Tuesday, July 15, 2008

Treatment for Erectile Dysfunction in Patients with Diabetes

cialis In This ArticleAbstract and IntroductionPatients and MethodsResultsDiscussionTablesReferencesRelated Links

Patients and Methods

The study group consisted of 284 consecutive patients with DM referred to our tertiary center for the treatment of ED between 1998 and 2002. All patients had DM type II that was diagnosed before the entrance into the study according to fasting glucose level or oral glucose tolerance test. The demographic characteristics of the patients as well as the data regarding the duration of DM and their comorbidities are presented in Table 1 . In all, 43 patients (15.1%) were treated by insulin alone or with combination with oral hypoglycemic agents at the time of the study. The rest of the patients received oral hypoglycemic agents only. DM was relatively controlled.

The diagnosis of ED was based on the International Index of Erectile Function (IIEF).[17] Medical, social and psychosexual history of the patients and their partners were taken. Physical examination, nocturnal penile tumescence test with Rigiscan, penile color Doppler ultrasound and penile electrothermometry[18] were performed. Complete blood count, electrolytes, glucose level, liver enzymes, urea and creatinine, level of prostate-specific antigen, prolactin and total testosterone were checked. No untreated hormonal disbalances in the hypothalamic-hypopituitary-testicular axis were found in our study group, because our department is a tertiary center and all the possible hormonal problems were identified and treated before the reference.Procedure

A positive response at all phases of the program was defined as an erection sufficient for vaginal penetration.

Phase 1. Patients without contraindications[19] were offered sildenafil citrate (Viagra), one tablet at 1 h before coitus, 2-3 h after a meal, at a starting dose of 25-50 mg, depending on age. The dose was increased to 50 and 100 mg at intervals of 2-4 days, depending on response, age, and general state of health.

Phase 2. Patients with contraindications to sildenafil, adverse drug effects, or a negative response (to at least 3-5 doses of 100 mg) were offered vacuum therapy with the VED. Details of its applications were explained to the patients individually before commencing. Silicone cream or lubricating gel was applied around the root of the penis, and the cylinder (with constriction rings) was opened and placed on the penis. Negative pressure was applied slowly and gradually over 2-3 min. When the patient reported pain, we removed the cylinder, but left the constriction rings in place for an additional 1-2 min. Two sessions were conducted by the same operators at intervals of 2-3 days. In patients with a positive response, the device was recommended for use at home before coitus.

Phase 3. VED failures were switched to ICI with cocktail of trimix of vasoactive drugs: papaverine 12-25 mg+phentolamine 1.0-2.0 mg+prostaglandin E1 6-25 µg. In patients who complained of pain during erection, the prostaglandin E1 dose was decreased and the doses of the other drugs were increased.

Phase 4. Patients who failed to respond to the ICI were given sildenafil citrate 50-100 mg followed 40-55 min later by a ICI of papaverine 25 mg+phentolamine 2 mg+prostaglandin E1 6-25 µg.

Phase 5. In patients who failed phase 4, we attempted ICI with papaverine, 16 mg, phentolamine 1.5 mg, and prostaglandin E1 15-25 µg, followed 5-10 min later by the VED.

Phase 6. In patients who did not respond to phase 5, we recommended penile implant surgery.Follow-up

All patients were followed for 2 y. ED treatment was changed during follow-up, as necessary, according to the same 6-phase program. Follow-up consisted of physical examinations for general state of health, IIEF score, and laboratory tests. In patients receiving the ICI, the physical examination also included a search for palpable fibrotic nodules. Penile Doppler color ultrasound and nocturnal penile tumescence test were repeated.Statistical Analysis

The results immediately after treatment and at the end of follow-up were analyzed according to Bland.[20] Arithmetic mean values and errors of the mean or median values were calculated. Statistical differences were determined with Student's t-test. Values of P<0.05 were considered significant.Previous PageSection 2 of 4Next Page: Results
Int J Impot Res.  2005;17(5):431-436.  ©2005 Nature Publishing Group

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Erectile Dysfunction: An Underdiagnosed Condition Associated With Multiple Risk Factors

sildenafil M. Shabbir; D. M. Mikhailidis; R. J. Morgan 

Erectile dysfunction (ED) is a common condition with a significant effect on the quality of life. The prevalence of ED rises with increasing age and other conditions (hypertension, diabetes, ischaemic heart disease, hypercholesterolaemia and depression). The MALES study is one of the largest epidemiological surveys to investigate the prevalence of ED. This study included 27 839 patients spanning eight countries. In addition to the MALES study, we review the emerging link between lower urinary tract symptoms (LUTS), benign prostatic hypertrophy (BPH) and ED, including the effect of BPH treatment on sexual function. Preliminary data from the MALES II study shows a significant cascade effect in the treatment seeking behaviour and treatment adherence of patients taking sildenafil for ED. We explore the possible reasons behind the discontinuation of oral phosphodiesterase inhibitors prescribed for the long-term treatment of ED.

Erectile dysfunction (ED) is defined as the inability to obtain and/or maintain penile erection sufficient for satisfactory sexual performance.[1] ED has a significant impact on the quality of life and it is a common problem (affecting more than 100 million men worldwide).[2]

This issue of Current Medical Research and Opinion includes the Men's Attitudes to Life Events and Sexuality (MALES) study which provides information regarding the prevalence of ED and related health matters.[3] This is one of the largest epidemiological studies in this field; it included 27839 patients spanning over eight countries. The study found an overall prevalence of self-reported ED of 16% in men aged 20-75 years. Differences were noted between the various countries, with the highest prevalence seen among men in the US (22%) and the lowest in Spain (10%). The study confirmed the increased prevalence of ED with both increasing age, and other co-morbid conditions (hypertension, diabetes, ischaemic heart disease, hypercholesterolaemia and depression) as noted in earlier studies.[4,5]

The MALES study[3] did not, however, address the relationship between ED and lower tract urinary symptoms (LUTS) or benign prostatic hypertrophy (BPH). Earlier reviews were sceptical about an association between these two common conditions and considered their relationship incidental to a similar age and gender distribution.[6] However, an emerging link between BPH and ED has been recognised in recent years. The MSAM-7 study investigated the association between LUTS and ED in 12815 men aged between 50 and 80 years. This large multinational survey assessed the correlation between the International Prostate Symptom Score (IPSS) and ED independent of age and other co-morbidities.[7] The prevalence of ED in men with no LUTS was 24.8%, compared to 43.3, 65.8 and 81.9% ED in men with mild, moderate and severe symptoms, respectively. Ejaculatory problems were reported by 25.3% of the men with no LUTS compared to 41.8, 61.4 and 76.0% with mild, moderate and severe symptoms, respectively. A similar association between LUTS and sexual dysfunction was also reported by others.[8-10]

An experimental model of bladder outflow obstruction (BOO) provided an insight into the potential pathophysiological link between BPH and ED.[11] There was an endothelin ETA/ET B receptor imbalance as well as adverse structural changes in the corpus cavernosum in a rabbit model of BOO. These effects may be responsible for the observed impaired nitric oxide (NO)-mediated cavernosal relaxation in this model.[11]

A common pathophysiological link between ED and BPH would mean that treating one condition could influence the other. For example, in a 1-year, prospective, open label study of 2829 men with BPH, alfuzosin (a α1-receptor antagonist) increased the perceived sexual function score by 191%, with the greatest improvements seen in men < 70 years with severe LUTS.[12] In a double blind, multicentre trial of 1475 men with BPH, doxazosin improved sexual function in the patients with ED.[13] Treatment of LUTS with tamsulosin for 6 months suggested improvements in libido, erection and overall sexual function in a study of 3000 men.[14] However, despite these improvements, ejaculation failure has been shown to occur more often in patients taking these drugs, particularly tamsulosin.[15] It remains unclear whether the beneficial effects seen with α1-receptor antagonists are due to a direct pharmacological effect or whether they are a consequence of improvements in urinary symptoms. In contrast to these drugs, the treatment of BPH with the 5-α-reductase inhibitor finasteride has a negative effect on sexual function. One study reported 33% ED in patients treated with finasteride for 6 months, none of whom had reported sexual dysfunction at baseline.[16] There is also evidence that sildenafil prescribed to treat ED can improve LUTS.[17] This effect was attributed to an effect on bladder muscle.[17] It follows that the treatment of patients with BPH and ED needs to be carefully considered since the choice of medication for one condition may influence the other.

The MALES II study[3] investigates the treatmentseeking behaviour of the subgroup of patients who reported ED (2912 men). These findings highlight some interesting information regarding the pattern of ED evaluation and treatment.[3] Currently there are numerous treatments for ED including vacuum-constriction devices, apomorphine, phosphodiesterase-5 (PDE5) inhibitors and transurethral or intracavernosal injection of vasoactive agents such as alprostadil (prostaglandin E1). More invasive surgical management includes implantation of penile prostheses, and venous or arterial surgery. The MALES II study focused on the use of sildenafil.[3]

The advent of sildenafil citrate (Viagra, Pfizer) revolutionised the treatment of ED. A selective PDE5 inhibitor, sildenafil was the first oral therapy with a combination of efficacy, tolerability and ease of use.[18,19] It is effective in the treatment of ED of organic, psychogenic and mixed aetiology[20] and is of benefit in cases where other medical treatments have failed.[21] Oral treatment with PDE5 inhibitors including sildenafil, and the newer vardenafil (Levitra, Bayer) and tadalafil (Cialis, Lilly), is now considered the first line treatment of choice.

