Cialis

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

ANNEX I 
 

SUMMARY OF PRODUCT CHARACTERISTICS 
 



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1. NAME OF THE MEDICINAL PRODUCT 
 
CIALIS 2.5 mg film-coated tablets 
 
 
2. QUALITATIVE AND QUANTITATIVE COMPOSITION 
 
Each tablet contains 2.5 mg tadalafil. 
 
Excipient with known effect: 
Each coated tablet contains 87 mg of lactose (as monohydrate). 
 
For the full list of excipients, see section 6.1. 
 
 
3. PHARMACEUTICAL FORM 
 
Film-coated tablet (tablet). 
 
Light orange-yellow and almond shaped tablets, marked "C 2 ½" on one side. 
 
 
4. CLINICAL PARTICULARS 
 
4.1 Therapeutic indications 
 
Treatment of erectile dysfunction in adult males. 
 
In order for tadalafil to be effective, sexual stimulation is required.  
 
CIALIS is not indicated for use by women. 
 
4.2 Posology and method of administration 
 
Posology 
Adult men 
In general, the recommended dose is 10 mg taken prior to anticipated sexual activity and with or 
without food. 
In those patients in whom tadalafil 10 mg does not produce an adequate effect, 20 mg might be tried. 
It may be taken at least 30 minutes prior to sexual activity. 
 
The maximum dose frequency is once per day. 
 
Tadalafil 10 and 20 mg is intended for use prior to anticipated sexual activity and it is not 
recommended for continuous daily use. 
 
In patients who anticipate a frequent use of CIALIS (i.e., at least twice weekly) a once daily regimen 
with the lowest doses of CIALIS might be considered suitable, based on patient choice and the 
physician’s judgement. 
 
In these patients the recommended dose is 5 mg taken once a day at approximately the same time of 
day. The dose may be decreased to 2.5 mg once a day based on individual tolerability. 
 
The appropriateness of continued use of the daily regimen should be reassessed periodically. 
 



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Special populations 
Elderly men 
Dose adjustments are not required in elderly patients. 
 
Men with renal impairment 
Dose adjustments are not required in patients with mild to moderate renal impairment. For patients 
with severe renal impairment 10 mg is the maximum recommended dose. Once-a-day dosing of 
tadalafil is not recommended in patients with severe renal impairment (see sections 4.4 and 5.2). 
 
Men with hepatic impairment 
The recommended dose of CIALIS is 10 mg taken prior to anticipated sexual activity and with or 
without food. There is limited clinical data on the safety of CIALIS in patients with severe hepatic 
impairment (Child-Pugh Class C); if prescribed, a careful individual benefit/risk evaluation should be 
undertaken by the prescribing physician. There are no available data about the administration of doses 
higher than 10 mg of tadalafil to patients with hepatic impairment. Once-a-day dosing has not been 
evaluated in patients with hepatic impairment; therefore, if prescribed, a careful individual 
benefit/risk evaluation should be undertaken by the prescribing physician (see sections 4.4 and 5.2). 
 
Men with diabetes 
Dose adjustments are not required in diabetic patients. 
 
Paediatric population 
There is no relevant use of CIALIS in the paediatric population with regard to the treatment of erectile 
dysfunction. 
 
Method of administration 
CIALIS is available as 2.5, 5, 10, and 20 mg film-coated tablets for oral use. 
 
4.3 Contraindications 
 
Hypersensitivity to the active substance or to any of the excipients listed in section 6.1. 
 
In clinical studies, tadalafil was shown to augment the hypotensive effects of nitrates. This is thought 
to result from the combined effects of nitrates and tadalafil on the nitric oxide/cGMP pathway. 
Therefore, administration of CIALIS to patients who are using any form of organic nitrate is 
contraindicated (see section 4.5). 
 
CIALIS, must not be used in men with cardiac disease for whom sexual activity is inadvisable. 
Physicians should consider the potential cardiac risk of sexual activity in patients with pre-existing 
cardiovascular disease. 
 
The following groups of patients with cardiovascular disease were not included in clinical trials and 
the use of tadalafil is therefore contraindicated:  
- patients with myocardial infarction within the last 90 days,  
- patients with unstable angina or angina occurring during sexual intercourse,  
- patients with New York Heart Association Class 2 or greater heart failure in the last 6 months,  
- patients with uncontrolled arrhythmias, hypotension (< 90/50 mm Hg), or uncontrolled 

hypertension,  
- patients with a stroke within the last 6 months. 
 
CIALIS is contraindicated in patients who have loss of vision in one eye because of non-arteritic 
anterior ischaemic optic neuropathy (NAION), regardless of whether this episode was in connection 
or not with previous PDE5 inhibitor exposure (see section 4.4). 
 



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The co-administration of PDE5 inhibitors, including tadalafil, with guanylate cyclase stimulators, 
such as riociguat, is contraindicated as it may potentially lead to symptomatic hypotension (see 
section 4.5). 
 
4.4 Special warnings and precautions for use 
 
Before treatment with CIALIS 
A medical history and physical examination should be undertaken to diagnose erectile dysfunction 
and determine potential underlying causes, before pharmacological treatment is considered. 
 
Prior to initiating any treatment for erectile dysfunction, physicians should consider the 
cardiovascular status of their patients, since there is a degree of cardiac risk associated with sexual 
activity. Tadalafil has vasodilator properties, resulting in mild and transient decreases in blood 
pressure (see section 5.1) and as such potentiates the hypotensive effect of nitrates (see section 4.3). 
 
The evaluation of erectile dysfunction should include a determination of potential underlying causes 
and the identification of appropriate treatment following an appropriate medical assessment. It is not 
known if CIALIS is effective in patients who have undergone pelvic surgery or radical non-nerve-
sparing prostatectomy. 
 
Cardiovascular 
Serious cardiovascular events, including myocardial infarction, sudden cardiac death, unstable angina 
pectoris, ventricular arrhythmia, stroke, transient ischemic attacks, chest pain, palpitations and 
tachycardia, have been reported either post marketing and/or in clinical trials.  Most of the patients in 
whom these events have been reported had pre-existing cardiovascular risk factors. However, it is not 
possible to definitively determine whether these events are related directly to these risk factors, to 
CIALIS, to sexual activity, or to a combination of these or other factors. 
 
In patients receiving concomitant antihypertensive medicinal products, tadalafil may induce a blood 
pressure decrease. When initiating daily treatment with tadalafil, appropriate clinical considerations 
should be given to a possible dose adjustment of the antihypertensive therapy.  
 
In patients who are taking alpha1 blockers, concomitant administration of CIALIS may lead to 
symptomatic hypotension in some patients (see section 4.5). The combination of tadalafil and 
doxazosin is not recommended. 
 
Vision 
Visual defects and cases of NAION have been reported in connection with the intake of CIALIS and 
other PDE5 inhibitors. Analyses of observational data suggest an increased risk of acute NAION in 
men with erectile dysfunction following exposure to tadalafil or other PDE5 inhibitors. As this may 
be relevant for all patients exposed to tadalafil, the patient should be advised that in case of sudden 
visual defect, he should stop taking CIALIS and consult a physician immediately (see section 4.3). 
 
Decreased or sudden hearing loss 
Cases of sudden hearing loss have been reported after the use of tadalafil. Although other risk factors 
were present in some cases (such as age, diabetes, hypertension and previous hearing loss history) 
patients should be advised to stop taking tadalafil and seek prompt medical attention in the event of 
sudden decrease or loss of hearing. 
 
Renal and hepatic impairment 
Due to increased tadalafil exposure (AUC), limited clinical experience and the lack of ability to 
influence clearance by dialysis, once-a-day dosing of CIALIS is not recommended in patients with 
severe renal impairment.  
 
There is limited clinical data on the safety of single-dose administration of CIALIS in patients with 
severe hepatic insufficiency (Child-Pugh Class C). Once-a-day administration has not been evaluated 



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in patients with hepatic insufficiency. If CIALIS is prescribed, a careful individual benefit/risk 
evaluation should be undertaken by the prescribing physician. 
 
Priapism and anatomical deformation of the penis 
Patients who experience erections lasting 4 hours or more should be instructed to seek immediate 
medical assistance. If priapism is not treated immediately, penile tissue damage and permanent loss of 
potency may result. 
 
CIALIS, should be used with caution in patients with anatomical deformation of the penis (such as 
angulation, cavernosal fibrosis or Peyronie's disease), or in patients who have conditions which may 
predispose them to priapism (such as sickle cell anaemia, multiple myeloma or leukaemia). 
 
Use with CYP3A4 inhibitors 
Caution should be exercised when prescribing CIALIS to patients using potent CYP3A4 inhibitors 
(ritonavir, saquinavir, ketoconazole, itraconazole, and erythromycin) as increased tadalafil exposure 
(AUC) has been observed if the medicinal products are combined (see section 4.5). 
 
CIALIS and other treatments for erectile dysfunction 
The safety and efficacy of combinations of CIALIS and other PDE5 inhibitors or other treatments for 
erectile dysfunction have not been studied. The patients should be informed not to take CIALIS in 
such combinations. 
 
Lactose 
CIALIS contains lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp 
lactase deficiency or glucose-galactose malabsorption should not take this medicinal product. 
 
4.5 Interaction with other medicinal products and other forms of interaction 
 
Interaction studies were conducted with 10 mg and/or 20 mg tadalafil, as indicated below. With 
regard to those interaction studies where only the 10 mg tadalafil dose was used, clinically relevant 
interactions at higher doses cannot be completely ruled out. 
 
Effects of other substances on tadalafil 
 
Cytochrome P450 inhibitors  
Tadalafil is principally metabolised by CYP3A4. A selective inhibitor of CYP3A4, ketoconazole  
(200 mg daily), increased tadalafil (10 mg) exposure (AUC) 2-fold and Cmax by 15 %, relative to the 
AUC and Cmax values for tadalafil alone. Ketoconazole (400 mg daily) increased tadalafil (20 mg) 
exposure (AUC) 4-fold and Cmax by 22 %. Ritonavir, a protease inhibitor (200 mg twice daily), which 
is an inhibitor of CYP3A4, CYP2C9, CYP2C19, and CYP2D6, increased tadalafil (20 mg) 
exposure (AUC) 2-fold with no change in Cmax. Although specific interactions have not been studied, 
other protease inhibitors, such as saquinavir, and other CYP3A4 inhibitors, such as erythromycin, 
clarithromycin, itraconazole and grapefruit juice should be co-administered with caution as they 
would be expected to increase plasma concentrations of tadalafil (see section 4.4). 
Consequently the incidence of the adverse reactions listed in section 4.8 might be increased. 
 
Transporters 
The role of transporters (for example p-glycoprotein) in the disposition of tadalafil is not known. 
Therefore there is the potential of drug interactions mediated by inhibition of transporters. 
 
Cytochrome P450 inducers 
A CYP3A4 inducer, rifampicin, reduced tadalafil AUC by 88 %, relative to the AUC values for 
tadalafil alone (10 mg). This reduced exposure can be anticipated to decrease the efficacy of tadalafil; 
the magnitude of decreased efficacy is unknown. Other inducers of CYP3A4 such as phenobarbital, 
phenytoin and carbamazepine, may also decrease plasma concentrations of tadalafil.  
 



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Effects of tadalafil on other medicinal products 
 
Nitrates 
In clinical studies, tadalafil (5, 10 and 20 mg) was shown to augment the hypotensive effects of 
nitrates. Therefore, administration of CIALIS to patients who are using any form of organic nitrate is 
contraindicated (see section 4.3). Based on the results of a clinical study in which 150 subjects 
receiving daily doses of tadalafil 20 mg for 7 days and 0.4 mg sublingual nitroglycerin at various 
times, this interaction lasted for more than 24 hours and was no longer detectable when 48 hours had 
elapsed after the last tadalafil dose. Thus, in a patient prescribed any dose of CIALIS (2.5 mg-20 mg), 
where nitrate administration is deemed medically necessary in a life-threatening situation, at least 48 
hours should have elapsed after the last dose of CIALIS before nitrate administration is considered. In 
such circumstances, nitrates should only be administered under close medical supervision with 
appropriate haemodynamic monitoring. 
 
Anti-hypertensives (including calcium channel blockers) 
The co-administration of doxazosin (4 and 8 mg daily) and tadalafil (5 mg daily dose and 20 mg as a 
single dose) increases the blood pressure-lowering effect of this alpha-blocker in a significant manner. 
This effect lasts at least twelve hours and may be symptomatic, including syncope. Therefore this 
combination is not recommended (see section 4.4). 
In interaction studies performed in a limited number of healthy volunteers, these effects were not 
reported with alfuzosin or tamsulosin. However, caution should be exercised when using tadalafil in 
patients treated with any alpha-blockers, and notably in the elderly. Treatments should be initiated at 
minimal dosage and progressively adjusted. 
 
In clinical pharmacology studies, the potential for tadalafil to augment the hypotensive effects of 
antihypertensive medicinal products was examined. Major classes of antihypertensive medicinal 
products were studied, including calcium channel blockers (amlodipine), angiotensin converting 
enzyme (ACE) inhibitors (enalapril), beta-adrenergic receptor blockers (metoprolol), thiazide 
diuretics (bendrofluazide), and angiotensin II receptor blockers (various types and doses, alone or in 
combination with thiazides, calcium channel blockers, beta-blockers, and/or alpha-blockers). Tadalafil 
(10 mg except for studies with angiotensin II receptor blockers and amlodipine in which a 20 mg dose 
was applied) had no clinically significant interaction with any of these classes. In another clinical 
pharmacology study tadalafil (20 mg) was studied in combination with up to 4 classes of 
antihypertensives. In subjects taking multiple antihypertensives, the ambulatory-blood-pressure 
changes appeared to relate to the degree of blood-pressure control. In this regard, study subjects 
whose blood pressure was well controlled, the reduction was minimal and similar to that seen in 
healthy subjects. In study subjects whose blood pressure was not controlled, the reduction was greater 
although this reduction was not associated with hypotensive symptoms in the majority of subjects. In 
patients receiving concomitant antihypertensive medicinal products, tadalafil 20 mg may induce a 
blood pressure decrease, which (with the exception of alpha blockers -see above-) is, in general, 
minor and not likely to be clinically relevant. Analysis of phase 3 clinical trial data showed no 
difference in adverse events in patients taking tadalafil with or without antihypertensive medicinal 
products. However, appropriate clinical advice should be given to patients regarding a possible 
decrease in blood pressure when they are treated with antihypertensive medicinal products. 
 
Riociguat 
Preclinical studies showed an additive systemic blood pressure lowering effect when PDE5 inhibitors 
were combined with riociguat.  In clinical studies, riociguat has been shown to augment the 
hypotensive effects of PDE5 inhibitors.  There was no evidence of favourable clinical effect of the 
combination in the population studied.  Concomitant use of riociguat with PDE5 inhibitors, including 
tadalafil, is contraindicated (see section 4.3).   
 
5- alpha reductase inhibitors 
In a clinical trial that compared tadalafil 5 mg coadministered with finasteride 5 mg to placebo plus 
finasteride 5 mg in the relief of BPH symptoms, no new adverse reactions were identified. However, 
as a formal drug-drug interaction study evaluating the effects of tadalafil and 5-alpha reductase 



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inhibitors (5-ARIs) has not been performed, caution should be exercised when tadalafil is co-
administered with 5-ARIs. 
 
CYP1A2 substrates (e.g. theophylline) 
When tadalafil 10 mg was administered with theophylline (a non-selective phosphodiesterase 
inhibitor) in a clinical pharmacology study, there was no pharmacokinetic interaction. The only 
pharmacodynamic effect was a small (3.5 bpm) increase in heart rate. Although this effect is minor 
and was of no clinical significance in this study, it should be considered when co-administering these 
medicinal products. 
 
Ethinylestradiol and terbutaline 
Tadalafil has been demonstrated to produce an increase in the oral bioavailability of ethinylestradiol; 
a similar increase may be expected with oral administration of terbutaline, although the clinical 
consequence of this is uncertain. 
 
Alcohol 
Alcohol concentrations (mean maximum blood concentration 0.08 %) were not affected by co-
administration with tadalafil (10 mg or 20 mg). In addition, no changes in tadalafil concentrations 
were seen 3 hours after co-administration with alcohol. Alcohol was administered in a manner to 
maximise the rate of alcohol absorption (overnight fast with no food until 2 hours after alcohol).  
Tadalafil (20 mg) did not augment the mean blood pressure decrease produced by alcohol (0.7 g/kg or 
approximately 180 ml of 40 % alcohol [vodka] in an 80-kg male) but in some subjects, postural 
dizziness and orthostatic hypotension were observed. When tadalafil was administered with lower 
doses of alcohol (0.6 g/kg), hypotension was not observed and dizziness occurred with similar 
frequency to alcohol alone. The effect of alcohol on cognitive function was not augmented by 
tadalafil (10 mg). 
 
Cytochrome P450 metabolised medicinal products 
Tadalafil is not expected to cause clinically significant inhibition or induction of the clearance of 
medicinal products metabolised by CYP450 isoforms. Studies have confirmed that tadalafil does not 
inhibit or induce CYP450 isoforms, including CYP3A4, CYP1A2, CYP2D6, CYP2E1, CYP2C9 and 
CYP2C19.  
 
CYP2C9 substrates (e.g. R-warfarin) 
Tadalafil (10 mg and 20 mg) had no clinically significant effect on exposure (AUC) to S-warfarin or 
R-warfarin (CYP2C9 substrate), nor did tadalafil affect changes in prothrombin time induced by 
warfarin.  
 
Aspirin 
Tadalafil (10 mg and 20 mg) did not potentiate the increase in bleeding time caused by acetyl salicylic 
acid.  
 
Antidiabetic medicinal products 
Specific interaction studies with antidiabetic medicinal products were not conducted.  
 
4.6 Fertility, pregnancy and lactation 
 
CIALIS is not indicated for use by women.  
 
Pregnancy 
There are limited data from the use of tadalafil in pregnant women. Animal studies do not indicate 
direct or indirect harmful effects with respect to pregnancy, embryonal/foetal development, 
parturition or postnatal development (see section 5.3). As a precautionary measure, it is preferable to 
avoid the use of CIALIS during pregnancy.  
 



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Breastfeeding 
Available pharmacodynamic/toxicological data in animals have shown excretion of tadalafil in milk. 
A risk to the suckling child cannot be excluded. CIALIS should not be used during breast feeding. 
 
Fertility 
Effects were seen in dogs that might indicate impairment of fertility. Two subsequent clinical studies 
suggest that this effect is unlikely in humans, although a decrease in sperm concentration was seen in 
some men (see sections 5.1 and 5.3). 
 
4.7 Effects on ability to drive and use machines 
 
CIALIS has negligible influence on the ability to drive or use machines. Although the frequency of 
reports of dizziness in placebo and tadalafil arms in clinical trials was similar, patients should be 
aware of how they react to CIALIS, before driving or using machines. 
 
4.8 Undesirable effects 
 
Summary of the safety profile 
 
The most commonly reported adverse reactions in patients taking CIALIS for the treatment of erectile 
dysfunction or benign prostatic hyperplasia were headache, dyspepsia, back pain and myalgia, in 
which the incidences increase with increasing dose of CIALIS.  The adverse reactions reported were 
transient, and generally mild or moderate. The majority of headaches reported with CIALIS once-a-
day dosing are experienced within the first 10 to 30 days of starting treatment. 
 
Tabulated summary of adverse reactions 
 
The table below lists the adverse reactions observed from spontaneous reporting and in placebo-
controlled clinical trials (comprising a total of 8022 patients on CIALIS and 4422 patients on placebo) 
for on-demand and once-a-day treatment of erectile dysfunction and the once-a-day treatment of 
benign prostatic hyperplasia. 
 
Frequency convention: very common (≥1/10), common (≥1/100 to <1/10), uncommon (≥1/1000 to 
<1/100), rare (≥1/10,000 to <1/1,000) and very rare (<1/10,000) and not known (cannot be estimated 
from the available data). 
 

Very common  
 

Common  
 

Uncommon  
 

Rare  
 

Immune system disorders 
  Hypersensitivity 

reactions 
Angioedema2 

Nervous system disorders 
 Headache  Dizziness Stroke1 (including 

haemorrhagic events), 
Syncope, Transient 
ischaemic attacks1, 
Migraine2, Seizures2, 
Transient amnesia 

Eye disorders 
  Blurred vision, 

Sensations described 
as eye pain 
 

Visual field defect, 
Swelling of eyelids, 
Conjunctival 
hyperaemia, Non-
arteritic anterior 
ischemic optic 



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neuropathy (NAION)2, 
Retinal vascular 
occlusion2 

Ear and labyrinth disorders 
  Tinnitus Sudden hearing loss 
Cardiac disorders1 
  Tachycardia, 

Palpitations 
Myocardial infarction, 
Unstable angina 
pectoris2, Ventricular 
arrhythmia2 

Vascular disorders 
 Flushing Hypotension3, 

Hypertension 
 

Respiratory, thoracic and mediastinal disorders 
 Nasal congestion Dyspnoea, Epistaxis  
Gastrointestinal disorders 
 Dyspepsia 

 
Abdominal pain, 
Vomiting, Nausea, 
Gastro-oesophageal 
reflux 

 

Skin and subcutaneous tissue disorders 
  Rash Urticaria,  

Stevens-Johnson 
syndrome2, 
Exfoliative 
dermatitis2, 
Hyperhydrosis 
(sweating) 

Musculoskeletal, connective tissue and bone disorders 
 Back pain, 

Myalgia, Pain in 
extremity 

  

Renal and urinary disorders 
  Haematuria  
Reproductive system and breast disorders 
  Prolonged erections Priapism, Penile 

haemorrhage, 
Haematospermia 

General disorders and administration site conditions 
  Chest pain1, Peripheral 

oedema, Fatigue 
Facial oedema2, 
Sudden cardiac 
death1, 2  

(1) Most of the patients had pre-existing cardiovascular risk factors (see section 4.4). 
(2) Postmarketing surveillance reported adverse reactions not observed in placebo-controlled clinical 
trials. 
(3) More commonly reported when tadalafil is given to patients who are already taking 
antihypertensive medicinal products. 
 
Description of selected adverse reactions 
 
A slightly higher incidence of ECG abnormalities, primarily sinus bradycardia, has been reported in 
patients treated with tadalafil once a day as compared with placebo. Most of these ECG abnormalities 
were not associated with adverse reactions. 
 



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Other special populations 
  
Data in patients over 65 years of age receiving tadalafil in clinical trials, either for the treatment of 
erectile dysfunction or the treatment of benign prostatic hyperplasia, are limited. In clinical trials with 
tadalafil taken on demand for the treatment of erectile dysfunction, diarrhoea was reported more 
frequently in patients over 65 years of age. In clinical trials with tadalafil 5mg taken once a day for 
the treatment of benign prostatic hyperplasia, dizziness and diarrhoea were reported more frequently 
in patients over 75 years of age.  
 
