Tadalafil, sold under the brand name Cialis among others, is a medication used to treat erectile dysfunction, benign prostatic hyperplasia, and pulmonary arterial hypertension. It is taken by mouth. Onset is typically within half an hour and the duration is up to 36 hours. Common side effects include headache, muscle pain, flushing, and nausea. Caution is advised in those with cardiovascular disease. Rare but serious side effects include a prolonged erection that can lead to damage to the penis, vision problems, and hearing loss. Tadalafil is not recommended in people taking nitrovasodilators such as nitroglycerin, as this may result in a serious drop in blood pressure. Tadalafil is a PDE5 inhibitor which increases blood flow to the penis. It also dilates blood vessels in the lungs, which lowers the pulmonary artery pressure. Tadalafil was approved for medical use in the United States in 2003. It is available as a generic medication. In 2022, it was the 172nd most commonly prescribed medication in the United States, with more than 3 million prescriptions.
Medical uses
Tadalafil is used to treat erectile dysfunction, benign prostatic hyperplasia, and pulmonary arterial hypertension. In the United States, tadalafil (as Cialis) is indicated for the treatment of erectile dysfunction and the signs and symptoms of benign prostatic hyperplasia; and (as Adcirca) for the treatment of pulmonary arterial hypertension to improve exercise ability.
Benign prostatic hyperplasia A meta-analysis found that tadalafil is an effective treatment for lower urinary tract symptoms due to benign prostatic hyperplasia and that such treatment had a low rate of adverse effects. Tadalafil is FDA-approved for males as a therapy to treat and prevent symptoms of benign prostatic hyperplasia, such as urinary urgency, hesitancy, weak stream, dribbling, and incontinence. Tadalafil was found to have similar benefits for lower urinary tract symptoms as the usually prescribed tamsulosin.
Pulmonary arterial hypertension Tadalafil is approved in the United States, Canada, and Japan to improve exercise ability in people with pulmonary arterial hypertension.
Adverse effects The most common potential side effects when using tadalafil are headache, stomach discomfort or pain, indigestion, burping, acid reflux, back pain, myalgia (pain in limbs and extremities), flushing, hypertension (or uncommonly hypotension), and stuffy/runny nose. Also common are dizziness, peripheral edema, fatigue, and urinary or respiratory tract infection; both diarrhea and constipation have been reported. Diarrhea was reported more frequently in patients 65 or older than in younger subjects. These side effects reflect the ability of PDE5 inhibition to cause vasodilation (causing blood vessels to widen) and usually resolve after a few hours.
Vision In May 2005, the US Food and Drug Administration (FDA) found that tadalafil (along with other PDE5 inhibitors) was associated with vision impairment related to NAION (non-arteritic anterior ischemic optic neuropathy). Most, but not all, of these patients, had underlying anatomic or vascular risk factors for the development of NAION, unrelated to PDE5 inhibitor use. The FDA concluded that they were not able to draw a cause and effect relationship, only an association; the label of all three PDE5 inhibitors was changed to alert clinicians to that fact. A 2019 meta-analysis found that tadalafil exposure was not associated with NAION.
Hearing In October 2007, the FDA announced that the labeling for all PDE5 inhibitors, including tadalafil, requires a more prominent warning of the potential risk of sudden hearing loss as the result of post-marketing reports of deafness associated with use of PDE5 inhibitors.
Metabolism Tadalafil is metabolized predominantly by the liver CYP3A4 enzyme system.
Mechanism of action Penile erection during sexual stimulation is caused by increased penile blood flow resulting from the relaxation of penile arteries and the smooth muscle of the corpus cavernosum. This response is mediated by the release of nitric oxide (NO) from nerve terminals and endothelial cells, which stimulates the synthesis of cyclic guanosine monophosphate (more commonly known as cyclic GMP or cGMP) in smooth muscle cells. cGMP relaxes smooth muscle and increases blood flow to the corpus cavernosum. The inhibition of phosphodiesterase type 5 (PDE5) enhances erectile function by increasing the amount of cGMP. Tadalafil (and sildenafil and vardenafil) inhibits PDE5. However, because sexual stimulation is required to initiate the local penile release of nitric oxide, tadalafil's inhibition of PDE5 will have no effect without sexual stimulation.
Duration of action Although sildenafil, vardenafil, and tadalafil all work by inhibiting PDE5, tadalafil's pharmacologic distinction is its longer half-life (17.5 hours), compared to sildenafil and vardenafil, which are both 4–5 hours. This translates to a longer duration of action, which is partly responsible for "The Weekend Pill" nickname. Furthermore, the longer half-life is the basis for tadalafil's daily therapeutic use in treating pulmonary arterial hypertension.
Comparison with actions of other PDE5 inhibitors Sildenafil and vardenafil inhibit PDE6, an enzyme found in the eye, more than tadalafil. Some sildenafil users see a bluish tinge and have a heightened sensitivity to light because of PDE6 inhibition. Sildenafil and vardenafil also inhibit PDE1 more than tadalafil. PDE1 is found in the brain, heart, and vascular smooth muscle. It is thought that the inhibition of PDE1 by sildenafil and vardenafil leads to vasodilation, flushing, and tachycardia. Tadalafil inhibits PDE11 more than sildenafil or vardenafil. PDE11 is expressed in skeletal muscle, the prostate, the liver, the kidney, the pituitary gland, and the testes. The effects on the body of inhibiting PDE11 are not known.
Chemistry Tadalafil is an annulated 2,5-diketopiperazine. It is also a 1,2,3,4-tetrahydro-β-carboline. Tadalafil can be synthesized starting from (D)-tryptophan methyl ester and piperonal via a Pictet–Spengler reaction. This is followed by condensations with chloroacetyl chloride and methylamine to complete the diketopiperazine ring:
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