My ECG is 'fine' from three years ago. Is that enough QT clearance for 20 mg?
The QT tick comes before either orange tablet
Rhythm first. In 59 healthy men, vardenafil 10 mg and an 80 mg supratherapeutic dose moved QTc in a band similar to moxifloxacin 400 mg. A later pairing of 10 mg Levitra with gatifloxacin 400 mg added the stretches: about 5 msec and 4 msec alone, about 9 msec together (QTcF). The clinical size of those milliseconds is unknown. The prescribing decision is not. Congenital long QT, or class IA / III antiarrhythmics, means avoid this molecule.
Only after that tick is clean do we draw milligrams. This folio's lock is a range: 2.5 mg or 20 mg. The usual labeled start for many adults is still 10 mg about 60 minutes before sex. We will not erase 10 mg. We will not let a high-card 20 mg conversation skip the QT line because someone saw a cash screenshot.
Nitrates and nitrites remain an absolute contraindication, the same family rule as on the other two PDE5 slips. Riociguat is the other hard stop. A 2.5 mg tablet does not purchase a kinder nitrate rule. A 20 mg tablet does not purchase a longer QT exemption.
Sexual stimulation is still required. An orange tablet is not desire in solid form. Ingrid has not read your ECG. A man who skips the QT question because 'I feel fine' is the letter I answer most often, and the letter I like least. Feeling fine is not a QTc measurement. The thorough QT set was done in healthy men. The avoid list exists for the men who are not that set.
A fatty meal still moves the 20 mg peak
Absorption
Absolute bioavailability about 15%. Fasted Tmax 30 minutes to 2 hours, median about 60. High-fat meals cut Cmax by 18% to 50% in the food-effect sets.
Distribution
The label does not lean on a single volume number the way Cialis does. Semen recovery after 20 mg was a trace (about 0.00018% at 1.5 hours).
Metabolism
CYP3A4 is the main path, with CYP3A5 and CYP2C help. Metabolite M1 is about 26% of parent levels and about 28% as potent at PDE5, so it adds about 7% of activity. Ritonavir raised vardenafil AUC about 49-fold and stretched half-life to about 26 hours.
Excretion
Clearance about 56 L/h. Terminal half-life of parent and M1 about 4 to 5 hours. Metabolites leave mostly in feces (about 91-95%); urine 2-6%.
Levitra's film-coated label allows food. The food-effect studies still cut Cmax by 18% to 50% with high-fat meals. That is a wider smear than sildenafil's 29% mean cut, and it is why a 20 mg high card after a cream-sauce supper can feel like a weaker 10. Absolute bioavailability is only about 15% to begin with. You do not have surplus absorption to donate to a fryer.
Median fasted peak sits near 60 minutes, range 30 minutes to 2 hours. Terminal half-life about 4 to 5 hours. This is not tadalafil's 17.5-hour leftover. If the couple wanted a Sunday morning from Saturday's tablet, they picked the wrong orange.
Practical note: a lighter plate keeps the high card closer to the hour you planned. A heavy plate plus a leap from 2.5 to 20 in the same week is two variables. Change one at a time. People also chase the missed peak with a late second swallow. Frequency is once per day. The 4- to 5-hour half-life is why a midnight extra 20 mg is still on board when he wanted a clean next morning, and why a nitrate the next day is still a problem if Saturday was a double.
When 2.5 mg is the card this desk actually draws
Two-point-five is not a children's dose and not a slight. Ritonavir 600 mg twice daily with vardenafil 5 mg raised vardenafil AUC about 49-fold and Cmax about 13-fold, and stretched half-life to about 26 hours. The labeled answer is a single 2.5 mg, then 72 hours before another. That is the loudest reason this range begins at 2.5.
Indinavir, saquinavir, atazanavir, clarithromycin, ketoconazole 400 mg daily, and itraconazole 400 mg daily: do not exceed 2.5 mg once daily. Ketoconazole 200 mg daily or itraconazole 200 mg daily: do not exceed 5 mg. Those numbers are why a 'just start at 20, everyone does' script is malpractice-adjacent when the antiviral or azole list is ignored.
