to relax the blood vessels in your penis, allowing blood to flow into your penis
when you get sexually excited. VIAGRA will only help you to get an erection if you are sexually
stimulated. You should not take VIAGRA if you do not have erectile dysfunction. You should not
take VIAGRA if you are a woman.
VIAGRA is a treatment for men with erectile dysfunction, sometimes known as impotence. This is
when a man cannot get, or keep a hard, erect penis suitable for sexual activity.
2.
BEFORE YOU TAKE VIAGRA
Do not take VIAGRA
If you are taking medicines called nitrates, as the combination may cause a potentially
dangerous decrease in your blood pressure. Tell your doctor if you are taking any of these
medicines which are often given for relief of angina pectoris (or “chest pain”). If you are not
certain, ask your doctor or pharmacist.
If you are using any of the drugs known as nitric oxide donors such as amyl nitrite (“poppers”),
as the combination may also lead to a potentially dangerous decrease in your blood pressure.
If you are allergic (hypersensitive) to sildenafil or any of the other ingredients of VIAGRA.
If you have a severe heart or liver problem.
If you have recently had a stroke or a heart attack, or if you have low blood pressure.
If you have certain rare inherited eye diseases (such as
retinitis pigmentosa
).
51
If you have ever had loss of vision due to non-arteritic anterior ischaemic optic neuropathy
(NAION).
Take special care with VIAGRA
Tell your doctor
If you have sickle cell anaemia (an abnormality of red blood cells), leukaemia (cancer of blood
cells), multiple myeloma (cancer of bone marrow).
If you have a deformity of your penis or Peyronie’s Disease.
If you have problems with your heart. Your doctor should in that case carefully check whether
your heart can take the additional strain of having sex.
If you currently have a stomach ulcer, or a bleeding problems (such as haemophilia).
If you experience sudden decrease or loss of vision, stop taking VIAGRA and contact your
doctor immediately.
You should not use VIAGRA with any other oral or local treatments for erectile dysfunction.
Special considerations for children and adolescents
VIAGRA should not be given to individuals under the age of 18.
Special considerations for patients with kidney or liver problems
You should tell your doctor if you have kidney or liver problems. Your doctor may decide on a lower
dose for you.
Taking other medicines:
Please tell your doctor or pharmacist if you are taking or have recently taken other medicines,
including medicines obtained without prescription.
VIAGRA tablets may interfere with some medicines, especially those used to treat chest pain. In the
event of a medical emergency, you should tell any health care professional treating your condition
that you have taken VIAGRA and when you did. Do not take VIAGRA with other medicines unless
your doctor tells you that you can.
You should not take VIAGRA if you are taking medicines called nitrates, as the combination of
these products may cause a potentially dangerous decrease in your blood pressure. Always tell your
doctor or pharmacist if you are taking any of these medicines that are often used for the relief of
angina pectoris (or “chest pain”).
You should not take Viagra if you are using any of the drugs known as nitric oxide donors such as
amyl nitrite (“poppers”) as the combination may also lead to a potentially dangerous decrease in your
blood pressure.
If you are taking medicines known as protease inhibitors, such as for the treatment of HIV, your
doctor may start you on the lowest dose (25 mg) of VIAGRA.
Some patients who take alpha-blocker therapy for the treatment of high blood pressure or prostate
enlargement may experience dizziness or light-headedness, which may be caused by low blood
pressure upon sitting or standing up quickly. Certain patients have experienced these symptoms when
taking VIAGRA with alpha-blockers. This is most likely to occur within 4 hours after taking
VIAGRA. In order to reduce the likelihood that these symptoms occur, you should be on a regular
52
daily dose of your alpha-blocker before you start VIAGRA. Your doctor may start you on a lower
dose (25 mg) of VIAGRA.
Taking VIAGRA with food and drink
VIAGRA can be taken with or without food. However, you may find that VIAGRA takes longer to
start working if you take it with a heavy meal.
Drinking alcohol can temporarily impair your ability to get an erection. To get the maximum benefit
from your medicine, you are advised not to drink excessive amounts of alcohol before taking
VIAGRA.
Pregnancy and Breast feeding
VIAGRA is not indicated for use by women.
Driving and using machines
VIAGRA can cause dizziness and can affect vision. You should be aware of how you react to
VIAGRA before you drive or use machinery.
Important information about some of the ingredients of VIAGRA
If you have been told by your doctor that you have an intolerance to some sugars, such as lactose,
contact your doctor before taking VIAGRA.
3.
HOW TO TAKE VIAGRA
Always take VIAGRA exactly as your doctor has told you. You should check with your doctor or
pharmacist if you are not sure. The usual starting dose is 50 mg.
You should not take VIAGRA more than once a day.
You should take VIAGRA about one hour before you plan to have sex. Swallow the tablet whole
with a glass of water.
If you have the impression that the effect of VIAGRA is too strong or too weak, talk to your doctor or
pharmacist.
