Part One: Q&A about Viagra and Cialis

An interview with Dr. Marian Davis of University of Colorado and CrossRoads Pharmacy

We will be talking with Dr. Marian Davis about the different types of medications to treat Erectile Dysfunction (ED), how exactly they work, how to properly take them, and what the difference between all of them is.

Is it true that Viagra is the number one sold drug in the world?

I don’t think that Viagra is the number one sold drug in the world. I believe that some blood pressure and cholesterol medications sell more than Viagra, but I can tell you that it is definitely one of the top-selling drugs in the world, because ED is such a common problem nowadays. Around 50% of men over 50 years old have some sort of erectile dysfunction, and I have seen 15 men in their early 20s with this problem in the last week.

What do you think is the cause of ED at such a young age?

If you are a healthy young man, the cause may be psychological. It doesn’t necessarily mean that medications like Viagra or Cialis won’t help. In fact, they do help as their effect is based on natural mechanisms.

So, how exactly do these medications work?

What people need to understand first is that the signal leading to an erection comes from the brain. When you get sexually excited, a message is sent down the nervous system. A release of the neurotransmitters occurs, which causes the tissues in the penis to expand, allowing more blood flow.

What you’re saying is that these medications don’t trigger sexual excitement, correct?

That is correct. Viagra, Cialis and other ED treatments belong to the group of medicines called phosphodiesterase inhibitors, and they do not increase your sex drive or libido. That’s regulated by testosterone. But they can be really helpful in getting and maintaining an erection. And the process is remarkably simple. When the neurotransmitter sent by the nervous system reaches the penis, it gradually gets broken down by another substance responsible for making the erection go away, and what these medications will do is block that substance, thus helping you maintain and sustain an erection.

In order for these ED medications to be effective, you need sexual stimulation. They do not enhance your libido, desire or anything of that nature, but work together with your natural excitement. There are three medications that I usually prescribe in my clinical practice: Viagra, Cialis and Levitra. We won’t be talking much about Levitra because the company hasn’t been pushing it very hard and, quite frankly, not that many people use it anymore.

So, the two most important ones are Sildenafil and Tadalafil or Viagra and Cialis. You can have Viagra, which starts working within about 30 minutes to one hour after you’ve taken it and can last for up to 6 to 8 hours (and that’s a question I get asked all the time). But that doesn’t mean that after you’ve taken it, you will suddenly find yourself walking down the street with a bulging erection.

So, it’s about half an hour to 60 minutes in advance and the effect can last for a period of 6 to 8 hours, which means that if you take it now and your significant other is still at work and comes home four hours later, the medication will still maintain its effectiveness. And this is not a one-time situation. In fact, if you take it now and have sex now, after six hours you’re still going to have that medication in your system, so there’s still a chance that you’ll have a second erection, and you can also have sex then. This means that Viagra can also reduce what we call the “refractory period” between erections. When you’re 18 years old, you can probably have sex four times in a row, so your refractory period is super-short. When you’re in your 50s, however, that’s not that likely to happen. Still, this medication can help you get a second erection much sooner than usual.

Cialis or Tadalafil, in its turn, remains effective for 36 hours, which is why it is known as the “weekend pill”. Cialis usually takes a little longer to reach that peak effectiveness, so you can take it 30 to 60 minutes in advance too if you want, but some patients have said they have seen better results taking it between at least an hour and two hours before the expected sexual activity. Either way, thanks to the long duration of effect, if you take it on a Friday night and your partner has a headache, you didn’t just waste your money on that pill, because Saturday night, you’re still going to be okay. That’s exactly why people have nicknamed Cialis the “weekend pill”.

So, which one is better?

People ask me that all the time, and the answer to that question is, none of them is better. I often tell my patients, maybe I’ll prescribe you a few tablets of each and you try it for yourself. Because some patients say that Viagra doesn’t work for them, and Cialis works better, or the other way around. It really is a patient’s choice in the end.

There’s another way to take Cialis, a third option that we give, and that’s the daily regimen. 20 milligrams is the maximum daily dose of this 36-hour pill, but there is also the 5-milligram pill, a quarter of the normal dose, that’s taken every day at about the same time. Just like your cholesterol medication you take every day. It works by slowly reaching up a level, so within about a week or so you are at that level, and because you’re taking a lower dose slowly, the side effects will be less significant. The other advantage is, you won’t have to remember to take the pill at the right time.

The medication is constantly in your system, and you’re always ready to go, so you won’t have to remind yourself that “Well, I have this date tonight, and I must take this pill now because it’s an hour or two hours in advance” and then your date doesn’t show up, and you say “Damn, I just wasted a pill.” You just take the medication every day, and it actually takes some of the pressure off.

The foolproof way to spoiling sex is by stressing about it. So, taking the pill every day and not stressing about the schedule may be the best course of action. And that’s what I tell all my patients.

So, if you choose to go for the daily regimen, within a week or two, it normalizes your erectile function. It is as effective as a full dose of Cialis or a pill of Viagra, but you have taken off the planning aspect, and that can be very helpful in certain relationships.

I always try to see what’s best for each patient. If you are a young individual who has sex a few times a week and you can’t always plan what’s going to happen, take a daily dose of Cialis. If you are a sixty-five-year-old man, who already knows that sexual intercourse will happen every first Tuesday of the month and you can plan it in advance, then Viagra is an excellent option. There’s no telling which one is more effective. It all goes to what you want, your lifestyle, how you’re able to plan, and things like that.

And what about the side effects?

These medications have the same side effects, and they are usually not dangerous. The most common side effects are sore muscles and/or sore back, headaches, a little upset stomach, a feeling of flushing in the face, and sometimes visual disturbances, like a little, blue-tinted vision. Patients may often experience these side effects once after taking the pill, maybe a few more times, but they frequently decrease in intensity or completely go away over the course of treatment.

Some patients, on the other hand, can’t tolerate these adverse reactions, and when they try Viagra, they feel horrible, but after taking Cialis, they don’t experience any side effects, so they will go with that pill. Of course, sometimes it happens the other way around – some patients have bad reactions to Cialis but take Viagra without any issues.

One question people often ask me is “Can it damage my heart?” It’s not bad for your heart. In fact, some doctors believe that a daily dose of ED medicine or at least regular use thereof may actually be good for the heart. I know a cardiologist who’s taking it.

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