Here’s What To Do When You Can’t Take Viagra

blue pills in dose pack
Katie Mui
Katie Mui is on the Research Team at GoodRx.
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Last December, not one, but two generic versions of Viagra (sildenafil) became available in pharmacies. As a result, men can now purchase the erectile dysfunction (ED) treatment for as low as $17 with GoodRx, compared to $72 for the brand version. And although Viagra is an extremely popular medication, with more than 60 million men worldwide having used it since 1998, it’s not the answer for everyone.

Below, Tim Aungst, PharmD and owner of The Digital Apothecary, shares his experience helping patients who are looking for ED treatment outside of Viagra and the class of drugs that work like it (PDE-5 inhibitors).


Consider the case of Mr. Jones, a patient I was helping in an outpatient cardiac clinic.

Most of my patients are on multiple medications for their heart conditions and other complicated issues, so I often review their medications to make sure everything is all right. This includes screening labs, checking vitals, reviewing past reports, and conducting drug interaction checks related to therapy. If there are any concerns, I’ll meet with the patient and make recommendations to the healthcare team.

At his last visit, Mr. Jones was prescribed Imdur (isosorbide mononitrate) to help with his heart condition. Reading through the notes, it looked like the Imdur worked. He was feeling better – so much better that he wanted to start having sex with his wife again.

And here was the problem: Mr. Jone’s doctor had renewed his Cialis (tadalafil) prescription.

Viagra sailing commercial

Viagra commercial with guy on sailboat. Youtube-ing it since I had trouble finding it anywhere else online.

The issue? Well, if you really listen to the advertisements on television for erectile dysfunction (ED) medications, ignoring the jazz from Viagra or the sunsets from Cialis, you may hear the line “Do not take if you take nitrates for chest pain, as it may cause an unsafe drop in blood pressure.” Viagra, Cialis, and Levitra belong to the same drug class called Phosphodiesterase 5 Inhibitors (abbreviated as PDE-5 inhibitors), and they all share the same interaction with nitrates. Many patients wonder how bad can a ‘drop in blood pressure’ be. The answer, as we learned after Viagra came out, is this reaction can lead to heart attack in patients and potentially cause death, leading to a black box warning for the whole class of drugs like Viagra.

Mr. Jones is on a nitrate, specifically Imdur. Fortunately for him, he had not yet used the Cialis. I advised him to avoid the combination, based on his significant cardiac history. But what can patients with ED and taking nitrates do to engage in an active sex life?

There is another drug that came out before Viagra, called alprostadil, available under two brand names: Caverject and Muse. It works by relaxing the penile tissue allowing for easier blood flow leading to an erection. The plus side is it works relatively quickly; the downside is that is not available as a pill.

And there’s the rub. Caverject must be directly injected into the base of the penis to work. Muse is an intraurethral (a fancy way of saying ‘insert via urethra’) version of alprostadil that comes as small pellets that have to be inserted into the urethra by the patient.

For many patients, when I mention there is another option to Viagra and other PDE-5 Inhibitors, their eyes light up, quickly followed by a nervous look as they find that it requires an injection to their penis or inserting something directly into their urethra. At this point, to not completely turn off the patient, I do try to get some information in to help them make a decision.

While both Caverject and Muse share the same active ingredient, there are some pros and cons of each. Caverject tends to work much faster (<10 mins) as it enters the bloodstream quicker, and has been found to work better. The drawback though is that it is an injection that needs to be applied to the base of the penis, and can cause irritation to the surrounding tissue. And let’s be honest, most men don’t want to engage in sex with a bruised member. It has a higher risk of causing priapism (basically an erection lasting for more than 4 hours, which incidentally is named after Greek god Priapus).

Muse, on the other hand, can cause a burning sensation to the penis along the urethra (this happens around 20% of the time) and it takes a little longer to work than the injectable formulation. But for men that don’t want a needle in their penis, it is an alternative. For this reason, I generally recommend starting with Muse prior to moving onto Caverject.

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You’re probably wondering why alprostadil can’t just be applied directly to the penis as a topical agent instead of directly injecting or inserting it. A study conducted in 2006 in 1732 patients using a topical formulation did demonstrate some efficacy (though less than Caverject or Muse). Common side effects were burning sensation (for both men and women) though this was relatively low, with only 2.7% of subjects stopping its use. Currently, drug manufacturer Apricus Biosciences is looking to bring this formulation, named Vitaros, to market in the US (it’s currently available in Europe) but FDA approval has been slow. When and if this formulation makes it to the US market, it may be preferred by men who cannot take PDE-5 inhibitors.

Talking to Mr. Jones and those like him about these options takes some time and often requires some trial and error to find what works. At this point, I usually recommend most men to start with Muse and see if they have success with it, and if not they can move on to Caverject (they both run at about $75-$105 a dose). Some men are fine starting with Caverject right away and don’t mind the administration, but I would say it comes down to personal preference on what side effects are manageable for the patient.

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