4PLAY sublingual

Our assessment

We have reviewed eight combination products. This is the furthest any of them goes: sildenafil, tadalafil and vardenafil are all present, and all three are PDE5 inhibitors. They block the same enzyme, in the same tissue, by the same mechanism. Every approved product in this category contains exactly one.

The argument against two of them applies with more force to three, and it is not ours alone. Georgia Urology, addressing combination products directly, concluded it is “unlikely there will be any substantial difference between a single and dual medication therapy” and that a patient combining them is “now subjected to the risk profile of two drugs rather than just one.” Make it three and you have tripled the risk profile to reach the same enzyme.

What makes this entry harder to assess than the others is the absence of numbers. No milligram figure appears for any of the four ingredients on either page we read. That is not a small omission: the approved ceilings — 100mg sildenafil, 20mg tadalafil on demand, 20mg vardenafil — are the only external standard a reader has, and without strengths there is nothing to check them against. We could grade [BlueChew GOLD](/bluechew-gold-reviews) harshly precisely because it published its figures and two of them sat above their limits. Here the arithmetic cannot be done at all.

The fourth ingredient is apomorphine, which is not a PDE5 inhibitor and has never been approved for erectile dysfunction in the United States. It acts centrally rather than on penile blood flow, and nausea is its characteristic dose-limiting effect. As with every other product we have found it in, no rationale for including it is offered.

The duration claim deserves a note. “Up to 36 hrs” is tadalafil’s property, and a real one — but it is what tadalafil does by itself, at about a dollar a tablet. Neither the sildenafil nor the vardenafil contributes to it. Meanwhile a short-acting drug and a 36-hour drug in the same dose means that if something goes wrong you cannot stop one without stopping all of them, and you will not know which was responsible.

Two disclaimers appear across these pages and they do not agree. The landing page carries the correct one for a compounded prescription drug, stating plainly that compounded drugs are not FDA-approved and are not reviewed for safety, effectiveness or quality. The product page instead carries “These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any disease” — which is the dietary-supplement formula, and is not the right disclaimer for a prescription medicine containing four active drugs.

Credit where it is due, and there is some. The nitrate warning is present and correctly extends to guanylate cyclase stimulators such as riociguat, which several sellers omit. Auto-refill is opt-in rather than a subscription you must remember to cancel, the price is locked at checkout, and an unapproved prescription is refunded in full. Those are better commercial manners than much of this market shows.

None of which resolves the pharmacology. If you want a fast on-demand drug, sildenafil or vardenafil alone is approved. If you want coverage into the next day, [tadalafil alone](/generic-sildenafil-tadalafil-reviews) is approved and costs about a dollar a tablet. Three at once, at undisclosed strengths, is not a stronger version of that — it is the same target hit three ways with three sets of side effects and no published dose.