ED Medication and Blood Pressure: What's Safe?

How much ED medication lowers blood pressure

Sildenafil and tadalafil relax the smooth muscle in blood vessel walls. That's how they help erections, and it also means vessels elsewhere relax a little, so blood pressure dips.

The FDA labels put numbers on it. In healthy men, a 100 mg dose of sildenafil lowered blood pressure by about 8 points on the top number and 5 on the bottom, and it came back up as the dose wore off. Tadalafil at 20 mg barely moved it: the difference from placebo was under 2 points.

For perspective, standing up too fast after a long Florida beach day can do more than that. Most men never notice the dip at all, though a little flushing or a mild headache is the same effect showing up in a different place.

Can I take ED medication with blood pressure medicine?

Usually yes. High blood pressure is one of the most common reasons men have ED in the first place, so plenty of men take both. The labels tested common combinations and found modest extra drops:

• Amlodipine (a calcium channel blocker) with sildenafil 100 mg: about 8 extra points on top and 7 on the bottom.
• ARBs like losartan with tadalafil 20 mg: about 8 points on top and 4 on the bottom in round-the-clock monitoring.
• Enalapril, metoprolol and water pills with tadalafil 10 mg: roughly 4 to 6 points on top.

Those numbers are why your provider wants your full medication list, and why the first dose is often a lower one when you already take two or three blood pressure medicines. It's arithmetic more than danger, and the arithmetic matters.

Why you can't take ED medication with nitrates

This one is a hard stop on every label. Nitrates (nitroglycerin tablets or spray, isosorbide, and amyl nitrite "poppers") work on the same blood vessel pathway from the other side. Together with sildenafil or tadalafil, blood pressure can fall low enough to cause fainting, a heart attack or a stroke.

The American Heart Association's guidance says nitrates shouldn't be given within 24 hours of sildenafil, or within 48 hours of tadalafil, because tadalafil stays in the body much longer. The same kind of warning applies to riociguat, a medicine for lung blood pressure, whose own label lists ED medicines as a contraindication.

Alpha-blockers: the combination that needs a plan

Alpha-blockers like tamsulosin, doxazosin, terazosin and alfuzosin relax blood vessels and the prostate. Many men take one for urinary symptoms. Stacked with ED medication, the blood pressure drop adds up, and the sildenafil label showed an extra drop of about 8 points on top with doxazosin.

The fix is planning, and it rarely means no. The sildenafil label says men should be stable on the alpha-blocker before starting and should begin with the lowest dose. The tadalafil label also advises caution. Your provider may adjust the dose or the timing between the two.

Is ED medication bad for your heart?

For men with stable heart disease, the American Heart Association says PDE5 inhibitors (the drug family that includes sildenafil and tadalafil) are useful for treating ED. The bigger question is whether your heart is ready for sexual activity itself, which is a bit like asking whether it's ready for a brisk walk up a couple of flights of stairs.

The tadalafil label lists the groups that weren't included in its studies and for whom it isn't recommended: a heart attack within the last 90 days, unstable chest pain or chest pain during sex, heart failure that causes symptoms with ordinary activity or worse (NYHA class 2 or higher) in the last 6 months, uncontrolled heart rhythm problems, blood pressure below 90/50, uncontrolled high blood pressure, or a stroke within the last 6 months.

ED can also be an early clue to heart disease itself, sometimes showing up years before heart symptoms. If your history suggests that, we'll say so and suggest the right checks.

Alcohol, dizziness and other everyday details

The tadalafil label warns that heavy drinking (5 or more drinks) plus tadalafil can make you dizzy or lightheaded when you stand. Alcohol also makes ED worse on its own, so a lighter evening helps on two fronts.

• Stand up slowly the first few times you take a new ED medicine, especially if you're also on blood pressure medicine.
• Stay hydrated. Dehydration and heat stack with the dip, and Florida supplies plenty of both.
• Never double up or take two ED medicines on your own to make up for a dose that didn't work.

What if my blood pressure already runs low?

Men with naturally low blood pressure, or men who are older, dehydrated or on several medicines that lower it, feel the dip more. The tadalafil label specifically flags blood pressure below 90/50 as a group it isn't recommended for, and the same caution makes sense for sildenafil.

Low and steady usually isn't a problem in daily life, and plenty of fit men run there. It just means the starting dose and the timing deserve more thought, and that you should know what lightheadedness feels like before it surprises you.

• If you feel dizzy after a dose, sit or lie down right away and raise your legs.
• Sip water, skip the second drink, and give it 15 to 20 minutes.
• Fainting, chest pain, or dizziness that doesn't settle means call 911 and tell them what you took.

Then tell your provider, even if it passed. A dose that's slightly too strong is easy to adjust, and with a scored troche it often doesn't even need a new prescription.

How we check before prescribing

Before anything is prescribed, Chris reviews your blood pressure history, heart history and every medication and supplement you take, including the ones that seem too minor to mention. If a combination needs a lower starting dose or a different medicine, he'll say so. If ED medicine isn't the right call, he'll tell you that too.

Our sildenafil and tadalafil troches are compounded by a state-licensed 503A pharmacy, scored so the dose can be set lower, and kept inside the FDA-approved dose range for the tablets. Compounded medications are not FDA-approved, and the FDA does not review them for safety, effectiveness or quality. You can compare the options side by side on our sexual wellness page.

Sources & further reading

• FDA prescribing information: sildenafil citrate tablets
• FDA prescribing information: tadalafil tablets
• American Family Physician: AHA statement on sexual activity and cardiovascular disease
• NIDDK: Symptoms and Causes of Erectile Dysfunction
• Princeton III Consensus (Mayo Clinic Proceedings, 2012): ED and cardiovascular disease