Injection
Bi-Mix Injection
Combination of papaverine and phentolamine for intracavernosal injection. Vasodilator mix for erectile dysfunction. Priapism risk and rescue requirements.
Starting at $171/mo
Sexual healthCombinationCompounded
Apomorphine + Sildenafil + Tadalafil + Vardenafil Troches
RxPrescription onlyDissolved under the tongue · As needed, 20–30 min before · Sexual health · Combination · Compounded
Starting at $69/mo
A four-ingredient troche (mint) for men who have not responded to standard options: three PDE5 inhibitors plus apomorphine, dissolved in the mouth as needed.
How many troches per month?
MonthlyEvery 3 months
4 trochesper month
8 trochesper month
12 trochesper month
You'll receive 8 troches per month. $99 billed monthly. Cancel anytime.
Real prices from our pharmacy. Longer plans cost less per month and are billed up front. Pause or cancel anytime.
- Central and local action together
- For men who did not respond to single agents
- As needed, no more than once a day
Every plan includes
- Personalized, physician-guided plan
- 4, 8 or 12 troches per month, monthly and 3-month
- Dispensed by a US-licensed compounding pharmacy
- Unlimited protocol adjustments and messaging
- Ongoing support and check-ins
- Pause or cancel anytime
- Reviewed by our in-house physicians
- Physician-guided care
- Ongoing, expert support
- 100% online
- Free, discreet shipping
What is the four-ingredient troche?
(quad troche)
It combines the blood-flow effect of three PDE5 inhibitors with apomorphine, which acts in the brain. Apomorphine acts on dopamine receptors in the brain that help start an erection, so it adds a central push to the local effect of the PDE5 inhibitor. It commonly causes nausea, yawning, dizziness or drowsiness; do not drive until you know how it affects you.
- How it is taken
- Dissolved under the tongue
- How often
- As needed, 20–30 min before
- Form
- Sexual health · Combination · Compounded
4
active ingredients in one troche
Off-label compounded combination for refractory cases; no trials of this exact product.
How it works,
week by week.
Day 1
A US-licensed physician reviews your health, medications (especially nitrates and blood pressure drugs) and goals, and chooses the dose and form.
First doses
Take it 20 to 30 minutes before intimacy, on a light stomach. Arousal is still needed; the medicine helps the response, it does not create it.
Week 2
You know how your body responds. Timing, dose and food effects are clear, and confidence builds.
Month 1
Check-in with your physician: the dose is adjusted up or down, or the form is changed, based on your response and side effects.
Beyond
It works for as long as you use it. Your physician reviews your health at least yearly, including blood pressure and heart health.
What you may notice,
and when.
Firmer erections
when aroused, with a reliable response
Predictable timing
you know when it starts and how long it lasts
Confidence
less performance worry, more presence
Physician oversight
dose and form adjusted to you
Individual results vary. Benefits reflect what Zepym Health members commonly report to their physician at check-ins; they are not the results of a clinical trial.
Safety first:
what to know before you start.
Important safety information and common side effects
PDE5 inhibitors are generally well tolerated. Common effects are flushing, headache, nasal congestion, indigestion and, with sildenafil, a temporary blue tint to vision. CRITICAL: never combine with nitrates or poppers (dangerous drop in blood pressure). Use with care alongside alpha-blockers. Seek emergency care for an erection lasting more than 4 hours, sudden vision or hearing loss, or chest pain. Tell your physician about heart disease, low blood pressure, liver or kidney problems and retinal disease before starting. Apomorphine adds nausea, yawning, dizziness and drowsiness; avoid driving until you know how you react.
The research behind
PDE5 combinations.
These products put two or more PDE5 inhibitors, sometimes with apomorphine, into one troche, dissolving tablet or drop. We found no published human trial of any of these combinations. Each part does have trial evidence on its own.
- The combinationsno trials
We searched for trials of the combined troches, dissolving tablets, drops and apomorphine mixes and found none. The evidence below is for each part on its own, not for the mix.
PubMed search, PDE5 combination products (2026) - Apomorphine3 mg vs placebo
In a crossover trial of 296 men, sublingual apomorphine 3 mg was significantly more effective than placebo (P below 0.001) for erections firm enough for intercourse and for intercourse, rated by both men and partners. Nausea was reported in 3.3% on 3 mg.
Dula et al., European Urology 2001 - Two PDE5 drugs togethernot studied
Taking two PDE5 inhibitors together has not been tested in trials of these combinations. The sildenafil label names nitric oxide donors, including organic nitrates, as contraindicated.
