What an IIEF point costs that a comment never will
The first thing the sildenafil programme bought was a way to score a private complaint. Without that, 25-100 mg would still be anecdote.
The International Index of Erectile Function is a questionnaire, not a vibe. It scores erectile function, orgasm, desire, intercourse satisfaction, and overall satisfaction. Two items carried the approval weight: ability to get an erection sufficient for intercourse, and ability to keep it after penetration. Answers run from 0 (no attempt) through 5 (almost always). A man filled those for the last four weeks of double-blind treatment after a four-week treatment-free run-in. That is a slow, slightly awkward instrument. It is also why a trial can be repeated.
The Sexual Encounter Profile is even blunter. After each attempt, a man logs whether he got an erection and whether he held it long enough for satisfactory sex. SEP2 and SEP3 still sit under later PDE5 trials. A yes or a no, tallied against placebo across hundreds of men, is a number a forum cannot mint. Sildenafil's US licence stood on that kind of count. The mechanism those scores ride is in the sildenafil signal note.
Goldstein 1998: 25, 50, and 100 mg on a scored ladder
Ping the paper, not the meme. Irwin Goldstein and colleagues reported two sequential double-blind studies in the New England Journal of Medicine in May 1998.
| Study | N | Design | Signal worth keeping |
|---|---|---|---|
| Dose-response, 24 weeks | 532 | Fixed 25 / 50 / 100 mg vs placebo | IIEF achieve/maintain rose with dose; 100 mg: 4.0 vs 2.0 baseline |
| Flexible, 12 weeks | 329 | Climb toward 100 mg | 69% vs 22% successful attempts; 5.9 vs 1.5 per month |
| Open-label extension | 225 of 329 | 32 weeks | 92% completed |
The dose-response study ran 24 weeks in 532 men with organic, psychogenic, or mixed erectile dysfunction. Arms were placebo or oral sildenafil at 25, 50, or 100 mg. Rising dose tracked rising scores on the two IIEF questions about achieving and maintaining erections. At 100 mg, the mean score for achieving an erection doubled from a baseline of 2.0 to 4.0 on a 5-point item. That is a clean ladder, not a single lucky arm.
The flexible study ran 12 weeks in 329 different men, starting and then climbing toward 100 mg on efficacy and tolerance. In the last four weeks, 69 percent of intercourse attempts succeeded on sildenafil against 22 percent on placebo. Successful attempts per month averaged 5.9 versus 1.5. Headache, flushing, and dyspepsia sat between 6 and 18 percent in that climb. Two hundred twenty-five of the 329 entered a 32-week open-label extension; 92 percent finished it. Those are the numbers a 'it worked for my cousin' post is trying to impersonate.
A diary beat a thread about a cousin
Forum lore collapses three different facts into one shout. 'It works' might mean a global yes on a single night. '69 percent' might mean that man thinks he is in Goldstein's last four weeks. '100 mg is the real dose' might mean he never sat on 25 mg long enough to see a side-effect flag. The diary does not allow that collapse. Each attempt is a row. Each dose is an arm. Placebo is in the room, and placebo already delivered 22 percent successful attempts. That 22 percent is the part reviews skip, because it makes the drug look less like magic.
The labelled usual start is still 50 mg about an hour before sex, movable to 100 mg or down to 25 mg. This desk's SERP lock is 25 or 100 mg because those are the edges a man actually fights over after a first disappointing night. The ceiling is one dose in 24 hours. Stimulation is required, because the scores measure an amplified signal, not a manufactured one. How to time that swallow against a plate is in the clock-and-plate guide.
Who the 25 mg start is written for
A lower tablet is not a lesser man. It is a labelled response to higher exposure.
The US label tells you when to open at 25 mg. Age over 65. Hepatic impairment such as cirrhosis. Severe renal impairment, creatinine clearance under 30 mL/min. Strong CYP3A4 inhibitors - ketoconazole, itraconazole, saquinavir - or erythromycin, which raised levels about three-fold. Alpha-blocker users who are already stable on that blocker. Ritonavir is in a class of its own: 11-fold AUC, so the cap is 25 mg in 48 hours, not a cheap daily 100 mg.