Reporting of suspected adverse reactions 
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It 
allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare 
professionals are asked to report any suspected adverse reactions via the national reporting system 
listed in Appendix V. 
 
4.9 Overdose 
 
Single doses of up to 500 mg have been given to healthy subjects, and multiple daily doses up to 
100 mg have been given to patients.  Adverse events were similar to those seen at lower doses.  
In cases of overdose, standard supportive measures should be adopted as required. Haemodialysis 
contributes negligibly to tadalafil elimination. 
 
 
5. PHARMACOLOGICAL PROPERTIES 
 
5.1  Pharmacodynamic properties 
 
Pharmacotherapeutic group: Urologicals, Drugs used in erectile dysfunction, ATC Code: G04BE08.  
 
Mechanism of action 
Tadalafil is a selective, reversible inhibitor of cyclic guanosine monophosphate (cGMP)-specific 
phosphodiesterase type 5 (PDE5). When sexual stimulation causes the local release of nitric oxide, 
inhibition of PDE5 by tadalafil produces increased levels of cGMP in the corpus cavernosum. This 
results in smooth muscle relaxation and inflow of blood into the penile tissues, thereby producing an 
erection. Tadalafil has no effect in the absence of sexual stimulation. 
 
Pharmacodynamic effects 
Studies in vitro have shown that tadalafil is a selective inhibitor of PDE5. PDE5 is an enzyme found 
in corpus cavernosum smooth muscle, vascular and visceral smooth muscle, skeletal muscle, platelets, 
kidney, lung, and cerebellum. The effect of tadalafil is more potent on PDE5 than on other 
phosphodiesterases. Tadalafil is > 10,000-fold more potent for PDE5 than for PDE1, PDE2, and 
PDE4, enzymes which are found in the heart, brain, blood vessels, liver, and other organs. Tadalafil is 
> 10,000-fold more potent for PDE5 than for PDE3, an enzyme found in the heart and blood vessels. 
This selectivity for PDE5 over PDE3 is important because PDE3 is an enzyme involved in cardiac 
contractility. Additionally, tadalafil is approximately 700-fold more potent for PDE5 than for PDE6, 
an enzyme which is found in the retina and is responsible for phototransduction. Tadalafil is also 
> 10,000-fold more potent for PDE5 than for PDE7 through PDE10. 
 
Clinical efficacy and safety 
Three clinical studies were conducted in 1054 patients in an at-home setting to define the period of 
responsiveness to CIALIS on demand. Tadalafil demonstrated statistically significant improvement in 
erectile function and the ability to have successful sexual intercourse up to 36 hours following dosing, 
as well as patients’ ability to attain and maintain erections for successful intercourse compared to 
placebo as early as 16 minutes following dosing. 
 

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Tadalafil administered to healthy subjects produced no significant difference compared to placebo in 
supine systolic and diastolic blood pressure (mean maximal decrease of 1.6/0.8 mm Hg, respectively), 
in standing systolic and diastolic blood pressure (mean maximal decrease of 0.2/4.6 mm Hg, 
respectively), and no significant change in heart rate.  
 
In a study to assess the effects of tadalafil on vision, no impairment of colour discrimination 
(blue/green) was detected using the Farnsworth-Munsell 100-hue test. This finding is consistent with 
the low affinity of tadalafil for PDE6 compared to PDE5. Across all clinical studies, reports of 
changes in colour vision were rare (< 0.1 %). 
 
Three studies were conducted in men to assess the potential effect on spermatogenesis of CIALIS  
10 mg (one 6-month study) and 20 mg (one 6-month and one 9-month study) administered daily. In 
two of these studies decreases were observed in sperm count and concentration related to tadalafil 
treatment of unlikely clinical relevance. These effects were not associated with changes in other 
parameters such as motility, morphology and FSH. 
 
Tadalafil at doses of 2.5, 5, and 10 mg taken once a day was initially evaluated in 3 clinical studies 
involving 853 patients of various ages (range 21-82 years) and ethnicities, with erectile dysfunction of 
various severities (mild, moderate, severe) and etiologies. In the two primary efficacy studies of 
general populations, the mean per-subject proportion of successful intercourse attempts were 57 and 
67 % on CIALIS 5 mg, 50 % on CIALIS 2.5 mg as compared to 31 and 37 % with placebo. In the 
study in patients with erectile dysfunction secondary to diabetes, the mean per-subject proportion of 
successful attempts were 41 and 46 % on CIALIS 5 mg and 2.5 mg, respectively, as compared to 28 % 
with placebo. Most patients in these three studies were responders to previous on-demand treatment 
with PDE5 inhibitors. In a subsequent study, 217 patients who were treatment-naïve to PDE5 
inhibitors were randomized to CIALIS 5 mg once a day vs. placebo.  The mean per-subject proportion 
of successful sexual intercourse attempts was 68 % for CIALIS patients compared to 52 % for patients 
on placebo. 
 
In a 12-week study performed in 186 patients (142 tadalafil, 44 placebo) with erectile dysfunction 
secondary to spinal cord injury, tadalafil significantly improved the erectile function leading to a 
mean per-subject proportion of successful attempts in patients treated with tadalafil 10 or 20 mg 
(flexible-dose, on demand) of 48 % as compared to 17 % with placebo. 
 
Paediatric population 
A single study has been performed in paediatric patients with Duchenne Muscular Dystrophy (DMD) 
in which no evidence of efficacy was seen. The randomised, double-blind, placebo-controlled, 
parallel, 3-arm study of tadalafil was conducted in 331 boys aged 7-14 years with DMD receiving 
concurrent corticosteroid therapy. The study included a 48-week double-blind period where patients 
were randomised to tadalafil 0.3 mg/kg, tadalafil 0.6 mg/kg, or placebo daily. Tadalafil did not show 
efficacy in slowing the decline in ambulation as measured by the primary 6 minute walk distance 
(6MWD) endpoint: least squares (LS) mean change in 6MWD at 48 weeks was -51.0 meters (m) in 
the placebo group, compared with -64.7 m in the tadalafil 0.3 mg/kg group (p = 0.307) and -59.1 m in 
the tadalafil 0.6 mg/kg group (p = 0.538). In addition, there was no evidence of efficacy from any of 
the secondary analyses performed in this study. The overall safety results from this study were 
generally consistent with the known safety profile of tadalafil and with adverse events (AEs) expected 
in a paediatric DMD population receiving corticosteroids. 
 
The European Medicines Agency has waived the obligation to submit the results of studies in all 
subsets of the paediatric population in the treatment of the erectile dysfunction. See section 4.2 for 
information on paediatric use. 
 



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5.2 Pharmacokinetic properties 
 
Absorption 
Tadalafil is readily absorbed after oral administration and the mean maximum observed plasma 
concentration (Cmax) is achieved at a median time of 2 hours after dosing. Absolute bioavailability of 
tadalafil following oral dosing has not been determined. 
The rate and extent of absorption of tadalafil are not influenced by food, thus CIALIS may be taken 
with or without food. The time of dosing (morning versus evening) had no clinically relevant effects 
on the rate and extent of absorption. 
 
Distribution  
The mean volume of distribution is approximately 63 l, indicating that tadalafil is distributed into 
tissues. At therapeutic concentrations, 94 % of tadalafil in plasma is bound to proteins. Protein 
binding is not affected by impaired renal function. 
Less than 0.0005 % of the administered dose appeared in the semen of healthy subjects. 
 
Biotransformation 
Tadalafil is predominantly metabolised by the cytochrome P450 (CYP) 3A4 isoform. The major 
circulating metabolite is the methylcatechol glucuronide. This metabolite is at least 13,000-fold less 
potent than tadalafil for PDE5. Consequently, it is not expected to be clinically active at observed 
metabolite concentrations. 
 
Elimination  
The mean oral clearance for tadalafil is 2.5 l/h and the mean half-life is 17.5 hours in healthy subjects. 
Tadalafil is excreted predominantly as inactive metabolites, mainly in the faeces (approximately 61 % 
of the dose) and to a lesser extent in the urine (approximately 36 % of the dose).  
 
Linearity/non-linearity 
Tadalafil pharmacokinetics in healthy subjects are linear with respect to time and dose. Over a dose 
range of 2.5 to 20 mg, exposure (AUC) increases proportionally with dose. Steady-state plasma 
concentrations are attained within 5 days of once-daily dosing. 
 
Pharmacokinetics determined with a population approach in patients with erectile dysfunction are 
similar to pharmacokinetics in subjects without erectile dysfunction. 
 
Special populations 
 
Elderly 
Healthy elderly subjects (65 years or over), had a lower oral clearance of tadalafil, resulting in 25 % 
higher exposure (AUC) relative to healthy subjects aged 19 to 45 years. This effect of age is not 
clinically significant and does not warrant a dose adjustment. 
 
Renal insufficiency 
In clinical pharmacology studies using single-dose tadalafil (5 to 20 mg), tadalafil exposure (AUC) 
approximately doubled in subjects with mild (creatinine clearance 51 to 80 ml/min) or moderate 
(creatinine clearance 31 to 50 ml/min) renal impairment and in subjects with end-stage renal disease 
on dialysis. In haemodialysis patients, Cmax was 41 % higher than that observed in healthy subjects. 
Haemodialysis contributes negligibly to tadalafil elimination. 
 



 13 

Hepatic insufficiency 
Tadalafil exposure (AUC) in subjects with mild and moderate hepatic impairment (Child-Pugh Class 
A and B) is comparable to exposure in healthy subjects when a dose of 10 mg is administered. There 
is limited clinical data on the safety of CIALIS in patients with severe hepatic insufficiency (Child-
Pugh Class C). There are no available data about the administration of once-a-day dosing of tadalafil 
to patients with hepatic impairment. If CIALIS is prescribed once-a-day, a careful individual 
benefit/risk evaluation should be undertaken by the prescribing physician. 
  
Patients with diabetes 
Tadalafil exposure (AUC) in patients with diabetes was approximately 19 % lower than the AUC 
value for healthy subjects. This difference in exposure does not warrant a dose adjustment. 
 
5.3 Preclinical safety data 
 
Non-clinical data reveal no special hazard for humans based on conventional studies of safety 
pharmacology, repeated dose toxicity, genotoxicity, carcinogenic potential, and toxicity to 
reproduction. 
There was no evidence of teratogenicity, embryotoxicity or foetotoxicity in rats or mice that received 
up to 1000 mg/kg/day tadalafil. In a rat prenatal and postnatal development study, the no observed 
effect dose was 30 mg/kg/day. In the pregnant rat the AUC for calculated free drug at this dose was 
approximately 18 times the human AUC at a 20 mg dose. 
There was no impairment of fertility in male and female rats. In dogs given tadalafil daily for 6 to 12 
months at doses of 25 mg/kg/day (resulting in at least a 3-fold greater exposure [range 3.7 – 18.6] than 
seen in humans given a single 20 mg dose) and above, there was regression of the seminiferous 
tubular epithelium that resulted in a decrease in spermatogenesis in some dogs. See also section 5.1.  
 
 
6. PHARMACEUTICAL PARTICULARS 
 
6.1 List of excipients 
 
Tablet core:  
lactose monohydrate,  
croscarmellose sodium,  
hydroxypropylcellulose,  
microcrystalline cellulose,  
sodium laurilsulfate,  
magnesium stearate. 
 
Film-coat:  
lactose monohydrate,  
hypromellose,  
triacetin,  
titanium dioxide (E171),  
iron oxide yellow (E172),  
iron oxide red (E172), 
talc. 
 
6.2 Incompatibilities 
 
Not applicable. 
 
6.3 Shelf life 
 
3 years. 
 



 14 

6.4 Special precautions for storage 
 
Store in the original package in order to protect from moisture. Do not store above 30°C. 
 
6.5 Nature and contents of container 
 
Aluminium/PVC blisters in cartons of 28 film-coated tablets. 
 
6.6 Special precautions for disposal   
 
Any unused medicinal product or waste material should be disposed of in accordance with local 
requirements. 
 
 
7. MARKETING AUTHORISATION HOLDER 
 
Eli Lilly Nederland B.V. 
Papendorpseweg 83, 3528 BJ Utrecht 
The Netherlands 
 
 
8. MARKETING AUTHORISATION NUMBER(S)  
 
EU/1/02/237/006 
 
 
9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION 
 
Date of first authorisation: 12 November 2002 
Date of last renewal: 12 November 2012 
 
 
10. DATE OF REVISION OF THE TEXT 
 
 
Detailed information on this medicinal product is available on the website of the European Medicines 
Agency http://www.ema.europa.eu. 

http://www.ema.europa.eu/


 15 

1. NAME OF THE MEDICINAL PRODUCT 
 
CIALIS 5 mg film-coated tablets 
 
 
2. QUALITATIVE AND QUANTITATIVE COMPOSITION 
 
Each tablet contains 5 mg tadalafil. 
 
Excipient with known effect: 
Each coated tablet contains 121 mg lactose (as monohydrate). 
 
For the full list of excipients, see section 6.1. 
 
 
3. PHARMACEUTICAL FORM 
 
Film-coated tablet (tablet). 
 
Light yellow and almond shaped tablets, marked "C 5" on one side. 
 
 
4. CLINICAL PARTICULARS 
 
4.1 Therapeutic indications 
 
Treatment of erectile dysfunction in adult males. 
 
In order for tadalafil to be effective for the treatment of erectile dysfunction, sexual stimulation is 
required.  
 
Treatment of the signs and symptoms of benign prostatic hyperplasia in adult males. 
 
CIALIS is not indicated for use by women. 
 
4.2 Posology and method of administration 
 
Posology 
Erectile dysfunction in adult men 
In general, the recommended dose is 10 mg taken prior to anticipated sexual activity and with or 
without food. 
In those patients in whom tadalafil 10 mg does not produce an adequate effect, 20 mg might be tried. 
It may be taken at least 30 minutes prior to sexual activity. 
 
The maximum dose frequency is once per day. 
 
Tadalafil 10 and 20 mg is intended for use prior to anticipated sexual activity and it is not 
recommended for continuous daily use. 
 
In patients who anticipate a frequent use of CIALIS (i.e., at least twice weekly) a once daily regimen 
with the lowest doses of CIALIS might be considered suitable, based on patient choice and the 
physician’s judgement. 
 
In these patients the recommended dose is 5 mg taken once a day at approximately the same time of 
day. The dose may be decreased to 2.5 mg once a day based on individual tolerability. 
 



 16 

The appropriateness of continued use of the daily regimen should be reassessed periodically. 
 
Benign prostatic hyperplasia in adult men 
The recommended dose is 5 mg, taken at approximately the same time every day with or without food. 
For adult men being treated for both benign prostatic hyperplasia and erectile dysfunction the 
recommended dose is also 5 mg taken at approximately the same time every day. Patients who are 
unable to tolerate tadalafil 5 mg for the treatment of  benign prostatic hyperplasia should consider an 
alternative therapy as the efficacy of tadalafil 2.5mg for the treatment of benign prostatic hyperplasia 
has not been demonstrated. 
 
Special populations  
Elderly men 
Dose adjustments are not required in elderly patients. 
 
Men with renal impairment 
Dose adjustments are not required in patients with mild to moderate renal impairment. For patients 
with severe renal impairment 10 mg is the maximum recommended dose for on-demand treatment.  
 
Once-a-day dosing of 2.5 or 5 mg tadalafil both for the treatment of erectile dysfunction or benign 
prostatic hyperplasia is not recommended in patients with severe renal impairment (see sections 4. 4 
and 5.2). 
 
Men with hepatic impairment 
For the treatment of erectile dysfunction using on-demand CIALIS the recommended dose of CIALIS 
is 10 mg taken prior to anticipated sexual activity and with or without food. There is limited clinical 
data on the safety of CIALIS in patients with severe hepatic impairment (Child-Pugh Class C); if 
prescribed, a careful individual benefit/risk evaluation should be undertaken by the prescribing 
physician. There are no available data about the administration of doses higher than 10 mg of tadalafil 
to patients with hepatic impairment.  
 
Once-a-day dosing of CIALIS both for the treatment of erectile dysfunction and benign prostatic 
hyperplasia has not been evaluated in patients with hepatic impairment; therefore, if prescribed, a 
careful individual benefit/risk evaluation should be undertaken by the prescribing physician (see 
sections 4.4 and 5.2). 
 
Men with diabetes 
Dose adjustments are not required in diabetic patients. 
 
Paediatric population 
There is no relevant use of CIALIS in the paediatric population with regard to the treatment of erectile 
dysfunction.  
 
Method of administration 
CIALIS is available as 2.5, 5, 10, and 20 mg film-coated tablets for oral use. 
 
4.3 Contraindications 
 
Hypersensitivity to the active substance or to any of the excipients listed in section 6.1. 
 
In clinical studies, tadalafil was shown to augment the hypotensive effects of nitrates. This is thought 
to result from the combined effects of nitrates and tadalafil on the nitric oxide/cGMP pathway. 
Therefore, administration of CIALIS to patients who are using any form of organic nitrate is 
contraindicated (see section 4.5). 
 



 17 

CIALIS, must not be used in men with cardiac disease for whom sexual activity is inadvisable. 
Physicians should consider the potential cardiac risk of sexual activity in patients with pre-existing 
cardiovascular disease. 
 
The following groups of patients with cardiovascular disease were not included in clinical trials and 
the use of tadalafil is therefore contraindicated:  
- patients with myocardial infarction within the last 90 days,  
- patients with unstable angina or angina occurring during sexual intercourse,  
- patients with New York Heart Association Class 2 or greater heart failure in the last 6 months,  
- patients with uncontrolled arrhythmias, hypotension (< 90/50 mm Hg), or uncontrolled 

hypertension,  
- patients with a stroke within the last 6 months. 
 
CIALIS is contraindicated in patients who have loss of vision in one eye because of non-arteritic 
anterior ischaemic optic neuropathy (NAION), regardless of whether this episode was in connection 
or not with previous PDE5 inhibitor exposure (see section 4.4). 
 
The co-administration of PDE5 inhibitors, including tadalafil, with guanylate cyclase stimulators, 
such as riociguat, is contraindicated as it may potentially lead to symptomatic hypotension (see 
section 4.5). 
 
4.4 Special warnings and precautions for use 
 
Before treatment with CIALIS  
A medical history and physical examination should be undertaken to diagnose erectile dysfunction or 
benign prostatic hyperplasia and determine potential underlying causes, before pharmacological 
treatment is considered. 
 
Prior to initiating any treatment for erectile dysfunction, physicians should consider the 
cardiovascular status of their patients, since there is a degree of cardiac risk associated with sexual 
activity. Tadalafil has vasodilator properties, resulting in mild and transient decreases in blood 
pressure (see section 5.1) and as such potentiates the hypotensive effect of nitrates (see section 4.3). 
 
Prior to initiating treatment with tadalafil for benign prostatic hyperplasia patients should be 
examined to rule out the presence of carcinoma of the prostate and carefully assessed for 
cardiovascular conditions (see section 4.3). 
 
The evaluation of erectile dysfunction should include a determination of potential underlying causes 
and the identification of appropriate treatment following an appropriate medical assessment. It is not 
known if CIALIS is effective in patients who have undergone pelvic surgery or radical non-nerve-
sparing prostatectomy. 
 
Cardiovascular 
Serious cardiovascular events, including myocardial infarction, sudden cardiac death, unstable angina 
pectoris, ventricular arrhythmia, stroke, transient ischemic attacks, chest pain, palpitations and 
tachycardia, have been reported either post marketing and/or in clinical trials.  Most of the patients in 
whom these events have been reported had pre-existing cardiovascular risk factors. However, it is not 
possible to definitively determine whether these events are related directly to these risk factors, to 
CIALIS, to sexual activity, or to a combination of these or other factors. 
 
In patients receiving concomitant antihypertensive medicinal products, tadalafil may induce a blood 
pressure decrease. When initiating daily treatment with tadalafil, appropriate clinical considerations 
should be given to a possible dose adjustment of the antihypertensive therapy.  
 



 18 

In patients who are taking alpha1 blockers, concomitant administration of CIALIS may lead to 
symptomatic hypotension in some patients (see section 4.5). The combination of tadalafil and 
doxazosin is not recommended. 
 
Vision 
Visual defects and cases of NAION have been reported in connection with the intake of CIALIS and 
other PDE5 inhibitors. Analyses of observational data suggest an increased risk of acute NAION in 
men with erectile dysfunction following exposure to tadalafil or other PDE5 inhibitors. As this may 
be relevant for all patients exposed to tadalafil, the patient should be advised that in case of sudden 
visual defect, he should stop taking CIALIS and consult a physician immediately (see section 4.3). 
 
Decreased or sudden hearing loss 
Cases of sudden hearing loss have been reported after the use of tadalafil. Although other risk factors 
were present in some cases (such as age, diabetes, hypertension and previous hearing loss history) 
patients should be advised to stop taking tadalafil and seek prompt medical attention in the event of 
sudden decrease or loss of hearing. 
 
Renal and hepatic impairment  
Due to increased tadalafil exposure (AUC), limited clinical experience and the lack of ability to 
influence clearance by dialysis, once-a-day dosing of CIALIS is not recommended in patients with 
severe renal impairment.  
 
There is limited clinical data on the safety of single-dose administration of CIALIS in patients with 
severe hepatic insufficiency (Child-Pugh Class C). Once-a-day administration either for the treatment 
of erectile dysfunction or benign prostatic hyperplasia has not been evaluated in patients with hepatic 
insufficiency. If CIALIS is prescribed, a careful individual benefit/risk evaluation should be 
undertaken by the prescribing physician. 
 
Priapism and anatomical deformation of the penis 
Patients who experience erections lasting 4 hours or more should be instructed to seek immediate 
medical assistance. If priapism is not treated immediately, penile tissue damage and permanent loss of 
potency may result. 
 
CIALIS, should be used with caution in patients with anatomical deformation of the penis (such as 
angulation, cavernosal fibrosis or Peyronie's disease), or in patients who have conditions which may 
predispose them to priapism (such as sickle cell anaemia, multiple myeloma or leukaemia). 
 
Use with CYP3A4 inhibitors 
Caution should be exercised when prescribing CIALIS to patients using potent CYP3A4 inhibitors 
(ritonavir, saquinavir, ketoconazole, itraconazole, and erythromycin) as increased tadalafil exposure 
(AUC) has been observed if the medicinal products are combined (see section 4.5). 
 
CIALIS and other treatments for erectile dysfunction 
The safety and efficacy of combinations of CIALIS and other PDE5 inhibitors or other treatments for 
erectile dysfunction have not been studied. The patients should be informed not to take CIALIS in 
such combinations. 
 
Lactose 
CIALIS contains lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp 
lactase deficiency or glucose-galactose malabsorption should not take this medicinal product. 
 



 19 

4.5 Interaction with other medicinal products and other forms of interaction 
 
Interaction studies were conducted with 10 mg and/or 20 mg tadalafil, as indicated below. With 
regard to those interaction studies where only the 10 mg tadalafil dose was used, clinically relevant 
interactions at higher doses cannot be completely ruled out. 
 