Alpha-blocker already stable: start Levitra at the lowest recommended rung - on this label that conversation begins at 2.5 or 5, not at the high card. Age 65 or older: consider 5 mg first (Cmax about 34% higher, AUC about 52% higher than in young men). Moderate hepatic impairment: start 5 mg, do not exceed 10 mg. Severe hepatic disease was not studied. Two-point-five is how this folio keeps the floor visible when the title also names 20. A reader who feels insulted by 2.5 mg is usually arguing with the CYP list, not with his dignity. The 49-fold AUC jump under ritonavir is not a personality comment.
How a 2.5 or 20 mg Levitra card gets priced
| Pharmacy | Strength / count | How the window works | Official page |
|---|---|---|---|
| Kroger | 20 mg x 12 | Grocery pharmacy cash window | Kroger pharmacy |
| H-E-B | 20 mg x 12 | Texas grocery pharmacy desk | H-E-B pharmacy |
| Sam's Club | 20 mg x 12 | Club pharmacy; membership may apply | Sam's Club pharmacy |
| Albertsons | 20 mg x 12 | Grocery pharmacy cash window | Albertsons pharmacy |
Pricing talk on this desk has to name both ends, then show the carton we actually quoted. The lock is 2.5 or 20. The cash set is generic vardenafil 20 mg times 12, because that is the high card a window can put on a shelf. Nearby public prints for a 10-count of 20 mg, and for a 30-count of 2.5 mg, sit in the caption. They are not your ZIP.
A 2.5 mg month-bottle and a 20 mg 12-count are different products. Do not divide one caption by the other and call it a unit price. Each row opens that chain only. GoodRx and SingleCare stay in the caption. This Copenhagen shelf does not fill.
If the question under the quote is 'which PDE5 even belongs here,' finish the QT and CYP work, then read the three-card rack. A cheap 20 mg that ignores amiodarone is not cheap.
Alpha-blockers plus vardenafil need a quiet first week
Both classes dilate. The Levitra program watched tamsulosin and terazosin with 5, 10, and 20 mg in BPH and in forced-titration healthy sets. Symptomatic hypotension showed up, including a standing 80/60 after 5 mg vardenafil with 10 mg terazosin in one man. The simultaneous Tmax arm with terazosin in healthy volunteers ended early because standing systolic values under 85 mmHg kept appearing.
Rule that survived: be stable on the alpha-blocker first. Start Levitra at the lowest recommended dose. If the PDE5 is already optimized, start the alpha low. Volume depletion and extra antihypertensives make the stack uglier. This is not 'tamsulosin is always fine at 20 mg.'
Do not use a 20 mg high card as the first vardenafil night in a man still finding his alpha-blocker legs. That is how a QT-clean list still ends on the floor.
Staxyn is a different card - do not swap it
Staxyn is vardenafil 10 mg as an orally disintegrating tablet. It is not interchangeable with 10 mg film-coated Levitra because systemic exposure runs higher. People crush a film-coated 20 mg, or they assume an ODT is a 'faster 10,' and they invent a third product. This SERP lock is the film-coated 2.5 or 20 conversation. Staxyn stays on its own blister.
ODT counseling is fussy: on the tongue, saliva, no chase water in some instructions, no splitting the blister ahead of time. None of that rewrites the QT hold or the nitrate hold. A higher-exposure 10 mg ODT in a man on amiodarone is still the wrong story.
If a pharmacy substitutes ODT for film-coated because 'vardenafil is vardenafil,' send it back. Interchange is a label sentence, not a wholesaler convenience. I have seen a 20 mg film-coated plan quietly become an ODT 10 because the warehouse was short, and the exposure math was then nobody's job. Make it somebody's job. Ask what was actually dispensed. Look at the blister. If it dissolves on the tongue, it is not the card this title locked.