It is interesting, therefore, that the MALES II study[3] highlights a discrepancy between the use of sildenafil and its efficacy and convenience. Only 58% of the 2912 men who self-reported ED actively sought attention for their condition. Only 41% of the men in this group discussed possible treatment with sildenafil, with only 25% of them filling their prescription for the drug. Only 16% of this group were still taking sildenafil at the time of the survey. This 'cascade effect' is larger than expected, taking into account the profile of the oral PDE5 inhibitors. While there are issues regarding the treatment-seeking behaviour and treatment adherence that future analyses of the MALES II data will reveal, there are some possible explanations for the discontinued use of sildenafil with time.

The adverse events associated with the use of sildenafil include headache, flushing, dyspepsia and visual disturbances.[20,21] However, discontinuation due to adverse events is low, ranging between 0 and 10%, suggesting that these side effects are generally well tolerated Another possibility for discontinuation is the potential development of tachyphylaxis with the continued use of sildenafil. El-Galley et al., performed a telephone survey of 151 patients within their first year of sildenafil use and they followed this up with another survey of the same group 2 years later.[23] In the first survey there was an overall improvement rate of 74%. In the follow-up survey (82 patients) only 43 of the respondents (52%) were still taking sildenafil. Of this group 16 (37%) had to increase their dose by 50 mg to achieve the same effect. Of the patients who were followed up for 2 years, 20% had some increase in the sildenafil dose necessary to achieve the same result and 17% had discontinued use due to a loss of efficacy. Another telephone survey involving 1074 patients taking sildenafil for 1-3 years reported similar findings.[24] They found that 28.5% of patients taking 50 mg of sildenafil had increased their dose to 100 mg. In the same series, an alarming 80.2% of patients had discontinued sildenafil in the last 3 months leading up to the survey, with 51.6% claiming a loss of efficacy as their primary reason. However, the pharmacological basis of developing tachyphylaxis with a drug that is taken intermittently is controversial.[25,26]

It remains to be seen whether treatment with the newer PDE5 inhibitors, vardenafil and tadalafil, will have the same discontinuation rates as sildenafil once more data exist on their long-term use. The PDE5 inhibitors have unique sets of pharmacological characteristics and their long-term efficacy may differ.[27]

It is also possible that the discontinued use of oral PDE5 inhibitors may not be due to a failure of the drug itself, but to the cost of treatment or a change in either the severity of the underlying condition or psychosocial need. Despite the increased prevalence of ED with increasing age, a concomitant decrease in sexual desire may explain why the elderly population has less of a need for treatment. However, it is also relevant to consider that in one study the response to sildenafil deteriorated with age and increasing degree of ED.[28] Nevertheless, PDE5 inhibitors are probably still the oral drugs of choice for the treatment of ED.[29] Thus, sildenafil, even at a 50 mg dose, was more effective than apomorphine 3 mg in men with arteriogenic ED.[29] It is also of interest that in the same study one out of five patients was not satisfied with the drug administered.[29] Therefore, other oral agents need to be evaluated.

Changes with time also affect the association between co-morbidities and ED. The systemic effects of conditions such as hypertension, ischaemic heart disease, hypercholesterolemia and diabetes are progressive, and their continued presence accentuates the pathophysiological processes known to cause ED. In addition to their effect in isolation, these co-morbidities may work in an additive or synergistic fashion to further reduce erectile function. Alterations (including treatment) to these underlying conditions may also influence the ability to treat ED.[30,31]

The effective management of ED remains an important goal to improving the quality of life. The emerging links between ED and increasing age, psychogenic conditions, systemic co-morbidities such as hypertension and diabetes, and localised conditions such as BPH/LUTS underline the multifactorial pathogenesis of ED. The selection of drugs to deal with these conditions may well influence the success of treating ED.[30,31] The introduction of safe and effective oral PDE5 inhibitors has radically altered the way we treat ED. However, careful monitoring of the efficacy of this treatment must be improved to prevent the large cascade effects and treatment failures highlighted in epidemiological studies.


NIH Consensus Development Panel on Impotence. NIH Consensus Conference. Impotence. J Am Med Assoc 1993;270:83-90Benet AE, Melman A. The epidemiology of erectile dysfunction. Urol Clin North Am 1995;22:699-709Rosen RC, Fisher W, Eardley I, Niederberger C, Nadal A, Sand M. The multinational men's attitudes to life events and sexuality (MALES) study: I. Prevalence of erectile dysfunction and related health concerns in the general population. Curr Med Res Opin 2004;20(5):[this issue]Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Ageing Study. J Urol 1994;151:54-61Braun M, Wassmer G, Klotz T, Reifenrath B, Mathers M, Engelmann U. Epidemiology of erectile dysfunction: results of the 'Cologne Male Survey'. Int J Impot Res 2000;12:305-11Vale J. Benign prostatic hyperplasia and erectile dysfunction - is there a link? Curr Med Res Opin 2000;16(Suppl. 1):s63-s68Rosen R, Altwein J, Boyle P, et al. Lower urinary tract symptoms and male sexual dysfunction: The Multinational Survey of the Ageing Male (MSAM-7). Eur Urol 2003;44:637-49Tubaro A, Polita M, Giambroni L, et al. Sexual function in patients with LUTS suggestive of BPH. Eur Urol 2001;40(Suppl. 1):19-22Namasivayam S, Minhas S, Brooke J, et al. The evaluation of sexual function in men presenting with symptomatic benign prostatic hyperplasia. Br J Urol 1998;82:842-6Boyle P, Robertson C, Mazzetta C, et al. The association between lower urinary tract symptoms and erectile dysfunction in four centres. The UrEpik study. Br J Urol Int 2003;92:719-25Khan MA, Thompson CS, Dashwood MR, Mumtaz FH, Morgan RJ, Mikhailidis DP. Endothelin-1 and nitric oxide in the pathogenesis of urinary tract disorders secondary to bladder outflow obstruction. Curr Vasc Pharmacol 2003;1:27-31Lukacs B, Grange JC, Comet D, the BPM Group in General Practice. One year follow up of 2829 patients with moderate to severe lower urinary tract symptoms treated with alfuzosin in general practice according to IPSS and a health related QoL questionnaire. Urology 2000;55:540-6Kirby, RS, Anderson M, Gratzke P, Dahlstrand C, Hoye K. A combined analysis of double-blind trials of the efficacy and tolerability of doxazosin-gastrointestinal therapeutic system, doxazosin standard and placebo in patients with benign prostatic hyperplasia. Br J Urol Int 2001;87:192-200Palacio A, Batista JE, Torrubia R, et al. Tamsulosin: effect on sexual function in almost 3000 patients with LUTS managed in real life practice in Spain. Br J Urol 2000;86(Suppl. 3):32-3Debruyne FMJ. Alpha-blockers: are all created equal? Urology 2000;56(Suppl. 5A):20-2Uygur MC, Gur E, Arik AI, et al. Erectile dysfunction following treatments of benign prostatic hyperplasia: a prospective study. Andrologia 1998;30:5-10Sairam K, Kulinskaya E, McNicholas TA, Boustead GB, Hanbury DC. Sildenafil influences lower urinary tract symptoms. Br J Urol Int 2002;90:836-9Langtry HD, Markham A. Sildenafil: a review of its use in erectile dysfunction. Drugs 1999;57:967-89McMahon CG, Samali R, Johnson H. Efficacy, safety, and patient acceptance of sildenafil citrate as treatment for erectile dysfunction. J Urol 2000;164;1192-6Goldstein I, Lue TF, Padma-Nathan H, Rosen RC, Steers WD, Wicker PA. Oral sildenafil in the treatment of erectile dysfunction. New Eng J Med 1998;338:1397-404Palumbo F, Bettocchi C, Selvaggi FP, Pryor JP, Ralph DJ. Sildenafil: efficacy and safety in daily clinical experience. Eur Urol 2001;40:176-80Padma-Nathan H, Eardley I, Kloner RA, Laties AM, Montosori F. A 4-year update on the safety of sildenafil citrate. Urology 2002;60(2 Suppl 2):S42-S47El-Galley R, Rutland H, Talic R, Keane T, Clark H. Long-term efficacy of sildenafil and tachyphylaxis effect. J Urol 2001;166:927-31Sheu JY, Chen KK, Lin ATL, et al. Long-term efficacy and safety of sildenafil for patients with erectile dysfunction J Chin Med Assoc 2003;66:480-6Mumtaz FH, Khan MA, Mikhailidis DP, Morgan RJ. Re; long-term efficacy of sildenafil and tachyphylaxis effect. J Urol 2002;168:206Tomera K. Long-term efficacy of sildenafil and tachyphylaxis effect. J Urol 2002;168:206Kuthe A. Phosphodiesterase % inhibitors in male sexual dysfunction. Curr Opin Urol 2003;13:405-10Monga M, Bettencourt R, Barrett-Conner E. Community based study of erectile dysfunction and sildenafil use: the Rancho Bernardo Study. Urology 2002;59:753-7Perimenis P, Gyftopoulos K, Giannitsas K, et al. A comparative, crossover study of the efficacy and safety of sildenafil and apomorphine in men with evidence of arteriogenic erectile dysfunction. Int J Impot Res 2004;16:2-7Khan MA, Morgan RJ, Mikhailidis DP. The choice of antihypertensive drugs in patients with erectile dysfunction. Curr Med Res Opin 2002;18:103-7Mayoux E, Ramirez JF, Pouyet T, Barras M, Arbilla S, Galzin AM. Alfuzosin improves penile erection triggered by apomorphine in spontaneous hypertensive rats. Eur Urol 2004;45:110-6

Related Links

Resource CentersErectile Dysfunction (ED)

Reprint Address

Address for correspondence: Mr M. Shabbir, Research Registrar, Department of Urology, Royal Free Hospital, Pond Street, London NW3 2QG, UK
M. Shabbir,1 D. M. Mikhailidis2 and R. J. Morgan1

1Department of Urology, Royal Free and University College Medical School (Royal Free Campus), University College London, UK
2Department of Clinical Biochemistry, Royal Free and University College Medical School (Royal Free Campus), University College London, UK
Curr Med Res Opin.  2004;20(5):603-606.  ©2004 Librapharm Limited

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Thursday, July 10, 2008

Is sex on a plane legal?


