Hezkue is a UK Prescription-Only Medicine containing sildenafil 12.5mg per actuation as a mint-flavoured oromucosal spray suspension.
It is the first licensed sildenafil oral spray in the UK, offering an alternative delivery format to standard sildenafil tablets for the treatment of erectile dysfunction in adult men.
The spray is administered onto the tongue and swallowed, with initial absorption beginning within around 5 minutes. Standard dose is 50mg (4 sprays) approximately 1 hour before sexual activity, with flexible dosing from 25mg up to 100mg in 12.5mg steps.
Effects last up to 4 to 5 hours.
Clinical efficacy is comparable to sildenafil tablets; the distinguishing features are the spray format, flexible dosing, faster initial absorption, and mint flavour.
Available from Courier Pharmacy with prescriber support and treatment that fits your situation.
Hezkue (sildenafil 12.5mg per actuation, oromucosal spray suspension) is a relatively new addition to the UK erectile dysfunction treatment landscape. Sildenafil has been the established first-line oral treatment for erectile dysfunction since 1998 (originally as Viagra, with generic sildenafil widely available since 2013), but until Hezkue arrived in 2025, the available delivery formats were tablets, orodispersible films, and chewable tablets. Hezkue introduces oromucosal spray delivery as a new option.
How Hezkue compares to other sildenafil formats
The clinical effect of all sildenafil formats is the same at equivalent doses: PDE5 inhibition increases cGMP in penile vascular smooth muscle, producing vasodilation and improved erectile response to sexual stimulation. The differences between formats are in absorption characteristics, convenience, and patient experience:
Sildenafil tablets (Viagra 25mg/50mg/100mg, generic equivalents): the original and most established format. Swallowed with water. Onset 30 to 60 minutes, peak effect 1 to 2 hours, duration 4 to 5 hours. Fixed dose strengths (25mg, 50mg, 100mg). Lowest cost; widely available
Sildenafil orodispersible films and chewable tablets: dissolve in the mouth without water. Onset slightly faster than standard tablets in some patients. Convenient where water isn’t available. Fixed dose strengths
Hezkue oromucosal spray (12.5mg per actuation): sprayed onto the tongue and swallowed. Initial absorption from the oral mucosa within around 5 minutes (most of the dose is still swallowed and absorbed through the GI tract, but a portion absorbs directly from the oromucosal route). Mint-flavoured, discreet, no water needed. Flexible dosing in 12.5mg steps from 12.5mg up to 100mg per dose
What’s distinctive about Hezkue
The features that make Hezkue worth considering for some patients:
Spray delivery format: no need to swallow a tablet. Useful for patients who have difficulty swallowing tablets, who want a more discreet format, or who travel without easy access to water
Faster initial absorption: independent pharmacokinetic studies show initial absorption within around 5 minutes after spray administration, compared to standard sildenafil tablets where measurable plasma levels typically appear later. While the difference in time-to-peak effect is more modest, some patients find the rapid onset profile useful
Flexible dose titration: each spray delivers 12.5mg, so doses can be fine-tuned in small steps (25mg = 2 sprays, 37.5mg = 3 sprays, 50mg = 4 sprays, 62.5mg = 5 sprays, 75mg = 6 sprays, 87.5mg = 7 sprays, 100mg = 8 sprays). This is finer-grained dose titration than the fixed 25mg/50mg/100mg tablet strengths
Mint flavour: more palatable than the bitter taste of sildenafil itself, making the oromucosal experience tolerable
Less reliance on GI absorption: although most of the dose is still swallowed and absorbed through the GI tract, the initial oromucosal absorption component may reduce dependence on GI function. This is most relevant for patients with significant GI absorption concerns, although the clinical effect of this difference is modest
Discreet on-the-go format: the spray bottle is more discreet than a tablet bottle or blister pack for some patients
What’s similar to other sildenafil formats
On the clinically important measures, Hezkue is broadly similar to other sildenafil formats:
Efficacy: sildenafil is sildenafil regardless of format. Hezkue is bioequivalent to sildenafil tablets in overall pharmacokinetic profile, meaning clinical efficacy is comparable
Duration of effect: around 4 to 5 hours, similar to tablets
Maximum dose: 100mg per 24 hours, same as standard sildenafil
Need for sexual stimulation: like all PDE5 inhibitors, sildenafil doesn’t cause automatic erection; sexual stimulation is still needed
Side effect profile: largely the same as standard sildenafil (headache, flushing, dyspepsia, nasal congestion, visual changes, dizziness)
Contraindications and interactions: the same as standard sildenafil (nitrates, severe cardiovascular disease, severe hepatic impairment, hereditary retinal disorders, certain medicines)
Cost: typically higher than generic sildenafil tablets, which are among the most affordable PDE5 inhibitors
Who Hezkue might genuinely suit
Patients who have difficulty swallowing tablets (dysphagia, swallowing anxiety, gag reflex sensitivity)
Patients who prefer a more discreet format for travel, work scenarios, or situations where taking a tablet feels less practical
Patients who value flexible dose titration in 12.5mg steps rather than fixed tablet strengths
Patients who want to fine-tune their dose to minimise side effects while maintaining efficacy
Patients with significant GI absorption concerns (although the clinical impact of the partial oromucosal absorption is modest)
Patients who find the rapid onset profile useful for spontaneity (although the clinically meaningful difference in time-to-effect is modest)
Patients who have tried standard sildenafil tablets and want to try a different format
Who Hezkue probably won’t suit better than tablets
Patients for whom cost is a significant factor: generic sildenafil tablets are typically substantially cheaper than Hezkue
Patients who want longer duration of action: tadalafil (Cialis, generic) lasts up to 36 hours, much longer than any sildenafil format
Patients who do well on standard sildenafil tablets: there’s usually no compelling reason to switch from a working treatment to a more expensive format
Patients who haven’t responded to sildenafil in any format: switching delivery format alone is unlikely to overcome non-response; tadalafil, vardenafil, avanafil, or non-PDE5-inhibitor options may be more useful
Key features and specifications
Active ingredient: sildenafil 12.5mg per actuation (delivered as 0.5mL of oromucosal suspension)
Concentration: 25mg sildenafil per 1 mL of suspension
Form: white to off-white oromucosal suspension with mint aroma flavour, in a metered-dose spray bottle
Pack size: 30 mL bottle, providing approximately 60 actuations (around 20 doses at the standard 50mg dose level)
Indication: treatment of erectile dysfunction in adult men
Standard adult dose: 50mg (4 sprays) approximately 1 hour before sexual activity. Dose can be increased to maximum 100mg (8 sprays) or reduced to 25mg (2 sprays) based on efficacy and tolerability
Maximum dosing frequency: once per 24 hours
Onset of action: initial absorption within around 5 minutes; clinical effect typically over 20 to 60 minutes; duration up to 4 to 5 hours
Legal category: Prescription-Only Medicine (POM)
Supplied by: Courier Pharmacy, UK GPhC-registered, with prescriber and pharmacist support
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Quantity
1 x 30ml, 2 x 30ml, 3 x 30ml, 4 x 30ml, 5 x 30ml, 6 x 30ml
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Hezkue is the first licensed sildenafil oral spray available in the UK, offering an alternative delivery format to the standard sildenafil tablets that have been the mainstay of erectile dysfunction treatment for over 25 years. Each spray delivers 12.5mg of sildenafil in a mint-flavoured oromucosal suspension that is sprayed onto the tongue and swallowed. Initial absorption begins within around 5 minutes (compared to longer onset for swallowed tablets), with effects developing over the following 20 to 60 minutes and lasting up to 4 to 5 hours. The flexible spray-based dosing (12.5mg per actuation) means patients can fine-tune their dose in small steps rather than being limited to fixed tablet strengths.
