What Is the Best ED Medication for Men With High Blood Pressure?
No trial ranks the four tablets in men with hypertension. The labels and two sildenafil trials do show which blood pressure drugs need care and which are rarely an issue.
The short version
- In two randomized trials of men taking two or more blood pressure drugs, sildenafil improved erections (71% vs 18% on placebo in the larger one).12
- Label studies show single-digit extra blood pressure drops with amlodipine, enalapril, metoprolol and thiazides, and tadalafil 20 mg with angiotensin receptor blockers showed 8/4 mmHg.345
- Alpha-blockers need the most care: all four labels call for stable alpha-blocker therapy and the lowest starting dose.3465
- Nitrates are contraindicated with every ED tablet, and labels advise against use when blood pressure is uncontrolled.3465
No ED tablet is the single best choice for high blood pressure. Sildenafil, tadalafil, vardenafil and avanafil all lower blood pressure a little, and each label says they can be used with most blood pressure medicines when a prescriber has reviewed the list.3465 Sildenafil is the one tested in randomized trials of men taking two or more blood pressure drugs, and it improved erections in both.12 What decides the choice is usually which blood pressure medicines you take (alpha-blockers need the most care), whether your pressure is controlled, and whether you take a nitrate.
This guide sets out what the labels and trials say, class by class. It does not rank the four tablets, because no trial compared them in men with hypertension.
Is it safe to take an ED pill with blood pressure medicine?
Usually, with a prescriber's review. PDE5 inhibitors are mild vasodilators, so every label warns they can add to the effect of blood pressure drugs.3465 In the label studies the extra drop was small for most drug classes, but larger for alpha-blockers, and the one hard stop is a nitrate.
Two points matter before anything else. First, nitrates in any form (nitroglycerin, isosorbide) are contraindicated with all four tablets, because blood pressure can fall dangerously.345 Second, the labels say these drugs are not recommended, or have not been studied, in men whose blood pressure is not controlled. The sildenafil label lists pressure above 170/110 mmHg, the vardenafil label the same, and the avanafil label above 170/100 mmHg; the tadalafil label names uncontrolled hypertension.3654 Treating the blood pressure first is part of the answer.
What did the trials show in men taking blood pressure medicine?
A randomized, double-blind trial enrolled 568 men with ED and hypertension who were taking two or more blood pressure drugs. At six weeks, 71% of those on sildenafil reported improved erections against 18% on placebo, and results did not differ between men on two drugs and men on three or more. Adverse events were reported by 40% on sildenafil and 25% on placebo, and fewer than 2% in each group stopped treatment because of them.1 A second, smaller randomized trial of 120 Brazilian men on two or more blood pressure drugs found 87% on sildenafil reported improved erections against 37% on placebo, with no significant change in blood pressure measurements in either group.2
Both trials were short, and the larger one had Pfizer-affiliated authors, so they show that sildenafil was tolerated over weeks, not years. They do not tell us tadalafil, vardenafil or avanafil would do better or worse.
How do the four tablets compare with each class of blood pressure drug?
Each manufacturer ran its own interaction studies with different doses and designs, so the numbers below describe separate studies and should not be compared across rows. The label tables are the best direct evidence on how much extra blood pressure drop to expect.
| Medicine | Blood pressure drug tested | Reported extra drop |
|---|---|---|
| Sildenafil 100 mg | Amlodipine, in hypertensive patients | 8 mmHg systolic, 7 mmHg diastolic3 |
| Tadalafil 10 mg | Amlodipine | 3/2 mmHg4 |
| Tadalafil 10 mg | Enalapril | 4/1 mmHg4 |
| Tadalafil 10 mg | Metoprolol | 5/3 mmHg4 |
| Tadalafil 10 mg | Bendrofluazide (a thiazide diuretic) | 6/4 mmHg4 |
| Tadalafil 20 mg | Angiotensin receptor blockers, alone or in a multi-drug regimen (ambulatory readings) | 8/4 mmHg4 |
| Avanafil 200 mg | Amlodipine and enalapril | 3 to 5 mmHg additional reduction5 |
| Vardenafil | Label lists the interaction for antihypertensives generally | Specific class figures were not found in the label text reviewed6 |
The pattern is that common blood pressure drugs (calcium channel blockers, ACE inhibitors, angiotensin receptor blockers, beta-blockers, thiazides) produced single-digit extra drops in these studies. That is why the labels say to discuss the combination rather than forbid it. The studies mostly used healthy volunteers or stable patients, so a man who already runs low or feels faint on standing is not represented by these numbers.
Why do alpha-blockers need extra care?
Alpha-blockers (doxazosin, tamsulosin and similar, often prescribed for blood pressure or an enlarged prostate) are the exception. All four labels say the two classes together can lower blood pressure enough to cause symptomatic hypotension, such as dizziness or fainting.3465 The labels advise that a man be stable on the alpha-blocker before starting the ED tablet, and that the tablet start at the lowest dose: 25 mg for sildenafil, 5 mg for vardenafil and 50 mg for avanafil, with the lowest recommended dose for tadalafil.3465
The tadalafil label adds that it is not recommended for the combination with an alpha-blocker used for prostate symptoms, because efficacy has not been adequately studied and because of the blood pressure effect.4 If you take an alpha-blocker, tell the prescriber before ordering anything.
