CLINICAL PHARMACOLOGY
Mechanism Of Action
Penile erection during sexual
stimulation is caused by increased penile blood flow resulting from the
relaxation of penile arteries and corpus cavernosal smooth muscle. This response
is mediated by the release of nitric oxide (NO) from nerve terminals and
endothelial cells, which stimulates the synthesis of cGMP in smooth muscle
cells. Cyclic GMP causes smooth muscle relaxation and increased blood flow into
the corpus cavernosum. The inhibition of phosphodiesterase type 5 (PDE5)
enhances erectile function by increasing the amount of cGMP. Tadalafil inhibits
PDE5. Because sexual stimulation is required to initiate the local release of
nitric oxide, the inhibition of PDE5 by tadalafil has no effect in the absence
of sexual stimulation.
The effect of PDE5 inhibition
on cGMP concentration in the corpus cavernosum and pulmonary arteries is also
observed in the smooth muscle of the prostate, the bladder and their vascular
supply. The mechanism for reducing BPH symptoms has not been established.
Studies in vitro have
demonstrated that tadalafil is a selective inhibitor of PDE5. PDE5 is found in
the smooth muscle of the corpus cavernosum, prostate, and bladder as well as in
vascular and visceral smooth muscle, skeletal muscle, urethra, platelets,
kidney, lung, cerebellum, heart, liver, testis, seminal vesicle, and pancreas.
In vitro studies have shown that the effect of tadalafil is more
potent on PDE5 than on other phosphodiesterases. These studies have shown that
tadalafil is >10,000-fold more potent for PDE5 than for PDE1, PDE2, PDE4,
and PDE7 enzymes, which are found in the heart, brain, blood vessels, liver,
leukocytes, skeletal muscle, and other organs. Tadalafil is >10,000-fold
more potent for PDE5 than for PDE3, an enzyme found in the heart and blood
vessels. Additionally, tadalafil is 700-fold more potent for PDE5 than for
PDE6, which is found in the retina and is responsible for phototransduction.
Tadalafil is >9,000-fold more potent for PDE5 than for PDE8, PDE9, and
PDE10. Tadalafil is 14-fold more potent for PDE5 than for PDE11A1 and 40-fold
more potent for PDE5 than for PDE11A4, two of the four known forms of PDE11.
PDE11 is an enzyme found in human prostate, testes, skeletal muscle and in
other tissues (e.g., adrenal cortex). In vitro, tadalafil inhibits human
recombinant PDE11A1 and, to a lesser degree, PDE11A4 activities at
concentrations within the therapeutic range. The physiological role and
clinical consequence of PDE11 inhibition in humans have not been defined.
Pharmacodynamics
Effects On Blood Pressure
Tadalafil 20 mg administered to
healthy male subjects produced no significant difference compared to placebo in
supine systolic and diastolic blood pressure (difference in the mean maximal
decrease of 1.6/0.8 mm Hg, respectively) and in standing systolic and diastolic
blood pressure (difference in the mean maximal decrease of 0.2/4.6 mm Hg,
respectively). In addition, there was no significant effect on heart rate.
Effects On Blood Pressure When
Administered With Nitrates
In clinical pharmacology
studies, tadalafil (5 to 20 mg) was shown to potentiate the hypotensive effect
of nitrates. Therefore, the use of CIALIS in patients taking any form of
nitrates is contraindicated [see CONTRAINDICATIONS].
A study was conducted to assess
the degree of interaction between nitroglycerin and tadalafil, should
nitroglycerin be required in an emergency situation after tadalafil was taken.
This was a double-blind, placebo-controlled, crossover study in 150 male
subjects at least 40 years of age (including subjects with diabetes mellitus
and/or controlled hypertension) and receiving daily doses of tadalafil 20 mg or
matching placebo for 7 days. Subjects were administered a single dose of 0.4 mg
sublingual nitroglycerin (NTG) at pre-specified timepoints, following their
last dose of tadalafil (2, 4, 8, 24, 48, 72, and 96 hours after tadalafil). The
objective of the study was to determine when, after tadalafil dosing, no
apparent blood pressure interaction was observed. In this study, a significant
interaction between tadalafil and NTG was observed at each timepoint up to and
including 24 hours. At 48 hours, by most hemodynamic measures, the interaction
between tadalafil and NTG was not observed, although a few more tadalafil
subjects compared to placebo experienced greater blood-pressure lowering at
this timepoint. After 48 hours, the interaction was not detectable (see Figure
1).
Figure 1: Mean Maximal
Change in Blood Pressure (Tadalafil Minus Placebo, Point Estimate with 90% CI)
in Response to Sublingual Nitroglycerin at 2 (Supine Only), 4, 8, 24, 48, 72,
and 96 Hours after the Last Dose of Tadalafil 20 mg or Placebo
Therefore, CIALIS
administration with nitrates is contraindicated. In a patient who has taken
CIALIS, where nitrate administration is deemed medically necessary in a
life-threatening situation, at least 48 hours should elapse after the last dose
of CIALIS before nitrate administration is considered. In such circumstances,
nitrates should still only be administered under close medical supervision with
appropriate hemodynamic monitoring [see CONTRAINDICATIONS].
Effect On Blood Pressure When
Administered With Alpha-Blockers
Six randomized, double-blinded,
crossover clinical pharmacology studies were conducted to investigate the
potential interaction of tadalafil with alpha-blocker agents in healthy male
subjects [see DOSAGE AND ADMINISTRATION and WARNINGS AND
PRECAUTIONS]. In
four studies, a single oral dose of tadalafil was administered to healthy male subjects
taking daily (at least 7 days duration) an oral alpha-blocker. In two studies,
a daily oral alpha-blocker (at least 7 days duration) was administered to
healthy male subjects taking repeated daily doses of tadalafil.
Doxazosin
Three clinical pharmacology studies were conducted with
tadalafil and doxazosin, an alpha[1]adrenergic blocker.
In the first doxazosin study, a
single oral dose of tadalafil 20 mg or placebo was administered in a 2-period,
crossover design to healthy subjects taking oral doxazosin 8 mg daily (N=18
subjects). Doxazosin was administered at the same time as tadalafil or placebo
after a minimum of seven days of doxazosin dosing (see Table 5 and Figure 2).
Table 5: Doxazosin (8
mg/day) Study 1: Mean Maximal Decrease (95% CI) in Systolic Blood Pressure
Placebo-subtracted mean maximal decrease in systolic blood pressure (mm Hg) |
Tadalafil 20 mg |
Supine |
3.6 (-1.5, 8.8) |
Standing |
9.8 (4.1, 15.5) |
Figure 2: Doxazosin Study 1:
Mean Change from Baseline in Systolic Blood Pressure
 |
Blood pressure was measured
manually at 1, 2, 3, 4, 5, 6, 7, 8, 10, 12, and 24 hours after tadalafil or
placebo administration. Outliers were defined as subjects with a standing
systolic blood pressure of <85 mm Hg or a decrease from baseline in standing
systolic blood pressure of >30 mm Hg at one or more time points. There were
nine and three outliers following administration of tadalafil 20 mg and
placebo, respectively. Five and two subjects were outliers due to a decrease
from baseline in standing systolic BP of >30 mm Hg, while five and one
subject were outliers due to standing systolic BP <85 mm Hg following
tadalafil and placebo, respectively. Severe adverse events potentially related
to blood-pressure effects were assessed. No such events were reported following
placebo. Two such events were reported following administration of tadalafil.
