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Which ED medication is best for you?
Several medications are approved by the FDA to treat erectile dysfunction. Which is the best fit for you? Here, the factors to consider when it comes to your health, sex life and bank account.
If you’ve started looking into erectile dysfunction (ED) medications, you may wonder what the differences are among them and whether you may be better off with one over another. Is one better for spontaneous sex? Is another best for daily use? How much do they cost? And what are the side effects?
It’s a lot to consider, but once you know the facts, you’ll have an easier time of sifting through the options with your health care provider.
For starters, there are currently 4 medications approved by the Food and Drug Administration (FDA) to treat ED, and they are all in the same class known as oral phosphodiesterase type 5 (PDE5) inhibitors. That means they all work basically the same way, by relaxing the muscles in the blood vessels that lead to the penis, which increases blood flow.
All these PDE5 inhibitors for ED drive your penile arterial system to work harder, says Marc Cohen, MD. He’s a urologist in Sarasota, Florida, and a medical adviser at Bastion Health, which specializes in male fertility and prostate health. But because each person’s body is different — and because the root cause of each man’s ED varies — the results of the medication may differ as well.
In addition, the best ED medication for your needs depends on a few other things, including your existing health, the medications you’re already taking and your goals in the bedroom.
You may want a pill that kicks in right away for an impromptu romantic moment. Or perhaps you’d rather have a medication that stays in your system longer and is meant to last for a weekend getaway. The side effects of each pill, which vary slightly, and their cost may also come into play for you.
Here’s what you and your doctor may consider when deciding whether an ED medication is a good next step, and — if so — which one might be a good fit for you.
Is ED medication safe for you?
There are 2 main things your doctor will consider before giving you the green light to try an ED medication:
Your existing health conditions
If you have any of the conditions below, your doctor will need to assess whether an ED medication is the right treatment for you. If your doctor does decide that an ED medication may be helpful, they will likely monitor you closely to make sure that it doesn’t interfere with your current treatment medications or worsen your condition. The good news: Getting proper treatment for many of these underlying health issues may also improve your ED. (Learn more about the link between ED and your health.)
- Very low blood pressure or high blood pressure that is not well-controlled
- Liver disease or kidney problems that require dialysis
- Retina problems such as retinitis pigmentosa, a genetic condition that causes retina degeneration
- Cardiovascular diseases
- Sickle cell anemia
- Certain types of cancer, such as leukemia and multiple myeloma
- A penis that is abnormally shaped
Be sure to discuss your full health background with your doctor.
The medications you’re taking now
ED medications can interact or interfere with other important prescriptions you’re taking, including nitrates for angina. In the body, ED medications can do the same thing as nitrates: They both dilate blood vessels. Taken together, these medications can cause your blood pressure to drop suddenly and seriously, possibly causing heart attack.
ED meds are usually not recommended for these patients. (Talk to your doctor if you are on nitrates. There are other ways to treat ED, including injections, pumps and implants.)
ED medications should not be taken if you use recreational drugs such as amyl or butyl nitrite, also known as poppers, which can provoke a similar blood pressure drop.
Certain blood-pressure lowering drugs — such as alpha-adrenergic medications— in combination with an ED medication can lower blood pressure, says Dr. Cohen. This can result in light-headedness and sometimes fainting. Patients should be cautioned about this risk when using these medications together.
If you’re worried about being on a statin and an ED medication, studies show that they usually can be used together, says Dr. Cohen. “Most statins can have a positive effect on blood vessels, including those in the penis. This could actually have a mild, beneficial impact on ED or increase the effectiveness of an ED medication.”
Which ED medication might work best for you?
Once you have the doctor’s thumbs-up to try an ED medication, you can discuss which of the 4 FDA-approved choices might be right for you. The American College of Physicians recommends looking at how quickly the medication takes effect, how long it lasts, the side effects and the price.
Note that the length of time the medication is effective does not refer to the duration of the erection itself. Rather, it’s the period of time that the medication will allow you to achieve a satisfactory erection. (If an erection lasts longer than 4 hours, it can damage tissues in the penis. If any ED medication produces an erection lasting more than 4 hours, seek medical help right away.)
