Dissolve 1 Ro Sparks under tongue at least 15 minutes prior to sexual activity. Do not exceed 1 Ro Sparks per 24 hours, and do not use any other medications containing tadalafil or sildenafil within 24 hours of this medication.

Unlike taking a traditional sildenafil pill, you don’t need to take this treatment on an empty stomach. The drop gets directly absorbed into your bloodstream under your tongue. In order to avoid disrupting this process, we recommend that you not eat or drink anything while the drop is dissolving.

You can speed up the time it takes for the Spark to dissolve by drinking a glass of water before you place the Spark under your tongue. You can also gently move the Spark around under your tongue to speed up the process. Finally, once the Spark starts to soften, you can bite it in half and immediately place both halves back under your tongue.

This medication is a compounded formulation. Drug compounding is the process of combining, mixing, or altering ingredients by pharmacies to create a medication tailored to an individual patient’s needs. Please let me know if you have additional questions about the medication.

This may be stating the obvious, but for most people starting ED treatment means having more sex.  With that comes the positive aspects of intimacy: increased confidence, a stronger connection with your partner(s), and a whole list of health benefits.

However, that means having to consider your risk of sexually transmitted infections (STIs). Sharing your STI status with your partner(s) is an important part of intimacy, and regular testing keeps everyone healthier and informed.

It’s also important to ask any prospective partner about their status and to disclose immediately if you do have an STI. Informed consent is an important part of sharing sexual intimacy with honesty and clarity.

General Information

This medication should not be used in anyone allergic to Cialis/tadalafil or Viagra/sildenafil. In patients with pulmonary veno-occlusive disease, or PVOD, significant worsening of their cardiovascular system (heart and blood vessel status) may occur. Also, Cialis is not recommended when a patient is on alpha blocker medication. As can be seen in the drug interaction section below, caution must be exercised when Cialis is combined with alpha blockers being used for any reason. Used together they can lower blood pressure significantly.

Nitrate/Nitrite Therapy/Poppers 

ABSOLUTELY no one should take this medication if they “are currently on nitrate/nitrite therapy.” That includes even if the patient uses nitrates/nitrite therapy intermittently. Also, no one who uses recreational nitrates/nitrites (poppers, etc.) should use this medication, as well as no one on nitrate-boosting supplements.

Geriatric (The Elderly), Hepatic (Liver) Disease, Renal (Kidney) Impairment

Cialis is metabolized by a complex system that can be compromised in the elderly, or in patients who suffer from liver disease, or those whose kidney function is reduced by illness or age. It is generally very well tolerated in the elderly but the dose given should be adjusted if the patient has mild to moderate liver impairment, whether due to age or illness. The same is true for those whose kidneys are compromised for any reason. Also, it is not recommended for use in patients with severe liver impairment, and daily use is not recommended at any dose for patients “when the creatinine clearance is less than 30 ml/minute (which means the kidney is severely compromised) or the patient has renal failure or is receiving dialysis.”

Moreover, certain drugs have a dramatic effect on the metabolism of Cialis similarly increasing the blood level dramatically. Therefore, those taking erythromycin, itraconazole, ketoconazole, saquinavir, and ritonavir should have very significant dosage adjustments made.

Angina (Chest Pain), Cardiac Arrhythmias (Irregular Heartbeats), Cardiac Disease (Heart Disease), Coronary Artery Disease (Narrowing of the Heart Arteries), Heart Failure, Hypertension (High Blood Pressure), Hypotension (Low Blood Pressure), IHSS (Idiopathic Hypertrophic Subaortic Stenosis–a Heart Defect), Hypovolemia (Low Blood Volume–like dehydration), Myocardial Infarction (Heart Attack), Stroke (like a heart attack but affecting the brain)

“There is a degree of cardiac risk associated with sexual activity; therefore, prescribers should evaluate the cardiovascular status of their patients prior to initiating any treatment for erectile dysfunction.” [NOTE: This means that if you and your provider have a reason to believe after diagnosing erectile dysfunction that you are not healthy enough for sex, you shouldn’t use anything that will help you have sex until you are healthier. Your provider counts on an honest answer about your health and your capacity to be sexually active. It may seem overly cautious but think about it; if you aren’t healthy enough for sex, shouldn’t you take care of your health before trying to regain your sex life? There have been over 75 heart attacks associated with the use of phosphodiesterase inhibitors. It may not seem like many deaths but you don’t want to be the person who bumps that number over 100.]