VIAGRA will only help you to get an erection if you are sexually stimulated. The amount of time
VIAGRA takes to work varies from person to person, but it normally takes between half an hour and
one hour. You may find that VIAGRA takes longer to work if you take it with a heavy meal.
If VIAGRA does not help you to get an erection, or if your erection does not last long enough for you
to complete sexual intercourse you should tell your doctor.
If you take more VIAGRA than you should:
You may experience an increase in side effects and their severity. Doses above 100 mg do not
increase the efficacy.
You should not take more tablets than your doctor tells you to.
Contact your doctor if you take more tablets than you should.
If you have any further questions on the use of this medicine, ask your doctor or pharmacist.
53
4.
POSSIBLE SIDE EFFECTS
Like all medicines, VIAGRA can cause side effects although not everybody gets them. The side
effects reported in association with the use of Viagra are usually mild to moderate and of a short
duration.
If you have chest pains during or after intercourse:
- Get in a semi-sitting position and try to relax.
-
Do not use nitrates
to treat your chest pain.
- Contact your doctor immediately.
All medicines including VIAGRA can cause allergic reactions. You should contact your doctor
immediately if you experience any of the following symptoms after taking VIAGRA: sudden
wheeziness, difficulty in breathing or dizziness, swelling of the eyelids, face, lips or throat.
Prolonged and sometimes painful erections have been reported after taking VIAGRA. If you have an
erection which lasts for more than 4 hours, you should contact a doctor immediately.
If you experience a sudden decrease or loss of vision,
stop taking VIAGRA and contact your doctor
immediately.
A very common side effect
(likely to occur in more than 1 in 10 patients) is headache.
Common side effects
(likely to occur in 1 to 10 patients in 100) include: facial flushing, indigestion,
effects on vision (including colour tinge to vision, light sensitivity, blurred vision or reduced
sharpness of vision) stuffy nose and dizziness.
Uncommon side effects
(likely to occur in 1 to 10 patients in 1000) include: vomiting, , skin rash,
bleeding at the back of the eye, eye irritation, bloodshot eyes /red eyes, eye pain, double vision,
abnormal sensation in the eye, irregular or rapid heartbeat, muscle pain, feeling sleepy, reduced sense
of touch, vertigo, ringing in the ears, nausea, dry mouth, chest pain and feeling tired.
Rare side effects
(likely to occur in 1 to 10 patients in 10000) include: high blood pressure, low
blood pressure, fainting, stroke, nosebleed and sudden decrease or loss of hearing.
Additional side effects reported from post-marketing experience include: pounding heartbeat, chest
pain, sudden death, heart attack or temporary decreased blood flow to parts of the brain. Most, but not
all, of these men had heart problems before taking this medicine. It is not possible to determine
whether these events were directly related to VIAGRA. Cases of convulsions or seizures and serious
skin reactions characterised by rash, blisters, peeling skin and pain which require immediate medical
attention have also been reported.
If any of the side effects get serious, or if you notice any side effects not listed in this leaflet please
tell your doctor.
5.
HOW TO STORE VIAGRA
Keep out of the reach and sight of children
Do not store above 30
o
C.
Store in the original package, in order to protect from moisture.
Do not use VIAGRA after the expiry date which is stated on the carton. The expiry date refers to the
last day of that month.
54
Medicines should not be disposed of via wastewater or household waste. Ask your pharmacist how to
dispose of medicines no longer required. These measures will help to protect the environment.
6.
FURTHER INFORMATION
What VIAGRA contains
The active substance is sildenafil. Each tablet contains 25 mg of sildenafil (as the citrate salt).
The other ingredients are:
Tablet core: microcrystalline cellulose, calcium hydrogen phosphate (anhydrous),
croscarmellose sodium, magnesium stearate,
Film coat:
hypromellose, titanium dioxide (E171), lactose, triacetin, indigo carmine
What VIAGRA looks like and contents of the pack
VIAGRA film-coated tablets are blue, with a rounded-diamond shape. They are marked “PFIZER” on
one side and “VGR 25” on the other side. The tablets are provided in blister packs containing 2, 4, 8
or 12 tablets. Some pack sizes may not be marketed in your country.
Marketing Authorisation Holder and Manufacturer
The marketing authorisation holder of VIAGRA is Pfizer Limited, Sandwich, Kent, CT13 9NJ,
United Kingdom.
The manufacturer of VIAGRA is Pfizer PGM, Zone Industrielle, 29 route des Industries, 37530 Pocé-
sur-Cisse, France.
For any information about this medicinal product, please contact the local representative of the
Marketing Authorisation Holder.
België /Belgique / Belgien
Pfizer S.A./ N.V.
Tél/Tel: +32 (0)2 554 62 11
Luxembourg/Luxemburg
Pfizer S.A.
Tél/Tel: +32 (0)2 554 62 11
България
Пфайзер Люксембург САРЛ, Клон България
Тел.: +359 2 970 4333
Magyarország
Pfizer Kft.
