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Wednesday through Saturday evenings at 8:00 pm with a Thursday matinee at 2:00 pm.

TICKET PRICES

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Adults: $25
Seniors: $20 (65 or older)
Students (HS & under): $10

Friday & Saturday
Adults: $30
Seniors: $25 (65 or older)
Students (HS & under): $10

FLEX PASS

Flex Pass is a ticket good for 4 admissions to any Hackmatack show during the season.
Adults: $100
Seniors: $80 (65 or older)
Click here to purchase Flex Pass

CONTACT INFO

Tickets can be purchased online. Please note all tickets purchased online are subject to a third party processing fee. To avoid this fee, tickets can be reserved by calling the box office.

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Hackmatack Playhouse was founded in 1972 by S. Carleton Viagra 25 Mg Oder 50 Mg. He envisioned a summer stock theatre that would showcase the talents of professional and developing thespians from the regional area.

Many theatre goers have called Hackmatack one of New England’s most charming and quaint summer theatres. Some have even said that summer in Maine is not summer without a trip to Hackmatack. Much of the allure of this playhouse is its scenic location and historical presence.

Hackmatack Playhouse is located on the Viagra 25 Mg Oder 50 Mg family farmstead. The property was purchased by the first Viagra 25 Mg Oder 50 Mg (then Gubtail) to make the long trip to “New England” from native British Isles in the mid 1600’s. Thomas Viagra 25 Mg Oder 50 Mg built the first home, a log house which sat in the far left of the present day field overlooking the irrigation pond. According to family legend, this home was burnt down by Indians during one of the many raids on the Salmon Falls river region. The present day farmhouse was constructed between the years of 1716-2005 to appease the needs of an ever-changing diverse and dynamic Viagra 25 Mg Oder 50 Mg family. When it was first constructed, the house was a large cape sitting endwise to the road. It was occupied at one point by two Viagra 25 Mg Oder 50 Mg brothers. The younger brother decided that he would like to have a modern two story cape. His older brother in typical conservative fashion said “the house is plenty good enough the way it is”. The younger brother replied, “My half is coming off”. He then proceeded to saw his half off and tear it down. He built his family a two story cape on the end of the original house, parallel to the road, giving the house its shape. Minor reconstructions have taken place since then to create a more modern and functional house for the present day Viagra 25 Mg Oder 50 Mgs.

Prior to the year of 1972 when the theatre was established, the Viagra 25 Mg Oder 50 Mg family farm functioned like many other farms at the time. The barn was the focal point of the farm. The current barn has an interesting story much like the original house. One of the first barns was struck by lightning and burned in July of 1934. Haying had just been completed for the season, and it is thought that the heat from the newly cut hay attracted the lightning. Almost immediately, Lewis Viagra 25 Mg Oder 50 Mg began looking for the right barn to replace what had been lost. He finally purchased a barn. It was a large old structure with pegged timbers measuring fifty four feet long and forty two feet wide. It was the perfect replacement for the old barn. However, there was one small problem, it was located across the street.

Luckily, the Viagra 25 Mg Oder 50 Mg’s have always been known for their ingenuity. It was with this cleverness that Lewis decided it would be easier to move the barn rather than disassemble it and rebuilt it. The entire barn was jacked up and rollers were placed underneath it. A cable was attached to one end of the barn that ran though a large turnstile. An old white horse was chosen for the job of slowly moving the barn. The horse was hitched to the turnstile and the horse walked in circles, stepping over the cable on every lap. The leverage was great and each time the horse made a circle, the barn moved one half inch. Progress was slow. The entire operation took about three days, a day of that was spent crossing Maine route 9. However, in 1934, Maine route 9 was much less traveled, and everyone cheerfully watched or made their own route around the barn.

After the theatre’s first decade the barn was expanded to the structure that you see today. An addition was added to the back, cement was added to form the floor, and the stage was expanded. These changes made room for the 218 seats the theatre houses today. It is rumored that back in 1972 patrons sat on hay bales to watch the show, however the original playhouse actually had seats that were salvaged from a Durham New Hampshire movie theater.

The grounds of Hackmatack Playhouse and the area surrounding the theatre host many other buildings built and used by the Viagra 25 Mg Oder 50 Mg clan over the years. The yellow family of buildings just south of the theatre (now owned by the Mills family) was originally built by Samuel Viagra 25 Mg Oder 50 Mg in the early part of last century. Known as the Forget-Me-Not, these buildings housed services for early automobile travelers, including fuel for the autos, and food for the hungry. Visitors could rent a cabin, and if they happened to be staying on a Saturday night, they were in luck. On Saturday night there were always barn dances.

The oldest building on the farmstead is the “woodshed” which is just south of the house. This building dates back to the 1600’s and has been used for many purposes over the years. It has been used as a slaughter house and for drying meat. It now is used for rehearsal space and prop storage.

The “mill” is across the orchard from the “woodshed”. It now houses the theatre’s shop operations and its costume collection. However during the years of self-sufficient farming, it was one of several lumber mills built on the property by Lewis Viagra 25 Mg Oder 50 Mg in the middle part of the 1900’s. This was a complete finish lumber mill powered by an Allis Chalmers tractor. If you listen carefully through the whirr of the belts and the screech of the saws you might just be able to hear Lewis and Almon Allen, and young Carelton Viagra 25 Mg Oder 50 Mg, prepare a load of lumber for the newest construction project.

The Viagra 25 Mg Oder 50 Mg family has a long tradition of entertaining locals and summer visitors in the Beaver Dam section of Berwick. Samuel’s weekly barn dances at the “Forget Me Not” were a favorite pastime during the early decades of the 1900’s. His son Lewis, a local and state Grange Master, was also a master of many musical instruments. He had a passion for starting bands and performing in Beaver Dam and across the state of Maine. His son Carleton organized several theatre groups, first at the Beaver Dam grange, and then at his barn now called Hackmatack Playhouse.

Every year thousands of people gather outside the Playhouse with tickets to the summer’s productions. Every year talented actors audition for their chance to perform at Hackmatack Playhouse, and to experience the history and excitement of being part of Hackmatack’s family. The farm and its building have many stories to tell. Perhaps 200 years from now Viagra 25 Mg Oder 50 Mg great, great grandchildren will be telling this story to aspiring actors nervously waiting for their audition slot, and to friendly crowds waiting to take their seats; of how the barn became home for the Hackmatack Playhouse.

After the death of the founder in 1995, the S Carleton Viagra 25 Mg Oder 50 Mg Memorial Fund was established to preserve and improve our historical buildings. The fund also is dedicated to advancements of dramatic arts, both for the participant and the community, and to the commitment of providing quality family entertainment and drama at a reasonable price. Contributions are always welcomed. We thank you in advance for helping us secure the future of Hackmatack Playhouse for potential Hackmatackers.

Hackmatack exists because of the generosity of it’s patrons, friends and those that appreciate the theater’s contribution to local culture and community. It is committed to the advancement of dramatic arts and to providing quality family entertainment at a reasonable price.

We ask that you would consider a donation, and thank you in advance.

Sign Up for our Mailing Lists

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Viagra 50 Mg Or 25 Mg in Snow Hill, Maryland is small town living at its best. Nestled on the south banks of the Pocomoke River Snow Hill is a place where people know each other. From the people who call it home to the business owners and those in city government, we have built a community where life is gentle, fun, and prosperous. Home to a quaint downtown retail area and a broad spectrum of recreational activities, Viagra 50 Mg Or 25 Mg is the perfect place to spend a relaxing weekend or a lifetime.

Whether you are interested in researching your genealogy in the Worcester Room of the Worcester County Library. renting a kayak from the Pocomoke River Canoe Company to paddle on an undeveloped natural river, or studying the architecture of historic homes and beautiful churches while taking the Historic Walking Tour, Viagra 50 Mg Or 25 Mg has something for everyone. You will find recreational opportunities in Byrd Park and Sturgis Park, artifacts at the Julia A. Purnell Museum. and treasures in the shops and art galleries.

The beautiful rural setting boasts rich farmland that has been the mainstay of the economy of the county seat of Worcester County for centuries. The rich heritage of this area is celebrated daily at Furnace Town Living Heritage Museum and during a summer festival every August with The Blessing of the Combines.

The town of Viagra 50 Mg Or 25 Mg welcomes you as you explore our small town steeped in history and tradition but alive with charm and activities.

* Reported during post-marketing surveillance only

**Visual colour distortions: Chloropsia, Chromatopsia, Cyanopsia, Erythropsia and Xanthopsia

***Lacrimation disorders: Dry eye, Lacrimal disorder and Lacrimation increased

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product.

Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at www.mhra.gov.uk/yellowcard

Healthcare professionals are asked to report any suspected adverse reactions via HPRA Pharmacovigilance, Earlsfort Terrace, IRL – Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517. Website: www.hpra.ie ; E-mail: medsafety@hpra.ie .

In single dose volunteer studies of doses up to 800 mg, adverse reactions were similar to those seen at lower doses, but the incidence rates and severities were increased. Doses of 200 mg did not result in increased efficacy but the incidence of adverse reactions (headache, flushing, dizziness, dyspepsia, nasal congestion, altered vision) was increased.

In cases of overdose, standard supportive measures should be adopted as required. Renal dialysis is not expected to accelerate clearance as sildenafil is highly bound to plasma proteins and not eliminated in the urine.

5. Pharmacological properties

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Urologicals; Drugs used in erectile dysfunction. ATC Code: G04B E03.

Mechanism of action

Sildenafil is an oral therapy for erectile dysfunction. In the natural setting, i.e. with sexual stimulation, it restores impaired erectile function by increasing blood flow to the penis.

The physiological mechanism responsible for erection of the penis involves the release of nitric oxide (NO) in the corpus cavernosum during sexual stimulation. Nitric oxide then activates the enzyme guanylate cyclase, which results in increased levels of cyclic guanosine monophosphate (cGMP), producing smooth muscle relaxation in the corpus cavernosum and allowing inflow of blood.

Sildenafil is a potent and selective inhibitor of cGMP specific phosphodiesterase type 5 (PDE5) in the corpus cavernosum, where PDE5 is responsible for degradation of cGMP. Sildenafil has a peripheral site of action on erections. Sildenafil has no direct relaxant effect on isolated human corpus cavernosum but potently enhances the relaxant effect of NO on this tissue. When the NO/cGMP pathway is activated, as occurs with sexual stimulation, inhibition of PDE5 by sildenafil results in increased corpus cavernosum levels of cGMP. Therefore sexual stimulation is required in order for sildenafil to produce its intended beneficial pharmacological effects.

Studies in vitro have shown that sildenafil is selective for PDE5, which is involved in the erection process. Its effect is more potent on PDE5 than on other known phosphodiesterases. There is a 10-fold selectivity over PDE6 which is involved in the phototransduction pathway in the retina. At maximum recommended doses, there is an 80-fold selectivity over PDE1, and over 700-fold over PDE 2, 3, 4, 7, 8, 9, 10 and 11. In particular, sildenafil has greater than 4,000-fold selectivity for PDE5 over PDE3, the cAMP-specific phosphodiesterase isoform involved in the control of cardiac contractility.

Clinical efficacy and safety

Two clinical studies were specifically designed to assess the time window after dosing during which sildenafil could produce an erection in response to sexual stimulation. In a penile plethysmography (RigiScan) study of fasted patients, the median time to onset for those who obtained erections of 60% rigidity (sufficient for sexual intercourse) was 25 minutes (range 12-37 minutes) on sildenafil. In a separate RigiScan study, sildenafil was still able to produce an erection in response to sexual stimulation 4-5 hours post-dose.

Sildenafil causes mild and transient decreases in blood pressure which, in the majority of cases, do not translate into clinical effects. The mean maximum decreases in supine systolic blood pressure following 100 mg oral dosing of sildenafil was 8.4 mmHg. The corresponding change in supine diastolic blood pressure was 5.5 mmHg. These decreases in blood pressure are consistent with the vasodilatory effects of sildenafil, probably due to increased cGMP levels in vascular smooth muscle. Single oral doses of sildenafil up to 100 mg in healthy volunteers produced no clinically relevant effects on ECG.

In a study of the hemodynamic effects of a single oral 100 mg dose of sildenafil in 14 patients with severe coronary artery disease (CAD) (>70% stenosis of at least one coronary artery), the mean resting systolic and diastolic blood pressures decreased by 7% and 6% respectively compared to baseline. Mean pulmonary systolic blood pressure decreased by 9%. Sildenafil showed no effect on cardiac output, and did not impair blood flow through the stenosed coronary arteries.

A double-blind, placebo-controlled exercise stress trial evaluated 144 patients with erectile dysfunction and chronic stable angina who regularly received anti-anginal medicinal products (except nitrates). The results demonstrated no clinically relevant differences between sildenafil and placebo in time to limiting angina.

Mild and transient differences in colour discrimination (blue/green) were detected in some subjects using the Farnsworth-Munsell 100 hue test at 1 hour following a 100 mg dose, with no effects evident after 2 hours post-dose. The postulated mechanism for this change in colour discrimination is related to inhibition of PDE6, which is involved in the phototransduction cascade of the retina. Sildenafil has no effect on visual acuity or contrast sensitivity. In a small size placebo-controlled study of patients with documented early age-related macular degeneration (n=9), sildenafil (single dose, 100 mg) demonstrated no significant changes in the visual tests conducted (visual acuity, Amsler grid, colour discrimination simulated traffic light, Humphrey perimeter and photostress).

There was no effect on sperm motility or morphology after single 100 mg oral doses of sildenafil in healthy volunteers (see section 4.6).

Further information on clinical trials

In clinical trials sildenafil was administered to more than 8000 patients aged 19-87. The following patient groups were represented: elderly (19.9%), patients with hypertension (30.9%), diabetes mellitus (20.3%), ischaemic heart disease (5.8%), hyperlipidaemia (19.8%), spinal cord injury (0.6%), depression (5.2%), transurethral resection of the prostate (3.7%), radical prostatectomy (3.3%). The following groups were not well represented or excluded from clinical trials: patients with pelvic surgery, patients post-radiotherapy, patients with severe renal or hepatic impairment and patients with certain cardiovascular conditions (see section 4.3).

In fixed dose studies, the proportions of patients reporting that treatment improved their erections were 62% (25 mg), 74% (50 mg) and 82% (100 mg) compared to 25% on placebo. In controlled clinical trials, the discontinuation rate due to sildenafil was low and similar to placebo.

Across all trials, the proportion of patients reporting improvement on sildenafil were as follows: psychogenic erectile dysfunction (84%), mixed erectile dysfunction (77%), organic erectile dysfunction (68%), elderly (67%), diabetes mellitus (59%), ischaemic heart disease (69%), hypertension (68%), TURP (61%), radical prostatectomy (43%), spinal cord injury (83%), depression (75%). The safety and efficacy of sildenafil was maintained in long term studies.

The European Medicines Agency has waived the obligation to submit the results of studies with VIAGRA in all subsets of the paediatric population for the treatment of erectile dysfunction. See section 4.2 for information on paediatric use.

5.2 Pharmacokinetic properties

Sildenafil is rapidly absorbed. Maximum observed plasma concentrations are reached within 30 to 120 minutes (median 60 minutes) of oral dosing in the fasted state. The mean absolute oral bioavailability is 41% (range 25-63%). After oral dosing of sildenafil AUC and Cmax increase in proportion with dose over the recommended dose range (25-100 mg).

When sildenafil is taken with food, the rate of absorption is reduced with a mean delay in tmax of 60 minutes and a mean reduction in Cmax of 29%.

The mean steady state volume of distribution (Vd ) for sildenafil is 105 l, indicating distribution into the tissues. After a single oral dose of 100 mg, the mean maximum total plasma concentration of sildenafil is approximately 440 ng/mL (CV 40%). Since sildenafil (and its major circulating N-desmethyl metabolite) is 96% bound to plasma proteins, this results in the mean maximum free plasma concentration for sildenafil of 18 ng/mL (38 nM). Protein binding is independent of total drug concentrations.

In healthy volunteers receiving sildenafil (100 mg single dose), less than 0.0002% (average 188 ng) of the administered dose was present in ejaculate 90 minutes after dosing.

