The Low Down on Viagra, Cialis and Levitra

Many men have problems with their erection. Many also take medicines to solve this. So much so that Viagra has more or less become a household name.

Viagra, Levitra, Cialis

Viagra, Levitra, Cialis

Viagra is one of a group of medicines known as PDE5-inhibitors (so named because they inhibit an enzyme called PDE5). The other 2 are called Cialis and Levitra. They are all used to treat Erectile Dysfunction.

Confused on which one of these PDE-5 inhibitors to take? You’re not the only one. Sildenafil, otherwise known as Viagra is the most well known and hence popular of the 3 since it is the first drug to be approved by the Food and Drug Administration (FDA). However, popularity alone should not be a determining factor.

The success of Viagra made other competing drug companies come up with effective alternatives and hence Tadalafil (Cialis) and Vardenafil (Levitra) came into the market to compete for a share of the (highly lucrative) pie. Far from “me too” drugs, these competitors are also highly effective and very safe alternatives to Viagra, although they are not as popular yet. For a lot of people, deciding which the best alternative is the real issue here.

They are all PDE-5 inhibitors. For starters, these drugs all cause the dilatation of blood vessels in the corpus cavernosum of the penis in response to sexual stimulation, resulting in increased blood flow and an erection. However, this is where the similarities end. They are quite different drugs in practice. Let’s review the differences so patients can make an informed choice:

Viagra

Viagra was the first and hence probably the most researched drug. 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; In contrast, studies for the other two drugs were based on patients who had success with Viagra.

Its major disadvantage is decreased absorption due to food intake. You should take the pill on an empty stomach as absorption takes approximately 30 minutes and about one hour for maximum effect. Its half life is about 4 hours, meaning that Viagra loses 50% of its maximal concentration every four hours. Sexual stimulation is necessary to achieve erection.

One interesting preference among patients for Viagra is that it is easier to split the pill compared to Levitra or Cialis. However, it may compromise the effect, since of the three drugs, the maximal concentration for Viagra appears to be the therapeutic concentration. Hence, most people need 100mg per dose to achieve the necessary therapeutic effect.

Side effects include mild headaches, facial flushing, stomach upset and unusual eye disturbances including giving a bluish tint to vision and/or making whites look whiter. These are all harmless side effects and are not permanent. However, they seem to be slightly more common with Viagra than either Cialis or Levitra.

Viagra now comes in a new kind of tablet that melts in your mouth. It is called the Viagra Melt Tabs or Orodispersible Tablets (ODT). Click here to learn more. 

Levitra

Levitra was the second FDA approved drug for erectile dysfunction. In lab studies, it is six to 10 more times more potent than Viagra. However, it is highly bound by proteins in the blood and only 15% of the drug is active. Studies on Levitra included only patients had success with Viagra; In addition, the efficacy is based on sexual satisfaction or successful penetration rather than improvement, which were the endpoints for Viagra.

Levitra is considered more potent than Viagra. Patients with complications, e.g. diabetes or post-prostatectomy, will likely fare better with Levitra than Viagra.
In addition, absorption is less affected by food, or a high fat diet intake. Most patients can eat and take the drug without affecting its absorption and maximal concentration.

The half-life is five hours (somewhat similar to Viagra); however, as it is more potent, multiple half-lives may occur before the drug loses efficacy. In Europe, Levitra is considered a 24-hour drug. Most physicians consider it to be a drug that has efficacy longer than Viagra.

It is also faster acting, reaching its peak concentration at 40 minutes. In studies, 25% of patients had optimal responses within 16 minutes of intake.

Cialis

If duration is the goal, Cialis appears to be the champion. Indeed, it is known as the “weekend” pill, since its effects can last a whole weekend. Cialis has been approved for duration of 36 hours, yet, there are studies showing high efficacy out to 100 hours especially in older patients. Indeed, due to this advantage, patients are freed from the need to time intercourse with taking of the pill.

Other advantages include its intake not being affected by any food whatsoever and in fact can be taken with pure fat.

For patients with cardiac problems, Cialis seems to be the safest drug to take as it is the least likely to prolong the QTc interval of the heart.

A previous concern of Cialis relates to its possible effect on human fertility due to its effects on the PDE-11 enzyme system but these concerns have been addressed with studies which show no significant effects on semen quality. However, these studies are only 6 months in duration and longer studies need to be done.

Other disadvantages are muscle aches and pains especially in the low back and gluteal area are more common with Cialis (7%) versus Levitra or Viagra (less than 1%). It seems that younger men, particularly those who are more muscular are affected. Hence, a case can be made that in these younger men to use Viagra or Levitra as a first line of treatment. Notwithstanding, physical activity makes the pain disappear and should be advised if such pain occurs.