Tel.: + 36 1 488 37 00
Česká republika
Pfizer s.r.o.
Tel: +420-283-004-111
Malta
V.J. Salomone Pharma Ltd.
Tel: + 356 21 22 01 74
Danmark
Pfizer ApS
Tlf: +45 44 20 11 00
Nederland
Pfizer bv
Tel: +31 (0)10 406 43 01
Deutschland
Pfizer Pharma GmbH
Tel: +49 (0)30 550055 51000
Norge
Pfizer AS
Tlf: +47 67 52 61 00
Eesti
Pfizer Luxembourg SARL, Eesti filiaal
Tel: +372 6 405 328
Österreich
Pfizer Corporation Austria Ges.m.b.H.
Tel: +43 (0)1 521 15-0
55
aluminium lake (E132)
Ελλάδα
Pfizer Hellas A.E.
Τλ: +30 210 6785800
Polska
Pfizer Polska Sp. z o.o.,
Tel.: +48 22 335 61 00
España
Pfizer S.A.
Tel: +34 91 490 99 00
Portugal
Laboratórios Pfizer, Lda.
Tel: +351 21 423 5500
France
Pfizer
Tél: +33 (0)1 58 07 34 40
România
Pfizer România S.R.L.
Tel: +40 (0)21 207 28 00
Ireland
Pfizer Healthcare Ireland
Tel: 1800 633 363 (toll free)
Tel: +44 (0)1304 616161
Slovenija
Pfizer Luxembourg SARL, Pfizer, podružnica za
svetovanje s področja farmacevtske dejavnosti,
Ljubljana
Tel: + 386(0)152 11 400
Ísland
Vistor hf.
Sími: + 354 535 7000
Slovenská republika
Pfizer Luxembourg SARL, organizačná zložka
Tel: +421–2–3355 5500
Italia
Pfizer Italia S.r.l.
Tel: +39 06 33 18 21
Suomi/Finland
Pfizer Oy
Puh/Tel: +358(0)9 43 00 40
Κύπρος
GEO. PAVLIDES & ARAOUZOS LTD,
Τηλ: +35722818087
Sverige
Pfizer AB
Tel: +46 (0)8 550 520 00
Latvija
Pfizer Luxembourg SARL filiāle Latvijā
Tel: +371 670 35 775
United Kingdom
Pfizer Limited
Tel: +44 (0)1304 616161
Lietuva
Pfizer Luxembourg SARL, filialas Lietuvoje
Tel. +3705 2514000
This leaflet was last approved in
Detailed information on VIAGRA is available on the European Medicines Agency web site:
http://www.ema.europa.eu/
56
PACKAGE LEAFLET: INFORMATION FOR THE USER
VIAGRA 50 mg film-coated tablets
Sildenafil citrate
Read all of this leaflet carefully before you start taking this medicine.
Keep this leaflet. You may need to read it again.
If you have any further questions, please ask your doctor or pharmacist.
This medicine has been prescribed for you. Do not pass it on to others. It may harm them, even
if their symptoms are the same as yours.
If any of the side effects get serious, or you notice any side effects not listed in this leaflet,
please tell your doctor or pharmacist.
In this leaflet:
1.
What VIAGRA is and what it is used for
2.
Before you take VIAGRA
3.
How to take VIAGRA
4.
Possible side effects
5.
How to store VIAGRA
6.
Further information
1.
WHAT VIAGRA IS AND WHAT IT IS USED FOR
VIAGRA belongs to a group of medicines called phosphodiesterase type 5 (PDE5) inhibitors. It
works by helping to relax the blood vessels in your penis, allowing blood to flow into your penis
when you get sexually excited. VIAGRA will only help you to get an erection if you are sexually
stimulated. You should not take VIAGRA if you do not have erectile dysfunction. You should not
take VIAGRA if you are a woman.
VIAGRA is a treatment for men with erectile dysfunction, sometimes known as impotence. This is
when a man cannot get, or keep a hard, erect penis suitable for sexual activity.
2.
BEFORE YOU TAKE VIAGRA
Do not take VIAGRA
If you are taking medicines called nitrates, as the combination may cause a potentially
dangerous decrease in your blood pressure. Tell your doctor if you are taking any of these
medicines which are often given for relief of angina pectoris (or “chest pain”). If you are not
certain, ask your doctor or pharmacist.
If you are using any of the drugs known as nitric oxide donors such as amyl nitrite (“poppers”),
as the combination may also lead to a potentially dangerous decrease in your blood pressure.
If you are allergic (hypersensitive) to sildenafil or any of the other ingredients of VIAGRA.
If you have a severe heart or liver problem.
If you have recently had a stroke or a heart attack, or if you have low blood pressure.
If you have certain rare inherited eye diseases (such as
retinitis pigmentosa
).
57
If you have ever had loss of vision due to non-arteritic anterior ischaemic optic neuropathy
(NAION).