At Courier Pharmacy, we believe treatment that fits the person, not the marketing budget. For erectile dysfunction, that means honest framing of how the different sildenafil delivery formats compare, when Hezkue’s specific features make it a useful choice, and when standard sildenafil tablets, tadalafil, or other treatments would suit you better. This page covers what Hezkue is, who it might genuinely suit, how to get the best from it, and where it fits in the wider erectile dysfunction treatment landscape.
Five key takeaways
Hezkue is a UK Prescription-Only Medicine (POM) containing sildenafil 12.5mg per actuation, supplied as a mint-flavoured oromucosal suspension spray. It is the first and only licensed sildenafil oral spray in the UK, manufactured by Farmalider for marketing authorisation holder Aspargo Labs Italia
The 30ml bottle delivers approximately 60 actuations, which equates to around 20 doses at the standard 50mg dose level (4 sprays), 10 doses at 100mg (8 sprays), or 30 doses at 25mg (2 sprays)
Onset of absorption is rapid (initial absorption within around 5 minutes), with maximum effect typically developing over 20 to 60 minutes. Most patients take Hezkue around 1 hour before planned sexual activity, with effects lasting up to 4 to 5 hours. This is similar to standard sildenafil tablets in overall duration but with potentially faster early absorption
Hezkue is bioequivalent to sildenafil tablets in overall pharmacokinetics, meaning clinical efficacy is comparable. The distinguishing features are the spray delivery format (useful for patients who can’t or don’t want to swallow tablets), the flexible 12.5mg dose-titration steps, the mint flavour, and the discreet on-the-go format. Cost is typically higher than generic sildenafil tablets
Strict contraindications apply, including use with nitrate medicines (significant blood pressure drop risk), recent stroke or heart attack, severe cardiovascular disease, severe liver impairment, hereditary retinal disorders, and a few other specific conditions. Cardiovascular suitability is assessed by our prescriber before supply
Product description: Hezkue Oromucosal Spray
Hezkue (sildenafil 12.5mg per actuation, oromucosal spray suspension) is a relatively new addition to the UK erectile dysfunction treatment landscape. Sildenafil has been the established first-line oral treatment for erectile dysfunction since 1998 (originally as Viagra, with generic sildenafil widely available since 2013), but until Hezkue arrived in 2025, the available delivery formats were tablets, orodispersible films, and chewable tablets. Hezkue introduces oromucosal spray delivery as a new option.
How Hezkue compares to other sildenafil formats
The clinical effect of all sildenafil formats is the same at equivalent doses: PDE5 inhibition increases cGMP in penile vascular smooth muscle, producing vasodilation and improved erectile response to sexual stimulation. The differences between formats are in absorption characteristics, convenience, and patient experience:
Sildenafil tablets (Viagra 25mg/50mg/100mg, generic equivalents): the original and most established format. Swallowed with water. Onset 30 to 60 minutes, peak effect 1 to 2 hours, duration 4 to 5 hours. Fixed dose strengths (25mg, 50mg, 100mg). Lowest cost; widely available
Sildenafil orodispersible films and chewable tablets: dissolve in the mouth without water. Onset slightly faster than standard tablets in some patients. Convenient where water isn’t available. Fixed dose strengths
Hezkue oromucosal spray (12.5mg per actuation): sprayed onto the tongue and swallowed. Initial absorption from the oral mucosa within around 5 minutes (most of the dose is still swallowed and absorbed through the GI tract, but a portion absorbs directly from the oromucosal route). Mint-flavoured, discreet, no water needed. Flexible dosing in 12.5mg steps from 12.5mg up to 100mg per dose
What’s distinctive about Hezkue
The features that make Hezkue worth considering for some patients:
Spray delivery format: no need to swallow a tablet. Useful for patients who have difficulty swallowing tablets, who want a more discreet format, or who travel without easy access to water
Faster initial absorption: independent pharmacokinetic studies show initial absorption within around 5 minutes after spray administration, compared to standard sildenafil tablets where measurable plasma levels typically appear later. While the difference in time-to-peak effect is more modest, some patients find the rapid onset profile useful
Flexible dose titration: each spray delivers 12.5mg, so doses can be fine-tuned in small steps (25mg = 2 sprays, 37.5mg = 3 sprays, 50mg = 4 sprays, 62.5mg = 5 sprays, 75mg = 6 sprays, 87.5mg = 7 sprays, 100mg = 8 sprays). This is finer-grained dose titration than the fixed 25mg/50mg/100mg tablet strengths
Mint flavour: more palatable than the bitter taste of sildenafil itself, making the oromucosal experience tolerable
Less reliance on GI absorption: although most of the dose is still swallowed and absorbed through the GI tract, the initial oromucosal absorption component may reduce dependence on GI function. This is most relevant for patients with significant GI absorption concerns, although the clinical effect of this difference is modest
Discreet on-the-go format: the spray bottle is more discreet than a tablet bottle or blister pack for some patients
What’s similar to other sildenafil formats
On the clinically important measures, Hezkue is broadly similar to other sildenafil formats:
Efficacy: sildenafil is sildenafil regardless of format. Hezkue is bioequivalent to sildenafil tablets in overall pharmacokinetic profile, meaning clinical efficacy is comparable
Duration of effect: around 4 to 5 hours, similar to tablets
Maximum dose: 100mg per 24 hours, same as standard sildenafil
Need for sexual stimulation: like all PDE5 inhibitors, sildenafil doesn’t cause automatic erection; sexual stimulation is still needed
Side effect profile: largely the same as standard sildenafil (headache, flushing, dyspepsia, nasal congestion, visual changes, dizziness)
