Tadalafil and Entresto: Can They Be Taken Together?

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What is tadalafil and Entresto?

Tadalafil is a phosphodiesterase type 5 (PDE5) inhibitor licensed to treat erectile dysfunction. It works by relaxing blood vessels in the penis, allowing increased blood flow during sexual stimulation. Tadalafil is available as on-demand tablets (10 mg or 20 mg taken at least 30 minutes before sex, with effects lasting up to 36 hours) or as a daily low-dose option (2.5 mg or 5 mg) [4]. It is the generic version of Cialis and is available on prescription after a clinical assessment.

Entresto is a combination medicine containing sacubitril and valsartan, prescribed for chronic heart failure. Sacubitril is a neprilysin inhibitor that helps the body eliminate sodium and water, while valsartan is an angiotensin receptor blocker (ARB) that relaxes blood vessels. Together, they reduce the workload on the heart and lower blood pressure [12]. Entresto is taken twice daily and is an important treatment for people with reduced ejection fraction heart failure.

Both medicines affect the cardiovascular system, which is why understanding their interaction is essential for safe and effective treatment of erectile dysfunction in men with heart failure.

How do tadalafil and Entresto interact?

Tadalafil and Entresto can both lower blood pressure, so taking them together may add to this effect. Tadalafil causes mild vasodilation (widening of blood vessels) throughout the body, not just in the penis, which can lead to a modest drop in blood pressure [4]. Entresto is specifically designed to reduce blood pressure and fluid retention as part of heart failure management [12]. When used together, the combined blood-pressure-lowering effect can occasionally cause dizziness, light-headedness, or fainting, especially when standing up quickly.

This interaction is not an absolute contraindication—unlike nitrates, nicorandil, or riociguat, which must never be taken with tadalafil—but it does require careful prescriber review. Your doctor or pharmacist will assess your current blood pressure, heart failure severity, other medicines, and overall cardiovascular health before approving tadalafil. Most men on stable Entresto therapy can use tadalafil safely, provided their blood pressure is well controlled and sexual activity is not inadvisable for their heart condition [2].

It is important to note that tadalafil does not interfere with how Entresto works to manage heart failure, and Entresto does not reduce the effectiveness of tadalafil for erectile dysfunction. The concern is purely about the additive blood-pressure effect.

When to get urgent help

• Chest pain during or after sexual activity—stop, sit down, and call 999 immediately
• Severe dizziness, fainting, or collapse—call 999 or go to A&E
• Erection lasting more than 4 hours (priapism)—go to A&E immediately
• Sudden loss of vision or hearing—seek urgent medical attention
• Worsening breathlessness, ankle swelling, or rapid weight gain—contact your GP or heart failure team the same day

Call 999 or go to A&E in an emergency, or contact NHS 111 for urgent advice.

What will my prescriber check before approving tadalafil?

Before prescribing tadalafil to someone taking Entresto, a UK prescriber will review several key factors. They will ask about your current blood pressure readings and whether you experience dizziness or fainting, particularly when standing. They will also assess the severity of your heart failure, your exercise tolerance, and whether your doctor has advised that sexual activity is safe for you. Sexual activity places extra demands on the heart, so it is not suitable for everyone with heart failure, particularly those with unstable or severe symptoms [2].

Your prescriber will review all your current medicines to check for other interactions. For example, if you also take an alpha-blocker (such as doxazosin or tamsulosin) for prostate symptoms, the risk of low blood pressure increases further, and you may need to start on the lowest dose of tadalafil. They will also check for any medicines that affect how tadalafil is broken down in the body, such as potent CYP3A4 inhibitors, which can raise tadalafil levels [4].

If you have recently had a heart attack or stroke, have unstable angina, very low blood pressure, or severe heart failure, tadalafil may not be suitable. Your prescriber will also ask about any history of sudden vision loss (NAION) or inherited retinal disorders, as these are contraindications to PDE5 inhibitors [4]. The online consultation at Cured Pharmacy is reviewed by a UK-registered prescriber who will make these checks before approving your order.

Starting on a lower dose

If you are approved for tadalafil while taking Entresto, your prescriber may recommend starting with the lowest effective dose—typically 10 mg on-demand or 2.5 mg daily—to minimise the risk of low blood pressure. You should take tadalafil as directed, avoid taking more than the prescribed dose, and monitor how you feel, especially during the first few uses. If you experience dizziness, light-headedness, or fainting, stop taking tadalafil and contact your GP or prescriber for advice.