Vertigo was reported in one subject that began 7 hours after dosing and lasted
about 5 days. This subject previously experienced a mild episode of vertigo on
doxazosin and placebo. Dizziness was reported in another subject that began 25
minutes after dosing and lasted 1 day. No syncope was reported.
In the second doxazosin study,
a single oral dose of tadalafil 20 mg was administered to healthy subjects
taking oral doxazosin, either 4 or 8 mg daily. The study (N=72 subjects) was
conducted in three parts, each a 3-period crossover.
In part A (N=24), subjects were
titrated to doxazosin 4 mg administered daily at 8 a.m. Tadalafil was
administered at either 8 a.m., 4 p.m., or 8 p.m. There was no placebo control.
In part B (N=24), subjects were
titrated to doxazosin 4 mg administered daily at 8 p.m. Tadalafil was
administered at either 8 a.m., 4 p.m., or 8 p.m. There was no placebo control.
In part C (N=24), subjects were
titrated to doxazosin 8 mg administered daily at 8 a.m. In this part, tadalafil
or placebo were administered at either 8 a.m. or 8 p.m.
The placebo-subtracted mean
maximal decreases in systolic blood pressure over a 12-hour period after dosing
in the placebo-controlled portion of the study (part C) are shown in Table 6
and Figure 3.
Table 6: Doxazosin (8
mg/day) Study 2 (Part C): Mean Maximal Decrease in Systolic Blood Pressure
Placebo-subtracted mean maximal decrease in systolic blood pressure (mm Hg) |
Tadalafil 20 mg at 8 a.m. |
Tadalafil 20 mg at 8 p.m. |
Ambulatory Blood-Pressure Monitoring (ABPM) |
7 |
8 |
Figure 3: Doxazosin Study 2 (Part C): Mean Change from Time-Matched Baseline in Systolic Blood Pressure
Blood pressure was measured by
ABPM every 15 to 30 minutes for up to 36 hours after tadalafil or placebo.
Subjects were categorized as outliers if one or more systolic blood pressure
readings of <85 mm Hg were recorded or one or more decreases in systolic
blood pressure of >30 mm Hg from a time-matched baseline occurred during the
analysis interval.
Of the 24 subjects in part C,
16 subjects were categorized as outliers following administration of tadalafil
and 6 subjects were categorized as outliers following placebo during the
24-hour period after 8 a.m. dosing of tadalafil or placebo. Of these, 5 and 2
were outliers due to systolic BP <85 mm Hg, while 15 and 4 were outliers due
to a decrease from baseline in systolic BP of >30 mm Hg following tadalafil
and placebo, respectively.
During the 24-hour period after
8 p.m. dosing, 17 subjects were categorized as outliers following
administration of tadalafil and 7 subjects following placebo. Of these, 10 and
2 subjects were outliers due to systolic BP <85 mm Hg, while 15 and 5
subjects were outliers due to a decrease from baseline in systolic BP of >30
mm Hg, following tadalafil and placebo, respectively.
Some additional subjects in
both the tadalafil and placebo groups were categorized as outliers in the
period beyond 24 hours.
Severe adverse events
potentially related to blood-pressure effects were assessed. In the study (N=72
subjects), 2 such events were reported following administration of tadalafil
(symptomatic hypotension in one subject that began 10 hours after dosing and
lasted approximately 1 hour, and dizziness in another subject that began 11
hours after dosing and lasted 2 minutes). No such events were reported
following placebo. In the period prior to tadalafil dosing, one severe event
(dizziness) was reported in a subject during the doxazosin run-in phase.
In the third doxazosin study,
healthy subjects (N=45 treated; 37 completed) received 28 days of once per day
dosing of tadalafil 5 mg or placebo in a two-period crossover design. After 7
days, doxazosin was initiated at 1 mg and titrated up to 4 mg daily over the
last 21 days of each period (7 days on 1 mg; 7 days of 2 mg; 7 days of 4 mg
doxazosin). The results are shown in Table 7.
Table 7: Doxazosin Study 3:
Mean Maximal Decrease (95% CI) in Systolic Blood Pressure
Placebo-subtracted mean maximal decrease in systolic blood pressure |
Tadalafil 5 mg |
Day 1 of 4 mg Doxazosin |
Supine |
2.4 (-0.4, 5.2) |
Standing |
-0.5 (-4.0, 3.1) |
Day 7 of 4 mg Doxazosin |
Supine |
2.8 (-0.1, 5.7) |
Standing |
1.1 (-2.9, 5.0) |
Blood pressure was measured
manually pre-dose at two time points (-30 and -15 minutes) and then at 1, 2, 3,
4, 5, 6, 7, 8, 10, 12 and 24 hours post dose on the first day of each doxazosin
dose, (1 mg, 2 mg, 4 mg), as well as on the seventh day of 4 mg doxazosin
administration.
Following the first dose of doxazosin
1 mg, there were no outliers on tadalafil 5 mg and one outlier on placebo due
to a decrease from baseline in standing systolic BP of >30 mm Hg.
There were 2 outliers on tadalafil 5 mg and none on
placebo following the first dose of doxazosin 2 mg due to a decrease from
baseline in standing systolic BP of >30 mm Hg.
There were no outliers on
tadalafil 5 mg and two on placebo following the first dose of doxazosin 4 mg
due to a decrease from baseline in standing systolic BP of >30 mm Hg. There
was one outlier on tadalafil 5 mg and three on placebo following the first dose
of doxazosin 4 mg due to standing systolic BP <85 mm Hg. Following the
seventh day of doxazosin 4 mg, there were no outliers on tadalafil 5 mg, one
subject on placebo had a decrease >30 mm Hg in standing systolic blood
pressure, and one subject on placebo had standing systolic blood pressure
<85 mm Hg. All adverse events potentially related to blood pressure effects
were rated as mild or moderate. There were two episodes of syncope in this
study, one subject following a dose of tadalafil 5 mg alone, and another
subject following coadministration of tadalafil 5 mg and doxazosin 4 mg.
Tamsulosin
In the first tamsulosin study,
a single oral dose of tadalafil 10, 20 mg, or placebo was administered in a 3
period, crossover design to healthy subjects taking 0.4 mg once per day
tamsulosin, a selective alpha[1A]adrenergic blocker (N=18 subjects). Tadalafil
or placebo was administered 2 hours after tamsulosin following a minimum of
seven days of tamsulosin dosing.