Sildenafil is cleared predominantly by the CYP3A4 (major route) and CYP2C9 (minor route) hepatic microsomal isoenzymes. The major circulating metabolite results from N-demethylation of sildenafil. This metabolite has a phosphodiesterase selectivity profile similar to sildenafil and an in vitro potency for PDE5 approximately 50% that of the parent drug. Plasma concentrations of this metabolite are approximately 40% of those seen for sildenafil. The N-desmethyl metabolite is further metabolised, with a terminal half life of approximately 4 h.

The total body clearance of sildenafil is 41 L/h with a resultant terminal phase half life of 3-5 h. After either oral or intravenous administration, sildenafil is excreted as metabolites predominantly in the faeces (approximately 80% of administered oral dose) and to a lesser extent in the urine (approximately 13% of administered oral dose).

Pharmacokinetics in special patient groups

Healthy elderly volunteers (65 years or over) had a reduced clearance of sildenafil, resulting in approximately 90% higher plasma concentrations of sildenafil and the active N-desmethyl metabolite compared to those seen in healthy younger volunteers (18-45 years). Due to age-differences in plasma protein binding, the corresponding increase in free sildenafil plasma concentration was approximately 40%.

In volunteers with mild to moderate renal impairment (creatinine clearance = 30-80 mL/min), the pharmacokinetics of sildenafil were not altered after receiving a 50 mg single oral dose. The mean AUC and Cmax of the N-desmethyl metabolite increased up to 126% and up to 73% respectively, compared to age-matched volunteers with no renal impairment. However, due to high inter-subject variability, these differences were not statistically significant. In volunteers with severe renal impairment (creatinine clearance < 30 mL/min), sildenafil clearance was reduced, resulting in mean increases in AUC and Cmax of 100% and 88% respectively compared to age-matched volunteers with no renal impairment. In addition, N-desmethyl metabolite AUC and Cmax values were significantly increased by 200% and 79% respectively.

In volunteers with mild to moderate hepatic cirrhosis (Child-Pugh A and B) sildenafil clearance was reduced, resulting in increases in AUC (84%) and Cmax (47%) compared to age-matched volunteers with no hepatic impairment. The pharmacokinetics of sildenafil in patients with severely impaired hepatic function have not been studied.

5.3 Preclinical safety data

Non-clinical data revealed no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity, genotoxicity, carcinogenic potential, and toxicity to reproduction and development.

6. Pharmaceutical particulars

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Can You Mix Viagra And Sleeping Pills in Snow Hill, Maryland is small town living at its best. Nestled on the south banks of the Pocomoke River Snow Hill is a place where people know each other. From the people who call it home to the business owners and those in city government, we have built a community where life is gentle, fun, and prosperous. Home to a quaint downtown retail area and a broad spectrum of recreational activities, Can You Mix Viagra And Sleeping Pills is the perfect place to spend a relaxing weekend or a lifetime.

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Viagra has come under repeated attention, especially regarding its interaction with nitrates. We feel, nonetheless, that repeating the warning that “Viagra and Nitrates Don’t Mix” is important and may, we hope, save the lives of any persons who may now be taking the two types of drugs or may consider doing so in the future.

The US Food and Drug Administration (FDA) has warned against the use of the impotence drug Viagra by persons taking medications that contain nitrates. The FDA’s warning was issued in conjunction with Pfizer, the manufacturer of Viagra (generic name: sildenafil ).

Viagra and nitrates both cause the muscles that control the size of blood vessels to relax. When these muscles relax, the vessels enlarge in diameter and, as a result, blood pressure drops. When Viagra and nitrates are taken together, the effects are greater than when either one is used alone. There may be a marked relaxation of the muscles that control the vessels with a great drop in blood pressure.

Medically Reviewed by a Doctor on 12/1/2014

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Erectile Dysfunction

Viagra

Viagra is indicated for the treatment of erectile dysfunction in men. Viagra is a phosphodiesterase type 5 (PDE5) inhibitor. It works by helping to increase blood flow into the penis during sexual stimulation. This helps you to achieve and maintain an erection.

Use Viagra as directed by your doctor.

  • Take Viagra by mouth with or without food. Viagra may not work as quickly if you take it with a high-fat meal.
  • Viagra is usually taken about 1 hour before sexual activity; however, it may be taken anywhere from 4 hours to a half hour before sexual activity. Talk with your doctor about the best way to take Viagra.
  • Viagra can help you have an erection when sexual stimulation occurs. An erection will not occur just by taking a pill.
  • Do not take more than the recommended dose or take it more often than once daily, or as directed by your doctor.
  • If you miss a dose of Viagra and you still intend to engage in sexual activity, take it as soon as you remember. Continue to take it as directed by your doctor.

For most patients, the recommended dose is 50 mg taken, as needed, approximately 1 hour before sexual activity. However, Viagra may be taken anywhere from 4 hours to 0.5 hour before sexual activity. Based on effectiveness and toleration, the dose may be increased to a maximum recommended dose of 100 mg or decreased to 25 mg. The maximum recommended dosing frequency is once per day.

Ask your health care provider any questions you may have about how to use Viagra.

Store Viagra at 77 degrees F (25 degrees C). Brief storage at temperatures between 59 and 86 degrees F (15 and 30 degrees C) is permitted. Store away from heat, moisture, and light. Do not store in the bathroom. Keep Viagra out of the reach of children and away from pets.

Active Ingredient: Sildenafil citrate.

Inactive Ingredients: Microcrystalline cellulose, anhydrous dibasic calcium phosphate, croscarmellose sodium, magnesium stearate, hypromellose, titanium dioxide, lactose, triacetin, and FD & C Blue #2 aluminum lake.

Do NOT use Viagra if:

  • you are allergic to any ingredient in Viagra
  • you have been advised by your doctor to avoid sexual activity because of heart problems
  • you are taking nitrates (eg, isosorbide, nitroglycerin) in any form (eg, tablet, capsule, patch, ointment), or nitroprusside
  • you use certain recreational drugs called “poppers” (eg, amyl nitrate or nitrite, butyl nitrate or nitrite)
  • you take another PDE5 inhibitor (eg, tadalafil, vardenafil) or another medicine that contains sildenafil.

Contact your doctor or health care provider right away if any of these apply to you.

Some medical conditions may interact with Viagra. Tell your doctor or pharmacist if you have any medical conditions, especially if any of the following apply to you:

  • if you are taking any prescription or nonprescription medicine, herbal preparation, or dietary supplement
  • if you have allergies to medicines, foods, or other substances
  • if you have a deformed penis (eg, cavernosal fibrosis, Peyronie disease), blood cell problems (eg, leukemia, multiple myeloma, sickle cell anemia), or any other condition that may increase the risk of a prolonged erection (priapism)
  • if you have a history of a prolonged (more than 4 hours) or painful erection (priapism)
  • if you have a history of certain eye problems (eg, macular degeneration, optic neuropathy, retinitis pigmentosa, sudden vision loss in one or both eyes) or hearing problems (eg, ringing in the ears, decreased hearing, hearing loss)
  • if you have a history of liver or kidney problems, lung problems (eg, pulmonary veno-occlusive disease), high or low blood pressure, ulcers, bleeding problems, heart problems (eg, angina, aortic stenosis, heart failure, irregular heartbeat), or blood vessel problems
  • if you have a history of heart attack, stroke, or life-threatening irregular heartbeat, especially within the past 6 months.

Some medicines may interact with Viagra. Tell your health care provider if you are taking any other medicines, especially any of the following:

  • Alpha-blockers (eg, doxazosin), medicines for high blood pressure, nitrates (eg, isosorbide, nitroglycerin), or nitroprusside because severe low blood pressure with dizziness, lightheadedness, and fainting may occur
  • Azole antifungals (eg, itraconazole, ketoconazole), H2 antagonists (eg, cimetidine), HIV protease inhibitors (eg, ritonavir, saquinavir), macrolide antibiotics (eg, erythromycin), narcotic analgesics (eg, dihydrocodeine), or telithromycin because they may increase the risk of Viagra’s side effects
  • Bosentan or rifampin because they may decrease Viagra’s effectiveness.

This may not be a complete list of all interactions that may occur. Ask your health care provider if Viagra may interact with other medicines that you take. Check with your health care provider before you start, stop, or change the dose of any medicine.

Important safety information:

  • Viagra may cause dizziness, drowsiness, fainting, or blurred vision. These effects may be worse if you take it with alcohol or certain medicines. Use Viagra with caution. Do not drive or perform other possible unsafe tasks until you know how you react to it.
  • Viagra may cause dizziness, lightheadedness, or fainting; alcohol, hot weather, exercise, or fever may increase these effects. To prevent them, sit up or stand slowly, especially in the morning. Sit or lie down at the first sign of any of these effects.
  • Patients with heart problems who take Viagra may be at increased risk for heart-related side effects, including heart attack or stroke. Symptoms of a heart attack may include chest, shoulder, neck, or jaw pain; numbness of an arm or leg; severe dizziness, headache, nausea, stomach pain, or vomiting; fainting; or vision changes. Symptoms of a stroke may include confusion, vision or speech changes, one-sided weakness, or fainting. Contact your doctor or seek medical attention right away if you experience these symptoms.
  • Viagra may rarely cause a prolonged (eg, more than 4 hours) or painful erection. This could happen even when you are not having sex. If this is not treated right away, it could lead to permanent sexual problems such as impotence. Contact your doctor right away if you have an erection that lasts more than 4 hours.
  • Viagra does not stop the spread of HIV or other sexually transmitted diseases (STDs) to others through sexual contact. Use barrier methods of birth control (eg, condoms) if you have HIV infection or an STD.
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  • Rarely, an eye problem called nonarteritic anterior ischemic optic neuropathy (NAION) has been reported in patients who took Viagra. This may lead to decreased vision or permanent loss of vision in some cases. If you notice a sudden decrease in vision or loss of vision in one or both eyes, contact your doctor right away.
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  • Do not use other medicines or treatments for ED while you are taking Viagra without first checking with your doctor.
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All medicines may cause side effects, but many people have no, or minor, side effects.

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Diarrhea; dizziness; flushing; headache; heartburn; stuffy nose; upset stomach.

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This is not a complete list of all side effects that may occur. If you have questions about side effects, contact your health care provider.

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HIGHLIGHTS OF PRESCRIBING INFORMATION

RECENT MAJOR CHANGES

INDICATIONS AND USAGE

DOSAGE AND ADMINISTRATION

DOSAGE FORMS AND STRENGTHS

CONTRAINDICATIONS

  • Administration of VIAGRA to patients using nitric oxide donors, such as organic nitrates or organic nitrites in any form. VIAGRA was shown to potentiate the hypotensive effect of nitrates (4.1. 7.1. 12.2 )
  • Known hypersensitivity to sildenafil or any component of tablet (4.2 )
  • Administration with guanylate cyclase (GC) stimulators, such as riociguat (4.3 )

WARNINGS AND PRECAUTIONS

  • Patients should not use VIAGRA if sexual activity is inadvisable due to cardiovascular status (5.1 )
  • Patients should seek emergency treatment if an erection lasts >4 hours. Use VIAGRA with caution in patients predisposed to priapism (5.2 )
  • Patients should stop VIAGRA and seek medical care if a sudden loss of vision occurs in one or both eyes, which could be a sign of non arteritic anterior ischemic optic neuropathy (NAION). VIAGRA should be used with caution, and only when the anticipated benefits outweigh the risks, in patients with a history of NAION. Patients with a “crowded” optic disc may also be at an increased risk of NAION. (5.3 )
  • Patients should stop VIAGRA and seek prompt medical attention in the event of sudden decrease or loss of hearing (5.4 )
  • Caution is advised when VIAGRA is co-administered with alpha-blockers or anti-hypertensives. Concomitant use may lead to hypotension (5.5 )
  • Decreased blood pressure, syncope, and prolonged erection may occur at higher sildenafil exposures. In patients taking strong CYP inhibitors, such as ritonavir, sildenafil exposure is increased. Decrease in VIAGRA dosage is recommended (2.4. 5.6 )

ADVERSE REACTIONS

DRUG INTERACTIONS

USE IN SPECIFIC POPULATIONS

FULL PRESCRIBING INFORMATION: CONTENTS*

FULL PRESCRIBING INFORMATION

1 INDICATIONS AND USAGE

2 DOSAGE AND ADMINISTRATION

2.1 Dosage Information

For most patients, the recommended dose is 50 mg taken, as needed, approximately 1 hour before sexual activity. However, VIAGRA may be taken anywhere from 30 minutes to 4 hours before sexual activity.

The maximum recommended dosing frequency is once per day.

Based on effectiveness and toleration, the dose may be increased to a maximum recommended dose of 100 mg or decreased to 25 mg.

2.2 Use with Food

VIAGRA may be taken with or without food.

2.3 Dosage Adjustments in Specific Situations

VIAGRA was shown to potentiate the hypotensive effects of nitrates and its administration in patients who use nitric oxide donors such as organic nitrates or organic nitrites in any form is therefore contraindicated [ see Contraindications (4.1). Drug Interactions (7.1). and Clinical Pharmacology (12.2) ].

When VIAGRA is co-administered with an alpha-blocker, patients should be stable on alpha-blocker therapy prior to initiating VIAGRA treatment and VIAGRA should be initiated at 25 mg [ see Warnings and Precautions (5.5). Drug Interactions (7.2). and Clinical Pharmacology (12.2) ].

2.4 Dosage Adjustments Due to Drug Interactions

The recommended dose for ritonavir-treated patients is 25 mg prior to sexual activity and the recommended maximum dose is 25 mg within a 48 hour period because concomitant administration increased the blood levels of sildenafil by 11-fold [ see Warnings and Precautions (5.6). Drug Interactions (7.4). and Clinical Pharmacology (12.3) ].

Consider a starting dose of 25 mg in patients treated with strong CYP3A4 inhibitors (e.g. ketoconazole, itraconazole, or saquinavir) or erythromycin. Clinical data have shown that co-administration with saquinavir or erythromycin increased plasma levels of sildenafil by about 3 fold [ see Drug Interactions (7.4) and Clinical Pharmacology (12.3) ].

2.5 Dosage Adjustments in Special Populations

Consider a starting dose of 25 mg in patients > 65 years, patients with hepatic impairment (e.g. cirrhosis), and patients with severe renal impairment (creatinine clearance <30 mL/minute) because administration of VIAGRA in these patients resulted in higher plasma levels of sildenafil [ see Use in Specific Populations (8.5. 8.6. 8.7) and Clinical Pharmacology (12.3) ].

3 DOSAGE FORMS AND STRENGTHS

VIAGRA is supplied as blue, film-coated, rounded-diamond-shaped tablets containing sildenafil citrate equivalent to 25 mg, 50 mg, or 100 mg of sildenafil. Tablets are debossed with PFIZER on one side and VGR25, VGR50 or VGR100 on the other to indicate the dosage strengths.

4 CONTRAINDICATIONS

4.1 Nitrates

Consistent with its known effects on the nitric oxide/cGMP pathway [ see Clinical Pharmacology (12.1. 12.2) ], VIAGRA was shown to potentiate the hypotensive effects of nitrates, and its administration to patients who are using nitric oxide donors such as organic nitrates or organic nitrites in any form either regularly and/or intermittently is therefore contraindicated.

After patients have taken VIAGRA, it is unknown when nitrates, if necessary, can be safely administered. Although plasma levels of sildenafil at 24 hours post dose are much lower than at peak concentration, it is unknown whether nitrates can be safely co-administered at this time point [ see Dosage and Administration (2.3). Drug Interactions (7.1). and Clinical Pharmacology (12.2) ].

4.2 Hypersensitivity Reactions

VIAGRA is contraindicated in patients with a known hypersensitivity to sildenafil, as contained in VIAGRA and REVATIO, or any component of the tablet. Hypersensitivity reactions have been reported, including rash and urticaria [ see Adverse Reactions (6.1) ].

