avanafil. Mechanism: additive vasodilation. Contraindicated. Potentially fatal hypotension.nitroprusside sodiumSerious - Use Alternative (1)nitroprusside sodium, avanafil. Either increases effects of the other by Mechanism: pharmacodynamic synergism. Contraindicated. Additive hypotensive effects.olmesartanMonitor Closely (1)avanafil increases effects of olmesartan by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.oxcarbazepineMonitor Closely (1)oxcarbazepine will decrease the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. For patients with ED, monitor response carefully because of potential for decreased effectiveness.pazopanibMonitor Closely (1)pazopanib will increase the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.penbutololMonitor Closely (1)avanafil increases effects of penbutolol by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.pentobarbitalMonitor Closely (1)pentobarbital will decrease the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. For patients with ED, monitor response carefully because of potential for decreased effectiveness.phenobarbitalMonitor Closely (1)phenobarbital will decrease the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. For patients with ED, monitor response carefully because of potential for decreased effectiveness.phenoxybenzamineMonitor Closely (1)avanafil increases effects of phenoxybenzamine by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.phentolamineMonitor Closely (1)avanafil increases effects of phentolamine by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.phenytoinMonitor Closely (1)phenytoin will decrease the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. For patients with ED, monitor response carefully because of potential for decreased effectiveness.posaconazoleSerious - Use Alternative (1)posaconazole will increase the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. CYP3A4 inhibitors may reduce avanafil clearance increasing systemic exposure to avanafil; significantly increased levels may result in significant adverse events including severe hypotension, syncope, visual changes, and priapism. Coadministration with strong CYP3A4 is contraindicated. prazosinMonitor Closely (1)avanafil increases effects of prazosin by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.primidoneMonitor Closely (1)primidone will decrease the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. For patients with ED, monitor response carefully because of potential for decreased effectiveness.propranololMonitor Closely (1)avanafil increases effects of propranolol by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.quinaprilMonitor Closely (1)avanafil increases effects of quinapril by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.quinupristin/dalfopristinMonitor Closely (1)quinupristin/dalfopristin will increase the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. CYP3A4 inhibitors may reduce avanafil clearance increasing systemic exposure to avanafil; increased levels may result in increased associated adverse events; the maximum recommended dose of STENDRA is 50 mg, not to exceed once every 24 hours for patients taking concomitant moderate CYP3A4 inhibitorsramiprilMonitor Closely (1)avanafil increases effects of ramipril by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.ranolazineMinor (1)ranolazine will increase the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown. CYP3A4 inhibitors may reduce avanafil clearance increasing systemic exposure to avanafil; increased levels may result in increased associated adverse events; the maximum recommended dose of STENDRA is 50 mg, not to exceed once every 24 hours for patients taking concomitant moderate CYP3A4 inhibitorsribociclibMonitor Closely (1)ribociclib will increase the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely.rifabutinMonitor Closely (1)rifabutin will decrease the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. For patients with ED, monitor response carefully because of potential for decreased effectiveness.rifampinMonitor Closely (1)rifampin will decrease the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. For patients with ED, monitor response carefully because of potential for decreased effectiveness.rifapentineMonitor Closely (1)rifapentine will decrease the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. For patients with ED, monitor response carefully because of potential for decreased effectiveness.riociguatContraindicated (1)avanafil, riociguat. Either increases effects of the other by additive vasodilation. Contraindicated. Coadministration of PDE-5 inhibitors (eg, avanafil, sildenafil, tadalafil, vardenafil) and guanylate cyclase stimulators (eg, riociguat) is contraindicated due to risk of additive hypotension.ritonavirSerious - Use Alternative (1)ritonavir will increase the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. CYP3A4 inhibitors may reduce avanafil clearance increasing systemic exposure to avanafil; significantly increased levels may result in significant adverse events including severe hypotension, syncope, visual changes, and priapism. Coadministration with strong CYP3A4 is contraindicated.rucaparibMonitor Closely (1)rucaparib will increase the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Adjust dosage of CYP3A4 substrates, if clinically indicated.rufinamideMonitor Closely (1)rufinamide will decrease the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. For patients with ED, monitor response carefully because of potential for decreased effectiveness.sacubitril/valsartanMonitor Closely (1)avanafil increases effects of sacubitril/valsartan by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.sapropterinMonitor Closely (1)sapropterin, avanafil. