Tadalafil, a phosphodiesterase type 5 (PDE5) inhibitor prescribed for erectile dysfunction and benign prostatic hyperplasia, is generally well tolerated but can cause digestive side effects in some patients. Dyspepsia (indigestion) is a common adverse effect, affecting 1–10% of users, whilst gastro-oesophageal reflux occurs less frequently. The mechanism may involve smooth muscle relaxation of the lower oesophageal sphincter, potentially allowing stomach acid to reflux into the oesophagus. Individual susceptibility varies considerably, with those who have pre-existing gastro-oesophageal reflux disease (GORD) potentially more prone to symptoms. This article examines the relationship between tadalafil and acid reflux, management strategies, and when to seek medical advice.

Can Tadalafil Cause Acid Reflux or Heartburn?

Tadalafil is a phosphodiesterase type 5 (PDE5) inhibitor commonly prescribed for erectile dysfunction and benign prostatic hyperplasia. Whilst it is generally well tolerated, digestive symptoms can occur during treatment.

According to the MHRA/EMC Summary of Product Characteristics (SmPC), dyspepsia (indigestion) is a common side effect of tadalafil, affecting between 1 and 10% of patients. Gastro-oesophageal reflux has also been reported, though typically less frequently than dyspepsia.

The mechanism by which tadalafil might contribute to reflux symptoms may relate to its effect on smooth muscle relaxation. PDE5 inhibitors work by increasing cyclic guanosine monophosphate (cGMP) levels, which causes smooth muscle relaxation in blood vessels. Some physiological studies suggest this relaxation might theoretically affect the lower oesophageal sphincter (LOS) — the muscular valve that prevents stomach acid from flowing back into the oesophagus. When the LOS relaxes inappropriately, gastric contents may reflux upwards, causing the characteristic burning sensation of heartburn.

It is important to note that not everyone taking tadalafil will experience reflux symptoms. Individual susceptibility varies considerably, and patients with pre-existing gastro-oesophageal reflux disease (GORD) may be more prone to experiencing symptoms. If you develop new or worsening heartburn after starting tadalafil, this should be discussed with your GP or prescribing clinician to determine whether the medication is the likely cause and whether management strategies are needed.

Managing Acid Reflux While Taking Tadalafil

If you experience acid reflux whilst taking tadalafil, several practical measures can help minimise symptoms without necessarily discontinuing the medication. Lifestyle modifications form the cornerstone of reflux management and are recommended by NICE guidelines (NG1) for all patients with GORD symptoms.

Dietary and timing adjustments can be particularly effective:

• Avoid large meals within 2–3 hours before taking tadalafil or before lying down

• Reduce intake of known reflux triggers including fatty foods, chocolate, caffeine, alcohol, and spicy dishes

• Eat smaller, more frequent meals rather than large portions

• Remain upright for at least 2–3 hours after eating

• Elevate the head of your bed by 10–20 cm if nocturnal symptoms occur

Pharmacological management may be appropriate for persistent symptoms. Over-the-counter antacids containing magnesium or aluminium salts can provide rapid, short-term relief by neutralising stomach acid. According to the tadalafil SmPC, no clinically significant interactions are expected between tadalafil and antacids. Alginate-based products (such as Gaviscon) form a protective barrier on top of stomach contents and are recommended by NICE for reflux symptoms.

For more sustained symptom control, proton pump inhibitors (PPIs) such as omeprazole or lansoprazole may be considered. These medications reduce gastric acid production and are highly effective for reflux symptoms. Low-dose PPIs are available over the counter for short-term use, but NICE recommends review after 4-8 weeks with consideration of step-down therapy. H2-receptor antagonists like famotidine represent an alternative acid-suppressing option. There are no known clinically relevant interactions between tadalafil and PPIs or H2-receptor antagonists.

Timing of tadalafil administration may also influence reflux symptoms. Tadalafil can be taken with or without food. If you are prescribed daily low-dose tadalafil (2.5–5 mg), experimenting with the time of day you take it — such as morning rather than evening — might help if reflux is problematic at night. Always discuss any medication adjustments with your healthcare provider before making changes to your prescribed regimen.