The Physicians Desk Reference states, “the manufacturer does not recommend the use of tadalafil be used in these groups until more data are available: myocardial infarction (heart attack) in the last 90 days, coronary artery disease resulting in unstable angina (chest pain) or angina occurring during sexual intercourse, NYHA Class II or greater heart failure in the last six months, uncontrolled cardiac arrhythmias (irregular heart beats), hypotension (BP<90/50), uncontrolled hypertension (BP>170/100), or a stroke in the last 6 months.”

The Physicians Desk Reference advises that “caution should be used if Viagra (sildenafil) is prescribed in the following groups: patients who have suffered a myocardial infarct, stroke, or life threatening arrhythmias in the last 6 months; patients with resting hypotension (BP<90/50) or resting hypertension (BP>170/100); patients with fluid depletion; patients with cardiac disease, heart failure, or coronary artery disease which causes unstable angina.”

The Physicians Desk Reference notes that the American College of Cardiology recommends that sildenafil be used in caution with patients (not on nitrates, of course) with active coronary ischemia, meaning they have blocked heart arteries that is compromising the function of their heart, such as would show by having symptoms like chest pain or by failing a stress test. They also advise caution in anyone with low blood pressure or low blood volume or in anyone with high blood pressure on a “complicated, multidrug, antihypertensive program.”

The Physicians Desk Reference also notes that the American College of Cardiology recommends that Cialis be used in caution with patients (not on nitrates, of course) with active coronary ischemia, meaning they have blocked heart arteries that is compromising the function of their heart, such as would show by having symptoms like chest pain or by failing a stress test. They also advise caution in anyone with low blood pressure or low blood volume or in anyone with high blood pressure on a “complicated, multidrug, antihypertensive program.” Patients with “Left Ventricular Outflow Obstruction (e.g., aortic stenosis, idiopathic hypertrophic subaortic stenosis)” should be approached with caution as they, and patients with poor control of the swings in their blood pressure, can be very sensitive to Cialis and other vasodilators (drugs that open up the blood vessels). They also point out that it should be used with caution if the patient is on other drugs that can markedly elevate the level of Cialis in the blood.

Patients with “Left Ventricular Outflow Obstruction (e.g., aortic stenosis, idiopathic hypertrophic subaortic stenosis)” should be approached with caution as they, and patients with poor control of the swings in their blood pressure, can be very sensitive to sildenafil and other vasodilators (drugs that open up the blood vessels). They also recommend that doses of Viagra (sildenafil) over 25 mg not be given within 4 hours of taking an alpha-blocker (e.g. doxazosin).

Leukemia, Multiple Myeloma, Penile Structural Abnormality, Polycythemia, Priapism, Sickle Cell Disease

Priapism is an erection lasting more than 4 hours and it can occur with the use of tadalafil or sildenafil. Priapism can be painful but, with or without pain, an erection that lasts over 4 hours could result in damage to the tissues of the penis. People with the above conditions are at greater risk of suffering from priapism with the use of Cialis (tadalafil) or Viagra (sildenafil). The Physicians Desk Reference states, “Use tadalafil, and other agents for the treatment of erectile dysfunction, with caution in patients with penile structural abnormality (such as angulation, cavernosal fibrosis, or Peyronie’s disease), or in patients who have conditions which may predispose them to priapism (such as sickle cell disease, leukemia, multiple myeloma, polycythemia, or history of priapism).”

Human Immunodeficiency Virus (HIV) Infection

The Physicians Desk Reference states, “tadalafil, when used for erectile dysfunction, offers no protection against sexually transmitted disease.” The same is true of sildenafil.

Gastroesophageal Reflux Disease (GERD–heartburn due to reflux of acid), Hiatal Hernia (part of stomach slips upward through the diaphragm), Peptic Ulcer Disease (Stomach Ulcer)

The phosphodiesterase inhibitors decrease the pressure of the valve that stops acid from coming back up from the stomach and into the esophagus. It also inhibits the movement of the esophagus itself. It could make symptoms worse for people with GERD or a hiatal hernia so it is recommended that it be used with caution in these patients. Also, since it has yet to be studied, caution is recommended in patients with active peptic ulcer disease (bleeding stomach ulcers).