Effects of other substances on tadalafil 
 
Cytochrome P450 inhibitors 
Tadalafil is principally metabolised by CYP3A4. A selective inhibitor of CYP3A4, ketoconazole  
(200 mg daily), increased tadalafil (10 mg) exposure (AUC) 2-fold and Cmax by 15 %, relative to the 
AUC and Cmax values for tadalafil alone. Ketoconazole (400 mg daily) increased tadalafil (20 mg) 
exposure (AUC) 4-fold and Cmax by 22 %. Ritonavir, a protease inhibitor (200 mg twice daily), which 
is an inhibitor of CYP3A4, CYP2C9, CYP2C19, and CYP2D6, increased tadalafil (20 mg) 
exposure (AUC) 2-fold with no change in Cmax. Although specific interactions have not been studied, 
other protease inhibitors, such as saquinavir, and other CYP3A4 inhibitors, such as erythromycin, 
clarithromycin, itraconazole and grapefruit juice should be co-administered with caution as they 
would be expected to increase plasma concentrations of tadalafil (see section 4.4). 
Consequently the incidence of the adverse reactions listed in section 4.8 might be increased. 
 
Transporters 
The role of transporters (for example p-glycoprotein) in the disposition of tadalafil is not known. 
Therefore there is the potential of drug interactions mediated by inhibition of transporters. 
 
Cytochrome P450 inducers 
A CYP3A4 inducer, rifampicin, reduced tadalafil AUC by 88 %, relative to the AUC values for 
tadalafil alone (10 mg). This reduced exposure can be anticipated to decrease the efficacy of tadalafil; 
the magnitude of decreased efficacy is unknown. Other inducers of CYP3A4 such as phenobarbital, 
phenytoin and carbamazepine, may also decrease plasma concentrations of tadalafil.  
 
Effects of tadalafil on other medicinal products 
 
Nitrates  
In clinical studies, tadalafil (5, 10 and 20 mg) was shown to augment the hypotensive effects of 
nitrates. Therefore, administration of CIALIS to patients who are using any form of organic nitrate is 
contraindicated (see section 4.3). Based on the results of a clinical study in which 150 subjects 
receiving daily doses of tadalafil 20 mg for 7 days and 0.4 mg sublingual nitroglycerin at various 
times, this interaction lasted for more than 24 hours and was no longer detectable when 48 hours had 
elapsed after the last tadalafil dose. Thus, in a patient prescribed any dose of CIALIS (2.5 mg-20 mg), 
where nitrate administration is deemed medically necessary in a life-threatening situation, at least 48 
hours should have elapsed after the last dose of CIALIS before nitrate administration is considered. In 
such circumstances, nitrates should only be administered under close medical supervision with 
appropriate haemodynamic monitoring. 
 
Anti-hypertensives (including calcium channel blockers) 
The co-administration of doxazosin (4 and 8 mg daily) and tadalafil (5 mg daily dose and 20 mg as a 
single dose) increases the blood pressure-lowering effect of this alpha-blocker in a significant manner. 
This effect lasts at least twelve hours and may be symptomatic, including syncope. Therefore this 
combination is not recommended (see section 4.4). 
In interaction studies performed in a limited number of healthy volunteers, these effects were not 
reported with alfuzosin or tamsulosin. However, caution should be exercised when using tadalafil in 
patients treated with any alpha-blockers, and notably in the elderly. Treatments should be initiated at 
minimal dosage and progressively adjusted. 
 
In clinical pharmacology studies, the potential for tadalafil to augment the hypotensive effects of 
antihypertensive medicinal products was examined. Major classes of antihypertensive medicinal 



 20 

products were studied, including calcium channel blockers (amlodipine), angiotensin converting 
enzyme (ACE) inhibitors (enalapril), beta-adrenergic receptor blockers (metoprolol), thiazide 
diuretics (bendrofluazide), and angiotensin II receptor blockers (various types and doses, alone or in 
combination with thiazides, calcium channel blockers, beta-blockers, and/or alpha-blockers). Tadalafil 
(10 mg except for studies with angiotensin II receptor blockers and amlodipine in which a 20 mg dose 
was applied) had no clinically significant interaction with any of these classes. In another clinical 
pharmacology study tadalafil (20 mg) was studied in combination with up to 4 classes of 
antihypertensives. In subjects taking multiple antihypertensives, the ambulatory-blood-pressure 
changes appeared to relate to the degree of blood-pressure control. In this regard, study subjects 
whose blood pressure was well controlled, the reduction was minimal and similar to that seen in 
healthy subjects. In study subjects whose blood pressure was not controlled, the reduction was greater 
although this reduction was not associated with hypotensive symptoms in the majority of subjects. In 
patients receiving concomitant antihypertensive medicinal products, tadalafil 20 mg may induce a 
blood pressure decrease, which (with the exception of alpha blockers -see above-) is, in general, 
minor and not likely to be clinically relevant. Analysis of phase 3 clinical trial data showed no 
difference in adverse events in patients taking tadalafil with or without antihypertensive medicinal 
products. However, appropriate clinical advice should be given to patients regarding a possible 
decrease in blood pressure when they are treated with antihypertensive medicinal products. 
 
Riociguat 
Preclinical studies showed an additive systemic blood pressure lowering effect when PDE5 inhibitors 
were combined with riociguat.  In clinical studies, riociguat has been shown to augment the 
hypotensive effects of PDE5 inhibitors.  There was no evidence of favourable clinical effect of the 
combination in the population studied.  Concomitant use of riociguat with PDE5 inhibitors, including 
tadalafil, is contraindicated (see section 4.3).   
 
5- alpha reductase inhibitors 
In a clinical trial that compared tadalafil 5 mg coadministered with finasteride 5 mg to placebo plus 
finasteride 5 mg in the relief of BPH symptoms, no new adverse reactions were identified. However, 
as a formal drug-drug interaction study evaluating the effects of tadalafil and 5-alpha reductase 
inhibitors (5-ARIs) has not been performed, caution should be exercised when tadalafil is co-
administered with 5-ARIs. 
 
CYP1A2 substrates (e.g. theophylline) 
When tadalafil 10 mg was administered with theophylline (a non-selective phosphodiesterase 
inhibitor) in a clinical pharmacology study, there was no pharmacokinetic interaction. The only 
pharmacodynamic effect was a small (3.5 bpm) increase in heart rate. Although this effect is minor 
and was of no clinical significance in this study, it should be considered when co-administering these 
medicinal products. 
 
Ethinylestradiol and terbutaline 
Tadalafil has been demonstrated to produce an increase in the oral bioavailability of ethinylestradiol; 
a similar increase may be expected with oral administration of terbutaline, although the clinical 
consequence of this is uncertain. 
 
Alcohol 
Alcohol concentrations (mean maximum blood concentration 0.08 %) were not affected by co-
administration with tadalafil (10 mg or 20 mg). In addition, no changes in tadalafil concentrations 
were seen 3 hours after co-administration with alcohol. Alcohol was administered in a manner to 
maximise the rate of alcohol absorption (overnight fast with no food until 2 hours after alcohol).  
Tadalafil (20 mg) did not augment the mean blood pressure decrease produced by alcohol (0.7 g/kg or 
approximately 180 ml of 40 % alcohol [vodka] in an 80-kg male) but in some subjects, postural 
dizziness and orthostatic hypotension were observed. When tadalafil was administered with lower 
doses of alcohol (0.6 g/kg), hypotension was not observed and dizziness occurred with similar 
frequency to alcohol alone. The effect of alcohol on cognitive function was not augmented by 
tadalafil (10 mg). 



 21 

Cytochrome P450 metabolised medicinal products 
Tadalafil is not expected to cause clinically significant inhibition or induction of the clearance of 
medicinal products metabolised by CYP450 isoforms. Studies have confirmed that tadalafil does not 
inhibit or induce CYP450 isoforms, including CYP3A4, CYP1A2, CYP2D6, CYP2E1, CYP2C9 and 
CYP2C19.  
 
CYP2C9 substrates (e.g. R-warfarin) 
Tadalafil (10 mg and 20 mg) had no clinically significant effect on exposure (AUC) to S-warfarin or 
R-warfarin (CYP2C9 substrate), nor did tadalafil affect changes in prothrombin time induced by 
warfarin.  
 
Aspirin 
Tadalafil (10 mg and 20 mg) did not potentiate the increase in bleeding time caused by acetyl salicylic 
acid.  
 
Antidiabetic medicinal products 
Specific interaction studies with antidiabetic medicinal products were not conducted.  
 
4.6 Fertility, pregnancy and lactation 
 
CIALIS is not indicated for use by women.  
 
Pregnancy 
There are limited data from the use of tadalafil in pregnant women. Animal studies do not indicate 
direct or indirect harmful effects with respect to pregnancy, embryonal/foetal development, 
parturition or postnatal development (see section 5.3). As a precautionary measure, it is preferable to 
avoid the use of CIALIS during pregnancy.  
 
Breastfeeding 
Available pharmacodynamic/toxicological data in animals have shown excretion of tadalafil in milk. 
A risk to the suckling child cannot be excluded. CIALIS should not be used during breast feeding. 
 
Fertility 
Effects were seen in dogs that might indicate impairment of fertility. Two subsequent clinical studies 
suggest that this effect is unlikely in humans, although a decrease in sperm concentration was seen in 
some men (see sections 5.1 and 5.3). 
 
4.7 Effects on ability to drive and use machines 
 
CIALIS has negligible influence on the ability to drive or use machines. Although the frequency of 
reports of dizziness in placebo and tadalafil arms in clinical trials was similar, patients should be 
aware of how they react to CIALIS, before driving or using machines. 
 
4.8 Undesirable effects 
 
Summary of the safety profile 
 
The most commonly reported adverse reactions in patients taking CIALIS for the treatment of erectile 
dysfunction or benign prostatic hyperplasia were headache, dyspepsia, back pain and myalgia, in 
which the incidences increase with increasing dose of CIALIS.  The adverse reactions reported were 
transient, and generally mild or moderate. The majority of headaches reported with CIALIS once-a-
day dosing are experienced within the first 10 to 30 days of starting treatment. 
 



 22 

Tabulated summary of adverse reactions 
 
 The table below lists the adverse reactions observed from spontaneous reporting and in placebo-
controlled clinical trials (comprising a total of 8022 patients on CIALIS and 4422 patients on placebo) 
for on-demand and once-a-day treatment of erectile dysfunction and the once-a-day treatment of 
benign prostatic hyperplasia. 
 
Frequency convention: very common (≥1/10), common (≥1/100 to <1/10), uncommon (≥1/1000 to 
<1/100), rare (≥1/10,000 to <1/1,000) and very rare (<1/10,000) and not known (cannot be estimated 
from the available data). 
 

Very common  
 

Common  
 

Uncommon 
 

Rare  
 

Immune system disorders 
  Hypersensitivity 

reactions 
Angioedema2 

Nervous system disorders 
 Headache Dizziness Stroke1 (including 

haemorrhagic events), 
Syncope, Transient 
ischaemic attacks1, 
Migraine2, Seizures2, 
Transient amnesia 

Eye disorders 
  Blurred vision, 

Sensations described 
as eye pain 
 

Visual field defect, 
Swelling of eyelids, 
Conjunctival 
hyperaemia, Non-
arteritic anterior 
ischemic optic 
neuropathy (NAION)2, 
Retinal vascular 
occlusion2 

Ear and labyrinth disorders 
  Tinnitus Sudden hearing loss 
Cardiac disorders1 
  Tachycardia, 

Palpitations 
Myocardial infarction, 
Unstable angina 
pectoris2, Ventricular 
arrhythmia2 

Vascular disorders 
 Flushing Hypotension3, 

Hypertension 
 

Respiratory, thoracic and mediastinal disorders 
 Nasal congestion Dyspnoea, Epistaxis  
Gastrointestinal disorders 
 Dyspepsia 

 
Abdominal pain, 
Vomiting, Nausea, 
Gastro-oesophageal 
reflux 

 

Skin and subcutaneous tissue disorders 
  Rash Urticaria, Stevens-

Johnson syndrome2, 
Exfoliative 



 23 

dermatitis2, 
Hyperhydrosis 
(sweating) 

Musculoskeletal, connective tissue and bone disorders 
 Back pain, 

Myalgia, Pain in 
extremity 

  

Renal and urinary disorders 
  Haematuria  
Reproductive system and breast disorders 
   Prolonged erections Priapism, Penile 

haemorrhage, 
Haematospermia 

General disorders and administration site conditions 
  Chest pain1, Peripheral 

oedema, Fatigue 
Facial oedema2, 
Sudden cardiac 
death1, 2 

(1) Most of the patients had pre-existing cardiovascular risk factors (see section 4.4). 
(2) Postmarketing surveillance reported adverse reactions not observed in placebo-controlled clinical 
trials. 
(3) More commonly reported when tadalafil is given to patients who are already taking 
antihypertensive medicinal products. 
 
Description of selected adverse reactions 
 
A slightly higher incidence of ECG abnormalities, primarily sinus bradycardia, has been reported in 
patients treated with tadalafil once a day as compared with placebo. Most of these ECG abnormalities 
were not associated with adverse reactions. 
 
Other special populations 
  
Data in patients over 65 years of age receiving tadalafil in clinical trials, either for the treatment of 
erectile dysfunction or the treatment of benign prostatic hyperplasia, are limited. In clinical trials with 
tadalafil taken on demand for the treatment of erectile dysfunction, diarrhoea was reported more 
frequently in patients over 65 years of age. In clinical trials with tadalafil 5mg taken once a day for 
the treatment of benign prostatic hyperplasia, dizziness and diarrhoea were reported more frequently 
in patients over 75 years of age. 
 
Reporting of suspected adverse reactions 
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It 
allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare 
professionals are asked to report any suspected adverse reactions via the national reporting system 
listed in Appendix V. 
 
4.9 Overdose 
 
Single doses of up to 500 mg have been given to healthy subjects, and multiple daily doses up to 
100 mg have been given to patients.  Adverse events were similar to those seen at lower doses.  
In cases of overdose, standard supportive measures should be adopted as required. Haemodialysis 
contributes negligibly to tadalafil elimination. 
 
 

http://www.ema.europa.eu/docs/en_GB/document_library/Template_or_form/2013/03/WC500139752.doc


 24 

5. PHARMACOLOGICAL PROPERTIES 
 
5.1  Pharmacodynamic properties 
 
Pharmacotherapeutic group: Urologicals, Drugs used in erectile dysfunction, ATC Code: G04BE08.  
 
Mechanism of action 
Tadalafil is a selective, reversible inhibitor of cyclic guanosine monophosphate (cGMP)-specific 
phosphodiesterase type 5 (PDE5). When sexual stimulation causes the local release of nitric oxide, 
inhibition of PDE5 by tadalafil produces increased levels of cGMP in the corpus cavernosum. This 
results in smooth muscle relaxation and inflow of blood into the penile tissues, thereby producing an 
erection. Tadalafil has no effect in the treatment of erectile dysfunction in the absence of sexual 
stimulation. 
 
The effect of PDE5 inhibition on cGMP concentration in the corpus cavernosum is also observed in 
the smooth muscle of the prostate, the bladder and their vascular supply. The resulting vascular 
relaxation increases blood perfusion which may be the mechanism by which symptoms of benign 
prostatic hyperplasia are reduced. These vascular effects may be complemented by inhibition of 
bladder afferent nerve activity and smooth muscle relaxation of the prostate and bladder. 
 
Pharmacodynamic effects 
Studies in vitro have shown that tadalafil is a selective inhibitor of PDE5. PDE5 is an enzyme found 
in corpus cavernosum smooth muscle, vascular and visceral smooth muscle, skeletal muscle, platelets, 
kidney, lung, and cerebellum. The effect of tadalafil is more potent on PDE5 than on other 
phosphodiesterases. Tadalafil is > 10,000-fold more potent for PDE5 than for PDE1, PDE2, and 
PDE4, enzymes which are found in the heart, brain, blood vessels, liver, and other organs. Tadalafil is 
> 10,000-fold more potent for PDE5 than for PDE3, an enzyme found in the heart and blood vessels. 
This selectivity for PDE5 over PDE3 is important because PDE3 is an enzyme involved in cardiac 
contractility. Additionally, tadalafil is approximately 700-fold more potent for PDE5 than for PDE6, 
an enzyme which is found in the retina and is responsible for phototransduction. Tadalafil is also 
> 10,000-fold more potent for PDE5 than for PDE7 through PDE10. 
 
Clinical efficacy and safety 
Tadalafil administered to healthy subjects produced no significant difference compared to placebo in 
supine systolic and diastolic blood pressure (mean maximal decrease of 1.6/0.8 mm Hg, respectively), 
in standing systolic and diastolic blood pressure (mean maximal decrease of 0.2/4.6 mm Hg, 
respectively), and no significant change in heart rate.  
 
In a study to assess the effects of tadalafil on vision, no impairment of colour discrimination 
(blue/green) was detected using the Farnsworth-Munsell 100-hue test. This finding is consistent with 
the low affinity of tadalafil for PDE6 compared to PDE5. Across all clinical studies, reports of 
changes in colour vision were rare (< 0.1 %). 
 
Three studies were conducted in men to assess the potential effect on spermatogenesis of CIALIS  
10 mg (one 6-month study) and 20 mg (one 6-month and one 9-month study) administered daily. In 
two of these studies decreases were observed in sperm count and concentration related to tadalafil 
treatment of unlikely clinical relevance. These effects were not associated with changes in other 
parameters such as motility, morphology and FSH. 
 
Erectile dysfunction 
For CIALIS on demand, three clinical studies were conducted in 1054 patients in an at-home setting 
to define the period of responsiveness. Tadalafil demonstrated statistically significant improvement in 
erectile function and the ability to have successful sexual intercourse up to 36 hours following dosing, 
as well as patients’ ability to attain and maintain erections for successful intercourse compared to 
placebo as early as 16 minutes following dosing.  
 



 25 

In a 12-week study performed in 186 patients (142 tadalafil, 44 placebo) with erectile dysfunction 
secondary to spinal cord injury, tadalafil significantly improved the erectile function leading to a 
mean per-subject proportion of successful attempts in patients treated with tadalafil 10 or 20 mg 
(flexible-dose, on demand) of 48% as compared to 17% with placebo. 
 
For once-a-day evaluation of tadalafil at doses of 2.5, 5, and 10 mg 3 clinical studies were initially 
conducted involving 853 patients of various ages (range 21-82 years) and ethnicities, with erectile 
dysfunction of various severities (mild, moderate, severe) and etiologies. In the two primary efficacy 
studies of general populations, the mean per-subject proportion of successful intercourse attempts 
were 57 and 67 % on CIALIS 5 mg, 50 % on CIALIS 2.5 mg as compared to 31 and 37 % with 
placebo. In the study in patients with erectile dysfunction secondary to diabetes, the mean per-subject 
proportion of successful attempts were 41 and 46 % on CIALIS 5 mg and 2.5 mg, respectively, as 
compared to 28 % with placebo. Most patients in these three studies were responders to previous on-
demand treatment with PDE5 inhibitors. In a subsequent study, 217 patients who were treatment-
naïve to PDE5 inhibitors were randomized to CIALIS 5 mg once a day vs. placebo.  The mean per-
subject proportion of successful sexual intercourse attempts was 68 % for CIALIS patients compared 
to 52 % for patients on placebo. 
 
Benign prostatic hyperplasia 
CIALIS was studied in 4 clinical studies of 12 weeks duration enrolling over 1500 patients with signs 
and symptoms of benign prostatic hyperplasia.  The improvement in the total international prostate 
symptom score with CIALIS 5mg in the four studies were -4.8, -5.6, -6.1 and -6.3 compared to -2.2, -
3.6, -3.8 and -4.2 with placebo. The improvements in total international prostate symptom score 
occurred as early as 1 week.  In one of the studies, which also included tamsulosin 0.4 mg as an active 
comparator, the improvement in total international prostate symptom score with CIALIS 5mg, 
tamsulosin and placebo were -6.3, -5.7 and -4.2 respectively. 
   
One of these studies assessed improvements in erectile dysfunction and signs and symptoms of benign 
prostatic hyperplasia in patients with both conditions. The improvements in the erectile function 
domain of the international index of erectile function and the total international prostate symptom 
score in this study were 6.5 and -6.1 with CIALIS 5 mg compared to 1.8 and -3.8 with placebo, 
respectively.  The mean per-subject proportion of successful sexual intercourse attempts was 71.9% 
with CIALIS 5 mg compared to 48.3% with placebo.  
 
The maintenance of the effect was evaluated in an open-label extension to one of the studies, which 
showed that the improvement in total international prostate symptom score seen at 12 weeks was 
maintained for up to 1 additional year of treatment with CIALIS 5mg.  
 
Paediatric population 
A single study has been performed in paediatric patients with Duchenne Muscular Dystrophy (DMD) 
in which no evidence of efficacy was seen. The randomised, double-blind, placebo-controlled, 
parallel, 3-arm study of tadalafil was conducted in 331 boys aged 7-14 years with DMD receiving 
concurrent corticosteroid therapy. The study included a 48-week double-blind period where patients 
were randomised to tadalafil 0.3 mg/kg, tadalafil 0.6 mg/kg, or placebo daily. Tadalafil did not show 
efficacy in slowing the decline in ambulation as measured by the primary 6 minute walk distance 
(6MWD) endpoint: least squares (LS) mean change in 6MWD at 48 weeks was -51.0 meters (m) in 
the placebo group, compared with -64.7 m in the tadalafil 0.3 mg/kg group (p = 0.307) and -59.1 m in 
the tadalafil 0.6 mg/kg group (p = 0.538). In addition, there was no evidence of efficacy from any of 
the secondary analyses performed in this study. The overall safety results from this study were 
generally consistent with the known safety profile of tadalafil and with adverse events (AEs) expected 
in a paediatric DMD population receiving corticosteroids. 
 
The European Medicines Agency has waived the obligation to submit the results of studies in all 
subsets of the paediatric population in the treatment of the erectile dysfunction. See section 4.2 for 
information on paediatric use. 
 



 26 

5.2 Pharmacokinetic properties 
 
Absorption 
Tadalafil is readily absorbed after oral administration and the mean maximum observed plasma 
concentration (Cmax) is achieved at a median time of 2 hours after dosing. Absolute bioavailability of 
tadalafil following oral dosing has not been determined. 
The rate and extent of absorption of tadalafil are not influenced by food, thus CIALIS may be taken 
with or without food. The time of dosing (morning versus evening) had no clinically relevant effects 
on the rate and extent of absorption. 
 
Distribution  
The mean volume of distribution is approximately 63 l, indicating that tadalafil is distributed into 
tissues. At therapeutic concentrations, 94 % of tadalafil in plasma is bound to proteins. Protein 
binding is not affected by impaired renal function. 
Less than 0.0005 % of the administered dose appeared in the semen of healthy subjects. 
 
