|
Older men who have less frequent sex and who are happy with the responses
using Viagra should certainly continue Viagra. Some patients
who do not get optimal responses to Cialis may find that Viagra
is more to their liking. In general, all three drugs work and the patients
should talk to their doctors about finding the one that works best for
them and their sexual lifestyle. (Main information created August, 2004,
some content updated 2006)
ImageThree drugs now and others in various stages of clinical trials
has not only further expanded the treatment options for ED, but
in many ways has caused new confusion among physicians and patients. Add
this to other medications and vacuum therapy and it’s easy to see
why patients and potential patients have questions.
For all practical purposes, these oral drugs are a first line of medical
treatment. In certain circumstances in which the males are healthy, young,
and laboratory blood tests and such are normal one should look for the
physical cause of their erectile dysfunction before instituting treatment
since the disease process may be more serious than the symptoms, i.e.,
the ED itself.
In some cases, treatment of the primary disease may in fact resolve the
sexual dysfunction. However, most men have other physical causes for ED
as found in their health history and lab tests, making PDE-5 inhibitors
a first line of choice. Selecting the appropriate drug is sometimes extremely
difficult to do without proper information on each drug and a careful
discussion about the sexual history of the patient and his partner.
Let us discuss the pros and cons of each of these three drugs and the
sexual circumstances that may indicate the use of one drug over another.
Viagra was the first and is probably the most famous of the three
PDE-5 inhibitors used to treat erectile dysfunction. It had been
researched for over a dozen years before becoming available to the American
public. 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; however, all patients
in the Viagra studies had ED, whereas studies for the other
two drugs were based on patients who had success with Viagra.
Viagra’s major drawbacks include decreased absorption due
to food intake. You should take the pill on an empty stomach as absorption
takes approximately 30 minutes. The drug takes about one hour for maximum
effect, but loses 50% of its maximal concentration every four hours. Sexual
stimulation is necessary to achieve erection. Of the three drugs,
the maximal concentration for Viagra appears to be the therapeutic
concentration. Side effects include mild headaches, facial flushing, stomach
upset and unusual ocular disturbances including a bright vision and a
blue-green halo around the vision.
Levitra was the second oral PDE-5 inhibitor for erectile dysfunction
to be FDA approved. In vitro, it is six to 10 more times more potent than
Viagra, however, 15% of the drug is nonprotein-bound and bioactive.
Studies on Levitra have excluded patients who did not have success
with Viagra, therefore the efficacies are somewhat shifted toward
the positive. In general, the thought is that Levitra is more potent
and efficient than Viagra as demonstrated by the hard-to-treat
groups of patients. Diabetics and post-radical-nerve-sparing-prostatectomy
patients appear to have a higher incidence of success than for Viagra.
In addition, the efficacy is based on sexual satisfaction or successful
penetration rather than improvement, which were the endpoints for Viagra.
Levitra reaches its peak concentration at 40 minutes, is only
affected by a very high fat diet. Most patients can eat and take the drug
without affecting its absorption and maximal concentration. The half-life
of Levitra is five hours; however, the therapeutic levels appear not to
be the maximal concentration and therefore multiple half-lives may occur
with efficacy of the drug. In Europe, Levitra is considered a 24-hour
drug whereas in the United States the package insert states, “No
duration of action for Levitra” although the majority of physicians
consider it to be a drug that has efficacy longer than Viagra.
Overall the slight chemical change noted in Levitra appears to
give it more potency, efficacy, longer duration, and probably more rapid
onset. Levitra has shown that 25% of patients had optimal responses within
16 minutes of the oral intake of the pill. In recent studies, Viagra
has also shown longer duration of action than four hours even though the
package insert shows four hours of duration. However, if duration is the
goal, Cialis appears to be the winner.
Cialis has been approved for duration of 36 hours, yet, there
are studies showing high efficacy out to 100 hours. It is not affected
by any food whatsoever and in fact can be taken with pure fat. The typical
McDonald’s double cheeseburger with French fries and malted milkshake
would certainly inhibit the effect of Levitra, but a steak with
potatoes, a glass of wine, salad, and dessert would probably not. Neither
of these would affect the absorption of Cialis. Cialis is
protein-bound that causes a serum peak concentration of two hours and
a half-life anywhere between 16 and 22 hours depending on the age of the
patient. The older the patient, the longer the half-life. Because of the
long duration of action, the lack of absorption effects, and efficacy
at least as good as Viagra, if not better. The paradigm of taking these
PDE-5s may in fact change as people gain more and more experience with
Cialis.
Cardiac-wise Cialis has the shortest QTc interval and may in fact
be the safest to use for cardiac patients although all three drugs are
extremely safe. None of them have a QTc interval of greater of 10 milliseconds,
which would have caused the drug to fail FDA clearance. The long half-life
of approximately 20 hours is not unusual in today’s modern health.