Non-arteritic Anterior Ischemic Optic Neuropathy (NAION), Retinitis Pigmentosa, Visual Disturbance

The Physicians Desk Reference states, “Use tadalafil cautiously in patients with pre-existing visual disturbance. Postmarketing reports of sudden vision loss have occurred with phosphodiesterase inhibitors. Vision loss is attributed to a condition known as non-arteritic anterior ischemic optic neuropathy (NAION), where blood flow is blocked to the optic nerve.” It is never recommended for patients with known hereditary degenerative retinal disorders, including retinitis pigmentosa.

A Special Warning for Pilots and Air Traffic Controllers

Some people experience visual side effects when taking PDE5 inhibitors for erectile dysfunction. Due to the sensitive nature of their work, pilots and air traffic controllers should not take Viagra or sildenafil within 6 hours of aviation related duties. Cialis (tadalafil) is a much longer acting medication. Pilots and air traffic controllers should not take Cialis within 36 hours of aviation related duties. Daily Cialis use, at any dose, is not an option for people with these professions.

Hematological Disease

Phosphodiesterase type 5 is found in platelets (the cells that help us clot and stop bleeding when it occurs). Therefore caution is recommended if tadalafil is given to patients with bleeding disorders. There are other situations that would give a healthcare provider pause. Some would be if you have lightheadedness, fainting spells, leg cramping when you walk, inability to climb stairs or walk a few blocks without getting short of breath, or if you have allergies to any of the other phosphodiesterases or their components. These, and any other symptoms, must be discussed.

The list below is long and not one drug on the list is meaningless. That is why we need to know every drug you take and every healthcare provider needs to know you take this medication which has both sildenafil and tadalafil.

Note: Some medications are not on the list but are included in the PDR, which is why it must be read as well. In addition, the list changes as medications may be added over time.

• Alfuzosin (Uroxatral) (Treats High Blood Pressure or Enlarged Prostate)

• Aliskiren (Tekturna, Rasilez) (Treats High Blood Pressure)

• Alpha-blockers (e.g., Cardura, Coreg Flomax, Hytrin, Minipress, Oravase, Rapaflo, Regitine,Trandate) (Treats High Blood Pressure or Enlarged Prostate)

• Ambrisentan (Letairis) (Treats PAH–High Blood Pressure in the Arteries of the Lungs)

• Amiodarone (Cordarone IV) (An IV drug used to treat serious irregular heartbeats)

• Amlodipine (Norvasc) (Treats High Blood Pressure)

• Amprenavir (Agenerase) (Treats HIV)

• Amyl Nitrite (Amyl nitrite Systemic, Poppers, Rush) (Recreational Drug)

• Aprepitant (Emend) (Treats Nausea)

• Atazanavir (Reyataz) (Treats HIV)

• Atropine (Isopto Atropine) (Treats Eye Conditions)

• Boceprevir (Pegasys, Pegintron) (Treats PAH and Hepatitis C)

• Butyl Nitrate (Poppers, Rush, Liquid Gold) (It is a recreational drug)

• Brigatinib (Alunbrig) (Cancer)

• Capecitabine (Xeloda) (Cancer)

• Cariprazine (Vraylar) (Psychiatric Disorders)

• Ceritinib (Zykadia) (Cancer)

• Cimetidine (Tagamet) (Stomach Ulcers)

• Ciprofloxacin (Proquin, Cipro) (Antibiotic)

• Clarithromycin (Biaxin) (Antibiotic)

• Clopidogrel (Plavix) (Blood Thinner)

• Cobicistat (Stribild, Tybost) (Treats HIV)

• Conivaptan (Vaprisol) (Treats Low Sodium in the blood)

• Crizotinib (Xalkori) (Cancer)

• Darunavir (Prezista) (Treats HIV)

• Dasabuvir (Viekira XR, Viekira Pak–contains Ritonavir*) (Treats Hepatitis C)

• Delavirdine (Treats HIV)

• Dihydroergotamine (Migranal) (Treats Migraines)

• Diltiazem (e.g., Cartia, Cardizem, Dilacor XR, Tiazac,) (Treats High Blood Pressure)

• Doxazosin (Cardura, Carduran) (Treats High Blood Pressure or Enlarged Prostate)

• Dronedarone (Multaq) (Irregular Heartbeats)

• Duloxetine (Cymbalta) (Treats Depression and certain nerve pain disorders)

• Elbasvir; Grazoprevir (Zepatier) (Treats Hepatitis C)

• Erythromycin (Erythrocin, Ery-Tab, E-Mycin, Eryc) (Antibiotic)

• Fluconazole (Diflucan) (Treats Fungal and Yeast Infections)