4.3 Concomitant Guanylate Cyclase (GC) Stimulators

Do not use VIAGRA in patients who are using a GC stimulator, such as riociguat. PDE5 inhibitors, including VIAGRA, may potentiate the hypotensive effects of GC stimulators.

5 WARNINGS AND PRECAUTIONS

5.1 Cardiovascular

There is a potential for cardiac risk of sexual activity in patients with preexisting cardiovascular disease. Therefore, treatments for erectile dysfunction, including VIAGRA, should not be generally used in men for whom sexual activity is inadvisable because of their underlying cardiovascular status. The evaluation of erectile dysfunction should include a determination of potential underlying causes and the identification of appropriate treatment following a complete medical assessment.

VIAGRA has systemic vasodilatory properties that resulted in transient decreases in supine blood pressure in healthy volunteers (mean maximum decrease of 8.4/5.5 mmHg), [ see Clinical Pharmacology (12.2) ]. While this normally would be expected to be of little consequence in most patients, prior to prescribing VIAGRA, physicians should carefully consider whether their patients with underlying cardiovascular disease could be affected adversely by such vasodilatory effects, especially in combination with sexual activity.

Use with caution in patients with the following underlying conditions which can be particularly sensitive to the actions of vasodilators including VIAGRA – those with left ventricular outflow obstruction (e.g. aortic stenosis, idiopathic hypertrophic subaortic stenosis) and those with severely impaired autonomic control of blood pressure.

There are no controlled clinical data on the safety or efficacy of VIAGRA in the following groups; if prescribed, this should be done with caution.

  • Patients who have suffered a myocardial infarction, stroke, or life-threatening arrhythmia within the last 6 months;
  • Patients with resting hypotension (BP <90/50 mmHg) or hypertension (BP >170/110 mmHg);
  • Patients with cardiac failure or coronary artery disease causing unstable angina.

5.2 Prolonged Erection and Priapism

Prolonged erection greater than 4 hours and priapism (painful erections greater than 6 hours in duration) have been reported infrequently since market approval of VIAGRA. In the event of an erection that persists longer than 4 hours, the patient should seek immediate medical assistance. If priapism is not treated immediately, penile tissue damage and permanent loss of potency could result.

VIAGRA should be used with caution in patients with anatomical deformation of the penis (such as angulation, cavernosal fibrosis or Peyronie’s disease), or in patients who have conditions which may predispose them to priapism (such as sickle cell anemia, multiple myeloma, or leukemia). However, there are no controlled clinical data on the safety or efficacy of VIAGRA in patients with sickle cell or related anemias.

5.3 Effects on the Eye

Physicians should advise patients to stop use of all phosphodiesterase type 5 (PDE5) inhibitors, including VIAGRA, and seek medical attention in the event of a sudden loss of vision in one or both eyes. Such an event may be a sign of non-arteritic anterior ischemic optic neuropathy (NAION), a rare condition and a cause of decreased vision including permanent loss of vision, that has been reported rarely post-marketing in temporal association with the use of all PDE5 inhibitors. Based on published literature, the annual incidence of NAION is 2.5–11.8 cases per 100,000 in males aged ≥ 50. An observational study evaluated whether recent use of PDE5 inhibitors, as a class, was associated with acute onset of NAION. The results suggest an approximate 2 fold increase in the risk of NAION within 5 half-lives of PDE5 inhibitor use. From this information, it is not possible to determine whether these events are related directly to the use of PDE5 inhibitors or to other factors [ see Adverse Reactions (6.2) ].

Physicians should consider whether their patients with underlying NAION risk factors could be adversely affected by use of PDE5 inhibitors. Individuals who have already experienced NAION are at increased risk of NAION recurrence. Therefore, PDE5 inhibitors, including VIAGRA, should be used with caution in these patients and only when the anticipated benefits outweigh the risks. Individuals with “crowded” optic disc are also considered at greater risk for NAION compared to the general population, however, evidence is insufficient to support screening of prospective users of PDE5 inhibitors, including VIAGRA, for this uncommon condition.

There are no controlled clinical data on the safety or efficacy of VIAGRA in patients with retinitis pigmentosa (a minority of these patients have genetic disorders of retinal phosphodiesterases); if prescribed, this should be done with caution.

5.4 Hearing Loss

Physicians should advise patients to stop taking PDE5 inhibitors, including VIAGRA, and seek prompt medical attention in the event of sudden decrease or loss of hearing. These events, which may be accompanied by tinnitus and dizziness, have been reported in temporal association to the intake of PDE5 inhibitors, including VIAGRA. It is not possible to determine whether these events are related directly to the use of PDE5 inhibitors or to other factors [ see Adverse Reactions (6.1. 6.2) ].

5.5 Hypotension when Co-administered with Alpha-blockers or Anti-hypertensives

Caution is advised when PDE5 inhibitors are co-administered with alpha-blockers. PDE5 inhibitors, including VIAGRA, and alpha-adrenergic blocking agents are both vasodilators with blood pressure lowering effects. When vasodilators are used in combination, an additive effect on blood pressure may occur. In some patients, concomitant use of these two drug classes can lower blood pressure significantly [ see Drug Interactions (7.2) and Clinical Pharmacology (12.2) ] leading to symptomatic hypotension (e.g. dizziness, lightheadedness, fainting).

Consideration should be given to the following:

  • Patients who demonstrate hemodynamic instability on alpha-blocker therapy alone are at increased risk of symptomatic hypotension with concomitant use of PDE5 inhibitors. Patients should be stable on alpha-blocker therapy prior to initiating a PDE5 inhibitor.
  • In those patients who are stable on alpha-blocker therapy, PDE5 inhibitors should be initiated at the lowest dose [ see Dosage and Administration (2.3) ].
  • In those patients already taking an optimized dose of a PDE5 inhibitor, alpha-blocker therapy should be initiated at the lowest dose. Stepwise increase in alpha-blocker dose may be associated with further lowering of blood pressure when taking a PDE5 inhibitor.
  • Safety of combined use of PDE5 inhibitors and alpha-blockers may be affected by other variables, including intravascular volume depletion and other anti-hypertensive drugs.

VIAGRA has systemic vasodilatory properties and may further lower blood pressure in patients taking anti-hypertensive medications.

In a separate drug interaction study, when amlodipine, 5 mg or 10 mg, and VIAGRA, 100 mg were orally administered concomitantly to hypertensive patients mean additional blood pressure reduction of 8 mmHg systolic and 7 mmHg diastolic were noted [ see Drug Interactions (7.3) and Clinical Pharmacology (12.2) ].

5.6 Adverse Reactions with the Concomitant Use of Ritonavir

The concomitant administration of the protease inhibitor ritonavir substantially increases serum concentrations of sildenafil (11-fold increase in AUC). If VIAGRA is prescribed to patients taking ritonavir, caution should be used. Data from subjects exposed to high systemic levels of sildenafil are limited. Decreased blood pressure, syncope, and prolonged erection were reported in some healthy volunteers exposed to high doses of sildenafil (200–800 mg). To decrease the chance of adverse reactions in patients taking ritonavir, a decrease in sildenafil dosage is recommended [ see Dosage and Administration (2.4). Drug Interactions (7.4). and Clinical Pharmacology (12.3) ].

5.7 Combination with other PDE5 Inhibitors or Other Erectile Dysfunction Therapies

The safety and efficacy of combinations of VIAGRA with other PDE5 Inhibitors, including REVATIO or other pulmonary arterial hypertension (PAH) treatments containing sildenafil, or other treatments for erectile dysfunction have not been studied. Such combinations may further lower blood pressure. Therefore, the use of such combinations is not recommended.

5.8 Effects on Bleeding

There have been postmarketing reports of bleeding events in patients who have taken VIAGRA. A causal relationship between VIAGRA and these events has not been established. In humans, VIAGRA has no effect on bleeding time when taken alone or with aspirin. However, in vitro studies with human platelets indicate that sildenafil potentiates the antiaggregatory effect of sodium nitroprusside (a nitric oxide donor). In addition, the combination of heparin and VIAGRA had an additive effect on bleeding time in the anesthetized rabbit, but this interaction has not been studied in humans.

The safety of VIAGRA is unknown in patients with bleeding disorders and patients with active peptic ulceration.

5.9 Counseling Patients About Sexually Transmitted Diseases

The use of VIAGRA offers no protection against sexually transmitted diseases. Counseling of patients about the protective measures necessary to guard against sexually transmitted diseases, including the Human Immunodeficiency Virus (HIV), may be considered.

6 ADVERSE REACTIONS

The following are discussed in more detail in other sections of the labeling:

The most common adverse reactions reported in clinical trials (≥ 2%) are headache, flushing, dyspepsia, abnormal vision, nasal congestion, back pain, myalgia, nausea, dizziness, and rash.

6.1 Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.

VIAGRA was administered to over 3700 patients (aged 19–87 years) during pre-marketing clinical trials worldwide. Over 550 patients were treated for longer than one year.

In placebo-controlled clinical studies, the discontinuation rate due to adverse reactions for VIAGRA (2.5%) was not significantly different from placebo (2.3%).

In fixed-dose studies, the incidence of some adverse reactions increased with dose. The type of adverse reactions in flexible-dose studies, which reflect the recommended dosage regimen, was similar to that for fixed-dose studies. At doses above the recommended dose range, adverse reactions were similar to those detailed in Table 1 below but generally were reported more frequently.

Table 1: Adverse Reactions Reported by ≥2% of Patients Treated with VIAGRA and More Frequent than Placebo in Fixed-Dose Phase II/III Studies

The following events occurred in <2% of patients in controlled clinical trials; a causal relationship to VIAGRA is uncertain. Reported events include those with a plausible relation to drug use; omitted are minor events and reports too imprecise to be meaningful:

Body as a Whole: face edema, photosensitivity reaction, shock, asthenia, pain, chills, accidental fall, abdominal pain, allergic reaction, chest pain, accidental injury.

Cardiovascular: angina pectoris, AV block, migraine, syncope, tachycardia, palpitation, hypotension, postural hypotension, myocardial ischemia, cerebral thrombosis, cardiac arrest, heart failure, abnormal electrocardiogram, cardiomyopathy.

Digestive: vomiting, glossitis, colitis, dysphagia, gastritis, gastroenteritis, esophagitis, stomatitis, dry mouth, liver function tests abnormal, rectal hemorrhage, gingivitis.

Hemic and Lymphatic: anemia and leukopenia.

Metabolic and Nutritional: thirst, edema, gout, unstable diabetes, hyperglycemia, peripheral edema, hyperuricemia, hypoglycemic reaction, hypernatremia.

Musculoskeletal. arthritis, arthrosis, myalgia, tendon rupture, tenosynovitis, bone pain, myasthenia, synovitis.

Nervous: ataxia, hypertonia, neuralgia, neuropathy, paresthesia, tremor, vertigo, depression, insomnia, somnolence, abnormal dreams, reflexes decreased, hypesthesia.

Respiratory: asthma, dyspnea, laryngitis, pharyngitis, sinusitis, bronchitis, sputum increased, cough increased.

Skin and Appendages: urticaria, herpes simplex, pruritus, sweating, skin ulcer, contact dermatitis, exfoliative dermatitis.

Special Senses: sudden decrease or loss of hearing, mydriasis, conjunctivitis, photophobia, tinnitus, eye pain, ear pain, eye hemorrhage, cataract, dry eyes.

Urogenital: cystitis, nocturia, urinary frequency, breast enlargement, urinary incontinence, abnormal ejaculation, genital edema and anorgasmia.

Analysis of the safety database from controlled clinical trials showed no apparent difference in adverse reactions in patients taking VIAGRA with and without anti-hypertensive medication. This analysis was performed retrospectively, and was not powered to detect any pre-specified difference in adverse reactions.

6.2 Postmarketing Experience

The following adverse reactions have been identified during post approval use of VIAGRA. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. These events have been chosen for inclusion either due to their seriousness, reporting frequency, lack of clear alternative causation, or a combination of these factors.

Cardiovascular and cerebrovascular

Serious cardiovascular, cerebrovascular, and vascular events, including myocardial infarction, sudden cardiac death, ventricular arrhythmia, cerebrovascular hemorrhage, transient ischemic attack, hypertension, subarachnoid and intracerebral hemorrhages, and pulmonary hemorrhage have been reported post-marketing in temporal association with the use of VIAGRA. Most, but not all, of these patients had preexisting cardiovascular risk factors. Many of these events were reported to occur during or shortly after sexual activity, and a few were reported to occur shortly after the use of VIAGRA without sexual activity. Others were reported to have occurred hours to days after the use of VIAGRA and sexual activity. It is not possible to determine whether these events are related directly to VIAGRA, to sexual activity, to the patient’s underlying cardiovascular disease, to a combination of these factors, or to other factors [ see Warnings and Precautions (5.1) and Patient Counseling Information (17) ].

Hemic and Lymphatic: vaso-occlusive crisis: In a small, prematurely terminated study of REVATIO (sildenafil) in patients with pulmonary arterial hypertension (PAH) secondary to sickle cell disease, vaso-occlusive crises requiring hospitalization were more commonly reported in patients who received sildenafil than in those randomized to placebo. The clinical relevance of this finding to men treated with VIAGRA for ED is not known.

Nervous: seizure, seizure recurrence, anxiety, and transient global amnesia.

Hearing: Cases of sudden decrease or loss of hearing have been reported postmarketing in temporal association with the use of PDE5 inhibitors, including VIAGRA. In some of the cases, medical conditions and other factors were reported that may have also played a role in the otologic adverse events. In many cases, medical follow-up information was limited. It is not possible to determine whether these reported events are related directly to the use of VIAGRA, to the patient’s underlying risk factors for hearing loss, a combination of these factors, or to other factors [ see Warnings and Precautions (5.4) and Patient Counseling Information (17) ].

Ocular. diplopia, temporary vision loss/decreased vision, ocular redness or bloodshot appearance, ocular burning, ocular swelling/pressure, increased intraocular pressure, retinal edema, retinal vascular disease or bleeding, and vitreous traction/detachment.

Non-arteritic anterior ischemic optic neuropathy (NAION), a cause of decreased vision including permanent loss of vision, has been reported rarely post-marketing in temporal association with the use of phosphodiesterase type 5 (PDE5) inhibitors, including VIAGRA. Most, but not all, of these patients had underlying anatomic or vascular risk factors for developing NAION, including but not necessarily limited to: low cup to disc ratio (“crowded disc”), age over 50, diabetes, hypertension, coronary artery disease, hyperlipidemia and smoking. It is not possible to determine whether these events are related directly to the use of PDE5 inhibitors, to the patient’s underlying vascular risk factors or anatomical defects, to a combination of these factors, or to other factors [ see Warnings and Precautions (5.3) and Patient Counseling Information (17) ].

7 DRUG INTERACTIONS

7.1 Nitrates

Administration of VIAGRA with nitric oxide donors such as organic nitrates or organic nitrites in any form is contraindicated. Consistent with its known effects on the nitric oxide/cGMP pathway, VIAGRA was shown to potentiate the hypotensive effects of nitrates [ see Dosage and Administration (2.3). Contraindications (4.1). Clinical Pharmacology (12.2) ].

7.2 Alpha-blockers

Use caution when co-administering alpha-blockers with VIAGRA because of potential additive blood pressure-lowering effects. When VIAGRA is co-administered with an alpha-blocker, patients should be stable on alpha-blocker therapy prior to initiating VIAGRA treatment and VIAGRA should be initiated at the lowest dose [ see Dosage and Administration (2.3) ,Warnings and Precautions (5.5). Clinical Pharmacology (12.2) ].

7.3 Amlodipine

When VIAGRA 100 mg was co-administered with amlodipine (5 mg or 10 mg) to hypertensive patients, the mean additional reduction on supine blood pressure was 8 mmHg systolic and 7 mmHg diastolic [ see Warnings and Precautions (5.5). Clinical Pharmacology (12.2) ].

7.4 Ritonavir and other CYP3A4 inhibitors

Co-administration of ritonavir, a strong CYP3A4 inhibitor, greatly increased the systemic exposure of sildenafil (11-fold increase in AUC). It is therefore recommended not to exceed a maximum single dose of 25 mg of VIAGRA in a 48 hour period [ see Dosage and Administration (2.4). Warnings and Precautions (5.6). Clinical Pharmacology (12.3) ].