Twenty milligrams is the high card, not a trophy
| Orange tablet | What the Levitra label uses it for | What this folio binds |
|---|---|---|
| 2.5 mg | Floor card under ritonavir (every 72 h) and other strong CYP3A4 cover; also the lowest labeled start when an alpha-blocker is already on | Low end of the SERP lock |
| 5 mg | Considered start at age 65+; moderate hepatic start (max 10 mg there) | Middle rung, not the title |
| 10 mg | Usual start for many adults about 60 minutes before sex | Exists; this title does not lock it |
| 20 mg | Labeled ceiling; cash quote on this desk is 20 mg x 12 | High card - only after QT and holds |
| Staxyn 10 mg ODT | Higher exposure than 10 mg film-coated; not interchangeable | A different blister, not this lock |
IP-04 shelf ticket - 2.5 or 20 after QT
This folio locks2.5 mg or 20 mg - both discussed
Before either cardQT line; class IA / III off the slip
High-card quote20 mg x 12 at cash windows
FoodLabel allows food; fatty meal still cuts Cmax 18-50%
Half-life~4-5 hours
Not this lockStaxyn ODT - higher exposure, do not swap
Twenty is the labeled ceiling for film-coated Levitra, once per day. It is a step after 10 mg is tolerated and still thin, or a specialist choice when the list is clean and 10 mg was honestly tried. It is not a personality. It is not a proof of severity. Men treat 20 mg like a status tablet. This desk treats it like a ceiling with a QT preface.
North American fixed-dose work (n=762) moved EF domain at 3 months to 18, 21, and 21 on 5, 10, and 20 mg versus 15 on placebo, from baselines near 13-14. SEP3 - erection maintained to intercourse - sat at 51%, 64%, and 65% versus 32% placebo. The 20 mg card was not a different universe from 10 mg on that SEP3 line. Diabetes and post-prostatectomy sets still showed 10 and 20 mg beating placebo, with smaller absolute rates after prostatectomy, as anyone who has done that ward already knows.
Treadmill angina sets at 10 and 20 mg did not steal exercise time versus placebo in men with stable exertional angina. That is not a license to hand 20 mg to last week's infarct. Sex is still a load. Unstable coronary disease is still a hold. The North American 20 mg SEP3 of 65% versus 32% placebo is a group mean, not a promise that your Saturday will match a trial cell. Post-prostatectomy SEP3 sat near 34-37% on 10 or 20 mg versus 10% placebo - better than nothing, not a miracle restore. Counsel that gap before the high card becomes a disappointment he blames on the factory.
Bind both ends of the range on one slip
Shelf-check is a two-ended ritual here. Confirm the QT line and the IA/III list. Confirm nitrates and poppers are gone. Then decide whether tonight's card is 2.5 mg because a protease inhibitor or an alpha start demands the floor, or whether a clean list that already tried 10 mg honestly may step toward 20. Binding only the high card in the title would have been a prettier lie.
CYP3A4 inhibitors rewrite the floor more than they rewrite a speech about 20 mg. Ritonavir is a 2.5 mg / 72-hour story. Ketoconazole 400 mg is a 2.5 mg / 24-hour story. A man on those drugs does not get to 'borrow the 20 because the 2.5 felt polite.'
Once you pick an end, stay there for more than one messy night. Food, stimulation, and alcohol are enough variables. Selectivity and QT at essay length if the enzyme map is the remaining itch.
Class IA and III stay off this slip
Rhythm drugs that keep both orange tablets in the bottle
- Class IA examples the label names: quinidine, procainamide.
- Class III examples the label names: amiodarone, sotalol.
- Congenital QT prolongation: avoid vardenafil.
- Other QT-prolonging drugs: the post-marketing pair with gatifloxacin was additive - treat combinations as a clinical decision, not a shrug.
- Moxifloxacin 400 mg was the active control in the thorough QT set - similar QTc stretch, unknown clinical size.