Contraindications and interactions: the same as standard sildenafil (nitrates, severe cardiovascular disease, severe hepatic impairment, hereditary retinal disorders, certain medicines)
Cost: typically higher than generic sildenafil tablets, which are among the most affordable PDE5 inhibitors
Who Hezkue might genuinely suit
Patients who have difficulty swallowing tablets (dysphagia, swallowing anxiety, gag reflex sensitivity)
Patients who prefer a more discreet format for travel, work scenarios, or situations where taking a tablet feels less practical
Patients who value flexible dose titration in 12.5mg steps rather than fixed tablet strengths
Patients who want to fine-tune their dose to minimise side effects while maintaining efficacy
Patients with significant GI absorption concerns (although the clinical impact of the partial oromucosal absorption is modest)
Patients who find the rapid onset profile useful for spontaneity (although the clinically meaningful difference in time-to-effect is modest)
Patients who have tried standard sildenafil tablets and want to try a different format
Who Hezkue probably won’t suit better than tablets
Patients for whom cost is a significant factor: generic sildenafil tablets are typically substantially cheaper than Hezkue
Patients who want longer duration of action: tadalafil (Cialis, generic) lasts up to 36 hours, much longer than any sildenafil format
Patients who do well on standard sildenafil tablets: there’s usually no compelling reason to switch from a working treatment to a more expensive format
Patients who haven’t responded to sildenafil in any format: switching delivery format alone is unlikely to overcome non-response; tadalafil, vardenafil, avanafil, or non-PDE5-inhibitor options may be more useful
Key features and specifications
Active ingredient: sildenafil 12.5mg per actuation (delivered as 0.5mL of oromucosal suspension)
Concentration: 25mg sildenafil per 1 mL of suspension
Form: white to off-white oromucosal suspension with mint aroma flavour, in a metered-dose spray bottle
Pack size: 30 mL bottle, providing approximately 60 actuations (around 20 doses at the standard 50mg dose level)
Indication: treatment of erectile dysfunction in adult men
Standard adult dose: 50mg (4 sprays) approximately 1 hour before sexual activity. Dose can be increased to maximum 100mg (8 sprays) or reduced to 25mg (2 sprays) based on efficacy and tolerability
Maximum dosing frequency: once per 24 hours
Onset of action: initial absorption within around 5 minutes; clinical effect typically over 20 to 60 minutes; duration up to 4 to 5 hours
Legal category: Prescription-Only Medicine (POM)
Supplied by: Courier Pharmacy, UK GPhC-registered, with prescriber and pharmacist support
Why choose Courier Pharmacy for Hezkue
At Courier Pharmacy, our whole approach is built on a simple idea: treatment that fits the person, not force the person to fit the system. For erectile dysfunction specifically, that means honest framing of where each treatment fits, careful cardiovascular and medication screening, and supporting patients through what can be a sensitive area without judgement.
Our service is shaped by the philosophy of Dr Ada Jex-Cori, our brand pharmacist. Dr Ada represents the spirit of the pharmacy: evidence-led, community-rooted, and willing to challenge the one-size-fits-all approach to medicine. She is named in honour of three pioneering women in science: Ada Lovelace, the mathematician and visionary; Sophia Jex-Blake, the first female doctor in the UK who fought the medical establishment; and Gerty Cori, the biochemist and Nobel Prize winner. In our fictional world of Ethrewell, Dr Ada fights against pharma’s standardised approach to medicine. In the real world, she represents what we stand for. Her view is straightforward: you are not broken. The system is. And we are here to change that.
Honest framing of where Hezkue fits
We won’t oversell Hezkue. The clinical efficacy is comparable to sildenafil tablets at equivalent doses; what distinguishes Hezkue is the spray delivery format, the flexible 12.5mg dose-titration steps, the faster initial absorption, and the mint flavour. These features genuinely matter for some patients but not for others.
For patients new to PDE5 inhibitors who want the most cost-effective starting option, generic sildenafil tablets remain a sensible first step. For patients who do well on standard sildenafil tablets, there’s usually no compelling reason to switch to a more expensive format. For patients who specifically value the spray format, flexible dosing, or rapid onset profile, Hezkue is genuinely different from tablets and worth considering.
Treatment that fits, not one-size-fits-all
Most online pharmacies push whatever ED medicine has the highest margin without thinking through whether it’s the right choice for the individual patient. Courier Pharmacy is different. We think through your situation: what symptoms you have, what you’ve already tried, your cardiovascular and medication picture, what fits with your wider life, and what you actually want from treatment. Hezkue may be the right answer for you; standard sildenafil tablets may suit better; tadalafil for longer duration may be what you need; or second-line treatments like alprostadil may be appropriate if you haven’t responded to PDE5 inhibitors. We’ll think through this with you honestly.
Careful prescriber assessment
Our prescriber screens carefully for the patient groups where PDE5 inhibitor use warrants extra caution or contraindicates the treatment:
Significant cardiovascular disease, recent stroke or heart attack, severe hypertension or hypotension
Use of any nitrate medicine (regular or occasional, including recreational poppers)
Use of alpha-blockers and other significant interaction medicines
Conditions predisposing to priapism
History of visual disturbances or NAION with PDE5 inhibitors
Severe renal or hepatic impairment
Other medical conditions or medicines warranting careful assessment
If any of these apply, we’ll discuss the picture honestly and consider alternatives where Hezkue isn’t appropriate.
