What are the next steps for a 55-year-old male with erectile dysfunction (ED) who is not responding to Viagra (sildenafil) 50mg?

Management of Erectile Dysfunction Not Responding to Sildenafil 50mg

For a 55-year-old male with erectile dysfunction not responding to sildenafil 50mg, the next step should be to increase the dose to 100mg, as higher doses have shown improved efficacy without significantly increasing adverse effects. 1, 2

Assessment Before Dose Adjustment

Before adjusting medication, ensure:

1. Proper medication use: Many treatment failures occur due to incorrect use 3

   • Verify patient is taking medication on an empty stomach
   • Confirm adequate sexual stimulation is occurring
   • Ensure patient has tried at least 5 separate occasions at current dose 1

2. Medical evaluation:

   • Check for testosterone deficiency (total testosterone <300 ng/dL) 3
   • Assess cardiovascular risk factors (ED is a risk marker for cardiovascular disease) 3, 1
   • Review current medications that may interfere with PDE5i efficacy

Treatment Algorithm

Step 1: Optimize Current PDE5i (Sildenafil)

• Increase to 100mg dose - Research shows sildenafil 100mg improves sexual experience, reduces anxiety, and increases treatment satisfaction compared to 50mg 2
• Studies demonstrate that sildenafil at doses up to 200mg can be effective as salvage therapy for previous non-responders 4
• Allow for multiple trials (at least 5) at the higher dose before declaring treatment ineffective 1

Step 2: If Higher Dose Sildenafil Fails

Consider these alternatives:

1. Try alternative PDE5i:

   • Tadalafil (5-20mg as needed or 2.5-5mg daily) 1
   • Vardenafil (5-20mg as needed) 1
   • Avanafil (50-200mg as needed) 1

2. Combination therapy:

   • If testosterone deficiency is present (total testosterone <300 ng/dL), add testosterone therapy with PDE5i 3
   • PDE5i combined with other therapies may be more effective than PDE5i alone 3

3. Alternative treatment modalities:

   • Vacuum erection device (VED) 3, 1
   • Intracavernosal injection therapy 3, 1
   • Penile prosthesis (for cases refractory to all other treatments) 1

Important Considerations

Safety Precautions

• Monitor for adverse effects with higher doses, which may include headache, flushing, dyspepsia, nasal congestion, and visual disturbances 4
• Ensure patient is not taking nitrates (absolute contraindication) 1
• Use with caution if patient is on alpha-blockers 1

Addressing Underlying Factors

• Lifestyle modifications (weight loss, smoking cessation, physical activity) can improve erectile function 3, 1
• Consider psychological factors that may contribute to ED and refer for psychosexual counseling if appropriate 3

Follow-up Plan

• Reassess treatment response after 4-6 weeks on the higher dose 1
• If response remains inadequate after multiple attempts with optimized PDE5i therapy, proceed to alternative treatment options

The evidence strongly supports increasing sildenafil to 100mg as the most appropriate next step, with studies showing 24-68% of previous non-responders may benefit from higher doses 2, 4.