Tom McNicholas has written widely on many aspects of urinary disease. He is particularly in demand for teaching on benign prostatic disease and urinary symptoms. He has major interests in the management of prostate cancer, the treatment of urinary stone disease and in making common urological investigations (especially prostatic biopsy) both painless and safer.
He has written over 150 major scientific papers which can be reviewed in the bibliography. Most recently he has been lead author of the chapter on Benign Prostatic Disease in the latest addition of Campbell’s Urology. This 4 volume textbook is the “bible” for urology and is used by urological experts worldwide. He is one of only a small handful of British urologists to have been recognised in this way.




You say try Cialis tablets but my GP will not prescribe them for me!

“You say try Cialis but my GP won’t prescribe them for me!”
Viagra like drugs are valuable for other difficult conditions as well and should be more available.  Even the Government agrees! However, GPs are often not aware of the current prescribing rules so will not prescribe them on the NHS.
I am often asked about whether Cialis (tadalafil) can be prescribed on the NHS for men with other medical problems such as male lower urinary tract symptoms or “BPH”. There is no doubt that this class of drugs (Phosphodiesterase inhibitors such as Viagra (sildenafil), Levitra (vardenafil) and Cialis (tadalafil) can be an important option in some difficult conditions for some men (and for some women – for instance those with a serious heart and lung condition which affects both sexes called pulmonary artery hypertension). In practice Cialis will be the most relevant drug for most people due to its longer and more convenient duration of action allowing once a day medication.
My research group were the first to show that these PDEI agents improved men’s urinary symptoms way back in 2002.  It took a few years for others to confirm the benefit in large, high quality medical trials.  As a result Cialis has been legally licenced in the UK for male urinary symptoms since 2012. But the prescribing regulations so you can get an NHS prescription have only just been made clear and many, probably most GPs in my experience, don’t know that and are reluctant to prescribe.  Especially since they are all abused if they prescribe anything outside the carefully controlled local “Formulary”. Therefore they understandably tend to “play safe.” Unfortunately these Formularies are always somewhat out of date, which cynics might say, delays the introduction of new drugs or, as in this case, relatively old drugs for a new use. 
The following information gives chapter and verse on the current prescribing position for ‘Cialis’ (tadalafil) and specifically on the Schedule II guidelines and the recent update to these guidelines. I hope specialists, GPs and patients might find it helpful in negotiating a way through the complexities of prescribing these PDEI agents and Cialis in particular for conditions other than erectile dysfunction.  
Schedule 2 guidelines can be found at:
http://www.legislation.gov.uk/uksi/2004/629/pdfs/uksi_20040629_en.pdf
and the recent new Schedule 2 additions can be viewed via the following link:
http://www.legislation.gov.uk/uksi/2013/2194/contents/made
Go to the PDF on the left hand side of this ‘link’ and the appropriate wording is found on page 2 - “Treatment of a condition, other than erectile dysfunction, in respect of which the drug ordered is considered an appropriate treatment”.
In addition a NICE Evidence Summary has been published: ‘ESNM18: Lower urinary tract symptoms secondary to benign prostatic hyperplasia: tadalafil’. Evidence summaries are designed to provide summaries of key evidence for selected new medicines, or for existing medicines with new indications or formulations, that are considered to be of significance to the NHS. They provide a review of relevant scientific evidence as well as information on costs and reimbursement. The following is an excerpt from this summary:
The prescribing of tadalafil for erectile dysfunction in England is subject to statutory prescribing restrictions through Schedule 2 of the NHS (general medical services contracts) (prescription of drugs etc.) regulations 2004 and the NHS (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013. Under these restrictions tadalafil may currently be prescribed in primary care on the NHS for benign prostatic hyperplasia’ (NICE Evidence Summary).
A recent publication (January 2014) by the Department of Health also includes information relating to the reimbursement of tadalafil for conditions other than ED and is aligned with the NICE Evidence summary. It recognises that tadalafil is licensed as Adcirca for the treatment of Pulmonary Arterial Hypertension (PAH) and Cialis for the treatment of Benign Prostatic Hyperplasia (BPH) and states that:
‘The prescribing restrictions only apply when these treatments are prescribed for ED’ (Department of Health).
Under the revised schedule 2 conditions tadalafil may now be reimbursed on the NHS for benign prostatic hyperplasia.
Other references of interest include:

  • Evidence Summary: ESNM18: Lower urinary tract symptoms secondary to benign prostatic hyperplasia: tadalafil. 23 May 2013. Available at:http://publications.nice.org.uk/esnm18- lower-urinary-tract-symptoms-secondary-to-benign-prostatic-hyperplasia-tadalafil- esnm18/overview
  • Department of Health. Proposed Changes to NHS Availability of Erectile Dysfunction Treatments. Changing Prescribing Restrictions of Erectile Dysfunction Treatments. January 2014. Available at: https://www.gov.uk/government/consultations/nhs-availability-of- erectile-dysfunction-drugs-proposed-changes


I hope that this information will be of help to you if you should be trying Cialis, at least for a trial period. Three months is often long enough to see if it helps.
Don’t give up if your GP just says “Can’t be done on the NHS!”  Share this with them!!

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