Pharmacist and prescriber support before and after purchase
Our team is available to discuss:
Whether Hezkue is the right ED treatment for your situation, or whether another format or different agent would suit better
How to use Hezkue for best effect, including timing, spray technique, and managing food and alcohol effects
Managing side effects or non-response
Cardiovascular suitability for sexual activity and PDE5 inhibitor use
Drug interactions, particularly nitrates and alpha-blockers
Whether your situation warrants further investigation for underlying contributors (cardiovascular, hormonal, psychological)
Coordination with your GP or specialist
This is free and available before and after purchase. Get in touch if you have any questions.
Care for specific patient groups
We are happy to provide tailored support for:
Men new to ED treatment who want to understand their options and start with the right approach
Men who have tried sildenafil tablets and want to try a different format like Hezkue
Men with difficulty swallowing tablets who need an alternative format
Men with cardiovascular disease where careful PDE5 inhibitor selection and dosing matters
Men on multiple medicines where interaction review is important
Men with diabetes, where vascular contributors to ED are particularly relevant
Older men where careful assessment of cardiovascular fitness for sexual activity is appropriate
Men with anxiety or psychological contributors to ED alongside any pharmacological treatment
Patients with MCAS, CFS, fibromyalgia, or other long-term conditions where ED overlaps with broader health concerns and personalised care matters
Coordination with your GP and other care
If you have a GP, urologist, cardiologist, or other healthcare professional involved in your care, we are happy to coordinate. For patients with significant cardiovascular disease, diabetes, or other comorbidities, joined-up care across primary care, pharmacy, and specialist services produces better outcomes than fragmented care.
Trust earned, not claimed
We are GPhC-regulated, we ground our content in NHS, BNF, EMC, and BAUS (British Association of Urological Surgeons) guidance, and we will tell you honestly if Hezkue isn’t the right answer for your situation. We’d rather give you the right advice than a quick sale.
How to buy Hezkue from Courier Pharmacy
Hezkue is a UK Prescription-Only Medicine (POM) supplied through Courier Pharmacy under prescriber and pharmacist supervision. The supply requires a prescription, which our prescriber can issue following an online consultation, or which you can supply if you already have one.
Here is how our service works:
Add Hezkue to your basket and complete a brief online consultation covering your erectile dysfunction symptoms, what you’ve tried before, your cardiovascular history, current medicines, and any relevant medical conditions
Our prescriber reviews your answers to confirm Hezkue is suitable for you. Where the prescriber needs to ask additional questions, recommend alternatives, or decline the supply, we will do so before processing
Once approved, your prescription is dispensed and dispatched discreetly to your door
Free pharmacist support is available before and after your purchase for any questions
If Hezkue isn’t the right product for your situation, we will explain why and suggest alternatives. That might be:
Generic sildenafil tablets (25mg, 50mg, 100mg) as the most cost-effective starting option for patients new to PDE5 inhibitors
Tadalafil (Cialis, generic) for patients wanting longer duration (up to 36 hours) or daily dosing for spontaneity
Vardenafil or avanafil as alternative oral PDE5 inhibitors
Sildenafil orodispersible films or chewable tablets as alternative non-water-needed formats
Alprostadil intracavernosal injection (Viridal Duo, Caverject) for patients who haven’t responded to oral PDE5 inhibitors
Vacuum erection device as a non-pharmacological option
Cardiovascular assessment with your GP before any ED treatment if you have significant cardiac risk factors that haven’t been recently assessed
Investigation for underlying contributors (testosterone, cardiovascular risk markers, mental health assessment) where these would meaningfully inform treatment
Referral to a urologist for complex, refractory, or unusual presentations
Our free fortnightly drop-in clinics at Insomnia, Derby run every other week from 10am to 12pm. Healthcare shouldn’t only happen when you’re paying for it. We show up, even when it’s free. We cover men’s health, ED, premature ejaculation, testosterone deficiency, hair loss, MCAS, CFS, fibromyalgia, allergies, weight management, and whatever else people bring through the door. No appointment needed, no charge, no pressure.
Active ingredients
Each 1 mL of Hezkue oromucosal suspension contains sildenafil citrate equivalent to 25mg sildenafil. Each actuation (spray) releases 0.5 mL of suspension delivering 12.5mg of sildenafil.
Sildenafil (active ingredient, 12.5mg per actuation): a phosphodiesterase type 5 (PDE5) inhibitor that increases blood flow to the penis in response to sexual stimulation. Sildenafil was developed by Pfizer in the 1990s, originally for angina, and approved for erectile dysfunction in 1998 as Viagra. The compound is now globally established as the first-line oral treatment for erectile dysfunction across multiple delivery formats including standard tablets (25mg, 50mg, 100mg), orodispersible films, chewable tablets, and now oromucosal sprays like Hezkue
The Hezkue suspension formulation contains excipients including flavourings (mint aroma), ethanol, glycerol, purified water, and other spray-formulation ingredients. The mint flavouring is designed to make the oral spray more palatable than the bitter taste of sildenafil itself. Patients with specific excipient sensitivities should check the patient information leaflet supplied with their pack.
Where Hezkue fits in erectile dysfunction treatment
Erectile dysfunction (ED) affects around 1 in 5 UK men at some point, with prevalence increasing significantly with age. By age 70, around half of men report some degree of erectile difficulty. The clinical picture is often multifactorial, involving cardiovascular, neurological, hormonal, psychological, and medication-related contributors. Effective ED treatment usually involves both addressing underlying contributors and using specific ED treatments where helpful.
