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An overall 24.9% increase in prescription items was observed from 2015–2019. In the least deprived region, the rate of increase in the number of prescriptions was 38.9% during the same period (Figure 2).

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An overall 24.9% increase in prescription items was observed from 2015–2019. In the least deprived region, the rate of increase in the number of prescriptions was 38.9% during the same period (Figure 2). A wide variation in the rate of prescribing across the six English regions were observed. The North East and the North West regions had approximately 50% higher rates of prescribing compared with London. Rates of prescribing were 15.9, 15.3, and 10.3 items per 1000 men each month, respectively, in these regions (Figure 3).

Comparison with existing literature

The aim of this study was to investigate the trend in prescribing of drugs for ED in primary care settings in England and to assess the impact of deprivation, regional demography, and legal reclassification of sildenafil on prescribing practices of ED drugs. There was a persistent increase in the rate of prescribing for treatment of ED in men between 2009 and 2019 in English primary care. Sildenafil remained the most frequently prescribed medication out of the two drugs of choice. A strong link between deprivation and prescribing trends were observed across all data points. These can be linked to higher prevalence of risk factors of ED, such as cardiovascular and mental health conditions, with deprivation.14 A north–south divide was observed in the rate of prescriptions, with higher prescribing rates observed in the northern regions of England compared with London and the southern regions. A wide variation in the rate of prescribing across the six English regions were observed.

• Erectile dysfunction may reflect diabetes, cardiovascular issues, or stress.
• Drug safety information is included in prescription packaging.
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The North East and the North West regions had approximately 50% higher rates of prescribing compared with London. Rates of prescribing were 15.9, 15.3, and 10.3 items per 1000 men each month, respectively, in these regions (Figure 3). The aim of this study was to investigate the trend in prescribing of drugs for ED in primary care settings in England and to assess the impact of deprivation, regional demography, and legal reclassification of sildenafil on prescribing practices of ED drugs.

There was a persistent increase in the rate of prescribing for treatment of ED in men between 2009 and 2019 in English primary care. Sildenafil remained the most frequently prescribed medication out of the two drugs of choice. A strong link between deprivation and prescribing trends were observed across all data points. These can be linked to higher prevalence of risk factors of ED, such as cardiovascular and mental health conditions, with deprivation.14 A north–south divide was observed in the rate of prescriptions, with higher prescribing rates observed in the northern regions of England compared with London and the southern regions. While some of the regional variations are explained by the differences in deprivation level, London’s younger population compared with the rest of the country15 could explain low ED prevalence and the observed low prescribing for ED. In addition, patient behaviours around use of online sources for access to sildenafil may be different across various geographical regions. Data showed that reclassification of sildenafil to a pharmacy medicine from ‘prescription-only' medicine had modest impact on the trend of prescribing.

Mechanism of action

It could be assumed that the reclassification of sildenafil would lead to a decrease in the number of items prescribed as people would be able to get their medicine directly from the pharmacy instead of needing to go to the doctors and wait for an appointment. It is important to note, however, that the pharmacy version of sildenafil costs approximately £20 for a pack of four tablets (as of April 2020) whereas the generic sildenafil prescriptions from a GP only costs £9 for the same number of tablets. The higher cost of the pharmacy version of the medicine compared with the prescription cost may dissuade patients from using pharmacy for accessing sildenafil.

What should I do if I forget a dose?

While some of the regional variations are explained by the differences in deprivation level, London’s younger population compared with the rest of the country15 could explain low ED prevalence and the observed low prescribing for ED. In addition, patient behaviours around use of online sources for access to sildenafil may be different across various geographical regions. Data showed that reclassification of sildenafil to a pharmacy medicine from ‘prescription-only' medicine had modest impact on the trend of prescribing. It could be assumed that the reclassification of sildenafil would lead to a decrease in the number of items prescribed as people would be able to get their medicine directly from the pharmacy instead of needing to go to the doctors and wait for an appointment. It is important to note, however, that the pharmacy version of sildenafil costs approximately £20 for a pack of four tablets (as of April 2020) whereas the generic sildenafil prescriptions from a GP only costs £9 for the same number of tablets.