• Fluoxetine (e.g., Prozac, Sarafem) (Treats Psychiatric disorders like depression)

• Fluvoxamine (Faverin, Fevarin, Floxyfral, Dumyrox, Luvox) (Treats OCD)

• Fosamprenavir (Lexiva) (Treats HIV)

• Grapefruit juice

• Hydralazine; Isosorbide dinitrate, ISDN (e.g., Bidil) (Heart Failure)

• Idelalisib (Zydelig) (Treats Cancer–Leukemia)

• Imatinib (Gleevec) (Treats Cancer–Leukemia)

• Indinavir (Crixivan) (Treats HIV)

• Isavuconazonium (Cresemba) (Treats Fungal Infections)

• Isoniazid. INH (Nydrazid) (Treats Tuberculosis TB)

• Isocarboxazid (Marplan) (Treats Depression)

• Isosorbide Dinitrate or Monohydrate (Isordil Titradose, Dilatrate-SR, Imdur, Imdur ER, Ismo, Monoket, IsoDitrate) (Treats Heart Disease and Chest Pain)

• Itraconazole (Sporanox, Onmel) (Treats Fungus and Yeast)

• Ivacaftor (Kalydeco) (Treats Cystic Fibrosis)

• Ketoconazole (Nizoral, Extina, Ketodan Kit, Kuric, Nizoral A-D, Xolegel) (Treats Fungal Infections)

• Lopinavir; Ritonavir (Kaletra) (Contains Ritonavir and Treats HIV)

• Lorcaserin (Belviq) (Weight Control)

• Lurasidone (Latuda) (Treats Depression)

• Mifepristone, RU-486 (Korlym, Mifeprex) (Treats Cushing’s Syndrome and Ends Pregnancy)

• Mitotane (Lysodren) (Treats Cancer and Cushing’s Syndrome)

• Monoamine oxidase inhibitors (e.g., Azilect, Marplan, Nardil, Parnate) (Treats Depression)

• Nebivolol (Bystolic) (Treats High Blood Pressure)

• Nefazodone (Serzone) (Treats Depression)

• Nelfinavir (Viracept) (Treats HIV)

• Netupitant (Akynzeo) (Prevents Nausea and Vomiting)

• Netupitant (Akynzeo) (Prevents Nausea and Vomiting)

• Nesiritide (Natrecor) (Treats Heart Failure but is an IV drug)

• Nifedipine (Procardia, Nifedical XL, Adalat, Procardia XL) (Heart Disease among others)

• Nilotinib (Tasigna) (Treats Cancer–Leukemia)

• Nitrates (Isordil Titradose, Dilatrate-SR, Imdur, Imdur ER, Ismo, Monoket, IsoDitrate) (Treats Heart Disease and Chest Pain)

• Nitroglycerin (Nitro-bid, Nitrocot SA Capsule, Nitro-dur, Nitrostat, Nitrodisc, Nitrek transdermal, Minitran, Nitrol ointment, Transderm-Nitro, Nitro-Time, Nitrotab, NitroMist, Nitro-Par, Nitrolingual, Nitroquick, Transderm-Nitro, Nitrogard, Nitroglyn, Nitrong) (Treats Chest Pain and Heart Conditions)

• Nitroprusside (Nipride RTU, Nitropress) (Heart Failure and High Blood Pressure)

• Ombitasvir; Paritaprevir; Ritonavir (Technivie, Viekira Pak) (Treat Hepatitis C)

• Pazopanib (Votrient) (Treats Kidney Cancer)

• Phenoxybenzamine (Dibenzyline) (Treat High Blood Pressure and Pheochromocytoma)

• Phentolamine (Regitine, Oraverse) (Erectile Dysfunction, High Blood Pressure)

• Phenylephrine (e.g.,Sudafed) (Decongestant)

• Posaconazole (Noxafil) (Treats Fungal Infections)

• Prazosin (e.g., Minipress, Vasoflex, Lentopres, Hypovase) (Treats High Blood Pressure, PTSD, and Anxiety)

• Quinidine (Cardioquin, Quinaglute, Quinalan, Quinidex Extentabs) (Treats Malaria and abnormal heart beats)

• Ranolazine (Ranexa) (Treats Chest Pain)

• Ribociclib (Kisqali) (Treats Cancer)

• Riociguat (Adempas) (Treats High Blood Pressure in the Arteries of the Lung)

• Ritonavir (Norvir) (Also found in Technivie and Viekira Pak) (Treats HIV and Hepatitis C)