Most drugs given by general practitioners to their patients have half-lives
even greater than 20 hours and there is no concern about side effect profiles.
If side effects occur with Cialis, they are usually short duration,
mild, and occur within the first 24 hours.
(This information was written in August 2004) Another concern about Cialis
is the fact that it has the greatest affect on the PDE-11 enzyme system,
which is found in many organs including the heart, muscle, and testicle.
Concerns about fertility have been diminished with several studies of
six-months duration/two sperm cycles in which there appears to be no quantitative
or qualitative abnormalities in the semen analysis. Longer studies or
experiences may be necessary to determine whether or not this drug does
in fact have negative effects on fertility in men. In addition, muscle
aches and pains particularly in the low back and gluteal area are more
common with Cialis (7%) versus Levitra or Viagra
(less than 1%). Younger, more muscular and more physically active men,
particularly when confined or not physically active for a period of time,
get this discomfort, which seems to be related to PDE-5 inhibitors in
general and muscular vascular congestion. Physical activity makes the
pain disappear and in addition when taking multiple Cialis tablets
in time the discomfort disappears. One interesting study involved PDE-11
knockout rats in which the genetic material to make PDE-11 has been destroyed
and the generations of rats that form have no PDE-11 activity. There was
found to be no fertility, muscle pathology, or cardiac pathology in these
rats indicating that PDE-11 inhibition even though unknown appears not
to be detrimental.
Having discussed the basic information about Viagra (sildenafil),
Levitra (vardenafil), and Cialis (tadalafil)
let us look at the ideal circumstances for using these drugs.
Cialis with its long half-life and relatively long duration of
action of 36 to 100 hours appears to be the easiest, most cost effective,
spontaneous, and natural of the three drugs. Two or three pills per week
may be all that is necessary for function without concern for time and
spontaneity.
On the other hand, having the ability to maximize nocturnal erections
by using two pills per week of Cialis is extremely advantageous
since it maximizes nocturnal blood flow during the three to five erections
that every male gets at night, oxygenates the penis, decreases the chances
of fibrosis and scarring, and in the process prevents irreversible penile
damage and irreversible untreatable erectile dysfunction. As we gain experience,
it is possible that the treatment of choice will be to combine Cialis
with one of the shorter-acting drugs. A booster of Levitra or Viagra
prior to sexual activity after taking Cialis on Tuesday and Friday
may be the ideal choice for many patients who do not get an optimal response
to 20 mg of Cialis every 36 hours. Lastly, if sexual activity occurs more
than twice per week Cialis becomes more cost effective and becomes
the drug of choice.
For those patients who have hard-to-treat erectile dysfunction, Levitra
may be the drug of choice because of its relatively high potency and effectiveness
in these types of patients. Many think of Levitra as a more potent
Viagra, however, 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. Levitra tends to work very rapidly with 25%
of the patients getting an optimal response within 16 minutes of taking
the drug. Certain individuals, such as single men who cannot plan their
sexual activity until the last minute, may find Levitra to be their drug
of choice.
Viagra has certainly maintained itself over time as the safest
“gold standard” of PDE-5 inhibitors. We are really not able
to compare Viagra to Levitra and Cialis because the
studies on Viagra used improvement in sexual function rather than
penetration or sexual satisfaction as their endpoint and therefore the
efficacy statistics may be higher than they should be.
On the other hand, Levitra and Cialis used penetration
and sexual satisfaction as their endpoint, but disqualified those patients
who did not respond to Viagra; therefore their efficacy figures may in
fact be higher than they should be. Both inequalities may actually cancel
each other out and many feel from an efficacy point of view that the three
drugs are fairly close in their ability to produce satisfactory and optimal
erections for sexual activity.
Viagra has the longest safety record and profile of just about
any drug approved by the FDA. However, Levitra and Cialis
have equally safe profiles for a shorter period of time. The overall side
effect profile percentages for all three drugs are approximately the same
with the exception that there are no eye manifestations or flushing with
Cialis and minimal eye manifestations with Levitra. However,
there is some question as to whether or not Levitra and Cialis
have a milder degree of side effects including headache, stomach upset,
and nasal congestion. Cialis rarely causes nasal congestion.
Older men who have less frequent sex and who are happy with the responses
using Viagra should certainly continue Viagra. Some patients
who do not get optimal responses to Cialis may find that Viagra
is more to their liking. In general, all three drugs work and the patients
should talk to their doctors about finding the one that works best for
them and their sexual lifestyle. (Main information created August, 2004)
 |
 |
Mini
ED Special Pack
Viagra® 4 Pills
Cialis® 4 Pills
Levitra® 4 Pills
BUY
Mini ED |
|
Super ED Pack
Viagra 8 Pills 100 Mg
Cialis 8 Pills 20 Mg
Levitra 8 Pills 20 Mg
BUY
Super ED |
We give you the opportunity to find out which of our products works
the best for you. Buy 3 or more medications in one order! |
 |
|