When to Seek Medical Advice About Reflux and Tadalafil

Whilst mild, occasional heartburn during tadalafil treatment is generally not cause for alarm, certain symptoms warrant prompt medical evaluation. You should contact your GP or healthcare provider if you experience:

• Severe or persistent heartburn that does not respond to over-the-counter remedies

• Difficulty or pain when swallowing (dysphagia or odynophagia)

• Unintentional weight loss accompanying reflux symptoms

• Persistent nausea or vomiting

• Evidence of gastrointestinal bleeding, such as black, tarry stools or vomiting blood

• Chest pain, particularly if severe or associated with breathlessness

• New onset of persistent abdominal pain, particularly if you are aged 55 or over

• Iron-deficiency anaemia or an epigastric mass

In line with NICE guidance (NG12), urgent specialist referral (within 2 weeks) is recommended for anyone with dysphagia, and for people aged 55 and over with weight loss and upper abdominal pain, reflux or dyspepsia.

Chest pain requires particular attention as it can be challenging to distinguish cardiac from oesophageal causes. Tadalafil is contraindicated in patients taking nitrates for angina and in those taking riociguat (for pulmonary hypertension) due to the risk of severe hypotension. If you experience sudden, severe chest pain, especially with radiation to the arm, jaw, or back, seek emergency medical attention immediately by calling 999.

Regular medication review is important for patients experiencing persistent reflux symptoms. Your GP may need to assess whether tadalafil is the most appropriate treatment option for you, particularly if you have pre-existing GORD or other gastrointestinal conditions. In some cases, adjusting the dose, switching to an alternative PDE5 inhibitor, or exploring different treatment approaches for erectile dysfunction or lower urinary tract symptoms may be warranted.

Patients should also inform their healthcare provider about all medications they are taking, as certain drugs can exacerbate reflux symptoms or interact with tadalafil. A comprehensive medication review can identify potential contributing factors and optimise your overall treatment plan whilst maintaining therapeutic efficacy for your primary condition.

If you suspect tadalafil is causing side effects, you can report this through the MHRA Yellow Card Scheme, which helps monitor the safety of medicines.

Alternative Treatments If Tadalafil Worsens Reflux

If reflux symptoms remain problematic despite management strategies, or if tadalafil significantly worsens pre-existing GORD, alternative treatment options should be discussed with your prescribing clinician. The choice of alternative depends on the indication for which tadalafil was originally prescribed.

For erectile dysfunction, other PDE5 inhibitors may be considered. Individual responses to different PDE5 inhibitors can vary, and some patients may find one agent more tolerable than another regarding digestive side effects. Sildenafil (Viagra) and vardenafil have shorter durations of action compared to tadalafil, which may result in a briefer window of potential side effects. Non-pharmacological approaches include vacuum erection devices, which are mechanical aids that do not carry the risk of systemic side effects. For patients with specific underlying causes of erectile dysfunction, addressing these — such as optimising diabetes control, managing cardiovascular risk factors, or psychological counselling — may improve function without medication.

For benign prostatic hyperplasia and lower urinary tract symptoms, alpha-blockers such as tamsulosin or alfuzosin represent an alternative pharmacological approach. These medications relax smooth muscle in the prostate and bladder neck through a different mechanism and are not typically associated with reflux symptoms. The 5-alpha reductase inhibitors finasteride and dutasteride, which reduce prostate size over time, are another option, particularly for men with significantly enlarged prostates.

Combination therapy may occasionally be appropriate, where tadalafil is used alongside an alpha-blocker. However, this approach requires careful consideration. According to the tadalafil SmPC, patients should be on a stable dose of alpha-blocker before starting tadalafil, which should be initiated at the lowest dose. Blood pressure monitoring is recommended due to the potential for additive hypotensive effects, with particular caution advised when using doxazosin.

Ultimately, the decision to continue, modify, or switch from tadalafil should be made collaboratively between you and your healthcare provider, weighing the benefits of treatment against the impact of side effects on your quality of life. NICE guidance emphasises shared decision-making in managing both erectile dysfunction and lower urinary tract symptoms, ensuring that treatment aligns with individual patient preferences and tolerability.

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