Table 8: Tamsulosin (0.4
mg/day) Study 1: Mean Maximal Decrease (95% CI) in Systolic Blood Pressure
Placebo-subtracted mean maximal decrease in systolic blood pressure (mm Hg) |
Tadalafil 10 mg |
Tadalafil 20 mg |
Supine |
3.2 (-2.3, 8.6) |
3.2 (-2.3, 8.7) |
Standing |
1.7 (-4.7, 8.1) |
2.3 (-4.1, 8.7) |
Blood pressure was measured
manually at 1, 2, 3, 4, 5, 6, 7, 8, 10, 12, and 24 hours after tadalafil or
placebo dosing. There were 2, 2, and 1 outliers (subjects with a decrease from
baseline in standing systolic blood pressure of >30 mm Hg at one or more time
points) following administration of tadalafil 10 mg, 20 mg, and placebo,
respectively. There were no subjects with a standing systolic blood pressure
<85 mm Hg. No severe adverse events potentially related to blood-pressure
effects were reported. No syncope was reported.
In the second tamsulosin study,
healthy subjects (N=39 treated; and 35 completed) received 14 days of once per
day dosing of tadalafil 5 mg or placebo in a two-period crossover design. Daily
dosing of tamsulosin 0.4 mg was added for the last seven days of each period.
Table 9: Tamsulosin Study 2:
Mean Maximal Decrease (95% CI) in Systolic Blood Pressure
Placebo-subtracted mean maximal decrease in systolic blood pressure |
Tadalafil 5 mg |
Day 1 of 0.4 mg Tamsulosin |
Supine |
-0.1 (-2.2, 1.9) |
Standing |
0.9 (-1.4, 3.2) |
Day 7 of 0.4 mg Tamsulosin |
Supine |
1.2 (-1.2, 3.6) |
Standing |
1.2 (-1.0, 3.5) |
Blood pressure was measured
manually pre-dose at two time points (-30 and -15 minutes) and then at 1, 2, 3,
4, 5, 6, 7, 8, 10, 12, and 24 hours post dose on the first, sixth and seventh
days of tamsulosin administration. There were no outliers (subjects with a
decrease from baseline in standing systolic blood pressure of >30 mm Hg at
one or more time points). One subject on placebo plus tamsulosin (Day 7) and
one subject on tadalafil plus tamsulosin (Day 6) had standing systolic blood
pressure <85 mm Hg. No severe adverse events potentially related to blood
pressure were reported. No syncope was reported.
Alfuzosin
A single oral dose of tadalafil
20 mg or placebo was administered in a 2-period, crossover design to healthy
subjects taking once-daily alfuzosin HCl 10 mg extended-release tablets, an
alpha[1]-adrenergic blocker (N=17 completed subjects). Tadalafil or placebo was
administered 4 hours after alfuzosin following a minimum of seven days of
alfuzosin dosing.
Table 10: Alfuzosin (10
mg/day) Study: Mean Maximal Decrease (95% CI) in Systolic Blood Pressure
Placebo-subtracted mean maximal decrease in systolic blood pressure (mm Hg) |
Tadalafil 20 mg |
Supine |
2.2 (-0.9,-5.2) |
Standing |
4.4 (-0.2, 8.9) |
Blood pressure was measured
manually at 1, 2, 3, 4, 6, 8, 10, 20, and 24 hours after tadalafil or placebo
dosing. There was 1 outlier (subject with a standing systolic blood pressure
<85 mm Hg) following administration of tadalafil 20 mg. There were no
subjects with a decrease from baseline in standing systolic blood pressure of
>30 mm Hg at one or more time points. No severe adverse events potentially
related to blood pressure effects were reported. No syncope was reported.
Effects On Blood Pressure When
Administered With Antihypertensives
Amlodipine
A study was conducted to assess
the interaction of amlodipine (5 mg daily) and tadalafil 10 mg. There was no
effect of tadalafil on amlodipine blood levels and no effect of amlodipine on
tadalafil blood levels. The mean reduction in supine systolic/diastolic blood
pressure due to tadalafil 10 mg in subjects taking amlodipine was 3/2 mm Hg, compared
to placebo. In a similar study using tadalafil 20 mg, there were no clinically
significant differences between tadalafil and placebo in subjects taking
amlodipine.
Angiotensin II Receptor
Blockers (with and without other
antihypertensives)
A study was conducted to assess
the interaction of angiotensin II receptor blockers and tadalafil 20 mg.
Subjects in the study were taking any marketed angiotensin II receptor blocker,
either alone, as a component of a combination product, or as part of a multiple
antihypertensive regimen. Following dosing, ambulatory measurements of blood
pressure revealed differences between tadalafil and placebo of 8/4 mm Hg in
systolic/diastolic blood pressure.
Bendrofluazide
A study was conducted to assess
the interaction of bendrofluazide (2.5 mg daily) and tadalafil 10 mg. Following
dosing, the mean reduction in supine systolic/diastolic blood pressure due to
tadalafil 10 mg in subjects taking bendrofluazide was 6/4 mm Hg, compared to
placebo.
Enalapril
A study was conducted to assess
the interaction of enalapril (10 to 20 mg daily) and tadalafil 10 mg. Following
dosing, the mean reduction in supine systolic/diastolic blood pressure due to
tadalafil 10 mg in subjects taking enalapril was 4/1 mm Hg, compared to placebo.
Metoprolol
A study was conducted to assess
the interaction of sustained-release metoprolol (25 to 200 mg daily) and
tadalafil 10 mg. Following dosing, the mean reduction in supine
systolic/diastolic blood pressure due to tadalafil 10 mg in subjects taking
metoprolol was 5/3 mm Hg, compared to placebo.
Effects On Blood Pressure When
Administered With Alcohol
Alcohol and PDE5 inhibitors,
including tadalafil, are mild systemic vasodilators. The interaction of
tadalafil with alcohol was evaluated in 3 clinical pharmacology studies. In 2
of these, alcohol was administered at a dose of 0.7 g/kg, which is equivalent
to approximately 6 ounces of 80-proof vodka in an 80-kg male, and tadalafil was
administered at a dose of 10 mg in one study and 20 mg in another. In both
these studies, all patients imbibed the entire alcohol dose within 10 minutes
of starting. In one of these two studies, blood alcohol levels of 0.08% were
confirmed. In these two studies, more patients had clinically significant
decreases in blood pressure on the combination of tadalafil and alcohol as
compared to alcohol alone. Some subjects reported postural dizziness, and
orthostatic hypotension was observed in some subjects. When tadalafil 20 mg was
administered with a lower dose of alcohol (0.6 g/kg, which is equivalent to
approximately 4 ounces of 80-proof vodka, administered in less than 10
minutes), orthostatic hypotension was not observed, dizziness occurred with
similar frequency to alcohol alone, and the hypotensive effects of alcohol were
not potentiated.
Tadalafil did not affect
alcohol plasma concentrations and alcohol did not affect tadalafil plasma
concentrations.