VIAGRA prescribing information, DailyMed
What the studies found
- No human trial of the combined troches, dissolving tablets or drops was found, so no benefit of the mix itself has been shown (PubMed search, 2026)
- Apomorphine 3 mg under the tongue was more effective than placebo for intercourse in 296 men (Dula et al., European Urology 2001)
- Each PDE5 component has human trial benefit on its own (Goldstein et al., NEJM 1998; Porst et al., European Urology 2014)
These are compounded products. They were not studied as a mix. Each ingredient's trial results were for that ingredient alone, at approved tablet doses, and the doses in the mix are not those studied. Your physician decides which product, if any, suits you.
What this does not say
- No trial shows that a mix works better than one approved drug taken alone.
- The combined amount has not been studied for safety.
- Nausea was among the reported effects of apomorphine; the prescriber screens for heart disease and for nitrates before prescribing.
The research
behind it.
Each ingredient has evidence alone; the combination is based on clinical experience in men who did not respond to one medicine.
More ingredients mean more side effects. Your physician starts it only after reviewing your heart, blood pressure and medications.
Erections as a vital sign:
what the cohorts showWhy a change in erections is worth a heart check, what the numbers say, and what they do not.Read the researchPDE5 inhibitors:
what the trials showSildenafil, tadalafil and vardenafil compared, daily and as-needed use, and the rule on nitrates.Read the research
what the cohorts showWhy a change in erections is worth a heart check, what the numbers say, and what they do not.Read the researchPDE5 inhibitors:
what the trials showSildenafil, tadalafil and vardenafil compared, daily and as-needed use, and the rule on nitrates.Read the research
Getting started
takes a few minutes.
- 1
Connect with a physician
Answer a few questions online and a US-licensed physician reviews your health, history and goals to make sure treatment is right for you. 100% online. No in-person visit required.
- 2
Get your discreet shipment
If approved, your treatment is compounded by a US-licensed, LegitScript-certified pharmacy, inspected for quality, and shipped discreetly to your door.
- 3
Receive continuous support
Start with one goal, then keep building over time. Unlimited physician messaging, easy refills and dose adjustments, all from the Zepym Health app.
Frequently asked questions
Contact supportHow do I take Apomorphine / Sildenafil / Tadalafil / Vardenafil Troches?
Dissolved under the tongue, as needed, 20–30 min before. The starting prescription is one troche each time. Your physician sets your own dose and it is printed on your label.
What exactly is in it?
Apomorphine, Sildenafil, Tadalafil, Vardenafil.
How much arrives in each shipment?
8 troches at the starting strength, shipped to your door from a licensed US pharmacy.
When is this used?
Only after standard PDE5 inhibitors at adequate doses did not work. It is not a first choice.
Can I take it with other medications?
Never with nitrates (nitroglycerin, isosorbide) or recreational poppers: the combination can drop blood pressure dangerously. Tell your physician about alpha-blockers, blood pressure medicines, antifungals and HIV medicines, which change how the drug is processed.
What if it does not work the first time?
Arousal is still required, and a heavy or fatty meal can delay absorption. Most men need two or three attempts at a given dose before judging it. If it still falls short, your physician adjusts the dose or the formulation.
What are the warning signs?
An erection lasting more than 4 hours, sudden loss of vision or hearing, chest pain or fainting need immediate care. Stop the medication and go to the emergency room.
Is a compounded version as reliable as the brand?
Compounded troches, capsules and ODTs contain the same active ingredient, prepared by a US-licensed pharmacy, but they have not gone through FDA review as a finished product. Your physician chooses the form that fits how you want to use it.
Quad troche educational content reviewed by our physician
Scott Nass, MD Doctor of Medicine, board-certified in Family Medicine
Charles R. Drew University and David Geffen School of Medicine at UCLA. Family Medicine residency at Ventura County Medical Center.
More options
in this area.
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Topical cream for female sexual arousal and pleasure. Contains oxytocin, theophylline, arginine, and sildenafil for enhanced sensation and response.
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Troche
Female Desire Troches
Sublingual troche for female sexual desire and arousal. Combines apomorphine, bremelanotide, oxytocin, and L-theanine for comprehensive support.
4, 8 or 12 troches per month
Starting at $59/mo
References
- 1.Sildenafil citrate for erectile dysfunction: a systematic review of randomized controlled trials. Arch Intern Med, 2002
- 2.Apomorphine SL for erectile dysfunction: randomized, placebo-controlled trials. Urology, 2000
Prescription products require an online evaluation with a licensed medical professional who will determine if a prescription is appropriate. Products are compounded by a licensed pharmacy. The FDA has not reviewed or approved compounded products for any use for safety, efficacy, or quality. Compounded medications are not FDA-approved brand-name products.