Biotransformation 
Tadalafil is predominantly metabolised by the cytochrome P450 (CYP) 3A4 isoform. The major 
circulating metabolite is the methylcatechol glucuronide. This metabolite is at least 13,000-fold less 
potent than tadalafil for PDE5. Consequently, it is not expected to be clinically active at observed 
metabolite concentrations. 
 
Elimination  
The mean oral clearance for tadalafil is 2.5 l/h and the mean half-life is 17.5 hours in healthy subjects. 
Tadalafil is excreted predominantly as inactive metabolites, mainly in the faeces (approximately 61 % 
of the dose) and to a lesser extent in the urine (approximately 36 % of the dose).  
 
Linearity/non-linearity 
Tadalafil pharmacokinetics in healthy subjects are linear with respect to time and dose. Over a dose 
range of 2.5 to 20 mg, exposure (AUC) increases proportionally with dose. Steady-state plasma 
concentrations are attained within 5 days of once-daily dosing. 
 
Pharmacokinetics determined with a population approach in patients with erectile dysfunction are 
similar to pharmacokinetics in subjects without erectile dysfunction. 
 
Special populations 
 
Elderly 
Healthy elderly subjects (65 years or over), had a lower oral clearance of tadalafil, resulting in 25 % 
higher exposure (AUC) relative to healthy subjects aged 19 to 45 years. This effect of age is not 
clinically significant and does not warrant a dose adjustment. 
 
Renal insufficiency 
In clinical pharmacology studies using single-dose tadalafil (5 to 20 mg), tadalafil exposure (AUC) 
approximately doubled in subjects with mild (creatinine clearance 51 to 80 ml/min) or moderate 
(creatinine clearance 31 to 50 ml/min) renal impairment and in subjects with end-stage renal disease 
on dialysis. In haemodialysis patients, Cmax was 41 % higher than that observed in healthy subjects. 
Haemodialysis contributes negligibly to tadalafil elimination. 
 



 27 

Hepatic insufficiency 
Tadalafil exposure (AUC) in subjects with mild and moderate hepatic impairment (Child-Pugh Class 
A and B) is comparable to exposure in healthy subjects when a dose of 10 mg is administered. There 
is limited clinical data on the safety of CIALIS in patients with severe hepatic insufficiency (Child-
Pugh Class C). There are no available data about the administration of once-a-day dosing of tadalafil 
to patients with hepatic impairment. If CIALIS is prescribed once-a-day, a careful individual 
benefit/risk evaluation should be undertaken by the prescribing physician. 
  
Patients with diabetes 
Tadalafil exposure (AUC) in patients with diabetes was approximately 19 % lower than the AUC 
value for healthy subjects. This difference in exposure does not warrant a dose adjustment. 
 
5.3 Preclinical safety data 
 
Non-clinical data reveal no special hazard for humans based on conventional studies of safety 
pharmacology, repeated dose toxicity, genotoxicity, carcinogenic potential, and toxicity to 
reproduction. 
There was no evidence of teratogenicity, embryotoxicity or foetotoxicity in rats or mice that received 
up to 1000 mg/kg/day tadalafil. In a rat prenatal and postnatal development study, the no observed 
effect dose was 30 mg/kg/day. In the pregnant rat the AUC for calculated free drug at this dose was 
approximately 18 times the human AUC at a 20 mg dose. 
There was no impairment of fertility in male and female rats. In dogs given tadalafil daily for 6 to 12 
months at doses of 25 mg/kg/day (resulting in at least a 3-fold greater exposure [range 3.7 – 18.6] than 
seen in humans given a single 20 mg dose) and above, there was regression of the seminiferous 
tubular epithelium that resulted in a decrease in spermatogenesis in some dogs. See also section 5.1. 
 
 
6. PHARMACEUTICAL PARTICULARS 
 
6.1 List of excipients 
 
Tablet core:  
lactose monohydrate,  
croscarmellose sodium,  
hydroxypropylcellulose,  
microcrystalline cellulose,  
sodium laurilsulfate,  
magnesium stearate. 
 
Film-coat:  
lactose monohydrate,  
hypromellose,  
triacetin,  
titanium dioxide (E171),  
iron oxide yellow (E172), 
talc. 
 
6.2 Incompatibilities 
 
Not applicable. 
 
6.3 Shelf life 
 
3 years. 
 



 28 

6.4 Special precautions for storage 
 
Store in the original package in order to protect from moisture. Do not store above 25°C.  
 
6.5 Nature and contents of container 
 
Aluminium/PVC blisters in cartons of 14, 28 or 84 film-coated tablets. 
 
Not all packs sizes may be marketed. 
 
6.6 Special precautions for disposal  
 
 Any unused medicinal product or waste material should be disposed of in accordance with local 
requirements. 
 
 
 
7. MARKETING AUTHORISATION HOLDER 
 
Eli Lilly Nederland B.V. 
Papendorpseweg 83, 3528 BJ Utrecht 
The Netherlands 
 
 
8. MARKETING AUTHORISATION NUMBER(S)  
 
EU/1/02/237/007-008, 010 
 
 
9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION 
 
Date of first authorisation: 12 November 2002 
Date of last renewal: 12 November 2012 
 
 
10. DATE OF REVISION OF THE TEXT 
 
 
Detailed information on this medicinal product is available on the website of the European Medicines 
Agency http://www.ema.europa.eu. 

http://www.ema.europa.eu/


 29 

1. NAME OF THE MEDICINAL PRODUCT 
 
CIALIS 10 mg film-coated tablets 
CIALIS 20 mg film-coated tablets 
 
 
2. QUALITATIVE AND QUANTITATIVE COMPOSITION 
 
CIALIS 10 mg film-coated tablets 
Each tablet contains 10 mg tadalafil. 
 
Excipient with known effect: 
Each coated tablet contains 170 mg lactose (as monohydrate). 
 
CIALIS 20 mg film-coated tablets 
Each tablet contains 20 mg tadalafil. 
 
Excipient with known effect: 
Each coated tablet contains 233 mg lactose (as monohydrate). 
 
For the full list of excipients, see section 6.1. 
 
 
3. PHARMACEUTICAL FORM 
 
Film-coated tablet (tablet). 
 
CIALIS 10 mg film-coated tablets 
Light yellow and almond shaped tablets, marked "C 10" on one side. 
 
CIALIS 20 mg film-coated tablets 
Yellow and almond shaped tablets, marked "C 20" on one side. 
 
 
4. CLINICAL PARTICULARS 
 
4.1 Therapeutic indications 
 
Treatment of erectile dysfunction in adult males. 
 
In order for tadalafil to be effective, sexual stimulation is required.  
 
CIALIS is not indicated for use by women. 
 
4.2 Posology and method of administration 
 
Posology 
Adult men 
In general, the recommended dose is 10 mg taken prior to anticipated sexual activity and with or 
without food.  
In those patients in whom tadalafil 10 mg does not produce an adequate effect, 20 mg might be tried.  
It may be taken at least 30 minutes prior to sexual activity.  
 
The maximum dose frequency is once per day.  
 



 30 

Tadalafil 10 and 20 mg is intended for use prior to anticipated sexual activity and it is not 
recommended for continuous daily use.  
 
In patients who anticipate a frequent use of CIALIS (i.e., at least twice weekly) a once daily regimen 
with the lowest doses of CIALIS might be considered suitable, based on patient choice and the 
physician’s judgement. 
 
In these patients the recommended dose is 5 mg taken once a day at approximately the same time of 
day. The dose may be decreased to 2.5 mg once a day based on individual tolerability. 
 
The appropriateness of continued use of the daily regimen should be reassessed periodically. 
 
Special populations  
Elderly men 
Dose adjustments are not required in elderly patients. 
 
Men with renal impairment 
Dose adjustments are not required in patients with mild to moderate renal impairment. For patients 
with severe renal impairment 10 mg is the maximum recommended dose. Once-a-day dosing of 
tadalafil is not recommended in patients with severe renal impairment (see sections 4.4 and 5.2). 
 
Men with hepatic impairment 
The recommended dose of CIALIS is 10 mg taken prior to anticipated sexual activity and with or 
without food. There is limited clinical data on the safety of CIALIS in patients with severe hepatic 
impairment (Child-Pugh Class C); if prescribed, a careful individual benefit/risk evaluation should be 
undertaken by the prescribing physician. There are no available data about the administration of doses 
higher than 10 mg of tadalafil to patients with hepatic impairment. Once-a-day dosing has not been 
evaluated in patients with hepatic impairment; therefore if prescribed, a careful individual benefit/risk 
evaluation should be undertaken by the prescribing physician (see sections 4.4 and 5.2). 
 
Men with diabetes 
Dose adjustments are not required in diabetic patients. 
 
Paediatric population 
There is no relevant use of CIALIS in the paediatric population with regard to the treatment of erectile 
dysfunction.  
 
Method of administration 
CIALIS is available as 2.5, 5, 10, and 20 mg film-coated tablets for oral use. 
 
4.3 Contraindications 
 
Hypersensitivity to the active substance or to any of the excipients listed in section 6.1. 
 
In clinical studies, tadalafil was shown to augment the hypotensive effects of nitrates. This is thought 
to result from the combined effects of nitrates and tadalafil on the nitric oxide/cGMP pathway. 
Therefore, administration of CIALIS to patients who are using any form of organic nitrate is 
contraindicated (see section 4.5). 
 
CIALIS, must not be used in men with cardiac disease for whom sexual activity is inadvisable. 
Physicians should consider the potential cardiac risk of sexual activity in patients with pre-existing 
cardiovascular disease. 
 



 31 

The following groups of patients with cardiovascular disease were not included in clinical trials and 
the use of tadalafil is therefore contraindicated:  
- patients with myocardial infarction within the last 90 days,  
- patients with unstable angina or angina occurring during sexual intercourse,  
- patients with New York Heart Association Class 2 or greater heart failure in the last 6 months,  
- patients with uncontrolled arrhythmias, hypotension (< 90/50 mm Hg), or uncontrolled 

hypertension,  
- patients with a stroke within the last 6 months. 
 
CIALIS is contraindicated in patients who have loss of vision in one eye because of non-arteritic 
anterior ischaemic optic neuropathy (NAION), regardless of whether this episode was in connection 
or not with previous PDE5 inhibitor exposure (see section 4.4). 
 
The co-administration of PDE5 inhibitors, including tadalafil, with guanylate cyclase stimulators, 
such as riociguat, is contraindicated as it may potentially lead to symptomatic hypotension (see 
section 4.5). 
 
4.4 Special warnings and precautions for use 
 
Before treatment with CIALIS  
A medical history and physical examination should be undertaken to diagnose erectile dysfunction 
and determine potential underlying causes, before pharmacological treatment is considered. 
 
Prior to initiating any treatment for erectile dysfunction, physicians should consider the 
cardiovascular status of their patients, since there is a degree of cardiac risk associated with sexual 
activity. Tadalafil has vasodilator properties, resulting in mild and transient decreases in blood 
pressure (see section 5.1) and as such potentiates the hypotensive effect of nitrates (see section 4.3). 
 
The evaluation of erectile dysfunction should include a determination of potential underlying causes 
and the identification of appropriate treatment following an appropriate medical assessment. It is not 
known if CIALIS is effective in patients who have undergone pelvic surgery or radical non-nerve-
sparing prostatectomy. 
 
Cardiovascular 
Serious cardiovascular events, including myocardial infarction, sudden cardiac death, unstable angina 
pectoris, ventricular arrhythmia, stroke, transient ischemic attacks, chest pain, palpitations and 
tachycardia, have been reported either post marketing and/or in clinical trials.  Most of the patients in 
whom these events have been reported had pre-existing cardiovascular risk factors. However, it is not 
possible to definitively determine whether these events are related directly to these risk factors, to 
CIALIS, to sexual activity, or to a combination of these or other factors. 
 
In patients who are taking alpha1 blockers, concomitant administration of CIALIS may lead to 
symptomatic hypotension in some patients (see section 4.5). The combination of tadalafil and 
doxazosin is not recommended. 
 
Vision 
Visual defects and cases of NAION have been reported in connection with the intake of CIALIS and 
other PDE5 inhibitors. Analyses of observational data suggest an increased risk of acute NAION in 
men with erectile dysfunction following exposure to tadalafil or other PDE5 inhibitors. As this may 
be relevant for all patients exposed to tadalafil, the patient should be advised that in case of sudden 
visual defect, he should stop taking CIALIS and consult a physician immediately (see section 4.3). 
 
Decreased or sudden hearing loss 
Cases of sudden hearing loss have been reported after the use of tadalafil. Although other risk factors 
were present in some cases (such as age, diabetes, hypertension and previous hearing loss history) 



 32 

patients should be advised to stop taking tadalafil and seek prompt medical attention in the event of 
sudden decrease or loss of hearing. 
 
Hepatic impairment 
There is limited clinical data on the safety of single-dose administration of CIALIS in patients with 
severe hepatic insufficiency (Child-Pugh Class C). If CIALIS is prescribed, a careful individual 
benefit/risk evaluation should be undertaken by the prescribing physician. 
 
Priapism and anatomical deformation of the penis  
Patients who experience erections lasting 4 hours or more should be instructed to seek immediate 
medical assistance. If priapism is not treated immediately, penile tissue damage and permanent loss of 
potency may result. 
 
CIALIS, should be used with caution in patients with anatomical deformation of the penis (such as 
angulation, cavernosal fibrosis or Peyronie's disease), or in patients who have conditions which may 
predispose them to priapism (such as sickle cell anaemia, multiple myeloma or leukaemia). 
 
Use with CYP3A4 inhibitors 
Caution should be exercised when prescribing CIALIS to patients using potent CYP3A4 inhibitors 
(ritonavir, saquinavir, ketoconazole, itraconazole, and erythromycin) as increased tadalafil exposure 
(AUC) has been observed if the medicinal products are combined (see section 4.5). 
 
CIALIS and other treatments for erectile dysfunction  
The safety and efficacy of combinations of CIALIS and other PDE5 inhibitors or other treatments for 
erectile dysfunction have not been studied. The patients should be informed not to take CIALIS in 
such combinations. 
 
Lactose  
CIALIS contains lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp 
lactase deficiency or glucose-galactose malabsorption should not take this medicinal product. 
 
4.5 Interaction with other medicinal products and other forms of interaction 
 
Interaction studies were conducted with 10 mg and/or 20 mg tadalafil, as indicated below. With 
regard to those interaction studies where only the 10 mg tadalafil dose was used, clinically relevant 
interactions at higher doses cannot be completely ruled out. 
 
Effects of other substances on tadalafil 
 
Cytochrome P450 inhibitors 
Tadalafil is principally metabolised by CYP3A4. A selective inhibitor of CYP3A4, ketoconazole  
(200 mg daily), increased tadalafil (10 mg) exposure (AUC) 2-fold and Cmax by 15 %, relative to the 
AUC and Cmax values for tadalafil alone. Ketoconazole (400 mg daily) increased tadalafil (20 mg) 
exposure (AUC) 4-fold and Cmax by 22 %. Ritonavir, a protease inhibitor (200 mg twice daily), which 
is an inhibitor of CYP3A4, CYP2C9, CYP2C19, and CYP2D6, increased tadalafil (20 mg) 
exposure (AUC) 2-fold with no change in Cmax. Although specific interactions have not been studied, 
other protease inhibitors, such as saquinavir, and other CYP3A4 inhibitors, such as erythromycin, 
clarithromycin, itraconazole and grapefruit juice should be co-administered with caution as they 
would be expected to increase plasma concentrations of tadalafil (see section 4.4). 
Consequently the incidence of the adverse reactions listed in section 4.8 might be increased. 
 
Transporters 
The role of transporters (for example p-glycoprotein) in the disposition of tadalafil is not known. 
Therefore  there is the potential of drug interactions mediated by inhibition of transporters. 
 



 33 

Cytochrome P450 inducers 
A CYP3A4 inducer, rifampicin, reduced tadalafil AUC by 88 %, relative to the AUC values for 
tadalafil alone (10 mg). This reduced exposure can be anticipated to decrease the efficacy of tadalafil; 
the magnitude of decreased efficacy is unknown. Other inducers of CYP3A4 such as phenobarbital, 
phenytoin and carbamazepine, may also decrease plasma concentrations of tadalafil.  
 
Effects of tadalafil on other medicinal products 
 
Nitrates 
In clinical studies, tadalafil (5, 10 and 20 mg) was shown to augment the hypotensive effects of 
nitrates. Therefore, administration of CIALIS to patients who are using any form of organic nitrate is 
contraindicated (see section 4.3). Based on the results of a clinical study in which 150 subjects 
receiving daily doses of tadalafil 20 mg for 7 days and 0.4 mg sublingual nitroglycerin at various 
times, this interaction lasted for more than 24 hours and was no longer detectable when 48 hours had 
elapsed after the last tadalafil dose. Thus, in a patient prescribed any dose of CIALIS (2.5 mg – 
20 mg), where nitrate administration is deemed medically necessary in a life-threatening situation, at 
least 48 hours should have elapsed after the last dose of CIALIS before nitrate administration is 
considered. In such circumstances, nitrates should only be administered under close medical 
supervision with appropriate haemodynamic monitoring. 
 
Anti-hypertensives (including calcium channel blockers) 
The co-administration of doxazosin (4 and 8 mg daily) and tadalafil (5 mg daily dose and 20 mg as a 
single dose) increases the blood pressure-lowering effect of this alpha-blocker in a significant manner. 
This effect lasts at least twelve hours and may be symptomatic, including syncope. Therefore this 
combination is not recommended (see section 4.4). 
In interaction studies performed in a limited number of healthy volunteers, these effects were not 
reported with alfuzosin or tamsulosin. However, caution should be exercised when using tadalafil in 
patients treated with any alpha-blockers, and notably in the elderly. Treatments should be initiated at 
minimal dosage and progressively adjusted. 
 
In clinical pharmacology studies, the potential for tadalafil to augment the hypotensive effects of 
antihypertensive medicinal products was examined. Major classes of antihypertensive medicinal 
products were studied, including calcium channel blockers (amlodipine), angiotensin converting 
enzyme (ACE) inhibitors (enalapril), beta-adrenergic receptor blockers (metoprolol), thiazide 
diuretics (bendrofluazide), and angiotensin II receptor blockers (various types and doses, alone or in 
combination with thiazides, calcium channel blockers, beta-blockers, and/or alpha-blockers). Tadalafil 
(10 mg except for studies with angiotensin II receptor blockers and amlodipine in which a 20 mg dose 
was applied) had no clinically significant interaction with any of these classes. In another clinical 
pharmacology study tadalafil (20 mg) was studied in combination with up to 4 classes of 
antihypertensives. In subjects taking multiple antihypertensives, the ambulatory-blood-pressure 
changes appeared to relate to the degree of blood-pressure control. In this regard, study subjects 
whose blood pressure was well controlled, the reduction was minimal and similar to that seen in 
healthy subjects. In study subjects whose blood pressure was not controlled, the reduction was greater 
although this reduction was not associated with hypotensive symptoms in the majority of subjects. In 
patients receiving concomitant antihypertensive medicinal products, tadalafil 20 mg may induce a 
blood pressure decrease, which (with the exception of alpha blockers -see above-) is, in general, 
minor and not likely to be clinically relevant. Analysis of phase 3 clinical trial data showed no 
difference in adverse events in patients taking tadalafil with or without antihypertensive medicinal 
products. However, appropriate clinical advice should be given to patients regarding a possible 
decrease in blood pressure when they are treated with antihypertensive medicinal products. 
 
Riociguat 
Preclinical studies showed an additive systemic blood pressure lowering effect when PDE5 inhibitors 
were combined with riociguat.  In clinical studies, riociguat has been shown to augment the 
hypotensive effects of PDE5 inhibitors.  There was no evidence of favourable clinical effect of the 



 34 

combination in the population studied.  Concomitant use of riociguat with PDE5 inhibitors, including 
tadalafil, is contraindicated (see section 4.3).   
 
5- alpha reductase inhibitors 
In a clinical trial that compared tadalafil 5 mg coadministered with finasteride 5 mg to placebo plus 
finasteride 5 mg in the relief of BPH symptoms, no new adverse reactions were identified. However, 
as a formal drug-drug interaction study evaluating the effects of tadalafil and 5-alpha reductase 
inhibitors (5-ARIs) has not been performed, caution should be exercised when tadalafil is co-
administered with 5-ARIs. 
 
CYP1A2 substrates (e.g. theophylline) 
When tadalafil 10 mg was administered with theophylline (a non-selective phosphodiesterase 
inhibitor) in a clinical pharmacology study, there was no pharmacokinetic interaction. The only 
pharmacodynamic effect was a small (3.5 bpm) increase in heart rate. Although this effect is minor 
and was of no clinical significance in this study, it should be considered when co-administering these 
medicinal products. 
 
Ethinylestradiol and terbutaline 
Tadalafil has been demonstrated to produce an increase in the oral bioavailability of ethinylestradiol; 
a similar increase may be expected with oral administration of terbutaline, although the clinical 
consequence of this is uncertain. 
 
Alcohol 
Alcohol concentrations (mean maximum blood concentration 0.08 %) were not affected by co-
administration with tadalafil (10 mg or 20 mg). In addition, no changes in tadalafil concentrations 
were seen 3 hours after co-administration with alcohol. Alcohol was administered in a manner to 
maximise the rate of alcohol absorption (overnight fast with no food until 2 hours after alcohol).  
Tadalafil (20 mg) did not augment the mean blood pressure decrease produced by alcohol (0.7 g/kg or 
approximately 180 ml of 40 % alcohol [vodka] in an 80-kg male) but in some subjects, postural 
dizziness and orthostatic hypotension were observed. When tadalafil was administered with lower 
doses of alcohol (0.6 g/kg), hypotension was not observed and dizziness occurred with similar 
frequency to alcohol alone. The effect of alcohol on cognitive function was not augmented by 
tadalafil (10 mg). 
 
Cytochrome P450 metabolised medicinal products 
Tadalafil is not expected to cause clinically significant inhibition or induction of the clearance of 
medicinal products metabolised by CYP450 isoforms. Studies have confirmed that tadalafil does not 
inhibit or induce CYP450 isoforms, including CYP3A4, CYP1A2, CYP2D6, CYP2E1, CYP2C9 and 
CYP2C19.  
 
CYP2C9 substrates (e.g. R-warfarin) 
Tadalafil (10 mg and 20 mg) had no clinically significant effect on exposure (AUC) to S-warfarin or 
R-warfarin (CYP2C9 substrate), nor did tadalafil affect changes in prothrombin time induced by 
warfarin.  
 
Aspirin 
Tadalafil (10 mg and 20 mg) did not potentiate the increase in bleeding time caused by acetyl salicylic 
acid.  
 
Antidiabetic medicinal products 
Specific interaction studies with antidiabetic medicinal products were not conducted.  
 
4.6 Fertility, pregnancy and lactation 
 
CIALIS is not indicated for use by women. 
 



 35 

Pregnancy 
There are limited data from the use of tadalafil in pregnant women. Animal studies do not indicate 
direct or indirect harmful effects with respect to pregnancy, embryonal/foetal development, 
parturition or postnatal development (see section 5.3). As a precautionary measure, it is preferable to 
avoid the use of CIALIS during pregnancy.  
 