Cialis comes in 2 strengths. 20mg for use as and when necessary and 5mg for use everyday. The 5mg Cialis low dose once-per-day pill has several advantages:

1. There is no need to plan and time when you take the pill and when you will have intercourse.

2. When taken daily, the effect of Cialis 5mg is MORE than 5mg. In other words, just because the dose is only 5mg, you do not get only a quarter of the effect of the 20mg.

3. If a patient is taking 2 or more 20mg pills per week, it is cheaper to take the 5mg pill daily.

4. The Cialis 5mg once-a-day pill has been found to be very effective in treating symptoms due to prostate enlargement.

5. The Cialis 5mg once-a-day pill  has been found to be very effective in treating Premature Ejaculation when taken with Dapoxetine (Priligy).

Conclusion and Summary

Cialis, with its long duration of action, appears to be the easiest and with least restriction on spontaneity of the sexual experience. Two or three pills per week may be all that is necessary without concern for time and spontaneity. Of course the best pill regime for spontaneity is the Cialis low dose 5mg once-a-day.

It is possible as well that the treatment of choice will be to combine Cialis lose dose 5mg once-a-day pill with one of the shorter-acting drugs. A booster of Cialis 20mg, Levitra or Viagra prior to sexual activity after taking Cialis 5mg daily may be the ideal choice for many patients who do not get an optimal response to 20 mg of Cialis every 36 hours.

For patients with other medical problems that may impede erectile function e.g. diabetes, Levitra seems to be the drug of choice. Compared to Viagra, 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.

As Levitra tends to work very rapidly with as much as a quarter of patients getting an optimal response within 16 minutes of taking the drug, individuals who cannot plan their sexual activity until the last minute, may find Levitra to be their drug of choice.

Those patients, who are currently using Viagra and satisfied with their response of the drug, probably need not make a change.

advise


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Related Topics:

Testosterone Deficiency Syndrome / Andropause

Erectile Dysfunction

Premature-Ejaculation

HPV Vaccine for Men

STD General Info

Electro Shockwave Treatment for ED

About Dr. Tan
Dr. Tan graduated from the National University of Singapore in 2001. His residency was in the two largest public hospitals in Singapore; Tan Tock Seng Hospital and Singapore General Hospital.

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53 Comments

  1. Hi Dr. Tan

    Can I use Levitra with heart stent fitted?

    Thanks

  2. Tom O'Reilly

    Hi Dr. Tan;

    I am 76 years old but am in excellent condition. I have no medical issues and am a long distance runner. Both my wife and I still run half and full marathons each year.
    For personal reasons about 4 years ago I decided to remain completely celibate and did so. My wife was okay with that. Quite recently, however, we both decided that we wanted to return ton having sexual intercourse. Prior to my period of celibacy, everything worked great.

    However, upon attempting to return to active sexual intercourse, I experienced a number of issues. First, my penis had actually shrunk in size––both in length and girth. And when I began to experience an erection, I noticed that it had a bend in it that it did not have before the period of celibacy.

    Finally, while I was able to achieve some level of an erection, I was not able to maintain it in a very rigid state either while engaging in intercourse or when masturbating. Both I and my wife are very much interested in having sex, but things are really not like they were before.

    My question, therefore, is my situation something that a drug like Cialis, Levitra or Viagra would most likely be able to address successfully? Despite my chronological age, I am very fit and sexually interested.

    Thank you,

    Tom

    • Hi Tom. It is always such a joy and inspiration to hear stories like yours. I can’t even complete a marathon now. Can’t imagine what kind of physical state I will be in at 76! Few issues here: 1. How bad is the bend? Did you injure it? You can palpate the area of the shaft where the bend is. If you feel a nodule, this could be Peyronie’s and you will need to treat that. Either with medication, injection, shock wave or surgery. If you don’t feel a lump, leave it for now as it might be related to issue 2. Atrophy of the cavernosal sinuses. For this you can try shock wave treatment to induce the penis to make new blood vessels. You can also try PDE5Is of which in my opinion once a day low dose Cialis should be the treatment of choice. Issue 3. is your testosterone levels. I understand your libido is still high so this is unlikely an issue. However, you are 76 and I would want to be sure this is not contributing to the issues. Those are my opinions. Just a friendly reminder that this does not constitute medical advice. You should still see your doctor. You are obviously welcome to see us. Click here for location info.