Effects On Exercise Stress
Testing
The effects of tadalafil on
cardiac function, hemodynamics, and exercise tolerance were investigated in a
single clinical pharmacology study. In this blinded crossover trial, 23
subjects with stable coronary artery disease and evidence of exercise-induced cardiac
ischemia were enrolled. The primary endpoint was time to cardiac ischemia. The
mean difference in total exercise time was 3 seconds (tadalafil 10 mg minus
placebo), which represented no clinically meaningful difference. Further
statistical analysis demonstrated that tadalafil was non-inferior to placebo
with respect to time to ischemia. Of note, in this study, in some subjects who
received tadalafil followed by sublingual nitroglycerin in the post-exercise
period, clinically significant reductions in blood pressure were observed,
consistent with the augmentation by tadalafil of the blood-pressure-lowering
effects of nitrates.
Effects On Vision
Single oral doses of
phosphodiesterase inhibitors have demonstrated transient dose-related
impairment of color discrimination (blue/green), using the Farnsworth-Munsell
100-hue test, with peak effects near the time of peak plasma levels. This
finding is consistent with the inhibition of PDE6, which is involved in
phototransduction in the retina. In a study to assess the effects of a single
dose of tadalafil 40 mg on vision (N=59), no effects were observed on visual
acuity, intraocular pressure, or pupilometry. Across all clinical studies with
CIALIS, reports of changes in color vision were rare (<0.1% of patients).
Effects On Sperm
Characteristics
Three studies were conducted in
men to assess the potential effect on sperm characteristics of tadalafil 10 mg
(one 6 month study) and 20 mg (one 6 month and one 9 month study) administered
daily. There were no adverse effects on sperm morphology or sperm motility in
any of the three studies. In the study of 10 mg tadalafil for 6 months and the study
of 20 mg tadalafil for 9 months, results showed a decrease in mean sperm
concentrations relative to placebo, although these differences were not
clinically meaningful. This effect was not seen in the study of 20 mg tadalafil
taken for 6 months. In addition there was no adverse effect on mean
concentrations of reproductive hormones, testosterone, luteinizing hormone or
follicle stimulating hormone with either 10 or 20 mg of tadalafil compared to
placebo.
Effects On Cardiac Electrophysiology
The effect of a single 100-mg dose of tadalafil on the QT
interval was evaluated at the time of peak tadalafil concentration in a
randomized, double-blinded, placebo, and active (intravenous ibutilide)
-controlled crossover study in 90 healthy males aged 18 to 53 years. The mean
change in QTc (Fridericia QT correction) for tadalafil, relative to placebo,
was 3.5 milliseconds (two-sided 90% CI=1.9, 5.1). The mean change in QTc (Individual
QT correction) for tadalafil, relative to placebo, was 2.8 milliseconds
(two-sided 90% CI=1.2, 4.4). A 100-mg dose of tadalafil (5 times the highest
recommended dose) was chosen because this dose yields exposures covering those
observed upon coadministration of tadalafil with potent CYP3A4 inhibitors or
those observed in renal impairment. In this study, the mean increase in heart
rate associated with a 100-mg dose of tadalafil compared to placebo was 3.1
beats per minute.
Pharmacokinetics
Over a dose range of 2.5 to 20 mg, tadalafil exposure
(AUC) increases proportionally with dose in healthy subjects. Steady-state
plasma concentrations are attained within 5 days of once per day dosing and
exposure is approximately 1.6-fold greater than after a single dose. Mean
tadalafil concentrations measured after the administration of a single oral
dose of 20 mg and single and once daily multiple doses of 5 mg, from a separate
study, (see Figure 4) to healthy male subjects are depicted in Figure 4.
Figure 4: Plasma tadalafil
concentrations (mean ± SD) following a single 20-mg tadalafil dose and single
and once daily multiple doses of 5 mg
Absorption
After single oral-dose
administration, the maximum observed plasma concentration (Cmax) of tadalafil
is achieved between 30 minutes and 6 hours (median time of 2 hours). Absolute
bioavailability of tadalafil following oral dosing has not been determined.
The rate and extent of
absorption of tadalafil are not influenced by food; thus CIALIS may be taken
with or without food.
Distribution
The mean apparent volume of
distribution following oral administration is approximately 63 L, indicating
that tadalafil is distributed into tissues. At therapeutic concentrations, 94%
of tadalafil in plasma is bound to proteins.
Less than 0.0005% of the
administered dose appeared in the semen of healthy subjects.
Metabolism
Tadalafil is predominantly
metabolized by CYP3A4 to a catechol metabolite. The catechol metabolite
undergoes extensive methylation and glucuronidation to form the methylcatechol
and methylcatechol glucuronide conjugate, respectively. The major circulating
metabolite is the methylcatechol glucuronide. Methylcatechol concentrations are
less than 10% of glucuronide concentrations. In vitro data suggests that
metabolites are not expected to be pharmacologically active at observed
metabolite concentrations.
Excretion
The mean oral clearance for
tadalafil is 2.5 L/hr and the mean terminal half-life is 17.5 hours in healthy
subjects. Tadalafil is excreted predominantly as metabolites, mainly in the
feces (approximately 61% of the dose) and to a lesser extent in the urine
(approximately 36% of the dose).
Geriatric
Healthy male elderly subjects (65 years or over) had a
lower oral clearance of tadalafil, resulting in 25% higher exposure (AUC) with
no effect on Cmax relative to that observed in healthy subjects 19 to 45 years
of age. No dose adjustment is warranted based on age alone. However, greater
sensitivity to medications in some older individuals should be considered [see Use
In Specific Populations].
Patients With Diabetes Mellitus
In male patients with diabetes mellitus after a 10 mg
tadalafil dose, exposure (AUC) was reduced approximately 19% and Cmax was 5%
lower than that observed in healthy subjects. No dose adjustment is warranted.
Patients With BPH
In patients with BPH following single and multiple-doses
of 20 mg tadalafil, no statistically significant differences in exposure (AUC
and Cmax) were observed between elderly (70 to 85 years) and younger (≤60
years of age) subjects. No dose adjustment is warranted.
Animal Toxicology And/Or Pharmacology
Animal studies showed vascular inflammation in
tadalafil-treated mice, rats, and dogs. In mice and rats, lymphoid necrosis and
hemorrhage were seen in the spleen, thymus, and mesenteric lymph nodes at
unbound tadalafil exposure of 2-to 33-fold above the human exposure (AUCs) at
the MRHD of 20 mg. In dogs, an increased incidence of disseminated arteritis
was observed in 1-and 6-month studies at unbound tadalafil exposure of 1-to
54-fold above the human exposure (AUC) at the MRHD of 20 mg. In a 12-month dog
study, no disseminated arteritis was observed, but 2 dogs exhibited marked
decreases in white blood cells (neutrophils) and moderate decreases in
platelets with inflammatory signs at unbound tadalafil exposures of
approximately 14-to 18-fold the human exposure at the MRHD of 20 mg. The
abnormal blood-cell findings were reversible within 2 weeks after stopping
treatment.