Breastfeeding 
Available pharmacodynamic/toxicological data in animals have shown excretion of tadalafil in milk. 
A risk to the suckling child cannot be excluded. CIALIS should not be used during breast feeding. 
 
Fertility 
Effects were seen in dogs that might indicate impairment of fertility. Two subsequent clinical studies 
suggest that this effect is unlikely in humans, although a decrease in sperm concentration was seen in 
some men (see sections 5.1 and 5.3). 
 
4.7 Effects on ability to drive and use machines 
 
 CIALIS has negligible influence on the ability to drive or use machines. Although the frequency of 
reports of dizziness in placebo and tadalafil arms in clinical trials was similar, patients should be 
aware of how they react to CIALIS, before driving or using machines. 
 
4.8 Undesirable effects 
 
Summary of the safety profile 
 
The most commonly reported adverse reactions in patients taking CIALIS for the treatment of erectile 
dysfunction or benign prostatic hyperplasia were headache, dyspepsia, back pain and myalgia, in 
which the incidences increase with increasing dose of CIALIS.  The adverse reactions reported were 
transient, and generally mild or moderate. The majority of headaches reported with CIALIS once-a-
day dosing are experienced within the first 10 to 30 days of starting treatment. 
 
Tabulated summary of adverse reactions 
 
The table below lists the adverse reactions observed from spontaneous reporting and in placebo-
controlled clinical trials (comprising a total of 8022 patients on CIALIS and 4422 patients on placebo) 
for on-demand and once-a-day treatment of erectile dysfunction and the once-a-day treatment of 
benign prostatic hyperplasia. 
 
Frequency convention: very common (≥1/10), common (≥1/100 to <1/10), uncommon (≥1/1000 to 
<1/100), rare (≥1/10,000 to <1/1,000) and very rare (<1/10,000) and not known (cannot be estimated 
from the available data). 
 

Very common  Common  Uncommon  Rare  
 

Immune system disorders 
  Hypersensitivity 

reactions 
Angioedema2 

Nervous system disorders 
 Headache Dizziness Stroke1 (including 

haemorrhagic events), 
Syncope, Transient 
ischaemic attacks1, 
Migraine2, Seizures2, 
Transient amnesia 



 36 

Eye disorders 
  Blurred vision, 

Sensations described 
as eye pain 
 

Visual field defect, 
Swelling of eyelids, 
Conjunctival 
hyperaemia, Non-
arteritic anterior 
ischemic optic 
neuropathy (NAION) 2, 
Retinal vascular 
occlusion2 

Ear and labyrinth disorders 
  Tinnitus Sudden hearing loss 
Cardiac disorders1 
  Tachycardia, 

Palpitations 
Myocardial infarction, 
Unstable angina 
pectoris2, Ventricular 
arrhythmia2 

Vascular disorders 
 Flushing Hypotension3, 

Hypertension 
 

Respiratory, thoracic and mediastinal disorders 
 Nasal congestion Dyspnoea, Epistaxis  
Gastrointestinal disorders 
 Dyspepsia 

 
Abdominal pain, 
Vomiting, Nausea, 
Gastro-oesophageal 
reflux 
 

 

 

Skin and subcutaneous tissue disorders 
  Rash Urticaria, Stevens-

Johnson syndrome2, 
Exfoliative dermatitis2, 
Hyperhydrosis 
(sweating) 

Musculoskeletal, connective tissue and bone disorders 
 Back pain, 

Myalgia, Pain in 
extremity 

  

Renal and urinary disorders 
  Haematuria  
Reproductive system and breast disorders 
   Prolonged erections Priapism, Penile 

haemorrhage, 
Haematospermia 

General disorders and administration site conditions 
  Chest pain1, Peripheral 

oedema, Fatigue 
 

Facial oedema2, 
Sudden cardiac 
death1,2 

(1) Most of the patients had pre-existing cardiovascular risk factors (see section 4.4). 
(2) Postmarketing surveillance reported adverse reactions not observed in placebo-controlled clinical 
trials. 
(3) More commonly reported when tadalafil is given to patients who are already taking 
antihypertensive medicinal products. 
 



 37 

Description of selected adverse reactions 
 
A slightly higher incidence of ECG abnormalities, primarily sinus bradycardia, has been reported in 
patients treated with tadalafil once a day as compared with placebo. Most of these ECG abnormalities 
were not associated with adverse reactions. 
 
Other special populations 
  
Data in patients over 65 years of age receiving tadalafil in clinical trials, either for the treatment of 
erectile dysfunction or the treatment of benign prostatic hyperplasia, are limited. In clinical trials with 
tadalafil taken on demand for the treatment of erectile dysfunction, diarrhoea was reported more 
frequently in patients over 65 years of age. In clinical trials with tadalafil 5mg taken once a day for 
the treatment of benign prostatic hyperplasia, dizziness and diarrhoea were reported more frequently 
in patients over 75 years of age. 
 
Reporting of suspected adverse reactions 
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It 
allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare 
professionals are asked to report any suspected adverse reactions via the national reporting system 
listed in Appendix V. 
 
4.9 Overdose 
 
Single doses of up to 500 mg have been given to healthy subjects, and multiple daily doses up to 
100 mg have been given to patients.  Adverse events were similar to those seen at lower doses.  
In cases of overdose, standard supportive measures should be adopted as required. Haemodialysis 
contributes negligibly to tadalafil elimination. 
 
 
5. PHARMACOLOGICAL PROPERTIES 
 
5.1  Pharmacodynamic properties 
 
Pharmacotherapeutic group: Urologicals, Drugs used in erectile dysfunction, ATC Code: G04BE08.  
 
Mechanism of action 
Tadalafil is a selective, reversible inhibitor of cyclic guanosine monophosphate (cGMP)-specific 
phosphodiesterase type 5 (PDE5). When sexual stimulation causes the local release of nitric oxide, 
inhibition of PDE5 by tadalafil produces increased levels of cGMP in the corpus cavernosum. This 
results in smooth muscle relaxation and inflow of blood into the penile tissues, thereby producing an 
erection. Tadalafil has no effect in the absence of sexual stimulation. 
 
Pharmacodynamic effects 
Studies in vitro have shown that tadalafil is a selective inhibitor of PDE5. PDE5 is an enzyme found 
in corpus cavernosum smooth muscle, vascular and visceral smooth muscle, skeletal muscle, platelets, 
kidney, lung, and cerebellum. The effect of tadalafil is more potent on PDE5 than on other 
phosphodiesterases. Tadalafil is > 10,000-fold more potent for PDE5 than for PDE1, PDE2, and 
PDE4, enzymes which are found in the heart, brain, blood vessels, liver, and other organs. Tadalafil is 
> 10,000-fold more potent for PDE5 than for PDE3, an enzyme found in the heart and blood vessels. 
This selectivity for PDE5 over PDE3 is important because PDE3 is an enzyme involved in cardiac 
contractility. Additionally, tadalafil is approximately 700-fold more potent for PDE5 than for PDE6, 
an enzyme which is found in the retina and is responsible for phototransduction. Tadalafil is also 
> 10,000-fold more potent for PDE5 than for PDE7 through PDE10. 
 

http://www.ema.europa.eu/docs/en_GB/document_library/Template_or_form/2013/03/WC500139752.doc


 38 

Clinical efficacy and safety 
Three clinical studies were conducted in 1054 patients in an at-home setting to define the period of 
responsiveness to CIALIS. Tadalafil demonstrated statistically significant improvement in erectile 
function and the ability to have successful sexual intercourse up to 36 hours following dosing, as well 
as patients’ ability to attain and maintain erections for successful intercourse compared to placebo as 
early as 16 minutes following dosing.  
 
Tadalafil administered to healthy subjects produced no significant difference compared to placebo in 
supine systolic and diastolic blood pressure (mean maximal decrease of 1.6/0.8 mm Hg, respectively), 
in standing systolic and diastolic blood pressure (mean maximal decrease of 0.2/4.6 mm Hg, 
respectively), and no significant change in heart rate.  
 
In a study to assess the effects of tadalafil on vision, no impairment of colour discrimination 
(blue/green) was detected using the Farnsworth-Munsell 100-hue test. This finding is consistent with 
the low affinity of tadalafil for PDE6 compared to PDE5. Across all clinical studies, reports of 
changes in colour vision were rare (< 0.1 %). 
 
Three studies were conducted in men to assess the potential effect on spermatogenesis of CIALIS  
10 mg (one 6-month study) and 20 mg (one 6-month and one 9-month study) administered daily. In 
two of these studies decreases were observed in sperm count and concentration related to tadalafil 
treatment of unlikely clinical relevance. These effects were not associated with changes in other 
parameters such as motility, morphology and FSH. 
 
Tadalafil at doses of 2 to 100 mg has been evaluated in 16 clinical studies involving 3250 patients, 
including patients with erectile dysfunction of various severities (mild, moderate, severe), etiologies, 
ages (range 21-86 years), and ethnicities. Most patients reported erectile dysfunction of at least 1 year 
in duration. In the primary efficacy studies of general populations, 81 % of patients reported that 
CIALIS improved their erections as compared to 35 % with placebo. Also, patients with erectile 
dysfunction in all severity categories reported improved erections whilst taking CIALIS (86 %, 83 %, 
and 72 % for mild, moderate, and severe, respectively, as compared to 45 %, 42 %, and 19 % with 
placebo). In the primary efficacy studies, 75 % of intercourse attempts were successful in CIALIS 
treated patients as compared to 32 % with placebo. 
 
In a 12-week study performed in 186 patients (142 tadalafil, 44 placebo) with erectile dysfunction 
secondary to spinal cord injury, tadalafil significantly improved the erectile function leading to a 
mean per-subject proportion of successful attempts in patients treated with tadalafil 10 or 20 mg 
(flexible-dose, on demand) of 48 % as compared to 17 % with placebo. 
 
Paediatric population 
A single study has been performed in paediatric patients with Duchenne Muscular Dystrophy (DMD) 
in which no evidence of efficacy was seen. The randomised, double-blind, placebo-controlled, 
parallel, 3-arm study of tadalafil was conducted in 331 boys aged 7-14 years with DMD receiving 
concurrent corticosteroid therapy. The study included a 48-week double-blind period where patients 
were randomised to tadalafil 0.3 mg/kg, tadalafil 0.6 mg/kg, or placebo daily. Tadalafil did not show 
efficacy in slowing the decline in ambulation as measured by the primary 6 minute walk distance 
(6MWD) endpoint: least squares (LS) mean change in 6MWD at 48 weeks was -51.0 meters (m) in 
the placebo group, compared with -64.7 m in the tadalafil 0.3 mg/kg group (p = 0.307) and -59.1 m in 
the tadalafil 0.6 mg/kg group (p = 0.538). In addition, there was no evidence of efficacy from any of 
the secondary analyses performed in this study. The overall safety results from this study were 
generally consistent with the known safety profile of tadalafil and with adverse events (AEs) expected 
in a paediatric DMD population receiving corticosteroids. 
 
The European Medicines Agency has waived the obligation to submit the results of studies in all 
subsets of the paediatric population in the treatment of the erectile dysfunction. See section 4.2 for 
information on paediatric use. 
 



 39 

5.2 Pharmacokinetic properties 
 
Absorption 
Tadalafil is readily absorbed after oral administration and the mean maximum observed plasma 
concentration (Cmax) is achieved at a median time of 2 hours after dosing. Absolute bioavailability of 
tadalafil following oral dosing has not been determined. 
The rate and extent of absorption of tadalafil are not influenced by food, thus CIALIS may be taken 
with or without food. The time of dosing (morning versus evening) had no clinically relevant effects 
on the rate and extent of absorption. 
 
Distribution  
The mean volume of distribution is approximately 63 l, indicating that tadalafil is distributed into 
tissues. At therapeutic concentrations, 94 % of tadalafil in plasma is bound to proteins. Protein 
binding is not affected by impaired renal function. 
Less than 0.0005 % of the administered dose appeared in the semen of healthy subjects. 
 
Biotransformation 
Tadalafil is predominantly metabolised by the cytochrome P450 (CYP) 3A4 isoform. The major 
circulating metabolite is the methylcatechol glucuronide. This metabolite is at least 13,000-fold less 
potent than tadalafil for PDE5. Consequently, it is not expected to be clinically active at observed 
metabolite concentrations. 
 
Elimination  
The mean oral clearance for tadalafil is 2.5 l/h and the mean half-life is 17.5 hours in healthy subjects. 
Tadalafil is excreted predominantly as inactive metabolites, mainly in the faeces (approximately 61 % 
of the dose) and to a lesser extent in the urine (approximately 36 % of the dose).  
 
Linearity/non-linearity 
Tadalafil pharmacokinetics in healthy subjects are linear with respect to time and dose. Over a dose 
range of 2.5 to 20 mg, exposure (AUC) increases proportionally with dose. Steady-state plasma 
concentrations are attained within 5 days of once-daily dosing. 
 
Pharmacokinetics determined with a population approach in patients with erectile dysfunction are 
similar to pharmacokinetics in subjects without erectile dysfunction. 
 
Special populations 
 
Elderly 
Healthy elderly subjects (65 years or over), had a lower oral clearance of tadalafil, resulting in 25 % 
higher exposure (AUC) relative to healthy subjects aged 19 to 45 years. This effect of age is not 
clinically significant and does not warrant a dose adjustment. 
 
Renal insufficiency 
In clinical pharmacology studies using single-dose tadalafil (5 to 20 mg), tadalafil exposure (AUC) 
approximately doubled in subjects with mild (creatinine clearance 51 to 80 ml/min) or moderate 
(creatinine clearance 31 to 50 ml/min) renal impairment and in subjects with end-stage renal disease 
on dialysis. In haemodialysis patients, Cmax was 41 % higher than that observed in healthy subjects. 
Haemodialysis contributes negligibly to tadalafil elimination. 
 



 40 

Hepatic insufficiency 
Tadalafil exposure (AUC) in subjects with mild and moderate hepatic impairment (Child-Pugh Class 
A and B) is comparable to exposure in healthy subjects when a dose of 10 mg is administered. There 
is limited clinical data on the safety of CIALIS in patients with severe hepatic insufficiency (Child-
Pugh Class C). If CIALIS is prescribed, a careful individual benefit/risk evaluation should be 
undertaken by the prescribing physician. There are no available data about the administration of doses 
higher than 10 mg of tadalafil to patients with hepatic impairment. 
 
Patients with diabetes 
Tadalafil exposure (AUC) in patients with diabetes was approximately 19 % lower than the AUC 
value for healthy subjects. This difference in exposure does not warrant a dose adjustment. 
 
5.3 Preclinical safety data 
 
Non-clinical data reveal no special hazard for humans based on conventional studies of safety 
pharmacology, repeated dose toxicity, genotoxicity, carcinogenic potential, and toxicity to 
reproduction. 
There was no evidence of teratogenicity, embryotoxicity or foetotoxicity in rats or mice that received 
up to 1000 mg/kg/day tadalafil. In a rat prenatal and postnatal development study, the no observed 
effect dose was 30 mg/kg/day. In the pregnant rat the AUC for calculated free drug at this dose was 
approximately 18 times the human AUC at a 20 mg dose. 
There was no impairment of fertility in male and female rats. In dogs given tadalafil daily for 6 to 12 
months at doses of 25 mg/kg/day (resulting in at least a 3-fold greater exposure [range 3.7 – 18.6] than 
seen in humans given a single 20 mg dose) and above, there was regression of the seminiferous 
tubular epithelium that resulted in a decrease in spermatogenesis in some dogs. See also section 5.1.  
 
 
6. PHARMACEUTICAL PARTICULARS 
 
6.1 List of excipients 
 
Tablet core:  
lactose monohydrate,  
croscarmellose sodium,  
hydroxypropylcellulose,  
microcrystalline cellulose,  
sodium laurilsulfate,  
magnesium stearate. 
 
Film-coat:  
lactose monohydrate,  
hypromellose,  
triacetin,  
titanium dioxide (E171),  
iron oxide yellow (E172),  
talc. 
 
6.2 Incompatibilities 
 
Not applicable. 
 
6.3 Shelf life 
 
3 years. 
 



 41 

6.4 Special precautions for storage 
 
Store in the original package in order to protect from moisture. Do not store above 30°C.  
 
6.5 Nature and contents of container 
 
CIALIS 10 mg film-coated tablets 
Aluminium/PVC blisters in cartons of 4 film-coated tablets. 
 
CIALIS 20 mg film-coated tablets 
Aluminium/PVC blisters in cartons of 2, 4, 8, 10 and 12 film-coated tablets. 
 
Not all packs sizes may be marketed. 
 
6.6 Special precautions for disposal   
 
 Any unused medicinal product or waste material should be disposed of in accordance with local 
requirements. 
 
 
 
7. MARKETING AUTHORISATION HOLDER 
 
Eli Lilly Nederland B.V. 
Papendorpseweg 83, 3528 BJ Utrecht 
The Netherlands 
 
 
8. MARKETING AUTHORISATION NUMBER(S)  
 
EU/1/02/237/001-005, 009 
 
 
9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION 
 
Date of first authorisation: 12 November 2002 
Date of last renewal: 12 November 2012 
 
 
10. DATE OF REVISION OF THE TEXT 
 
 
Detailed information on this medicinal product is available on the website of the European Medicines 
Agency http://www.ema.europa.eu. 
 

http://www.ema.europa.eu/


 42 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

ANNEX II 
 
A. MANUFACTUR ER(S) RESPONSIBLE FOR BATCH 

RELEASE 
 
B. CONDITIONS OR RESTRICTIONS REGARDING SUPPLY 

AND USE 
 

C. OTHER CONDITIONS AND REQUIREMENTS OF THE 
MARKETING AUTHORISATION 

 
D. CONDITIONS OR RESTRICTIONS WITH REGARD TO 

THE SAFE AND EFFECTIVE USE OF THE MEDICINAL 
PRODUCT 

 
 



 43 

A. MANUFACTURER(S) RESPONSIBLE FOR BATCH RELEASE 
 
Name and address of the manufacturers responsible for batch release 
 
Lilly S.A., Avda. de la Industria 30, 28108 Alcobendas, Madrid, Spain 
 
The printed package leaflet of the medicinal product must state the name and address of the 
manufacturer responsible for the release of the concerned batch. 
 
 
B. CONDITIONS OR RESTRICTIONS REGARDING SUPPLY AND USE 
 
Medicinal product subject to medical prescription 
 

 
C. OTHER CONDITIONS AND REQUIREMENTS OF THE MARKETING 

AUTHORISATION 
 
• Periodic Safety Update Reports  
The requirements for submission of periodic safety update reports for this medicinal product are set 
out in the list of Union reference dates (EURD list) provided for under Article 107c(7) of Directive 
2001/83/EC and any subsequent updates published on the European medicines web-portal. 
 
D. CONDITIONS OR RESTRICTIONS WITH REGARD TO THE SAFE AND 

EFFECTIVE USE OF THE MEDICINAL PRODUCT   
 
• Risk Management Plan (RMP) 
The MAH shall perform the required pharmacovigilance activities and interventions detailed in the 
agreed RMP presented in Module 1.8.2 of the Marketing Authorisation and any agreed subsequent 
updates of the RMP. 
 
An updated RMP shall be submitted every three years. 
  
When the submission of a PSUR and the update of a RMP coincide, they should be submitted at the 
same time. 
 
In addition, an updated RMP should be submitted 

• At the request of the European Medicines Agency 
• Whenever the risk management system is modified, especially as the result of new 

information being received that may lead to a significant change to the benefit/risk profile or 
as the result of an important (pharmacovigilance or risk minimisation) milestone being 
reached. 



 44 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 

ANNEX III 
 

LABELLING AND PACKAGE LEAFLET 
 
  



 45 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

A. LABELLING 



 46 

 
PARTICULARS TO APPEAR ON THE OUTER PACKAGING  
 
OUTER CARTON 

 
 
1. NAME OF THE MEDICINAL PRODUCT 
 
CIALIS 2.5 mg film-coated tablets 
tadalafil 
 
 
2. STATEMENT OF ACTIVE SUBSTANCE(S) 
 
Each tablet contains 2.5 mg tadalafil 
 
3. LIST OF EXCIPIENTS 
 
lactose 
 
See leaflet for further information. 
 
4. PHARMACEUTICAL FORM AND CONTENTS 
 
28 film-coated tablets 
 
 
5. METHOD AND ROUTE(S) OF ADMINISTRATION 
 
How to take CIALIS once-a-day 
 
1. Start with the pill from the blister pack that corresponds with the day you start taking CIALIS. 
 
 
 
 
 
2. Take CIALIS with water every day at approximately the same time, either with or without food. 
 
 
 
 
 
3. When taken once a day, CIALIS allows you to obtain an erection, when sexually stimulated, at any 
time point during the 24 hours of the day. You and your partner will need to engage in foreplay, just 
as you would if you were not taking a medicine for erectile dysfunction. 
 
• Always take CIALIS exactly as your doctor has told you. Check with your doctor or pharmacist 

if you are not sure.  
• Drinking alcohol may affect your ability to get an erection so avoid excessive drinking with 

CIALIS. 
• You should not take CIALIS more than once a day. If you take more than you should, tell your 

doctor. 
 



 47 

Read the package leaflet before use. 
For oral once-a-day use. 
 
6. SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT 

OF THE SIGHT AND REACH OF CHILDREN 
 
Keep out of the sight and reach of children. 
 
 
7. OTHER SPECIAL WARNING(S), IF NECESSARY 
 
 
8. EXPIRY DATE 
 
EXP 
 
 
9. SPECIAL STORAGE CONDITIONS 
 
Store in the original package in order to protect from moisture. Do not store above 30°C.  
 
 
10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS 

OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF 
APPROPRIATE 

 
 
 
11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER 
 
Eli Lilly Nederland B.V. 
Papendorpseweg 83, 3528 BJ Utrecht 
The Netherlands 
 
12. MARKETING AUTHORISATION NUMBER(S) 
 
EU/1/02/237/006 
 
 
13. BATCH NUMBER 
 
Lot. 
 
 
14. GENERAL CLASSIFICATION FOR SUPPLY 
 
Medicinal product subject to medical prescription. 
 
 
15. INSTRUCTIONS ON USE 
 
 
16. INFORMATION IN BRAILLE 
 
cialis 2.5 mg 



 48 

 
 
17. UNIQUE IDENTIFIER – 2D BARCODE 
 
2D barcode carrying the unique identifier included. 
 
 
18. UNIQUE IDENTIFIER - HUMAN READABLE DATA 
 
PC:  
SN:  
NN:  



 49 

 
PARTICULARS TO APPEAR ON THE OUTER PACKAGING  
 
OUTER CARTON 

 
 
1. NAME OF THE MEDICINAL PRODUCT 
 
CIALIS 5 mg film-coated tablets 
tadalafil 
 
2. STATEMENT OF ACTIVE SUBSTANCE(S) 
 
Each tablet contains 5 mg tadalafil 
 
 
3. LIST OF EXCIPIENTS 
 
lactose 
 
See leaflet for further information. 
 
