Tadalafil (Cialis) alternatives: What can I take instead of tadalafil?

Compare tadalafil alternatives | Viagra | Stendra | Staxyn | Caverject | Muse | Natural alternatives | How to switch meds

While it may feel like a taboo topic, erectile dysfunction (ED) is a very common men’s health concern in middle-aged and older men; so much so that as many as 30 million men in the United States suffer from the disorder. Erectile dysfunction is a type of sexual dysfunction and may also be called impotence. 

By definition, ED is persistent (at least three months) or recurrent failure to maintain an erection to allow for a satisfactory sex life. Men may be slow to seek medical advice about this. Still, they should get past any embarrassment since it is so common and manageable with several treatment options! Reversible causes may exist, ranging from damage from medical conditions like high blood sugar or high blood pressure to nerves and blood vessels that allow the blood flow required to have an erection, medications, psychogenic causes, tobacco or alcohol use, and sleep disorders. Many treatment modalities exist if reversible causes have been investigated and managed without improvement or irreversible causes are present—like spinal cord injuries, surgery, or radiation therapy. 

Treatment of erectile dysfunction with medications like Cialis—or its generic version, tadalafil— can increase the blood flow required to have and maintain an erection. While it may serve as effective ED treatment for some men, it may be ineffective for others, come with intolerable side effects, or interact with other medications. Here, we will compare Cialis (tadalafil) with other alternatives in the management of ED.

What can I take in place of tadalafil?

Cialis, which is the brand name of tadalafil, is in the drug class called phosphodiesterase type 5 (PDE5) inhibitors. The active ingredients in these medications work by releasing nitric oxide (NO), which has downstream effects to produce smooth muscle relaxation and increased blood flow to the penis. This drug class is considered first-line for patients with erectile dysfunction. PDE5 inhibitors can be a confusing class of drugs since different brand names of the same PDE5 inhibitor can have different indications. For the ED indication, at recommended doses, these prescription drugs have no effect in the absence of sexual stimulation. They may also require more than one trial to determine efficacy, as well as require dose titrations to balance adverse effects and efficacy. 

The benefits of tadalafil over other medications in the PDE5 inhibitor class in terms of lowest adverse effects include the least likely to cause flushing. Tadalafil also comes with the longest duration of action and can be taken once daily or used as needed. Other medications in this drug class come with some nuance between them, but alternatives are available to those who do not respond or cannot take these medications—such as those taking nitrates for a heart condition called angina due to the potential of causing life-threatening low blood pressure. Alprostadil (prostaglandin E1) allows for another mechanism to increase penile blood flow and improve erectile function. These options may be more suitable for certain individuals due to their different uses and side effect profiles. 

Top 5 tadalafil alternatives

The following are some of the most common alternatives to tadalafil.

1. Viagra (sildenafil)

Sildenafil is another PDE5 inhibitor, similar to tadalafil. It is best known by its brand name, Viagra, but is available as a generic medication. Sildenafil is available as another branded medication, known as Revatio, which is specific to be used for pulmonary arterial hypertension. Sildenafil tablets are available in 25, 50, and 100 mg tablets. To take effect, sildenafil can be taken as long as 4 hours prior to sexual activity and as short as 30 to 60 minutes beforehand. The cost of generic sildenafil makes this stand out as an ED medication option; tablets are generally the least expensive compared to other PDE5 inhibitors. However, sildenafil is more likely to cause the side effects of visual impairment in comparison to the other medications in this drug class, including blurred vision, impaired color perception, or a color tinge to vision.

2. Stendra (avanafil)

Avanafil, known by its brand name Stendra, is yet another member of the PDE5 inhibitor class of erectile dysfunction medications. What sets this option apart from others in the class is its shortest onset of action—as soon as 15 minutes after taking it. Avanafil is also the least likely of members of this drug class to cause stomach upset or dyspepsia. It comes with a lower risk of causing myalgias than other PDE5 inhibitors. In patients receiving hemodialysis or severely impaired renal or hepatic impairment, Stendra is not the best option for ED. Tadalafil has more dosing recommendations available for patients with renal dysfunction, but also should be avoided in patients with severe liver dysfunction. 

3. Staxyn (vardenafil)

Staxyn (vardenafil) is a unique PDE5 inhibitor in that it is available as an orally disintegrating tablet. It should be taken about 1-hour before sexual intercourse to achieve the desired effect. This may be a good option for people who have trouble swallowing pills.

