Avanafil (Stendra) for erectile dysfunction
Avanafil is an FDA-approved erectile dysfunction (ED) pill with a labeled lead time as short as about 15 minutes before sex. It shares every serious warning of its class, and it cannot be used with strong CYP3A4 inhibitors. This page covers the label facts, trial numbers, and how it compares with the other three.
Information current as of November 10, 2026. Educational only. Confirm everything here with your own clinician before starting, stopping or changing any medication.
At a glance
Drug class
A phosphodiesterase type 5 (PDE5) inhibitor, like sildenafil, vardenafil and tadalafil.
Timing
The 100 mg starting dose is taken as early as about 15 minutes before sexual activity. The 50 mg dose is taken about 30 minutes before.
Strengths
50, 100 and 200 mg tablets. The label says to use the lowest dose that gives benefit.
Food
May be taken with or without food. A high-fat meal slows absorption.
Main cautions
Never with nitrates or riociguat. Strong CYP3A4 inhibitors rule it out. Sudden vision or hearing loss, or an erection past 4 hours, needs urgent care.
What it is
How avanafil works
An erection depends on cyclic GMP, a messenger that relaxes the smooth muscle in the penis so blood can flow in. The enzyme PDE5 breaks it down. Avanafil blocks that enzyme, so the signal from sexual stimulation lasts longer.
It does not create desire and does nothing without arousal. What sets avanafil apart on paper is speed. In the fasted state the median time to peak blood level is 30 to 45 minutes, and the label allows the standard dose as early as about 15 minutes before sex.
Stendra is the brand name, and this page draws on the Stendra label.
Who it is for
Who avanafil is, and is not, meant for
Avanafil is approved for ED in men. The American Urological Association guideline recommends that clinicians review every treatment that is not contraindicated and decide together with the patient (Burnett, see sources). Speed is one reason men ask about avanafil, for example if planning ahead is hard. It is a preference, not a rule.
- Not for you if you use any nitrate, daily or occasionally, or riociguat.
- Not for you if you take a strong CYP3A4 inhibitor such as ketoconazole, ritonavir, atazanavir, clarithromycin, indinavir, itraconazole, nefazodone, nelfinavir, saquinavir or telithromycin.
- Not for you if you have severe liver impairment.
- Think twice if sex is not advisable for your heart, if you have a deformed penis, or if you have sickle cell disease, multiple myeloma or leukemia.
How it is taken
Label dosing, food and alcohol
- Starting dose: 100 mg, taken as early as about 15 minutes before sexual activity, as needed.
- Up: 200 mg, also as early as about 15 minutes before sex.
- Down: 50 mg, taken about 30 minutes before sex.
- On an alpha-blocker: start at 50 mg.
- On a moderate CYP3A4 inhibitor (erythromycin, diltiazem, fluconazole, verapamil, aprepitant, amprenavir or fosamprenavir): no more than 50 mg in 24 hours.
Food
The label says avanafil may be taken with or without food. After a high-fat meal the 200 mg dose peaked 1.1 to 1.3 hours later. If a quick onset matters, a heavy meal works against it. Grapefruit juice is likely to raise avanafil levels, so skip it around a dose.
Alcohol
Alcohol and PDE5 inhibitors both widen blood vessels. The label says drinking more than about 3 units alongside avanafil can increase dizziness, a faster heartbeat, a drop in standing blood pressure and headache. Keep drinking light.
The evidence
What the trials showed
- Goldstein 2012 (646 men): 12 weeks of 50, 100 or 200 mg versus placebo, taken about 30 minutes before sex, with no food or alcohol limits. All three doses beat placebo on the main measures. Among attempts within 15 minutes of dosing, 64 to 71 percent succeeded on avanafil versus 27 percent on placebo. Attempts more than 6 hours after the dose also succeeded more often (59 to 83 percent versus 25 percent), though those were a small share of all attempts.