4. PHARMACEUTICAL FORM AND CONTENTS 
 
14 film-coated tablets 
28 film-coated tablets 
84 film-coated tablets 
 
5. METHOD AND ROUTE(S) OF ADMINISTRATION 
. 
 
How to take CIALIS once-a-day 
 
1. Start with the pill from the blister pack that corresponds with the day you start taking CIALIS. 
 
 
 
 
 
2. Take CIALIS with water every day at approximately the same time, either with or without food. 
 
 
 
 
 
3. When taken once a day for erectile dysfunction, CIALIS allows you to obtain an erection, when 
sexually stimulated, at any time point during the 24 hours of the day. You and your partner will need 
to engage in foreplay, just as you would if you were not taking a medicine for erectile dysfunction. 
 
• Always take CIALIS exactly as your doctor has told you. Check with your doctor or pharmacist 

if you are not sure.  
• Drinking alcohol may affect your ability to get an erection so avoid excessive drinking with 

CIALIS. 



 50 

• You should not take CIALIS more than once a day. If you take more than you should, tell your 
doctor. 

 
Read the package leaflet before use. 
For oral once-a-day use. 
 
 
6. SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT 

OF THE SIGHT AND REACH OF CHILDREN 
 
Keep out of the sight and reach of children. 
 
 
7. OTHER SPECIAL WARNING(S), IF NECESSARY 
 
 
8. EXPIRY DATE 
 
EXP. 
 
 
9. SPECIAL STORAGE CONDITIONS 
 
Store in the original package in order to protect from moisture. Do not store above 25°C.  
 
 
10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS 

OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF 
APPROPRIATE 

 
 
11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER 
 
Eli Lilly Nederland B.V. 
Papendorpseweg 83, 3528 BJ Utrecht 
The Netherlands 
 
12. MARKETING AUTHORISATION NUMBER(S) 
 
 EU/1/02/237/007-008, 010 
 
 
13. BATCH NUMBER 
 
Lot. 
 
 
14. GENERAL CLASSIFICATION FOR SUPPLY 
 
Medicinal product subject to medical prescription. 
 
 
15. INSTRUCTIONS ON USE 
 
 



 51 

16. INFORMATION IN BRAILLE 
 
cialis 5 mg 
 
 
17. UNIQUE IDENTIFIER – 2D BARCODE 
 
2D barcode carrying the unique identifier included. 
 
 
18. UNIQUE IDENTIFIER - HUMAN READABLE DATA 
 
PC:  
SN: 
NN: 



 52 

 
PARTICULARS TO APPEAR ON THE OUTER PACKAGING  
 
OUTER CARTON 

 
 
1. NAME OF THE MEDICINAL PRODUCT 
 
CIALIS 10 mg film-coated tablets 
tadalafil 
 
 
2. STATEMENT OF ACTIVE SUBSTANCE(S) 
 
Each tablet contains 10 mg tadalafil 
 
3. LIST OF EXCIPIENTS 
 
lactose 
 
See leaflet for further information.  
 
 
4. PHARMACEUTICAL FORM AND CONTENTS 
 
4 film-coated tablets 
 
 
5. METHOD AND ROUTE(S) OF ADMINISTRATION 
 
Read the package leaflet before use. 
For oral use. 
 
 
6. SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT 

OF THE SIGHT AND REACH OF CHILDREN 
 
Keep out of the sight and reach of children. 
 
 
7. OTHER SPECIAL WARNING(S), IF NECESSARY 
 
 
8. EXPIRY DATE 
 
EXP  
 
 
9. SPECIAL STORAGE CONDITIONS 
 
Store in the original package in order to protect from moisture. Do not store above 30°C.  
 
 



 53 

10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS 
OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF 
APPROPRIATE 

 
 
11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER 
 
Eli Lilly Nederland B.V. 
Papendorpseweg 83, 3528 BJ Utrecht 
The Netherlands 
 
12. MARKETING AUTHORISATION NUMBER(S) 
 
EU/1/02/237/001 
 
 
13. BATCH NUMBER 
 
Lot. 
 
 
14. GENERAL CLASSIFICATION FOR SUPPLY 
 
Medicinal product subject to medical prescription. 
 
 
15. INSTRUCTIONS ON USE 
 
 
16. INFORMATION IN BRAILLE 
 
cialis 10 mg 
 
 
17. UNIQUE IDENTIFIER – 2D BARCODE 
 
2D barcode carrying the unique identifier included. 
 
 
18. UNIQUE IDENTIFIER - HUMAN READABLE DATA 
 
PC: 
SN: 
NN: 



 54 

 
PARTICULARS TO APPEAR ON THE OUTER PACKAGING  
 
OUTER CARTON 

 
 
1. NAME OF THE MEDICINAL PRODUCT 
 
CIALIS 20 mg film-coated tablets 
tadalafil 
 
2. STATEMENT OF ACTIVE SUBSTANCE(S) 
 
Each tablet contains 20 mg tadalafil 
 
 
3. LIST OF EXCIPIENTS 
 
lactose 
 
See leaflet for further information.  
 
 
4. PHARMACEUTICAL FORM AND CONTENTS 
 
2 film-coated tablets 
4 film-coated tablets 
8 film-coated tablets 
10 film-coated tablets 
12 film-coated tablets 
 
 
5. METHOD AND ROUTE(S) OF ADMINISTRATION 
 
Read the package leaflet before use. 
For oral use. 
 
 
6. SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT 

OF THE SIGHT AND REACH OF CHILDREN 
 
Keep out of the sight and reach of children. 
 
 
7. OTHER SPECIAL WARNING(S), IF NECESSARY 
 
 
8. EXPIRY DATE 
 
EXP 
 
 
9. SPECIAL STORAGE CONDITIONS 
 



 55 

Store in the original package in order to protect from moisture. Do not store above 30°C.  
 
 
10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS 

OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF 
APPROPRIATE 

 
 
11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER 
 
Eli Lilly Nederland B.V. 
Papendorpseweg 83, 3528 BJ Utrecht 
The Netherlands 
 
12. MARKETING AUTHORISATION NUMBER(S) 
 
 EU/1/02/237/002-005, 009 
 
 
13. BATCH NUMBER 
 
Lot. 
 
 
14. GENERAL CLASSIFICATION FOR SUPPLY 
 
Medicinal product subject to medical prescription. 
 
 
15. INSTRUCTIONS ON USE 
 
 
16. INFORMATION IN BRAILLE 
 
cialis 20 mg 
 
 
17. UNIQUE IDENTIFIER – 2D BARCODE 
 
2D barcode carrying the unique identifier included. 
 
 
18. UNIQUE IDENTIFIER - HUMAN READABLE DATA 
 
PC: 
SN: 
NN: 
 
 
 
 
 
 
 
 



 56 

 
MINIMUM PARTICULARS TO APPEAR ON BLISTERS OR STRIPS 
 
BLISTER 
 
 
1. NAME OF THE MEDICINAL PRODUCT 
 
CIALIS 2.5 mg tablets 
tadalafil 
 
 
2. NAME OF THE MARKETING AUTHORISATION HOLDER 
 
Lilly  
 
 
3. EXPIRY DATE 
 
EXP 
 
 
4. BATCH NUMBER 
 
Lot 
 
 
5. OTHER 
 
MON, TUE, WED, THU, FRI, SAT, SUN 



 57 

 
MINIMUM PARTICULARS TO APPEAR ON BLISTERS OR STRIPS 
 
BLISTERS 
 
 
1. NAME OF THE MEDICINAL PRODUCT 
 
CIALIS 5 mg tablets 
tadalafil 
 
 
2. NAME OF THE MARKETING AUTHORISATION HOLDER 
 
Lilly  
 
 
3. EXPIRY DATE 
 
EXP 
 
 
4. BATCH NUMBER 
 
Lot 
 
 
5. OTHER 
 
MON, TUE, WED, THU, FRI, SAT, SUN 



 58 

 
MINIMUM PARTICULARS TO APPEAR ON BLISTERS OR STRIPS 
 
BLISTER 
 
 
1. NAME OF THE MEDICINAL PRODUCT 
 
CIALIS 10 mg tablets 
tadalafil 
 
 
2. NAME OF THE MARKETING AUTHORISATION HOLDER 
 
Lilly  
 
 
3. EXPIRY DATE 
 
EXP 
 
 
4. BATCH NUMBER 
 
Lot 
 
 
5. OTHER 
 



 59 

 
MINIMUM PARTICULARS TO APPEAR ON BLISTERS OR STRIPS 
 
BLISTER 
 
 
1. NAME OF THE MEDICINAL PRODUCT 
 
CIALIS 20 mg tablets 
tadalafil 
 
 
2. NAME OF THE MARKETING AUTHORISATION HOLDER 
 
Lilly  
 
 
3. EXPIRY DATE 
 
EXP 
 
 
4. BATCH NUMBER 
 
Lot 
 
 
5. OTHER 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 



 60 

 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

B. PACKAGE LEAFLET 



 61 

Package leaflet: Information for the user 
 

CIALIS 2.5 mg film-coated tablets 
Tadalafil 

 
Read all of this leaflet carefully before you start taking this medicine because it contains 
important information for you. 
- Keep this leaflet. You may need to read it again. 
- If you have any further questions, ask your doctor or pharmacist. 
- This medicine has been prescribed for you only. Do not pass it on to others. It may harm them, 

even if their signs of illness are the same as yours. 
- If you get any side effects talk to your doctor or pharmacist. This includes any possible side 

effects not listed in this leaflet. See section 4. 
 
What is in this leaflet:  
1. What CIALIS is and what it is used for 
2. What you need to know before you take CIALIS 
3. How to take CIALIS 
4. Possible side effects 
5 How to store CIALIS 
6. Contents of the pack and other information 
 
 
1. What CIALIS is and what it is used for 
 
CIALIS is a treatment for adult men with erectile dysfunction. This is when a man cannot get, or keep 
a hard, erect penis suitable for sexual activity. CIALIS has been shown to significantly improve the 
ability of obtaining a hard erect penis suitable for sexual activity. 
 
CIALIS contains the active substance tadalafil which belongs to a group of medicines called 
phosphodiesterase type 5 inhibitors. Following sexual stimulation CIALIS works by helping the blood 
vessels in your penis to relax, allowing the flow of blood into your penis. The result of this is 
improved erectile function. CIALIS will not help you if you do not have erectile dysfunction.  
 
It is important to note that CIALIS does not work if there is no sexual stimulation. You and your 
partner will need to engage in foreplay, just as you would if you were not taking a medicine for 
erectile dysfunction. 
 
 
2. What you need to know before you take CIALIS 
 
Do not take CIALIS if you: 
 
- are allergic to tadalafil or any of the other ingredients of this medicine (listed in section 6).  
 
- are taking any form of organic nitrate or nitric oxide donors such as amyl nitrite. This is a group 

of medicines (“nitrates”) used in the treatment of angina pectoris (“chest pain”). CIALIS has 
been shown to increase the effects of these medicines. If you are taking any form of nitrate or 
are unsure tell your doctor. 

 
- have serious heart disease or recently had a heart attack within the last 90 days.  
 
- recently had a stroke within the last 6 months. 
 
-    have low blood pressure or uncontrolled high blood pressure. 
 



 62 

-  ever had loss of vision because of non-arteritic anterior ischemic optic neuropathy  (NAION), a 
condition described as “stroke of the eye”. 

 
- are taking riociguat. This drug is used to treat pulmonary arterial hypertension (i.e., high blood 

pressure in the lungs) and chronic thromboembolic pulmonary hypertension (i.e., high blood 
pressure in the lungs secondary to blood clots).  PDE5 inhibitors, such as CIALIS, have been 
shown to increase the hypotensive effects of this medicine.  If you are taking riociguat or are 
unsure tell your doctor. 

 
Warnings and precautions 
Talk to your doctor before taking CIALIS. 
 
Be aware that sexual activity carries a possible risk to patients with heart disease because it puts an 
extra strain on your heart. If you have a heart problem you should tell your doctor.  
 
Before taking the tablets, tell your doctor if you have: 
- sickle cell anaemia (an abnormality of red blood cells). 
- multiple myeloma (cancer of the bone marrow). 
- leukaemia (cancer of the blood cells). 
- any deformation of your penis. 
- a serious liver problem. 
- a severe kidney problem. 
 
It is not known if CIALIS is effective in patients who have had: 
- pelvic surgery. 
- removal of all or part of the prostate gland in which nerves of the prostate are cut (radical non-

nerve-sparing prostatectomy). 
 
If you experience sudden decrease or loss of vision, stop taking CIALIS and contact your doctor 
immediately.  
 
Decreased or sudden hearing loss has been noted in some patients taking tadalafil. Although it is not 
known if the event is directly related to tadalafil, if you experience decreased or sudden hearing loss, 
stop taking CIALIS and contact your doctor immediately. 
 
CIALIS is not intended for use by women.   
 
Children and adolescents 
CIALIS is not intended for use by children and adolescents under the age of 18. 
 
Other medicines and CIALIS 
Tell your doctor if you are taking, have recently taken or might take any other medicines 
 
Do not take CIALIS if you are already taking nitrates. 
 
Some medicines may be affected by CIALIS or they may affect how well CIALIS will work. Tell your 
doctor or pharmacist if you are already taking: 
 
- an alpha blocker (used to treat high blood pressure or urinary symptoms associated with benign 

prostatic hyperplasia). 
- other medicines to treat high blood pressure. 
- riociguat. 
- a 5- alpha reductase inhibitor (used to treat benign prostatic hyperplasia). 



 63 

- medicines such as ketoconazole tablets (to treat fungal infections) and protease inhibitors for 
treatment of AIDS or HIV infection. 

- phenobarbital, phenytoin and carbamazepine (anticonvulsant medicines). 
- rifampicin, erythromycin , clarithromycin or itraconazole. 
- other treatments for erectile dysfunction. 
 
CIALIS with drink and alcohol 
Information on the effect of alcohol is in section 3. Grapefruit juice may affect how well CIALIS will 
work and should be taken with caution. Talk to your doctor for further information. 
 
Fertility 
When dogs were treated there was reduced sperm development in the testes.  A reduction in sperm 
was seen in some men. These effects are unlikely to lead to a lack of fertility. 
 
Driving and using machines 
Some men taking CIALIS in clinical studies have reported dizziness. Check carefully how you react 
to the tablets before driving or using machines. 
 
CIALIS contains lactose: 
If you have an intolerance to some sugars, contact your doctor before taking this medicine. 
 
 
3. How to take CIALIS 
 
Always take this medicine exactly as your doctor has told you. Check with your doctor or pharmacist 
if you are not sure.  
 
CIALIS tablets are for oral use in men only. Swallow the tablet whole with some water. The tablets 
can be taken with or without food.  
 
The recommended dose is one 5 mg tablet taken once a day at approximately the same time of the 
day. Your doctor may adjust the dose to 2.5 mg based on your response to CIALIS. This will be given 
as a 2.5mg tablet. 
Do not take CIALIS more than once a day.  
 
Once a day dosing of CIALIS may be useful to men who anticipate having sexual activity two or more 
times per week. 
 
When taken once a day CIALIS allows you to obtain an erection, when sexually stimulated, at any 
time point during the 24 hours of the day.  
It is important to note that CIALIS does not work if there is no sexual stimulation. You and your 
partner will need to engage in foreplay, just as you would if you were not taking a medicine for 
erectile dysfunction. 
 
Drinking alcohol may affect your ability to get an erection and may temporarily lower your blood 
pressure. If you have taken or are planning to take CIALIS, avoid excessive drinking (blood alcohol 
level of 0.08 % or greater), since this may increase the risk of dizziness when standing up. 
 
If you take more CIALIS than you should  
Contact your doctor. You may experience side effects described in section 4. 
 
If you forget to take CIALIS 
Take your dose as soon as you remember but do not take a double dose to make up for a forgotten 
tablet. You should not take CIALIS more than once a day. 
 
If you have any further questions on the use of this medicine, ask your doctor or pharmacist. 



 64 

 
 
4. Possible side effects 
 
Like all medicines, this medicine can cause side effects, although not everybody gets them. These 
effects are normally mild to moderate in nature. 
 
If you experience any of the following side effects stop using the medicine and seek medical help 
immediately: 
- allergic reactions including rashes (frequency uncommon). 

- chest pain - do not use nitrates but seek immediate medical assistance (frequency uncommon). 

- priapsim, a prolonged and possibly painful erection after taking CIALIS (frequency rare). If you 
have such an erection, which lasts continuously for more than 4 hours you should contact a 
doctor immediately. 

- sudden loss of vision (frequency rare). 

Other side effects have been reported:  
 
Common (seen in 1 to 10 in every 100 patients) 
- headache, back pain, muscle aches, pain in arms and legs, facial flushing, nasal congestion and 

indigestion. 
 
Uncommon (seen in 1 to 10 in every 1,000 patients) 
- dizziness, stomach ache, feeling sick, being sick (vomiting), reflux, blurred vision, eye pain, 

difficulty in breathing, presence of blood in urine, prolonged erection, pounding heartbeat 
sensation, a fast heart rate, high blood pressure, low blood pressure, nose bleeds, ringing in the 
ears, swelling of the hands, feet or ankles and feeling tired.  

 
Rare (seen in 1 to 10 in every 10,000 patients)  
- fainting, seizures and passing memory loss, swelling of the eyelids, red eyes, sudden decrease 

or loss of hearing, hives (itchy red welts on the surface of the skin), penile bleeding, presence 
of blood in semen and increased sweating. 

 
Heart attack and stroke have also been reported rarely in men taking CIALIS. Most of these men had 
known heart problems before taking this medicine. 
 
Partial, temporary, or permanent decrease or loss of vision in one or both eyes has been rarely 
reported. 
 
Some additional rare side effects have been reported in men taking CIALIS that were not seen in 
clinical trials.  These include: 
- migraine, swelling of the face, serious allergic reaction which causes swelling of the face or 

throat, serious skin rashes, some disorders affecting blood flow to the eyes, irregular heartbeats, 
angina and sudden cardiac death. 

 
The side effect dizziness has been reported more frequently in men over 75 years of age taking 
CIALIS. Diarrhoea has been reported more frequently in men over 65 years of age taking CIALIS. 
 
 
Reporting of side effects 
If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects 
not listed in this leaflet. You can also report side effects directly via the national reporting system 
listed in Appendix V. By reporting side effects you can help provide more information on the safety 
of this medicine. 
 

http://www.ema.europa.eu/docs/en_GB/document_library/Template_or_form/2013/03/WC500139752.doc


 65 

 
5. How to store CIALIS 
 
Keep this medicine out of the sight and reach of children. 
 
Do not use this medicine after the expiry date which is stated on the carton and blister after ‘EXP’. 
The expiry date refers to the last day of that month. 
 
Store in the original package in order to protect from moisture. Do not store above 30°C. 
 
Do not throw away any medicines via wastewater or household waste. Ask your pharmacist how to 
throw away medicines you no longer use. These measures will help protect the environment. 
 
 
6. Contents of the pack and other information 
 
What CIALIS contains 
- The active substance is tadalafil. Each tablet contains 2.5 mg of tadalafil. 
- The other ingredients are: 

Tablet core: lactose monohydrate (see end of section 2), croscarmellose sodium, 
hydroxypropylcellulose, microcrystalline cellulose, sodium laurilsulfate, magnesium stearate. 
Film-coat: lactose monohydrate, hypromellose, triacetin, titanium dioxide (E171), iron oxide 
yellow (E172), iron oxide red (E172), talc. 

 
What Cialis looks like and contents of the pack 
CIALIS 2.5 mg is a light orange-yellow film-coated tablet in the shape of an almond and has "C 2 ½" 
marked on one side. 
 
CIALIS 2.5 mg is available in blister packs containing 28 tablets. 
 
Marketing Authorisation Holder and Manufacturer 
 
Marketing Authorisation Holder: Eli Lilly Nederland B.V., Papendorpseweg 83, 3528 BJ Utrecht, 
The Netherlands. 
 
Manufacturer: Lilly S.A., Avda. de la Industria 30, 28108 Alcobendas, Madrid, Spain. 
 
For any information about this medicine, please contact the local representative of the Marketing 
Authorisation Holder. 
 
Belgique/België/Belgien 
Eli Lilly Benelux S.A./N.V. 
Tél/Tel: + 32-(0)2 548 84 84 

Lietuva 
Eli Lilly Holdings Limited atstovybė 
Tel. +370 (5) 2649600 

България 
ТП "Ели Лили Недерланд" Б.В. - България 
тел. + 359 2 491 41 40 

Luxembourg/Luxemburg 
Eli Lilly Benelux S.A./N.V. 
Tél/Tel: + 32-(0)2 548 84 84 

Česká republika 
ELI LILLY ČR, s.r.o. 
Tel: + 420 234 664 111 

Magyarország 
Lilly Hungária Kft. 
Tel: + 36 1 328 5100 

Danmark 
Eli Lilly Danmark A/S  
Tlf: +45 45 26 60 00 

Malta 
Charles de Giorgio Ltd. 
Tel: + 356 25600 500 

Deutschland 
Lilly Deutschland GmbH  
Tel. + 49-(0) 6172 273 2222 

Nederland 
Eli Lilly Nederland B.V.  
Tel: + 31-(0) 30 60 25 800 

Eesti Norge 



 66 

Eli Lilly Holdings Limited Eesti filiaal  
Tel: +372 6 817 280 

Eli Lilly Norge A.S. 
Tlf: + 47 22 88 18 00 

Ελλάδα 
ΦΑΡΜΑΣΕΡΒ-ΛΙΛΛΥ Α.Ε.Β.Ε.  
Τηλ: +30 210 629 4600 

Österreich 
Eli Lilly Ges.m.b.H. 
Tel: + 43-(0) 1 711 780 

España 
Lilly S.A.  
Tel: + 34-91 663 50 00 

Polska 
Eli Lilly Polska Sp. z o.o. 
Tel: +48 22 440 33 00 

France 
Lilly France SAS  
Tél: +33-(0) 1 55 49 34 34 

Portugal 
Lilly Portugal Produtos Farmacêuticos, Lda 
Tel: + 351-21-4126600 

Hrvatska 
Eli Lilly Hrvatska d.o.o. 
Tel: +385 1 2350 999 

România 
Eli Lilly România S.R.L. 
Tel: + 40 21 4023000 

Ireland 
Eli Lilly and Company (Ireland) Limited 
Tel: + 353-(0) 1 661 4377 

Slovenija 
Eli Lilly farmacevtska družba, d.o.o. 
Tel: +386 (0)1 580 00 10 

Ísland 
Icepharma hf. 
Sími: + 354 540 8000 

Slovenská republika 
Eli Lilly Slovakia, s.r.o. 
Tel: + 421 220 663 111 

Italia 
Eli Lilly Italia S.p.A. 
Tel: + 39- 055 42571 

Suomi/Finland 
Oy Eli Lilly Finland Ab 
Puh/Tel: + 358-(0) 9 85 45 250 

Κύπρος 
Phadisco Ltd  
Τηλ: +357 22 715000 

Sverige 
Eli Lilly Sweden AB 
Tel: + 46-(0) 8 7378800 

Latvija 
Eli Lilly Holdings Limited  
pārstāvniecība Latvijā 
Tel: +371 67364000 

United Kingdom 
Eli Lilly and Company Limited 
Tel: + 44-(0) 1256 315000 

 
This leaflet was last revised in  
 
Detailed information on this medicine is available on the European Medicines Agency web site: 
http://www.ema.europa.eu 



 67 

Package leaflet: Information for the user 
 

CIALIS 5 mg film-coated tablets 
Tadalafil 

 
Read all of this leaflet carefully before you start taking this medicine because it contains 
important information for you. 
- Keep this leaflet. You may need to read it again. 
- If you have any further questions, ask your doctor or pharmacist. 
- This medicine has been prescribed for you only. Do not pass it on to others. It may harm them, 

even if their signs of illness are the same as yours. 
- If you get any side effects talk to your doctor or pharmacist. This includes any possible side 

effects not listed in this leaflet. See section 4. 
 