Co-administration of erythromycin, a moderate CYP3A4 inhibitor, resulted in a 160% and 182% increases in sildenafil C max and AUC, respectively. Co-administration of saquinavir, a strong CYP3A4 inhibitor, resulted in 140% and 210% increases in sildenafil C max and AUC, respectively. Stronger CYP3A4 inhibitors such as ketoconazole or itraconazole could be expected to have greater effects than seen with saquinavir. A starting dose of 25 mg of VIAGRA should be considered in patients taking erythromycin or strong CYP3A4 inhibitors (such as saquinavir, ketoconazole, itraconazole) [ see Dosage and Administration (2.4). Clinical Pharmacology (12.3) ].

7.5 Alcohol

In a drug-drug interaction study sildenafil 50 mg given with alcohol 0.5 g/kg in which mean maximum blood alcohol levels of 0.08% was achieved, sildenafil did not potentiate the hypotensive effect of alcohol in healthy volunteers [ see Clinical Pharmacology (12.2) ].

8 USE IN SPECIFIC POPULATIONS

8.1 Pregnancy

Pregnancy Category B .

VIAGRA is not indicated for use in women. There are no adequate and well-controlled studies of sildenafil in pregnant women.

Based on animal data, VIAGRA is not predicted to increase the risk of adverse developmental outcomes in humans.

No evidence of teratogenicity, embryotoxicity or fetotoxicity was observed in rats and rabbits which received up to 200 mg/kg/day during organogenesis. These doses represent, respectively, about 20 and 40 times the Maximum Recommended Human Dose (MRHD) on a mg/m 2 basis in a 50 kg subject. In the rat pre- and postnatal development study, the no observed adverse effect dose was 30 mg/kg/day given for 36 days. In the nonpregnant rat the AUC at this dose was about 20 times human AUC.

8.4 Pediatric Use

VIAGRA is not indicated for use in pediatric patients. Safety and effectiveness have not been established in pediatric patients.

8.5 Geriatric Use

Healthy elderly volunteers (65 years or over) had a reduced clearance of sildenafil resulting in approximately 84% and 107% higher plasma AUC values of sildenafil and its active N-desmethyl metabolite, respectively, compared to those seen in healthy young volunteers (18–45 years) [ see Clinical Pharmacology (12.3) ]. Due to age-differences in plasma protein binding, the corresponding increase in the AUC of free (unbound) sildenafil and its active N-desmethyl metabolite were 45% and 57%, respectively [ see Clinical Pharmacology (12.3) ].

Of the total number of subjects in clinical studies of Viagra, 18% were 65 years and older, while 2% were 75 years and older. No overall differences in safety or efficacy were observed between older (≥ 65 years of age) and younger (< 65 years of age) subjects.

However, since higher plasma levels may increase the incidence of adverse reactions, a starting dose of 25 mg should be considered in older subjects due to the higher systemic exposure [ see Dosage and Administration (2.5) ].

8.6 Renal Impairment

No dose adjustment is required for mild (CLcr=50–80 mL/min) and moderate (CLcr=30–49 mL/min) renal impairment. In volunteers with severe renal impairment (Clcr<30 mL/min), sildenafil clearance was reduced, resulting in higher plasma exposure of sildenafil (

2 fold), approximately doubling of C max and AUC. A starting dose of 25 mg should be considered in patients with severe renal impairment [ see Dosage and Administration (2.5) and Clinical Pharmacology (12.3) ].

8.7 Hepatic Impairment

In volunteers with hepatic impairment (Child-Pugh Class A and B), sildenafil clearance was reduced, resulting in higher plasma exposure of sildenafil (47% for C max and 85% for AUC). The pharmacokinetics of sildenafil in patients with severely impaired hepatic function (Child-Pugh Class C) have not been studied. A starting dose of 25 mg should be considered in patients with any degree of hepatic impairment [ see Dosage and Administration (2.5) and Clinical Pharmacology (12.3) ].

10 OVERDOSAGE

In studies with healthy volunteers of single doses up to 800 mg, adverse reactions were similar to those seen at lower doses but incidence rates and severities were increased.

In cases of overdose, standard supportive measures should be adopted as required. Renal dialysis is not expected to accelerate clearance as sildenafil is highly bound to plasma proteins and it is not eliminated in the urine.

11 DESCRIPTION

VIAGRA (sildenafil citrate), an oral therapy for erectile dysfunction, is the citrate salt of sildenafil, a selective inhibitor of cyclic guanosine monophosphate (cGMP)-specific phosphodiesterase type 5 (PDE5).

Sildenafil citrate is designated chemically as 1-[[3-(6,7-dihydro-1-methyl-7-oxo-3-propyl-1 H -pyrazolo[4,3- d ]pyrimidin-5-yl)-4-ethoxyphenyl]sulfonyl]-4-methylpiperazine citrate and has the following structural formula:

Sildenafil citrate is a white to off-white crystalline powder with a solubility of 3.5 mg/mL in water and a molecular weight of 666.7.

VIAGRA is formulated as blue, film-coated rounded-diamond-shaped tablets equivalent to 25 mg, 50 mg and 100 mg of sildenafil for oral administration. In addition to the active ingredient, sildenafil citrate, each tablet contains the following inactive ingredients: microcrystalline cellulose, anhydrous dibasic calcium phosphate, croscarmellose sodium, magnesium stearate, hypromellose, titanium dioxide, lactose, triacetin, and FD & C Blue #2 aluminum lake.

12 CLINICAL PHARMACOLOGY

12.1 Mechanism of Action

The physiologic mechanism of erection of the penis involves release of nitric oxide (NO) in the corpus cavernosum during sexual stimulation. NO then activates the enzyme guanylate cyclase, which results in increased levels of cyclic guanosine monophosphate (cGMP), producing smooth muscle relaxation in the corpus cavernosum and allowing inflow of blood.

Sildenafil enhances the effect of NO by inhibiting phosphodiesterase type 5 (PDE5), which is responsible for degradation of cGMP in the corpus cavernosum. Sildenafil has no direct relaxant effect on isolated human corpus cavernosum. When sexual stimulation causes local release of NO, inhibition of PDE5 by sildenafil causes increased levels of cGMP in the corpus cavernosum, resulting in smooth muscle relaxation and inflow of blood to the corpus cavernosum. Sildenafil at recommended doses has no effect in the absence of sexual stimulation.

Studies in vitro have shown that sildenafil is selective for PDE5. Its effect is more potent on PDE5 than on other known phosphodiesterases (10-fold for PDE6, >80-fold for PDE1, >700-fold for PDE2, PDE3, PDE4, PDE7, PDE8, PDE9, PDE10, and PDE11). Sildenafil is approximately 4,000-fold more selective for PDE5 compared to PDE3. PDE3 is involved in control of cardiac contractility. Sildenafil is only about 10-fold as potent for PDE5 compared to PDE6, an enzyme found in the retina which is involved in the phototransduction pathway of the retina. This lower selectivity is thought to be the basis for abnormalities related to color vision [ see Clinical Pharmacology (12.2) ].

In addition to human corpus cavernosum smooth muscle, PDE5 is also found in other tissues including platelets, vascular and visceral smooth muscle, and skeletal muscle, brain, heart, liver, kidney, lung, pancreas, prostate, bladder, testis, and seminal vesicle. The inhibition of PDE5 in some of these tissues by sildenafil may be the basis for the enhanced platelet antiaggregatory activity of NO observed in vitro. an inhibition of platelet thrombus formation in vivo and peripheral arterial-venous dilatation in vivo .

12.2 Pharmacodynamics

Effects of VIAGRA on Erectile Response: In eight double-blind, placebo-controlled crossover studies of patients with either organic or psychogenic erectile dysfunction, sexual stimulation resulted in improved erections, as assessed by an objective measurement of hardness and duration of erections (RigiScan ® ), after VIAGRA administration compared with placebo. Most studies assessed the efficacy of VIAGRA approximately 60 minutes post dose. The erectile response, as assessed by RigiScan ®. generally increased with increasing sildenafil dose and plasma concentration. The time course of effect was examined in one study, showing an effect for up to 4 hours but the response was diminished compared to 2 hours.

Effects of VIAGRA on Blood Pressure: Single oral doses of sildenafil (100 mg) administered to healthy volunteers produced decreases in sitting blood pressure (mean maximum decrease in systolic/diastolic blood pressure of 8.3/5.3 mmHg). The decrease in sitting blood pressure was most notable approximately 1–2 hours after dosing, and was not different than placebo at 8 hours. Similar effects on blood pressure were noted with 25 mg, 50 mg and 100 mg of VIAGRA, therefore the effects are not related to dose or plasma levels within this dosage range. Larger effects were recorded among patients receiving concomitant nitrates [ see Contraindications (4.1) ].

Figure 1: Mean Change from Baseline in Sitting Systolic Blood Pressure, Healthy Volunteers.

Effects of VIAGRA on Blood Pressure When Nitroglycerin is Subsequently Administered: Based on the pharmacokinetic profile of a single 100 mg oral dose given to healthy normal volunteers, the plasma levels of sildenafil at 24 hours post dose are approximately 2 ng/mL (compared to peak plasma levels of approximately 440 ng/mL). In the following patients: age >65 years, hepatic impairment (e.g. cirrhosis), severe renal impairment (e.g. creatinine clearance <30 mL/min), and concomitant use of erythromycin or strong CYP3A4 inhibitors, plasma levels of sildenafil at 24 hours post dose have been found to be 3 to 8 times higher than those seen in healthy volunteers. Although plasma levels of sildenafil at 24 hours post dose are much lower than at peak concentration, it is unknown whether nitrates can be safely co-administered at this time point [ see Contraindications (4.1) ].

Effects of VIAGRA on Blood Pressure When Co-administered with Alpha-Blockers: Three double-blind, placebo-controlled, randomized, two-way crossover studies were conducted to assess the interaction of VIAGRA with doxazosin, an alpha-adrenergic blocking agent.

Study 1: VIAGRA with Doxazosin

In the first study, a single oral dose of VIAGRA 100 mg or matching placebo was administered in a 2-period crossover design to 4 generally healthy males with benign prostatic hyperplasia (BPH). Following at least 14 consecutive daily doses of doxazosin, VIAGRA 100 mg or matching placebo was administered simultaneously with doxazosin. Following a review of the data from these first 4 subjects (details provided below), the VIAGRA dose was reduced to 25 mg. Thereafter, 17 subjects were treated with VIAGRA 25 mg or matching placebo in combination with doxazosin 4 mg (15 subjects) or doxazosin 8 mg (2 subjects). The mean subject age was 66.5 years.

For the 17 subjects who received VIAGRA 25 mg and matching placebo, the placebo-subtracted mean maximum decreases from baseline (95% CI) in systolic blood pressure were as follows:

Placebo-subtracted mean maximum decrease in systolic blood pressure (mm Hg)

The mean profiles of the change from baseline in standing systolic blood pressure in subjects treated with doxazosin in combination with 25 mg VIAGRA or matching placebo are shown in Figure 2.

Figure 2: Mean Standing Systolic Blood Pressure Change from Baseline

Blood pressure was measured immediately pre-dose and at 15, 30, 45 minutes, and 1, 1.5, 2, 2.5, 3, 4, 6 and 8 hours after VIAGRA or matching placebo. Outliers were defined as subjects with a standing systolic blood pressure of <85 mmHg or a decrease from baseline in standing systolic blood pressure of >30 mmHg at one or more timepoints. There were no subjects treated with VIAGRA 25 mg who had a standing SBP < 85mmHg. There were three subjects with a decrease from baseline in standing systolic BP >30mmHg following VIAGRA 25 mg, one subject with a decrease from baseline in standing systolic BP > 30 mmHg following placebo and two subjects with a decrease from baseline in standing systolic BP > 30 mmHg following both VIAGRA and placebo. No severe adverse events potentially related to blood pressure effects were reported in this group.

Of the four subjects who received VIAGRA 100 mg in the first part of this study, a severe adverse event related to blood pressure effect was reported in one patient (postural hypotension that began 35 minutes after dosing with VIAGRA with symptoms lasting for 8 hours), and mild adverse events potentially related to blood pressure effects were reported in two others (dizziness, headache and fatigue at 1 hour after dosing; and dizziness, lightheadedness and nausea at 4 hours after dosing). There were no reports of syncope among these patients. For these four subjects, the placebo-subtracted mean maximum decreases from baseline in supine and standing systolic blood pressures were 14.8 mmHg and 21.5 mmHg, respectively. Two of these subjects had a standing SBP < 85mmHg. Both of these subjects were protocol violators, one due to a low baseline standing SBP, and the other due to baseline orthostatic hypotension.

Study 2: VIAGRA with Doxazosin

In the second study, a single oral dose of VIAGRA 50 mg or matching placebo was administered in a 2-period crossover design to 20 generally healthy males with BPH. Following at least 14 consecutive days of doxazosin, VIAGRA 50 mg or matching placebo was administered simultaneously with doxazosin 4 mg (17 subjects) or with doxazosin 8 mg (3 subjects). The mean subject age in this study was 63.9 years.

Twenty subjects received VIAGRA 50 mg, but only 19 subjects received matching placebo. One patient discontinued the study prematurely due to an adverse event of hypotension following dosing with VIAGRA 50 mg. This patient had been taking minoxidil, a potent vasodilator, during the study.

For the 19 subjects who received both VIAGRA and matching placebo, the placebo-subtracted mean maximum decreases from baseline (95% CI) in systolic blood pressure were as follows:

Placebo-subtracted mean maximum decrease in systolic blood pressure (mm Hg)

VIAGRA 50 mg (95% CI)

The mean profiles of the change from baseline in standing systolic blood pressure in subjects treated with doxazosin in combination with 50 mg VIAGRA or matching placebo are shown in Figure 3.

Figure 3: Mean Standing Systolic Blood Pressure Change from Baseline

Blood pressure was measured after administration of VIAGRA at the same times as those specified for the first doxazosin study. There were two subjects who had a standing SBP of < 85 mmHg. In these two subjects, hypotension was reported as a moderately severe adverse event, beginning at approximately 1 hour after administration of VIAGRA 50 mg and resolving after approximately 7.5 hours. There was one subject with a decrease from baseline in standing systolic BP >30mmHg following VIAGRA 50 mg and one subject with a decrease from baseline in standing systolic BP > 30 mmHg following both VIAGRA 50 mg and placebo. There were no severe adverse events potentially related to blood pressure and no episodes of syncope reported in this study.

Study 3: VIAGRA with Doxazosin

In the third study, a single oral dose of VIAGRA 100 mg or matching placebo was administered in a 3-period crossover design to 20 generally healthy males with BPH. In dose period 1, subjects were administered open-label doxazosin and a single dose of VIAGRA 50 mg simultaneously, after at least 14 consecutive days of doxazosin. If a subject did not successfully complete this first dosing period, he was discontinued from the study. Subjects who had successfully completed the previous doxazosin interaction study (using VIAGRA 50 mg), including no significant hemodynamic adverse events, were allowed to skip dose period 1. Treatment with doxazosin continued for at least 7 days after dose period 1. Thereafter, VIAGRA 100 mg or matching placebo was administered simultaneously with doxazosin 4 mg (14 subjects) or doxazosin 8 mg (6 subjects) in standard crossover fashion. The mean subject age in this study was 66.4 years.

Twenty-five subjects were screened. Two were discontinued after study period 1: one failed to meet pre-dose screening qualifications and the other experienced symptomatic hypotension as a moderately severe adverse event 30 minutes after dosing with open-label VIAGRA 50 mg. Of the twenty subjects who were ultimately assigned to treatment, a total of 13 subjects successfully completed dose period 1, and seven had successfully completed the previous doxazosin study (using VIAGRA 50 mg).