- Hellstrom 2015 (440 men): a 12-week trial of 100 mg, 200 mg or placebo that scored success within about 15 minutes of dosing. The mean per-man success rate was 25.9 percent on 100 mg and 29.1 percent on 200 mg, versus 14.9 percent on placebo. The gap over placebo showed as early as 10 to 12 minutes.
- Men with diabetes: the label describes a 3-month trial of 390 men with type 1 or type 2 diabetes.
These are modest absolute numbers within a short window, which is realistic for a few minutes after a pill. They come from trial populations, and results vary by man. A 2013 network meta-analysis of 118 trials found avanafil was less effective than tadalafil or vardenafil on one global question about erection improvement (Yuan, see sources), but that was an indirect comparison and the newer drug had fewer trials.
Safety
Side effects and warnings
Never with nitrates or riociguat
Avanafil can strengthen the blood-pressure-lowering effect of nitrates, and the label contraindicates their use together. The label addresses only a life-threatening emergency, in which a clinician may consider a nitrate once at least 12 hours have passed since the last dose, with close monitoring. That is a hospital decision, not a green light. Always tell emergency staff you took avanafil and when.
In three placebo-controlled trials, headache occurred in 5.1, 6.9 and 10.5 percent of men on 50, 100 and 200 mg, against 1.7 percent on placebo. Flushing was 3.2, 4.3 and 4.0 percent against none on placebo. Nasal congestion, nasopharyngitis and back pain each ran at about 1 to 3 percent. Stopping because of side effects was 1.4, 2.0 and 2.0 percent against 1.7 on placebo. The label draws on 2,215 men exposed to the drug.
Sudden vision loss
Stop the drug and get care at once if vision drops suddenly in one or both eyes. It may be non-arteritic anterior ischemic optic neuropathy (NAION), a rare condition. Use caution if you have had it before.
Sudden hearing loss
A sudden decrease or loss of hearing, sometimes with ringing or dizziness, has been reported with PDE5 inhibitors. Stop and seek prompt care.
Erection past 4 hours
Go to an emergency department. Untreated priapism can permanently damage penile tissue.
Interactions
Alpha-blockers, blood pressure drugs and CYP3A4 inhibitors
- Alpha-blockers and other blood pressure drugs. Together with avanafil they can lower blood pressure further. Be stable on the alpha-blocker, then start at 50 mg.
- Strong CYP3A4 inhibitors. Ketoconazole raised avanafil exposure 13-fold, and ritonavir raised it about 13-fold, with the half-life extending to about 9 hours. The label says not to use avanafil with them.
- Moderate CYP3A4 inhibitors. Erythromycin raised exposure about 3-fold. The label caps avanafil at 50 mg, once every 24 hours.
- Amlodipine raised the peak avanafil level by about 22 percent and total exposure by about 70 percent.
- Other PDE5 pills. Combining them is not recommended.
Heart
Cardiac cautions
In healthy volunteers a single 200 mg dose lowered systolic and diastolic pressure by 5.3 and 3.7 mmHg one hour after dosing, compared with a rise of 2.7 and a small fall of 0.4 on placebo. The 100 mg dose had no significant effect on the QT interval in a study of 52 healthy men. Sexual activity itself raises heart demand, so the label tells prescribers to weigh the heart before treating.
The Princeton III consensus advises assessing exercise capacity, with stress testing where needed, before treating ED in men with heart disease, and treats ED as a prompt to look at cardiovascular risk (Nehra, see sources). See our post on cardiac inflammation for one related lab.
If it does not work
What to try when avanafil falls short
- Check for sexual stimulation, which the drug needs.
- Check the dose. The 100 mg start can move to 200 mg within label limits.
- Check meals and interacting drugs, including grapefruit juice.
- Check whether too much alcohol, or a long delay after a fatty meal, blunted the fast onset.
If the basics are fine, your physician looks at causes a pill cannot fix: diabetes, sleep apnea, depression, medicines, heart health and testosterone. If labs show low testosterone, see testosterone. Moving to another PDE5 inhibitor is a common next step, and so is a conversation about the non-pill options in the AUA guideline.