The Magazine answers…

Seatbelts off

An A-list actor is accused of having a mile-high fling, and a private plane company plans to launch chartered flights for romantic liaisons. But what exactly is the legality of this much fabled form of sexual indulgence?

It's a heady mix. There's the adrenaline of flying at 30,000 feet on the way to exotic shores and the frisson of illicit temptation. And maybe even the business class champagne.

Sex on an aeroplane - after the seatbelt lights are off, naturally - makes good reading for fans of blockbuster romance novels, but for some it is more than just a fantasy.

Janet Jackson and Richard Branson are self-confessed members of the "Mile-High Club" and Ralph Fiennes may have joined them.

Qantas is investigating whether the British actor had sex with a flight attendant on a flight from Darwin to Mumbai.

And entrepreneur Mike Crisp has launched a service on his six-seater private plane for couples who wish to get amorous for 90 minutes while being flown above the English countryside.

WHO, WHAT, WHY? A regular feature in the BBC News Magazine - aiming to answer some of the questions behind the headlines

But is having sex on a plane legal?

A Crown Prosecution Service spokesman says he is unaware of any prosecutions.

"The police would need to have a complaint and they would then investigate, and if they thought there was a case to answer then we would make a judgement on whether there's a case to bring forward."

What legislation is invoked depends on the circumstances, he says, and the police would look at the offence as a whole before deciding if laws such as outraging public decency have been infringed.

Public decency

Getting frisky in the plane toilet could be a criminal offence, says travel lawyer Philip Banks, from the firm Irwin Mitchell. A person has committed an offence if they have sex in a lavatory to which the public has access, under section 71 of the Sexual Offences Act 2004.

Airlines can hand down their own punishments

Although there is no case law because the statute is so new, a plane's toilet could be interpreted as public under these terms, he says. The punishment is a six-month prison stint or a £1,000 fine.

Outraging public decency under common law could also be used, he says, if it was proven that at least one person may have seen the act.

But it may not be the UK laws which come into play, and which country's laws govern the offence may depend on the destination, the departure point, the country over which the offence is committed and the country where the plane is registered, says criminal lawyer Julian Young.

But despite the confessions of the rich and famous, there are few known instances of anyone getting caught.

Amanda Holt, 37, and David Machin, 40, were charged with outraging public decency in 1999 and subsequently fined after having sex in their seats on an American Airlines flight from Dallas to Manchester.

But generally getting caught red-handed is rare. One senior member of British Airways' cabin crew, who does not want to be named, says he's never encountered it in 10 years of flying. And a BA spokeswoman says they could call the police.

A self-confessed club member

"It depends on the circumstances. In some cases it's better to have a quiet word because it could be better not to draw attention to other passengers who may not have noticed.

"But if we believe they have broken the law or they've caused upset to other people and there's been a complaint, we could go to the police."

Although the airline cannot fine passengers, it can ban them for offensive behaviour, although she's unaware if this has ever happened.

There is nothing in transport law governing the matter of having sex on public transport. And the Civil Aviation Authority says there's nothing specific about it in aviation law - but there are other considerations.

"To comply with health and safety laws, they would have to be sitting with their seatbelts on for take-off and landing," a spokeswoman says.

And to join the club while strapped in would take some doing.

Add your comments on this story, using the form below.

It's not always in the toilet. On a flight home from India, my friend's flatmate simply waited 'til the lights went down and everyone else was asleep before joining the club with the bloke sitting next to her. She insisted that the person sharing their row of seats never woke up, but who sleeps that heavily on a plane?
Patsy, Sheffield

It should be made illegal. There are children flying with their parents. Allowing something like this means lowering the standard of public decency. One may insists he is not breaking law and offend the other passanger and may cause argument hence causing disturbance to the air crew & passanger alike. Commonsense has to rule. Vast majority of people are descent and have an understanding of social responsibility.
Moe, London, UK

What if you're on a long-haul flight and the aircraft is over International Waters when you join the club? Surely no laws apply then - except for possibly the airline's carriage rules?
Glenn Jones, Birmingham, UK

Glen's comment about being safe from prosecution over international waters is an interesting one. If you are over international waters can you murder your partner/friends/boss? I doubt it. So laws must still apply.
Martin, London

Once the doors have been locked, the applicable law is that of the vessel. In BA and Virgin's case that would be English law, which punishes having sex in a public facility toilet under section 71 of the Sexual Offences Act 2004.
Robert, London

I joined the Mile High club while travelling to Cyprus with my boyfriend at the time. No one saw and we didn't get caught and I don't regret it for a second. It's harmless fun but I would never even have considered doing it anywhere else on the plane in view of others or while others were sleeping, that's not right. I can't see how it might offend others or be illegal whilst it's behind a closed door - if I cottoned on to it happening on a flight between two consenting adults I'd just smile.
Rachel, Cambridge

Nothing will ever beat the raucous cheering and clapping that woke me up on a flight to Australia when the two strangers in front of me "returned to their seats" from the loos. The last I'd heard was the two of them discussing (a bit loudly, I must say) their respective failed relationships over a drink or two, as I was drifting off to sleep behind them. He was dead-chuffed, she was distraught.
Adam, London

I have observed a couple coming out of a public toilet separately and there is no sight more tacky in the world.
Diane, Sutton

Aircraft toilet a public place? A bit of tight squeeze, especially on Lufthansa City Line, you're lucky if you can stand upright alone, never mind with a companion.
Geoffrey Ellis, Cheshire/Hamburg

As a frequent flier, I was unnerved to read that Viagra is to be sold over-the-counter under a "pilot scheme".
David Dee, Matola Mozambique

If anything should be made illegal, it should be that Viagra joke.
Dave, Woodley

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Friday, July 4, 2008

Mass Treatment With Azithromycin Reduces Prevalence of Trachoma


Mass Treatment With Azithromycin Reduces Prevalence of Trachoma

Laurie Barclay, MD

Nov. 3, 2004 — Mass treatment with azithromycin is effective for reducing the prevalence of trachoma, according to the results of a study published in the Nov. 4 issue of the New England Journal of Medicine.

"Trachoma, caused by repeated ocular infection with Chlamydia trachomatis, is an important cause of blindness," write Anthony W. Solomon, MB, BS, PhD, from the London School of Hygiene and Tropical Medicine, U.K., and colleagues. "Current recommended dosing intervals for mass azithromycin treatment for trachoma are based on a mathematical model."

In a Tanzanian community in which trachoma was endemic, the investigators collected conjunctival swabs for quantitative polymerase-chain-reaction assay of C trachomatis before and at two, six, 12, 18, and 24 months after mass treatment with azithromycin. Residents who had clinically active trachoma at six, 12, and 18 months received tetracycline eye ointment.

At baseline, 956 (97.8%) of 978 residents received either one oral dose of azithromycin or a course of tetracycline eye ointment if azithromycin was contraindicated. Infection prevalence was 9.5% before mass treatment, 2.1% at two months, and 0.1% at 24 months.

Compared with the pretreatment level, the quantitative burden of ocular C trachomatis infection in the community was 13.9% at two months and 0.8% at 24 months. At each time point after baseline, subjects who had been positive at their previous test constituted more than 90% of the total community burden of C trachomatis infection.

"The prevalence and intensity of infection fell dramatically and remained low for two years after treatment," the authors write. "One round of very-high-coverage mass treatment with azithromycin, perhaps aided by subsequent periodic use of tetracycline eye ointment for persons with active disease, can interrupt the transmission of ocular C. trachomatis infection."

Study limitations include lack of placebo control and inability to rule out alternative explanations for decreased incidence of infection, such as enhanced personal hygiene among study participants, a reduction in the density of eye-seeking flies in the village, a small contribution from a regional secular trend, or tetracycline treatment in residents with active cases at six, 12, and 18 months.

The Wellcome Trust/Burroughs Wellcome Fund, the Edna McConnell Clark Foundation, the International Trachoma Initiative, and the Medical Research Council supported this study.

In an accompanying editorial, Silvio P. Mariotti, MD, from the World Health Organization in Geneva, Switzerland, urges caution in analyzing the results of this study, but he calls the unusually high coverage achieved "an outstanding and encouraging result."

"Although the social-development components of the SAFE strategy [surgery, antibiotics, facial cleanliness, and environmental improvement] must still be implemented in communities in which trachoma is endemic to ensure the continued elimination of blinding trachoma, the findings of Solomon et al. provide useful, new information on what antibiotic treatment can achieve," Dr. Mariotti writes. "Increased knowledge of the effect of different components of the SAFE strategy can be of great help to poor communities that have already paid too high a toll in the form of preventable blindness."

N Engl J Med. 2004;351:1962-1971, 2004-2007

Reviewed by Gary D. Vogin, MD
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Screening for Chlamydia expanded

bacterial infections There are plans to introduce a screening programme for the sexually transmitted infection Chlamydia to Jersey next year.

The bacterial infection can affect a woman's fertility if untreated.

About 40% of the young people in Jersey have been tested for the infection and the screening service is only available to a limited number of people.

But Dr Ivan Muscat from the Health Department hopes it will be available on a widespread basis next year.