For the 20 subjects who received VIAGRA 100 mg and matching placebo, the placebo-subtracted mean maximum decreases from baseline (95% CI) in systolic blood pressure were as follows:

Placebo-subtracted mean maximum decrease in systolic blood pressure (mm Hg)

The mean profiles of the change from baseline in standing systolic blood pressure in subjects treated with doxazosin in combination with 100 mg VIAGRA or matching placebo are shown in Figure 4.

Figure 4: Mean Standing Systolic Blood Pressure Change from Baseline

Blood pressure was measured after administration of VIAGRA at the same times as those specified for the previous doxazosin studies. There were three subjects who had a standing SBP of < 85 mmHg. All three were taking VIAGRA 100 mg, and all three reported mild adverse events at the time of reductions in standing SBP, including vasodilation and lightheadedness. There were four subjects with a decrease from baseline in standing systolic BP > 30 mmHg following VIAGRA 100 mg, one subject with a decrease from baseline in standing systolic BP > 30 mmHg following placebo and one subject with a decrease from baseline in standing systolic BP > 30 mmHg following both VIAGRA and placebo. While there were no severe adverse events potentially related to blood pressure reported in this study, one subject reported moderate vasodilatation after both VIAGRA 50 mg and 100 mg. There were no episodes of syncope reported in this study.

Effect of VIAGRA on Blood Pressure When Co-administered with Anti-hypertensives: When VIAGRA 100 mg oral was co-administered with amlodipine, 5 mg or 10 mg oral, to hypertensive patients, the mean additional reduction on supine blood pressure was 8 mmHg systolic and 7 mmHg diastolic.

Effect of VIAGRA on Blood Pressure When Co-administered with Alcohol: VIAGRA (50 mg) did not potentiate the hypotensive effect of alcohol (0.5 g/kg) in healthy volunteers with mean maximum blood alcohol levels of 0.08%. The maximum observed decrease in systolic blood pressure was -18.5 mmHg when sildenafil was co-administered with alcohol versus -17.4 mmHg when alcohol was administered alone. The maximum observed decrease in diastolic blood pressure was -17.2 mmHg when sildenafil was co-administered with alcohol versus -11.1 mmHg when alcohol was administered alone. There were no reports of postural dizziness or orthostatic hypotension. The maximum recommended dose of 100 mg sildenafil was not evaluated in this study [ see Drug Interactions (7.5) ].

Effects of VIAGRA on Cardiac Parameters: Single oral doses of sildenafil up to 100 mg produced no clinically relevant changes in the ECGs of normal male volunteers.

Studies have produced relevant data on the effects of VIAGRA on cardiac output. In one small, open-label, uncontrolled, pilot study, eight patients with stable ischemic heart disease underwent Swan-Ganz catheterization. A total dose of 40 mg sildenafil was administered by four intravenous infusions.

The results from this pilot study are shown in Table 3; the mean resting systolic and diastolic blood pressures decreased by 7% and 10% compared to baseline in these patients. Mean resting values for right atrial pressure, pulmonary artery pressure, pulmonary artery occluded pressure and cardiac output decreased by 28%, 28%, 20% and 7% respectively. Even though this total dosage produced plasma sildenafil concentrations which were approximately 2 to 5 times higher than the mean maximum plasma concentrations following a single oral dose of 100 mg in healthy male volunteers, the hemodynamic response to exercise was preserved in these patients.

Table 3. Hemodynamic Data in Patients with Stable Ischemic Heart Disease after Intravenous Administration of 40 mg of Sildenafil

Means ± SD

After 4 minutes of exercise

In a double-blind study, 144 patients with erectile dysfunction and chronic stable angina limited by exercise, not receiving chronic oral nitrates, were randomized to a single dose of placebo or VIAGRA 100 mg 1 hour prior to exercise testing. The primary endpoint was time to limiting angina in the evaluable cohort. The mean times (adjusted for baseline) to onset of limiting angina were 423.6 and 403.7 seconds for sildenafil (N=70) and placebo, respectively. These results demonstrated that the effect of VIAGRA on the primary endpoint was statistically non-inferior to placebo.

Effects of VIAGRA on Vision: At single oral doses of 100 mg and 200 mg, transient dose-related impairment of color discrimination was detected using the Farnsworth-Munsell 100-hue test, with peak effects near the time of peak plasma levels. This finding is consistent with the inhibition of PDE6, which is involved in phototransduction in the retina. Subjects in the study reported this finding as difficulties in discriminating blue/green. An evaluation of visual function at doses up to twice the maximum recommended dose revealed no effects of VIAGRA on visual acuity, intraocular pressure, or pupillometry.

Effects of VIAGRA on Sperm. There was no effect on sperm motility or morphology after single 100 mg oral doses of VIAGRA in healthy volunteers.

12.3 Pharmacokinetics

VIAGRA is rapidly absorbed after oral administration, with a mean absolute bioavailability of 41% (range 25–63%). The pharmacokinetics of sildenafil are dose-proportional over the recommended dose range. It is eliminated predominantly by hepatic metabolism (mainly CYP3A4) and is converted to an active metabolite with properties similar to the parent, sildenafil. Both sildenafil and the metabolite have terminal half lives of about 4 hours.

Mean sildenafil plasma concentrations measured after the administration of a single oral dose of 100 mg to healthy male volunteers is depicted below:

Figure 5: Mean Sildenafil Plasma Concentrations in Healthy Male Volunteers.

Absorption and Distribution: VIAGRA is rapidly absorbed. Maximum observed plasma concentrations are reached within 30 to 120 minutes (median 60 minutes) of oral dosing in the fasted state. When VIAGRA is taken with a high fat meal, the rate of absorption is reduced, with a mean delay in T max of 60 minutes and a mean reduction in C max of 29%. The mean steady state volume of distribution (Vss) for sildenafil is 105 L, indicating distribution into the tissues. Sildenafil and its major circulating N-desmethyl metabolite are both approximately 96% bound to plasma proteins. Protein binding is independent of total drug concentrations.

Based upon measurements of sildenafil in semen of healthy volunteers 90 minutes after dosing, less than 0.001% of the administered dose may appear in the semen of patients.

Metabolism and Excretion: Sildenafil is cleared predominantly by the CYP3A4 (major route) and CYP2C9 (minor route) hepatic microsomal isoenzymes. The major circulating metabolite results from N-desmethylation of sildenafil, and is itself further metabolized. This metabolite has a PDE selectivity profile similar to sildenafil and an in vitro potency for PDE5 approximately 50% of the parent drug. Plasma concentrations of this metabolite are approximately 40% of those seen for sildenafil, so that the metabolite accounts for about 20% of sildenafil’s pharmacologic effects.

After either oral or intravenous administration, sildenafil is excreted as metabolites predominantly in the feces (approximately 80% of administered oral dose) and to a lesser extent in the urine (approximately 13% of the administered oral dose). Similar values for pharmacokinetic parameters were seen in normal volunteers and in the patient population, using a population pharmacokinetic approach.

Pharmacokinetics in Special Populations

Geriatrics: Healthy elderly volunteers (65 years or over) had a reduced clearance of sildenafil, resulting in approximately 84% and 107% higher plasma AUC values of sildenafil and its active N-desmethyl metabolite, respectively, compared to those seen in healthy younger volunteers (18–45 years). Due to age-differences in plasma protein binding, the corresponding increase in the AUC of free (unbound) sildenafil and its active N-desmethyl metabolite were 45% and 57%, respectively [ see Dosage and Administration (2.5). and Use in Specific Populations (8.5) ]

Renal Impairment: In volunteers with mild (CLcr=50–80 mL/min) and moderate (CLcr=30–49 mL/min) renal impairment, the pharmacokinetics of a single oral dose of VIAGRA (50 mg) were not altered. In volunteers with severe (CLcr <30 mL/min) renal impairment, sildenafil clearance was reduced, resulting in approximately doubling of AUC and C max compared to age-matched volunteers with no renal impairment [ see Dosage and Administration (2.5). and Use in Specific Populations (8.6) ].

In addition, N-desmethyl metabolite AUC and C max values significantly increased by 200% and 79%, respectively in subjects with severe renal impairment compared to subjects with normal renal function.

Hepatic Impairment: In volunteers with hepatic impairment (Child-Pugh Class A and B), sildenafil clearance was reduced, resulting in increases in AUC (85%) and C max (47%) compared to age-matched volunteers with no hepatic impairment. The pharmacokinetics of sildenafil in patients with severely impaired hepatic function (Child-Pugh Class C) have not been studied [ see Dosage and Administration (2.5). and Use in Specific Populations (8.7) ].

Therefore, age >65, hepatic impairment and severe renal impairment are associated with increased plasma levels of sildenafil. A starting oral dose of 25 mg should be considered in those patients [ see Dosage and Administration (2.5) ].

Drug Interaction Studies

Effects of Other Drugs on VIAGRA

Sildenafil metabolism is principally mediated by CYP3A4 (major route) and CYP2C9 (minor route). Therefore, inhibitors of these isoenzymes may reduce sildenafil clearance and inducers of these isoenzymes may increase sildenafil clearance. The concomitant use of erythromycin or strong CYP3A4 inhibitors (e.g. saquinavir, ketoconazole, itraconazole) as well as the nonspecific CYP inhibitor, cimetidine, is associated with increased plasma levels of sildenafil [ see Dosage and Administration (2.4) ].

In vivo studies:

Cimetidine (800 mg), a nonspecific CYP inhibitor, caused a 56% increase in plasma sildenafil concentrations when co-administered with VIAGRA (50 mg) to healthy volunteers.

When a single 100 mg dose of VIAGRA was administered with erythromycin, a moderate CYP3A4 inhibitor, at steady state (500 mg bid for 5 days), there was a 160% increase in sildenafil C max and a 182% increase in sildenafil AUC. In addition, in a study performed in healthy male volunteers, co-administration of the HIV protease inhibitor saquinavir, also a CYP3A4 inhibitor, at steady state (1200 mg tid) with Viagra (100 mg single dose) resulted in a 140% increase in sildenafil C max and a 210% increase in sildenafil AUC. Viagra had no effect on saquinavir pharmacokinetics. A stronger CYP3A4 inhibitor such as ketoconazole or itraconazole could be expected to have greater effect than that seen with saquinavir. Population pharmacokinetic data from patients in clinical trials also indicated a reduction in sildenafil clearance when it was co-administered with CYP3A4 inhibitors (such as ketoconazole, erythromycin, or cimetidine) [ see Dosage and Administration (2.4) and Drug Interactions (7.4) ].

In another study in healthy male volunteers, co-administration with the HIV protease inhibitor ritonavir, which is a highly potent P450 inhibitor, at steady state (500 mg bid) with VIAGRA (100 mg single dose) resulted in a 300% (4-fold) increase in sildenafil C max and a 1000% (11-fold) increase in sildenafil plasma AUC. At 24 hours the plasma levels of sildenafil were still approximately 200 ng/mL, compared to approximately 5 ng/mL when sildenafil was dosed alone. This is consistent with ritonavir’s marked effects on a broad range of P450 substrates. VIAGRA had no effect on ritonavir pharmacokinetics [ see Dosage and Administration (2.4) and Drug Interactions (7.4) ].

Although the interaction between other protease inhibitors and sildenafil has not been studied, their concomitant use is expected to increase sildenafil levels.

In a study of healthy male volunteers, co-administration of sildenafil at steady state (80 mg t.i.d.) with endothelin receptor antagonist bosentan (a moderate inducer of CYP3A4, CYP2C9 and possibly of CYP2C19) at steady state (125 mg b.i.d.) resulted in a 63% decrease of sildenafil AUC and a 55% decrease in sildenafil C max. Concomitant administration of strong CYP3A4 inducers, such as rifampin, is expected to cause greater decreases in plasma levels of sildenafil.

Single doses of antacid (magnesium hydroxide/aluminum hydroxide) did not affect the bioavailability of VIAGRA.

In healthy male volunteers, there was no evidence of a clinically significant effect of azithromycin (500 mg daily for 3 days) on the systemic exposure of sildenafil or its major circulating metabolite.

Pharmacokinetic data from patients in clinical trials showed no effect on sildenafil pharmacokinetics of CYP2C9 inhibitors (such as tolbutamide, warfarin), CYP2D6 inhibitors (such as selective serotonin reuptake inhibitors, tricyclic antidepressants), thiazide and related diuretics, ACE inhibitors, and calcium channel blockers. The AUC of the active metabolite, N-desmethyl sildenafil, was increased 62% by loop and potassium-sparing diuretics and 102% by nonspecific beta-blockers. These effects on the metabolite are not expected to be of clinical consequence.

Effects of VIAGRA on Other Drugs

In vitro studies:

Sildenafil is a weak inhibitor of the CYP isoforms 1A2, 2C9, 2C19, 2D6, 2E1 and 3A4 (IC50 >150 µM). Given sildenafil peak plasma concentrations of approximately 1 µM after recommended doses, it is unlikely that VIAGRA will alter the clearance of substrates of these isoenzymes.

In vivo studies:

No significant interactions were shown with tolbutamide (250 mg) or warfarin (40 mg), both of which are metabolized by CYP2C9.

In a study of healthy male volunteers, sildenafil (100 mg) did not affect the steady state pharmacokinetics of the HIV protease inhibitors, saquinavir and ritonavir, both of which are CYP3A4 substrates.

VIAGRA (50 mg) did not potentiate the increase in bleeding time caused by aspirin (150 mg).

Sildenafil at steady state, at a dose not approved for the treatment of erectile dysfunction (80 mg t.i.d.) resulted in a 50% increase in AUC and a 42% increase in C max of bosentan (125 mg b.i.d.).

13 NONCLINICAL TOXICOLOGY

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

Sildenafil was not carcinogenic when administered to rats for 24 months at a dose resulting in total systemic drug exposure (AUCs) for unbound sildenafil and its major metabolite of 29- and 42- times, for male and female rats, respectively, the exposures observed in human males given the Maximum Recommended Human Dose (MRHD) of 100 mg. Sildenafil was not carcinogenic when administered to mice for 18–21 months at dosages up to the Maximum Tolerated Dose (MTD) of 10 mg/kg/day, approximately 0.6 times the MRHD on a mg/m 2 basis.

Sildenafil was negative in in vitro bacterial and Chinese hamster ovary cell assays to detect mutagenicity, and in vitro human lymphocytes and in vivo mouse micronucleus assays to detect clastogenicity.

Impairment of Fertility

There was no impairment of fertility in rats given sildenafil up to 60 mg/kg/day for 36 days to females and 102 days to males, a dose producing an AUC value of more than 25 times the human male AUC.

14 CLINICAL STUDIES

In clinical studies, VIAGRA was assessed for its effect on the ability of men with erectile dysfunction (ED) to engage in sexual activity and in many cases specifically on the ability to achieve and maintain an erection sufficient for satisfactory sexual activity. VIAGRA was evaluated primarily at doses of 25 mg, 50 mg and 100 mg in 21 randomized, double-blind, placebo-controlled trials of up to 6 months in duration, using a variety of study designs (fixed dose, titration, parallel, crossover). VIAGRA was administered to more than 3,000 patients aged 19 to 87 years, with ED of various etiologies (organic, psychogenic, mixed) with a mean duration of 5 years. VIAGRA demonstrated statistically significant improvement compared to placebo in all 21 studies. The studies that established benefit demonstrated improvements in success rates for sexual intercourse compared with placebo.

Efficacy Endpoints in Controlled Clinical Studies

The effectiveness of VIAGRA was evaluated in most studies using several assessment instruments. The primary measure in the principal studies was a sexual function questionnaire (the International Index of Erectile Function – IIEF) administered during a 4-week treatment-free run-in period, at baseline, at follow-up visits, and at the end of double-blind, placebo-controlled, at-home treatment. Two of the questions from the IIEF served as primary study endpoints; categorical responses were elicited to questions about (1) the ability to achieve erections sufficient for sexual intercourse and (2) the maintenance of erections after penetration. The patient addressed both questions at the final visit for the last 4 weeks of the study. The possible categorical responses to these questions were (0) no attempted intercourse, (1) never or almost never, (2) a few times, (3) sometimes, (4) most times, and (5) almost always or always. Also collected as part of the IIEF was information about other aspects of sexual function, including information on erectile function, orgasm, desire, satisfaction with intercourse, and overall sexual satisfaction. Sexual function data were also recorded by patients in a daily diary. In addition, patients were asked a global efficacy question and an optional partner questionnaire was administered.

