Updated: Apr 27
Many men may not respond to Viagra or Cialis. There are several important steps you can take before moving on to second line therapies for ED.
Keywords: Cialis, Viagra, Stendra, Staxyn, Levtira, Erectile Dysfunction therapy, ED Meds, ED meds dont work, Nitric Oxide
The first line treatment for erectile dysfunction therapy is the use of oral medications called phosphodiesterase inhibitors (PDE5i). PDE5i are more commonly known as Viagra, Cialis, Levitra, Stayxn and Stendra. Oral medications for ED are an easy option for men to improve their rigidity and stamina during activity. Yet often times men can find themselves not responding to the medication. Oral ED meds have an overall effectiveness of approximately 60-70%. Oral ED meds in clinical trials fail to achieve a response in 30-35% of men. In clinical practice the failure of rate of oral ED medication can be as much as 50%, given patients may have more severe vascular conditions that prevent the efficacy of the drug.
What can a man do next if oral ED meds don’t work? What is the best next step?
Approximately 1/3 of patients who find themselves not responding to ED meds may be salvaged with counseling and appropriate dosing. There are no guidelines or a standardize stepwise approach for men who fail oral ED meds other than to move on to second line therapies.
When a physician is evaluating a patient, who has failed to respond to oral ED meds consider the following issues:
Lack of Follow up
Lack of persistence
Reluctance to treat
Unaddressed physiological issues
When counseling the patient, it’s important to find out if there was an actual physical response. Was there any engorgement or rigidity to the phallus during stimuli? Was it satisfactory for penetration or to weak? Was the patient able to achieve climax or was there premature ejaculation?
When counseling a patient about oral ED meds, the majority of failures can be improved by proper counseling on how to best use the medication. Patients should be aware of the following:
ED meds only work with sexual stimuli. Foreplay is advised and can improve response.
Often times men say they can get an erection on their own but not with a partner. This can be more performance anxiety induced ED. This can be secondary to having a new partner and desiring to meet their expectation. Often a medication to reduce nervous tendencies can be instituted.
Make sure the patient is not taking the medication with food. Most ED meds, especially Viagra has a reduced effectiveness when taken with food.
Reduce and/or omit alcohol consumption when taking ED meds. This can lower blood pressure and may also make the medication less effective while reducing sexual stimuli response.
· Ensure the patient is swallowing the medication. Some patients may be dissolving it in water (believe it or not)
Other counseling aspects a physician should consider:
Sexual stimulation and foreplay needed
When should PDE5i taken?
If patient has eaten, delay intercourse
Avoid excessive alcohol
PDE5i to expensive
Trial of at least 7-8 doses
Often times patients may ask to increase the dosage of medication. This has been studied in several clinical trials and is not effective as one may think. One study in particular of 54 men who did not initially respond to Sildenafil 100mg who had ED secondary to a vascular, post radical prostatectomy or psychogenic cause were treated with increasing dosages over a month of Sildenafil 100mg, 150mg and 200mg. Improvement in ED scores were 37%, 46%, 68% respectively. However more importantly 63% patients on 200mg experienced headache, flushing, nasal congestion, visual disturbances, and dizziness that were not tolerable. Increasing the dosage may shift the benefit to risk ratio in favor of adverse events and side effect. This approach is not advised.
An alternative approach is to try a different oral ED medication. A meta-analysis of 1118 clinical trials suggest Tadalafil and Vardenafil may be more effective than Sildenafil based on changes in IIEF scores. IIEF is the International Index of Erectile Function, it is a question that can quantify erectile dysfunction severity. The questionnaire is set of 5 questions that pertain to the past 6 months of activity:
How do you rate your confidence that you could achieve and keep and erection?
When you had erections with sexual stimulation, how often were your erections hard enough for penetration?
During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?
During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
When you attempted sexual intercourse, how often was it satisfactory for you?
An additional option a patient may try is switching from an on-demand dosing to a daily dosing of ED medication. In a prospective open label study: Tadalafil 5mg Daily vs Tadalafil daily + Sildenafil 50mg on demand was utilized. Patients on combination therapy who had a baseline of severe ED had greater improvement than men who had mild ED at baseline. Adverse events were not significantly different in either group
Testosterone therapy can make non responder to oral ED medications into responders. Men with low testosterone levels may find it hard to get an erection with medication (no pun intended). Testosterone replacement (TRT) can improve response to ED medication significantly. Increased testosterone levels are associated with significantly improved sexual activity, sexual desire and erectile function. In trials of patients with testosterone deficiency, treatment with testosterone undecanoate or enanthate improves erectile response to vardenafil and tadalafil.
Finally, noninvasive Low Intensity Shockwave Therapy for ED can turn non responders into responders to ED medications. Several clinical trials have documented this phenomenon. LISWT is a great noninvasive next best option in patients who fail to respond to ED meds. A protocol for LISWT is treatment once per week for 12 weeks. 3000 shocks applied at 6 sites along the phallus. 500 shocks per site at proximal and distal corpora. All patients to remain on once-daily dosing of Cialis during therapy.
Next Best Option for Non-Responders to ED Medication
Failure to respond, offer an alternative medication
Assess medications, patient/partner issues, help define patient as a true PDE5i failure
Limited data to support raising the dosage above the standard guidelines, only increases significant risk of SE.
Consider Low Intensity Shockwave Therapy (LISWT)