For the vast majority of men of men dealing with erectile dysfunction, drugs like Viagra and Cialis will help them successfully get an erection – over 80% of men with ED responded to these drugs during clinical trials. For others, ED meds may fail to help recover their virulence after certain surgeries and medical treatments, like a radical prostatectomy and cancer treatments that affect hormones.
That leaves a gap of men who don't respond to the most popular and effective ED meds we have available. For these men, the future of sex can feel bleak. But there are options.
Viagra Doesn't Work: Now What?
The most popular medications for ED are Viagra (sildenafil), Cialis (tadalafil), and Levitra (vardenafil), and they all work by the same mechanism of action. They're phosphodiesterase Type 5 (PDE5) inhibitors, and while there are some nuances that make them all a little different, they all do the same thing: help blood flow in the penis by removing one of the brakes on that system.
Despite a success rate of over 80% in clinical studies twenty years ago when PDE5 inhibitors were approved, newer real-world data suggest as many as 30% of men who try these medications won't get the erection they want or need. Part of this, according to the data, is age. The older you are, the less effective medications like sildenafil may be, with only about 60% of men over 75 years responding to sildenafil.
For men who've tried these PDE5 inhibitors with no success, the first step should be to talk to your doctor. Depending at what dose you began treatment, a higher dose is the likely first move.
Higher ED Med Doses
Viagra (sildenafil) is available in doses of 25, 50 and 100 mg and taken in the hours before sex, called "on demand" treatment. Most men begin treatment at 25 or 50 mg, but if these lower doses aren't working, their doctor may move them up to 100 mg.
Cialis (tadalafil) is available in 2.5, 5, 10, and 25 mg tablets and is also taken on-demand, though 2.5 and 5 mg tablets are also used as a once-daily treatment, called Cialis Daily. Most men will begin treatment with lower doses and move higher as necessary.
Levitra (vardenafil) is available in 2.5, 5, 10, and 25 mg tablets for on-demand treatment.
But if you're reading this, chances are you've already tried higher doses, to no avail, and you're wondering what's next.
ED Meds Besides Viagra and PED5 Inhibitors
A common next step, especially for men who may be dealing with ED due to a surgery like radical prostetectomy, is an injectable ED treatment. Yes, these are injected straight into the penis. But take heart! This is a tiny needle and you'll have plenty of guidance from a trained physician.
Injectables can work really well by delivering medication directly to where it's needed for blood flow. Two of these injectable medications are:
Tri-mix is a mix of three drugs: papaverine, phentolamine, and prostaglandin E-1 (PGE1). This cocktail is injected into the base of the penis and works within 20 minutes.
Cavaject (alprostidil) is another injectable that contains the PGE1 alprostidil. PGE1s cause the blood vessels in the penis to relax and dilate, allowing for healthy blood flow.
Both work quite well, but the hurdles to guys adopting these potent treatments is high: a needle in your penis isn't exactly my idea of fun. Guys looking for other options often ask us about a combination of ED meds, sometimes even for recreational use.
Can I Combine ED Meds?
We sometimes get questions about combining ED medications for a more powerful erection. To begin: you should never combine ED meds on your own, for ED or recreationally, and none of these medications are approved by the FDA for use with one another.
The truth is that recreational use of Viagra "for better sex" has been shown NOT to work in research studies. In one study that looked at healthy young men who had used no medications in the prior 6 months and who were in a stable relationship for at least 3 months, researchers found that half of the men, who began taking sildenafil (Viagra), had no improvement in reported erection quality compared to the other half of guys who took a placebo.
If you're hoping to put ED meds to use just for fun, think again. The use of ED meds without a doctor's blessing can lead to unexpected health consequences, like a sudden drop in blood pressure, blurred vision, or worse if you're taking other medications or have unaddressed health conditions.
New research has pointed to some evidence that a combination of PDE5 inhibitors may get certain men with health conditions over the hump. A 2020 publication in Journal of Men's Health looked at men who had had a radical prostatectomy (RP) and were still dealing with erectile dysfunction despite treatment with tadalafil. The researchers found that combining daily tadalafil 5 mg with sildenafil 50 mg or udenafil 100 mg tablets on-demand helped about 40% of these particularly challenging patients achieve success. For these men, who often resort to all kinds of treatments for ED after surgery, a combination of the right PDE5 inhibitors could be a pharmacologic option that avoids using needles.
Another systematic review of oral combination therapies after PDE5 failure asserts no improvements when combining daily low-dose tadalafil (chronic treatment) with on-demand sildenafil in young men. The researchers indicate that the study was too small to be conclusive, but that it should be tested in older men.
Ultimately combining ED meds has been only somewhat tested by researchers, and we'd caution against doing anything like this without strict medical advice.
Your ED May Have Underlying Causes That Need Addressed
If you've tried ED medications with no success, it's also important to consider what's going on with your overall health. Diabetes, obesity, high blood pressure and more chronic conditions are known to cause and contribute to ED, mainly because of their impact on blood flow. Hormonal issues like low testosterone (Low T) can also affect your sexual desire. This is part of the reason it's so important to talk to your doctor about your situation and underlying health before trying ED medications.
Learn About Treating Erectile Dysfunction With The Right Meds
If you're struggling with erectile dysfunction, doctors at Rex MD can help you find the right path forward. With a free virtual visit and order from Rex MD, our physicians can assess whether one of these powerful medications is a good fit for you. If approved, your medication could be on your doorstep within days.