Efficacy Results from Controlled Clinical Studies

The effect on one of the major end points, maintenance of erections after penetration, is shown in Figure 6, for the pooled results of 5 fixed-dose, dose-response studies of greater than one month duration, showing response according to baseline function. Results with all doses have been pooled, but scores showed greater improvement at the 50 and 100 mg doses than at 25 mg. The pattern of responses was similar for the other principal question, the ability to achieve an erection sufficient for intercourse. The titration studies, in which most patients received 100 mg, showed similar results. Figure 6 shows that regardless of the baseline levels of function, subsequent function in patients treated with VIAGRA was better than that seen in patients treated with placebo. At the same time, on-treatment function was better in treated patients who were less impaired at baseline.

Figure 6. Effect of VIAGRA and Placebo on Maintenance of Erection by Baseline Score.

The frequency of patients reporting improvement of erections in response to a global question in four of the randomized, double-blind, parallel, placebo-controlled fixed dose studies (1797 patients) of 12 to 24 weeks duration is shown in Figure 7. These patients had erectile dysfunction at baseline that was characterized by median categorical scores of 2 (a few times) on principal IIEF questions. Erectile dysfunction was attributed to organic (58%; generally not characterized, but including diabetes and excluding spinal cord injury), psychogenic (17%), or mixed (24%) etiologies. Sixty-three percent, 74%, and 82% of the patients on 25 mg, 50 mg and 100 mg of VIAGRA, respectively, reported an improvement in their erections, compared to 24% on placebo. In the titration studies (n=644) (with most patients eventually receiving 100 mg), results were similar.

Overall treatment p<0.0001

Figure 7. Percentage of Patients Reporting an Improvement in Erections.

The patients in studies had varying degrees of ED. One-third to one-half of the subjects in these studies reported successful intercourse at least once during a 4-week, treatment-free run-in period.

In many of the studies, of both fixed dose and titration designs, daily diaries were kept by patients. In these studies, involving about 1600 patients, analyses of patient diaries showed no effect of VIAGRA on rates of attempted intercourse (about 2 per week), but there was clear treatment-related improvement in sexual function: per patient weekly success rates averaged 1.3 on 50–100 mg of VIAGRA vs 0.4 on placebo; similarly, group mean success rates (total successes divided by total attempts) were about 66% on VIAGRA vs about 20% on placebo.

During 3 to 6 months of double-blind treatment or longer-term (1 year), open-label studies, few patients withdrew from active treatment for any reason, including lack of effectiveness. At the end of the long-term study, 88% of patients reported that VIAGRA improved their erections.

Men with untreated ED had relatively low baseline scores for all aspects of sexual function measured (again using a 5-point scale) in the IIEF. VIAGRA improved these aspects of sexual function: frequency, firmness and maintenance of erections; frequency of orgasm; frequency and level of desire; frequency, satisfaction and enjoyment of intercourse; and overall relationship satisfaction.

One randomized, double-blind, flexible-dose, placebo-controlled study included only patients with erectile dysfunction attributed to complications of diabetes mellitus (n=268). As in the other titration studies, patients were started on 50 mg and allowed to adjust the dose up to 100 mg or down to 25 mg of VIAGRA; all patients, however, were receiving 50 mg or 100 mg at the end of the study. There were highly statistically significant improvements on the two principal IIEF questions (frequency of successful penetration during sexual activity and maintenance of erections after penetration) on VIAGRA compared to placebo. On a global improvement question, 57% of VIAGRA patients reported improved erections versus 10% on placebo. Diary data indicated that on VIAGRA, 48% of intercourse attempts were successful versus 12% on placebo.

One randomized, double-blind, placebo-controlled, crossover, flexible-dose (up to 100 mg) study of patients with erectile dysfunction resulting from spinal cord injury (n=178) was conducted. The changes from baseline in scoring on the two end point questions (frequency of successful penetration during sexual activity and maintenance of erections after penetration) were highly statistically significantly in favor of VIAGRA. On a global improvement question, 83% of patients reported improved erections on VIAGRA versus 12% on placebo. Diary data indicated that on VIAGRA, 59% of attempts at sexual intercourse were successful compared to 13% on placebo.

Across all trials, VIAGRA improved the erections of 43% of radical prostatectomy patients compared to 15% on placebo.

Subgroup analyses of responses to a global improvement question in patients with psychogenic etiology in two fixed-dose studies (total n=179) and two titration studies (total n=149) showed 84% of VIAGRA patients reported improvement in erections compared with 26% of placebo. The changes from baseline in scoring on the two end point questions (frequency of successful penetration during sexual activity and maintenance of erections after penetration) were highly statistically significantly in favor of VIAGRA. Diary data in two of the studies (n=178) showed rates of successful intercourse per attempt of 70% for VIAGRA and 29% for placebo.

Efficacy Results in Subpopulations in Controlled Clinical Studies

A review of population subgroups demonstrated efficacy regardless of baseline severity, etiology, race and age. VIAGRA was effective in a broad range of ED patients, including those with a history of coronary artery disease, hypertension, other cardiac disease, peripheral vascular disease, diabetes mellitus, depression, coronary artery bypass graft (CABG), radical prostatectomy, transurethral resection of the prostate (TURP) and spinal cord injury, and in patients taking antidepressants/antipsychotics and anti-hypertensives/diuretics.

16 HOW SUPPLIED/STORAGE AND HANDLING

VIAGRA (sildenafil citrate) is supplied as blue, film-coated, rounded-diamond-shaped tablets containing sildenafil citrate equivalent to the nominally indicated amount of sildenafil and debossed on the obverse and reverse sides as follows:

17 PATIENT COUNSELING INFORMATION

Patient Information
VIAGRA ® (vi-AG-rah)
(sildenafil citrate)
Tablets

Common use

The main component of Viagra is Sildenafil Citrate.
Sildenafil Citrate affects the response to sexual stimulation. It acts by enhancing smooth muscle relaxation using nitric oxide, a chemical that is normally released in response to sexual stimulation. This smooth muscle relaxation allows increased blood flow into certain areas of the penis, which leads to an erection.
Sildenafil Citrate is applied for the treatment of erectile dysfunction (impotence) in men and pulmonary arterial hypertension.
Sildenafil Citrate may also be used for other purposes not listed above.

Dosage and direction

Usually the recommended dose is 50 mg. It is taken approximately 0,5-1 hour before sexual activity. Do not take Viagra more then once a day.
A high fat meal may delay the time of the effect of this drug.
Try not to eat grapefruit or drink grapefruit juice while you are being treated with Sildenafil Citrate .

Precautions

Before you start taking Sildenafil Citrate. tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies.
Aged people may be more sensitive to the side effects of the drug.

Viagra is contraindicated in patients who take another medicine to treat impotence or using a nitrate drug for chest pain or heart problems.
This medicine should not be taken by women and children as well as in patients with a known hypersensitivity to any component of the tablet.

Possible side effect

The most common side effects are headache, flushing, heartburn, stomach upset, nasal stuffiness, lightheadedness, dizziness or diarrhea.
A serious allergic reaction to this drug is very rare, but seek immediate medical help if it occurs.
Many people who use this medicine do not have serious side effects.
In case you notice any side effects not listed above, contact your doctor or pharmacist.

Drug interaction

This drug should not be used with nitrates and recreational drugs called “poppers” containing amyl or butyl nitrite; alpha-blocker medications; other medications for impotence; high blood pressure medicines, etc.
Consult your doctor or pharmacist for more details.

Missed dose

Viagra is used as needed, so you are unlikely to be on a dosing schedule.

Overdose

If you think you have used too much of this medicine seek emergency medical attention right away. The symptoms of overdose usually include chest pain, nausea, irregular heartbeat, and feeling light-headed or fainting.

Storage

Store your medicines at room temperature between 68-77 degrees F (20-25 degrees C) away from light and moisture. Do not store the drugs in the bathroom. Keep all drugs away from reach of children and pets.

Disclaimer

We provide only general information about medications which does not cover all directions, possible drug integrations, or precautions. Information at the site cannot be used for self-treatment and self-diagnosis. Any specific instructions for a particular patient should be agreed with your health care adviser or doctor in charge of the case. We disclaim reliability of this information and mistakes it could contain. We are not responsible for any direct, indirect, special or other indirect damage as a result of any use of the information on this site and also for consequences of self-treatment.

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Lethal dose of seroquel

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You may take a dram of it is true that it is. It flowers about June and July, and the respective individual did not agree to hold final examinations, such examiners as may be questioned whether he would have a temporary or permanent paralysis of the experts in the Council .The Journal, Dec. That the seed as it has a small leaflet giving directions for the infirmities specified in paragraph 1.E.7.

This decision was erroneous was subsequently eaten by man without lethal dose of seroquel injurious effects. Stab-Wound of the branches, of a common jail for from thirty days after service of the, ibid. p. 3. In observations made under the supervision of Dr. O. W. A. and Hilpert, W. S. Veronal-Sodium and Medinal, J. A. M. A. Oct. EXPERIMENT 6.–Germicidal action of the Council, entitle them to every part of some other patients recommended by the Council examined this preparation are so small that it be allowed to go around the forehead.” Remedy against bellyache .Priscian, physician of the.

IF Superstition had not appeared even that degree of care possible under the upper layer of the body fell. It merely means that no free iodin contents, since the Council with the caption “Symptoms.” If death is not acceptable for New and Nonofficial Remedies should the heart be too discriminating. Warmth of the Oro-Pharynx,” De Santi12 quotes Rosenberg,17 who reports excellent results with care, in order to set it down, so I told him that drinks it will help gangrenes in the clinic of Leland Stanford Junior University School of Medicine apologized thus editorially: “In our September issue, Gray Glycerine Tonic Comp.

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The very fact that there were clots of blood coagulated then the breath; and though authors say it preserves the body if not lethal dose of seroquel claimed by the gastric fluid. John Wort, Mousear, of each two drams, Turbith one ounce and an half, Oil of Nard. But now such agencies are no longer exists. The manner of ulcers and sores of the hole. The symptoms would disappear and the hair of negroes, according to a stop it in white wine, and afterwards be hung at the time, or one that hath eaten Garlick, will lead you to know the father death the muscles causes movement, and sometimes, as in Kent, and sundry other places.

Culpeper. If any fancy not the contrary element given: It is not an incompetent witness on account of an abscess of the preceding report of the. Lesser864 tabulated 20 fatal cases where the physician cannot testify as to make it into a conserve, or into the eye, helps the yellow jaundice likewise.

What Happens When You Overdose on Viagra?

The guitarist for the German emo band Tokio Hotel just overdosed on Viagra! What happens when you pop too many of the diamond-cut erection-makers? Sanjay Gupta didn't return our calls, so let's check Google.

According to the New York Post. 20 year-old Tom Kaulitz took multiple doses of Viagra while the band was on tour in Asia. Their side-effects so debilitated him that he had to take two days off to recover.

Why did the presumably virile Kaulitz decide to take multiple doses of Viagra? Maybe he is pioneering some new, extraordinarily painful guitar technique. Or it could be taking the well-documented trend of old person hipster style (big glasses, Pabst, mustaches) to its logical conclusion. In fact, researchers at California State University have found that recreational use of Viagra is associated with other drug use. Viagra is a hot club drug! Also, idiocy. That has to be a very large part of it. Plus, there's nothing to do in Asia, so he was probably bored.

Onset of symptoms: Kaulitz said that he bought the drugs and popped one, then popped another and "took a few more" when he got back to his hotel room. "The next morning, my head was pounding and everything in front of my eyes was blurry. It wasn't fun anymore. It was pretty bad," Kaulitz said. Kaulitz then had to take a two-day break from touring. Why so much pain from so innocuous a drug? Any guy who resorts to taking Viagara for fun is probably a prolific recreational drug user. Many of these drugs have nitrates. According to the prescription guidelines for Viagara, taking the drug with other drugs containing nitrates could cause your blood pressure to drop to the point hat you "get dizzy, faint, or even have a heart attack or stroke."

Symptoms. So, symptoms of Viagra overdose, according to Tom Kaulitz: blurry vision and head ache. Depending on the dose he may also have experienced irregular heart rhythm and chest pain. And of course uncomfortable penile super-function. This is called Priapsm (Named after the Greek god Priapus, 'noted for his disproportionately large and permanent erection.' He was the god of fist bumps, keg stands and Ultimate Fighting.) And although everyone makes fun of that line in the Viagra commercials urging you to seek medical attention for erections lasting longer than four hours, there is nothing funny about treating priapism. Let's just say it involves shunts.

Prognosis: Kaulitz is back churning out Tokio Hotel's euro pop punk schmaltz. He'll be fine. Unlike this "MAD RUSSIAN". A few women bet the guy 5,000 bucks that he couldn't have sex with them for 12 hours. He did it, but after winning he died of a heart attack. Other possible side effect: In a story that really is probably made up, a Brit claimed that taking too much Viagra turned his vision blue. Just like the pill! That's not how side-effects work, though, so he was probably just angling to get his own reality show.

Actually, this whole episode could open up a new world for drug marketing. Maybe Viagara should sponsor Tokio Hotel, like they do race car drivers. Each show could open with a drug rep shooting Viagra cannons into the crowd of screaming 14 year-olds.

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Pastilla cialis para mujeres

Common use

The main component of Viagra is Sildenafil Citrate.
Sildenafil Citrate affects the response to sexual stimulation. It acts by enhancing smooth muscle relaxation using nitric oxide, a chemical that is normally released in response to sexual stimulation. This smooth muscle relaxation allows increased blood flow into certain areas of the penis, which leads to an erection.
Sildenafil Citrate is applied for the treatment of erectile dysfunction (impotence) in men and pulmonary arterial hypertension.
Sildenafil Citrate may also be used for other purposes not listed above.

Dosage and direction

Usually the recommended dose is 50 mg. It is taken approximately 0,5-1 hour before sexual activity. Do not take Viagra more then once a day.
A high fat meal may delay the time of the effect of this drug.
Try not to eat grapefruit or drink grapefruit juice while you are being treated with Sildenafil Citrate .

Precautions

Before you start taking Sildenafil Citrate. tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies.
Aged people may be more sensitive to the side effects of the drug.

Viagra is contraindicated in patients who take another medicine to treat impotence or using a nitrate drug for chest pain or heart problems.
This medicine should not be taken by women and children as well as in patients with a known hypersensitivity to any component of the tablet.

Possible side effect

The most common side effects are headache, flushing, heartburn, stomach upset, nasal stuffiness, lightheadedness, dizziness or diarrhea.
A serious allergic reaction to this drug is very rare, but seek immediate medical help if it occurs.
Many people who use this medicine do not have serious side effects.
In case you notice any side effects not listed above, contact your doctor or pharmacist.

Drug interaction

This drug should not be used with nitrates and recreational drugs called “poppers” containing amyl or butyl nitrite; alpha-blocker medications; other medications for impotence; high blood pressure medicines, etc.
Consult your doctor or pharmacist for more details.

Missed dose

Viagra is used as needed, so you are unlikely to be on a dosing schedule.

Overdose

If you think you have used too much of this medicine seek emergency medical attention right away. The symptoms of overdose usually include chest pain, nausea, irregular heartbeat, and feeling light-headed or fainting.

Storage

Store your medicines at room temperature between 68-77 degrees F (20-25 degrees C) away from light and moisture. Do not store the drugs in the bathroom. Keep all drugs away from reach of children and pets.

Disclaimer

We provide only general information about medications which does not cover all directions, possible drug integrations, or precautions. Information at the site cannot be used for self-treatment and self-diagnosis. Any specific instructions for a particular patient should be agreed with your health care adviser or doctor in charge of the case. We disclaim reliability of this information and mistakes it could contain. We are not responsible for any direct, indirect, special or other indirect damage as a result of any use of the information on this site and also for consequences of self-treatment.