Those are exposure flags, not moral ones. Older clearance, a sick liver, a sick kidney, or a stacked CYP3A4 inhibitor all leave more citrate in the blood. Starting at 100 mg in that room is how you buy a pounding headache and a faint, not a better IIEF. Titrate up if the 25 mg night is honest and quiet. Do not let a forum talk you into the ceiling because 'trial cost' sounded like 'more milligrams bought more manhood.'
SUPER-1 walked 45 metres; that is not an ED score
| Card | What was scored | What it does not buy |
|---|---|---|
| Goldstein ED | IIEF items, attempt diaries, 25-100 mg as needed | A lung walk, a daily 20 mg habit |
| SUPER-1 PAH | 6-minute walk, mPAP, WHO class, 20/40/80 mg TID | An IIEF point, a cheap 100 mg evening |
Galiè and the SUPER Study Group randomised 278 adults with symptomatic pulmonary arterial hypertension - idiopathic, connective-tissue, or repaired congenital shunts - to placebo or sildenafil 20, 40, or 80 mg three times daily for 12 weeks. The primary endpoint was change in six-minute walk distance. Placebo-corrected gains at week 12 were 45, 46, and 50 metres. Mean pulmonary-artery pressure fell. WHO functional class improved. The study was not powered for death. Among 222 people who completed a year on monotherapy, the walk gain from baseline was 51 metres.
Here is the flag. Walk distance barely separated 20 mg from 80 mg. Haemodynamics moved a little more at the top. Side effects - flushing, dyspepsia, diarrhoea - climbed with dose. So the approved Revatio dose was 20 mg three times daily, the lowest effective walk dose, not the highest tolerated one. That card does not set your evening 25-100 mg. It does prove the citrate is a real pressure drug, which is exactly why a nitrate next to any of those strengths is not a casual stack. The origin of both files is in the Sandwich file note.
Diabetes and nerve-spare: where the ladder shortens
An honest read includes the rooms where 25-100 mg helps less. That is where forums over-promise and then call the tablet a dud.
Men with diabetes often carry both small-vessel and nerve damage. Response rates run lower than in men whose erectile failure has no clear physical cause. Many still improve, especially if they give 100 mg a few honest, stimulated attempts rather than one anxious night. After radical prostatectomy the story is harsher. If the cavernous nerves were spared, there is a signal left to amplify. If they were cut, the tablet has less to work with. The drug does not grow a nerve. It preserves cyclic GMP when nitric oxide arrives.
None of that makes a 25-100 mg trial a waste in those rooms. It makes the conversation adult. Several attempts. Decent timing. A willingness to move to injections or a device if pills stay flat. Safety framing does not loosen because the efficacy number is smaller: no nitrates, review other pressure drugs, start at 25 mg when age or CYP3A4 already shout. Tadalafil and vardenafil sit on the same enzyme and the same hold. They do not rescue a missing nerve either.
Cheap generic 25-100 mg does not cheapen the endpoint
Once the patents lapsed, the receipt shrank. The IIEF did not. A licensed generic 25 or 100 mg tablet has to deliver the same citrate into blood. What it does not have to do is reprint Goldstein in the box. That is why a man can buy a cheap blister and still need the same scored expectations: stimulation, a clock, a food flag, one dose per day, a 25 mg start when the label says so. Price is not an endpoint.
Reviews that treat 'cheap' as 'weaker' and '100 mg' as 'the real trial' are spending lore. Goldstein's ladder included 25 mg. The flexible study climbed. Placebo already cleared 22 percent of attempts. If a cheap tablet 'fails' after a fry-up and a five-minute wait, you have not spent the trial cost. You have spent a night. How to spend the night correctly is in the clock-and-plate guide.
Post: keep the score, drop the lore
Post this. 25-100 mg beat placebo on IIEF and on diaries, with a dose-response Goldstein actually published. 69 percent versus 22 percent is a last-four-weeks attempt figure, not a personality. SUPER-1 is metres on a three-times-daily lung dose. Diabetes and nerve injury shorten the ladder. Cheap generics change the receipt.
The holds that came with those scores are not footnotes. No nitrates. No riociguat. Stimulation required. One swallow in 24 hours, or 25 mg in 48 hours on ritonavir. Take the score to a clinician who has your list before you change a tablet. The desk disclaimer is the last stamp on this page, not a decoration.