What is in this leaflet:  
1. What CIALIS is and what it is used for 
2. What you need to know before you take CIALIS 
3. How to take CIALIS 
4. Possible side effects 
5 How to store CIALIS 
6. Contents of the pack and other information 
 
 
1. What CIALIS is and what it is used for 
CIALIS contains the active substance tadalafil which belongs to a group of medicines called 
phosphodiesterase type 5 inhibitors.  
 
CIALIS 5 mg is used to treat adult men with: 
- erectile dysfunction. This is when a man cannot get, or keep a hard, erect penis suitable for 

sexual activity. CIALIS has been shown to significantly improve the ability of obtaining a hard 
erect penis suitable for sexual activity.   
Following sexual stimulation CIALIS works by helping the blood vessels in your penis to relax, 
allowing the flow of blood into your penis. The result of this is improved erectile function. 
CIALIS will not help you if you do not have erectile dysfunction. It is important to note that 
CIALIS for the treatment of erectile dysfunction does not work if there is no sexual stimulation. 
You and your partner will need to engage in foreplay, just as you would if you were not taking 
a medicine for erectile dysfunction. 
 

- urinary symptoms associated with a common condition called benign prostatic hyperplasia.  
This is when the prostate gland gets bigger with age. Symptoms include difficulty in starting to 
pass water, a feeling of not completely emptying the bladder and a more frequent need to pass 
water even at night. CIALIS improves blood flow to, and relaxes the muscles of, the prostate 
and bladder which may reduce symptoms of benign prostatic hyperplasia. CIALIS has been 
shown to improve these urinary symptoms as early as 1-2 weeks after starting treatment. 

 
 
2. What you need to know before you take CIALIS 
 
Do not take CIALIS if you: 
 
- are allergic to tadalafil or any of the other ingredients of this medicine (listed in section 6).  
 
- are taking any form of organic nitrate or nitric oxide donors such as amyl nitrite. This is a group 

of medicines (“nitrates”) used in the treatment of angina pectoris (“chest pain”). CIALIS has 
been shown to increase the effects of these medicines. If you are taking any form of nitrate or 
are unsure tell your doctor. 



 68 

 
- have serious heart disease or recently had a heart attack within the last 90 days.  
 
- recently had a stroke within the last 6 months. 
 
-    have low blood pressure or uncontrolled high blood pressure. 
 
-  ever had loss of vision because of non-arteritic anterior ischemic optic neuropathy  (NAION), a 

condition described as “stroke of the eye”. 
 
- are taking riociguat. This drug is used to treat pulmonary arterial hypertension (i.e., high blood 

pressure in the lungs) and chronic thromboembolic pulmonary hypertension (i.e., high blood 
pressure in the lungs secondary to blood clots).  PDE5 inhibitors, such as CIALIS, have been 
shown to increase the hypotensive effects of this medicine.  If you are taking riociguat or are 
unsure tell your doctor. 

 
Warnings and precautions 
Talk to your doctor before taking CIALIS. 
 
Be aware that sexual activity carries a possible risk to patients with heart disease because it puts an 
extra strain on your heart. If you have a heart problem you should tell your doctor.  
 
Since benign prostatic hyperplasia and prostate cancer may have the same symptoms, your doctor will 
check you for prostate cancer before starting treatment with CIALIS for benign prostatic hyperplasia. 
CIALIS does not treat prostate cancer. 
 
Before taking the tablets, tell your doctor if you have: 
- sickle cell anaemia (an abnormality of red blood cells). 
- multiple myeloma (cancer of the bone marrow). 
- leukaemia (cancer of the blood cells). 
- any deformation of your penis. 
- a serious liver problem. 
- a severe kidney problem. 
 
It is not known if CIALIS is effective in patients who have had: 
- pelvic surgery. 
- removal of all or part of the prostate gland in which nerves of the prostate are cut (radical non-

nerve-sparing prostatectomy). 
 
If you experience sudden decrease or loss of vision, stop taking CIALIS and contact your doctor 
immediately.  
 
Decreased or sudden hearing loss has been noted in some patients taking tadalafil. Although it is not 
known if the event is directly related to tadalafil, if you experience decreased or sudden hearing loss, 
stop taking CIALIS and contact your doctor immediately. 
 
CIALIS is not intended for use by women.   
 
Children and adolescents 
CIALIS is not intended for use by children and adolescents under the age of 18. 
 
Other medicines and CIALIS 
Tell your doctor if you are taking, have recently taken or might take any other medicines 
 



 69 

Do not take CIALIS if you are already taking nitrates. 
 
Some medicines may be affected by CIALIS or they may affect how well CIALIS will work. Tell your 
doctor or pharmacist if you are already taking: 
 
- an alpha blocker (used to treat high blood pressure or urinary symptoms associated with benign 

prostatic hyperplasia). 
- other medicines to treat high blood pressure. 
- riociguat. 
- a 5- alpha reductase inhibitor (used to treat benign prostatic hyperplasia). 
- medicines such as ketoconazole tablets (to treat fungal infections) and protease inhibitors for 

treatment of AIDS or HIV infection. 
- phenobarbital, phenytoin and carbamazepine (anticonvulsant medicines). 
- rifampicin, erythromycin , clarithromycin or itraconazole. 
- other treatments for erectile dysfunction. 
 
CIALIS with drink and alcohol 
Information on the effect of alcohol is in section 3. Grapefruit juice may affect how well CIALIS will 
work and should be taken with caution. Talk to your doctor for further information. 
 
Fertility 
When dogs were treated there was reduced sperm development in the testes.  A reduction in sperm 
was seen in some men. These effects are unlikely to lead to a lack of fertility. 
 
Driving and using machines 
Some men taking CIALIS in clinical studies have reported dizziness. Check carefully how you react 
to the tablets before driving or using machines. 
 
CIALIS contains lactose: 
If you have an intolerance to some sugars, contact your doctor before taking this medicine. 
 
 
3. How to take CIALIS 
 
Always take this medicine exactly as your doctor has told you. Check with your doctor or pharmacist 
if you are not sure.  
 
CIALIS tablets are for oral use in men only. Swallow the tablet whole with some water. The tablets 
can be taken with or without food.  
 
Drinking alcohol may temporarily lower your blood pressure. If you have taken or are planning to take 
CIALIS, avoid excessive drinking (blood alcohol level of 0.08% or greater), since this may increase 
the risk of dizziness when standing up. 
 
For the treatment of erectile dysfunction 
The recommended dose is one 5 mg tablet taken once a day at approximately the same time of the 
day. Your doctor may adjust the dose to 2.5 mg based on your response to CIALIS. This will be given 
as a 2.5mg tablet. 
Do not take CIALIS more than once a day.  
 
When taken once a day CIALIS allows you to obtain an erection, when sexually stimulated, at any 
time point during the 24 hours of the day. Once a day dosing of CIALIS may be useful to men who 
anticipate having sexual activity two or more times per week. 
It is important to note that CIALIS does not work if there is no sexual stimulation. You and your 
partner will need to engage in foreplay, just as you would if you were not taking a medicine for 
erectile dysfunction. 



 70 

 
Drinking alcohol may affect your ability to get an erection. 
 
For the treatment benign prostatic hyperplasia 
The dose is one 5 mg tablet taken once a day at approximately the same time of the day. 
If you have benign prostatic hyperplasia and erectile dysfunction, the dose remains one 5 mg tablet 
taken once a day. 
Do not take CIALIS more than once a day.  
 
If you take more CIALIS than you should  
Contact your doctor. You may experience side effects described in section 4. 
 
If you forget to take CIALIS 
Take your dose as soon as you remember but do not take a double dose to make up for a forgotten 
tablet. You should not take CIALIS more than once a day. 
 
If you have any further questions on the use of this medicine, ask your doctor or pharmacist. 
 
 
4. Possible side effects 
 
Like all medicines, this medicine can cause side effects, although not everybody gets them. These 
effects are normally mild to moderate in nature. 
 
If you experience any of the following side effects stop using the medicine and seek medical help 
immediately: 
- allergic reactions including rashes (frequency uncommon). 

- chest pain - do not use nitrates but seek immediate medical assistance (frequency uncommon). 

- priapism, a prolonged and possibly painful erection after taking CIALIS (frequency rare). If you 
have such an erection, which lasts continuously for more than 4 hours you should contact a 
doctor immediately. 

- sudden loss of vision (frequency rare). 

 
Other side effects have been reported:  
 
Common (seen in 1 to 10 in every 100 patients) 
- headache, back pain, muscle aches, pain in arms and legs, facial flushing, nasal congestion and 

indigestion. 
 
Uncommon (seen in 1 to 10 in every 1,000 patients) 
- dizziness, stomach ache, feeling sick, being sick (vomiting), reflux, blurred vision, eye pain, 

difficulty in breathing, presence of blood in urine, prolonged erection, pounding heartbeat 
sensation, a fast heart rate, high blood pressure, low blood pressure, nose bleeds, ringing in the 
ears, swelling of the hands, feet or ankles and feeling tired. 

 
Rare (seen in 1 to 10 in every 10,000 patients) 
- fainting, seizures and passing memory loss, swelling of the eyelids, red eyes, sudden decrease 

or loss of hearing, hives (itchy red welts on the surface of the skin), penile bleeding, presence 
of blood in semen and increased sweating.  

 
Heart attack and stroke have also been reported rarely in men taking CIALIS. Most of these men had 
known heart problems before taking this medicine. 
 



 71 

Partial, temporary, or permanent decrease or loss of vision in one or both eyes has been rarely 
reported. 
 
Some additional rare side effects have been reported in men taking CIALIS that were not seen in 
clinical trials.  These include: 
- migraine, swelling of the face, serious allergic reaction which causes swelling of the face or 

throat, serious skin rashes, some disorders affecting blood flow to the eyes, irregular heartbeats, 
angina and sudden cardiac death. 

 
The side effect dizziness  has been reported more frequently in men over 75 years of age taking 
CIALIS. Diarrhoea has been reported more frequently in men over 65 years of age taking CIALIS. 
 
 
Reporting of side effects 
If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects 
not listed in this leaflet. You can also report side effects directly via the national reporting system 
listed in Appendix V. By reporting side effects you can help provide more information on the safety 
of this medicine. 
 
 
5. How to store CIALIS 
 
Keep this medicine out of the sight and reach of children. 
 
Do not use this medicine after the expiry date which is stated on the carton and blister after ‘EXP’. 
The expiry date refers to the last day of that month. 
 
Store in the original package in order to protect from moisture. Do not store above 25°C. 
 
Do not throw away any medicines via wastewater or household waste. Ask your pharmacist how to 
throw away medicines you no longer use. These measures will help protect the environment. 
 
 
6. Contents of the pack and other information 
 
What CIALIS contains 
- The active substance is tadalafil. Each tablet contains 5 mg of tadalafil. 
- The other ingredients are: 

Tablet core: lactose monohydrate (see end of section 2), croscarmellose sodium, 
hydroxypropylcellulose, microcrystalline cellulose, sodium laurilsulfate, magnesium stearate. 
Film-coat: lactose monohydrate, hypromellose, triacetin, titanium dioxide (E171), iron oxide 
yellow (E172), talc. 

 
What CIALIS looks like and contents of the pack 
CIALIS 5 mg is a light yellow film-coated tablet in the shape of  an almond and has "C 5" marked on 
one side. 
 
CIALIS 5 mg is available in blister packs containing 14, 28 or 84 tablets.  
 
Not all pack sizes may be marketed. 
 
Marketing Authorisation Holder and Manufacturer 
 
Marketing Authorisation Holder: Eli Lilly Nederland B.V., Papendorpseweg 83, 3528 BJ Utrecht, 
The Netherlands. 
 

http://www.ema.europa.eu/docs/en_GB/document_library/Template_or_form/2013/03/WC500139752.doc


 72 

Manufacturer: Lilly S.A., Avda. de la Industria 30, 28108 Alcobendas, Madrid, Spain. 
 
For any information about this medicine, please contact the local representative of the Marketing 
Authorisation Holder. 
 
Belgique/België/Belgien 
Eli Lilly Benelux S.A./N.V. 
Tél/Tel: + 32-(0)2 548 84 84 

Lietuva 
Eli Lilly Holdings Limited atstovybė 
Tel. +370 (5) 2649600 

България 
ТП "Ели Лили Недерланд" Б.В. - България 
тел. + 359 2 491 41 40 

Luxembourg/Luxemburg 
Eli Lilly Benelux S.A./N.V. 
Tél/Tel: + 32-(0)2 548 84 84 

Česká republika 
ELI LILLY ČR, s.r.o. 
Tel: + 420 234 664 111 

Magyarország 
Lilly Hungária Kft. 
Tel: + 36 1 328 5100 

Danmark 
Eli Lilly Danmark A/S  
Tlf: +45 45 26 60 00 

Malta 
Charles de Giorgio Ltd. 
Tel: + 356 25600 500 

Deutschland 
Lilly Deutschland GmbH  
Tel. + 49-(0) 6172 273 2222 

Nederland 
Eli Lilly Nederland B.V.  
Tel: + 31-(0) 30 60 25 800 

Eesti 
Eli Lilly Holdings Limited Eesti filiaal  
Tel: +372 6 817 280 

Norge 
Eli Lilly Norge A.S. 
Tlf: + 47 22 88 18 00 

Ελλάδα 
ΦΑΡΜΑΣΕΡΒ-ΛΙΛΛΥ Α.Ε.Β.Ε.  
Τηλ: +30 210 629 4600 

Österreich 
Eli Lilly Ges.m.b.H. 
Tel: + 43-(0) 1 711 780 

España 
Lilly S.A.  
Tel: + 34-91 663 50 00 

Polska 
Eli Lilly Polska Sp. z o.o. 
Tel: +48 22 440 33 00 

France 
Lilly France SAS  
Tél: +33-(0) 1 55 49 34 34 

Portugal 
Lilly Portugal Produtos Farmacêuticos, Lda 
Tel: + 351-21-4126600 

Hrvatska 
Eli Lilly Hrvatska d.o.o. 
Tel: +385 1 2350 999 

România 
Eli Lilly România S.R.L. 
Tel: + 40 21 4023000 

Ireland 
Eli Lilly and Company (Ireland) Limited 
Tel: + 353-(0) 1 661 4377 

Slovenija 
Eli Lilly farmacevtska družba, d.o.o. 
Tel: +386 (0)1 580 00 10 

Ísland 
Icepharma hf. 
Sími: + 354 540 8000 

Slovenská republika 
Eli Lilly Slovakia, s.r.o. 
Tel: + 421 220 663 111 

Italia 
Eli Lilly Italia S.p.A. 
Tel: + 39- 055 42571 

Suomi/Finland 
Oy Eli Lilly Finland Ab  
Puh/Tel: + 358-(0) 9 85 45 250 

Κύπρος 
Phadisco Ltd  
Τηλ: +357 22 715000 

Sverige 
Eli Lilly Sweden AB 
Tel: + 46-(0) 8 7378800 

Latvija 
Eli Lilly Holdings Limited  
pārstāvniecība Latvijā 
Tel: +371 67364000 

United Kingdom 
Eli Lilly and Company Limited 
Tel: + 44-(0) 1256 315000 

 
This leaflet was last revised in  
 
Detailed information on this medicine is available on the European Medicines Agency web site: 
http://www.ema.europa.eu 



 73 

Package leaflet: Information for the user 
 

CIALIS 10 mg film-coated tablets 
Tadalafil 

 
Read all of this leaflet carefully before you start taking this medicine because it contains 
important information for you. 
- Keep this leaflet. You may need to read it again. 
- If you have any further questions, ask your doctor or pharmacist. 
- This medicine has been prescribed for you only. Do not pass it on to others. It may harm them, 

even if their signs of illness are the same as yours. 
- If you get any side effects talk to your doctor or pharmacist. This includes any possible side 

effects not listed in this leaflet. See section 4. 
 
What is in this leaflet:  
1. What CIALIS is and what it is used for 
2. What you need to know before you take CIALIS 
3. How to take CIALIS 
4. Possible side effects 
5 How to store CIALIS 
6. Contents of the pack and other information 
 
 
1. What CIALIS is and what it is used for 
 
CIALIS is a treatment for adult men with erectile dysfunction. This is when a man cannot get, or keep 
a hard, erect penis suitable for sexual activity. CIALIS has been shown to significantly improve the 
ability of obtaining a hard erect penis suitable for sexual activity. 
 
CIALIS contains the active substance tadalafil which belongs to a group of medicines called 
phosphodiesterase type 5 inhibitors. Following sexual stimulation CIALIS works by helping the blood 
vessels in your penis to relax, allowing the flow of blood into your penis. The result of this is 
improved erectile function. CIALIS will not help you if you do not have erectile dysfunction.  
 
It is important to note that CIALIS does not work if there is no sexual stimulation. You and your 
partner will need to engage in foreplay, just as you would if you were not taking a medicine for 
erectile dysfunction. 
 
 
2. What you need to know before you take CIALIS 
 
Do not take CIALIS if you: 
 
- are allergic to tadalafil or any of the other ingredients of this medicine (listed in section 6). 
 
- are taking any form of organic nitrate or nitric oxide donors such as amyl nitrite. This is a group 

of medicines (“nitrates”) used in the treatment of angina pectoris (“chest pain”). CIALIS has 
been shown to increase the effects of these medicines. If you are taking any form of nitrate or 
are unsure tell your doctor. 

 
- have serious heart disease or recently had a heart attack within the last 90 days.  
 
- recently had a stroke within the last 6 months. 
 
- have low blood pressure or uncontrolled high blood pressure. 
 



 74 

- ever had loss of vision because of non-arteritic anterior ischemic optic neuropathy (NAION), a 
condition described as “stroke of the eye”. 

 
- are taking riociguat. This drug is used to treat pulmonary arterial hypertension (i.e., high blood 

pressure in the lungs) and chronic thromboembolic pulmonary hypertension (i.e., high blood 
pressure in the lungs secondary to blood clots).  PDE5 inhibitors, such as CIALIS, have been 
shown to increase the hypotensive effects of this medicine.  If you are taking riociguat or are 
unsure tell your doctor. 

 
Warnings and precautions 
Talk to your doctor before taking CIALIS. 
 
Be aware that sexual activity carries a possible risk to patients with heart disease because it puts an 
extra strain on your heart. If you have a heart problem you should tell your doctor.  
 
Before taking the tablets, tell your doctor if you have: 
- sickle cell anaemia (an abnormality of red blood cells). 
- multiple myeloma (cancer of the bone marrow). 
- leukaemia (cancer of the blood cells). 
- any deformation of your penis. 
- a serious liver problem. 
- a severe kidney problem. 
 
It is not known if CIALIS is effective in patients who have had: 
- pelvic surgery. 
- removal of all or part of the prostate gland in which nerves of the prostate are cut (radical non-

nerve-sparing prostatectomy). 
  
If you experience sudden decrease or loss of vision, stop taking CIALIS and contact your doctor 
immediately.  
 
Decreased or sudden hearing loss has been noted in some patients taking tadalafil. Although it is not 
known if the event is directly related to tadalafil, if you experience decreased or sudden hearing loss, 
stop taking CIALIS and contact your doctor immediately. 
 
CIALIS is not intended for use by women.   
 
Children and adolescents 
CIALIS is not intended for use by children and adolescents under the age of 18. 
 
Other medicines and CIALIS 
Tell your doctor if you are taking, have recently taken or might take any other medicines 
 
Do not take CIALIS if you are already taking nitrates. 
 
Some medicines may be affected by CIALIS or they may affect how well CIALIS will work. Tell your 
doctor or pharmacist if you are already taking: 
 
- an alpha blocker (used to treat high blood pressure or urinary symptoms associated with benign 

prostatic hyperplasia). 
- other medicines to treat high blood pressure. 
- riociguat. 
- a 5- alpha reductase inhibitor (used to treat benign prostatic hyperplasia). 



 75 

- medicines such as ketoconazole tablets (to treat fungal infections) and protease inhibitors for 
treatment of AIDS or HIV infection. 

- phenobarbital, phenytoin and carbamazepine (anticonvulsant medicines). 
- rifampicin, erythromycin , clarithromycin or itraconazole. 
- other treatments for erectile dysfunction. 
 
CIALIS with drink and alcohol 
Information on the effect of alcohol is in section 3. Grapefruit juice may affect how well CIALIS will 
work and should be taken with caution. Talk to your doctor for further information. 
 
Fertility 
When dogs were treated there was reduced sperm development in the testes.  A reduction in sperm 
was seen in some men. These effects are unlikely to lead to a lack of fertility. 
 
Driving and using machines 
Some men taking CIALIS in clinical studies have reported dizziness. Check carefully how you react 
to the tablets before driving or using machines. 
 
CIALIS contains lactose: 
If you have an intolerance to some sugars, contact your doctor before taking this medicine. 
 
 
3. How to take CIALIS 
 
Always take this medicine exactly as your doctor has told you. Check with your doctor or pharmacist 
if you are not sure. 
 
CIALIS tablets are for oral use in men only. Swallow the tablet whole with some water. The tablets 
can be taken with or without food.   
 
The recommended starting dose is one 10 mg tablet before sexual activity. If the effect of this dose 
is too weak your doctor may increase the dose to 20 mg. CIALIS tablets are for oral use.  
 
You may take a CIALIS tablet at least 30 minutes before sexual activity.  
CIALIS may still be effective up to 36 hours after taking the tablet.  
 
Do not take CIALIS more than once a day. CIALIS 10 mg and 20 mg is intended for use prior to 
anticipated sexual activity and is not recommended for continuous daily use.   
 
It is important to note that CIALIS does not work if there is no sexual stimulation. You and your 
partner will need to engage in foreplay, just as you would if you were not taking a medicine for 
erectile dysfunction. 
 