Compared
How avanafil sits among the four pills
- Sildenafil: about 1 hour before, a fatty meal slows it.
- Vardenafil: about 1 hour before, also as a tongue-dissolving tablet.
- Avanafil: as early as 15 minutes before, and not for use with strong CYP3A4 inhibitors.
- Tadalafil: longer acting, with a daily dosing option.
Speed is the main trade. Fewer trials exist for avanafil than for the older three, so Dr. Miranda weighs that along with your medicines and goals.
Summit’s role
What Summit does with avanafil
Dr. Miranda decides which erectile dysfunction medicine fits you after your history and labs. Summit prescribes tadalafil in Summit Men. It does not dispense Stendra or any other brand-name product, and nothing here promises a prescription.
Summit is telehealth only. The review checks your medicines for nitrates, riociguat and CYP3A4 interactions, and your blood pressure and heart history. See pricing for what is included.
Common questions
Questions people ask
How soon before sex can I take avanafil?
The label allows the 100 mg and 200 mg doses as early as about 15 minutes before sexual activity, and the 50 mg dose about 30 minutes before. Sexual stimulation is still required.
Do food and alcohol matter?
Avanafil may be taken with or without food, but a high-fat meal delayed the peak by about an hour in one study. Drinking more than about 3 units of alcohol can increase dizziness, heart rate and headache.
Can I take avanafil with nitroglycerin?
No. Nitrates are contraindicated. The label mentions a 12-hour wait only for a life-threatening emergency where a clinician decides a nitrate is needed. It is not guidance for home use.
Which medicines rule avanafil out?
Strong CYP3A4 inhibitors such as ketoconazole, itraconazole, clarithromycin and ritonavir, plus nitrates and riociguat. Moderate inhibitors cap the dose at 50 mg.
When should I go to the emergency department?
For an erection lasting more than 4 hours, a sudden loss of vision in one or both eyes, or a sudden drop or loss of hearing. Stop the drug first.
Is avanafil stronger than the others?
No head-to-head trial in this page shows that. A 2013 network meta-analysis found it less effective than tadalafil or vardenafil on one measure. Its main difference is speed of onset.
Sources
Where this comes from
All retrieved November 10, 2026.
- Stendra (avanafil) prescribing information. DailyMed. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=fa7d93e3-b69b-4e02-8146-89760cd8e9d6
- Goldstein I et al. A randomized, double-blind, placebo-controlled evaluation of the safety and efficacy of avanafil in subjects with erectile dysfunction. J Sex Med 2012. https://pubmed.ncbi.nlm.nih.gov/22248153/
- Hellstrom WJ et al. Efficacy of avanafil 15 minutes after dosing in men with erectile dysfunction: a randomized, double-blind, placebo controlled study. J Urol 2015. https://pubmed.ncbi.nlm.nih.gov/25591992/
- Yuan J et al. Comparative effectiveness and safety of oral phosphodiesterase type 5 inhibitors for erectile dysfunction: a systematic review and network meta-analysis. Eur Urol 2013. https://pubmed.ncbi.nlm.nih.gov/23395275/
- Nehra A et al. The Princeton III Consensus recommendations for the management of erectile dysfunction and cardiovascular disease. Mayo Clin Proc 2012. https://pubmed.ncbi.nlm.nih.gov/22862865/
- Burnett AL et al. Erectile Dysfunction: AUA Guideline. J Urol 2018. https://pubmed.ncbi.nlm.nih.gov/29746858/
Confirm with your provider. This page is general education, not medical advice, and it does not diagnose or treat anything. Every medication carries risks and is not right for everyone. Medication is prescribed only after a physician evaluation determines it is appropriate for you. Individual results vary and no outcome is guaranteed. Information current as of November 10, 2026.
Next step
List every medicine and supplement you take
Avanafil cannot be used with strong CYP3A4 inhibitors, so Dr. Miranda reviews your full list before choosing an ED medicine.