Where Hezkue fits within the PDE5 inhibitor landscape
Hezkue is one specific format of sildenafil, sitting alongside other sildenafil delivery formats:
If you're new to PDE5 inhibitors and want the most cost-effective starting option: generic sildenafil tablets are usually the place to start
If you've tried sildenafil tablets and they work well: there's usually no compelling reason to switch to Hezkue unless you specifically value the spray format, flexible dosing, or rapid onset
If you have difficulty swallowing tablets: Hezkue or orodispersible films may suit better
If you want long-duration coverage for spontaneity over a weekend: tadalafil (10mg or 20mg on demand, or 5mg daily) is generally a better choice than any sildenafil format
If you specifically want the discreet on-the-go spray format with flexible dosing: Hezkue is the option that delivers this
If you've not responded to sildenafil tablets at maximum 100mg dose: switching to Hezkue is unlikely to overcome the non-response; consider switching to tadalafil, vardenafil, or avanafil, or specialist assessment for non-PDE5-inhibitor options
The stepped approach to erectile dysfunction in modern UK practice
Step 1: Investigation and addressing underlying contributors
ED is often a sign of broader cardiovascular health issues. Vascular ED can precede coronary artery disease by 3 to 5 years, making ED an important early warning marker. For most men presenting with new ED, investigation worth considering includes:
Cardiovascular risk assessment: blood pressure, cholesterol, fasting glucose or HbA1c, smoking status, family history
Blood tests: testosterone (morning sample), prolactin, thyroid function, fasting glucose or HbA1c, lipid profile, full blood count, renal and liver function
Medication review: many medicines contribute to ED including some antihypertensives (particularly thiazides and non-selective beta-blockers), antidepressants (SSRIs, SNRIs), antipsychotics, 5-alpha-reductase inhibitors (finasteride, dutasteride), some opioids, and others
Psychological assessment: relationship factors, performance anxiety, depression, life stressors
Addressing modifiable contributors (cardiovascular risk, lifestyle, medication review, mental health) often improves ED meaningfully alongside or instead of specific ED treatment.
Step 2: First-line oral PDE5 inhibitors
PDE5 inhibitors are the first-line pharmacological treatment for ED in modern UK practice. The four available in the UK:
Sildenafil: established since 1998, available as tablets (25mg, 50mg, 100mg, generic), orodispersible films, chewable tablets, and now Hezkue oromucosal spray. Duration 4 to 5 hours. Lowest cost option (generic)
Tadalafil: longer-acting alternative (up to 36 hours), available as on-demand tablets (10mg, 20mg) or low-dose daily tablets (2.5mg, 5mg) for patients wanting continuous coverage. Generic available
Vardenafil: similar profile to sildenafil. Duration 4 to 5 hours. Generic available
Avanafil: newer agent with faster onset (15 minutes) and similar duration to sildenafil
All four have comparable overall efficacy (around 60 to 70% response rate at appropriate doses) and similar safety profiles. The choice between them depends on:
Duration of effect preferred (short-acting vs longer-acting)
On-demand vs daily dosing preference
Cost considerations
Side effect tolerability
Format preference (tablet, orodispersible, chewable, spray)
Previous response to any PDE5 inhibitor
Step 3: Second-line treatments where PDE5 inhibitors aren't enough
For patients who haven't responded adequately to oral PDE5 inhibitors after appropriate trials, several options exist:
Alprostadil intracavernosal injection (Viridal Duo, Caverject): self-injected directly into the penis. Highly effective (around 80 to 90% response) even in PDE5 inhibitor non-responders. Specialist initiation required
Alprostadil intraurethral (MUSE): pellet inserted into the urethra. Less effective and more uncomfortable than injection, but tablet-free
Vacuum erection device: mechanical pump producing erection through negative pressure, maintained with a constriction ring. No medication needed; useful for patients who can't or don't want pharmacological treatment
Penile implants (specialist surgery): considered for severe refractory ED where other treatments have failed
Specialist assessment for underlying vascular, neurological, or hormonal contributors
How Hezkue works
Sildenafil, the active ingredient in Hezkue, is a phosphodiesterase type 5 (PDE5) inhibitor. The mechanism of action is identical to sildenafil tablets; the delivery format differs but the active pharmacology is the same.
The erectile response and PDE5
Normal erections occur through a coordinated vascular and neurological response to sexual stimulation:
Sexual stimulation triggers nerve signals to release nitric oxide (NO) in penile tissue
Nitric oxide activates an enzyme (guanylate cyclase) that increases cyclic GMP (cGMP) in penile smooth muscle
cGMP causes smooth muscle relaxation in the penile arteries and the corpus cavernosum (the erectile tissue)
Smooth muscle relaxation allows blood to flow into the penis
Increased blood flow expands the corpus cavernosum, compressing venous outflow and producing and maintaining an erection
After sexual activity, the enzyme PDE5 breaks down cGMP, smooth muscle returns to tone, blood flow normalises, and the erection subsides
In erectile dysfunction, this process is impaired at one or more points. PDE5 inhibitors work by blocking the enzyme that breaks down cGMP, allowing cGMP levels to build up and sustain the smooth muscle relaxation that produces an erection. Importantly, PDE5 inhibitors only work in the presence of sexual stimulation (the trigger that releases NO); they don't cause automatic erections without sexual stimulation.
Absorption profile of Hezkue specifically
Hezkue's distinctive pharmacokinetic feature is the absorption profile. When the spray is administered onto the tongue:
A portion of the dose is absorbed directly through the oral mucosa, bypassing first-pass hepatic metabolism. This produces measurable plasma sildenafil within around 5 minutes
Most of the dose is swallowed and absorbed through the standard GI route, similar to tablets
Peak plasma concentrations occur around 1 hour after dosing (similar to tablets)
Half-life is around 4 hours (similar to tablets)
Duration of clinically useful effect is up to 4 to 5 hours (similar to tablets)
The clinical implication of the rapid initial absorption is modest. While plasma levels are detectable earlier than with tablets, the time to peak effect and the overall duration of action are similar. Patients who value rapid onset may find the difference useful; for most patients, the practical difference in time-to-effect is small.
Effect of food on absorption
Like other sildenafil formats, Hezkue absorption can be delayed by a heavy meal, particularly a high-fat meal. For best onset characteristics, take Hezkue on an empty stomach or after a light meal. A heavy or fatty meal can delay onset and reduce peak plasma concentrations.
Effect of alcohol
Alcohol impairs erectile function directly and can also reduce the response to PDE5 inhibitors including Hezkue. Heavy alcohol use before sexual activity reduces the chance of Hezkue working effectively. Moderate alcohol (a glass or two of wine) is unlikely to significantly affect treatment; heavy drinking is best avoided when using Hezkue.
How to use Hezkue
The information below is a summary for reference. The definitive guide is the patient information leaflet supplied with the product. If you are unsure about any aspect of dosing or technique, contact our pharmacist for support.
