What is the recommended dose of tadalafil (Cialis) to take before sexual activity?

Tadalafil Dosage for Erectile Dysfunction

The recommended starting dose of tadalafil for use as needed in most patients is 10 mg taken prior to anticipated sexual activity, which may be increased to 20 mg or decreased to 5 mg based on individual efficacy and tolerability. 1

Dosing Options

• Tadalafil can be taken either as needed before sexual activity or once daily, depending on patient preference and sexual activity patterns 1
• For as-needed use:
  • Start with 10 mg taken prior to anticipated sexual activity 1
  • Dose may be adjusted between 5-20 mg based on response and side effects 1
  • Maximum recommended dosing frequency is once per day 1
• For once-daily use:
  • Start with 2.5 mg taken at approximately the same time every day 1
  • May be increased to 5 mg based on efficacy and tolerability 1
  • Eliminates the need to time medication with sexual activity 2

Timing Considerations

• Tadalafil for as-needed use has been shown to improve erectile function compared to placebo for up to 36 hours following dosing 1, 3
• Most patients take advantage of this extended window of efficacy, with studies showing that ≥53% of patients attempt intercourse 12-36 hours after taking tadalafil 4
• Unlike other PDE5 inhibitors, tadalafil can be taken without regard to food 1

Efficacy Considerations

• High-quality evidence shows that tadalafil significantly improves erectile function compared to placebo, with 69% of men using tadalafil as needed reporting successful sexual intercourse attempts compared to 33% with placebo 2
• Both 10 mg and 20 mg doses significantly improve erectile function at both 24 and 36 hours after dosing compared to placebo 3
• Improvement in erectile function with tadalafil is not strongly dose-dependent between 5-20 mg, unlike some other PDE5 inhibitors 2

Special Populations

• For patients with renal impairment:
  • Creatinine clearance 30-50 mL/min: Start with 5 mg not more than once per day, maximum 10 mg not more than once every 48 hours 1
  • Creatinine clearance <30 mL/min: Maximum 5 mg not more than once every 72 hours 1
• For patients with hepatic impairment:
  • Mild to moderate impairment: Dose should not exceed 10 mg once per day 1
  • Severe impairment: Use is generally not recommended 2

Common Pitfalls and Caveats

• Sexual stimulation is necessary for tadalafil to be effective; incorrect use accounts for a large percentage of treatment failures 2
• An adequate trial of tadalafil should include at least 5 separate occasions at the maximum tolerated dose before reporting it as ineffective 5
• PDE5 inhibitors like tadalafil are absolutely contraindicated with nitrate medications due to the risk of severe hypotension 5, 1
• The most common adverse events include headache, dyspepsia, back pain, nasal congestion, and myalgia 2, 6
• Patients with cardiovascular risks should be assessed before prescribing PDE5 inhibitors; those who cannot perform exercise equivalent to walking 1 mile in 20 minutes should be referred to a cardiologist before treatment 5

Clinical Pearls

• Tadalafil may be taken without regard to food, offering greater flexibility 1
• Daily dosing provides an alternative for couples who prefer spontaneous rather than scheduled sexual activity 2, 7
• Tadalafil tablets should not be split; the entire dose should be taken 1
• For men with ED and testosterone deficiency, combining tadalafil with testosterone therapy may be more effective than tadalafil alone 2