Viagra opens up opportunities for patients and industry alike
ELIZABETH NEUS
03/15/99
Gannett News Service
FINAL
Greg McGreer already knew a lot about treatments for impotence -- not only is he a psychotherapist specializing in sexual dysfunction, but his multiple sclerosis made him a candidate for medical remedies himself.
But when Viagra came along, he thought for three months before giving it a try. He compared the cost to that of his current treatment, the injectable Caverject, and considered some of the medical factors as well. Pure curiosity also played a part.
The payoff was not what he expected. ''The first time,'' said McGreer, 52, who practices in the Philadelphia area, ''(Viagra) didn't give me the effects I wanted. The Caverject erection is better than Viagra. It's more reliable.''
Patients and doctors alike are learning as they go when it comes to Viagra. That little blue pill, a revolutionary treatment for erectile dysfunction, the preferred term for impotence, is the only treatment that does not involve injecting, inserting or implanting something into the penis.
In theory, if a man takes Viagra an hour or so before intercourse and is in a situation where he could become sexually aroused, he will get an erection. Without the sexual stimulation -- which has to come from someplace other than Viagra, which is not a libido-booster -- the pill will do nothing.
To the dismay of about 30 percent of men who try it, it does nothing anyway. Among the other 70 percent, results may vary from man to man, even from dose to dose. But there is no way yet to find out without trying it.
''Many people didn't quite understand what the promise of Viagra was. The promise was that it would help between 65 percent and 70 percent of people, and to that extent it has,'' said Dr. Geoffrey Sklar, a urologist at the University of Maryland Medical Center who was among the original Viagra researchers. ''People thought it would be something that would make sex better, and it's not.''
Standard procedure for men who want to try Viagra begins with a visit to the doctor -- unless he buys it off the Internet, a practice which infuriates both urologists and Pfizer, the drug's maker. Viagra has enough potentially dangerous side effects, and a long enough list of people who should not take it, that a physical is recommended before a prescription is written.
Impotence can be a sign something else is physically wrong with a man.
''I diagnose a dozen cases of diabetes a year and hypertension that's gone untreated,'' said Dr. Andre Guay, an endocrinologist and director of the Center for Sexual Function at the Lahey Clinic near Boston.
''Anyone I've got any concern about, I call in a cardiologist and make them take an exercise stress test. We send about 10 people a year to get cardiac rehabilitation before (beginning) therapy,'' said Dr. John Mulhall, director of the Center for Male Sexual Health at Loyola University Medical Center in Maywood, Ill.
The standard prescription is between 6 and 8 pills a month, although some men complain that is not enough, while others can make it last a while. ''Older couples aren't looking to be porn stars. Maybe once or twice a week, Saturday night. These guys just want to be normal guys,'' said Dr. J. Francois Eid, director of the Erectile Dysfunction Unit at the New York Hospital-Cornell Medical Center.
For the majority of men, the most common side effects -- headache, blue vision, stuffy nose -- are not an issue. Some take aspirin with Viagra to stave off the headache.
''The biggest side effect is the pinch in the wallet, especially if (the pill) doesn't work,'' said Karen Brash McGreer, a sex therapist and Greg McGreer's wife.
What surprises many patients is the fact they don't get a guaranteed erection with Viagra and that getting an erection may take some time. ''If I'm tired, it will not have the same effect. It just won't work,'' Greg McGreer said.
Unplanned sex disappears with Viagra, since its effects only last so long and are not instantaneous. But doctors and patients disagree how much that matters. The McGreers say they turn to Caverject, a pen-like device containing a tiny needle that injects medication into the penis and which provides an almost-instant erection, if they don't feel like planning ahead for sex.
"Spontaneity is kind of a myth, anyhow. That goes out the window in your mid-30s. People have pretty tight schedules,'' said Dr. Andrew McCullough, director of male sexual health and fertility at the New York University Medical Center.
The biggest surprise may be complete failure. Sometimes the problem is as simple as stage fright.
''There were people in the clinical trial who had to try the pill three or four times before they overcame the hump of performance anxiety and are getting better erections now,'' said Eid.
Doctors have a few advance clues on who might become a Viagra failure. Smokers do not do as well, nor men with severe, uncontrolled diabetes. Men who had prostate surgery that damaged the nerve that controls blood supply to the penis may not have luck with Viagra, nor older men on multiple medications with multiple health problems.
Then there are the men who should never try Viagra: those with heart conditions or taking drugs containing nitrates (combining Viagra with nitrates can send the blood pressure plummeting dangerously).
For all those men, ''the honeymoon with Viagra is over,'' said Nina Ferrari, a spokeswoman for Vivus , the company that makes MUSE, a urethral suppository that was the market leader before Viagra came along. ''We know people are coming in and asking, 'What else is there?'''
Viagra decimated the market share of its competitors, but the competition is grateful for one thing.
''There was a market that was fairly untapped -- there are three times as many prescriptions (for Caverject) being written today than a year ago. There is a very big expansion in the entire market,'' said Kristen Elliott, spokeswoman for Pharmacia & Upjohn, maker of Caverject. ''Viagra can take credit for that.''
Doctors are pleased to have so many options to offer men with erectile dysfunction, compared to what they had a few years ago. What a patient chooses may depend on what his doctor is comfortable with. Guay likes MUSE; Eid promotes Caverject.
The choice may also depend on how the doctor makes the pitch or the patient's past experience with erectile dysfunction treatments.
''If you take a patient on penile injection therapy and change him to Viagra, he tries it, and says he likes the penile injection better. It gives him an erection regardless of the situation,'' said Eid.
''Take a patient who has never taken anything and has failed on Viagra and offer him the injection, he's horrified.''
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