Dosing
Adults (men aged 18 to 64 years):
Standard starting dose: 50mg (4 sprays), taken approximately 1 hour before planned sexual activity
Dose adjustment: based on efficacy and tolerability, dose may be increased step-wise to 100mg (8 sprays) maximum, or reduced to 25mg (2 sprays)
Maximum dose: 100mg (8 sprays) per 24 hours
Maximum dosing frequency: once per 24 hours
Older men (65 years and over):
No specific dose adjustment required for age alone, but cardiovascular and hepatic function should be carefully assessed before starting
Starting at the lower 25mg dose is sometimes appropriate where caution is warranted
Patients with renal impairment:
Mild to moderate renal impairment (creatinine clearance 30 to 80 mL/min): standard dosing
Severe renal impairment (creatinine clearance under 30 mL/min): start with 25mg; may increase to 50mg or 100mg based on efficacy and tolerability
Patients with hepatic impairment:
Mild to moderate hepatic impairment: start with 25mg
Severe hepatic impairment (Child-Pugh class C cirrhosis): Hezkue is contraindicated
How to administer Hezkue
Correct spray technique:
Shake the bottle well before each use to ensure even distribution of the suspension
Prime the spray if it is new or has not been used recently. Pump the spray several times into the air or onto a tissue until a fine mist appears
Open your mouth and direct the spray nozzle toward your tongue
Press the pump firmly to deliver one actuation onto your tongue
Swallow immediately with your saliva (do not hold the spray in your mouth; the formulation is designed for spray-and-swallow administration)
Repeat for each additional spray of your prescribed dose, with a brief pause between sprays
Wipe the nozzle and replace the cap on the bottle
No water is needed. The mint flavour makes the spray more palatable than the bitter taste of sildenafil itself.
When to take Hezkue
Take Hezkue approximately 1 hour before planned sexual activity for best effect
Initial absorption begins within around 5 minutes, but peak plasma levels and best erectile response typically occur around 1 hour after dosing
Effects last up to 4 to 5 hours, so the timing window is flexible
Avoid taking with a heavy or high-fat meal, which can delay onset and reduce peak effect
Don't take more than one dose per 24 hours
Sexual stimulation required
Hezkue, like all PDE5 inhibitors, doesn't cause automatic erections. Sexual stimulation is still required for the medicine to work. Without sexual arousal, taking Hezkue won't produce an erection. With sexual stimulation, the medicine helps the natural erectile response occur more reliably and last longer.
If Hezkue doesn't work
Some patients respond well to their first dose; others need a few attempts before the medicine works consistently. If your initial dose doesn't produce a satisfactory response:
Try the same dose 2 or 3 more times, at different times and circumstances
Try taking on an empty stomach if you've been taking after meals
Consider whether alcohol, anxiety, or relationship factors are affecting the response
Discuss dose adjustment with our prescriber (up to maximum 100mg)
If still not working after several adequate trials at maximum dose: consider switching to a different PDE5 inhibitor (tadalafil, vardenafil, avanafil) or pursuing further assessment for underlying contributors
Missing a dose
Hezkue is taken on-demand before sexual activity rather than on a regular schedule. There are no
missed doses in the conventional sense. Simply take a dose when you plan to be sexually active, observing the once-per-24-hours maximum.
Stopping Hezkue
Hezkue can be stopped without a taper. There is no withdrawal effect from stopping PDE5 inhibitors. The underlying erectile dysfunction may return if Hezkue was helping; many patients use PDE5 inhibitors for years or decades alongside addressing underlying contributors.
Storage
Store Hezkue at room temperature, below 25°C, in the original packaging, with the bottle upright. Do not freeze. Keep out of sight and reach of children. After first opening, the spray should be used within the period stated in the patient information leaflet.
Warnings and precautions for Hezkue
When not to use Hezkue (contraindications)
Hezkue must not be used in the following situations:
Patients with known hypersensitivity to sildenafil or any spray excipient
Patients taking any form of organic nitrate medicine: glyceryl trinitrate (GTN, including spray and tablet), isosorbide mononitrate, isosorbide dinitrate, amyl nitrate (poppers, recreational use). Combining sildenafil with nitrates can cause severe, potentially life-threatening hypotension. This applies regardless of whether the nitrate is regular, occasional, or recreational
Patients taking nitric oxide donors such as nicorandil
Patients taking riociguat (a soluble guanylate cyclase stimulator used in pulmonary hypertension)
Patients for whom sexual activity is inadvisable because of cardiovascular status, including unstable angina, heart failure, recent stroke or myocardial infarction (within the last 6 months), serious arrhythmias, severe hypertension (above 170/100), or severe hypotension (below 90/50)
Patients with severe hepatic impairment
Patients with hereditary degenerative retinal disorders including retinitis pigmentosa
Patients with a history of non-arteritic anterior ischaemic optic neuropathy (NAION) with vision loss
Patients under 18 years of age
Women (Hezkue is licensed for adult men only)
Patients with other forms of erectile dysfunction not suitable for PDE5 inhibitor treatment
Patient groups warranting prescriber assessment before use
Several patient groups need careful prescriber assessment before being supplied Hezkue:
Patients with significant cardiovascular disease: history of heart attack, stroke, angina, heart failure, significant arrhythmia, severe hypertension or hypotension
Patients taking alpha-blockers for prostate symptoms or blood pressure (doxazosin, tamsulosin, alfuzosin, terazosin): combined use can cause significant orthostatic hypotension; doses need careful management with prescriber guidance
Patients with conditions predisposing to priapism: sickle cell disease, multiple myeloma, leukaemia, anatomical penile deformity (Peyronie's disease, penile curvature)
Patients with active peptic ulcer disease or significant GI bleeding history
Patients with bleeding disorders or on anticoagulation
Patients with severe renal impairment (creatinine clearance under 30 mL/min)
Patients with significant hepatic impairment
Patients on multiple medicines where interaction review is needed
Patients who have experienced significant visual disturbances with PDE5 inhibitors previously
Patients with hearing loss or who have experienced sudden hearing loss with PDE5 inhibitors previously
Cardiovascular safety
Sexual activity itself carries a degree of cardiovascular load. PDE5 inhibitors don't independently cause cardiac events at standard doses in patients without significant cardiovascular disease, but they do enable sexual activity that itself carries cardiovascular load. Patients with significant cardiac disease should have cardiovascular suitability for sexual activity confirmed before starting any PDE5 inhibitor including Hezkue.