Before we get into the different medications, know that all these ED medications have several things in common:
- They are only available by prescription.
- They promote blood flow to the penis, which in turn produces an erection.
- They require physical stimulation of the penis.
- It’s recommended that when starting a new medication for the first time that you take the lowest dose possible. Patients can be started at a lower dose to make sure the side effects can be tolerated, says Dr. Cohen.
- For patients with recognized, significant underlying conditions such as diabetes that can affect their ability to get and maintain an erection, “I will consider starting them a higher dose of the medication,” he says.
- They all have the potential to produce similar side effects, with a few noted exceptions. Daniel Breisch, PharmD, a pharmacist who owns the Mountain View Pharmacy in Bountiful, Utah, near Salt Lake City, says the most common side effect for all ED medications is headaches.
- Other common side effects include flushing, congestion, back pain and indigestion, vision changes, dizziness and allergic skin reactions, such as a rash. If you experience unpleasant side effects on one medication, switching to a different one might help.
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Viagra, the famous “little blue pill,” was the first PDE5 inhibitor medication to be approved by the FDA for the treatment of ED. Viagra, whose generic name is sildenafil, was originally developed to treat chest pain (angina). During the trials, another interesting result was discovered: stiffer erections.
How it’s used: You take sildenafil 30 to 60 minutes before you plan to engage in sexual activity.
It can be effective for: Up to 5 hours. “If you don’t have sex within 3 to 4 of taking it, you’re not likely to get any benefit from it,” says Dr. Cohen.
Side effects: Breisch says that in addition to headaches, blurred or spotty vision is a common side effect of Viagra (and Cialis®, below). Some people also report a blue tinge to their vision.
Good to know: Dr. Cohen also notes that sildenafil can be impacted by food, especially a meal that’s fatty, which can make it more difficult for your body to absorb the medication. So if you eat a burger and fries, take the medication and then head to the bedroom, “you may get little or no results,” he says.
Cost: Sildenafil is generic, so you can get it for just $1 or $2 per dose. That’s a huge price drop from the brand-name cost. “Viagra used to be $80 a pill,” says Breisch. Brand-name versions are still available for those who prefer them.
When tadalafil first came out, it was called “the weekend pill,” says Breisch. That’s because it’s available in the body for a long time, so it could be taken on a Friday night and last through the weekend.
“It has less of a peak than Viagra or Stendra®, meaning it doesn’t hit as hard and as fast, so patients can tolerate it a little better,” says Breisch. It’s a very flexible pill that can be used for a range of sexual situations: as needed for a spontaneous moment or every day for regular and frequent sex.
How it’s used: You take tadalafil 30 to 60 minutes before sexual activity, on an as-needed basis (20 to 40 milligrams) or as a daily dose (2.5 to 5 milligrams).
It can be effective for: Up to 36 hours. If you have frequent sex, daily use can sometimes keep the fire burning without a second thought or extra planning. If sex isn’t a daily occurrence, you can still reap the benefits of a spontaneous moment with a low-dose, long-lasting dose of tadalafil.
“If you’re thinking, ‘Gee, tonight might be the night,’ then taking a Cialis in the morning and having sex within 24 hours might allow you to get a relatively spontaneous erection without much difficulty,” says Dr. Cohen. He adds that you may need to experiment with different doses over time to find the sweet spot.
Side effects: Some men report experiencing back or leg pain. That usually resolves within 2 days, according to Lilly, the makers of Cialis. And as with sildenafil, headaches and blurred or spotty vision are common side effects, says Breisch.
Good to know: Low dose tadalafil is also used to treat symptoms of an enlarged prostate gland (also called benign prostatic hyperplasia, or BPH) and pulmonary arterial hypertension, a kind of high blood pressure that occurs in the artery feeding blood from the heart to the lungs.
So tadalafil can be an efficient way to treat ED as well as those additional problems. And burger lovers need not worry: The absorption of tadalafil is not affected by food, says Dr. Cohen.
Cost: Tadalafil is available in generic form and costs a couple of dollars per dose. And the brand names are still available for those who prefer them.
Vardenafil (Levitra® and Staxyn®)
Vardenafil, the generic form of Levitra, is a pill that you swallow. Staxyn comes as a dissolvable tablet that you put on your tongue — a potential benefit for those who have difficulty swallowing pills.
