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OP Kapoor
Ex. Hon. Physician, Jaslok Hospital and Bombay Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.
Before Sildenafil came in the market, much excitement was created by the newspapers and the media. Public was anxiously waiting to buy this drug. All the pharmaceutical companies were competing to be the first to bring out such a drug in the market. At last, 1 1/2 years ago, the drug came in the market, and was within the reach of normal people. In a very short time, more than half a dozen companies put their Sildenafil tablet in the market and spent quite a substantial amount of money to promote the drug. In my opinion, the sale of this drug has been very low and the pharmaceutical companies have definitely gone in loss. Why is it so?

The following are my conclusions.

1.Promotion by the pharmaceutical companies was not adequate. They are promoting it for organic impotence. They are not keeping in mind that no patient of diabetes or hypertension has pure organic or iatrogenic impotence. There is always a psychological (functional) element as well. More often, latter is the cause of impotence and not mild diabetes or mild hypertension, or the tablets which are often wrongly blamed.

2.The commonest cause of Erectile Dysfunction is functional and psychological or lack of confidence. Thus the drug should be promoted by using it as a therapeutic test and giving confidence to the patients that they can perform normally and they have no organic dysfunction or disease.

3.The fear of side effects always remains in the mind of the patients. As such Indians are very afraid of side effects and suspect ‘hidden side effects’. In my opinion, the patients should be encouraged by telling them confidently that there are no side effects of Sildenafil and, if at all, there may be, an ache in the head or flushing or gastro-intestinal symptom (next morning).

These are the effects and not the side effects similar to as when a person has an alcoholic drink for sexual arousal.

All the serious side effects and deaths have occurred in the patients of IHD who are on nitrates. In my opinion, the doctors in the modern days should stop prescribing nitrates in all patients of stabilised angina pectoris and IHD. These patients form bulk of IHD and these are also the patients who have erectile dysfunction mainly due to fear of having underlying heart disease and they are the ones who will benefit most by the use of Sildenafil. Then why not make it a principle to stop prescribing nitrates to the patients so that they can safely take Sildenafil and improve their sexual performance satisfactorily.

All these patients can be prescribed a proper dose of betablockers or calcium blockers and do’s and don’ts like reduction in weight, no smoking and omitting alcohol. Nitrates have got a major role only in unstable angina patients and myocardial infarction patients which form the minority of total cases of IHD in the community. For such patients, nitrates work like magic when given orally or intravenously. But many such patients would have options (specially if they can afford an interventional procedure like angioplasty), which in the long term really speaking is cheaper than a long hospitalisation in the ICU for observation.

Thus, if nitrates are avoided, all patients of stabilised IHD with hypertension and diabetes can have normal sex life with the help of Sildenafil and therefore the sale of this drug can also be improved in the market.

Many GPs and public do not know that Sildenafil works only in 70-80% of the patients and the rest of them will have to use the new drug Apomorphin which is readily available in the foreign market or Prostaglandin (Muse) intra-urethrally. Thus, Sildenafil is not the only drug which will work in all 100% patients. In fact, the moment this drug is not effective, the doctors and the patients presume that they are really impotent and they will have erectile dysfunction permanently. Thus, the psychological and functional component increase markedly which makes it difficult to treat these patients.

Often the patients are not told that they should not have heavy dinner after taking the tablets and I have seen a number of patients who overdrink and overeat after consuming the tablet before having sex and thus do not have good results.

Indian patient is shy to buy a condom from the chemist for having extra marital sex or sleeping with his girl friend. Similarly, the Indian patients are very shy to ask the chemist to give them a tablet of Sildenafil. This problem can be solved only if the family physicians themselves buy the tablets in bulk from the pharmaceutical companies and supply their patients free (as I have been doing for the last 1 year) or charge them while dispensing other medicines.

Often I do not have to use more than 1-2 tablets and once the patient gets confidence, his erectile dysfunction disappears. The most important thing to know is that the good dose of Sildenafil is 100 mg. The pharmaceutical companies are trying to misguide the users by introducing the tablet of 25 and 50 mg in addition to 100 mg. According to them, the cheaper tablet will have more sales. (This is what exactly happened in the sale of Suminat prescribed for an attack of migraine. Although, a good therapeutic dose of this drug is 100 mg, the companies have introduced 25 and 50 mg tablets also because the migraine patients think that it is a waste of Rs. 100/- to get rid of an attack of migraine)!

Thus, for a real therapeutic test and to give confidence to the patients, a dose of 100 mg should be administered. Yes, the Indian patients have so much faith in their family doctors that even without telling them the name of the drug, if a tablet of 25 or 50 mg is given and advised that this tablet will act like a miracle on your erectile dysfunction performance, often it really works not because of the dose but because of the extra confidence - as if the doctor has given them a ‘Saibaba pill’.

Finally, the pharmaceutical companies should openly promote the sale of this drug to have ‘good sex’. Sex and better sex are not the same. Many people want to experience better performance for which they want to consume alcohol, tobacco or substance like "quat" in certain Arab countries or watch some sexy movie. Then why not swallow a pill which will cost more or less the same, once a week or once a fortnight to be satisfied and hence give a better performance to their sexual partner.

Why are the pharmaceutical companies reluctant to advertise the above facts and behave like hypocrites. As I can see a person who can lavishly spend on fresh fruits, dry fruits, fresh vegetables, fresh meat, etc. to promote his physical health, can also very easily spend on Sildenafil to have a better sexual life.

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