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The first and most important precaution involves nitrate drugs, including prescription drugs used for angina, which are taken in a variety of different ways: under the tongue, in pills, skin patches, through inhalers, or intravenously. The precaution also applies to the “recreational” use of inhaled nitrates, often referred to as “poppers.” This warning applies to all nitrates and all ED pills, and the rule is simple: they don’t mix. The problem is a potentially life-threatening fall in blood pressure. Men should not take a nitrate within 24 hours of using Viagra or Levitra or within 48 hours of taking Cialis, which stays in the body longer than the others.

Another concern is the potential interaction between ED pills and the alpha blockers used for benign prostatic hyperplasia (BPH). Although ED and BPH are separate entities, both conditions are common, especially in older men. The main worry is low blood pressure, but it’s a much greater concern with the older alpha blockers terazosin (Hytrin, generic) and doxazosin (Cardura, generic) than with the newer, uroselective medications tamsulosin (Flomax), alfuzosin (UroXatral), and silodosin (Rapaflo). The best advice for men with BPH and ED is to use a uroselective alpha blocker in the lowest dose that will control BPH symptoms, and then after a stable dose is established, to carefully begin using an ED pill, starting with the lowest dose and gradually increasing it if needed. Tadalafil appears less likely to interact with alpha blockers than other ED pills. It seems prudent for men who use both types of medications to take them at separate times, perhaps six hours apart.