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Possible additive vasorelaxation, leading to low blood pressure.saquinavirSerious - Use Alternative (1)saquinavir will increase the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. CYP3A4 inhibitors may reduce avanafil clearance increasing systemic exposure to avanafil; significantly increased levels may result in significant adverse events including severe hypotension, syncope, visual changes, and priapism. Coadministration with strong CYP3A4 is contraindicated.secobarbitalMonitor Closely (1)secobarbital will decrease the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. For patients with ED, monitor response carefully because of potential for decreased effectiveness.sertralineMonitor Closely (1)sertraline will increase the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. CYP3A4 inhibitors may reduce avanafil clearance increasing systemic exposure to avanafil; increased levels may result in increased associated adverse events; the maximum recommended dose of STENDRA is 50 mg, not to exceed once every 24 hours for patients taking concomitant moderate CYP3A4 inhibitorssilodosinMonitor Closely (1)avanafil increases effects of silodosin by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.sotalolMonitor Closely (1)avanafil increases effects of sotalol by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.spironolactoneMonitor Closely (1)avanafil increases effects of spironolactone by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.St John's WortMonitor Closely (1)St John's Wort will decrease the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. For patients with ED, monitor response carefully because of potential for decreased effectiveness.stiripentolMonitor Closely (1)stiripentol, avanafil. affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Stiripentol is a CYP3A4 inhibitor and inducer. Monitor CYP3A4 substrates coadministered with stiripentol for increased or decreased effects. CYP3A4 substrates may require dosage adjustment.tamsulosinMonitor Closely (1)avanafil, tamsulosin. Either increases effects of the other by additive vasodilation. Use Caution/Monitor. Risk of hypotension.tazemetostatMonitor Closely (1)tazemetostat will decrease the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.tecovirimatMonitor Closely (1)tecovirimat will decrease the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Tecovirimat is a weak CYP3A4 inducer. Monitor sensitive CYP3A4 substrates for effectiveness if coadministered.telmisartanMonitor Closely (1)avanafil increases effects of telmisartan by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.terazosinMonitor Closely (1)avanafil increases effects of terazosin by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.tetracyclineMonitor Closely (1)tetracycline will increase the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. CYP3A4 inhibitors may reduce avanafil clearance increasing systemic exposure to avanafil; increased levels may result in increased associated adverse events; the maximum recommended dose of STENDRA is 50 mg, not to exceed once every 24 hours for patients taking concomitant moderate CYP3A4 inhibitorstimololMonitor Closely (1)avanafil increases effects of timolol by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.tipranavirSerious - Use Alternative (1)tipranavir will increase the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. CYP3A4 inhibitors may reduce avanafil clearance increasing systemic exposure to avanafil; significantly increased levels may result in significant adverse events including severe hypotension, syncope, visual changes, and priapism. Coadministration with strong CYP3A4 is contraindicated.topiramateMonitor Closely (1)topiramate will decrease the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. For patients with ED, monitor response carefully because of potential for decreased effectiveness.torsemideMonitor Closely (1)avanafil increases effects of torsemide by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.trandolaprilMonitor Closely (1)avanafil increases effects of trandolapril by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.triamtereneMonitor Closely (1)avanafil increases effects of triamterene by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.tucatinibSerious - Use Alternative (1)tucatinib will increase