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Erectile Dysfunction Prescription guideline

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1) There are at least two other PDE-5's on the market that I'm aware of off the top of my head--Stendra and Levitra.

2) No nitrates, ever.

3) Never prescribe branded Viagra unless you own stock in Pfizer.  Sildenafil Citrate 20 mg tabs are far cheaper, even if you have to use 2-5 at a time.

4) ASK.  Especially your chronic pain patients or those on beta blockers or SSRIs.

5) Never put a 40-60 year old male on a beta blocker as a first line HTN medication as a primary care clinician.  If their cardiologist did it, leave them on it and work with the ED meds.

6) If you're giving ED meds to an unmarried gentleman, be sure to address safer sex, too. BUT, realize that ED med use doesn't always require a partner.

7) Be sure to address the underlying, reversible/controllable conditions which can lead to ED--stress, certain medications, DM II, etc.


My $0.02.

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Make sure the patient is healthy for sex.

A resting BP of 180/110 is not ok for any type of ED drug or vigorous sex.

When a guy is more worried about his rx than his stroke level bp - you have a prioritization problem.

When 4 L of O2 by NC only garners an O2 sat of 93 - ED is truly the least of the worries.


The most reversible types of ED are smoking, etoh, bp and dm - and this is usually an all inclusive deal.

Smoking a pack a day, 6-12 beers a day, high BP and an A1c of 9 or more = ED - no real chemical fix.

If those are ALL broken - all the ED drugs in the world might not help and patients have lost sight of the forest and are only looking for one strong tree - pun intended.

Stress fixing the underlying problems.


Dementia and ED drugs are not a good mix either.

If the partner is in the room and looks terrified of the idea of an ED drug - investigate the relationship and see if both parties are willing and able participants and if there are psychological issues in the couple or dementia.


Generic Viagra at the 20 mg pill dose is a great idea. It is usually used for pulmonary hypertension but works the same at the 40-60-80-100 mg dosing as 50mg or 100 mg of brand Viagra.


Don't forget psych issues and how SSRIs dampen orgasmic response. This isn't ED - it is SSRI side effect. Don't confuse the two.

Taking a pill to fix another pill to fix another issue becomes a circus of side effects and bad outcomes.


NOTHING is like the cutesy commercials on the TV - ever.

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Agree with above---general approach is to ask if they have a lack of sexual desire or a mechanical erectile problem. BBs, SSRIs are common medication culprits.


If it is purely mechanical, testosterone is unlikely to be the culprit and cialis, levitra, or sildenafil are all interchangeable. Stendra sucks, I've tried it on several patients and it did nothing for them.


If it is a combination of low libido and ED, then check testosterone. I've solved many men's ED issues by putting them on TRT when indicated. 

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Any insurance or pharmacy push-back on ordering the pulmonary hypertension dose of sildenafil and then not tid, which is the dose for that?

Nope.  I have had it covered as a generic nonpreferred, which can be about the same as cash price of ~$1.25 a pill, about 1/6th the price of branded viagra.

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