  3. hello dr Tan. some background. before I was related as sailing officer.year 2001 I made a misstake when wash my underwear, by using very strong soap which was not for cloths but for washing engine, and dya after i used this underwear and after 5 minutes it felt that i had fire on my for skinn. and I found it completely red like a burn injury, however after time the elasticity of the fore skinn get worse so 2009 i consulted a dr and he advise me to do a circomssion so i agree. during this time i could have erection but painful to to move the forskinn over the penis head. after I did the circumssion not much happen with my penis, I tried Viagra, levitra, calias and some chinese pills it works in the beginning, however now nothing works it can be half hard, I also have diabteis type 2 since 2001, but have had this resonable under control. so what u recommend me to do, please advise open for any of your suggetion

    • This forum is not for medical consultations. Please continue to see your doctor for medical advice.

  4. Hello doctor,
    i got so many problem in my sexual life…pls help me read and ans..thanks.
    when i was small(15) i feel got some problem in my body becoz i got small penis that arround 2.5inch when erection and circumcision problem but always at flaccid.that time dont take any medicine.after when i was 25 years i check with doctor doing circumcision operation.then my penis look little bit biger(3.5inch) when erction.finally i want to check my hormone check up the result is
    FSH -1.4 IU/L
    ICSH – 4.29 IU/L
    ESTRADIOL – 38 pmol/L
    PROLACTIN – 0.30 nmol/L
    TESTOSTERONE -13.4 nmol/L
    Then doctor told me its all normal only FSH only less then give me some medicine.after i finished all medicine then went to doctor he asked me its any different? i said nothing different really i dnt feel any different..
    one day i took viagra then trying to sex with girl my penis got erection but when i try in my penis girl vagina but go to erection half level..its some more i am using viagra..
    my penis always flaccid when i want masturbate also not so hard but when semen got come out that time only got fully erection…
    what i need to do?is it can solve the problem or just live life long,i cant sleep well one day also becoz this problem pl help me and ans..thanks..

    • This is not a problem that can be solved over the internet. You need to see a good urologist. Please post any follow up questions on http://www.askdrtan.com

      • Thanks for ur reply doctor,i try to register ur new website cant register.
        u said its can solve,can i looking for u for this problem? and i was type the hormone results is it
        normal?
        thanks

  5. BoB Choong

    Hi Dr.Tan,

    I am staying in Yishun town near the hospital.
    Is there any doctor at KTPHospital specialise in EF.

    Thank you

  6. Dear Dr Tan,

    I am a 26 year old male and sincerely seek your advice. I have had difficulty getting an erection since 18 yrs old .

    I do not experience any spontaneous erections anymore and have never experienced a natural erection ever since i was 18 yrs old even when i get aroused or exicted . I only can get a weak erection when i use my hands to stimulate my penis and the erection quickly goes away when i stop using my hands.

    I have seen 2 doctors before with regards to my condition one from a govt hospital and one from private sector and both doctors have diagnose my condition as a pyschological problem. I do respect both their opinions however i still have my doubts on both their diagnosis as i have been suffering with this problem for almost 8 years and there is no mental stress affecting me expect for this ereciton problem over these years …

    i have tried viagra and other prescription drugs but after a while they do not seem to work very well for me.

    i do also suffer from mild tremors ( when holding cups , carrying heavy objects , drinking soup or putting my hands and leg in a certain position ) in my hands and legs , could there be a possibility my erection problem be linked to this , something like a nerve problem ?

    i really appreaciate your advice on this matter and i am open to seek a thrid opinion from a medical professional .

    Look forward to your kind reply.

    • Hi joe,

      Your problem sounds very complex. You need a proper medical consultation for us to figure it out.

      Rgds

      Dr Tan

  7. Seanny

    Hi dr tan, I am 25 this year.. However I do have some problem in having sex because I cannot really get an erection whenever I want to / need to..I dare not speak to anyone as I am still at the age of 25 which is consider young. Can adv me? Thank you.

  8. Manmathan

    Hi
    I’m 27. I feel I have erection problem. I don’t have normal morning erection. I feel all ways tired and sleepy. If I wake up all so feel tired. Normally my penis is small. If I touch all so don’t have feeling. And my sex feeling all so getting low. I with my wife I want to do but starting have erection but not so strong after that totally getting low. I can enter in my wife. Wt is this call.