The Princeton Consensus on sexual activity and cardiac risk provides guidance:
Low cardiovascular risk: controlled hypertension, mild stable angina, prior uncomplicated MI more than 6 months ago, mild valve disease — PDE5 inhibitor use generally appropriate
Intermediate risk: warrants cardiology assessment before PDE5 inhibitor use and sexual activity
High risk: unstable angina, uncontrolled hypertension, recent MI or stroke, NYHA class III or IV heart failure, significant arrhythmia — PDE5 inhibitor use deferred until cardiac status is stabilised
Priapism
Priapism (a sustained painful erection lasting more than 4 hours) is a rare but serious complication of all PDE5 inhibitors including Hezkue. It requires emergency medical assessment because of risk of permanent erectile dysfunction if untreated. Patients should be aware:
Erection lasting more than 4 hours warrants urgent medical attention
Painful prolonged erection is a medical emergency
Higher risk in patients with sickle cell disease, multiple myeloma, leukaemia, or anatomical penile deformity
Visual disturbances
PDE5 inhibitors can cause visual disturbances including blue-tinted vision, increased light sensitivity, and blurred vision. These are usually mild and transient. Rarely, more serious visual events including non-arteritic anterior ischaemic optic neuropathy (NAION) have been reported. Patients should:
Be aware of the possibility of visual disturbances and avoid driving or operating machinery if affected
Stop Hezkue and seek urgent medical assessment if sudden vision loss, sudden severe blurring, or persistent visual disturbance occurs
Discuss with the prescriber if they have a history of visual disorders or NAION
Hearing loss
Rare reports of sudden hearing loss have been associated with PDE5 inhibitors. Patients should stop Hezkue and seek prompt medical assessment if sudden hearing loss or significant hearing change occurs.
Driving and operating machinery
Hezkue can cause dizziness, visual changes, or other effects that may affect driving or operating machinery. Patients should avoid driving or operating machinery if they experience any of these effects.
Side effects of Hezkue
The side effect profile of Hezkue is similar to that of sildenafil tablets, since the active ingredient is the same. Most side effects are mild to moderate and dose-related.
Very common side effects (more than 1 in 10 patients)
Local oral effects from the spray formulation: temporary unusual taste, minor mouth irritation, dry mouth
Rare but more significant side effects
Severe hypersensitivity reactions including anaphylaxis (very rare)
Priapism (sustained painful erection lasting more than 4 hours; medical emergency)
Non-arteritic anterior ischaemic optic neuropathy (NAION) with sudden vision loss
Sudden hearing loss
Significant cardiovascular events (heart attack, stroke, arrhythmia, severe hypotension; rare at standard doses in patients without significant cardiovascular disease)
Seizures (very rare)
Stop and seek urgent medical advice if
You develop an erection lasting more than 4 hours (priapism)
You develop sudden vision loss or sudden severe visual disturbance
You develop sudden hearing loss or significant hearing change
You develop chest pain, severe shortness of breath, or signs of heart attack
You develop signs of stroke (facial weakness, arm weakness, speech difficulty, sudden severe headache)
You develop signs of severe allergic reaction (significant swelling, difficulty breathing, severe rash)
You develop persistent significant hypotension with dizziness, fainting, or collapse
Yellow Card reporting
Suspected adverse drug reactions can be reported to the MHRA via the Yellow Card scheme at yellowcard.mhra.gov.uk. Reporting helps build the safety picture for everyone.
Drug interactions with Hezkue
Hezkue (sildenafil) has several clinically significant drug interactions. Our prescriber checks the picture during your consultation.
Absolute contraindications (do not combine)
Nitrate medicines: glyceryl trinitrate (GTN spray, GTN tablets), isosorbide mononitrate, isosorbide dinitrate, amyl nitrate (recreational poppers). Combining with sildenafil causes severe potentially life-threatening hypotension. This is the most important interaction to be aware of. If you take any nitrate medicine regularly or use poppers recreationally, Hezkue is contraindicated
Nitric oxide donors: nicorandil
Riociguat (used in pulmonary hypertension)
Significant interactions requiring care
Alpha-blockers: doxazosin, tamsulosin, alfuzosin, terazosin (used for prostate symptoms or blood pressure). Combined use can cause significant orthostatic hypotension. Doses need careful management; ideally take Hezkue and alpha-blocker at separated times, and start at lower sildenafil doses
CYP3A4 inhibitors (increase sildenafil levels): ketoconazole, itraconazole, ritonavir, indinavir, atazanavir, clarithromycin, erythromycin, grapefruit juice. Dose reduction of Hezkue may be needed; in some cases, an alternative ED treatment is preferable
CYP3A4 inducers (decrease sildenafil levels): rifampicin, carbamazepine, phenytoin, phenobarbital, St John's wort. May reduce Hezkue efficacy
Antihypertensives: most antihypertensive medicines can be used with sildenafil at standard doses, but caution is needed with combinations because of additive blood pressure lowering
Other PDE5 inhibitors (tadalafil, vardenafil, avanafil): do not combine; use one PDE5 inhibitor at a time
Other ED treatments (alprostadil, vacuum erection devices): generally not combined with PDE5 inhibitors without specialist guidance
Less significant interactions
Most antidiabetic medicines, statins, hormonal contraceptives, most antibiotics, most antidepressants: no significant interaction at standard doses
Anticoagulants (warfarin, DOACs): no significant pharmacokinetic interaction, but consider that bleeding risk from any cause could be relevant
PPIs and H2 antagonists: no significant interaction
For patients on any of the contraindicated or significant interaction medicines above, our prescriber will discuss alternatives or carefully manage the dosing if Hezkue use is appropriate.
Frequently asked questions about Hezkue
What is Hezkue?
Hezkue is the first licensed sildenafil oral spray in the UK. Each spray delivers 12.5mg of sildenafil in a mint-flavoured oromucosal suspension that is sprayed onto the tongue and swallowed. It is used for the treatment of erectile dysfunction in adult men.
How is Hezkue different from Viagra?
Both Hezkue and Viagra contain sildenafil as the active ingredient with the same clinical effect. The differences are in the delivery format (spray vs tablet), dose-titration flexibility (12.5mg steps vs fixed 25mg/50mg/100mg), initial absorption profile (faster with spray), and convenience (no water needed with spray). Cost is typically higher for Hezkue than for generic sildenafil tablets.
How quickly does Hezkue work?
Initial absorption begins within around 5 minutes after the spray is administered. Peak plasma sildenafil levels and maximum erectile effect typically occur around 1 hour after dosing. Most patients take Hezkue around 1 hour before planned sexual activity.
