Best Prescription Medications for Erectile Dysfunction Beyond Viagra and Cialis
Vardenafil (Levitra) is the best prescription alternative to sildenafil (Viagra) and tadalafil (Cialis) for erectile dysfunction, offering comparable efficacy with 75-80% of men achieving erections sufficient for penetration and 64-65% successfully maintaining erections for intercourse. 1
Why Vardenafil is the Optimal Alternative
Vardenafil demonstrates superior selectivity and potency compared to sildenafil, making it a highly effective PDE5 inhibitor with proven efficacy across multiple populations 2. The drug works through the same mechanism as other PDE5 inhibitors—enhancing nitric oxide-mediated vasodilation in penile arteries—but with potentially higher selectivity 3, 4.
Efficacy Data
- General ED population: Vardenafil 10-20 mg produces significant improvements in erectile function domain scores (from baseline of 13-14 to 21 at 3 months) compared to placebo (score of 15) 1
- Penetration success: 75-80% achieve erections sufficient for penetration versus 52% with placebo 1
- Intercourse completion: 64-65% successfully maintain erections for intercourse versus 32% with placebo 1
- Effectiveness is maintained across all age groups (<45-65, and ≥65 years) and all races 1
Special Populations Where Vardenafil Excels
Men with diabetes mellitus: Vardenafil 10-20 mg achieves 61-64% penetration success and 49-54% intercourse completion rates, compared to only 36% and 23% with placebo, respectively 1. This represents clinically meaningful improvement in a notoriously difficult-to-treat population 2.
Post-prostatectomy patients: Even in this challenging population, vardenafil achieves 47-48% penetration success and 34-37% intercourse completion versus 22% and 10% with placebo 1, 2.
Key Advantages Over Other PDE5 Inhibitors
- No visual disturbances: Unlike sildenafil, vardenafil does not inhibit phosphodiesterase-6, eliminating the rare but bothersome color vision changes that can occur with Viagra 4, 2
- Rapid onset: The oral dispersible tablet (ODT) formulation can produce successful intercourse in 62.5% of patients within the first 15 minutes after dosing 5
- Convenient administration: The ODT dissolves in seconds without water, allowing discreet use in any circumstance 6, 5
Dosing Strategy
Start with vardenafil 10 mg taken approximately 60 minutes before sexual activity 1. If response is inadequate after at least 5 separate attempts at maximum dose (20 mg), consider this a treatment failure and explore alternative therapies 7.
- Available doses: 5 mg, 10 mg, and 20 mg 1
- The 10 mg ODT formulation offers enhanced convenience without compromising efficacy 6, 5
- Sexual stimulation is necessary for effectiveness 7
Critical Safety Considerations
Absolute contraindication: Never prescribe vardenafil to patients taking any form of nitrates due to risk of potentially fatal hypotension 7. Explicitly ask about all nitrate use before prescribing 7.
Cardiovascular risk assessment is mandatory before prescribing any PDE5 inhibitor 8. Low-risk patients (controlled hypertension, mild stable angina, successful revascularization, uncomplicated past MI, mild valvular disease, NYHA class I heart failure) can safely receive vardenafil 7. Patients unable to perform moderate physical activity require cardiology referral before treatment 7.
Common Adverse Effects
The most frequently reported side effects mirror those of other PDE5 inhibitors and are typically mild to moderate 2:
When Vardenafil Fails: Second-Line Options
If vardenafil proves inadequate after proper trial, the AUA guideline recommends the following hierarchy 8:
Combination Therapy
For men with testosterone deficiency (total testosterone <350 ng/dL), adding testosterone therapy to vardenafil is more effective than vardenafil alone 8, 7. However, testosterone is not effective as monotherapy for ED 8.
Non-Oral Prescription Alternatives
Intraurethral alprostadil (prostaglandin E1): Achieves 64.9% success rate for intercourse, with other studies reporting 29.5-78.1% success 8. Requires in-office test and instruction before home use 8.
Intracavernosal injection (ICI) therapy: Only alprostadil is FDA-approved for single-agent ICI use, though combinations with papaverine, phentolamine, and atropine are commonly used 8. Success rates reach up to 90% but require in-office injection test and detailed counseling 3. The significant attrition rate due to patient inconvenience limits long-term use 3.
Common Pitfalls to Avoid
Many apparent treatment failures are actually inadequate trials 7. Before declaring vardenafil ineffective, verify:
- At least 5 attempts at maximum dose (20 mg) 7
- Adequate sexual stimulation is present 7
- Proper timing (60 minutes before activity) 3
- No heavy alcohol use 7
- No food or drug interactions 7
- Hormonal abnormalities have been addressed 7
Do not combine vardenafil with another PDE5 inhibitor, as this increases risk of severe hypotension without improving efficacy 7.