  9. I am 52 do I need to be on medication all the time for ED

    • Hi Bryan,

      It really depends on what is causing your ED. You need to be checked for chronic diseases like Diabetes, High Blood Pressure and High Cholesterol. These conditions need to be treated first. Furthermore, certain medications can also cause ED. If you have clinical symptoms of low Testosterone, this has to be checked too. Once all secondary causes have been ruled out and you are dependent on PDE5I medication then it is likely you will need to be on it for life.

      rgds

      Dr Tan

  10. Hi Doc… Im really feel down with myself.
    I felt that iam healthy & fit… Bt each time when me & wife have our “moment” it do becomes hard bt aftr sometime it went soft again… Bt the thing is im still
    Excited only my “brother” keep disappointing me… Im really would wana seek your advice & medical appointment. Thank you. Pls email.

    • Hi Raden,

      You have erectile dysfunction. This requires a formal consultation to diagnose and treat. Please see me at my clinic.

      rgds

      Dr Tan

  11. Can clear my erection problem?

  12. Dear sir,
    I visit your clinic one time about my erection problem. U take a blood test then u say no problem. my wife in India I’m working in Singapore. I just marrie.i say my
    Holiday go India I plane to make baby. Then U give tablet u say this is improve your activities.I fail to make baby. Holiday time i can make sex one day one time only. And your tablet finish then I can’t active I don’t have erection. And now I come back Singapore. I need your advice again. I can feel I getting week. Last 2 years I don’t have morning erection. And all ways my penis so small and week. Advice me. next month I plane to bring my wife in Singapore

    • Hi Basheer,

      It sounds like the medications worked but was not of an adequate duration. It sounds like you will need to be on these tablets until your wife is successfully pregnant.

      Rgds

      Dr Tan

      • But it’s not work. And now my main problem. I can’t doing sex fully. I have a erection problem. Advice about that.

        • Hi Basheer,

          What do you mean it didn’t work? You said you had sex once a day. That is not good enough? Or you mean your wife is still not pregnant? Nothing can guarantee pregnancy. Not even IVF.

          Rgds

          Dr Tan

          • IVF?
            Sir now my question. In future with out tablet I can’t perform normally? And how to clear my ere tion problem. Kindly advice me that one,

          • Hi Basheer,

            So you are saying the medicines work now but you are afraid they will stop working? Aren’t you getting a little ahead of yourself? Tackle the problem if and when it arises.

            Rgds

            Dr Ta

          • Hi sit
            The medicine work. The medicine only you give one month. It’s finish. And now I come back. My question is I take the medicine time I can sex once a day. Once finish then. I can do sex. Y?

          • Hi Basheer,

            Because you are dependent on the medicines. Unfortunately your condition cannot be solved permanently. You will be ok as long as you take your meds.

            Rgds

            Dr Tan

          • Hi sir,
            That mean. I need to take the medicion all the time?
            My problem can’t solved permanently?

          • Hi Basheer,

            Most likely yes.

            Rgds

            Dr Tan

          • Hi Basheer,

            That is most likely the case.

            rgds

            Dr Tan

          • Hi sir,
            If possible to make my wife pregnant? Have any treatment for that my problem?

          • Hi Basheer,

            A little patience would help. For your age, doctors will only step in if you have tried for 1 year to get your wife pregnant and was not successfull.

            rgds

            Dr Tan

          • Basheer

            Dear sir.
            Today I do my self to come out my spurm. It’s very hard to wake up my penis. And. Finely wake up all so it’s not so strong. And the spurm come out like yellow color and. Not forcely come out. Day by day I feel I getting loos my power. Last time u say abt my report. It’s normal but in my age is something low. Then y I like that. I bring my wife next 2 month latter. Kinky advice me.

          • Hi Basheer,

            Apologies but I really do not know what you are trying to tell me. Perhaps its best if you come down for a consult.

            rgds

            Dr Tan
            Help test out our new forum at http://www.askdrtan.com

  13. Hello Doc,

    I consulted a doc for ED and pain problem. They asked me to do lot of tests (CT Scan, Testicles Test, Harmon Test) but every thing was fine. He asked me to take some oral medicine for ED issue and after taking medicine I didn’t have any problem (expect some headache) (FYI: I did not try without medicine yet. Apart from Lavitra(20 mg). he gave me some other vitamin tabs. He asked me for sperm test as well. As per him I should not ejaculate within 5 days duration of test. So I ejaculated on Monday for sat morning test but it got ejaculated automatically on sat morning (test day) but without canceling test appointment and without telling doc. I collected my sperm and gave it for test (that mean ejaculated 2 hours before sperm collection) … could it be make difference in sperm report ( i.e. slow sperm). Shall I tell them that I ejaculated on the same day as well before collection? and give it again for testing (5 days after)? Please advise

    • Hi shek,

      Please direct all future questions to your doctor treating you for this problem. It is not right for me to interfere.