Take special care with VIAGRA
Tell your doctor
If you have sickle cell anaemia (an abnormality of red blood cells), leukaemia (cancer of blood
cells), multiple myeloma (cancer of bone marrow).
If you have a deformity of your penis or Peyronie’s Disease.
If you have problems with your heart. Your doctor should in that case carefully check whether
your heart can take the additional strain of having sex.
If you currently have a stomach ulcer, or a bleeding problems (such as haemophilia).
If you experience sudden decrease or loss of vision, stop taking VIAGRA and contact your
doctor immediately.
You should not use VIAGRA with any other oral or local treatments for erectile dysfunction.
Special considerations for children and adolescents
VIAGRA should not be given to individuals under the age of 18.
Special considerations for patients with kidney or liver problems
You should tell your doctor if you have kidney or liver problems. Your doctor may decide on a lower
dose for you.
Taking other medicines:
Please tell your doctor or pharmacist if you are taking or have recently taken other medicines,
including medicines obtained without prescription.
VIAGRA tablets may interfere with some medicines, especially those used to treat chest pain. In the
event of a medical emergency, you should tell any health care professional treating your condition
that you have taken VIAGRA and when you did. Do not take VIAGRA with other medicines unless
your doctor tells you that you can.
You should not take VIAGRA if you are taking medicines called nitrates, as the combination of
these products may cause a potentially dangerous decrease in your blood pressure. Always tell your
doctor or pharmacist if you are taking any of these medicines that are often used for the relief of
angina pectoris (or “chest pain”).
You should not take Viagra if you are using any of the drugs known as nitric oxide donors such as
amyl nitrite (“poppers”) as the combination may also lead to a potentially dangerous decrease in your
blood pressure.
If you are taking medicines known as protease inhibitors, such as for the treatment of HIV, your
doctor may start you on the lowest dose (25 mg) of VIAGRA.
Some patients who take alpha-blocker therapy for the treatment of high blood pressure or prostate
enlargement may experience dizziness or light-headedness, which may be caused by low blood
pressure upon sitting or standing up quickly. Certain patients have experienced these symptoms when
taking VIAGRA with alpha-blockers. This is most likely to occur within 4 hours after taking
VIAGRA. In order to reduce the likelihood that these symptoms occur, you should be on a regular
58
daily dose of your alpha-blocker before you start VIAGRA. Your doctor may start you on a lower
dose (25 mg) of VIAGRA.
Taking VIAGRA with food and drink
VIAGRA can be taken with or without food. However, you may find that VIAGRA takes longer to
start working if you take it with a heavy meal.
Drinking alcohol can temporarily impair your ability to get an erection. To get the maximum benefit
from your medicine, you are advised not to drink excessive amounts of alcohol before taking
VIAGRA.
Pregnancy and Breast feeding
VIAGRA is not indicated for use by women.
Driving and using machines
VIAGRA can cause dizziness and can affect vision. You should be aware of how you react to
VIAGRA before you drive or use machinery.
Important information about some of the ingredients of VIAGRA
If you have been told by your doctor that you have an intolerance to some sugars, such as lactose,
contact your doctor before taking VIAGRA.
3.
HOW TO TAKE VIAGRA
Always take VIAGRA exactly as your doctor has told you. You should check with your doctor or
pharmacist if you are not sure. The usual starting dose is 50 mg.
You should not take VIAGRA more than once a day.
You should take VIAGRA about one hour before you plan to have sex. Swallow the tablet whole with
a glass of water.
If you have the impression that the effect of VIAGRA is too strong or too weak, talk to your doctor or
pharmacist.
VIAGRA will only help you to get an erection if you are sexually stimulated. The amount of time
VIAGRA takes to work varies from person to person, but it normally takes between half an hour and
one hour. You may find that VIAGRA takes longer to work if you take it with a heavy meal.
If VIAGRA does not help you to get an erection, or if your erection does not last long enough for you
to complete sexual intercourse you should tell your doctor.
If you take more VIAGRA than you should:
You may experience an increase in side effects and their severity. Doses above 100 mg do not
increase the efficacy.
You should not take more tablets than your doctor tells you to.
Contact your doctor if you take more tablets than you should.
If you have any further questions on the use of this medicine, ask your doctor or pharmacist.
59
4.
POSSIBLE SIDE EFFECTS
Like all medicines, VIAGRA can cause side effects although not everybody gets them. The side
effects reported in association with the use of Viagra are usually mild to moderate and of a short
duration.
If you have chest pains during or after intercourse:
- Get in a semi-sitting position and try to relax.
-
Do not use nitrates
to treat your chest pain.
- Contact your doctor immediately.
All medicines including VIAGRA can cause allergic reactions. You should contact your doctor
immediately if you experience any of the following symptoms after taking VIAGRA: sudden
wheeziness, difficulty in breathing or dizziness, swelling of the eyelids, face, lips or throat.
Prolonged and sometimes painful erections have been reported after taking VIAGRA. If you have an
erection which lasts for more than 4 hours, you should contact a doctor immediately.
