In which case why can you only buy 50mg over the counter not 100mg, which seems to be about the optimum for effect, when you are probably suggesting that 100mg is no more risky ?
Because 50 mg is the optimum starting dose not 100mg. This can then be adjusted to 25mg or increased to 100mgg. Effective dosage per individual is another matter. The decision to reclassify any medicine from a purely POM to Pharmacy also, is based on its safety record amongst other factors. To maximise safety the optimum dosage (effectiveness v side effects) is normally approved. There is of course nothing to stop anyone exceeding that dose despite the recommendation that accompanies it.
Side effects are indeed to some degree dose related (per individual) but you specified 'heart attacks'. Not only are cases where sildenafil may have some involvement rare, but in most instances when it has occurred, the dosage has been in normal range (ie 25mg to 100mg) Also in most studies the slight drop in blood pressure associated with sildenafil in healthy individuals with no other medication, did not appear to be especially dose related.
It is also recommended you do not take sildenafil more than once a day and that is probably sensible, but given that a prescriber may in some severe cases suggest exceeding 100mg daily, then any particular individual may have taken a dose of between say 25mg and 200mg.
Given that the example in the opening post would result in a combined dose of 125 mg (but in divided doses) it is well within tolerance range, albeit against recommended advice. It is worth noting however that he is clearly not a spring chicken
and blood levels remain higher for longer with age.
During trials daily doses of up to 800mg were tested on healthy volunteers (I hope they were well paid!) with the only real issue being increased severity of common side effects. This gives you some idea of the safety margin.
My advice is always to follow guidelines, but do not get too concerned about minor discretions. It is a pretty safe drug with good safety margins especially in comparison to say Paracetamol which can be deadly.
Finally don't push your luck too much though
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