      Rgds

      Dr Tan

  14. Hello Doc,

    I am 29 years old and married from last 15 months. I usually have morning erection. I am fit and doing exercise daily. but seems while doing intercourse with my wife, sometimes I am not able to do it as its not hard enough. earlier it happened very rare but in last month, its happened 3-4 times. Sometimes I take Penegra 25 mg. please let me know, how to get rid of this problem? also would like to know, if it can be cured easily or not? is it a common problem with Men? … I would like to make an appointment for this as well. please let me know if you have any clinic near Tampines.

    • Hi shek,

      It does not sound to me like you have a medical problem. However, the onus will be on your doctor to rule out any potential medical issues. How easily this can be ‘cured’ really depends on what is the underlying cause. ED is a very common problem although not at your age. We do not have a clinic at Tampines. Our clinic locations are: http://www.drtanandpartners.com/where-to-find-us/. btw what is Penegra?

      rgds

      Dr Tan

      • Hi Doc,
        Thanks for you reply.

        Penegra containts Sildenafil Citrate and its bit useful for me (even 10mg works for me). As per you what could be reason of ED at the time of intercourse only at this age? and one more query I have that once ED is cured it will not occur again after some time … I mean in 1 or 2 years?

        • Hi shek,

          I have never heard of generic Viagra. Please be careful when using such medicines. They really should only be used under the guidance of a doctor. I really would not want to hazard a guess as to your diagnosis. You need to see a doctor and get some tests done. Again, the cure for ED and risk of recurrence depends entirely on the underlying cause.

          rgds

          Dr Tan

          • Hi,

            I visited GP today. I explained him that I have mild pain in lower abdominal and cant maintain Erection while doing intercourse.
            I did urine test and said I dont have blood in urine then
            He referred me to Singapore Urology centre. I have to go on Wednesday for check up.

            I tried sex again and it got erection but as soon as I was trying to insert it I felt some pain in lower abdominal and it became soft after sometime (5 mins) it again got hard but again same issue (felt pain while penetrate and it became soft) could it be related to my pain ? and could you please let me know whats usual fee of doc for ED treatment?

          • Hi shek,

            Your ED is very likely due to the pain. In my view, the important thing is to find out what is causing your pain first. It could be the bladder, prostate or large intestines. You should keep your appointment with the Urology Centre.

            rgds

            Dr Tan

  15. Hi doc,

    I m not sure if I have this problem called erectyle dysfunction…because my pelvis will tend to erect while I was lying down..but when I about to do the
    intercourse with my wife..it will just “turn off’. Its happen quite a few time and I m quite worried bout it..and I m just 26 years old….i hope you can telk me what wrong with me

    • Hi akbar,

      You mean you cannot sustain an erection when having sexual intercourse with you wife. But you have morning erections. It really does not sound to me like you have a medical issue. If anything, it sounds more psychological. However, you should still see your doctor to rule out any possible medical issues.

      rgds

      Dr Tan

  16. Hi Dr Tan,

    I just passed 60 and I am relatively fit with no problems carring out my daily life. I do not see doctors for the slightest reasons and as such, though my mother had diebetes, but, not of serious nature before she passed on,

    I on the other hand, do not go for check-ups as advised by the main stream people.

    However, my sex life seems to be not what it was before when I was much younger. I use 100m cialis each time when I have sex and it seemed to work for a while, but yet did not give me the desired strength which I would have liked.

    I don’t know why this is so, maybe it’s because I seem to take the pill much too early be the act itself.

    Recently, I took a 200m cialis pill, also, earlier than the time of the act say about 3 hours before and this time, I could not even get an satisfatory errection for sucessful penitration. This leaves my partner dissatisfied.

    Please advise what should I do to correct this problem so that I can continue to have a full and happy sex life.

    With Best Regards

    Jay

    • Hi Jay,

      You have erectile dysfunction. This is an early marker of blood vessel disease. Multiple studies have shown that men with ED have a much higher chance of developing heart disease. So the first thing you need to do is have a thorough health screen including measuring your blood pressure, blood sugar and cholesterol. Take the chance to also test your testosterone level and check your prostate. Once you have done this, you can talk to a doctor about treatment for ED. There are many options available and this forum is really not the platform for such a detailed discussion. You need a formal medical consultation for this.

      rgds

      Dr Tan

  17. How do i go about purchasing Cialis? I am in my late 30s and loses stamina due to fatigue

    • Hi Siva,

      First, see our doctors either at Robertson Walk or OUB Centre. Our doctors will prescribe you Cialis after assessing your situation. Subsequently, you will be able to purchase Cialis without seeing the doctor.

      rgds

      Dr Tan

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