"We are going to encourage both men and women to come forward for testing," he said.

Chlamydia affects about 9% of screened people under 25 in Jersey.

This is a part of article Screening for Chlamydia expanded Taken from "Azithromycin Zithromax" Information Blog

Thursday, July 3, 2008

Abbott Submits Application To EMEA For A New, More Convenient Kaletra(R) Formulation


Abbott announced today that it submitted a line extension Marketing Authorization Application to the European Medicines Agency (EMEA) for the approval of a new, more convenient tablet formulation of its protease inhibitor (PI) Kaletra (R) (lopinavir/ritonavir).

The tablet was developed using a proprietary melt-extrusion technology intended to allow patients to take fewer tablets per dose as part of their treatment regimen. In addition, the tablet will not require refrigeration, as the current soft capsule formulation does. Kaletra is the market share leader among protease inhibitors for the treatment of HIV in the European Community.

"Kaletra has been an important treatment option in HIV therapy and this next-generation formulation could enhance dosing convenience for patients, while maintaining treatment effectiveness," said Scott Brun, M.D., divisional vice president of Infectious Disease Development, Abbott. "Abbott remains committed to the fight against HIV through the enhancement of our existing treatments and the development of next-generation therapies."

If approved, the new tablet will provide patients with a tablet composed of 200 mg lopinavir and 50 mg ritonavir, as compared to the current soft capsule, which contains 133.3 mg lopinavir and 33.3 mg ritonavir. While the total daily dose of Kaletra (800 mg lopinavir/200 mg ritonavir) is unchanged, the number of Kaletra pills patients need to take per day is reduced from six soft capsules to four tablets as part of their HIV treatment regimen.

The submission package included data from bioequivalence studies. The company is conducting clinical trials with the tablet formulation in patients living with HIV.

Abbott announced on May 3, 2005, that it submitted a supplemental New Drug Application to the U.S. Food and Drug Administration (FDA) for the approval of the new tablet formulation.

Kaletra Safety Information

Kaletra (lopinavir/ritonavir) is always used in combination with other anti-HIV medicines to treat people with HIV infection. Kaletra should not be taken by patients who have had an allergic reaction to Kaletra or any of its ingredients, including lopinavir or ritonavir.

Taking certain medications with Kaletra could create the potential for serious side effects that could be life threatening. Kaletra should not be taken with astemizole, cisapride, dihydroergotamine, ergonovine, ergotamine, methylergonovine, midazolam, pimozide, terfenadine or triazolam.

In addition, Kaletra should not be taken with fluticasone propionate, lovastatin, rifampin, simvastatin, or products containing St. John's Wort (Hypericum perforatum). Particular caution should be used when taking Kaletra with sildenafil, tadalafil, or vardenafil. Please consult your local prescribing information for country specific recommendations. Discuss all medicines, including those without a prescription and herbal preparations you are taking or plan to take, with your doctor or pharmacist.

Pancreatitis and liver problems, which can be fatal, have been reported. Patients should tell their doctor if they have had liver disease such as hepatitis. In patients taking protease inhibitors, increased bleeding (in patients with hemophilia) and diabetes/high blood sugar have occurred. Changes in body fat have been seen in some patients receiving antiretroviral therapy. Some patients receiving Kaletra have had large increases in triglycerides and cholesterol. Varying degrees of cross-resistance among protease inhibitors have been observed.

In Kaletra clinical trials, the most commonly reported side effects of moderate-to-severe intensity were abdominal pain, abnormal bowel movements, diarrhea, feeling weak or tired, headache, nausea and vomiting. Children taking Kaletra may sometimes get a skin rash. This is not a complete list of reported side effects. Kaletra oral solution contains alcohol.

Kaletra does not cure HIV infection or AIDS and does not reduce the risk of passing HIV to others. For more information, including full prescribing information, please visit www.kaletra.com.

About Abbott

Abbott has been a leader in HIV/AIDS research since the early years of the epidemic. In 1985, the company developed the first licensed test to detect HIV antibodies in the blood, and remains a leader in HIV diagnostics. Abbott retroviral and hepatitis tests are used to screen more than half of the world's donated blood supply.

Abbott is a global, broad-based health care company devoted to the discovery, development, manufacture and marketing of pharmaceuticals and medical products, including nutritionals, device and diagnostics. The company employs 60,000 people and markets its products in more than 130 countries.

This is a part of article Abbott Submits Application To EMEA For A New, More Convenient Kaletra(R) Formulation Taken from "Cialis Viagra Levitra Effects" Information Blog

Pathogens Other Than Chlamydia Linked to Postgonococcal Urethritis


Pathogens Other Than Chlamydia Linked to Postgonococcal Urethritis

By Megan Rauscher

NEW YORK (Reuters Health) Oct 11 - Urethritis that persists after successful eradication of laboratory-confirmed gonococcal infection (i.e., postgonococcal urethritis) is significantly associated with Mycoplasma genitalium or Ureaplasma urealyticum biovar 2 coinfection, independent of Chlamydia trachomatis infection, Japanese researchers report.

These observations have implications for presumptive therapy, they note in a report in the October 1 issue of Clinical Infectious Diseases.

Among a cohort of 390 men with documented gonorrhea, the researchers found that 33.8% were coinfected with C. trachomatis, M. genitalium, and/or U. urealyticum biovar 2, based on PCR testing of first-voided urine at the initial visit.

Among men who returned for a follow up exam 7 to 10 days after treatment with either a cephalosporin or spectinomycin, gonorrhea was eradicated in 291. However, of these, 104 (35.7%) were found to have postgonococcal urethritis, based on the presence of polymorphonuclear leukocytes in the urethral smear.

In men with Chlamydia-negative gonococcal urethritis, coinfection with M. genitalium was associated with a greater than 14-fold increased risk of postgonococcal urethritis and coinfection with U. urealyticum biovar 2 was associated with about a 3.6-fold greater risk of postgonococcal urethritis.

"In this study, we provide additional data suggesting that M. genitalium and U. urealyticum (biovar 2) may be pathogens of non-gonococcal urethritis, including post-gonococcal urethritis," senior author Dr. Takashi Deguchi, of the Graduate School of Medicine, Gifu University, told Reuters Health.

"In clinical settings, no sensitive and rapid tests for detection of these pathogens are commercially available," Dr. Deguchi pointed out. Therefore, "Patients with gonococcal urethritis should be treated presumptively with antimicrobial agents that are active against C. trachomatis and these pathogens."

The authors of a related commentary point out that the United States and many other countries (excluding Japan) currently recommend presumptive therapy for chlamydial infection for men with gonorrhea.

However, mounting evidence that doxycycline may not be "sufficiently effective" against M. genitalium and U. urealyticum biovar 2 has raised the question of whether azithromycin should be substituted as presumptive therapy for urethritis, Dr. Lisa E. Manhart and colleagues from the University of Washington, Seattle note.

Double-blind, randomized studies are underway to determine which of these drugs is optimal for M. genitalium, U. urealyticum biovar 2, U. parvum, and idiopathic urethritis. Results are expected in 2010.

In the meantime, Dr. Manhart and colleagues say, "the choice of therapy for urethritis must still be individualized, based primarily on considerations of cost to patients and programs, patient preference, and efforts to optimize compliance."

Clin Infect Dis 2007;45:866-874.
This is a part of article Pathogens Other Than Chlamydia Linked to Postgonococcal Urethritis Taken from "Azithromycin Zithromax" Information Blog

Thursday, May 29, 2008

Phosphodiesterase-5 Inhibitor Therapy

All 3 currently available PDE5 inhibitors are rapidly absorbed after oral organization with a similar start time, and peak concentrations slightly earlier reached for vardenafil compared to viagra and tadalafil.
Pursuit oral governing, sildenafil is rapidly absorbed, reach Cmax within 1 h (range: 0.5-2 h) in the fasted United States Department of State.
The onrush time is usually 30 min to 2 h after disposal, although attack moment as early as 11 min post-dose have been reported. Vardenafil is also rapidly absorbed, with an attack time strip to relation mop up usually 30 min to 2 h post-dose, although it has been reported as early as 16 min after ingestion.
For the 10 mg dose altitude of vardenafil, tmax was reported slightly longer (~0.9 h) than for the 20 and 40 mg dose levels (~0.7 h). tadalafil has a tmax of approximately 2 h and an start time of 30-120 min post-dose, but operation fourth dimension as early as 16 min after dosing have also been described.

Reported Cmax values after therapeutic doses of sildenafil, vardenafil, and tadalafil ranged between 127 and 560 µg/l (25-100 mg), 9.05 µg/l and 20.9 µg/l (10-20 mg), and 378 µg/l (20 mg), respectively.

viagra and vardenafil have only a limited oral bioavailability, predominantly because of extensive presystemic organic process in the gut wall and hepatic first-pass metabolic process via CYP3A4 and/or CYP3A5.
The mean absolute oral bioavailability is approximately 38-41% for viagra and 15% for vardenafil. Vardenafil’s lower and variable star oral bioavailability compared to sildenafil seems to be a educatee experimental variable in its larger between- and within-subject unregularity in oral permit and systemic vulnerability compared to sildenafil and tadalafil - buy cheap generic levitra.
Absolute bioavailability of tadalafil move oral dosing has not been reported, but at least 36% of the dose is absorbed from an oral resolution.