Clinical Studies
CIALIS For Use As Needed For ED
The efficacy and safety of tadalafil in the treatment of
erectile dysfunction has been evaluated in 22 clinical trials of up to 24-weeks
duration, involving over 4000 patients. CIALIS, when taken as needed up to once
per day, was shown to be effective in improving erectile function in men with
erectile dysfunction (ED).
CIALIS was studied in the general ED population in 7
randomized, multicenter, double-blinded, placebo-controlled, parallel-arm
design, primary efficacy and safety studies of 12-weeks duration. Two of these
studies were conducted in the United States and 5 were conducted in centers
outside the US. Additional efficacy and safety studies were performed in ED
patients with diabetes mellitus and in patients who developed ED status post
bilateral nerve-sparing radical prostatectomy.
In these 7 trials, CIALIS was taken as needed, at doses
ranging from 2.5 to 20 mg, up to once per day. Patients were free to choose the
time interval between dose administration and the time of sexual attempts. Food
and alcohol intake were not restricted.
Several assessment tools were used to evaluate the effect
of CIALIS on erectile function. The 3 primary outcome measures were the
Erectile Function (EF) domain of the International Index of Erectile Function
(IIEF) and Questions 2 and 3 from Sexual Encounter Profile (SEP). The IIEF is a
4-week recall questionnaire that was administered at the end of a
treatment-free baseline period and subsequently at follow-up visits after
randomization. The IIEF EF domain has a 30point total score, where higher
scores reflect better erectile function. SEP is a diary in which patients
recorded each sexual attempt made throughout the study. SEP Question 2 asks,
“Were you able to insert your penis into the partner’s vagina?” SEP Question 3
asks, “Did your erection last long enough for you to have successful intercourse?”
The overall percentage of successful attempts to insert the penis into the
vagina (SEP2) and to maintain the erection for successful intercourse (SEP3) is
derived for each patient.
Results In ED Population In US Trials
The 2 primary US efficacy and safety trials included a
total of 402 men with erectile dysfunction, with a mean age of 59 years (range
27 to 87 years). The population was 78% White, 14% Black, 7% Hispanic, and 1%
of other ethnicities, and included patients with ED of various severities,
etiologies (organic, psychogenic, mixed), and with multiple co-morbid
conditions, including diabetes mellitus, hypertension, and other cardiovascular
disease. Most (>90%) patients reported ED of at least 1-year duration. Study
A was conducted primarily in academic centers. Study B was conducted primarily
in community-based urology practices. In each of these 2 trials, CIALIS 20 mg
showed clinically meaningful and statistically significant improvements in all
3 primary efficacy variables (see Table 11). The treatment effect of CIALIS did
not diminish over time.
Table 11: Mean Endpoint and Change from Baseline for
the Primary Efficacy Variables in the Two Primary US Trials
|
Study A |
Study B |
Placebo
(N=49) |
CIALIS 20 mg
(N=146) |
p-value |
Placebo
(N=48) |
CIALIS 20 mg
(N=159) |
p-value |
EF Domain Score |
Endpoint |
13.5 |
19.5 |
|
13.6 |
22.5 |
|
Change from baseline |
-0.2 |
6.9 |
<.001 |
0.3 |
9.3 |
<.001 |
Insertion of Penis (SEP2) |
Endpoint |
39% |
62% |
|
43% |
77% |
|
Change from baseline |
2% |
26% |
<.001 |
2% |
32% |
<.001 |
Maintenance of Erection (SEP3) |
Endpoint |
25% |
50% |
|
23% |
64% |
|
Change from baseline |
5% |
34% |
<.001 |
4% |
44% |
<.001 |
Results In General ED Population In Trials Outside The US
The 5 primary efficacy and
safety studies conducted in the general ED population outside the US included
1112 patients, with a mean age of 59 years (range 21 to 82 years). The
population was 76% White, 1% Black, 3% Hispanic, and 20% of other ethnicities,
and included patients with ED of various severities, etiologies (organic,
psychogenic, mixed), and with multiple co-morbid conditions, including diabetes
mellitus, hypertension, and other cardiovascular disease. Most (90%) patients
reported ED of at least 1-year duration. In these 5 trials, CIALIS 5, 10, and
20 mg showed clinically meaningful and statistically significant improvements
in all 3 primary efficacy variables (see Tables 12, 13 and 14). The treatment
effect of CIALIS did not diminish over time.
Table 12: Mean Endpoint and
Change from Baseline for the EF Domain of the IIEF in the General ED Population
in Five Primary Trials Outside the US
|
Placebo |
CIALIS 5 mg |
CIALIS 10 mg |
CIALIS 20 mg |
Study C |
Endpoint [Change from baseline] |
15.0 [0.7] |
17.9 [4.0] |
20.0 [5.6] |
|
|
|
p=. 006 |
p<.001 |
|
Study D |
Endpoint [Change from baseline] |
14.4 [1.1] |
17.5 [5.1] |
20.6 [6.0] |
|
|
|
p=. 002 |
p<.001 |
|
Study E |
Endpoint [Change from baseline] |
18.1 [2.6] |
|
22.6 [8.1] |
25.0 [8.0] |
|
|
|
p<.001 |
p<.001 |
Study Fa |
Endpoint [Change from baseline] |
12.7 [-1.6] |
|
|
22.8 [6.8] |
|
|
|
|
p<.001 |
Study G |
Endpoint [Change from baseline] |
14.5 [-0.9] |
|
21.2 [6.6] |
23.3 [8.0] |
|
|
|
p<.001 |
p<.001 |
a Treatment duration in Study F was 6 months |
Table 13: Mean Post-Baseline Success Rate and Change from Baseline for SEP Question 2 (“Were you able to
insert your penis into the partner’s vagina?”) in the General ED Population in
Five Pivotal Trials Outside the US
|
Placebo |
CIALIS 5 mg |
CIALIS 10 mg |
CIALIS 20 mg |
Study C |
Endpoint [Change from baseline] |
49% [6%] |
57% [15%] |
73% [29%] |
|
|
|
p=.063 |
p<.001 |
|
Study D |
Endpoint [Change from baseline] |
46% [2%] |
56% [18%] |
68% [15%] |
|
|
|
p=. 008 |
p<.001 |
|
Study E |
Endpoint [Change from baseline] |
55% [10%] |
|
77% [35%] |
85% [35%] |
|
|
|
p<.001 |
p<.001 |
Study Fa |
Endpoint [Change from baseline] |
42% [-8%] |
|
|
81% [27%] |
|
|
|
|
p<.001 |
Study G |
Endpoint [Change from baseline] |
45% [-6%] |
|
73% [21%] |
76% [21%] |
|
|
|
p<.001 |
p<.001 |
a Treatment duration in Study F was 6 months |
Table 14: Mean Post-Baseline Success Rate and Change from Baseline for SEP Question 3 (“Did your erection
last long enough for you to have successful intercourse?”) in the General ED
Population in Five Pivotal Trials Outside the US
|
Placebo |
CIALIS 5 mg |
CIALIS 10 mg |
CIALIS 20 mg |
Study C |
Endpoint [Change from baseline] |
26% [4%] |
38% [19%] |
58% [32%] |
|
|
|
p=. 040 |
p<.001 |
|
Study D |
Endpoint [Change from baseline] |
28% [4%] |
42% [24%] |
51% [26%] |
|
|
|
p<.001 |
p<.001 |
|
Study E |
Endpoint [Change from baseline] |
43% [15%] |
|
70% [48%] |
78% [50%] |
|
|
|
p<.001 |
p<.001 |
Study Fa |
Endpoint [Change from baseline] |
27% [1 %] |
|
|
74% [40%] |
|
|
|
|
p<.001 |
Study G |
Endpoint [Change from baseline] |
32% [5%] |
|
57% [33%] |
62% [29%] |
|
|
|
p<.001 |
p<.001 |
a Treatment duration in Study F was 6 months |
In addition, there were improvements in EF domain scores, success rates based upon SEP Questions 2 and
3, and patient-reported improvement in erections across patients with ED of all
degrees of disease severity while taking CIALIS, compared to patients on
placebo.