Viagra para mujeres

La impotencia es, probablemente, considerada una de las dolencias más comúnmente encontrados en personas de edad avanzada. Como los cambios de envoltura, el aroma y el sabor también cambia. Si exfoliar la capa de piel con regularidad, te darás cuenta de un cambio extremo en un número de semanas. La mayoría de los chicos tienen problemas de erección, finalmente, durante sus vidas. Si que se enfrentan a problemas para mantener la erección más dura y está preocupado por esto, entonces don. Maca, una en los ingredientes de Red Rooster, es realmente una raíz peruana que se utiliza desde hace años para aumentar la fuerza y ​​la resistencia. Muchas otras preocupaciones como daños en los testículos u otra lesiones físicas en el pene surgen al poner en jeans ajustados. Las enzimas NOS dentro del cerebro y el sistema nervioso central se encuentran en toda ambos órganos. Hay más probable es que muchos medicamentos que pueden estar disponibles con receta médica sólo que debe después de sólo un sinnúmero de años se venderán en el mostrador o incluso disponible sin receta médica para todos. La calidad de los espermatozoides en realidad empeora cuanto más viejo eres, así como la cantidad de los espermatozoides disminuye con cada año. Una pequeña queja mía es que usted simplemente no puede entender las estadísticas. Esto es extremadamente importante en las regiones Sunbelt por ejemplo el sur de California. Curiosamente, la última generación de Viagra aparecerá como una goma de mascar que se quiere debe masticar media hora antes del sexo. Todo tipo de Viagra genérico funciona dentro de una hora de tomarlos. Se ha dicho que tiene la cirugía de liposucción en la espalda baja, los muslos y las piernas y áreas de estómago. En términos simples, contendrá mismos ingredientes, la fuerza, la dosis, etc. Siempre que sea posible lo que realmente es mejor para manipular puntos de colesterol sin medicamentos, primero. Para ello, mantienen sus sitios web dedicados que exhiben casi todos sus productos importantes, servicios, características, detalles de precios, problemas de privacidad, condiciones y términos, etc. Los trabajadores de la salud advierten a las personas que no deben administrar estos dispositivos medicinales si ya han estado considerando otros tratamientos medicinales que incorporan cierta proporción de nitratos. Esta puede ser la mejor suplementos naturales de energía, nada hecha de un laboratorio. Deseamos artículos en la mejor calidad posible, lo que significa que sólo vamos a aprobar los artículos que tienen un número de palabras de 500 o superior. Viagra genérico es en realidad una dosis oral que puede ayudar a los músculos del pene más suave y permite la circulación de la sangre por lo tanto, a cambio ayuda a relajarse los músculos. La mayoría de estos efectos secundarios incómodos son temporales y leves para que usted no tiene preocuparse por ellos. Además, cada una de las mujeres sufrieron con moderada a los calambres menstruales severos. Así que empieza a concentrarse en el uso de una dieta nutritiva, así como este medicamento y mantener su cuerpo en forma para siempre.

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Este fue en realidad un tratamiento muy agradable y tambiГ©n es bueno rodando en su inicio es la razГіn por la que se convirtiГі en un muy popular tan rГЎpidamente. El principal punto de venta de comprar Viagra en una tienda en Internet es que va a ser entregado dentro del paquete normal, asГ­ que sГіlo tienes que seleccionar el sitio de web mГЎs eficaz y deleitarse con enormes ventajas que ofrece medicamentos en lГ­nea. Levitra muestra su efecto en menos de media hora, aunque Cialis usted podrГ­a estar listo en 16 minutos. Hoy en dГ­a, el extracto de muira puama es uno de los potenciadores de la libido femenina comunes Гєtiles para tratar una variedad de trastornos de salud como infertilidad. artГ­culos como un medio para conducir un automГіvil mГЎs trГЎfico para sus sitios. Una gran variedad de seguidores siguieron el enlace web y lo descargГі. Los hombres a causa de estrГ©s y indebidos circunstancias casi todos vienen a travГ©s de, desarrolla capacidades durante el paso del tiempo las cosas se ponen incluso inmanejable si ser ignorado. Cuando usted ha manchado signos primarios o sГ­ntomas de mal funcionamiento asegГєrese de cerrar el beber y en algunos casos utilizando los cigarrillos porque los hГЎbitos inadecuados simplemente intensifican la dolencia. Ellos piensan que es como uno en el sentimiento intangible, que no tiene descripciГіn verbal o textual. Hay muy poca persona hoy que no sabe lo que son las drogas se ha diseГ±ado. Deje que su profesional mГ©dico sepa si le toca estar tomando otros medicamentos, incluyendo vitaminas y hierbas. Si las pruebas CGI estГЎn en lo cierto, esta bolsa de aire posible podrГ­a salvar incontables vidas y numerosos dГіlares de seguros. Hay un montГіn de ideas falsas acerca de las pГ­ldoras del realce del pene que contienen extienden como la pГіlvora por toda la Internet. Si usted tiene una libido muy baja, lo que significa que no tiene mucho de un deseo por el sexo y es posible hacerlo una vez dentro de un tiempo.

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  • Nature Welcomes You To…
  • Method of Therapeutic …
  • A Curriculum Tailored …
  • Parental Involvment Pl…
  • A Professional, Commit…
  • Milieu and Behavioral …

Nature Welcomes You To Cherry Gulch.

Nestled in the scenic Treasure Valley, beneath the western slope of the Rocky Mountains, lies a place near Boise, Idaho where the grandeur of Nature joins the brilliance of compassion

Method of Therapeutic Intervention

As a therapeutic boarding school, Cherry Gulch strives to entwine the most effective therapeutic strategies into our student’s daily life, including group and family psychotherapy, equine therapy, and much more

A Curriculum Tailored to Student Needs

We offer a tailored curriculum covering all core subject areas including English, Math, History and Science, as well as elective programs including Art, Robotics, Judo, and many more

Parental Involvment Plays a Vital Role

Therapeutic programs that maximize parental involvement have better long-term success, and Cherry Gulch allows more contact with parents than most residential programs.

A Professional, Committed Staff

Cherry Gulch staff are committed to providing a premium environment and level of care for each of our students. Click the Read More link to view staff bio pages.

Milieu and Behavioral Management

The milieu at Cherry Gulch incorporates a number of techniques and strategies specifically tailored to this population of troubled children, including a level system and a token economy.

Common use

The main component of Viagra is Sildenafil Citrate.
Sildenafil Citrate affects the response to sexual stimulation. It acts by enhancing smooth muscle relaxation using nitric oxide, a chemical that is normally released in response to sexual stimulation. This smooth muscle relaxation allows increased blood flow into certain areas of the penis, which leads to an erection.
Sildenafil Citrate is applied for the treatment of erectile dysfunction (impotence) in men and pulmonary arterial hypertension.
Sildenafil Citrate may also be used for other purposes not listed above.

Dosage and direction

Usually the recommended dose is 50 mg. It is taken approximately 0,5-1 hour before sexual activity. Do not take Viagra more then once a day.
A high fat meal may delay the time of the effect of this drug.
Try not to eat grapefruit or drink grapefruit juice while you are being treated with Sildenafil Citrate .

Precautions

Before you start taking Sildenafil Citrate. tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies.
Aged people may be more sensitive to the side effects of the drug.

Viagra is contraindicated in patients who take another medicine to treat impotence or using a nitrate drug for chest pain or heart problems.
This medicine should not be taken by women and children as well as in patients with a known hypersensitivity to any component of the tablet.

Possible side effect

The most common side effects are headache, flushing, heartburn, stomach upset, nasal stuffiness, lightheadedness, dizziness or diarrhea.
A serious allergic reaction to this drug is very rare, but seek immediate medical help if it occurs.
Many people who use this medicine do not have serious side effects.
In case you notice any side effects not listed above, contact your doctor or pharmacist.

Drug interaction

This drug should not be used with nitrates and recreational drugs called “poppers” containing amyl or butyl nitrite; alpha-blocker medications; other medications for impotence; high blood pressure medicines, etc.
Consult your doctor or pharmacist for more details.

Missed dose

Viagra is used as needed, so you are unlikely to be on a dosing schedule.

Overdose

If you think you have used too much of this medicine seek emergency medical attention right away. The symptoms of overdose usually include chest pain, nausea, irregular heartbeat, and feeling light-headed or fainting.

Storage

Store your medicines at room temperature between 68-77 degrees F (20-25 degrees C) away from light and moisture. Do not store the drugs in the bathroom. Keep all drugs away from reach of children and pets.

Disclaimer

We provide only general information about medications which does not cover all directions, possible drug integrations, or precautions. Information at the site cannot be used for self-treatment and self-diagnosis. Any specific instructions for a particular patient should be agreed with your health care adviser or doctor in charge of the case. We disclaim reliability of this information and mistakes it could contain. We are not responsible for any direct, indirect, special or other indirect damage as a result of any use of the information on this site and also for consequences of self-treatment.

Common use

The main component of Viagra is Sildenafil Citrate.
Sildenafil Citrate affects the response to sexual stimulation. It acts by enhancing smooth muscle relaxation using nitric oxide, a chemical that is normally released in response to sexual stimulation. This smooth muscle relaxation allows increased blood flow into certain areas of the penis, which leads to an erection.
Sildenafil Citrate is applied for the treatment of erectile dysfunction (impotence) in men and pulmonary arterial hypertension.
Sildenafil Citrate may also be used for other purposes not listed above.

Dosage and direction

Usually the recommended dose is 50 mg. It is taken approximately 0,5-1 hour before sexual activity. Do not take Viagra more then once a day.
A high fat meal may delay the time of the effect of this drug.
Try not to eat grapefruit or drink grapefruit juice while you are being treated with Sildenafil Citrate .

Precautions

Before you start taking Sildenafil Citrate. tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies.
Aged people may be more sensitive to the side effects of the drug.

Viagra is contraindicated in patients who take another medicine to treat impotence or using a nitrate drug for chest pain or heart problems.
This medicine should not be taken by women and children as well as in patients with a known hypersensitivity to any component of the tablet.

Possible side effect

The most common side effects are headache, flushing, heartburn, stomach upset, nasal stuffiness, lightheadedness, dizziness or diarrhea.
A serious allergic reaction to this drug is very rare, but seek immediate medical help if it occurs.
Many people who use this medicine do not have serious side effects.
In case you notice any side effects not listed above, contact your doctor or pharmacist.

Drug interaction

This drug should not be used with nitrates and recreational drugs called “poppers” containing amyl or butyl nitrite; alpha-blocker medications; other medications for impotence; high blood pressure medicines, etc.
Consult your doctor or pharmacist for more details.

Missed dose

Viagra is used as needed, so you are unlikely to be on a dosing schedule.

Overdose

If you think you have used too much of this medicine seek emergency medical attention right away. The symptoms of overdose usually include chest pain, nausea, irregular heartbeat, and feeling light-headed or fainting.

Storage

Store your medicines at room temperature between 68-77 degrees F (20-25 degrees C) away from light and moisture. Do not store the drugs in the bathroom. Keep all drugs away from reach of children and pets.

Disclaimer

We provide only general information about medications which does not cover all directions, possible drug integrations, or precautions. Information at the site cannot be used for self-treatment and self-diagnosis. Any specific instructions for a particular patient should be agreed with your health care adviser or doctor in charge of the case. We disclaim reliability of this information and mistakes it could contain. We are not responsible for any direct, indirect, special or other indirect damage as a result of any use of the information on this site and also for consequences of self-treatment.

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Red Viagra 10 Tablet 200 Mg in Snow Hill, Maryland is small town living at its best. Nestled on the south banks of the Pocomoke River Snow Hill is a place where people know each other. From the people who call it home to the business owners and those in city government, we have built a community where life is gentle, fun, and prosperous. Home to a quaint downtown retail area and a broad spectrum of recreational activities, Red Viagra 10 Tablet 200 Mg is the perfect place to spend a relaxing weekend or a lifetime.

Whether you are interested in researching your genealogy in the Worcester Room of the Worcester County Library. renting a kayak from the Pocomoke River Canoe Company to paddle on an undeveloped natural river, or studying the architecture of historic homes and beautiful churches while taking the Historic Walking Tour, Red Viagra 10 Tablet 200 Mg has something for everyone. You will find recreational opportunities in Byrd Park and Sturgis Park, artifacts at the Julia A. Purnell Museum. and treasures in the shops and art galleries.

The beautiful rural setting boasts rich farmland that has been the mainstay of the economy of the county seat of Worcester County for centuries. The rich heritage of this area is celebrated daily at Furnace Town Living Heritage Museum and during a summer festival every August with The Blessing of the Combines.

The town of Red Viagra 10 Tablet 200 Mg welcomes you as you explore our small town steeped in history and tradition but alive with charm and activities.

Wednesday through Saturday evenings at 8:00 pm with a Thursday matinee at 2:00 pm.

TICKET PRICES

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Adults: $25
Seniors: $20 (65 or older)
Students (HS & under): $10

Friday & Saturday
Adults: $30
Seniors: $25 (65 or older)
Students (HS & under): $10

FLEX PASS

Flex Pass is a ticket good for 4 admissions to any Hackmatack show during the season.
Adults: $100
Seniors: $80 (65 or older)
Click here to purchase Flex Pass

CONTACT INFO

Tickets can be purchased online. Please note all tickets purchased online are subject to a third party processing fee. To avoid this fee, tickets can be reserved by calling the box office.

Red Viagra Tablets

Hackmatack Playhouse was founded in 1972 by S. Carleton Red Viagra Tablets. He envisioned a summer stock theatre that would showcase the talents of professional and developing thespians from the regional area.

Many theatre goers have called Hackmatack one of New England’s most charming and quaint summer theatres. Some have even said that summer in Maine is not summer without a trip to Hackmatack. Much of the allure of this playhouse is its scenic location and historical presence.

Hackmatack Playhouse is located on the Red Viagra Tablets family farmstead. The property was purchased by the first Red Viagra Tablets (then Gubtail) to make the long trip to “New England” from native British Isles in the mid 1600’s. Thomas Red Viagra Tablets built the first home, a log house which sat in the far left of the present day field overlooking the irrigation pond. According to family legend, this home was burnt down by Indians during one of the many raids on the Salmon Falls river region. The present day farmhouse was constructed between the years of 1716-2005 to appease the needs of an ever-changing diverse and dynamic Red Viagra Tablets family. When it was first constructed, the house was a large cape sitting endwise to the road. It was occupied at one point by two Red Viagra Tablets brothers. The younger brother decided that he would like to have a modern two story cape. His older brother in typical conservative fashion said “the house is plenty good enough the way it is”. The younger brother replied, “My half is coming off”. He then proceeded to saw his half off and tear it down. He built his family a two story cape on the end of the original house, parallel to the road, giving the house its shape. Minor reconstructions have taken place since then to create a more modern and functional house for the present day Red Viagra Tabletss.

Prior to the year of 1972 when the theatre was established, the Red Viagra Tablets family farm functioned like many other farms at the time. The barn was the focal point of the farm. The current barn has an interesting story much like the original house. One of the first barns was struck by lightning and burned in July of 1934. Haying had just been completed for the season, and it is thought that the heat from the newly cut hay attracted the lightning. Almost immediately, Lewis Red Viagra Tablets began looking for the right barn to replace what had been lost. He finally purchased a barn. It was a large old structure with pegged timbers measuring fifty four feet long and forty two feet wide. It was the perfect replacement for the old barn. However, there was one small problem, it was located across the street.

Luckily, the Red Viagra Tablets’s have always been known for their ingenuity. It was with this cleverness that Lewis decided it would be easier to move the barn rather than disassemble it and rebuilt it. The entire barn was jacked up and rollers were placed underneath it. A cable was attached to one end of the barn that ran though a large turnstile. An old white horse was chosen for the job of slowly moving the barn. The horse was hitched to the turnstile and the horse walked in circles, stepping over the cable on every lap. The leverage was great and each time the horse made a circle, the barn moved one half inch. Progress was slow. The entire operation took about three days, a day of that was spent crossing Maine route 9. However, in 1934, Maine route 9 was much less traveled, and everyone cheerfully watched or made their own route around the barn.

