IS THE SALE OF SILDENAFIL (VIAGRA) NOT PICKING UP IN THE INDIAN MARKET?
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