There were 2 145 393 items for ED prescribed in 2009 and 4 505 623 in 2019.

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Brian Williams, MDA board-certified family medicine physician with extensive experience in dermatology, Dr. Williams brings years of clinical expertise to the Hims & Hers patient experience. Dr. Alicia Warnock, MDAn endocrinologist and former U.S. Navy officer, Dr.

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Warnock directed the Diabetes Institute at Walter Reed and brings deep expertise in thyroid, metabolic, and endocrine care. Dr. Deepak L. Bhatt, MDOne of the world’s leading cardiologists, having earned leadership roles at top medical programs and countless awards for clinical innovation, Dr. Bhatt brings exceptional insight into heart health. The biggest year-on-year increase in the number of prescriptions was seen in 2014–2015, where an increase of 24% was observed.

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The total items prescribed for sildenafil was relatively steady from 2009–2013, at around 48 items prescribed a year per 1000 men. The prescribing increased rapidly from 2013–2017.

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Specific objectives related to the investigation of: a) whether a prescribing trend of ED drugs is associated with deprivation and demography of various English geographical regions; and b) whether the legal reclassification of sildenafil to ‘pharmacy-only’ medicine has impacted on the trend in quantity and cost of prescribing of ED drugs in England. A secondary analysis of routinely collected data on the prescribing and dispensing of two ED drugs, sildenafil and tadalafil, within the NHS England primary care settings between January 2009 and November 2019, was conducted. This time period includes switches from patented medicines to generic drugs for both tadalafil and sildenafil, as well as the reclassification of sildenafil to ‘pharmacy-only’ medicine in March 2018. Prescribing datasets cialis no perscription were extracted from NHS Digital sources including OpenPrescribing.net and Prescription Cost Analysis (PCA).11 These included data on the number of items prescribed, cost of prescribing, and prescribing patterns within specific clinical commissioning groups (CCGs) for both drugs. Data were adjusted for inflation using the Bank of England inflation calculator based on Office for National Statistics (ONS) composite price index.12 Data were also adjusted for male population estimates for each year.13 All data were extracted, independently checked for accuracy, and analysed using Microsoft Excel and IBM SPSS Statistics (version 21). The highest yearly increase occurred from 2014–2015, which showed a 42.1% increase.

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A 5.8% yearly increase in the rate of prescription was observed between 2017 and 2018.

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Background Sildenafil and tadalafil are recommended firstline treatments for erectile dysfunction (ED). Sildenafil was legally reclassified to a ‘pharmacy’ medicine in the UK in 2018. Aim To assess the prescribing patterns and costs associated with prescribing of ED drugs in England, and to investigate the link between prescribing and deprivation, regional demography, and legal reclassification. Design & setting Analyses were conducted of publicly available government data from various sources pertaining to primary care prescribing and demographics in England. Method Prescribing and cost data from January 2009 to November 2019 were extracted and adjusted for inflation, male populations, and regional deprivation.

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Results Between 2009 and 2019 the rate of prescribing, measured as the number of items per 1000 men, increased by 110%. In 2019, the rate of prescribing of ED medicines in the most deprived areas was 21.0% higher than the rate observed in least deprived areas. The northern regions of England approximately had a 50% higher rate of prescribing compared with London. A 1.3% annual increase in the number of prescription items was observed between 2018 and 2019 for Sildenafil, with a 5.8% increase observed from 2017–2018. Conclusion The two-fold increase in the rate of primary care prescriptions in the past 10 years suggests that more men are being screened for, or seeking help for, ED. A 0.5% increase in the rate of prescribing between 2018 and 2019 was observed, suggesting modest impact of reclassification on the prescribing practices.

Side Effect	Percentage of Users Reporting	Severity	Likelihood if Overused	Recommendations
Headache	20%	Mild	Higher	Take with water
Muscle Pain	10%	Mild to Moderate	Less likely	Monitor dosage
Flushing	15%	Mild	Same	Avoid hot environments
Indigestion	8%	Mild	Less likely	Take with food

The number of items prescribed per 1000 men were 124.2 and 125.8 in 2018 and 2019, respectively.