Quinidine and procainamide are the class IA names the label bothers to write. Amiodarone and sotalol are the class III names. If any of those are on the list, or if the ECG already showed congenital long QT, vardenafil is the wrong PDE5 conversation. Do not 'use 2.5 mg to be safe.' Avoid means avoid.
Other QT-prolonging drugs are a judgment, not a free pass. The gatifloxacin pairing was additive. A man on a macrolide plus a psychotropic plus a 'just in case' 20 mg is how a teaching slip becomes a telemetry story. Bring the full list. Ask for a recent ECG if the history is messy.
Selectivity versus sildenafil's PDE6 fringe is a different essay. Rhythm risk is this molecule's extra ink. The selectivity file keeps the enzyme map so this folio can keep the QT line short and hard.
Leave the high card in the drawer until QT is clear
This folio binds a range, not a trophy. Two-point-five milligrams is a real labeled floor. Twenty milligrams is a real labeled ceiling. The QT tick, the IA/III list, and the nitrate drawer sit above both. A fatty meal can still steal Cmax. Staxyn is another blister.
If leftover Sunday was the actual wish, you wanted the 10 mg Cialis almond. If an empty plate and a first diamond were the actual wish, you wanted the 25 mg Viagra slip. If the question is all three at once, use the class rack. Do not keep a 20 mg high card 'for special occasions' next to a 2.5 mg ritonavir rule and a borrowed diamond. One molecule, one method, one clinician who has seen the list.
Illustris does not fill. Ask the clinician who can see your ECG and your full list before you step from 2.5 to 20 or the other way around.
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Answered by Dr. Ingrid Halvorsen, MD · Internal medicine & clinical pharmacology
Letters on Levitra split in two piles: men who want the 20 mg high card because a screenshot looked decisive, and men who were handed 2.5 mg and felt insulted. Both piles usually skipped the QT line. I will not. I have not seen your ECG.
Fine from three years ago is a starting anecdote, not a clearance. If the list is clean, symptoms are quiet, and there is no congenital long-QT story, many clinicians will proceed without a fresh tracing. If there is syncope, a family QT story, or any class IA / III drug, I want a current ECG before anyone talks about 20 mg. Vardenafil moved QTc in a thorough QT study. That is why this folio puts the tick above the high card. 'Fine' needs a date and a medication list next to it.
He is on amiodarone. Can we use the 2.5 mg tablet 'to be safe'?
No. Avoid means avoid. Amiodarone is a class III antiarrhythmic the Levitra label names in the same breath as sotalol. A 2.5 mg tablet does not purchase a smaller QT problem. Congenital long QT and class IA (quinidine, procainamide) sit in that same avoid box. If the rhythm drug is truly coming off, that is a cardiology decision with a new ECG, not a kitchen down-titration of vardenafil.
Why does a cash window quote twelve 20 mg tablets when I was told to start at 2.5?
The lock on this folio is a range. Windows can price a 20 mg 12-count as a stock carton, which is the high-card set we filed. A 2.5 mg month bottle is a different SKU and a different caption line. Neither carton is an instruction to swallow twenty milligrams on night one. If your clinician wrote 2.5 mg because of ritonavir, an azole, or an alpha start, buy 2.5 mg. Do not split a 20 mg tablet into 'about 2.5' with a kitchen knife.
Ritonavir is on his HIV regimen. Is 20 mg ever the next step?
Not on that regimen. Ritonavir with vardenafil 5 mg raised vardenafil AUC about 49-fold and Cmax about 13-fold, and stretched half-life to about 26 hours. The labeled card is a single 2.5 mg, then 72 hours before another. Twenty milligrams is not a later rung in that story. Give the full antiviral list to whoever would write the PDE5. Borrowing a partner's 20 mg because 2.5 'felt polite' is how those fold-increases leave the page and enter a person.
He had a fatty dinner and the 20 mg felt like a blank. Double it?