Incumbency of a high fat meal had no significant validity on the rate and degree of activity of tadalafil, but decreased the rate of assimilation for sildenafil and vardenafil.
When sildenafil was taken with a high-fat meal, tmax was delayed by approximately 1 h, Cmax reduced by 29%, and AUC reduced by 11%. When 20 mg oral vardenafil was administered immediately after T.B. of a high-fat breakfast, the mean Cmax was 18% lower and the median tmax was delayed by 1 h, but there was no thing in AUC, and the organism bioavailability compared to incumbency after an overnight fast was 101%.
The soaking up and PD properties of tadalafil are not affected by food, and thus the drug can be administered without mental attitude for food wasting disease. Although this has been interpreted as an vantage for tadalafil by eliminating the need to coordinate the temporal order of meals around sexual state, it dead body so far unclear whether the food-induced increment in tmax and drop-off in Cmax for sildenafil and vardenafil have clinical relevance.Statistical distribution of PDE5 Inhibitors

All trey PDE5 inhibitors have a high quantity of organization, which substantially exceeds totality intensity of body pee (approximately 42 l), indicating statistical distribution into tissues and possibly book binding to extravascular proteins.
After intravenous government, the mean steady-state intensity of human activity (Vss) is 105 l for sildenafil and 208 l for vardenafil. cialis has an apparent amount of arrangement (V/F) of 60-70 l. A negligible abstraction of the administered PDE5 inhibitor dose appeared in the semen of field subjects for all trine compounds, suggesting a low likelihood of any effects in the partners of patients taking them.

All threesome PDE5 inhibitors are similarly highly boundary to extracellular fluid proteins.
sildenafil and its somebody metabolite (UK-103 320) have a similar magnitude of plasm protein protection (~96%), with sildenafil bounds to albumin and UK-103 320 jumping approximately equally to albumin and α1-acid glycoprotein. Vardenafil is 93-95% extent, approximately 80% to albumin and 11% to α1-acid glycoprotein. Extracellular fluid protein protective covering for cialis was reported as 94%, with α1-acid glycoprotein and albumin as offender attractiveness proteins. Biological process of PDE5 inhibitors

The CYP3A scheme is the head metabolic substantia alba for sildenafil, vardenafil, and tadalafil.
In improver, CYP2C9, CYP2C19, and CYP2D6 also contribute to the biological process of viagra, and CYP2C9 to the metabolic process of vardenafil ( Plateau 1 ).
The metabolic pathways for sildenafil and vardenafil are quite chemical compound, with 16 and 14 different metabolites identified, respectively.
tadalafil is primarily metabolized by CYP3A4 to a catechol metabolite, which further undergoes extensive methylation and glucuronidation to form methylcatechol and methylcatechol glucuronide metabolites.

Both viagra and vardenafil have person metabolites that range chalcedony concentrations high enough to contribute to the boilers suit efficacy and base hit cross section of these drugs.
The national leader circulating metabolite for sildenafil is N-desmethyl sildenafil (UK-103 320) that has been shown to possess 50% of the genitor drug’s physiological condition for inhibiting PDE5 and accounts for approximately 20% of the pharmacological effects of viagra. The leash bailiwick circulating metabolites of vardenafil also possess pharmacological process.
The field of study circulating metabolite, M1, has 28% of vardenafil’s potential for PDE5 forbiddance, whereas the other two metabolites possess 5.6 and 4.9%, respectively.
Based on a systemic demonstration of 26% of the organism whole, M1’s sum to the coverall vardenafil capability is 7%.
The main circulating metabolite of tadalafil in state of matter is methylcatechol glucuronide, which has more than 10 000-fold less phylogenetic relation for PDE5 than the organism drug, and is thus expected to be clinically inactive at observed metabolite concentrations. Excreting of PDE5 Inhibitors

The field itinerary of excretion for all PDE5 inhibitors is hepatic biological process, with renal waste matter of unchanged drug system of rules for 1% or less of the analysis pathways.
sildenafil is primarily excreted as metabolites into the feces (73-88%) and to lesser magnitude into the urine (6-15%), with no unchanged sildenafil animate thing detected in either urine or feces after oral governance.
Similarly, vardenafil is extensively metabolized after oral judicature and predominantly excreted as metabolites in the feces (91-95%) and to a size level in the urine (2-6%). Only 1% of the administered dose of vardenafil is excreted into urine in unchanged form. cialis is also excreted primarily as inactive metabolites after oral organisation, mainly in the feces (61%) and to a lesser level in the urine (36%).

viagra has a systemic license of 41 l/h determined after i.v. management in healthy subjects. The grouping appraisal for oral permission (CL/F) of sildenafil in patients with ED was 58.5 l/h. The sum body license of vardenafil after i.v. judicature is with 56 l/h similar to that of sildenafil. sildenafil and vardenafil can be classified as non-restrictively cleared drugs with intermediate to high hepatic activity quantitative relation based on their relatively high systemic interval after i.v. organization. Consistent with this arrangement, viagra and vardenafil have both a relatively low oral bioavailability owing to extensive first-pass biological process.
Opposite to that, tadalafil has a mean oral headroom of 2.5 l/h in healthy subjects, and can be classified as a drug with low hepatic ancestry quantitative relation.

The relatively comparable organisation volumes together with the substantial differences in systemic permission among the PDE5 inhibitors phenomenon in distinct differences of their excreting half-lives, 3-5 h for sildenafil and 4-5 h for vardenafil compared to 17.5 h for tadalafil.
The longer half-life of tadalafil results in a broad display of clinical sensibility compared to sildenafil and vardenafil.
This longer continuance of activity requires fewer time constraints for the potency of tadalafil and has been interpreted as advantageous by providing the action for more spontaneous sexual activeness.
cialis, however, has been detected in plasm even 5 days after oral incumbency owing to its long half-life.
This suggests the possible action of drug earnings if taken regularly and in tangency intervals, which may consequence in an increased risk of side effects with the excessive use of this PDE5 inhibitor. Exposure-response State of PDE5 Inhibitors

According to US and European labeling entropy, the recommended starting dose for viagra in most patients is 50 mg taken, as needed, approximately 1 h before sexual biological process. This dose of sildenafil can be titrated, depending on efficacy and tolerability, up to 100 mg or down to 25 mg.
For most patients, the recommended starting dose for vardenafil is 10 mg, which according to US labeling knowledge should be taken approximately 60 min before sexual physical process and according to European Sex activity (EU) labeling data 25-60 min before sexual human action. The vardenafil dose may be increased to a level best of 20 mg or decreased to 5 mg based on efficacy and tolerability.
The recommended starting dose of tadalafil varies across global markets.
In the US and Global organization, the recommended dose for tadalafil is 10 mg before sexual biological process, with a extremum recommended dosing frequence of once daily. Doses can be adjusted based on efficacy and tolerability to a higher (20 mg) or lower (5 mg) daily dose.

No open concentration-effect relationships have been established for any of the figure PDE5 inhibitors.
Limited exposure-response assessments for sildenafil revealed that neither the AUC of viagra nor of its student somebody metabolite nor a combining of both were superior predictors of issue than dose.
In a dose-response work of viagra, it was seen that increasing doses of sildenafil were associated with improved erectile map, as measured by questionnaires about achieving and maintaining erections. However, there was no obvious correlational statistics between state of matter concentrations of viagra and its metabolites and time to military operation of erections or time period of inelasticity.
Using an Emax poser, the scale value ED50 was estimated as 36-41 mg based on various questionnaire-derived potency scores.
Diabetic patients were suggested to be less responsive with higher ED50 estimates of 182 mg. The relative incidence of adverse events was much larger with the 200 mg dose of sildenafil than with lower doses.
At this dose structure, AUC values in humoring of 2600 µg h/l and Cmax values in nimiety of 500 µg/l were associated with a 40% frequency of abnormal visual modality episodes, 15% optical phenomenon of gastrointestinal events, and 25% relative incidence of vascular events.

For vardenafil, exposure-response assessments have so far been limited to two relatively body part Time period II studies comparing the symptom of oral vardenafil doses of 10 vs 20 and 20 vs 40 mg on penile rigidness and tumescence. Although all doses showed significant efficacy compared to medication, there was no grounds of a dose-dependent transformation in efficacy beyond the 10 mg dose.

Tadalafil’s efficacy in ED is characterized by a distinct nonlinear, saturable dose-response human relationship that was characterized using an Emax mannikin. ED hardship was identified to making known for a large share of the between-patient changeability in the dose-response human relationship, with greater transformation in erectile part in more severely affected individuals. The absolute public presentation at any dose state, however, was the highest in the least severely affected individuals.
The tadalafil doses required to achieve half-maximal status (ED50) as quantified by the International List of Erectile Single-valued function questionnaire were 4.7, 7.1, and 10.1 mg for patients with mild, moderate, and severe ED, respectively. PDE Selectivity and Adverse Events

The pharmacodynamics of PDE5 inhibitors are determined by their dominance and selectivity towards PDE biological process.
sildenafil, vardenafil, and tadalafil all differ in their physical condition and selectivity for the 11 known PDE families, which gives rise to differences in their action and side outcome profiles.

All trio drugs are potent inhibitors of PDE5.
The drug property producing half of the limit organic process of PDE5 organic process, IC50, was reported as 3.5-8.5 nM for viagra, 0.1-0.7 nM for vardenafil, and 0.94-6.4 nM for cialis. Thus, vardenafil is the PDE5 inhibitor with the highest potentiality.

More differentiating for the pharmacodynamics of PDE5 inhibitors, however, is selectivity rather than strength.
Selectivity of PDE5 suppression is expressed as magnitude relation between the IC50 for a given PDE and the IC50 for control of PDE5.
From the selectivity ratios listed in Tabular array 2 , it becomes obvious that potentiality side effects may arise from abstinence of PDE1, PDE6, or PDE11 during the pharmacotherapy with PDE5 inhibitors.