Could the blood pressure medicine itself be the problem?
Sometimes, but less often than people assume. A network meta-analysis of randomized trials found no major class of blood pressure drug differed significantly from placebo for erectile function, though most trials had a high risk of bias.7 In the TOMHS trial, men on the thiazide chlorthalidone reported more erection problems at two years than men on placebo, a gap that was no longer significant by four years.8 High blood pressure itself damages blood vessels and is a more established cause of ED.9
If ED began soon after a new blood pressure drug, raise that with the prescriber rather than stopping the drug yourself. Our guide to ED medication with the least side effects covers the side effects of the tablets themselves.
Which tablet suits which situation?
No trial supports naming a winner, but the labels point to practical differences.
- Taking an alpha-blocker: every label calls for stability first and the lowest dose, so the tablet matters less than the starting dose and the follow-up.3465
- Several blood pressure drugs: the only randomized evidence for this group is for sildenafil.12
- Taking tadalafil once daily: the label says daily use gives continuous drug levels, so interactions with antihypertensives deserve more thought than with an as-needed tablet.4
- Also managing diabetes or age-related issues: see our guides on ED medication for men with diabetes and men over 60.
- Alcohol: the avanafil label cites more than 3 units and the tadalafil label 5 units or more as amounts that can add to blood pressure lowering.54
What should you ask before getting a prescription?
- Is my blood pressure controlled well enough for this, and what were my last readings?36
- Do I take an alpha-blocker, a nitrate or more than one blood pressure drug?34
- Which dose should I start with, and what symptoms mean I should stop and call (dizziness, fainting, chest pain)?
- Does my heart condition make sexual activity unsafe? The AUA guideline treats ED as a prompt to look at overall health.10
- What do I do if an erection lasts more than four hours?34
A telehealth service helps only if its screening asks these questions; our guide to online prescriptions for Viagra lists what a proper check includes.
What this article does not cover
This guide covers FDA-approved oral tablets. Compounded versions are not FDA-approved.11 The interaction studies are small, short and sponsored by manufacturers, and the hypertension trials tested sildenafil only. Men with heart failure, recent heart attack or stroke, or very low or very high blood pressure need an individual assessment from a licensed clinician.
Frequently asked questions
What is the best ED medication for high blood pressure?
No label or trial names one best drug. Sildenafil has randomized trials in men on multiple blood pressure drugs; all four tablets can be used with most blood pressure medicines after a prescriber reviews the list.
Can I take Viagra with blood pressure pills?
Often, with review. In a label study, sildenafil 100 mg with amlodipine lowered blood pressure by an extra 8/7 mmHg. Nitrates are never allowed, and alpha-blockers need a low starting dose.
Is tadalafil safe with high blood pressure medicine?
The Cialis label reports small extra drops with amlodipine, enalapril, metoprolol, a thiazide and angiotensin receptor blockers, and tells prescribers to discuss the combination with patients.
Which blood pressure medicines cause ED?
A network meta-analysis found no major class clearly differed from placebo, though trial quality was weak. Thiazides showed a signal in TOMHS at two years that was gone by four years.
Can ED pills be used if my blood pressure is not controlled?
Labels do not recommend them above 170/110 mmHg (170/100 for avanafil) or with uncontrolled hypertension, so blood pressure control usually comes first.
Related reading
Sources
- Pickering TG, et al. Sildenafil citrate for erectile dysfunction in men receiving multiple antihypertensive agents: a randomized controlled trial. Am J Hypertens. 2004. PubMed.
- Albuquerque DC, et al. Efficacy, safety and tolerability of sildenafil in Brazilian hypertensive patients on multiple antihypertensive drugs. Int Braz J Urol. 2005. PubMed.
- Pfizer. VIAGRA (sildenafil citrate) prescribing information. DailyMed, U.S. National Library of Medicine.
- Eli Lilly. CIALIS (tadalafil) prescribing information. DailyMed, U.S. National Library of Medicine.
- Metuchen Pharmaceuticals. STENDRA (avanafil) prescribing information. DailyMed, U.S. National Library of Medicine.
- Teva Pharmaceuticals USA. Vardenafil hydrochloride tablets prescribing information. DailyMed, U.S. National Library of Medicine.
- Farmakis IT, et al. Effects of major antihypertensive drug classes on erectile function: a network meta-analysis. Cardiovasc Drugs Ther. 2022. PubMed.
- Grimm RH Jr, et al. Long-term effects on sexual function of five antihypertensive drugs and nutritional hygienic treatment in hypertensive men and women (TOMHS). Hypertension. 1997. PubMed.
- National Institute of Diabetes and Digestive and Kidney Diseases. Erectile Dysfunction (ED). National Institutes of Health.
- American Urological Association. Erectile Dysfunction (ED) Guideline.
- U.S. Food and Drug Administration. Compounding and the FDA: Questions and Answers.