This medication is structurally very similar to sildenafil, but it is biochemically more powerful. That means a smaller amount is needed to produce the same effect. (It doesn’t mean that it produces firmer erections.)
How it’s used: You take vardenafil about 60 minutes before you want it to start working.
It can be effective for: Up to 4 hours. As with sildenafil, you want to take this medication shortly before you think you’ll want to have sex.
Side effects: Similar to other ED medications.
Good to know: The dissolving Staxyn® tablet contains aspartame and sorbitol, so it should be avoided by people with phenylketonuria or those with a fructose intolerance.
Cost: Vardenafil is available in generic form and costs a couple of dollars per dose. The brand names are still available for those who prefer them.
Avanafil is a newer ED medication. “It has a reported quicker onset of action than some of the other medications,” says Dr. Cohen, who shares this information with his patients so they can determine whether it’s something they may want to consider or avoid.
How it’s used: You take avanafil just 15 minutes before sex.
It can be effective for: Up to 6 hours.
Side effects: A low dose of avanafil (50 milligrams) has been associated with the lowest rate of side effects of any ED medication, according to a study in the journal European Urology.
Good to know: Because it works the fastest of all the ED medications, avanafil is a good choice for spontaneous sex.
Cost: Avanafil costs more than other ED medications. It can run anywhere from $330 to $450 or more for 6 pills, or $55 to $75 per pill, according to Breisch. Because the cost per pill is the same regardless of the dosage, Breisch says that doctors might prescribe a high-dose pill that patients can cut in half or into quarters as a cost-saving measure.
How do you choose?
Each of these meds treats ED effectively. It comes down to your personal preference, what your doctor thinks and whether you have side effects. Be sure to go over the full list of medication interactions with your doctor and let them know of any side effects.
Although medications can be powerful tools for treating ED, Dr. Cohen cautions that they aren’t magic bullets.
“Too many people think their sex life is going to be perfect as a consequence of using these medications,” says Dr. Cohen, adding that many men will be disappointed if that’s the expectation. As with many conditions, medication can be a key way to experience improvement. “These drugs do not improve your sex drive. Quite the contrary, they require you to be sexually stimulated and ‘in the mood’ to work most effectively,” he says.
It’s just as important to look at your overall health and address any issues with your partner that could be contributing to the condition as well. “Patience, understanding and a willingness to collaborate with your partner and to work with the unique aspects of these medications are keys for success,” says Dr. Cohen. (Read more about how to support a partner with ED here.)
If these ED meds don’t fully address your issue, there are other treatments available as well. See the Erectile dysfunction: The Optum Guide to explore treatments and learn more about the condition.
Overview of ED medications:
- University of Iowa Hospitals and Clinics (2020). "Oral Medications for Erectile Dysfunction"
- Harvard Medical School (2020). "Which Drug for Erectile Dysfunction?"
- University of San Francisco Health (n.d.). "Oral Medications for Erectile Dysfunction"
How PDE inhibitors work: U.S. National Library of Medicine National Center for Biotechnology Information StatPearls (2021). "Phosphodiesterase Inhibitors"
ED medications and heart disease: Harvard Medical School Harvard Health Publishing (2019). "Are Erectile Dysfunction Pills Safe for Men with Heart Disease?"
ED medications and vision: American Academy of Ophthalmology (2021). "Erectile Dysfunction Medication and Your Eyes and Vision"
Lilly study on Cialis: Journal of Sexual Medicine (2014). "A Return to Normal Erectile Function With Tadalafil Once Daily After an Incomplete Response to As-needed PDE5 Inhibitor Therapy"
Avanafil: Patient Preference and Adherence (2015). “A Comparison of the Available Phosphodiesterase-5 Inhibitors in the Treatment of Erectile Dysfunction: A Focus on Avanafil”
Differences in pills:
- Boston University School of Medicine Sexual Medicine (n.d.). "Choosing the Right Pill to Treat ED"
- European Urology (2015). “Phosphodiesterase 5 Inhibitors for the Treatment of Erectile Dysfunction: a Trade-off Network Meta-analysis”