If you experience a sudden decrease or loss of vision,
stop taking VIAGRA and contact your doctor
immediately.
A very common side effect
(likely to occur in more than 1 in 10 patients) is headache.
Common side effects
(likely to occur in 1 to 10 patients in 100) include: facial flushing, indigestion,
effects on vision (including colour tinge to vision, light sensitivity, blurred vision or reduced
sharpness of vision) stuffy nose and dizziness.
Uncommon side effects
(likely to occur in 1 to 10 patients in 1000) include: vomiting, , skin rash,
bleeding at the back of the eye, eye irritation, bloodshot eyes /red eyes, eye pain, double vision,
abnormal sensation in the eye, irregular or rapid heartbeat, muscle pain, feeling sleepy, reduced sense
of touch, vertigo, ringing in the ears, nausea, dry mouth, chest pain and feeling tired.
Rare side effects
(likely to occur in 1 to 10 patients in 10000) include: high blood pressure, low
blood pressure, fainting, stroke, nosebleed and sudden decrease or loss of hearing.
Additional side effects reported from post-marketing experience include: pounding heartbeat, chest
pain, sudden death, heart attack or temporary decreased blood flow to parts of the brain. Most, but not
all, of these men had heart problems before taking this medicine. It is not possible to determine
whether these events were directly related to VIAGRA. Cases of convulsions or seizures and serious
skin reactions characterised by rash, blisters, peeling skin and pain which require immediate medical
attention have also been reported.
If any of the side effects get serious, or if you notice any side effects not listed in this leaflet please
tell your doctor.
5.
HOW TO STORE VIAGRA
Keep out of the reach and sight of children
Do not store above 30
o
C.
Store in the original package, in order to protect from moisture.
Do not use VIAGRA after the expiry date which is stated on the carton. The expiry date refers to the
last day of that month.
Medicines should not be disposed of via wastewater or household waste. Ask your pharmacist how to
dispose of medicines no longer required. These measures will help to protect the environment.
60
6.
FURTHER INFORMATION
What VIAGRA contains
The active substance is sildenafil. Each tablet contains 50 mg of sildenafil (as the citrate salt).
The other ingredients are:
Tablet core: microcrystalline cellulose, calcium hydrogen phosphate (anhydrous),
croscarmellose sodium, magnesium stearate,
Film coat:
hypromellose, titanium dioxide (E171), lactose, triacetin, indigo carmine
aluminium lake (E132)
What VIAGRA looks like and contents of the pack
VIAGRA film-coated tablets are blue, with a rounded-diamond shape. They are marked “PFIZER” on
one side and “VGR 50” on the other side. The tablets are provided in blister packs containing 2, 4, 8
or 12 tablets in a carton or card packaging. Some pack sizes may not be marketed in your country.
Marketing Authorisation Holder and Manufacturer
The marketing authorisation holder of VIAGRA is Pfizer Limited, Sandwich, Kent, CT13 9NJ,
United Kingdom.
The manufacturer of VIAGRA is Pfizer PGM, Zone Industrielle, 29 route des Industries, 37530 Pocé-
sur-Cisse, France.
For any information about this medicinal product, please contact the local representative of the
Marketing Authorisation Holder.
België /Belgique / Belgien
Pfizer S.A./ N.V.
Tél/Tel: +32 (0)2 554 62 11
Luxembourg/Luxemburg
Pfizer S.A.
Tél/Tel: +32 (0)2 554 62 11
България
Пфайзер Люксембург САРЛ, Клон България
Тел.: +359 2 970 4333
Magyarország
Pfizer Kft.
Tel.: + 36 1 488 37 00
Česká republika
Pfizer s.r.o.
Tel: +420-283-004-111
Malta
V.J. Salomone Pharma Ltd.
Tel: + 356 21 22 01 74
Danmark
Pfizer ApS
Tlf: +45 44 20 11 00
Nederland
Pfizer bv
Tel: +31 (0)10 406 43 01
Deutschland
Pfizer Pharma GmbH
Tel: +49 (0)30 550055 51000
Norge
Pfizer AS
Tlf: +47 67 52 61 00
Eesti
Pfizer Luxembourg SARL, Eesti filiaal
Tel: +372 6 405 328
Österreich
Pfizer Corporation Austria Ges.m.b.H.
Tel: +43 (0)1 521 15-0
61
Ελλάδα
Pfizer Hellas A.E.
Τλ: +30 210 6785800
Polska
Pfizer Polska Sp. z o.o.,
Tel.: +48 22 335 61 00
España
Pfizer S.A.
Tel: +34 91 490 99 00
Portugal
Laboratórios Pfizer, Lda.
Tel: +351 21 423 5500
France
Pfizer
Tél: +33 (0)1 58 07 34 40
România
Pfizer România S.R.L.