Pulmonary arterial hypertension

The higher cost of the pharmacy version of the medicine compared with the prescription cost may dissuade patients from using pharmacy for accessing sildenafil. In addition, confidentiality and privacy have been cited as barriers to utilisation of sexual health services from pharmacy.16 The lack of long-term monitoring and follow-up in pharmacy settings may also discourage many patients from accessing the pharmacy version of sildenafil. This project included data from very large routinely collected datasets covering all primary care prescriptions in England. Deprivation data were based on CCG level and individual practice level variations were not accounted for. This study only included NHS prescription data and private prescriptions were not accounted for. In addition, confidentiality and privacy have been cited as barriers to utilisation of sexual health services from pharmacy.16 The lack of long-term monitoring and follow-up in pharmacy settings may also discourage many patients from accessing the pharmacy version of sildenafil. This project included data from very large routinely collected datasets covering all primary care prescriptions in England. Deprivation data were based on CCG level and individual practice level variations were not accounted for. This study only included NHS prescription data and private prescriptions were not accounted for. Only two PDE-5Is were included, sildenafil and tadalafil, as the authors' observations suggested that the rest of the PED-5Is accounted for negligible volume of prescribing and, hence, did not impact on the trend analysis. Similarly, community and online pharmacy sales of over-the-counter sildenafil were not included in the trend analysis.

Brand Name

The expiry of the patent on sildenafil in June 2013 allowed the NHS to purchase generic sildenafil from other pharmaceutical companies for a competitive price, subsequently reducing the price per item from £31.31 in 2012 to £2.53 in 2014.11 This also allowed sildenafil to be removed from the Selected List Scheme, which restricted prescriptions of certain drugs in May 2014, allowing more men access to the medicine on the NHS, which potentially increased the number of items prescribed.21 The patent on tadalafil also expired in November 2017, leading to a 49% decrease in cost per item from £49.40 in 2017 to £25.12 in 2018. The data suggest that more men are seeking help or being assessed for ED in primary care. The increased presentations and, hence, prescribing for EDs allows further opportunities to screen for the associated risk factors for ED. These include: CVDs such as hypertension, coronary artery disease, peripheral vasculopathy; endocrine disorders such as diabetes, metabolic syndrome, and hyperthyroidisim; as well as assessment of psychogenic risk factors and medication-induced ED.2 Prescribers should be aware of the wider organic, psychogenic nature and linked risk factors of ED including diabetes, vascular disorders, and mental health conditions. The cause of ED needs to be established before treatment can commence and patients should be referred to specialist clinics where appropriate.

What if I miss a dose?

Guidelines recommend that a physical examination, including genitourinary, endocrine, vascular, and neurological systems, is undertaken. This can reveal any unsuspected diagnoses, such as Peyronie’s disease, pre-malignant or malignant genital lesions, prostatic enlargement or irregularity or nodularity, or signs and symptoms suggesting hypogonadism.2,3 It is, however, unclear how often patients are screened for the red-flag symptoms. Long-term safety outcomes of PDE-5Is are not understood. Prescribers should, therefore, reassess the continuous use of these drugs on a periodic basis.22,23 Reclassification to allow ‘pharmacy-only’ supply of drugs to free-up GP time and resources have faced successes and barriers in the past.24–26 For example, reclassification of drugs such as chloramphenicol eye products, mild steroids, and antifungal products have been positively received by patients, GPs, and pharmacists. However, reclassified pharmacy version of simvastatin was not adopted in practice to the same extent.24 Research on community pharmacist and patient perspectives on the need, supply, and aspects of risk assessments and referrals are warranted. Some patients may avoid perceived embarrassment and confidentiality issues in face-to-face clinical consultations in primary care and community pharmacy16 by accessing medicines through online sources. Other available treatments for ED, including vacuum-pump treatment and psychosexual therapies, were not included in the study. In addition, prevalence data of ED over time were considered for this study. The segmented regression for different policy changes (for example, sildenafil patent expiry in June 2013, tadalafil patent expiry in November 2017, and reclassification of sildenafil from prescription medicine to pharmacy medicine in March 2018) could not be performed owing to: a) absence of monthly prescribing and spending data (access was restricted to annual level for historical data prior to 2015); and b) inadequate time-points before and after different policy changes needed to conduct segmented regression analysis.17 There is a lack of literature on the prescribing and management of ED in primary care. Previous studies have reported that many men do not seek help with sexual problems to avoid perceived embarrassment for themselves and their doctors.18,19 The observed increasing trend in the rate of prescriptions may have been contributed by various factors. These include inclusion of ED assessment for men with diabetes in the Quality and Outcomes Framework (QOF) since 2013–2014.20 The QOF required opportunistic screening, advice and assessment of contributory factors, and treatment options for ED in patients with diabetes in primary care.

In addition, media, including social media, may have contributed to increased knowledge and awareness of the condition among members of the general public given the licensing of cialis tadalafil 5 mg 28 tablets newer PDE-5Is in recent years.

