Within two weeks of its introduction, sildenafil citrate, given the name Viagra by Pfizer, hit 30,000 prescriptions a day threatening to replace world leader Prozac, which held steady at 50,000 a day. Pfizer states Viagra only works if the right stimulus occurs and therefore is safe to take daily. Pfizer might, of course, benefit from this “safety”–selling 30 tablets per patient or $300 of Viagra a month rather than two tablets a week or $80 a month (which is all that can be justified as promoting health.)

Headlines in March: Impotence Pill Worries Insurers. HMOs are struggling to figure out how much they will pay for their customers to have sex. Kaiser-Permanente in Oakland, the nation’s biggest HMO, has tentatively decided to reimburse only half the cost, expected to be $10 per pill.

It is estimated that up to 30 million men have erectile dysfunction. They certainly have come out of the woodwork in the past couple of months. When told their HMO won’t cover it, they seem willing to shell out $10 a pill to get 15 or 30, depending on their budget. Some estimates state that half the men over 40 have a potency problem.

When the news hit that men lived several years longer if they had sex at least once a week, some patients asked if they’d live twice as long if they had it twice a week. But they also wanted performance help.

One patient said he normally had sex with his wife three times a day. He had slowed down to twice a day. He’d like to start coming home for lunch again. He thought 30 pills to take on his way home would solve the problem. . . I wonder if he’ll be back for an evening dose.

Requests for 60 pills a month can usually be managed after the patient finds out it isn’t covered and he’ll have to write a $600 check. I tell them there is no medical reason for more than 3 pills a week or 13 a month–but I’ll write for 15 in case they get nervous and drop one or two.

One lady brought her husband in with a request for a prescription. She watched intently as I did a complete genital and prostatic exam. She even took the prescription from me. I wonder if she had to slip it into his soup?

I explained the side effects of the pill to a patient, including headache, indigestion and a temporary blue tinge in one’s vision, to which he replied, “Well, I’d rather have a red velvet tinge to my vision during these times, but blue will do.”

A woman patient told me that she’s been married to her husband for over 50 years. She felt that the best part of her marriage was the last five years since his “manhood” dried up. She did not want me to prescribe Viagra to stir up any life “down there.”

Of all the complaints about erectile incompetence that have come through my office in recent years, with a negative GU evaluation, only two patients have found the Caverject phallic injection system acceptable. One was married to an RN and one was a DVM assistant who was handy with a needle. Caverject and Muse, the suppository form, had consistent sales but now only 1.5% and 3.8% of the market. Viagra captured 95% of the impotence market during the third week of sales which appeared to be new business. Previously only 5% of impotent men saw their performance as a problem. Hence, this $6 billion in anticipated revenue is new health care cost.

A prostate promotional brochure came across my desk about the same time the Pfizer promotion came. Since sildenafil works in about 2/3 of patients, maybe there still is a place for all the herbs mentioned. Serenoa serrulata decreases the size of the prostate and is a mild aphrodisiac. Panax extract increases testosterone levels and decreases the size of the prostate, providing for a vibrant sex life. The multi-herb product called Prostata, not available in this country, is available through a Canadian source which obtains it from Life Force Laboratories in Italy.

On a financial note, it will be interesting to observe when Kaiser and the For-Profit-HMOs start covering Viagra. Will there really be a 50% co-pay? This is the perfect demonstration that health care costs cannot be controlled without significant patient co-payment responsibility. This change will put every patient in charge of tests, procedures, or treatments, which will again personalize health care.