Treatment of Erectile Dysfunction in Patients Already Taking Cialis 10mg
If you are already taking Cialis (tadalafil) 10mg with inadequate response, increase the dose to 20mg taken as needed, which is the maximum recommended dose and has demonstrated superior efficacy in clinical trials. 1, 2
Dose Optimization Strategy
First-Line Adjustment: Increase Tadalafil Dose
- Escalate from 10mg to 20mg taken prior to anticipated sexual activity 2
- The 20mg dose significantly improves erectile function compared to lower doses, with 64% of patients achieving normal erectile function scores versus 16% with placebo 3
- Maximum dosing frequency remains once per day 2
- Tadalafil remains effective up to 36 hours after dosing, so timing flexibility should be optimized 2
Verify Proper Medication Use Before Escalation
- Confirm the patient is taking tadalafil correctly: on an empty or full stomach (food does not affect absorption), with adequate sexual stimulation, and allowing sufficient time for onset 1, 2
- Education about timing and sexual stimulation requirements can restore effectiveness in many apparent nonresponders 1
Second-Line Options if Maximum Dose Tadalafil Fails
Consider Testosterone Replacement (if hypogonadal)
- Measure morning total testosterone in all PDE5 inhibitor nonresponders 1
- If testosterone is low, testosterone therapy combined with PDE5 inhibitors may restore effectiveness in hypogonadal men 1
- This addresses a common reversible cause of PDE5 inhibitor failure 1
Alternative PDE5 Inhibitor Trial
- Switching between PDE5 inhibitors shows limited evidence but may be considered 1
- Options include sildenafil, vardenafil (including ODT formulation), or avanafil 1
- Selection depends on patient preference regarding onset time and duration of action 1
Combination and Adjunctive Therapies
- Low-intensity shockwave therapy (LI-SWT) combined with daily tadalafil has shown enhanced results in PDE5 inhibitor nonresponders 1
- Antioxidants combined with PDE5 inhibitors may provide additional benefit in complex cases 1
- Vacuum erection devices (VEDs) combined with tadalafil can augment response 1
Third-Line Options for Refractory Cases
Intracavernous Injection Therapy
- Vasoactive drug injection remains highly effective with mean IIEF-EF improvement of 3.21 points versus placebo, and can be used at any stage of treatment 1
- Efficacy rate of 66% in patients self-injecting at home 1
- Lower risk profile than proceeding directly to surgery 1
Intraurethral Alprostadil
- Alternative for patients who are needle-phobic 1
- Lower efficacy than intracavernous injection but suitable for select patients 1
Vacuum Erection Devices
- 90% initial efficacy, though drops to 50-64% at 2 years 1
- Particularly valuable in older patients with infrequent intercourse 1
Penile Prosthesis Implantation
- Reserved for end-stage ED after failure of medical therapies 1
- Technical success rates are high with 80% patient satisfaction 1
- Requires documentation of treatment-refractory ED 1
Critical Considerations and Contraindications
Cardiovascular Safety
- Tadalafil is absolutely contraindicated with nitrate use - nitrates must not be administered within 48 hours of tadalafil due to severe hypotension risk 1
- This is critical in acute coronary syndrome management 1
Dose Adjustments for Comorbidities
- Renal impairment (CrCl 30-50 mL/min): Maximum dose 10mg once every 48 hours 2
- Severe renal impairment (CrCl <30 mL/min): Maximum dose 5mg once every 72 hours 2
- Hepatic impairment (Child-Pugh A or B): Do not exceed 10mg once daily 2
Common Pitfalls to Avoid
- Do not split tadalafil tablets - the entire dose must be taken 2
- Ensure adequate sexual stimulation is occurring, as PDE5 inhibitors are facilitators, not initiators of erections 1
- Address concomitant erectile dysfunction if present, as this commonly causes secondary premature ejaculation 1