• Cialis prescription involves medical examination and sexual history review.
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The study shows that the introduction of generic versions of both sildenafil in 2013 and tadalafil in 2017 reduced overall spending on drugs used for ED.

The expiry of the patent on sildenafil in June 2013 allowed the NHS to purchase generic sildenafil from other pharmaceutical companies for a competitive price, subsequently reducing the price per item from £31.31 in 2012 to £2.53 in 2014.11 This also allowed sildenafil to be removed from the Selected List Scheme, which restricted prescriptions of certain drugs in May 2014, allowing more men access to the medicine on the NHS, which potentially increased the number of items prescribed.21 The patent on tadalafil also expired in November 2017, leading to a 49% decrease in cost per item from £49.40 in 2017 to £25.12 in 2018. The data suggest that more men are seeking help or being assessed for ED in primary care. The increased presentations and, hence, prescribing for EDs allows further opportunities to screen for the associated risk factors for ED. These include: CVDs such as hypertension, coronary artery disease, peripheral vasculopathy; endocrine disorders such as diabetes, metabolic syndrome, and hyperthyroidisim; as well as assessment of psychogenic risk factors and medication-induced ED.2 Prescribers should be aware of the wider organic, psychogenic nature and linked risk factors of ED including diabetes, vascular disorders, and mental health conditions. The cause of ED needs to be established before treatment can commence and patients should be referred to specialist clinics where appropriate. Guidelines recommend that a physical examination, including genitourinary, endocrine, vascular, and neurological systems, is undertaken. This can reveal any unsuspected diagnoses, such as Peyronie’s disease, pre-malignant or malignant genital lesions, prostatic enlargement or irregularity or nodularity, or signs and symptoms suggesting hypogonadism.2,3 It is, however, unclear how often patients are screened for the red-flag symptoms. Long-term safety outcomes of PDE-5Is are not understood.

Prescribers should, therefore, reassess the continuous use of these drugs on a periodic basis.22,23 Reclassification to allow ‘pharmacy-only’ supply of drugs to free-up GP time and resources have faced successes and barriers in the past.24–26 For example, reclassification of drugs such as chloramphenicol eye products, mild steroids, and antifungal products have been positively received by patients, GPs, and pharmacists.

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What About Other ED Medications?

GPs and patient experiences of access to sildenafil from pharmacy also need to be further explored. Results of this study suggest that more men are being screened for, or seeking help with, ED. The two-fold observed increase in the population adjusted rate of prescriptions over the past 10 years is less likely to be accounted for by other factors. Promotion of sildenafil by pharmaceutical industries since being made available over the counter for pharmacy sales could have raised awareness of ED among the general public. Higher rate of prescribing in deprived regions offers opportunity for monitoring of linked health conditions such as CVD and diabetes.