How long does Hezkue last?
Effects last up to 4 to 5 hours, similar to sildenafil tablets.
What's the standard dose?
Standard adult dose is 50mg (4 sprays), taken approximately 1 hour before sexual activity. Doses can be adjusted in 12.5mg steps from 25mg (2 sprays) up to 100mg (8 sprays) based on efficacy and tolerability.
How many doses are in a 30ml bottle?
The 30ml bottle contains approximately 60 actuations. At the standard 50mg dose (4 sprays), this provides around 20 doses. At 100mg (8 sprays per dose), around 10 doses. At 25mg (2 sprays per dose), around 30 doses.
Can I use Hezkue every day?
No. Hezkue is an on-demand treatment, taken before planned sexual activity, with a maximum of one dose per 24 hours. For patients wanting continuous coverage, daily low-dose tadalafil (2.5mg or 5mg daily) is a more appropriate option.
Can I take Hezkue with food?
Yes, but a heavy or high-fat meal can delay onset and reduce peak effect. For best results, take Hezkue on an empty stomach or after a light meal.
Can I drink alcohol with Hezkue?
Moderate alcohol (a glass or two of wine) is unlikely to significantly affect treatment. Heavy alcohol use impairs erectile function and can reduce response to Hezkue. Heavy drinking is best avoided when using the medicine.
Can I take Hezkue with poppers (amyl nitrate)?
Absolutely not. Combining sildenafil with any nitrate including recreational poppers (amyl nitrate, butyl nitrate) can cause severe, potentially life-threatening hypotension. This is one of the most important safety messages for PDE5 inhibitor use. If you use poppers, do not take Hezkue.
Can I take Hezkue with nitrate medicines for angina?
No. Hezkue is contraindicated with all nitrate medicines (GTN spray, GTN tablets, isosorbide mononitrate, isosorbide dinitrate). Patients on nitrate therapy for angina should use alternative ED treatments under specialist guidance, or have their angina management reviewed first.
Can older men take Hezkue?
Yes, with appropriate cardiovascular assessment. No specific dose adjustment is required for age alone, but cardiovascular fitness for sexual activity and PDE5 inhibitor use should be confirmed. Starting at the lower 25mg dose may be appropriate in some older patients.
What if Hezkue doesn't work?
Try the same dose 2 or 3 more times in different circumstances; consider taking on an empty stomach; address relationship or anxiety factors; discuss dose adjustment with our prescriber (up to maximum 100mg); if still not working after several adequate trials at maximum dose, consider switching to a different PDE5 inhibitor (tadalafil, vardenafil, avanafil) or pursuing further assessment for underlying contributors.
Is the spray format actually different from tablets?
Honestly, the clinical efficacy is the same as tablets at equivalent doses. The distinctive features of the spray format are faster initial absorption (within around 5 minutes vs longer for tablets), flexible 12.5mg dosing steps, mint flavour, no water needed, and discreet on-the-go format. Whether these features matter depends on your preferences.
Why is Hezkue more expensive than generic sildenafil tablets?
Hezkue is a newer branded product still under patent protection, while sildenafil tablets are widely available as generic with significant price competition. The spray formulation and delivery device also add manufacturing complexity. For patients where the spray format and flexible dosing genuinely add value, the cost may be worthwhile; for patients who would do equally well on generic tablets, the cost difference matters.
What if I get headaches with Hezkue?
Headache is the most common side effect, affecting more than 1 in 10 patients. Often dose-related; trying a lower dose (25mg or 37.5mg) may reduce headache while maintaining efficacy. Paracetamol can be taken if needed. If headaches are severe or persistent, discuss with the prescriber.
What if I get a long erection?
An erection lasting more than 4 hours (priapism) is a medical emergency. Seek urgent medical attention at A&E or call 999. Untreated priapism can cause permanent damage to erectile function. Patients with sickle cell disease, multiple myeloma, leukaemia, or anatomical penile deformity have higher risk and should discuss this with the prescriber before starting any PDE5 inhibitor.
What if I get visual changes?
Mild visual changes (blue-tinted vision, light sensitivity, blurred vision) are common with PDE5 inhibitors and usually resolve as the medicine wears off. Sudden vision loss or sudden severe visual disturbance warrants urgent medical assessment and stopping Hezkue. Patients with hereditary retinal disorders or a history of NAION should not use Hezkue.
Can I share Hezkue with a friend who has ED?
No. Hezkue is a prescription medicine that requires individual cardiovascular and medication screening before supply. Sharing prescription medicines is illegal, and PDE5 inhibitors have significant contraindications that someone else might have without you knowing. Your friend should get their own prescription through proper channels.
Is Hezkue available without a prescription?
No. Hezkue is a UK Prescription-Only Medicine. Some sildenafil formats (such as Viagra Connect over-the-counter tablets) are available without prescription after pharmacist consultation, but Hezkue specifically requires a prescription. Our prescriber can issue this following online consultation.
How should I store Hezkue?
Store at room temperature, below 25°C, in the original packaging with the bottle upright. Do not freeze. Keep out of sight and reach of children. After first opening, use within the period stated in the patient information leaflet.
How do I order Hezkue from Courier Pharmacy?
Add the product to your basket on courierpharmacy.co.uk and complete the online consultation. Our prescriber will review your answers and confirm suitability. Free pharmacist and prescriber support is available before and after your order.
More than a prescription: our community
Healthcare shouldn't only happen when you're paying for it. Every fortnight we run free drop-in talks and clinics at Insomnia, Derby, from 10am to 12pm. We show up, even when it's free. Bring a question, bring a friend, bring a stack of bewildering letters from another clinic; we'll sit with you. We cover men's health, ED, premature ejaculation, testosterone deficiency, hair loss, MCAS, CFS, fibromyalgia, allergies, weight management, menopause, and whatever else people bring through the door. No appointment. No cost. No pressure. Just real support and treatment that fits.
Disclaimer: This article is for information only and isn't a substitute for personal medical advice. Always speak to a qualified prescriber before starting or changing treatment.
How this content was created
Written by the Courier Pharmacy editorial team and reviewed by a GPhC-registered pharmacist. Grounded in the latest NHS, BNF, EMC, and BAUS (British Association of Urological Surgeons) guidance, and the real questions patients bring to our drop-in clinics in Derby.