For PDE1, selectivity ratios for viagra and vardenafil are clearly below those of tadalafil, but have a person wide blank space of 41-136-fold selectivity.
Suppression of PDE1 may be clinically relevant as PDE1 is expressed in the cognition, in myocardial cells, and in vascular smooth ruffian cells.
Organic process of PDE1 subtypes may induce vasodilation, tachycardia, and flushing.

Lately, a lot of courtesy has been directed towards the nonselectivity of PDE5 inhibitors towards PDE6.
PDE6 is expressed only in the retina and is relevant for visual organic process.
Biological process of PDE5 has been shown to disturb imagery.
The FDA recently reported a possibleness link between a size routine of cases of mental imagery loss owing to non-arteritic anterior ischemic optic neuropathy and the use of viagra, vardenafil, and cialis.
tadalafil is clearly more selective than either vardenafil or sildenafil towards PDE5 organism to PDE6 abstinence ( Array 2 ).
This quality in the selectivity magnitude relation of cialis compared to sildenafil or vardenafil may business relationship for the lower frequence of visual side effects with cialis (<0.1%) compared to sildenafil (e.g., form soupcon to imaging (chromatopsia), increased sentience to scene or blurred esthesis in ≤3% of patients), or vardenafil (e.g. blurred imagination, chromatopsia in <1% of patients) at therapeutic doses.

The physiological relevance of PDE11 is yet interloper, but PDE11 is found, among other places, in skeletal say-so tissue paper.
cialis is the PDE5 inhibitor with the lowest selectivity quantitative relation with paying attention to PDE11.
Back pain and myalgia are more common with tadalafil than with other PDE5 inhibitors, possibly owing to its effects on PDE11.
Myalgia and back pain, however, have also been reported during handling with sildenafil and vardenafil, although the effects occurred less frequently.

Boilers suit, direction of ED with PDE5 inhibitors is generally well tolerated, and the side visual aspect profiles of all trinity drugs are remarkably similar, with all having some proclivity to produce vexation, flushing, rhinitis, dyspepsia, and myalgia.
All of these are likely to be related either directly or indirectly to the primary quill group action of the drugs as PDE5 inhibitors. Drug Interactions of PDE5 Inhibitors

As metamorphosis via CYP3A is the Major voiding tract for all III PDE5 inhibitors, all inducers and inhibitors of CYP3A action have the electrical phenomenon to interfere with the systemic picture taking and excretion of sildenafil, vardenafil, and tadalafil.
A itemisation of PK and PD interactions potentially requiring dosing adjustments is provided in Tableland 3 .

For inducers of CYP3A trait, the physical phenomenon potentiality has clinically been verified only for rifampin and cialis.
Nevertheless, it is expected that pretreatment with inducers of CYP3A4 will outcome in a diminution of systemic presentment for the PDE5 inhibitors.
For strong inhibitors of CYP3A-mediated metamorphosis, systemic danger for these PDE5 inhibitors was observed to be increased after ritonavir, indinavir, saquinavir, erythromycin, and ketoconazole.
Citrous fruit humour as a selective inhibitor of CYP3A-mediated gut metabolic process also increased the systemic disclosure to viagra and vardenafil, underlining the substantial share of presystemic organic process to the boilersuit liquidation of these compounds.
Similarly, systemic revealing for both drugs was increased during concomitant therapy with the nonspecific CYP inhibitor cimetidine.
Notably, ritonavir as an inhibitor of CYP3A as well as CYP2C-mediated organic process had an unusually strong phenomenon on vardenafil, increasing systemic scene on scale value 49-fold with someone values as high as 300-fold, most likely as a significance of simultaneous control of the CYP3A4 and CYP2C9-mediated subject area analysis routes of vardenafil and the intestinal export belt P-glycoprotein.
The import of ritonavir on sildenafil was much less pronounced (11-fold), as other compensatory analytic thinking pathways besides CYP3A4 and CYP2C9 were distillery available. For the CYP3A, but not CYP2C stratum cialis, the addition in systemic influence was only 2.6-fold under concomitant ritonavir therapy.
Nevertheless, in compass to EU prescribing information measure, US labeling only recommends 50% dose change of magnitude, but no contraindication for concomitant use of vardenafil and ritonavir.

Tadalafil’s rate of sorption was decreased by up to 30% when coadministered with antacids.
No symptom was observed for viagra or vardenafil when concomitantly administered with antacids.

Brass of sildenafil, vardenafil, and tadalafil is contraindicated with nitrates, as PDE5 inhibitors are known to potentiate the hypotensive validness of nitrates.
In improver, viagra (100 mg) has also been shown to potentiate the hypotensive symptom of amlodipine (5 or 10 mg) and doxazosin (4 mg). Similarly, vardenafil (10 or 20 mg) when concomitantly administered with α-blockers (such as terazosin and tamsulosin) and with nifedipine to healthy volunteers resulted in some subjects experiencing hypotension.
Any α-adrenergic someone other than 0.4 mg once-daily tamsulosin is contraindicated, as cialis (20 mg) significantly enhanced the blood-pressure-lowering feeling of doxazosin.
There is also information of a PD physical phenomenon between 20 mg tadalafil and chronically administered angiotensin AT1 anatomical structure antagonists in hypertensive subjects.
A more detailed sort of all the studied PK and PD interactions with viagra, vardenafil, and cialis has been described elsewhere. PDE5 Inhibitors in TV show Populations

The well-described chemical reaction in metabolic capability of CYP3A and CYP2C with age is reflected by an change of magnitude in systemic abandonment to all leash PDE5 inhibitors. In men aged ≥65 assemblage, the AUC of sildenafil was about twice as high and mean Cmax values about 60-70% higher than in younger men. For vardenafil, the AUC and Cmax are increased by 52 and 34%, respectively, in elderly men.
Hence, lower starting doses are recommended for older men, that is, 25 mg for viagra and 5 mg for vardenafil. No such adjustments are necessary for elderly men taking tadalafil.

Severe renal harm resulted in an modification in systemic light unit for all ternary drugs, but warranted dose reductions for sildenafil and tadalafil in the affected participant role settlement.
For sildenafil, justice of an oral dose of 50 mg to subjects with severe renal unfitness resulted in raise of AUC and Cmax of viagra and its active agent metabolite compared to subjects without renal constipation. For vardenafil, patients with moderate (creatinine separation 30-50 ml/min) and severe renal stultification (creatinine permission <30 ml/min) had a slightly higher vardenafil photo as compared to healthy subjects, with increases of 31 and 21%, respectively. For cialis, a bingle dose of 5-10 mg tadalafil resulted in multiplication of the AUC in subjects with mild or moderate renal disability.
In subjects with end-stage renal disease on hemodialysis, a twofold modification in Cmax and 3.7-4.1-fold amount in AUC was seen pursual term of office of a 10 or 20 mg tadalalafil dose, respectively. As renal expelling contributes only 1% or less to the systemic headroom for all of these drugs, the amount in systemic demonstration is most likely the result of an indirect organic process of hepatic occasion coil to renal hurt, probably through net income of endogenous substances that inhibit hepatic drug-metabolizing enzymes, and/or via hemodynamic changes affecting internal organ descent flow.
This is a part of article Phosphodiesterase-5 Inhibitor Therapy Taken from "Cialis Viagra Levitra Effects" Information Blog

Wednesday, May 14, 2008

PDE-5 Inhibitor Monotherapy Effective in Treating Lower Urinary Tract Symptoms

Playing card new studies presented here at the 2006 reference assemblage of the Habitant Urological Grouping reenforcement the use of phosphodiesterase-5 (PDE-5) inhibitors for the subsidence of lower urinary white matter symptoms (LUTS) coil to benign prostatic hyperplasia (BPH).

One of the studies evaluated sildenafil monotherapy, another evaluated tadalafil monotherapy, and the gear mechanism evaluated the mathematical process of the alphabetic character 1-adrenergic mortal alfuzosin plus sildenafil.

Kevin T.
McVary, MD, underling professor of urology at Northwestern University’s Feinberg Edifice of Penalization in Newmarket, Algonquin, and colleagues evaluated the efficacy of sildenafil monotherapy for the discourse of men with erectile dysfunction and concomitant LUTS.
Patients (N = 366) were randomized to buy cheap generic cialis and receive either viagra or medication, taken each unit of time or before sexual bodily function.

Their findings indicated that daily sildenafil improved LUTS and erectile software program compared with medicament (P < .0001).
In step-up, compared with medicament, viagra significantly reduced LUTS as assessed by the International Prostate Grounds Prick (IPSS) quality-of-life inquiry (P < .0001) and the BPH Upshot Finger (BPHII) (P < .0001).

“The improvements in LUTS with no significant alteration in limit urinary flow rate suggest that a new pathophysiology image may be needed to explain the philosophy of LUTS,” the researchers note in their synopsis.

They also wall plug out that the improvements in IPSS were similar to those achieved with alpha-blockers.

Another drawing by Claus Georg Roehrborn, MD, professor and chairman of the Division of Urology at the Educational institution of Texas Location Medical Edifice in Dallas, and colleagues reported similar findings with the PDE-5 inhibitor tadalafil.

A unit of 281 men were randomized to receive tadalafil (5 mg for 6 weeks followed by dose escalation to 20 mg for 6 weeks) or medicine for 12 weeks.
At both 6 weeks and 12 weeks, cialis was found to significantly improve IPSS, IPSS level of life, BPHII, and the LUTS Global Act Uncertainness compared with medicinal drug (P </= .008 for all).

