ASK THE DOCTOR: Sex stimulants - Three pills treat erectile dysfunction
By Dr. JIM MITTERANDO
The Patriot LedgerQ. What's the difference between the three impotence drugs: Viagra, Levitra and Cialis?
A. When Viagra appeared in 1998, it revolutionized the way men talk and think about erectile dysfunction (decreased erections, sexual impotence). Sen. Bob Dole and NFL coach Mike Ditka turned a previous taboo topic into a problem that men now realize is common and treatable.
Effective medications
The advertising blitz is obvious with the newcomer drugs Levitra and Cialis trying to take a piece of Viagra's $1.7 billion market. The competitor drug companies may be trying to distinguish themselves but, in fact, these medications have many more similarities than differences. These drugs act on the same enzyme (phoshodiesterase-5) that increases blood flow to the penis.
All three drugs are pretty effective and help improve erections in about 70 percent of men. The response is best in men with milder problems (helps about 90 percent), but it's less favorable in diabetics (helps about 50 percent) and may only help up to 30 percent of men who have had prostate surgery.
Precautions
Doctors have had much more clinical experience with Viagra than its newer rivals and may feel more comfortable prescribing this drug. The newer drugs do have some additional drug interactions that include the prostate medications called alpha blockers (Cadura and Hytrin). All three drugs should not be used if you take nitrate heart medications such as nitroglycerin, Isosorbide, Isordil, Imdur or the recreational drug amyl nitrate (poppers); the combinations of these medications can cause dangerously low blood pressures. Viagra and Levitra can be used in men with stable heart disease under medical supervision.
Barring these interactions, these drugs are remarkably safe - probably safer than most prescription medications. They do have occasional side effects of headaches, nasal congestion and rare transient visual color changes, which most men seem to tolerate for the sexual benefits. Priapism - painful, prolonged erections - is an extremely rare side effect with these medications.
Food and alcohol
Viagra should be taken on an empty stomach since fatty foods decrease its absorption. Levitra and Cialis can be taken with or without food, which is a bit more convenient. All three drugs should not be taken with alcohol, which simply decreases the ability to get an erection.
Duration
Viagra and Levitra both take around 30 minutes to work but it is best if you take them one hour ahead of time. These medications generally last about four hours. Cialis takes a little longer to work but its effects can persist up to 36 hours. This does not mean you have an erection that lasts hours. These medications, simply, help obtain the erection. They are not aphrodisiacs; men still require stimulation, foreplay and the right conditions conducive for intimacy.
Which is best?
Until head-to-head trials are performed, it's impossible to be sure. They all seem to be equally effective. In the long run, insurance coverage and cost may be the deciding factors. For now, they are similarly priced at around $12 a pill. Most insurance companies will pay for four pills a month. You can receive a prescription for a higher dose to be cut in half so you effectively get 8 doses per prescription saving money and refills.
At present, the greater experience with Viagra and less drug interactions makes this the preferred drug. Additionally, Levitra and Cialis may require additional paperwork by some insurance companies. While Cialis may be longer acting, this may not be very important to older men for whom sexual activity is more likely to involve planning and predictability than urgent impulses and unexpected opportunities. Although a longer duration of action may provide convenience, it might also produce prolonged side effects. In particular, men with stable heart disease are better off with a short-acting drug like Viagra or Levitra in case they develop an unexpected need for nitroglycerin the day after using a pill for erections.
Causes of erectile dysfunction
Sexuality is a complex interplay between mind and body. The prescription treatments can certainly help improve blood supply to the penis. But often other issues may need to be addressed.
The most common factors contributing to erectile dysfunction include: alcohol (especially overuse), tobacco, fatigue, stress, relationship problems, diabetes, high blood pressure, depression, anxiety, age, medications and prostate surgery. Less common causes include low testosterone levels (which cause decreased sex drive as well) and chronic illnesses.
The brain is a sexual organ, too. Having an episode of impotence can lead to a cycle of performance anxiety and further inability to get erections. It is not uncommon for men with erectile dysfunction caused by stress or depression to take Viagra several times and find that they no longer require the medication once their confidence returns or mood improves. Additionally, stress reduction, exercise, weight loss and increased sleep all help improve sex life. Couple counseling and working out conflicts in a relationship can have positive effects in the bedroom. Sexual counseling can also be sought to specifically deal with certain sexual problems.
Try and try again
It is important to give the medication multiple attempts before declaring it a failure. I recommend trying the lower dose twice. If no success, you can double the dose and try that for an additional three or four attempts. Try to maximize your chance of success by being focused on the moment and not thinking or worrying about other things. Avoid alcohol and try to be rested. Men who do not develop satisfactory erections with one medication can ask their doctors about trying another.
If you have no success with two medications, you may have underlying problems with hardening of the arteries or other medical problems that may warrant further medical evaluation. There are additional treatments available for erectile dysfunction that will be discussed in my next column in two weeks.
Dr. Jim Mitterando is a family doctor at Cohasset Family Practice and a staff member at South Shore Hospital in Weymouth.
Readers should send questions to: Ask the Doctor, The Patriot Ledger, P.O. Box 699159, Quincy, MA 02269-9159, or by E-mail to his attention at features@ledger.com.
Questions of general interest will be answered in this column. The information in this column is not intended to diagnose individual conditions, and individual replies are not possible. Readers should see their own doctors about specific problems.
Copyright 2004 The Patriot Ledger
Transmitted Tuesday, July 06, 2004