Do not double it. High-fat meals cut vardenafil Cmax by 18% to 50% in the food-effect sets. Absolute bioavailability is only about 15% to start. A cream-sauce night can make a high card feel like a weaker middle rung. Try one clean-plate night at the same milligram before anyone talks about a second tablet. Frequency is still once per day. A midnight extra 20 mg is a 40 mg experiment the label did not write.
The pharmacist offered Staxyn instead of film-coated 10 mg. Same thing?
Not the same card. Staxyn is a 10 mg orally disintegrating tablet with higher systemic exposure than 10 mg film-coated Levitra. The label says they are not interchangeable. This folio's lock is film-coated 2.5 or 20. An ODT substitution because 'vardenafil is vardenafil' is a wholesaler convenience, not a shelf-check. Send it back and ask for the film-coated strength that was written.
He takes tamsulosin. Can the first Levitra night be 20 mg if we separate the clocks?
I would not make 20 mg the first vardenafil night on an alpha-blocker. Be stable on the alpha first, then start Levitra at the lowest recommended rung - 2.5 or 5, not the ceiling. The program saw standing 80/60 after 5 mg vardenafil with 10 mg terazosin in one man, and a healthy terazosin arm ended early because standing systolic values under 85 mmHg kept appearing. Separating clocks can help. It does not turn the high card into a first-night gift.
Is 10 mg just missing from this title because you ran out of words?
Ten milligrams is still the usual labeled start for many adults about 60 minutes before sex. This site's SERP lock chose the range 2.5 or 20 so the floor and the ceiling stay visible. A clean list with no QT flags and no CYP pile may still be written 10 mg by his own clinician. What I will not do is let a 20 mg cash screenshot erase 2.5 mg, or let a 2.5 mg HIV story sneak up to 20 mg because the title named both.
He is 68. Should we start at 2.5 or at 5?
The geriatric pharmacology set showed Cmax about 34% higher and AUC about 52% higher than in young men, so the label asks you to consider 5 mg first. Two-point-five becomes the card when a strong CYP3A4 inhibitor or a ritonavir-style rule is also on the list, or when you are crawling in next to an alpha-blocker. Age alone is not a 20 mg exemption and not automatically a 2.5 mg insult. His other bottles decide which end of the range you draw.
How is this different from the blue diamond if both last about four hours?
Clock length is similar - vardenafil about 4 to 5 hours, sildenafil about 4. The extra ink here is QT and the IA/III avoid list. Sildenafil's extra ink is PDE6 color fringe and a more famous empty-plate rule. Food still moves vardenafil's Cmax, sometimes by half. If leftover Sunday is the wish, neither short card will impersonate the 10 mg almond. Read the three-card rack before you collect bottles.
Moderate liver disease - which orange tablet is even on the table?
Child-Pugh B raised Cmax about 130% and AUC about 160% after a 10 mg dose. The labeled move is start 5 mg and do not exceed 10 mg. Twenty milligrams is off that table. Severe hepatic impairment was not studied. Two-point-five may still appear if a CYP inhibitor is stacked on the liver story. This is a hepatology-plus-prescriber conversation, not a cash-window upgrade.
Can he drink with the 20 mg high card?
A modest glass is not the interaction I lose sleep over. A heavy night plus a high-fat plate plus 20 mg is how standing pressure and a missed peak arrive together. Vardenafil already drops supine pressure a little (about 7 / 8 mmHg after 20 mg in one ED pharmacology set) and can add to other antihypertensives. I would rather he keep the plate lighter and the alcohol light than try to celebrate the high card with both.
Where do I put the selectivity chatter so this page stays about 2.5 or 20?
Put it in the selectivity file. This folio had to keep QT, the floor card, the high card, food, Staxyn, and the alpha procedure on one slip. Enzyme-map detail is a second article on purpose. If you came here from the 25 mg diamond looking for a blue-fringe twin, you will be underwhelmed - rhythm risk is the louder vardenafil mark.
These replies are teaching, not a treatment plan for the person who asked. Take your own history, labs and medicine list to a prescriber who can see all three.