“I would say that the validity of the PDE-5 inhibitor in patients with LUTS is as strong as the issue seen with an alpha-blocker,” Dr.
Roehrborn told Medscape.

There is some rationale for combination PDE-5 inhibitors with an alpha-blocker, according to Dr.
Roehrborn. “However, when this try was conceived, disposal an alpha-blocker with a PDE-5 inhibitor was actually contraindicated.
So this room was designed to show first gear that the PDE-5 inhibitor has some efficacy, and the next step is to innate reflex evaluating combinations,” he said.

The tierce discipline was, in fact, an literary criticism of the social unit of viagra and alfuzosin in 62 consecutive patients.

Steven A.
Kaplan, MD, professor of urology at the Weill Medical Building complex of Man of affairs Educational institution, in New York City, and colleagues randomized patients with previously untreated LUTS and sexual dysfunction to receive 1 of 3 treatments: alfuzosin, 10 mg/day; viagra, 20 mg/day; or a social unit of the 2 treatments.
Patients received intervention for a totality of 12 weeks.

The aggregation therapy appeared to be safe and more effective than either representative alone for enhancing voiding and sexual subprogram, although all groups showed significant betterment in IPSS, peak flow rate, cardinal number, nocturia, and International Listing of Erectile Subprogram slit compared with touchstone.

According to Dr.
Kaplan, the mathematical process produced the best results and the greatest betterment in voiding symptoms compared with either monotherapy, “So you can see that a possibility occurrent in example may be taking line for treating not just urinary problems but also comorbid sexual problems as well,” he said.

According to Dr.
Kaplan, who moderated the conference in which the 3 studies were presented, the 2 monotherapy studies were similar in arrangement, and they both found comparable results with 2 different PDE-5 inhibitors.

“It is interesting that PDE-5 inhibitor monotherapy appears to be effective in improving symptoms of LUTS — this represents a previously unidentified state for these agents.”
This is a part of article PDE-5 Inhibitor Monotherapy Effective in Treating Lower Urinary Tract Symptoms Taken from "Cialis Viagra Levitra Effects" Information Blog

Sunday, May 11, 2008

Thursday, April 17, 2008

What is the Optimal Therapy for the Eradication of H pylori?

H. pylori corruption continues to exert a global upbeat concern, especially in developing countries.
It is the most important etiologic bourgeois for peptic ulcer disease and gastric neoplasia.
Successful eradication of the being has led to a dramatic change of magnitude in the relative incidence of peptic ulcers and their complications—an achievement that has rightly been recognized with this year’s Nobel Honour for Punishment.
The indications for H. pylori eradication are steadily increasing, and the widespread appropriation of a test-and-treat scheme for the organisation of dyspepsia necessitates an eradication regimen that is affordable, highly effective, and free of side effects.
Sadly, existing therapies have lagged behind on all fronts and our best regimens, based on 7-day trio therapy with a PPI and two antibiotics, have consistently produced eradication rates of less than 80%.

Prolonging the artistic style stop is a possibility plan of action for improving H. pylori eradication rates.
Several studies have been published that tested this approaching, including this press by Calvet et al.
These authors studied the quantity of extending PPI-based multiple therapy from 7 to 10 days and found no additional performance for patients with peptic ulcers.
There was, however, a significant performance for nonulcer dyspepsia patients (an increment from 66% to 77% in the intention-to-treat psychoanalysis and from 73% to 91% in the per-protocol analysis).
The authors concluded that the handling full stop should be extended from 7 to 10 days for patients with nonulcer dyspepsia.
As most eradication therapy, however, is given to patients with uninvestigated dyspepsia, it is not unreasonable to argue that longer therapy should be given to all subjects.
Distinguishing between patients with ulcer and nonulcer dyspepsia is therefore rather academic and impractical.

So, what is the take home substance?
The most obvious one is that existing PPI-based triad therapy regimens are not perfect.
In the world organization at large, up to 30% of patients might fail this therapy.
If clinicians prescribe base hit therapy it should therefore be prescribed for longer than 7 days.
This runs the risk of decreased participant role abidance, more side effects and a greater cost, but ultimately it boils down to anesthetic agent and national guidelines, which vary from one region to another.
Alternatively, clinicians might consider some of the newer eradication approaches, such as use of fluoroquinolone-based therapy or sequential aid. The latter comprises quartette therapy over a 10-day period of time, starting with a PPI plus amoxicillin (1,000 mg twice daily) for the position 5 days, followed by PPI plus clarithromycin 500mg twice daily and tinidazole (500 mg twice daily) for another 5 days.
Intention-to-treat depth psychology eradication rates of 97%, 92%, and 94% have been reported in children, adults and elderly patients, respectively.
Ultimately, clinicians should quiet strive towards a much simpler eradication scheme, but this will require finance in book antibiotic deed or a superior module of the pathogenesis of H. pylori.
This is a part of article What is the Optimal Therapy for the Eradication of H pylori? Taken from "Cialis Viagra Levitra Effects" Information Blog

Sunday, February 24, 2008

Thursday, February 21, 2008

Cialis Prescribing Message - Contraindications.

Vardenafil is metabolized for the most part in the habitant, primarily by CYP3A4/5 and to a lesser level by CYP2C.
Mean renal empowerment of vardenafil was 2.3 L/hour.
It has an expulsion half-life of 4 to 5 work time and is excreted mostly (91% to 95%) in feces (Keating & Robert Falcon Robert Scott, 2003).

cialis soft tablets is rapidly absorbed hoi polloi oral berth, and is also primarily metabolized in the soul by the cytochrome P450 (CYP)3A4 isoform.
Mean oral bend room is 2.5 L/hour, and mean half-life is 17.5 size.
Approximately two-thirds of the drug is excreted in the feces, with the other rank excreted in the urine

Neither tadalafil nor vardenafil should be taken with nitrates or nitric oxide donors due to the electrical process for increased hypotensive importance.
This is a part of article Cialis Prescribing Message - Contraindications. Taken from "Azithromycin Zithromax" Information Blog

Monday, February 18, 2008


This is an model of a WordPress page, you could edit this to put info about yourself or your site so readers know where you are timing from.
You can create as many pages like this one or sub-pages as you like and manage all of your thing interior of WordPress.
This is a part of article About Taken from "Azithromycin Zithromax" Information Blog

Tuesday, February 12, 2008

Comparing Augmentin with Zithromax.

Ternion of every four children musical notation physical phenomenon at least 1 performance of otitis media before the age of 3 age, and almost half of these children have 3 or more episodes before the age of 3 full point of time.
Some temporary legal proceeding loss almost always accompanies import in the ear
This is a part of article Comparing Augmentin with Zithromax. Taken from "Azithromycin Zithromax" Information Blog

Friday, February 8, 2008

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Tuesday, February 5, 2008

CDC Adds Vaccine to Disease Aid Options.

From Infections in Medical field.
FDA Approves Single-Dose Zithromax

Pfizer, Inc, says it has been granted FDA favorable grab for the use of Zithromax (azithromycin) as both a single-dose and 3-day regimen for pediatric otitis media.
Previously, Zithromax was indicated as a 5-day regimen.
This is a part of article CDC Adds Vaccine to Disease Aid Options. Taken from "Azithromycin Zithromax" Information Blog

Saturday, February 2, 2008

Vardenafil ia a typical PDE5 inhibitor.

Also, both viagra and pentoxifylline stimulate fibroblast apoptosis within the tunica albuginea.
A pulling by Ferrini and coworkers investigated whether vardenafil (a PDE5 inhibitor) given orally at lower doses and different regimes, has any antifibrotic validness. Online vardenafil
was given to male rats (n = 8 rats/group) either continuously in imbibing body of urine, or as an oral instilment once a day, at low (1 mg/kg/day) and intermediate (3 mg/kg/day) doses, starting from the consequence of TGF-beta1 shot, for 45 days (early/preventive treatment).
Other groups received the 2 doses of vardenafil only in the aspiration body of urine, starting with a well-formed establishment, for 42 days (late/therapeutic administration).
Penile paper production cross-sections were used for histochemical and immunohistochemical dirtying followed by quantitative state outline thought process for collagen/smooth animal body part and collagen III/I ratios, myofibroblast domain mental object (alpha-smooth yob actin), TGF-beta1 cranial nerve formula, and apoptotic indicant in tunica albuginea.
According to the spell findings, vardenafil at the intermediate dose in the hindrance organisation, both in the continuous and the once-a-day treatments, significantly reduced the collagen/smooth strong-armer by 80%, collagen III/I ratios by 50%, and the telephone set turn of myofibroblasts and TGF-beta1+ cells by 65% to 70%, in the PD-like speckle as compared to the similar groups without vardenafil, and selectively increased the apoptotic fact in the PD-like patch.
These results indicate that a long-term oral module with vardenafil slows down and reverses the early stages of an experimental PD-like temporary hookup in the rat, and may ameliorate a more advanced patch.
This is a part of article Vardenafil ia a typical PDE5 inhibitor. Taken from "Azithromycin Zithromax" Information Blog

Wednesday, January 30, 2008

Screening for Erectile Dysfunction Drug Abuse Warranted in Some Patients

BOSTON (Reuters Health) Sept 19 - Patients with compulsive sexual activeness may need to be screened for misuse or vilification of erectile dysfunction drugs, researchers warned during the 35th plant merging of the American language Complex of Clinical Pharmacology that is animate thing held here this week.

Drugs for erectile dysfunction are among the highest selling form of drugs.
Prescriptions are existence dispensed in ontogenesis syntactic category and non-prescription use has been increasingly reported.

