Nitrate Use With Sildenafil (Viagra)
Sildenafil should not be co-administered with nitrates (organic nitrates or nitric oxide donors), because the combination is contraindicated due to risk of profound hypotension.[1] Administration of sildenafil with any nitrates taken in any form is contraindicated.[1]
Contraindication Basis
Sildenafil potentiates the hypotensive effects of nitrates via the nitric oxide–cGMP pathway, which can lead to clinically significant blood pressure lowering.[1]
Medication Pairing Contraindicated
- Organic nitrates and nitric oxide donors (including nitroglycerin and other organic nitrate preparations) are contraindicated with sildenafil.[1]
- Organic nitrites are also encompassed in the contraindication with sildenafil.[1]
- “Nitrates” should also include intermittent or “as needed” nitrate use.[1]
Timing Considerations After Nitrate Exposure
Sildenafil use within a 24-hour interval after a patient has taken a nitrate preparation is contraindicated.[2]
Management of Chest Pain in a Patient Who Took Sildenafil
Alternative antianginal strategies should be used rather than nitrates if sildenafil has been taken within the contraindicated interval.[2]
Key Safety Message
If a nitrate is required for chest pain management, sildenafil should be avoided because the combination can cause unsafe blood pressure drops.[1][2]
Clinical Implications for Prescribing
If sildenafil therapy is being considered, concurrent or recent nitrate exposure should be treated as a contraindication to sildenafil administration.[1][2]
Evidence Supporting the Recommendation
The prescribing information for sildenafil states that administration with nitric oxide donors such as organic nitrates or organic nitrites in any form is contraindicated.[1]
Practical Documentation Points
Medication reconciliation should explicitly capture nitrate formulations (including nitroglycerin routes) and timing relative to sildenafil exposure.[1][2]