Therefore, in all 7 primary
efficacy and safety studies, CIALIS showed statistically significant
improvement in patients' ability to achieve an erection sufficient for vaginal
penetration and to maintain the erection long enough for successful
intercourse, as measured by the IIEF questionnaire and by SEP diaries.
Efficacy Results In ED Patients
With Diabetes Mellitus
CIALIS was shown to be
effective in treating ED in patients with diabetes mellitus. Patients with
diabetes were included in all 7 primary efficacy studies in the general ED
population (N=235) and in one study that specifically assessed CIALIS in ED
patients with type 1 or type 2 diabetes (N=216). In this randomized,
placebo-controlled, double-blinded, parallel-arm design prospective trial,
CIALIS demonstrated clinically meaningful and statistically significant
improvement in erectile function, as measured by the EF domain of the IIEF
questionnaire and Questions 2 and 3 of the SEP diary (see Table 15).
Table 15: Mean Endpoint and Change from Baseline for
the Primary Efficacy Variables in a Study in ED Patients with Diabetes
|
Placebo
(N=71) |
CIALIS 10 mg
(N=73) |
CIALIS 20 mg
(N=72) |
p-value |
EF Domain Score |
Endpoint [Change from baseline] |
12.2 [0.1] |
19.3 [6.4] |
18.7 [7.3] |
<.001 |
Insertion of Penis (SEP2) |
Endpoint [Change from baseline] |
30% [-4%] |
57% [22%] |
54% [23%] |
<.001 |
Maintenance of Erection (SEP3) |
Endpoint [Change from baseline] |
20% [2%] |
48% [28%] |
42% [29%] |
<.001 |
Efficacy Results In ED Patients
Following Radical Prostatectomy
CIALIS was shown to be
effective in treating patients who developed ED following bilateral
nerve-sparing radical prostatectomy. In 1 randomized, placebo-controlled,
double-blinded, parallel-arm design prospective trial in this population
(N=303), CIALIS demonstrated clinically meaningful and statistically
significant improvement in erectile function, as measured by the EF domain of
the IIEF questionnaire and Questions 2 and 3 of the SEP diary (see Table 16).
Table 16: Mean Endpoint and
Change from Baseline for the Primary Efficacy Variables in a Study in Patients
who Developed ED Following Bilateral Nerve-Sparing Radical Prostatectomy
|
Placebo
(N=102) |
CIALIS 20 mg
(N=201) |
p-value |
EF Domain Score |
Endpoint [Change from baseline] |
13.3 [1.1] |
17.7 [5.3] |
<.001 |
Insertion of Penis (SEP2) |
Endpoint [Change from baseline] |
32% [2%] |
54% [22%] |
<.001 |
Maintenance of Erection (SEP3) |
Endpoint [Change from baseline] |
19% [4%] |
41% [23%] |
<.001 |
Results In Studies To Determine
The Optimal Use Of CIALIS
Several studies were conducted
with the objective of determining the optimal use of CIALIS in the treatment of
ED. In one of these studies, the percentage of patients reporting successful
erections within 30 minutes of dosing was determined. In this randomized,
placebo-controlled, double-blinded trial, 223 patients were randomized to
placebo, CIALIS 10, or 20 mg. Using a stopwatch, patients recorded the time
following dosing at which a successful erection was obtained. A successful
erection was defined as at least 1 erection in 4 attempts that led to
successful intercourse. At or prior to 30 minutes, 35% (26/74), 38% (28/74),
and 52% (39/75) of patients in the placebo, 10-, and 20-mg groups,
respectively, reported successful erections as defined above.
Two studies were conducted to
assess the efficacy of CIALIS at a given timepoint after dosing, specifically
at 24 hours and at 36 hours after dosing.
In the first of these studies,
348 patients with ED were randomized to placebo or CIALIS 20 mg. Patients were
encouraged to make 4 total attempts at intercourse; 2 attempts were to occur at
24 hours after dosing and 2 completely separate attempts were to occur at 36
hours after dosing. The results demonstrated a difference between the placebo
group and the CIALIS group at each of the pre-specified timepoints. At the
24-hour timepoint, (more specifically, 22 to 26 hours), 53/144 (37%) patients
reported at least 1 successful intercourse in the placebo group versus 84/138
(61%) in the CIALIS 20-mg group. At the 36-hour timepoint (more specifically,
33 to 39 hours), 49/133 (37%) of patients reported at least 1 successful
intercourse in the placebo group versus 88/137 (64%) in the CIALIS 20-mg group.
In the second of these studies,
a total of 483 patients were evenly randomized to 1 of 6 groups: 3 different
dosing groups (placebo, CIALIS 10, or 20 mg) that were instructed to attempt
intercourse at 2 different times (24 and 36 hours post-dosing). Patients were
encouraged to make 4 separate attempts at their assigned dose and assigned
timepoint. In this study, the results demonstrated a statistically significant
difference between the placebo group and the CIALIS groups at each of the
pre-specified timepoints. At the 24-hour timepoint, the mean, per patient
percentage of attempts resulting in successful intercourse were 42, 56, and 67%
for the placebo, CIALIS 10-, and 20-mg groups, respectively. At the 36-hour
timepoint, the mean, per-patient percentage of attempts resulting in successful
intercourse were 33, 56, and 62% for placebo, CIALIS 10-, and 20-mg groups,
respectively.
CIALIS For Once Daily Use For ED
The efficacy and safety of
CIALIS for once daily use in the treatment of erectile dysfunction has been
evaluated in 2 clinical trials of 12-weeks duration and 1 clinical trial of
24-weeks duration, involving a total of 853 patients. CIALIS, when taken once
daily, was shown to be effective in improving erectile function in men with
erectile dysfunction (ED).
CIALIS was studied in the
general ED population in 2 randomized, multicenter, double-blinded,
placebo-controlled, parallel-arm design, primary efficacy and safety studies of
12-and 24-weeks duration, respectively. One of these studies was conducted in
the United States and one was conducted in centers outside the US. An
additional efficacy and safety study was performed in ED patients with diabetes
mellitus. CIALIS was taken once daily at doses ranging from 2.5 to 10 mg. Food
and alcohol intake were not restricted. Timing of sexual activity was not
restricted relative to when patients took Cialis.