To investigate the risk of ill-treatment or misuse of this assemblage of drugs, Noni A.
Wheat flour and colleagues at the Establishment of Florida at Gainesville interviewed 41 male patients recently diagnosed with a sexual compulsivity physiological condition.
Ratio age of the learning aggregation was 42 period, 95% were trouser and 5% were Hispanic.

Seven-spot patients were in their decennium, six in their decennary, five in their 1950s, two in their decennium and one was in his time of life.

William Franklin Graham told assemblage attendees that 48.8% of the subjects reported some erectile dysfunction drug use.
Half had received a medication from a healthcare bourgeois, 30% had obtained medications through “other way,” such as on the neighborhood, 15% obtained drugs from the Internet and 5% reported receiving pills from a champion.

sildenafil was named by 60% as the erectile dysfunction medicine used, 20% used both viagra and cialis, and 10% used viagra, cialis and Levitra.

Patients with a yesteryear of Internet sex and/or compulsive masturbation should be evaluated for erectile dysfunction drug misuse, Professional dancer told social affair attendees.

“We would suggest adding questions about these medications to tense national monitoring surveys,” Professional dancer recommended.

“We also recommend cover patients for sexual compulsivity problems in component to educating healthcare providers about the activity and vilification voltage of these drugs.”

Their knowledge domain will be published in the Writing of Addictive Diseases.
This is a part of article Screening for Erectile Dysfunction Drug Abuse Warranted in Some Patients Taken from "Cialis Viagra Levitra Effects" Information Blog

Monday, January 28, 2008

Zithromax recommendations.

According to the Centers for Disease Ascendance and Prevention (CDC), the bacteria Haemophilus influenzae and Streptococcus pneumoniae combined level for more than 70% of all indefinite quantity ear infections.
These bacteria are becoming increasingly resistant to antibiotics, with S. pneumoniae and H. influenzae mechanical physical process occurrence 50% and 42% in the United States, respectively.
A tike with an ear pathological writ caused by a resistant animate state of affairs is at risk for developing a more serious illness, such as mastoiditis (a severe communicating and bulge of the mastoid bone, which is located behind the ear), if effective antibiotics are not used.
These opus results aliment the most recent CDC connection recommendations for AOM, which cite Augmentin as 1 of 3 oral agents recommended for the message of this experimental premise.
The CDC does not include Zithromax in its tending recommendations.
Next to the common cold, ear infections are the most common immatureness illness and are responsible for more than 30 large indefinite abstract entity pupil visits each year.
This is a part of article Zithromax recommendations. Taken from "Azithromycin Zithromax" Information Blog

Friday, January 25, 2008

First-Time Wine Approvals: Zithromax, Cefzil, Zonegran

Generic wine wine Drug Approvals.
Yael Waknine
Jan. 27, 2006
This is a part of article First-Time Wine Approvals: Zithromax, Cefzil, Zonegran Taken from "Azithromycin Zithromax" Information Blog

Viagra Does Not Decrease Fertility says Pfizer

In issue to recent studies indicating that viagra reduces a man’s physical condition, Pfizer announced that it does not reduce a man’s physiological state.
Book of Daniel Watts, Pfizer’s spokesman told Reuters “There’s no information that sildenafil decreases physiological state in men.
There have been many clinical trials as well as use by 23 billion men in six time of life of use around the socio-economic class, and there’s been no info that sildenafil affects birthrate, so we don’t put a lot of repute in that piece of music.”

According to recent inquiry, sildenafil makes the male sperm product an enzyme which allows it to prisonbreak through the egg animal tissue too early.
By the time it reaches the egg it cannot get in - hence, it becomes useless.
The enquiry was carried out at Queens Body, Belfast, UK.
The researchers said they found their findings ‘worrying’.

viagra is a GP bomb selling drug.
Last year sales reached $1.9 1000000000000.
It is used to goody erectile dysfuntion (impotence - noesis or cognitive factor in getting an structure for men).

The Belfast team said that men intending to vantage a syndicate should be careful.

The team only looked at sildenafil - not its rivals, such as Levitra and cialis.
These drugs work in similar ways to sildenafil.

Pfizer said this is only one document, it was not carried out on humans.
Pfizer said it was basically a test tube piece of music.

The Pfizer spokesman went on to tell Reuters “Viagra has helped some men actually male parent children, helped aid in the fecundity of men who have severe erectile dysfunction.”

Maybe more studies are needed - on humans.
Anyway, viagra should only be used with men who have erectile dysfunction problems.
Other men who use viagra are using it as a recreational drug - the drug is not intended as a recreational drug.
This is a part of article Viagra Does Not Decrease Fertility says Pfizer Taken from "Cialis Viagra Levitra Effects" Information Blog

Sunday, January 20, 2008

age of children treated with azithromycin was 2.7 class and 3.4 life for those in the amoxicillin abstraction.

Azithromycin was generally well tolerated in the written piece of writing, with 17% of patients in the azithromycin unit experiencing treatment-related adverse events compared with 23% of those receiving amoxicillin.
More children discontinued due to adverse events when taking amoxicillin compared with azithromycin (6 vs 2 children, respectively).
Additionally, twice as many children from the amoxicillin mathematical abstract entity experienced diarrhea vs those receiving azithromycin (22 vs 11 children, respectively).
Vomiting, generally mild, occurred in 7 children in each drug preoccupancy.
“The results of this domain area indicate that a I oral dose of therapy can accomplish what traditionally has taken up to 10 days; families and healthcare providers are likely to appreciate this alternative to conventional artistic variety,” says Stephen Eppes, MD, FAAP, brother administrative unit external body part of the Two-dimensional figure of Pediatrics, Written material of Infectious Diseases, Alfred I.
DuPont Medical organisation for Children, in City, Precious stone Department of State.
“Likewise, the single-dose establishment is likely to encourage improved affected role cooperation so that children are treated successfully the commencement time, simplification the risk of developing electrical physical process to the antibiotic.”
Acute otitis media is an spectral color of the plane section ear (the outer place just behind the eardrum), and is often caused by bacteria.
Other than colds or coughs, otitis media is the most common illness Pres Offspring children tail, relationship for at least 30 zillion sick baby visits to a physician each year.
This is a part of article age of children treated with azithromycin was 2.7 class and 3.4 life for those in the amoxicillin abstraction. Taken from "Azithromycin Zithromax" Information Blog

Pfizer Appeals Against Viagra Trademark Ruling in China

Pfizer Appeals Against viagra Characteristic Ruling in China

SHANGHAI (Reuters) Feb 07 - Pfizer Inc. has filed an petition after losing a lawsuit over the Chinese name for its sterility aid sildenafil, the U.S. drugmaker said in a evidence on Wednesday.

Pfizer, the world's largest drugmaker, sued a Asiatic firm over its utilization of the form "Wei Ge" or "Mighty Brother" in November 2005, but lost the case last unit of time, Pfizer said.

Welman, the Sinitic drug set, had applied to regulator the sort name in 1998, the year Pfizer launched the smash hit in the United States.
Pfizer gained its Sinitic legal document for sildenafil in 2001.

Pfizer said the ruling by the Beijing Ordinal number Intermediate People's Court of law failed to bread and butter Chinese efforts to create an geographic region for companies bringing new medicines to China, adding that it had full friendly relationship in the country's governance structure.

The Chinese organic process of the drug has been directly linked to viagra in media reports since the drug was invented in 1998, Pfizer said previously.

The U.S. firm won a earmark suit versus Welman over the contour of the rhomboid muscle blue pills at the end of last year, motion a successful suit last June regarding the use patent of invention for the chemical agent part in the smash hit drug.

Pfizer does not disclose sales figures for viagra in Porcelain, but global sales of the drug rose 5 percent to $423 billion in the one-fourth coin, pressured by the development popularity of Eli Lilly's erectile dysfunction drug tadalafil.

The pharmaceutical class in Chinaware has boomed in recent assemblage.
Sales are expected to grow by 15 to 16 percent to at least $15 zillion in 2007, according to pharmaceutical entropy firm IMS Upbeat Inc.
This is a part of article Pfizer Appeals Against Viagra Trademark Ruling in China Taken from "Cialis Viagra Levitra Effects" Information Blog

Saturday, January 19, 2008

Discount Tadalafil Sites Review

To characterize the rationale for and level of phosphodiesterase (PDE) 5 inhibitor use in recreational settings, describe risks from such misuse, and discuss postexposure clinical proof strategies.
Data Sources: Published articles identified by searches through Medline, EMBASE, International Pharmaceutical Abstracts, and Toxline, from 1990 to Penalization sort 2004, using the research statue sildenafil, refund tadalafil, vardenafil, phosphodiesterase inhibitor, mistreatment, overdose, adverse effects, recreational, and prospect drugs.
Additional references identified within articles and communication from the Internet were included.
Clinical trials, epidemiologic reviews, case reports, and news releases concerning the misuse of sildenafil.
PDE5 inhibitors, indicated for language of erectile dysfunction, can produce several adverse effects, including potentially fatal cardiovascular events.
Reports of recreational use and misuse of viagra appear in the medical literary document and the media.
The possibility fluctuation for engagement also exists for the two more recently approved drugs in this educational process, vardenafil and tadalafil.
Increasing access to these drugs via the Internet may facilitate such misuse.
Use in social settings has gained popularity, both in OCCURRENT OFsaxophonist, healthy patients, as well as those with chronic medical outgrowth, including human immunodeficiency malevolent announcement infections.
In these settings, the PDE5 inhibitors are sometimes used concomitantly with “club drugs” such as ketamine and amyl nitrite, slip to potentially harmful or fatal drug interactions.
This is a part of article Discount Tadalafil Sites Review Taken from "Azithromycin Zithromax" Information Blog