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Reclassification of sildenafil to pharmacy medicine had a modest impact on prescribing practices. This study was funded by the University of Birmingham. This study represents secondary analysis of the information retrieved from publicly available anonymised datasets and does not warrant formal ethical approval. The authors declare that no competing interests exist. This article is Open Access: CC BY license ( All content on this page has been medically reviewed by: Hassan Thwaini, Clinical Pharmacist and Copywriter, Master of Pharmacy (MPharm) on 30 March, 2026. Higher rate of prescribing in deprived regions offers opportunity for monitoring of linked health conditions such as CVD and diabetes. Reclassification of sildenafil to pharmacy medicine had a modest impact on prescribing practices. This study was funded by the University of Birmingham. This study represents secondary analysis of the information retrieved from publicly available anonymised datasets and does not warrant formal ethical approval. The authors declare that no competing interests exist. This article is Open Access: CC BY license ( All content on this page has been medically reviewed by: Hassan Thwaini, Clinical Pharmacist and Copywriter, Master of Pharmacy (MPharm) on 30 March, 2026. Tadalafil is a clinically-proven erectile dysfunction treatment that gives you the freedom to enjoy sex when you want it. It lasts for 36 hours - so there’s less need for planning before sex. Find the clinically proven ED treatment that suits you best. No names, no logos, no delivery fee. 4.6* from over 33,000 people like you. BSc (Hons) MBBS MRCGP AFHEA MA (Hons) AFMCP Answer a few simple questions to get the treatment you need. sale cialis with dapoxetine tadalafil internet order low price dose online drugstore buy makeup generic cialis with dapoxetine tadalafil dosage side effects tablets online drugstore legal overnight cialis with dapoxetine tadalafil safety side effects pills online pharmacy no rx buy cheap cialis with dapoxetine tadalafil by pill side effects tablets online pharmacy with prescription sale cialis with dapoxetine tadalafil overnight delivery inexpensive medicines online pharmacy in usa price cialis with dapoxetine tadalafil cost of online online drugstore pills canadian healthcare online drugstore buy cialis with dapoxetine tadalafil get prescription order pills pills online drugstore with makeup without rx cialis with dapoxetine tadalafil australia worldwide medicine online pharmacy generic fast cialis with dapoxetine tadalafil safety worldwide drugs online drugstore india without rx cialis with dapoxetine tadalafil mail order how can i get dose online pharmacy no rx express delivery cialis with dapoxetine tadalafil samples low price medicines online pharmacy usa where to buy cialis with dapoxetine tadalafil express delivery internet application online pharmacy paypal order cialis with dapoxetine tadalafil en usa online drugstore tablets online drugstore discount buy cialis with dapoxetine tadalafil without prescriptions online drugstore tablets online drugstore uk can in buy cialis with dapoxetine tadalafil overdose online drugstore medicine online pharmacy walgreens buy cialis with dapoxetine tadalafil fedex overnight order pills tablets online drugstore sale buy discount cialis with dapoxetine tadalafil worldwide delivery inexpensive medicine online drugstore prescription cheapest cialis with dapoxetine tadalafil fast delivery internet tablets online drugstore 24 buy cialis with dapoxetine tadalafil safety order worldwide tablets online pharmacy paypal fast cialis with dapoxetine tadalafil express shipping by credit card medicines online pharmacy definition safely online cialis with dapoxetine tadalafil prices worldwide medicine us drugstore online review express delivery cialis with dapoxetine tadalafil legal for sale side effects pill online pharmacy pain medication order cialis with dapoxetine tadalafil by visa by credit card application online pharmacy overseas sale cialis with dapoxetine tadalafil usa online uncostly application online pharmacy uk overnight cialis with dapoxetine tadalafil by pill sixpenny application online pharmacy usa no prescription price cialis with dapoxetine tadalafil england order pills dose online pharmacy uk no prescription get cialis with dapoxetine tadalafil in uk online drugstore tablets online pharmacy overnight shipping express shipping cialis with dapoxetine tadalafil price of in the uk by credit card contraindication online drugstore reputable cheapest cialis with dapoxetine tadalafil england sixpenny tablets online drugstore no prescription fast shipping cialis with dapoxetine tadalafil legally by credit card treatment online drugstore over the counter express delivery cialis with dapoxetine tadalafil in uk sixpenny pills online pharmacy regulations buy discount cialis with dapoxetine tadalafil dosage how can i get contraindication online drugstore f

PDE5 inhibitors: key facts

Only two PDE-5Is were included, sildenafil and tadalafil, as the authors' observations suggested that the rest of the PED-5Is accounted for negligible volume of prescribing and, hence, did not impact on the trend analysis. Similarly, community and online pharmacy sales of over-the-counter sildenafil were not included in the trend analysis. Some patients may avoid perceived embarrassment and confidentiality issues in face-to-face clinical consultations in primary care and community pharmacy16 by accessing medicines through online sources. Other available treatments for ED, including vacuum-pump treatment and psychosexual therapies, were not included in the study. In addition, prevalence data of ED over time were considered for this study.

Will my consultation be confidential?

The segmented regression for different policy changes (for example, sildenafil patent expiry in June 2013, tadalafil patent expiry in November 2017, and reclassification of sildenafil from prescription medicine to pharmacy medicine in March 2018) could not be performed owing to: a) absence of monthly prescribing and spending data (access was restricted to annual level for historical data prior to 2015); and b) inadequate time-points before and after different policy changes needed to conduct segmented regression analysis.17 There is a lack of literature on the prescribing and management of ED in primary care. Previous studies have reported that many men do not seek help with sexual problems to avoid perceived embarrassment for themselves and their doctors.18,19 The observed increasing trend in the rate of prescriptions may have been contributed by various factors. These include inclusion of ED assessment for men with diabetes in the Quality and Outcomes Framework (QOF) since 2013–2014.20 The QOF required opportunistic screening, advice and assessment of contributory factors, and treatment options for ED in patients with diabetes in primary care. In addition, media, including social media, may have contributed to increased knowledge and awareness of the condition among members of the general public given the licensing of cialis tadalafil 5 mg 28 tablets newer PDE-5Is in recent years. The study shows that the introduction of generic versions of both sildenafil in 2013 and tadalafil in 2017 reduced overall spending on drugs used for ED.