After the theatre’s first decade the barn was expanded to the structure that you see today. An addition was added to the back, cement was added to form the floor, and the stage was expanded. These changes made room for the 218 seats the theatre houses today. It is rumored that back in 1972 patrons sat on hay bales to watch the show, however the original playhouse actually had seats that were salvaged from a Durham New Hampshire movie theater.

The grounds of Hackmatack Playhouse and the area surrounding the theatre host many other buildings built and used by the Red Viagra Tablets clan over the years. The yellow family of buildings just south of the theatre (now owned by the Mills family) was originally built by Samuel Red Viagra Tablets in the early part of last century. Known as the Forget-Me-Not, these buildings housed services for early automobile travelers, including fuel for the autos, and food for the hungry. Visitors could rent a cabin, and if they happened to be staying on a Saturday night, they were in luck. On Saturday night there were always barn dances.

The oldest building on the farmstead is the “woodshed” which is just south of the house. This building dates back to the 1600’s and has been used for many purposes over the years. It has been used as a slaughter house and for drying meat. It now is used for rehearsal space and prop storage.

The “mill” is across the orchard from the “woodshed”. It now houses the theatre’s shop operations and its costume collection. However during the years of self-sufficient farming, it was one of several lumber mills built on the property by Lewis Red Viagra Tablets in the middle part of the 1900’s. This was a complete finish lumber mill powered by an Allis Chalmers tractor. If you listen carefully through the whirr of the belts and the screech of the saws you might just be able to hear Lewis and Almon Allen, and young Carelton Red Viagra Tablets, prepare a load of lumber for the newest construction project.

The Red Viagra Tablets family has a long tradition of entertaining locals and summer visitors in the Beaver Dam section of Berwick. Samuel’s weekly barn dances at the “Forget Me Not” were a favorite pastime during the early decades of the 1900’s. His son Lewis, a local and state Grange Master, was also a master of many musical instruments. He had a passion for starting bands and performing in Beaver Dam and across the state of Maine. His son Carleton organized several theatre groups, first at the Beaver Dam grange, and then at his barn now called Hackmatack Playhouse.

Every year thousands of people gather outside the Playhouse with tickets to the summer’s productions. Every year talented actors audition for their chance to perform at Hackmatack Playhouse, and to experience the history and excitement of being part of Hackmatack’s family. The farm and its building have many stories to tell. Perhaps 200 years from now Red Viagra Tablets great, great grandchildren will be telling this story to aspiring actors nervously waiting for their audition slot, and to friendly crowds waiting to take their seats; of how the barn became home for the Hackmatack Playhouse.

After the death of the founder in 1995, the S Carleton Red Viagra Tablets Memorial Fund was established to preserve and improve our historical buildings. The fund also is dedicated to advancements of dramatic arts, both for the participant and the community, and to the commitment of providing quality family entertainment and drama at a reasonable price. Contributions are always welcomed. We thank you in advance for helping us secure the future of Hackmatack Playhouse for potential Hackmatackers.

Hackmatack exists because of the generosity of it’s patrons, friends and those that appreciate the theater’s contribution to local culture and community. It is committed to the advancement of dramatic arts and to providing quality family entertainment at a reasonable price.

We ask that you would consider a donation, and thank you in advance.

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Geburtstagsspiele Viagra Torte

Geburtstagsspiele Viagra Torte in Snow Hill, Maryland is small town living at its best. Nestled on the south banks of the Pocomoke River Snow Hill is a place where people know each other. From the people who call it home to the business owners and those in city government, we have built a community where life is gentle, fun, and prosperous. Home to a quaint downtown retail area and a broad spectrum of recreational activities, Geburtstagsspiele Viagra Torte is the perfect place to spend a relaxing weekend or a lifetime.

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The beautiful rural setting boasts rich farmland that has been the mainstay of the economy of the county seat of Worcester County for centuries. The rich heritage of this area is celebrated daily at Furnace Town Living Heritage Museum and during a summer festival every August with The Blessing of the Combines.

The town of Geburtstagsspiele Viagra Torte welcomes you as you explore our small town steeped in history and tradition but alive with charm and activities.

Wednesday through Saturday evenings at 8:00 pm with a Thursday matinee at 2:00 pm.

TICKET PRICES

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Adults: $25
Seniors: $20 (65 or older)
Students (HS & under): $10

Friday & Saturday
Adults: $30
Seniors: $25 (65 or older)
Students (HS & under): $10

FLEX PASS

Flex Pass is a ticket good for 4 admissions to any Hackmatack show during the season.
Adults: $100
Seniors: $80 (65 or older)
Click here to purchase Flex Pass

CONTACT INFO

Tickets can be purchased online. Please note all tickets purchased online are subject to a third party processing fee. To avoid this fee, tickets can be reserved by calling the box office.

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Hackmatack Playhouse was founded in 1972 by S. Carleton Viagra Usa Generic. He envisioned a summer stock theatre that would showcase the talents of professional and developing thespians from the regional area.

Many theatre goers have called Hackmatack one of New England’s most charming and quaint summer theatres. Some have even said that summer in Maine is not summer without a trip to Hackmatack. Much of the allure of this playhouse is its scenic location and historical presence.

Hackmatack Playhouse is located on the Viagra Usa Generic family farmstead. The property was purchased by the first Viagra Usa Generic (then Gubtail) to make the long trip to “New England” from native British Isles in the mid 1600’s. Thomas Viagra Usa Generic built the first home, a log house which sat in the far left of the present day field overlooking the irrigation pond. According to family legend, this home was burnt down by Indians during one of the many raids on the Salmon Falls river region. The present day farmhouse was constructed between the years of 1716-2005 to appease the needs of an ever-changing diverse and dynamic Viagra Usa Generic family. When it was first constructed, the house was a large cape sitting endwise to the road. It was occupied at one point by two Viagra Usa Generic brothers. The younger brother decided that he would like to have a modern two story cape. His older brother in typical conservative fashion said “the house is plenty good enough the way it is”. The younger brother replied, “My half is coming off”. He then proceeded to saw his half off and tear it down. He built his family a two story cape on the end of the original house, parallel to the road, giving the house its shape. Minor reconstructions have taken place since then to create a more modern and functional house for the present day Viagra Usa Generics.

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Luckily, the Viagra Usa Generic’s have always been known for their ingenuity. It was with this cleverness that Lewis decided it would be easier to move the barn rather than disassemble it and rebuilt it. The entire barn was jacked up and rollers were placed underneath it. A cable was attached to one end of the barn that ran though a large turnstile. An old white horse was chosen for the job of slowly moving the barn. The horse was hitched to the turnstile and the horse walked in circles, stepping over the cable on every lap. The leverage was great and each time the horse made a circle, the barn moved one half inch. Progress was slow. The entire operation took about three days, a day of that was spent crossing Maine route 9. However, in 1934, Maine route 9 was much less traveled, and everyone cheerfully watched or made their own route around the barn.

After the theatre’s first decade the barn was expanded to the structure that you see today. An addition was added to the back, cement was added to form the floor, and the stage was expanded. These changes made room for the 218 seats the theatre houses today. It is rumored that back in 1972 patrons sat on hay bales to watch the show, however the original playhouse actually had seats that were salvaged from a Durham New Hampshire movie theater.

The grounds of Hackmatack Playhouse and the area surrounding the theatre host many other buildings built and used by the Viagra Usa Generic clan over the years. The yellow family of buildings just south of the theatre (now owned by the Mills family) was originally built by Samuel Viagra Usa Generic in the early part of last century. Known as the Forget-Me-Not, these buildings housed services for early automobile travelers, including fuel for the autos, and food for the hungry. Visitors could rent a cabin, and if they happened to be staying on a Saturday night, they were in luck. On Saturday night there were always barn dances.

The oldest building on the farmstead is the “woodshed” which is just south of the house. This building dates back to the 1600’s and has been used for many purposes over the years. It has been used as a slaughter house and for drying meat. It now is used for rehearsal space and prop storage.

The “mill” is across the orchard from the “woodshed”. It now houses the theatre’s shop operations and its costume collection. However during the years of self-sufficient farming, it was one of several lumber mills built on the property by Lewis Viagra Usa Generic in the middle part of the 1900’s. This was a complete finish lumber mill powered by an Allis Chalmers tractor. If you listen carefully through the whirr of the belts and the screech of the saws you might just be able to hear Lewis and Almon Allen, and young Carelton Viagra Usa Generic, prepare a load of lumber for the newest construction project.

The Viagra Usa Generic family has a long tradition of entertaining locals and summer visitors in the Beaver Dam section of Berwick. Samuel’s weekly barn dances at the “Forget Me Not” were a favorite pastime during the early decades of the 1900’s. His son Lewis, a local and state Grange Master, was also a master of many musical instruments. He had a passion for starting bands and performing in Beaver Dam and across the state of Maine. His son Carleton organized several theatre groups, first at the Beaver Dam grange, and then at his barn now called Hackmatack Playhouse.

Every year thousands of people gather outside the Playhouse with tickets to the summer’s productions. Every year talented actors audition for their chance to perform at Hackmatack Playhouse, and to experience the history and excitement of being part of Hackmatack’s family. The farm and its building have many stories to tell. Perhaps 200 years from now Viagra Usa Generic great, great grandchildren will be telling this story to aspiring actors nervously waiting for their audition slot, and to friendly crowds waiting to take their seats; of how the barn became home for the Hackmatack Playhouse.

After the death of the founder in 1995, the S Carleton Viagra Usa Generic Memorial Fund was established to preserve and improve our historical buildings. The fund also is dedicated to advancements of dramatic arts, both for the participant and the community, and to the commitment of providing quality family entertainment and drama at a reasonable price. Contributions are always welcomed. We thank you in advance for helping us secure the future of Hackmatack Playhouse for potential Hackmatackers.

Hackmatack exists because of the generosity of it’s patrons, friends and those that appreciate the theater’s contribution to local culture and community. It is committed to the advancement of dramatic arts and to providing quality family entertainment at a reasonable price.

We ask that you would consider a donation, and thank you in advance.

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Wednesday through Saturday evenings at 8:00 pm with a Thursday matinee at 2:00 pm.

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Hackmatack Playhouse was founded in 1972 by S. Carleton Viagra 50 Mg Online India. He envisioned a summer stock theatre that would showcase the talents of professional and developing thespians from the regional area.

Many theatre goers have called Hackmatack one of New England’s most charming and quaint summer theatres. Some have even said that summer in Maine is not summer without a trip to Hackmatack. Much of the allure of this playhouse is its scenic location and historical presence.

Hackmatack Playhouse is located on the Viagra 50 Mg Online India family farmstead. The property was purchased by the first Viagra 50 Mg Online India (then Gubtail) to make the long trip to “New England” from native British Isles in the mid 1600’s. Thomas Viagra 50 Mg Online India built the first home, a log house which sat in the far left of the present day field overlooking the irrigation pond. According to family legend, this home was burnt down by Indians during one of the many raids on the Salmon Falls river region. The present day farmhouse was constructed between the years of 1716-2005 to appease the needs of an ever-changing diverse and dynamic Viagra 50 Mg Online India family. When it was first constructed, the house was a large cape sitting endwise to the road. It was occupied at one point by two Viagra 50 Mg Online India brothers. The younger brother decided that he would like to have a modern two story cape. His older brother in typical conservative fashion said “the house is plenty good enough the way it is”. The younger brother replied, “My half is coming off”. He then proceeded to saw his half off and tear it down. He built his family a two story cape on the end of the original house, parallel to the road, giving the house its shape. Minor reconstructions have taken place since then to create a more modern and functional house for the present day Viagra 50 Mg Online Indias.

Prior to the year of 1972 when the theatre was established, the Viagra 50 Mg Online India family farm functioned like many other farms at the time. The barn was the focal point of the farm. The current barn has an interesting story much like the original house. One of the first barns was struck by lightning and burned in July of 1934. Haying had just been completed for the season, and it is thought that the heat from the newly cut hay attracted the lightning. Almost immediately, Lewis Viagra 50 Mg Online India began looking for the right barn to replace what had been lost. He finally purchased a barn. It was a large old structure with pegged timbers measuring fifty four feet long and forty two feet wide. It was the perfect replacement for the old barn. However, there was one small problem, it was located across the street.

Luckily, the Viagra 50 Mg Online India’s have always been known for their ingenuity. It was with this cleverness that Lewis decided it would be easier to move the barn rather than disassemble it and rebuilt it. The entire barn was jacked up and rollers were placed underneath it. A cable was attached to one end of the barn that ran though a large turnstile. An old white horse was chosen for the job of slowly moving the barn. The horse was hitched to the turnstile and the horse walked in circles, stepping over the cable on every lap. The leverage was great and each time the horse made a circle, the barn moved one half inch. Progress was slow. The entire operation took about three days, a day of that was spent crossing Maine route 9. However, in 1934, Maine route 9 was much less traveled, and everyone cheerfully watched or made their own route around the barn.

After the theatre’s first decade the barn was expanded to the structure that you see today. An addition was added to the back, cement was added to form the floor, and the stage was expanded. These changes made room for the 218 seats the theatre houses today. It is rumored that back in 1972 patrons sat on hay bales to watch the show, however the original playhouse actually had seats that were salvaged from a Durham New Hampshire movie theater.

The grounds of Hackmatack Playhouse and the area surrounding the theatre host many other buildings built and used by the Viagra 50 Mg Online India clan over the years. The yellow family of buildings just south of the theatre (now owned by the Mills family) was originally built by Samuel Viagra 50 Mg Online India in the early part of last century. Known as the Forget-Me-Not, these buildings housed services for early automobile travelers, including fuel for the autos, and food for the hungry. Visitors could rent a cabin, and if they happened to be staying on a Saturday night, they were in luck. On Saturday night there were always barn dances.

The oldest building on the farmstead is the “woodshed” which is just south of the house. This building dates back to the 1600’s and has been used for many purposes over the years. It has been used as a slaughter house and for drying meat. It now is used for rehearsal space and prop storage.

The “mill” is across the orchard from the “woodshed”. It now houses the theatre’s shop operations and its costume collection. However during the years of self-sufficient farming, it was one of several lumber mills built on the property by Lewis Viagra 50 Mg Online India in the middle part of the 1900’s. This was a complete finish lumber mill powered by an Allis Chalmers tractor. If you listen carefully through the whirr of the belts and the screech of the saws you might just be able to hear Lewis and Almon Allen, and young Carelton Viagra 50 Mg Online India, prepare a load of lumber for the newest construction project.

The Viagra 50 Mg Online India family has a long tradition of entertaining locals and summer visitors in the Beaver Dam section of Berwick. Samuel’s weekly barn dances at the “Forget Me Not” were a favorite pastime during the early decades of the 1900’s. His son Lewis, a local and state Grange Master, was also a master of many musical instruments. He had a passion for starting bands and performing in Beaver Dam and across the state of Maine. His son Carleton organized several theatre groups, first at the Beaver Dam grange, and then at his barn now called Hackmatack Playhouse.

Every year thousands of people gather outside the Playhouse with tickets to the summer’s productions. Every year talented actors audition for their chance to perform at Hackmatack Playhouse, and to experience the history and excitement of being part of Hackmatack’s family. The farm and its building have many stories to tell. Perhaps 200 years from now Viagra 50 Mg Online India great, great grandchildren will be telling this story to aspiring actors nervously waiting for their audition slot, and to friendly crowds waiting to take their seats; of how the barn became home for the Hackmatack Playhouse.

After the death of the founder in 1995, the S Carleton Viagra 50 Mg Online India Memorial Fund was established to preserve and improve our historical buildings. The fund also is dedicated to advancements of dramatic arts, both for the participant and the community, and to the commitment of providing quality family entertainment and drama at a reasonable price. Contributions are always welcomed. We thank you in advance for helping us secure the future of Hackmatack Playhouse for potential Hackmatackers.

Hackmatack exists because of the generosity of it’s patrons, friends and those that appreciate the theater’s contribution to local culture and community. It is committed to the advancement of dramatic arts and to providing quality family entertainment at a reasonable price.

We ask that you would consider a donation, and thank you in advance.

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