Practical advice for taking tadalafil with Entresto

If you have been approved to take tadalafil alongside Entresto, there are several practical steps you can take to use it safely. Take tadalafil exactly as prescribed—do not take more than one on-demand dose in 24 hours, and do not combine it with any other erectile dysfunction medicine. Avoid heavy alcohol, as it can worsen erectile dysfunction and add to the blood-pressure-lowering effect, increasing the risk of dizziness [4].

Stand up slowly from sitting or lying positions, especially in the first few hours after taking tadalafil, to reduce the risk of postural hypotension (a sudden drop in blood pressure when standing). If you feel dizzy or light-headed, sit or lie down until the feeling passes. Do not drive or operate machinery if you feel unwell. It is also advisable to avoid grapefruit juice, as it can raise tadalafil levels in the blood [4].

Continue taking Entresto exactly as prescribed by your heart failure specialist—do not stop or change the dose without medical advice. If you experience chest pain during sexual activity, stop immediately, sit down, and seek urgent medical help. Do not take GTN spray or any nitrate medicine if you have used tadalafil in the previous 48 hours, as this combination can cause a dangerous drop in blood pressure [4]. Always inform any healthcare professional treating you that you take both Entresto and tadalafil.

At a glance

Warning signs and when to seek help with tadalafil and Entresto

Most men tolerate the combination of tadalafil and Entresto well, but it is important to recognise warning signs that need medical attention. Seek urgent help (call 999 or go to A&E) if you experience chest pain, severe dizziness, fainting, an erection lasting more than four hours (priapism), sudden loss of vision, or sudden decrease or loss of hearing [4]. These are rare but serious side effects that require immediate assessment.

Contact your GP or prescriber on the same day if you have persistent dizziness, light-headedness when standing, a significant drop in blood pressure (if you monitor at home), or worsening heart failure symptoms such as increased breathlessness, swelling of the ankles, or rapid weight gain. These may indicate that the combination is not suitable for you or that your heart failure needs review.

If tadalafil does not improve your erections, do not increase the dose yourself. Speak to your prescriber, who may adjust the dose, suggest a different PDE5 inhibitor, or refer you for further investigation. Erectile dysfunction can be an early warning sign of cardiovascular disease, so it is always worth discussing with your GP if it is a new or worsening problem [1].

What to do if you miss a dose of Entresto

If you miss a dose of Entresto, take it as soon as you remember, unless it is close to the time of your next dose. Do not take a double dose to make up for a missed one [12]. Missing a dose of Entresto does not change the safety of tadalafil, but it is important to maintain consistent heart failure treatment. If you have any concerns about your Entresto regimen, speak to your GP or heart failure nurse.

Other ED treatment options if tadalafil and Entresto are not suitable

If your prescriber decides that tadalafil is not suitable for you while taking Entresto—for example, because your blood pressure is too low or your heart failure is unstable—there may be other options. Other PDE5 inhibitors, such as sildenafil (Viagra), vardenafil (Levitra), or avanafil (Spedra), have similar blood-pressure effects and the same precautions apply, so they are unlikely to be safer alternatives in this situation [3][5][6].

Non-tablet treatments may be considered. Eroxon is a topical gel medical device that works locally and does not lower blood pressure, so it may be an option for some men. Prescription treatments such as Vitaros (alprostadil cream) or Caverject (alprostadil injection) work differently from PDE5 inhibitors and may be suitable after specialist assessment [7]. Your GP or a specialist in sexual medicine or urology can discuss these alternatives with you.

Lifestyle measures can also help: losing weight if overweight, stopping smoking, reducing alcohol, exercising regularly (within the limits advised by your heart failure team), and managing diabetes or high cholesterol all improve erectile function and cardiovascular health [1][2]. Psychological factors such as anxiety or depression can contribute to ED, and counselling or cognitive behavioural therapy may be beneficial. Always discuss new or worsening erectile dysfunction with your GP, as it can be an important marker of heart health.

Cured Pharmacy consultation process

At Cured Pharmacy, all prescription ED medicines—including tadalafil—are supplied only after an online consultation reviewed by a UK-registered prescriber. You will be asked about your medical history, current medicines (including Entresto), blood pressure, heart health, and any contraindications. The prescriber will assess whether tadalafil is safe and appropriate for you, and may adjust the dose or suggest an alternative if needed. This ensures you receive treatment that is both effective and safe alongside your heart failure medication.

In summary

• Tadalafil and Entresto can be taken together if your prescriber approves and your blood pressure is stable.
• Both medicines can lower blood pressure; the combination may cause dizziness or light-headedness.
• Start on the lowest tadalafil dose and stand up slowly to reduce the risk of postural hypotension.
• Seek urgent help for chest pain, severe dizziness, fainting, or an erection lasting over four hours.
• All ED prescriptions at Cured Pharmacy require a UK prescriber review of your heart health and medicines.

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