Results In General ED
Population
The primary US efficacy and
safety trial included a total of 287 patients, with a mean age of 59 years
(range 25 to 82 years). The population was 86% White, 6% Black, 6% Hispanic,
and 2% of other ethnicities, and included patients with ED of various
severities, etiologies (organic, psychogenic, mixed), and with multiple
co-morbid conditions, including diabetes mellitus, hypertension, and other
cardiovascular disease. Most (>96%) patients reported ED of at least 1-year
duration.
The primary efficacy and safety
study conducted outside the US included 268 patients, with a mean age of 56
years (range 21 to 78 years). The population was 86% White, 3% Black, 0.4%
Hispanic, and 10% of other ethnicities, and included patients with ED of
various severities, etiologies (organic, psychogenic, mixed), and with multiple
co-morbid conditions, including diabetes mellitus, hypertension, and other
cardiovascular disease. Ninety-three percent of patients reported ED of at
least 1-year duration.
In each of these trials,
conducted without regard to the timing of dose and sexual intercourse, CIALIS
demonstrated clinically meaningful and statistically significant improvement in
erectile function, as measured by the EF domain of the IIEF questionnaire and
Questions 2 and 3 of the SEP diary (see Table 17). When taken as directed,
CIALIS was effective at improving erectile function.
In the 6 month double-blind
study, the treatment effect of CIALIS did not diminish over time.
Table 17: Mean Endpoint and
Change from Baseline for the Primary Efficacy Variables in the Two CIALIS for
Once Daily Use Studies
|
Study Ha |
Study Ib |
Placebo
(N=94) |
CIALIS 2.5 mg
(N=96) |
CIALIS 5 mg
(N=97) |
p-value |
Placebo
(N=54) |
CIALIS 5 mg
(N=109) |
p-value |
EF Domain Score |
Endpoint |
14.6 |
19.1 |
20.8 |
|
15.0 |
22.8 |
|
Change from baseline |
1.2 |
6.1c |
7.0c |
<.001 |
0.9 |
9.7c |
<.001 |
Insertion of Penis (SEP2) |
Endpoint |
51% |
65% |
71% |
|
52% |
79% |
|
Change from baseline |
5% |
24%c |
26%c |
<.001 |
11% |
37%c |
<.001 |
Maintenance of Erection (SEP3) |
Endpoint |
31% |
50% |
57% |
|
37% |
67% |
|
Change from baseline |
10% |
31%c |
35%c |
<.001 |
13% |
46%c |
<.001 |
a Twenty-four-week
study conducted in the US.
b Twelve-week study conducted outside the US.
c Statistically significantly different from placebo. |
Efficacy Results In ED Patients With Diabetes Mellitus
CIALIS for once daily use was
shown to be effective in treating ED in patients with diabetes mellitus.
Patients with diabetes were included in both studies in the general ED
population (N=79). A third randomized, multicenter, double-blinded,
placebo-controlled, parallel-arm design trial included only ED patients with
type 1 or type 2 diabetes (N=298). In this third trial, CIALIS demonstrated
clinically meaningful and statistically significant improvement in erectile
function, as measured by the EF domain of the IIEF questionnaire and Questions
2 and 3 of the SEP diary (see Table 18).
Table 18: Mean Endpoint and
Change from Baseline for the Primary Efficacy Variables in a CIALIS for Once
Daily Use Study in ED Patients with Diabetes
|
Placebo
(N=100) |
CIALIS 2.5 mg
(N=100) |
CIALIS 5 mg
(N=98) |
p-value |
EF Domain Score |
Endpoint |
14.7 |
18.3 |
17.2 |
|
Change from baseline |
1.3 |
4.8a |
4.5a |
<.001 |
Insertion of Penis (SEP2) |
Endpoint |
43% |
62% |
61% |
|
Change from baseline |
5% |
21%a |
29%a |
<.001 |
Maintenance of Erection (SEP3) |
Endpoint |
28% |
46% |
41% |
|
Change from baseline |
8% |
26%a |
25%a |
<.001 |
a Statistically significantly different from placebo. |
CIALIS 5 mg For Once Daily Use For Benign Prostatic
Hyperplasia (BPH)
The efficacy and safety of
CIALIS for once daily use for the treatment of the signs and symptoms of BPH
was evaluated in 3 randomized, multinational, double-blinded,
placebo-controlled, parallel-design, efficacy and safety studies of 12 weeks
duration. Two of these studies were in men with BPH and one study was specific
to men with both ED and BPH [see Clinical Studies]. The first study
(Study J) randomized 1058 patients to receive either CIALIS 2.5 mg, 5 mg, 10 mg
or 20 mg for once daily use or placebo. The second study (Study K) randomized
325 patients to receive either CIALIS 5 mg for once daily use or placebo. The
full study population was 87% White, 2% Black, 11% other races; 15% was of
Hispanic ethnicity. Patients with multiple co-morbid conditions such as
diabetes mellitus, hypertension, and other cardiovascular disease were
included.
The primary efficacy endpoint
in the two studies that evaluated the effect of CIALIS for the signs and
symptoms of BPH was the International Prostate Symptom Score (IPSS), a four
week recall questionnaire that was administered at the beginning and end of a
placebo run-in period and subsequently at follow-up visits after randomization.
The IPSS assesses the severity of irritative (frequency, urgency, nocturia) and
obstructive symptoms (incomplete emptying, stopping and starting, weak stream,
and pushing or straining), with scores ranging from 0 to 35; higher numeric
scores representing greater severity. Maximum urinary flow rate (Qmax), an
objective measure of urine flow, was assessed as a secondary efficacy endpoint
in Study J and as a safety endpoint in Study K.
The results for BPH patients
with moderate to severe symptoms and a mean age of 63.2 years (range 44 to 87)
who received either CIALIS 5 mg for once daily use or placebo (N=748) in
Studies J and K are shown in Table 19 and Figures 5 and 6, respectively.
In each of these 2 trials,
CIALIS 5 mg for once daily use resulted in statistically significant
improvement in the total IPSS compared to placebo. Mean total IPSS showed a
decrease starting at the first scheduled observation (4 weeks) in Study K and
remained decreased through 12 weeks.
Table 19: Mean IPSS Changes
in BPH Patients in Two CIALIS for Once Daily Use Studies
|
Study J |
Study K |
Placebo
(N=205) |
CIALIS 5 mg
(N=205) |
p-value |
Placebo
(N=164) |
CIALIS 5 mg
(N=160) |
p-value |
Total Symptom Score (IPSS) |
Baseline |
17.1 |
17.3 |
|
16.6 |
17.1 |
|
Change from Baseline to Week 12 |
-2.2 |
-4.8 |
<.001 |
-3.6 |
-5.6 |
.004 |
Figure 5: Mean IPSS Changes
in BPH Patients by Visit in Study J
Figure 6: Mean IPSS Changes
in BPH Patients by Visit in Study K
In Study J, the effect of
CIALIS 5 mg once daily on maximum urinary flow rate (Qmax) was evaluated as a
secondary efficacy endpoint. Mean Qmax increased from baseline in both the
treatment and placebo groups (CIALIS 5 mg: 1.6 mL/sec, placebo: 1.2
mL/sec); however, these changes were not significantly different between
groups.