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Both pharmacological and non-pharmacological treatment options are available for the treatment of ED. The National Institute for Health and Care Excellence (NICE) in England recommends using phosphodiesterase type-five inhibitors (PDE-5I) as a firstline pharmacological treatment option for men with ED. Four PDE-5Is are currently licensed in the UK and include sildenafil, tadalafil, vardenafil, and avanafil.5 However, only sildenafil and tadalafil remain the drugs of choice. Sildenafil was reclassified in March 2018 by the UK’s Medicines and Healthcare products Regulatory Agency (MHRA) to ‘pharmacy-only’ medicine, which allowed community and online pharmacies to supply the drug to the patients without the need of a prescription.6 MHRA make decisions to alter the legal status of medicines in the UK from ‘prescription-only’ to ‘pharmacy’ or ‘general sales list’ categories (Table 1).7,8 The decision to reclassify such medicines are primarily based on safety data.7 Such reclassifications are often expected to reduce the volume of prescribing and costs from the perspective of the NHS as patients are required to pay the price of the medicines at the point of purchase. A cardiovascular risk assessment by a pharmacist in the community pharmacy is a prerequisite to pharmacy supply of sildenafil.9 Such risk assessment is undertaken using a series of questions asked to the patients before a supply can be made.

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Sildenafil is still available on NHS prescription along with tadalafil, vardenafil, and avanafil. There is a lack of research in relation to presentation and management of ED in primary care, particularly in the UK. To date, no longitudinal research has looked into the prescribing patterns and costs of PDE-5Is in English primary care settings. Given the association of ED with CVDs, including diabetes, vascular disorders, and mental health conditions,2,3,10 understanding any link that exists between deprivation and ED drugs prescribing trend will enable targeted interventions to manage comorbidities and reduce health inequality. The primary aim of this study was to investigate the trend in quantity and cost of prescribing of sildenafil and tadalafil in primary care settings in England between 2009 and 2019. The spending on primary care prescriptions for ED decreased by 71.0% from £77.4 million in 2009 to £22.4 million in 2019.

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The spending on sildenafil decreased by 90% and tadalafil decreased by 75%.

UK DOCTORS AND CLINICIANS

The higher rate of prescribing offers opportunity for monitoring of linked risk factors, such as diabetes mellitus, dyslipidaemia, and vascular disorders, in deprived populations. Reclassification of sildenafil had a modest impact on prescribing practices. There is a dearth of research in relation to presentation and management of ED in primary care, particularly in the UK. This study shows that over the past 10 years, there has been more than a two-fold increase in the rate of primary care prescriptions for ED, accounting for the changes in population. The reclassification of sildenafil as a pharmacy cialis buy cheap medicine in 2018 seemed to have modest impact on the prescribing trend.

Data collection

It is very likely that more men are being assessed for ED or seeking help in primary care in England. In addition, data suggest that prescribing is linked with deprivation. There is an opportunity in primary care for assessment of linked risk factors in men who present with symptoms. ED, ‘the persistent inability to achieve or maintain an erection that is sufficient to permit satisfactory sexual performance’, can affect the physical, emotional, and psychosocial health of the sufferer.1 ED can have both an organic and psychogenic origin, and can be a risk marker for underlying cardiovascular diseases (CVDs) and mental health conditions, which may warrant further evaluation and treatment.2,3 Medications, such as antihypertensives, antidepressants, and antipsychotics, can also lead to ED through their mechanisms of action.2 A systematic review reported that men with ED have an increased risk of all-cause mortality (odds ratio [OR] = 1.26; 95% confidence interval [CI] = 1.01 to 1.57) and CVD mortality (OR = 1.43; 95% CI = 1.00 to 2.05).4 The global prevalence of ED has been estimated to range from 3%–76.5%.4 A significant number of patients are known to suffer in isolation and do not seek help. Therefore, prevalence data are likely to be an underestimate.5 It is common for men with ED to experience anxiety, depression, relationship difficulties, and a lack of sexual confidence.2,3 These factors often lead to poorer quality of life for the sufferer, their partner, and family. The biggest decreases were seen after 2014 for sildenafil and 2018 for tadalafil (Figure 1).

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The most deprived regions consistently showed higher rates of prescriptions for ED drugs. In 2019 there were 190.4 items prescribed per 1000 men of all ED drugs in the most deprived region. This figure was approximately 21.0% higher compared with the data from the least deprived regions, where a total of 150.5 items were prescribed per 1000 men.

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Prescription patterns in the 10 most and the 10 least deprived CCGs as per the ONS Index of Multiple Deprivation (IMD) in 2015 (Table 2) were also extracted and analysed to explore the link between prescribing pattern and deprivation. The CCGs are clinically-led autonomous NHS bodies involved in planning and commissioning healthcare services for their locality. The 10 most deprived and the 10 least deprived CCGs covered a population of 1.38 million and 1.30 million, respectively. Number of items prescribed for ED increased by 110% between 2009 and 2019 (Figure 1). The increase in the number of items prescribed was mostly accounted for by sildenafil prescriptions, which increased by 165%.