Updated recommendations for drug therapies of erectile dysfunction

This study reviewed recent evidence on drug therapy for erectile dysfunction (ED) and updated recommendations for treatment. Researchers concluded that phosphodiesterase-5 (PDE5) inhibitors remain the first choice due to their excellent safety and effectiveness.

Drug therapy is often the first-line treatment for ED. PDE5 inhibitors are the most commonly prescribed. PDE5 inhibitors expand blood vessels, which increases blood flow throughout the body, including the penis, to help achieve an erection. There are a number of different PDE5 inhibitors with slightly different modes of actions. Some of these include sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra), avanafil (Stendra), udenafil (Zydena), and mirodenafil (Mvix). PDE5 inhibitors are taken orally either daily or on demand (as needed). Other drugs, such as alprostadil (Caverjet, MUSE), are administered directly to the penis. This can be done via injection into the muscle, by suppository through the penile opening, or by a cream.

The aim of this study was to review recent evidence on drug therapy for ED and update recommendations for treatment. Ten recommendations have been updated following the Third and Fourth International Consultation on Sexual Medicine.

There is high-quality evidence supporting that PDE5 inhibitors are effective, safe, and well-tolerated therapies for the treatment of ED. For example, 25 separate studies reported high effectiveness of sildenafil in improving erectile function when taken on demand. There is also no evidence of major safety issues with PDE5 inhibitors. No significant differences in effectiveness, safety, or tolerability have been observed among PDE5 inhibitors. There also is strong evidence supporting the effectiveness of tadalafil, vardenafil, avanafil, udenafil, and mirodenafil.

Patients are recommended to increase the doses of PDE5 inhibitors to the maximum tolerated dose. There is high-quality evidence to suggest that treatment satisfaction and effectiveness can be increased at higher doses. For example, 5 mg of tadalafil daily was found to be more effective than 2.5 mg daily.

Based on some lower quality evidence, PDE5 inhibitors can be recommended as first-line therapy for most men with ED. Some PDE5 inhibitors are suited for specific types of ED patients. For example, avanafil is recommended for men with ED that also have diabetes. Udenafil and mirodenafil are recommended ED treatment for patients with high blood pressure or diabetes.

Injections of alprostadil directly into the penile muscle can also be highly recommended based on strong evidence. Three studies reported optimal erectile function for sexual satisfaction in over 70% of men following alprostadil injections. The rate of side effects is low, with 11% of patients reporting local pain after self-injection. Men with other medical conditions, such as diabetes, are less likely to benefit from alprostadil injections. Overall, alprostadil injections should be offered as a second-line therapy for ED.

Alprostadil administered as a suppository or a local cream has also been shown to be safe and effective. One study reported that 64.9% of men were able to achieve successful sexual intercourse after using the suppository. This was significantly higher compared to 18.6% of men using a placebo (control drug with no active effect). The topical cream was associated with a satisfactory erectile response in 74% of men. However, in direct comparisons, alprostadil was most effective when administered as an injection. The suppository or local cream should be considered second-line therapy for ED.

Treatment selection and follow-up care should address the needs and expectations of a patient from his sexual life. Sildenafil, tadalafil, and vardenafil have been consistently associated with improved psychological and relationship outcomes. In addition, it is recommended that the partner is involved in the decision-making process.

Avoiding counterfeit medicines is strongly recommended, as these have been shown to be potentially dangerous. It has been estimated that over 50% of ED therapies bought on the Internet come from unauthorized sources. Deaths and serious illnesses have been caused from unnamed products.

Researchers concluded that PDE5 inhibitors remain the first choice drug therapy due to their excellent safety and effectiveness.

One of the authors of this study is affiliated with the manufacturers of some of the drugs reviewed.