the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid concomitant use of tucatinib with CYP3A substrates, where minimal concentration changes may lead to serious or life-threatening toxicities. If unavoidable, reduce CYP3A substrate dose according to product labeling.valsartanMonitor Closely (1)avanafil increases effects of valsartan by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypotension.vardenafilSerious - Use Alternative (1)vardenafil, avanafil. Either increases effects of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Avoid combination; duplicate therapy is not recommended.verapamilMonitor Closely (1)verapamil will increase the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. CYP3A4 inhibitors may reduce avanafil clearance increasing systemic exposure to avanafil; increased levels may result in increased associated adverse events; the maximum recommended dose of STENDRA is 50 mg, not to exceed once every 24 hours for patients taking concomitant moderate CYP3A4 inhibitors vericiguatContraindicated (1)avanafil, vericiguat. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Coadministration of vericiguat with PDE-5 inhibitors may result in additive hypotensive effects.voriconazoleSerious - Use Alternative (1)voriconazole will increase the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. CYP3A4 inhibitors may reduce avanafil clearance increasing systemic exposure to avanafil; significantly increased levels may result in significant adverse events including severe hypotension, syncope, visual changes, and priapism. Coadministration with strong CYP3A4 is contraindicated.voxelotorSerious - Use Alternative (1)voxelotor will increase the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Voxelotor increases systemic exposure of sensitive CYP3A4 substrates. Avoid coadministration with sensitive CYP3A4 substrates with a narrow therapeutic index. Consider dose reduction of the sensitive CYP3A4 substrate(s) if unable to avoid.zafirlukastMonitor Closely (1)zafirlukast will increase the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. CYP3A4 inhibitors may reduce avanafil clearance increasing systemic exposure to avanafil; increased levels may result in increased associated adverse events; the maximum recommended dose of STENDRA is 50 mg, not to exceed once every 24 hours for patients taking concomitant moderate CYP3A4 inhibitors >2% Headache (5.6%) Flushing (3.5%) Nasal congestion (2.1%) Nasopharyngitis (3.4%) Back pain (2.5%) Upper respiratory infection (<2%) Bronchitis (<2%) Influenza (<2%) Sinusitis (<2%) Sinus congestion (<2%) Hypertension (<2%) Dyspepsia (<2%) Nausea (<2%) Constipation (<2%) Rash (<2%) <1% Peripheral edema Fatigue Angina Deep vein thrombosis Palpitations Gastritis Gastroesophageal reflux disease Hypoglycemia Hyperglycemia Oropharyngeal pain Stomach discomfort Vomiting Depression Insomnia Cough Dyspnea exertional Epistaxis Wheezing Pruritus Urinary tract infection Pollakiuria Nephrolithiasis Hematuria Increased erection Balanitis Postmarketing Reports Cardiovascular and cerebrovascular: Myocardial infarction, sudden cardiac death, cerebrovascular accident, and subarachnoid hemorrhage Nervous: Transient global amnesia Ophthalmologic: Vitreous detachment, visual impairment Otologic: Sudden decrease or loss of hearing Contraindications Hypersensitivity Soluble guanylate cyclase (sGC) stimulators (eg, riociguat or vericiguat); concomitant use can cause hypotension Coadministration with nitrates Coadministration with nitrates (either regularly and/or intermittently) and nitric oxide donors Consistent with the effects of PDE5 inhibition on the nitric oxide/cyclic guanosine monophosphate pathway, PDE5 inhibitors may potentiate the hypotensive effects of nitrates A suitable time interval following PDE5 dosing for the safe administration of nitrates or nitric oxide donors has not been determined Cautions Potential for cardiovascular risk during sexual activity in patients with underlying cardiovascular conditions Monitor patients with left ventricular outflow obstruction (eg, aortic stenosis, idiopathic hypertrophic subaortic stenosis) Dose should not exceed 50 mg/24hr when taking avanafil concomitantly with moderate CYP3A4 inhibitors Initiate therapy at 50 mg/24hr if coadministered with antihypertensive medications like alpha-blockers Priapism may occur especially in patients with predisposed conditions (eg, sickle cell anemia, multiple myeloma, or leukemia) Discontinue therapy if sudden loss of vision in one or both eyes occur (could be a sign of non-arteritic anterior ischemic optic neuropathy) Safety and efficacy not established in patients with hereditary retinal disorders, including retinitis pigmentosa (use not recommended) Sudden hearing loss may occur; discontinue therapy if tinnitus symptoms occur Alcohol may increase risk for orthostatic hypotension; may increase heart rate and cause dizziness and headache Pregnancy Category: C Lactation: Safety and efficacy not establishedPregnancy Categories A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk. B: May be acceptable.