• Sapropterin (Kuvan) (Treats a disorder that causes amino acid buildup in the brain)

• Saquinavir (Invirase, Fortovase) (Treats HIV)

• Silodosin (Rapaflo) (Treats an Enlarged Prostate)

• Tacrolimus (Prograft, Advagraf XL, Protopic, Hecoria) (Treats Organ Transplants)

• Tamsulosin (Flomax) (Treats an Enlarged Prostate)

• Telaprevir (Incivek, Incivo) (Treats Hepatitis C)

• Telithromycin (Ketek, Ketek Pak) (Antibiotic)

• Telotristat Ethyl (Xermelo) (Treats diarrhea in cancer patients)

• Terazosin (Hytrin) (Treats High Blood Pressure)

• Tipranavir (Aptivus) (Treats HIV)

• Verapamil (Calan, Isoptin) (Treats High Blood Pressure, Angina, Irregular Heart Beats)

• Vigabatrin (Sabril) (Treats Seizure Disorders)

• Voriconazole (Vfend) (Treats Fungal Infections)

The side effects of Sparks (sildenafil + tadalafil) are typically mild. Common side effects can include: 

• Headache -  ED medications can cause headaches by widening blood vessels and increasing blood flow, but these are usually mild and ease as the medication wears off (about 4 hours) and with continued use. To help:

  • Drink more water to reduce headache intensity.

  • Take over-the-counter Tylenol or Motrin 1 hour before your medication to lessen or prevent headaches.

• Indigestion/heartburn -  Heartburn is a common side effect of ED medications, affecting about 1 in 10 patients. To help:

  • Limit caffeine and avoid trigger foods (acidic, spicy, or alcohol) before taking your medication.

  • Drink plenty of water.

  • Avoid eating 2 hours before bed and elevate your head while sleeping.

  • Try over-the-counter remedies like Tums.

• Back pain or muscle aches - Muscle aches and back pain may appear 12-24 hours after taking the medication and go away within two days after taking the medication. To help:

  • Drink more water to reduce their intensity.

  • Take an over-the-counter pain reliever, like Tylenol or Motrin, 1 hour before your ED medication to lessen or prevent discomfort.

• Flushing or redness/warmth in the face - This is a common side effect of ED medications, caused by increased blood flow and dilation of blood vessels, including those in your skin. While it may result in a red, flushed appearance, it’s not dangerous and can even indicate the medication is working. To help:

  • Use a cold compress on your face.

  • Keep the room cool by opening a window or using a fan.

• Stuffy or runny nose - This side effect tends to fade within a few hours of using the medication. To help:

  • Use an over-the-counter nasal spray like Flonase when you take your medication to prevent congestion.

  • Take a warm shower after your dose; the steam can help relieve congestion.

• Lightheadedness or dizziness - Lightheadedness can happen due to a decrease in your blood pressure. Severe or persistent lightheadedness, and especially fainting, can be dangerous and should be evaluated in person. To help mild lightheadedness

  • Lie down until the sensation passes and stand up slowly.

  • Stay hydrated by drinking water.

  • If you take blood pressure medication, avoid taking it at the same time as your ED medication.

If you experience any of these common side effects and find them to be persistent, bothersome, or preventing you from taking your medication, please reach out to your Ro-affiliated healthcare provider.  

Rare side effects of Sparks can include: 

• An erection that lasts longer than four hours and won’t go away (priapism).

• Sudden loss of vision

• Sudden loss or decrease/change in hearing

• Chest pain or shortness of breath

• Fainting

If you experience any of these symptoms, stop your medication and seek immediate medical attention. If you experience a sudden loss of vision or a decrease/change in hearing, it is imperative that your evaluation include a vision and/or hearing test and possibly a specialist evaluation by a vision (ophthalmologist, optometrist, or hearing specialist (ENT/audiologist).

Rarely, patients using Sparks may experience blue-tinged vision. Typically, this is not dangerous, but if you experience changes to your vision, stop using your medication and make an appointment with an ophthalmologist. 

IMPORTANT: Please report any side effects you experience to your Ro-affiliated healthcare provider. This list is not exhaustive. A complete list of side effects can be found here.  If you are experiencing a medical emergency, seek immediate medical attention or call 9-1-1. Symptoms such as chest pain, shortness of breath, severe headache, fainting, visual changes, hearing loss or any other severe side effect warrant a visit to the emergency room.