Tel: +40 (0)21 207 28 00
Ireland
Pfizer Healthcare Ireland
Tel: 1800 633 363 (toll free)
Tel: +44 (0)1304 616161
Slovenija
Pfizer Luxembourg SARL, Pfizer, podružnica za
svetovanje s področja farmacevtske dejavnosti,
Ljubljana
Tel: + 386(0)152 11 400
Ísland
Vistor hf.
Sími: + 354 535 7000
Slovenská republika
Pfizer Luxembourg SARL, organizačná zložka
Tel: +421–2–3355 5500
Italia
Pfizer Italia S.r.l.
Tel: +39 06 33 18 21
Suomi/Finland
Pfizer Oy
Puh/Tel: +358(0)9 43 00 40
Κύπρος
GEO. PAVLIDES & ARAOUZOS LTD,
Τηλ: +35722818087
Sverige
Pfizer AB
Tel: +46 (0)8 550 520 00
Latvija
Pfizer Luxembourg SARL filiāle Latvijā
Tel: +371 670 35 775
United Kingdom
Pfizer Limited
Tel: +44 (0)1304 616161
Lietuva
Pfizer Luxembourg SARL, filialas Lietuvoje
Tel. +3705 2514000
This leaflet was last approved in
Detailed information on VIAGRA is available on the European Medicines Agency web site:
http://www.ema.europa.eu/
62
PACKAGE LEAFLET: INFORMATION FOR THE USER
VIAGRA 100 mg film-coated tablets
Sildenafil citrate
Read all of this leaflet carefully before you start taking this medicine.
Keep this leaflet. You may need to read it again.
If you have any further questions, please ask your doctor or pharmacist.
This medicine has been prescribed for you. Do not pass it on to others. It may harm them, even
if their symptoms are the same as yours.
If any of the side effects get serious, or you notice any side effects not listed in this leaflet,
please tell your doctor or pharmacist.
In this leaflet:
1. What VIAGRA is and what it is used for
2.
Before you take VIAGRA
3.
How to take VIAGRA
4.
Possible side effects
5.
How to store VIAGRA
6.
Further information
1.
WHAT VIAGRA IS AND WHAT IT IS USED FOR
VIAGRA belongs to a group of medicines called phosphodiesterase type 5 (PDE5) inhibitors. It
works by helping to relax the blood vessels in your penis, allowing blood to flow into your penis
when you get sexually excited. VIAGRA will only help you to get an erection if you are sexually
stimulated. You should not take VIAGRA if you do not have erectile dysfunction. You should not
take VIAGRA if you are a woman.
VIAGRA is a treatment for men with erectile dysfunction, sometimes known as impotence. This is
when a man cannot get, or keep a hard, erect penis suitable for sexual activity.
2.
BEFORE YOU TAKE VIAGRA
Do not take VIAGRA
If you are taking medicines called nitrates, as the combination may cause a potentially
dangerous decrease in your blood pressure. Tell your doctor if you are taking any of these
medicines which are often given for relief of angina pectoris (or “chest pain”). If you are not
certain, ask your doctor or pharmacist.
If you are using any of the drugs known as nitric oxide donors such as amyl nitrite (“poppers”),
as the combination may also lead to a potentially dangerous decrease in your blood pressure.
If you are allergic (hypersensitive) to sildenafil or any of the other ingredients of VIAGRA.
If you have a severe heart or liver problem.
If you have recently had a stroke or a heart attack, or if you have low blood pressure.
If you have certain rare inherited eye diseases (such as
retinitis pigmentosa
).
63
If you have ever had loss of vision due to non-arteritic anterior ischaemic optic neuropathy
(NAION).
Take special care with VIAGRA
Tell your doctor
If you have sickle cell anaemia (an abnormality of red blood cells), leukaemia (cancer of blood
cells), multiple myeloma (cancer of bone marrow).
If you have a deformity of your penis or Peyronie’s Disease.
If you have problems with your heart. Your doctor should in that case carefully check whether
your heart can take the additional strain of having sex.
If you currently have a stomach ulcer, or a bleeding problems (such as haemophilia).
If you experience sudden decrease or loss of vision, stop taking VIAGRA and contact your
doctor immediately.
You should not use VIAGRA with any other oral or local treatments for erectile dysfunction.
Special considerations for children and adolescents
VIAGRA should not be given to individuals under the age of 18.
Special considerations for patients with kidney or liver problems
You should tell your doctor if you have kidney or liver problems. Your doctor may decide on a lower
dose for you.
Taking other medicines:
Please tell your doctor or pharmacist if you are taking or have recently taken other medicines,
including medicines obtained without prescription.
VIAGRA tablets may interfere with some medicines, especially those used to treat chest pain. In the
event of a medical emergency, you should tell any health care professional treating your condition
that you have taken VIAGRA and when you did. Do not take VIAGRA with other medicines unless
your doctor tells you that you can.
You should not take VIAGRA if you are taking medicines called nitrates, as the combination of
these products may cause a potentially dangerous decrease in your blood pressure. Always tell your
doctor or pharmacist if you are taking any of these medicines that are often used for the relief of
angina pectoris (or “chest pain”).