Drinking alcohol may affect your ability to get an erection and may temporarily lower your blood 
pressure. If you have taken or are planning to take CIALIS, avoid excessive drinking (blood alcohol 
level of 0.08 % or greater), since this may increase the risk of dizziness when standing up. 
 
If you take more CIALIS than you should  
Contact your doctor. You may experience side effects described in section 4. 
 
If you have any further questions on the use of this medicine, ask your doctor or pharmacist. 
 
 



 76 

4. Possible side effects 
 
Like all medicines, this medicine can cause side effects, although not everybody gets them. These 
effects are normally mild to moderate in nature. 
 
If you experience any of the following side effects stop using the medicine and seek medical help 
immediately: 
- allergic reactions including rashes (frequency uncommon). 

- chest pain - do not use nitrates but seek immediate medical assistance (frequency uncommon). 

- priapsim, a prolonged and possibly painful erection after taking CIALIS (frequency rare). If you 
have such an erection, which lasts continuously for more than 4 hours you should contact a 
doctor immediately. 

- sudden loss of vision (frequency rare). 

Other side effects have been reported:  
 
Common (seen in 1 to 10 in every 100 patients) 
- headache, back pain, muscle aches, pain in arms and legs, facial flushing, nasal congestion and 

indigestion. 
 
Uncommon (seen in 1 to 10 in every 1,000 patients) 
- dizziness, stomach ache, feeling sick, being sick (vomiting), reflux, blurred vision, eye pain, 

difficulty in breathing, presence of blood in urine, prolonged erection, pounding heartbeat 
sensation, a fast heart rate, high blood pressure, low blood pressure, nose bleeds, ringing in the 
ears, swelling of the hands, feet or ankles and feeling tired.  

 
Rare (seen in 1 to 10 in every 10,000 patients)  
- fainting, seizures and passing memory loss, swelling of the eyelids, red eyes, sudden decrease 

or loss of hearing, hives (itchy red welts on the surface of the skin), penile bleeding, presence of 
blood in semen and increased sweating. 

 
Heart attack and stroke have also been reported rarely in men taking CIALIS. Most of these men had 
known heart problems before taking this medicine. 
 
Partial, temporary, or permanent decrease or loss of vision in one or both eyes has been rarely 
reported. 
 
Some additional rare side effects have been reported in men taking CIALIS that were not seen in 
clinical trials.  These include: 
- migraine, swelling of the face, serious allergic reaction which causes swelling of the face or 

throat, serious skin rashes, some disorders affecting blood flow to the eyes, irregular heartbeats, 
angina and sudden cardiac death. 

 
The side effect dizziness has been reported more frequently in men over 75 years of age taking 
CIALIS. Diarrhoea has been reported more frequently in men over 65 years of age taking CIALIS. 
 
 
Reporting of side effects 
If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects 
not listed in this leaflet. You can also report side effects directly via the national reporting system 
listed in Appendix V. By reporting side effects you can help provide more information on the safety 
of this medicine. 
 
 

http://www.ema.europa.eu/docs/en_GB/document_library/Template_or_form/2013/03/WC500139752.doc


 77 

5. How to store CIALIS 
 
Keep this medicine out of the sight and reach of children. 
 
Do not use this medicine after the expiry date which is stated on the carton and blister after ‘EXP’. 
The expiry date refers to the last day of that month. 
 
Store in the original package in order to protect from moisture. Do not store above 30°C. 
 
Do not throw away any medicines via wastewater or household waste. Ask your pharmacist how to 
throw away medicines you no longer use. These measures will help protect the environment. 
 
 
6. Contents of the pack and other information 
 
What CIALIS contains 

- The active substance is tadalafil. Each tablet contains 10 mg of tadalafil. 
- The other ingredients are: 

Tablet core: lactose monohydrate (see end of section 2), croscarmellose sodium, 
hydroxypropylcellulose, microcrystalline cellulose, sodium laurilsulfate, magnesium stearate. 
Film-coat: lactose monohydrate, hypromellose, triacetin, titanium dioxide (E171), iron oxide 
yellow (E172), talc. 

What CIALIS looks like and contents of the pack 
CIALIS 10 mg is a light yellow film-coated tablet in the shape of an almond and has "C 10" marked 
on one side.  
 
CIALIS 10 mg is available in blister packs containing 4 tablets. 
 
Marketing Authorisation Holder and Manufacturer 
 
Marketing Authorisation Holder: Eli Lilly Nederland B.V., Papendorpseweg 83, 3528 BJ Utrecht, 
The Netherlands. 
 
Manufacturer: Lilly S.A., Avda. de la Industria 30, 28108 Alcobendas, Madrid, Spain. 
 
For any information about this medicine, please contact the local representative of the Marketing 
Authorisation Holder. 
 
Belgique/België/Belgien 
Eli Lilly Benelux S.A./N.V. 
Tél/Tel: + 32-(0)2 548 84 84 

Lietuva 
Eli Lilly Holdings Limited atstovybė 
Tel. +370 (5) 2649600 

България 
ТП "Ели Лили Недерланд" Б.В. - България 
тел. + 359 2 491 41 40 

Luxembourg/Luxemburg 
Eli Lilly Benelux S.A./N.V. 
Tél/Tel: + 32-(0)2 548 84 84 

Česká republika 
ELI LILLY ČR, s.r.o. 
Tel: + 420 234 664 111 

Magyarország 
Lilly Hungária Kft. 
Tel: + 36 1 328 5100 

Danmark 
Eli Lilly Danmark A/S  
Tlf: +45 45 26 60 00 

Malta 
Charles de Giorgio Ltd. 
Tel: + 356 25600 500 

Deutschland 
Lilly Deutschland GmbH  
Tel. + 49-(0) 6172 273 2222 

Nederland 
Eli Lilly Nederland B.V.  
Tel: + 31-(0) 30 60 25 800 

Eesti Norge 



 78 

Eli Lilly Holdings Limited Eesti filiaal  
Tel: +372 6 817 280 

Eli Lilly Norge A.S. 
Tlf: + 47 22 88 18 00 

Ελλάδα 
ΦΑΡΜΑΣΕΡΒ-ΛΙΛΛΥ Α.Ε.Β.Ε.  
Τηλ: +30 210 629 4600 

Österreich 
Eli Lilly Ges.m.b.H. 
Tel: + 43-(0) 1 711 780 

España 
Lilly S.A.  
Tel: + 34-91 663 50 00 

Polska 
Eli Lilly Polska Sp. z o.o. 
Tel: +48 22 440 33 00 

France 
Lilly France SAS  
Tél: +33-(0) 1 55 49 34 34 

Portugal 
Lilly Portugal Produtos Farmacêuticos, Lda 
Tel: + 351-21-4126600 

Hrvatska 
Eli Lilly Hrvatska d.o.o. 
Tel: +385 1 2350 999 

România 
Eli Lilly România S.R.L. 
Tel: + 40 21 4023000 

Ireland 
Eli Lilly and Company (Ireland) Limited 
Tel: + 353-(0) 1 661 4377 

Slovenija 
Eli Lilly farmacevtska družba, d.o.o. 
Tel: +386 (0)1 580 00 10 

Ísland 
Icepharma hf. 
Sími: + 354 540 8000 

Slovenská republika 
Eli Lilly Slovakia, s.r.o. 
Tel: + 421 220 663 111 

Italia 
Eli Lilly Italia S.p.A. 
Tel: + 39- 055 42571 

Suomi/Finland 
Oy Eli Lilly Finland Ab  
Puh/Tel: + 358-(0) 9 85 45 250 

Κύπρος 
Phadisco Ltd  
Τηλ: +357 22 715000 

Sverige 
Eli Lilly Sweden AB 
Tel: + 46-(0) 8 7378800 

Latvija 
Eli Lilly Holdings Limited  
pārstāvniecība Latvijā 
Tel: +371 67364000 

United Kingdom 
Eli Lilly and Company Limited 
Tel: + 44-(0) 1256 315000 

 
This leaflet was last revised in  
 
Detailed information on this medicine is available on the European Medicines Agency web site: 
http://www.ema.europa.eu 
 



 79 

Package leaflet: Information for the user 
 

CIALIS 20 mg film-coated tablets 
Tadalafil 

 
Read all of this leaflet carefully before you start taking this medicine because it contains 
important information for you. 
- Keep this leaflet. You may need to read it again. 
- If you have any further questions, ask your doctor or pharmacist. 
- This medicine has been prescribed for you only. Do not pass it on to others. It may harm them, 

even if their signs of illness are the same as yours. 
- If you get any side effects talk to your doctor or pharmacist. This includes any possible side 

effects not listed in this leaflet. See section 4.  
 
What is in this leaflet:  
1. What CIALIS is and what it is used for 
2. What you need to know before you take CIALIS 
3. How to take CIALIS 
4. Possible side effects 
5 How to store CIALIS 
6. Contents of the pack and other information 
 
 
1. What CIALIS is and what it is used for 
 
CIALIS is a treatment for adult men with erectile dysfunction. This is when a man cannot get, or keep 
a hard, erect penis suitable for sexual activity. CIALIS has been shown to significantly improve the 
ability of obtaining a hard erect penis suitable for sexual activity. 
 
CIALIS contains the active substance tadalafil which belongs to a group of medicines called 
phosphodiesterase type 5 inhibitors. Following sexual stimulation CIALIS works by helping the blood 
vessels in your penis to relax, allowing the flow of blood into your penis. The result of this is 
improved erectile function. CIALIS will not help you if you do not have erectile dysfunction.  
 
It is important to note that CIALIS does not work if there is no sexual stimulation. You and your 
partner will need to engage in foreplay, just as you would if you were not taking a medicine for 
erectile dysfunction. 
 
 
2. What you need to know before you take CIALIS 
 
Do not take CIALIS if you: 
 
- are allergic to tadalafil or any of the other ingredients of this medicine (listed in section 6). 
 
- are taking any form of organic nitrate or nitric oxide donors such as amyl nitrite. This is a group 

of medicines (“nitrates”) used in the treatment of angina pectoris (“chest pain”). CIALIS has 
been shown to increase the effects of these medicines. If you are taking any form of nitrate or 
are unsure tell your doctor. 

 
- have serious heart disease or recently had a heart attack within the last 90 days.  
 
- recently had a stroke within the last 6 months. 
 
- have low blood pressure or uncontrolled high blood pressure. 
 



 80 

- ever had loss of vision because of non-arteritic anterior ischemic optic neuropathy (NAION), a 
condition described as “stroke of the eye”.  

 
- are taking riociguat. This drug is used to treat pulmonary arterial hypertension (i.e., high blood 

pressure in the lungs) and chronic thromboembolic pulmonary hypertension (i.e., high blood 
pressure in the lungs secondary to blood clots).  PDE5 inhibitors, such as CIALIS, have been 
shown to increase the hypotensive effects of this medicine.  If you are taking riociguat or are 
unsure tell your doctor. 

 
Warnings and precautions 
Talk to your doctor before taking CIALIS. 
 
Be aware that sexual activity carries a possible risk to patients with heart disease because it puts an 
extra strain on your heart. If you have a heart problem you should tell your doctor.  
 
Before taking the tablets, tell your doctor if you have: 
- sickle cell anaemia (an abnormality of red blood cells). 
- multiple myeloma (cancer of the bone marrow). 
- leukaemia (cancer of the blood cells). 
- any deformation of your penis. 
- a serious liver problem. 
- a severe kidney problem. 
 
It is not known if CIALIS is effective in patients who have had: 
- pelvic surgery. 
- removal of all or part of the prostate gland in which nerves of the prostate are cut (radical non-

nerve-sparing prostatectomy). 
 
If you experience sudden decrease or loss of vision, stop taking CIALIS and contact your doctor 
immediately.  
 
Decreased or sudden hearing loss has been noted in some patients taking tadalafil. Although it is not 
known if the event is directly related to tadalafil, if you experience decreased or sudden hearing loss, 
stop taking CIALIS and contact your doctor immediately. 
 
CIALIS is not intended for use by women.   
 
Children and adolescents 
CIALIS is not intended for use by children and adolescents under the age of 18. 
 
Other medicines and CIALIS 
Tell your doctor if you are taking, have recently taken or might take any other medicines 
 
Do not take CIALIS if you are already taking nitrates. 
 
Some medicines may be affected by CIALIS or they may affect how well CIALIS will work. Tell your 
doctor or pharmacist if you are already taking: 
 
- an alpha blocker (used to treat high blood pressure or urinary symptoms associated with benign 

prostatic hyperplasia). 
- other medicines to treat high blood pressure. 
- riociguat. 
- a 5- alpha reductase inhibitor (used to treat benign prostatic hyperplasia). 



 81 

- medicines such as ketoconazole tablets (to treat fungal infections) and protease inhibitors for 
treatment of AIDS or HIV infection. 

- phenobarbital, phenytoin and carbamazepine (anticonvulsant medicines). 
- rifampicin, erythromycin , clarithromycin or itraconazole. 
- other treatments for erectile dysfunction. 
 
CIALIS with drink and alcohol 
Information on the effect of alcohol is in section 3. Grapefruit juice may affect how well CIALIS will 
work and should be taken with caution. Talk to your doctor for further information. 
 
Fertility 
When dogs were treated there was reduced sperm development in the testes.  A reduction in sperm 
was seen in some men. These effects are unlikely to lead to a lack of fertility. 
 
Driving and using machines 
Some men taking CIALIS in clinical studies have reported dizziness. Check carefully how you react 
to the tablets before driving or using machines. 
 
CIALIS contains lactose: 
If you have an intolerance to some sugars, contact your doctor before taking this medicine. 
 
 
3. How to take CIALIS 
 
Always take this medicine exactly as your doctor has told you. Check with your doctor or pharmacist 
if you are not sure.  
 
CIALIS tablets are for oral use in men only. Swallow the tablet whole with some water. The tablets 
can be taken with or without food.  
 
The recommended starting dose is one 10 mg tablet before sexual activity. However, you have been 
given the dose of one 20mg tablet as your doctor has decided that the recommended dose of 10mg is 
too weak. 
 
You may take a CIALIS tablet at least 30 minutes before sexual activity.  
CIALIS may still be effective up to 36 hours after taking the tablet.  
 
Do not take CIALIS more than once a day. CIALIS 10 mg and 20 mg is intended for use prior to 
anticipated sexual activity and is not recommended for continuous daily use.   
 
It is important to note that CIALIS does not work if there is no sexual stimulation. You and your 
partner will need to engage in foreplay, just as you would if you were not taking a medicine for 
erectile dysfunction. 
 
Drinking alcohol may affect your ability to get an erection and may temporarily lower your blood 
pressure. If you have taken or are planning to take CIALIS, avoid excessive drinking (blood alcohol 
level of 0.08 % or greater), since this may increase the risk of dizziness when standing up. 
 
If you take more CIALIS than you should  
Contact your doctor. You may experience side effects described in section 4. 
 
If you have any further questions on the use of this medicine, ask your doctor or pharmacist. 
 
 



 82 

4. Possible side effects 
 
Like all medicines, this medicine can cause side effects, although not everybody gets them. These 
effects are normally mild to moderate in nature. 
 
If you experience any of the following side effects stop using the medicine and seek medical help 
immediately: 
- allergic reactions including rashes (frequency uncommon). 

- chest pain - do not use nitrates but seek immediate medical assistance (frequency uncommon). 

- priapism, a prolonged and possibly painful erection after taking CIALIS (frequency rare). If you 
have such an erection, which lasts continuously for more than 4 hours you should contact a 
doctor immediately. 

- sudden loss of vision (frequency rare). 

 
Other side effects have been reported:   
 
Common (seen in 1 to 10 in every 100 patients) 
- headache, back pain, muscle aches, pain in arms and legs, facial flushing, nasal congestion and 

indigestion. 
 
Uncommon (seen in 1 to 10 in every 1,000 patients) 
- dizziness, stomach ache, feeling sick, being sick (vomiting), reflux, blurred vision, eye pain, 

difficulty in breathing, presence of blood in urine, prolonged erection, pounding heartbeat 
sensation, a fast heart rate, high blood pressure, low blood pressure, nose bleeds, ringing in the 
ears, swelling of the hands, feet or ankles and feeling tired. 

 
Rare (seen in 1 to 10 in every 10,000 patients)  
- fainting, seizures and passing memory loss, swelling of the eyelids, red eyes, sudden decrease 

or loss of hearing, hives (itchy red welts on the surface of the skin), penile bleeding, presence 
of blood in semen and increased sweating. 

 
Heart attack and stroke have also been reported rarely in men taking CIALIS. Most of these men had 
known heart problems before taking this medicine. 
 
Partial, temporary, or permanent decrease or loss of vision in one or both eyes has been rarely 
reported. 
 
Some additional rare side effects have been reported in men taking CIALIS that were not seen in 
clinical trials.  These include: 
-  migraine, swelling of the face, serious allergic reaction which causes swelling of the face or 

throat, serious skin rashes, some disorders affecting blood flow to the eyes, irregular heartbeats, 
angina and sudden cardiac death. 

 
The side effect dizziness has been reported more frequently in men over 75 years of age taking 
CIALIS. Diarrhoea has been reported more frequently in men over 65 years of age taking CIALIS. 
 
 
Reporting of side effects 
If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects 
not listed in this leaflet. You can also report side effects directly via the national reporting system 
listed in Appendix V. By reporting side effects you can help provide more information on the safety 
of this medicine. 
 
 

http://www.ema.europa.eu/docs/en_GB/document_library/Template_or_form/2013/03/WC500139752.doc


 83 

5. How to store CIALIS 
 
Keep this medicine out of the sight and reach of children. 
 
Do not use this medicine after the expiry date which is stated on the carton and blister after ‘EXP’. 
The expiry date refers to the last day of that month. 
 
Store in the original package in order to protect from moisture. Do not store above 30°C. 
 
Do not throw away any medicines via wastewater or household waste. Ask your pharmacist how to 
throw away medicines you no longer use. These measures will help protect the environment. 
 
 
6. Contents of the pack and other information 
 
What CIALIS contains 
- The active substance is tadalafil. Each tablet contains 20 mg of tadalafil. 
- The other ingredients are: 

Tablet core: lactose monohydrate (see end of section 2), croscarmellose sodium, 
hydroxypropylcellulose,  microcrystalline cellulose, sodium laurilsulfate, magnesium stearate. 
Film-coat: lactose monohydrate, hypromellose, triacetin, titanium dioxide (E171), iron oxide 
yellow (E172), talc. 

What CIALIS looks like and contents of the pack 
CIALIS 20 mg is a yellow film-coated tablet in the shape of an almond and has "C 20" marked on one 
side.  
 
CIALIS 20 mg is available in blister packs containing 2, 4, 8, 10 or 12 tablets. 
 
Not all pack sizes may be marketed. 
 
Marketing Authorisation Holder and Manufacturer 
 
Marketing Authorisation Holder: Eli Lilly Nederland B.V., Papendorpseweg 83, 3528 BJ Utrecht, 
The Netherlands. 
 
Manufacturer: Lilly S.A., Avda. de la Industria 30, 28108 Alcobendas, Madrid, Spain. 
 
For any information about this medicine, please contact the local representative of the Marketing 
Authorisation Holder. 
 
Belgique/België/Belgien 
Eli Lilly Benelux S.A./N.V. 
Tél/Tel: + 32-(0)2 548 84 84 

Lietuva 
Eli Lilly Holdings Limited atstovybė 
Tel. +370 (5) 2649600 

България 
ТП "Ели Лили Недерланд" Б.В. - България 
тел. + 359 2 491 41 40 

Luxembourg/Luxemburg 
Eli Lilly Benelux S.A./N.V. 
Tél/Tel: + 32-(0)2 548 84 84 

Česká republika 
ELI LILLY ČR, s.r.o. 
Tel: + 420 234 664 111 

Magyarország 
Lilly Hungária Kft. 
Tel: + 36 1 328 5100 

Danmark 
Eli Lilly Danmark A/S  
Tlf: +45 45 26 60 00 

Malta 
Charles de Giorgio Ltd. 
Tel: + 356 25600 500 

Deutschland 
Lilly Deutschland GmbH  

Nederland 
Eli Lilly Nederland B.V.  



 84 

Tel. + 49-(0) 6172 273 2222 Tel: + 31-(0) 30 60 25 800 
Eesti 
Eli Lilly Holdings Limited Eesti filiaal  
Tel: +372 6 817 280 

Norge 
Eli Lilly Norge A.S. 
Tlf: + 47 22 88 18 00 

Ελλάδα 
ΦΑΡΜΑΣΕΡΒ-ΛΙΛΛΥ Α.Ε.Β.Ε.  
Τηλ: +30 210 629 4600 

Österreich 
Eli Lilly Ges.m.b.H. 
Tel: + 43-(0) 1 711 780 

España 
Lilly S.A.  
Tel: + 34-91 663 50 00 

Polska 
Eli Lilly Polska Sp. z o.o. 
Tel: +48 22 440 33 00 

France 
Lilly France SAS  
Tél: +33-(0) 1 55 49 34 34 

Portugal 
Lilly Portugal Produtos Farmacêuticos, Lda 
Tel: + 351-21-4126600 

Hrvatska 
Eli Lilly Hrvatska d.o.o. 
Tel: +385 1 2350 999 

România 
Eli Lilly România S.R.L. 
Tel: + 40 21 4023000 

Ireland 
Eli Lilly and Company (Ireland) Limited 
Tel: + 353-(0) 1 661 4377 

Slovenija 
Eli Lilly farmacevtska družba, d.o.o. 
Tel: +386 (0)1 580 00 10 

Ísland 
Icepharma hf. 
Sími: + 354 540 8000 

Slovenská republika 
Eli Lilly Slovakia, s.r.o. 
Tel: + 421 220 663 111 

Italia 
Eli Lilly Italia S.p.A. 
Tel: + 39- 055 42571 

Suomi/Finland 
Oy Eli Lilly Finland Ab  
Puh/Tel: + 358-(0) 9 85 45 250 

Κύπρος 
Phadisco Ltd  
Τηλ: +357 22 715000 

Sverige 
Eli Lilly Sweden AB 
Tel: + 46-(0) 8 7378800 

Latvija 
Eli Lilly Holdings Limited  
pārstāvniecība Latvijā 
Tel: +371 67364000 

United Kingdom 
Eli Lilly and Company Limited 
Tel: + 44-(0) 1256 315000 

 
This leaflet was last revised in  
 
Detailed information on this medicine is available on the European Medicines Agency web site: 
http://www.ema.europa.eu 
 

 


	SUMMARY OF PRODUCT CHARACTERISTICS
	A. MANUFACTURER(S) RESPONSIBLE FOR BATCH RELEASE
	B. CONDITIONS OR RESTRICTIONS REGARDING SUPPLY AND USE
	C. OTHER CONDITIONS AND REQUIREMENTS OF THE MARKETING AUTHORISATION
	D. CONDITIONS OR RESTRICTIONS WITH REGARD TO THE SAFE AND EFFECTIVE USE OF THE MEDICINAL PRODUCT  
	A. LABELLING
	B. PACKAGE LEAFLET