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Dr Martin Duerden: It is about time the restrictions for sildenafil were lifted

The Department of Health proposal to lift restrictions on prescribing of generic sildenafil is a welcome move but perhaps it is time to go further and make it available over the counter, says Dr Martin Duerden.

The prescribing restrictions on Viagra (sildenafil) seemed quite arbitrary when the drug was first made available on the NHS in May 1999.

In an unusual step the restrictions were imposed by Frank Dobson, the Secretary of State for Health, following an initial ‘ban’ on prescribing in 1998. It was obviously a difficult situation with an expensive drug available for a common problem and considerable potential for inappropriate demand and use for recreational use or experimentation at an overall cost the NHS could not afford.

But at the time suggesting that sexual intercourse on the NHS was only allowed once a week also seemed like undue state interference.

For many GPs the restriction criteria, still in place today, seem harsh and too prescriptive. To my knowledge, many choose to ignore them and prescribe based on their view of who has most need, which includes men severely distressed by their inability to perform. Why should these people need referring and why should a ‘specialist’ or hospital doctor be better at assessing this distress? The provision on NHS prescription has proved next to impossible to police as the patient record is confidential and this is a particularly sensitive area.

On the whole, I welcome the proposal to relax the criteria for provision of sildenafil in the NHS as it allows GPs to use their judgement. This is a highly effective treatment and improves enjoyment of life for many. The drug has few adverse effects but the dilemma remains: at what point does the NHS have responsibility for such things at the borderline of medical care and recreation?

I think we have to rely on GPs using their common sense and I suspect it won’t have too much impact on workload, as the demand is already there. If there is an increase I can live with this, as people or couples blighted by erectile dysfunction will feel more confident at coming forward for an effective treatment.  I think it will improve the doctor-patient relationship as it is difficult to explain that there is an effective treatment available on the NHS, but not for your particular problem, and you will have to pay a lot of money for it at the pharmacy.

A significant issue may be with the continued restrictions placed on the other drugs still on patent (tadalafil, vardenafil), and for branded Viagra. I suspect the manufacturers of these drugs may feel hard done by. It might be sensible to review and revise the current restrictions in the light of 15 or so years’ experience of using these drugs, to make provision more fair and less arbitrary.  

A rapid move to over-the-counter provision of generic sildenafil might also make sense and reduce the onus on the GP to restrict access to an effective drug within the NHS. The responsibility would then lie with the patient to use it sensibly and safely. A lot of patients get the drug covertly via online pharmacies already and this might be a better, more transparent option.

Dr Martin Duerden is a GP and a clinical adviser to RCGP on prescribing

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