You should not take Viagra if you are using any of the drugs known as nitric oxide donors such as
amyl nitrite (“poppers”) as the combination may also lead to a potentially dangerous decrease in your
blood pressure.
If you are taking medicines known as protease inhibitors, such as for the treatment of HIV, your
doctor may start you on the lowest dose (25 mg) of VIAGRA.
Some patients who take alpha-blocker therapy for the treatment of high blood pressure or prostate
enlargement may experience dizziness or light-headedness, which may be caused by low blood
pressure upon sitting or standing up quickly. Certain patients have experienced these symptoms when
taking VIAGRA with alpha-blockers. This is most likely to occur within 4 hours after taking
VIAGRA. In order to reduce the likelihood that these symptoms occur, you should be on a regular
64
daily dose of your alpha-blocker before you start VIAGRA. Your doctor may start you on a lower
dose (25 mg) of VIAGRA.
Taking VIAGRA with food and drink
VIAGRA can be taken with or without food. However, you may find that VIAGRA takes longer to
start working if you take it with a heavy meal.
Drinking alcohol can temporarily impair your ability to get an erection. To get the maximum benefit
from your medicine, you are advised not to drink excessive amounts of alcohol before taking
VIAGRA.
Pregnancy and Breast feeding
VIAGRA is not indicated for use by women.
Driving and using machines
VIAGRA can cause dizziness and can affect vision. You should be aware of how you react to
VIAGRA before you drive or use machinery.
Important information about some of the ingredients of VIAGRA
If you have been told by your doctor that you have an intolerance to some sugars, such as lactose,
contact your doctor before taking VIAGRA.
3.
HOW TO TAKE VIAGRA
Always take VIAGRA exactly as your doctor has told you. You should check with your doctor or
pharmacist if you are not sure. The usual starting dose is 50 mg.
You should not take VIAGRA more than once a day.
You should take VIAGRA about one hour before you plan to have sex. Swallow the tablet whole with
a glass of water.
If you have the impression that the effect of VIAGRA is too strong or too weak, talk to your doctor or
pharmacist.
VIAGRA will only help you to get an erection if you are sexually stimulated. The amount of time
VIAGRA takes to work varies from person to person, but it normally takes between half an hour and
one hour. You may find that VIAGRA takes longer to work if you take it with a heavy meal.
Drinking alcohol can temporarily impair the ability to get an erection. To get the maximum benefit
from your medicine, you are advised not to drink large amounts of alcohol before taking VIAGRA.
If VIAGRA does not help you to get an erection, or if your erection does not last long enough for you
to complete sexual intercourse you should tell your doctor.
If you take more VIAGRA than you should:
You may experience an increase in side effects and their severity. Doses above 100 mg do not
increase the efficacy.
You should not take more tablets than your doctor tells you to.
Contact your doctor if you take more tablets than you should.
If you have any further questions on the use of this medicine, ask your doctor or pharmacist.
65
4.
POSSIBLE SIDE EFFECTS
Like all medicines, VIAGRA can cause side effects although not everybody gets them. The side
effects reported in association with the use of Viagra are usually mild to moderate and of a short
duration.
If you have chest pains during or after intercourse:
- Get in a semi-sitting position and try to relax.
-
Do not use nitrates
to treat your chest pain.
- Contact your doctor immediately.
All medicines including VIAGRA can cause allergic reactions. You should contact your doctor
immediately if you experience any of the following symptoms after taking VIAGRA: sudden
wheeziness, difficulty in breathing or dizziness, swelling of the eyelids, face, lips or throat.
Prolonged and sometimes painful erections have been reported after taking VIAGRA. If you have an
erection which lasts for more than 4 hours, you should contact a doctor immediately.
If you experience a sudden decrease or loss of vision,
stop taking VIAGRA and contact your doctor
immediately.
A very common side effect
(likely to occur in more than 1 in 10 patients)is headache.
Common side effects
(likely to occur in 1 to 10 patients in 100) include: facial flushing, indigestion,
effects on vision (including colour tinge to vision, light sensitivity, blurred vision or reduced
sharpness of vision) stuffy nose and dizziness.
Uncommon side effects
(likely to occur in 1 to 10 patients in 1000) include: vomiting, , skin rash,
bleeding at the back of the eye, eye irritation, bloodshot eyes /red eyes, eye pain, double vision,
abnormal sensation in the eye, irregular or rapid heartbeat, muscle pain, feeling sleepy, reduced sense
of touch, vertigo, ringing in the ears, nausea, dry mouth, chest pain and feeling tired.
Rare side effects
(likely to occur in 1 to 10 patients in 10000) include: high blood pressure, low
blood pressure, fainting, stroke, nosebleed and sudden decrease or loss of hearing.
