The Low Down on Viagra, Cialis and Levitra

Many men have problems with their erection. Many also take medicines to solve this. So much so that Viagra has more or less become a household name.

Viagra is one of a group of medicines known as PDE5-inhibitors (so named because they inhibit an enzyme called PDE5). The other 2 are called Cialis and Levitra. They are all used to treat Erectile Dysfunction.

Confused on which one of these PDE-5 inhibitors to take? You’re not the only one. Sildenafil, otherwise known as Viagra is the most well known and hence popular of the 3 since it is the first drug to be approved by the Food and Drug Administration (FDA). However, popularity alone should not be a determining factor.

The success of Viagra made other competing drug companies come up with effective alternatives and hence Tadalafil (Cialis) and Vardenafil (Levitra) came into the market to compete for a share of the (highly lucrative) pie. Far from “me too” drugs, these competitors are also highly effective and very safe alternatives to Viagra, although they are not as popular yet. For a lot of people, deciding which the best alternative is the real issue here.

They are all PDE-5 inhibitors. For starters, these drugs all cause the dilatation of blood vessels in the corpus cavernosum of the penis in response to sexual stimulation, resulting in increased blood flow and an erection. However, this is where the similarities end. They are quite different drugs in practice. Let’s review the differences so patients can make an informed choice:


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Viagra was the first and hence probably the most researched drug. It works in about 70% of all men with all types of erectile dysfunction, although approximately 25% of them do not feel that the responses are optimal. When initially doing the studies on Viagra, the endpoint of efficacy was improvement in sexual function; In contrast, studies for the other two drugs were based on patients who had success with Viagra.

Its major disadvantage is decreased absorption due to food intake. You should take the pill on an empty stomach as absorption takes approximately 30 minutes and about one hour for maximum effect. Its half life is about 4 hours, meaning that Viagra loses 50% of its maximal concentration every four hours. Sexual stimulation is necessary to achieve erection.

One interesting preference among patients for Viagra is that it is easier to split the pill compared to Levitra or Cialis. However, it may compromise the effect, since of the three drugs, the maximal concentration for Viagra appears to be the therapeutic concentration. Hence, most people need 100mg per dose to achieve the necessary therapeutic effect.

Side effects include mild headaches, facial flushing, stomach upset and unusual eye disturbances including giving a bluish tint to vision and/or making whites look whiter. These are all harmless side effects and are not permanent. However, they seem to be slightly more common with Viagra than either Cialis or Levitra.

Viagra now comes in a new kind of tablet that melts in your mouth. It is called the Viagra Melt Tabs or Orodispersible Tablets (ODT). Click here to learn more.



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Levitra was the second FDA approved drug for erectile dysfunction. In lab studies, it is six to 10 more times more potent than Viagra. However, it is highly bound by proteins in the blood and only 15% of the drug is active. Studies on Levitra included only patients had success with Viagra; In addition, the efficacy is based on sexual satisfaction or successful penetration rather than improvement, which were the endpoints for Viagra.

Levitra is considered more potent than Viagra. Patients with complications, e.g. diabetes or post-prostatectomy, will likely fare better with Levitra than Viagra.
In addition, absorption is less affected by food, or a high fat diet intake. Most patients can eat and take the drug without affecting its absorption and maximal concentration.

The half-life is five hours (somewhat similar to Viagra); however, as it is more potent, multiple half-lives may occur before the drug loses efficacy. In Europe, Levitra is considered a 24-hour drug. Most physicians consider it to be a drug that has efficacy longer than Viagra.

It is also faster acting, reaching its peak concentration at 40 minutes. In studies, 25% of patients had optimal responses within 16 minutes of intake.


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If duration is the goal, Cialis appears to be the champion. Indeed, it is known as the “weekend” pill, since its effects can last a whole weekend. Cialis has been approved for duration of 36 hours, yet, there are studies showing high efficacy out to 100 hours especially in older patients. Indeed, due to this advantage, patients are freed from the need to time intercourse with taking of the pill.

Other advantages include its intake not being affected by any food whatsoever and in fact can be taken with pure fat.

For patients with cardiac problems, Cialis seems to be the safest drug to take as it is the least likely to prolong the QTc interval of the heart.

A previous concern of Cialis relates to its possible effect on human fertility due to its effects on the PDE-11 enzyme system but these concerns have been addressed with studies which show no significant effects on semen quality. However, these studies are only 6 months in duration and longer studies need to be done.

Other disadvantages are muscle aches and pains especially in the low back and gluteal area are more common with Cialis (7%) versus Levitra or Viagra (less than 1%). It seems that younger men, particularly those who are more muscular are affected. Hence, a case can be made that in these younger men to use Viagra or Levitra as a first line of treatment. Notwithstanding, physical activity makes the pain disappear and should be advised if such pain occurs.

Cialis comes in 2 strengths. 20mg for use as and when necessary and 5mg for use everyday. The 5mg Cialis low dose once-per-day pill has several advantages:

1. There is no need to plan and time when you take the pill and when you will have intercourse.

2. When taken daily, the effect of Cialis 5mg is MORE than 5mg. In other words, just because the dose is only 5mg, you do not get only a quarter of the effect of the 20mg.

3. If a patient is taking 2 or more 20mg pills per week, it is cheaper to take the 5mg pill daily.

4. The Cialis 5mg once-a-day pill has been found to be very effective in treating symptoms due to prostate enlargement.

5. The Cialis 5mg once-a-day pill has been found to be very effective in treating Premature Ejaculation when taken with Dapoxetine (Priligy).

Conclusion and Summary
Cialis, with its long duration of action, appears to be the easiest and with least restriction on spontaneity of the sexual experience. Two or three pills per week may be all that is necessary without concern for time and spontaneity. Of course the best pill regime for spontaneity is the Cialis low dose 5mg once-a-day.

It is possible as well that the treatment of choice will be to combine Cialis lose dose 5mg once-a-day pill with one of the shorter-acting drugs. A booster of Cialis 20mg, Levitra or Viagra prior to sexual activity after taking Cialis 5mg daily may be the ideal choice for many patients who do not get an optimal response to 20 mg of Cialis every 36 hours.

For patients with other medical problems that may impede erectile function e.g. diabetes, Levitra seems to be the drug of choice. Compared to Viagra, Levitra has a much longer duration of action and in many men a 20 mg Levitra tablet will be effective with stimulation up to 20 or 24 hours.

As Levitra tends to work very rapidly with as much as a quarter of patients getting an optimal response within 16 minutes of taking the drug, individuals who cannot plan their sexual activity until the last minute, may find Levitra to be their drug of choice.

Those patients, who are currently using Viagra and satisfied with their response of the drug, probably need not make a change.