4. Caverject (alprostadil)

Alprostadil intracavernosal injection is a second-line option to PDE5 inhibitors in ED medications for those who cannot tolerate or receive them due to drug interactions or side effects. Alprostadil is a prostaglandin that causes vasodilation, or widening of blood vessels, with localized injection allowing blood flow and entrapment in the penis. To use this product, the intended injection site must first be swabbed with an alcohol wipe before injecting into the penis, avoiding any visible veins. With continued use, alternate sides of the penis should be injected. 

Doses are individualized but should not exceed 60 mcg. The initial dose must be titrated in a healthcare provider setting so that if there is no response to the initial dose, the next higher dose may be given within one hour. If there remains no response after that second trial, one must wait one day until the next dose is given. Once a dose with good effect has been identified, patients may self-administer injections at a frequency no more than three times per week with at least 24 hours between doses. This is in comparison to PDE5 inhibitors, which can usually be taken every 24 hours. The initial doses are to be administered in a healthcare setting because the intracavernous injections can increase peripheral blood levels, resulting in low blood pressure. 

Like PDE5 inhibitors, alprostadil can also cause priapism or a prolonged erection. Immediate medical attention should be sought if an erection lasts longer than four hours, and always use the lowest effective dose.

5. Muse (alprostadil)

Alprostadil is also available for administration directly into the urethra under the brand name Muse. The dose ranges from 125 to 250 mcg and may be increased or decreased until the patient achieves a sufficient erection for sexual intercourse. These alprostadil formulations can cause localized side effects, in comparison to PDE5 inhibitors, including penile pain, and specifically with Muse urethral pain may be experienced. Alprostadil should be taken instead of, not in addition to, PDE5 inhibitors. 

Natural alternatives to tadalafil

Non-pharmacologic measures do play a significant role in the management of erectile dysfunction. Modification and optimal management of reversible health conditions and causes, in addition to lifestyle changes, may correct erectile dysfunction in some patients. 

For patients with high cardiovascular risk, the use of medication should be avoided since sexual intercourse requires the equivalent cardiac workload needed to walk up two flights of stairs. Therefore, lifestyle changes to incorporate include increased exercise and physical activity, coupled with weight loss if overweight, must be attempted prior to discussion of the addition of medications. These alone may also improve ED. Smoking cessation, minimizing alcohol, and dietary changes (e.g., reduced cholesterol) also may play a role in naturally reversing ED. For patients with psychogenic factors, including stress, performance anxiety, and/or mental illness, a mental health professional and sexual counseling is another non-medication approach. 

For patients unable to take the available pharmacologic options, or wishing to pursue a more natural approach to the management of ED, several vitamins and dietary supplements have been promoted and investigated for erectile dysfunction. Potential vitamins include vitamin B9 (folic acid), vitamin B3 (niacin), vitamin D, vitamin C; supplements to consider include L-arginine, red ginseng, and yohimbe. Ultimately, none of these treatments come with strong evidence for efficacy and may have additional side effects or drug interactions. It is also important to remember that many of these products have not been tested or approved by the U.S. Food and Drug Administration (FDA). 

DHEA, or dehydroepiandrosterone, is an over-the-counter hormone supplement that the body can convert into both estrogen and testosterone. The use of DHEA and increasing testosterone may assist with erectile dysfunction symptoms, but testosterone monotherapy is not recommended for erectile dysfunction treatment, even if the patient has low testosterone. The only treatment of testosterone deficiency syndrome, which is low testosterone levels, plus symptoms of testosterone deficiency, is known to improve sexual function. 

Before using any vitamin or supplement, review any known conditions and medications (prescription and over-the-counter) with a healthcare provider or pharmacist to identify any issues.

Vacuum erection devices (VEDs) may be an option if there is an intolerance or medication contraindication. These create negative pressure to promote blood flow, which is then trapped in the penis by a construction ring. While cumbersome and daunting to think about, up to 90% of patients may achieve functional erections. However, there are known common side effects, such as bruising and painful ejaculation.

How to switch to a tadalafil alternative

There are many nuances between PDE5 inhibitors, including cost, the onset of action, duration of action, and adverse effects. If cost is a concern, using a SingleCare prescription discount card can help with savings at participating pharmacies. Switching between PDE5 inhibitors requires an understanding of comparable doses. Tadalafil 10 mg is similar to sildenafil 50 mg, vardenafil 10 mg, and avanafil 100 mg. Getting the correct dose is essential, so working on managing ED with a healthcare professional is crucial in getting the desired results.