OPINION: Viagra - Balancing medical need and responsible use for erectile dysfunction

Sildenafil Citrate, the active molecule in the medication Viagra, was initially developed by Pfizer for the treatment of heart conditions such as pulmonary hypertension and angina pectoris. Pulmonary hypertension refers to elevated blood pressure in the vessels that carry oxygen-poor blood from the heart to the lungs, while angina pectoris refers to chest pain caused by coronary heart disease.

The proposed mechanism of action of sildenafil in these heart conditions involved the dilation of blood vessels by inhibiting a protein called PDE5, leading to the subsequent development of similar drugs known as PDE5 inhibitors.

During the clinical trials for sildenafil's approval, an interesting observation was made. Men participating in these trials exhibited behaviour indicating embarrassment and often preferred to lie on their stomachs. Nurses discovered that this behaviour was due to the men experiencing erections. Researchers concluded that while the drug was indeed effective, it was dilating the blood vessels in the penis instead of the intended heart vessels, resulting in erections. In 1998, the FDA approved sildenafil for the treatment of erectile dysfunction, a deviation from its original intended purpose. This accidental discovery of a new use during the investigation of another use is commonly referred to as drug discovery by serendipity (fun fact: penicillin antibiotics were also discovered by serendipity).

Erectile dysfunction, defined as the inability to achieve or maintain an erection suitable for sexual activity, encompasses a range of diagnostic criteria. These criteria include the ability to attain an erection suitable for penetration, the hardness of the erection, the ability to maintain the erection and achieve ejaculation, and the time required to achieve orgasm. A comprehensive assessment involves considering the patient's psychological history, sexual history, medical and surgical history, as well as their use of medications and non-prescription drugs. Information obtained from this history-taking process can be utilized to educate both the patient and their partner and guide the implementation of both pharmacological and non-pharmacological interventions.

The diagnosis and treatment of erectile dysfunction are complex, and it is crucial to identify underlying causes before initiating pharmacotherapy. Certain prescription medications, such as antihypertensives and antidepressants, have been associated with erectile dysfunction. Additionally, the patient's psychological state should be evaluated, as conditions like depression, insomnia, mood swings, and lethargy have been linked to erectile dysfunction. Commencing treatment for erectile dysfunction without addressing these underlying issues may prove futile and potentially foster dependence on PDE5 inhibitors.

Given the complexities involved in obtaining an accurate diagnosis for erectile dysfunction, the casual use of sildenafil, commonly known as the blue pill or Viagra, should not be as widespread as it is today. Not everyone seeking Viagra over the counter necessarily requires it. In fact, access to this medication should be restricted, and it should be available only as a prescription-only medicine.This precautionary approach is primarily due to the growing instances of misuse of the pill, including by very young men who may not necessarily need it. Instead, these individuals could potentially enhance their sexual performance naturally through exercise and dietary considerations.

By making sildenafil a prescription-only medication, healthcare professionals can ensure that it is used appropriately and only when medically necessary. This approach helps safeguard against misuse and promotes a more responsible use of the medication, focusing on those who genuinely require it for the treatment of erectile dysfunction under proper medical supervision.

[The writer is a Medical Superintendent at Caremark Hospital.]