Dear Dr G,

I am a patient who has suffered from erectile dysfunction (ED) for several years.

Admittedly, my doctor tells me the causes of my ED is due to an unhealthy lifestyle.

After years of indulgence, I now have high blood pressure and cholesterol.

In the last few clinic visits, the doctor also detected high glucose levels.

My doctor says it is the disease process that caused my sexual dysfunction; personally, I blame the medicine I take for my medical conditions.

Despite my medical conditions, my doctor assures me it is safe for me to take medications to improve my erection.

After months of hesitancy, I started taking the blue pills.

On several occasions when I took the pills, I don’t seem to get an erection fast enough for sexual activities.

Most frustratingly, I managed to get a hard-on several hours later when the mood for love was long gone.

I went back to the doctors who asked me to change the pills to the latest impotence pills in the market, as it is branded “new generation”.

I am hesitant to try the new medications as I do not want it to be experimental.

On that note, I am putting Dr G on the spot for your opinion on this new blue horizon for the treatment of ED.

First of all, can you tell me what is the exact cause of my erectile dysfunction?

I understand there are several pills in the market?

How do these pills work and what are the differences between them?

Appreciate the clarification.


Optimal Oliver

Erectile dysfunction (ED) is defined as an inability to achieve or maintain erectile rigidity during sexual intercourse.

This medical condition is well recognized to be associated non-communicable diseases such as hypertension, dyslipidemia and diabetes.

The recent Health and Morbidity Survey Malaysia revealed the prevalence of this sexual dysfunction affects one in three men, likely to be related to the worsening general health of the population.

However, other correlations such as smoking, alcoholism, side effects of many medications, and needless to say, anxiety and stress are major obstacles in providing and sustain the erection.

The accidental discovery leading to the FDA approval of the blue pills in March 1998 had essentially altered the landscape of the treatment of ED.

The compound PDE5-I (Phosphodiesterase 5 Inhibitor) initially intended for the treatment of hypertension in the United Kingdom, is now the game changer for the treatment of men with ED. When the trial was observed to be ineffective for the control of blood pressure, the “desirable” side effect of erection enhancement was accidentally observed.

This lead to the first line of oral therapy for the treatment of ED, and the rest is history.

Twenty-six year since the introduction of the blue pills, many couples have benefited from awakening of their sexual relationship, regardless of the etiology of the ED. The development of other PDE5-I has also evolved to provide a range of other medications to suit different needs in the bedrooms.

Five different types PDE5-I are now available in Malaysia, namely Sildenafil, Tadalafil, Vardenafil and Udenafil, and the latest being Avanafil. The mechanism of action of all the formulary are all the same, however, it is the difference in pharmacokinetics that determines different drug characteristics.

All five medications share the common ability to enhance the blood flow to the penis, with overall efficacy around 80%. Technically, the characteristics that distinguish the drugs from each other are the pharmacokinetics determining speed of onset, duration of actions and the degree of attachment of the receptors.

The speed of onset is determined by the T(max), time for the drug to achieve its maximum concentration. Generally, the fastest onset of the medication is around thirty minutes, but some may take up to two hours to see the effect. Therefore, this knowledge allows men to work out the optimal time to “ride” the wave.

The so-call newer generation of PDE5-I essentially is fine-tuning the timing of onset and duration of action. The half-life of up to 17 hours, technically allowing spontaneous erection in much longer duration.

Studies demonstrated that more than 70% of men still enjoy the efficacy of the medication six hours after consumption.

The fast Tmax of up to 30 minutes of Avanafil also demonstrated speed of action in 15 minutes after consumption in more than 80% of patients.

Although the onset and duration of action for the all five PDE5-Inhibitors are variable, the ability of achieving satisfactory erection remains the same for all, even the new kid on the block.

Twenty-six years since the discovery of the blue pills has allowed the evolution of the medicine into different forms, with different timing to act, but the same outcome of hardness.

Although some may view this as an unnatural act of lovemaking, others would consider this as a gift with fine-tuning of bespoke action of love.

Many men with no real understanding of the characteristics of the pills may face the obstacles of not “riding the wave” and fail to seize the maximum potential of the medicine.

The American baseball player, Yogi Berra widely regarded as one of the greatest catchers in baseball history once said: “You don’t have to swing hard to hit a home run. If you’ve got the timing, it’ll go!”

When men enticed by the new blue horizon in the market put Dr G on the spot, his advise is, “The new pills are not for a harder swing, it is more like a fine-tuning of timing for the new blue horizon”.

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