Additional side effects reported from post-marketing experience include: pounding heartbeat, chest
pain, sudden death, heart attack or temporary decreased blood flow to parts of the brain. Most, but not
all, of these men had heart problems before taking this medicine. It is not possible to determine
whether these events were directly related to VIAGRA. Cases of convulsions or seizures and serious
skin reactions characterised by rash, blisters, peeling skin and pain which require immediate medical
attention have also been reported.
If any of the side effects get serious, or if you notice any side effects not listed in this leaflet please
tell your doctor.
5.
HOW TO STORE VIAGRA
Keep out of the reach and sight of children
Do not store above 30
o
C.
Store in the original package, in order to protect from moisture.
Do not use VIAGRA after the expiry date which is stated on the carton. The expiry date refers to the
last day of that month.
66
Medicines should not be disposed of via wastewater or household waste. Ask your pharmacist how to
dispose of medicines no longer required. These measures will help to protect the environment.
6.
FURTHER INFORMATION
What VIAGRA contains
The active substance is sildenafil. Each tablet contains 100 mg of sildenafil (as the citrate salt).
The other ingredients are:
Tablet core: microcrystalline cellulose, calcium hydrogen phosphate (anhydrous),
croscarmellose sodium, magnesium stearate,
Film coat:
hypromellose, titanium dioxide (E171), lactose, triacetin, indigo carmine
What VIAGRA looks like and contents of the pack
VIAGRA film-coated tablets are blue, with a rounded-diamond shape. They are marked “PFIZER” on
one side and “VGR 100” on the other side. The tablets are provided in blister packs containing 2, 4, 8
or 12 tablets. Some pack sizes may not be marketed in your country.
Marketing Authorisation Holder and Manufacturer
The marketing authorisation holder of VIAGRA is Pfizer Limited, Sandwich, Kent, CT13 9NJ,
United Kingdom.
The manufacturer of VIAGRA is Pfizer PGM, Zone Industrielle, 29 route des Industries, 37530 Pocé-
sur-Cisse, France.
For any information about this medicinal product, please contact the local representative of the
Marketing Authorisation Holder.
België /Belgique / Belgien
Pfizer S.A./ N.V.
Tél/Tel: +32 (0)2 554 62 11
Luxembourg/Luxemburg
Pfizer S.A.
Tél/Tel: +32 (0)2 554 62 11
България
Пфайзер Люксембург САРЛ, Клон България
Тел.: +359 2 970 4333
Magyarország
Pfizer Kft.
Tel.: + 36 1 488 37 00
Česká republika
Pfizer s.r.o.
Tel: +420-283-004-111
Malta
V.J. Salomone Pharma Ltd.
Tel: + 356 21 22 01 74
Danmark
Pfizer ApS
Tlf: +45 44 20 11 00
Nederland
Pfizer bv
Tel: +31 (0)10 406 43 01
Deutschland
Pfizer Pharma GmbH
Tel: +49 (0)30 550055 51000
Norge
Pfizer AS
Tlf: +47 67 52 61 00
67
aluminium lake (E132)
Eesti
Pfizer Luxembourg SARL, Eesti filiaal
Tel: +372 6 405 328
Österreich
Pfizer Corporation Austria Ges.m.b.H.
Tel: +43 (0)1 521 15-0
Ελλάδα
Pfizer Hellas A.E.
Τλ: +30 210 6785800
Polska
Pfizer Polska Sp. z o.o.,
Tel.: +48 22 335 61 00
España
Pfizer S.A.
Tel: +34 91 490 99 00
Portugal
Laboratórios Pfizer, Lda.
Tel: +351 21 423 5500
France
Pfizer
Tél: +33 (0)1 58 07 34 40
România
Pfizer România S.R.L.
Tel: +40 (0)21 207 28 00
Ireland
Pfizer Healthcare Ireland
Tel: 1800 633 363 (toll free)
Tel: +44 (0)1304 616161
Slovenija
Pfizer Luxembourg SARL, Pfizer, podružnica za
svetovanje s področja farmacevtske dejavnosti,
Ljubljana
Tel: + 386(0)152 11 400
Ísland
Vistor hf.
Sími: + 354 535 7000
Slovenská republika
Pfizer Luxembourg SARL, organizačná zložka
Tel: +421–2–3355 5500
Italia
Pfizer Italia S.r.l.
Tel: +39 06 33 18 21
Suomi/Finland
Pfizer Oy
Puh/Tel: +358(0)9 43 00 40
Κύπρος
GEO. PAVLIDES & ARAOUZOS LTD,
Τηλ: +35722818087
Sverige
Pfizer AB
Tel: +46 (0)8 550 520 00
Latvija
Pfizer Luxembourg SARL filiāle Latvijā
Tel: +371 670 35 775
United Kingdom
Pfizer Limited
Tel: +44 (0)1304 616161
Lietuva
Pfizer Luxembourg SARL, filialas Lietuvoje
Tel. +3705 2514000
This leaflet was last approved in
Detailed information on VIAGRA is available on the European Medicines Agency web site:
http://www.ema.europa.eu/
68
Source: European Medicines Agency
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