In Study K, the effect of
CIALIS 5 mg once daily on Qmax was evaluated as a safety endpoint. Mean Qmax increased
from baseline in both the treatment and placebo groups (CIALIS 5 mg: 1.6
mL/sec, placebo: 1.1 mL/sec); however, these changes were not significantly
different between groups.
Efficacy Results In Patients With
BPH Initiating CIALIS And Finasteride
CIALIS for once daily use
initiated together with finasteride was shown to be effective in treating the
signs and symptoms of BPH in men with an enlarged prostate (>30 cc) for up
to 26 weeks. This additional double-blinded, parallel-design study of 26 weeks
duration randomized 696 men to initiate either CIALIS 5 mg with finasteride 5
mg or placebo with finasteride 5 mg. The study population had a mean age of 64
years (range 46-86). Patients with multiple co-morbid conditions such as
erectile dysfunction, diabetes mellitus, hypertension, and other cardiovascular
disease were included.
CIALIS with finasteride demonstrated
statistically significant improvement in the signs and symptoms of BPH compared
to placebo with finasteride, as measured by the total IPSS at 12 weeks, the
primary study endpoint (see Table 20). Key secondary endpoints demonstrated
improvement in total IPSS starting at the first scheduled observation at week 4
(CIALIS -4.0, placebo -2.3: p<.001) and the score remained decreased through
26 weeks (CIALIS -5.5, placebo -4.5; p=.022). However, the magnitude of the
treatment difference between placebo/finasteride and CIALIS/finasteride
decreased from 1.7 points at Week 4 to 1.0 point at Week 26, as shown in Table
20 and in Figure 7. The incremental benefit of CIALIS beyond 26 weeks is
unknown.
Table 20: Mean Total IPSS
Changes in BPH Patients in a CIALIS for Once Daily Use Study Together with
Finasteride
|
n |
Placebo and finasteride 5 mg
(N=350)a |
n |
CIALIS 5mg and finasteride 5 mg
(N=345)a |
Treatment difference |
p-valueb |
Total Symptom Score (IPSS) |
Baselinec |
349 |
17.4 |
344 |
17.1 |
|
|
Change from Baseline to Week 4b |
340 |
-2.3 |
330 |
-4.0 |
-1.7 |
<.001 |
Change from Baseline to Week 12b |
318 |
-3.8 |
317 |
-5.2 |
-1.4 |
.001 |
Change from Baseline to Week 26b |
295 |
-4.5 |
308 |
-5.5 |
-1.0 |
.022 |
a Overall ITT
population.
b Mixed model for repeated measurements. Unadjusted mean. |
Figure 7: Mean Total IPSS Changes By Visit in BPH Patients Taking CIALIS for Once Daily Use Together With Finasteride
In the 404 patients who had
both ED and BPH at baseline, changes in erectile function were assessed as key
secondary endpoints using the EF domain of the IIEF questionnaire. CIALIS with
finasteride (N=203) was compared to placebo with finasteride (N=201). A
statistically significant improvement from baseline (CIALIS/finasteride 13.7,
placebo/finasteride 15.1) was observed at week 4 (CIALIS/finasteride 3.7,
placebo/finasteride -1.1; p<.001), week 12 (CIALIS/finasteride 4.7,
placebo/finasteride 0.6; p<.001), and week 26 (CIALIS/finasteride 4.7,
placebo/finasteride 0.0; p<.001).
CIALIS 5 mg For Once Daily Use For
ED And BPH
The efficacy and safety of
CIALIS for once daily use for the treatment of ED, and the signs and symptoms
of BPH, in patients with both conditions was evaluated in one
placebo-controlled, multinational, double-blind, parallel-arm study which
randomized 606 patients to receive either CIALIS 2.5 mg, 5 mg, for once daily
use or placebo. ED severity ranged from mild to severe and BPH severity ranged
from moderate to severe. The full study population had a mean age of 63 years
(range 45 to 83) and was 93% White, 4% Black, 3% other races; 16% were of
Hispanic ethnicity. Patients with multiple co-morbid conditions such as
diabetes mellitus, hypertension, and other cardiovascular disease were
included.
In this study, the co-primary
endpoints were total IPSS and the Erectile Function (EF) domain score of the
International Index of Erectile Function (IIEF). One of the key secondary
endpoints in this study was Question 3 of the Sexual Encounter Profile diary
(SEP3). Timing of sexual activity was not restricted relative to when patients
took CIALIS.
The efficacy results for
patients with both ED and BPH, who received either CIALIS 5 mg for once daily
use or placebo (N=408) are shown in Tables 21 and 22 and Figure 8.
CIALIS 5 mg for once daily use
resulted in statistically significant improvements in the total IPSS and in the
EF domain of the IIEF questionnaire. CIALIS 5 mg for once daily use also
resulted in statistically significant improvement in SEP3. CIALIS 2.5 mg did
not result in statistically significant improvement in the total IPSS.
Table 21: Mean IPSS and IIEF
EF Domain Changes in the CIALIS 5 mg for Once Daily Use Study in Patients with ED and BPH
|
Placebo |
CIALIS 5 mg |
p-value |
Total Symptom Score (IPSS) |
|
(N=193) |
(N=206) |
|
Baseline |
18.2 |
18.5 |
|
Change from Baseline to Week 12 |
-3.8 |
-6.1 |
<.001 |
EF Domain Score (IIEF EF) |
|
(N=188) |
(N=202) |
|
Baseline |
15.6 |
16.5 |
|
Endpoint |
17.6 |
22.9 |
|
Change from Baseline to Week 12 |
1.9 |
6.5 |
<.001 |
Table 22: Mean SEP Question 3 Changes in the CIALIS 5
mg for Once Daily Use Study in Patients with ED and BPH
|
Placebo
(N=187) |
CIALIS 5 mg
(N=199) |
p-value |
Maintenance of Erection (SEP3) |
Baseline |
36% |
43% |
|
Endpoint |
48% |
72% |
|
Change from Baseline to Week 12 |
12% |
32% |
<.001 |
CIALIS for once daily use resulted in improvement in the IPSS total score at the first scheduled
observation (week 2) and throughout the 12 weeks of treatment (see Figure 8).
Figure 8: Mean IPSS Changes in ED/BPH Patients by Visit in Study L
In this study, the effect of
CIALIS 5 mg once daily on Qmax was evaluated as a safety endpoint. Mean Qmax increased
from baseline in both the treatment and placebo groups (CIALIS 5 mg: 1.6
mL/sec, placebo: 1.2 mL/sec); however, these changes were not significantly
different between groups.