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Predam Viagra Pfizer 100mg Cialis 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, Predam Viagra Pfizer 100mg Cialis 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, Predam Viagra Pfizer 100mg Cialis 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 Predam Viagra Pfizer 100mg Cialis 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 Predam Viagra Pfizer 100mg Cialis. 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 Predam Viagra Pfizer 100mg Cialis family farmstead. The property was purchased by the first Predam Viagra Pfizer 100mg Cialis (then Gubtail) to make the long trip to “New England” from native British Isles in the mid 1600’s. Thomas Predam Viagra Pfizer 100mg Cialis 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 Predam Viagra Pfizer 100mg Cialis 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 Predam Viagra Pfizer 100mg Cialis 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 Predam Viagra Pfizer 100mg Cialiss.

Prior to the year of 1972 when the theatre was established, the Predam Viagra Pfizer 100mg Cialis 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 Predam Viagra Pfizer 100mg Cialis 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 Predam Viagra Pfizer 100mg Cialis’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 Predam Viagra Pfizer 100mg Cialis 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 Predam Viagra Pfizer 100mg Cialis 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 Predam Viagra Pfizer 100mg Cialis 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 Predam Viagra Pfizer 100mg Cialis, prepare a load of lumber for the newest construction project.

The Predam Viagra Pfizer 100mg Cialis 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 Predam Viagra Pfizer 100mg Cialis 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 Predam Viagra Pfizer 100mg Cialis 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.

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

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Instructions For Viagra Use 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, Instructions For Viagra Use 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, Instructions For Viagra Use 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 Instructions For Viagra Use welcomes you as you explore our small town steeped in history and tradition but alive with charm and activities.

Viagra

GENERIC NAME(S): SILDENAFIL CITRATE

Uses

Sildenafil is used to treat male sexual function problems (impotence or erectile dysfunction -ED). In combination with sexual stimulation, sildenafil works by increasing blood flow to the penis to help a man get and keep an erection.

OTHER USES: This section contains uses of this drug that are not listed in the approved professional labeling for the drug but that may be prescribed by your health care professional. Use this drug for a condition that is listed in this section only if it has been so prescribed by your health care professional.

Sildenafil is also available in other brands and strengths for treating high blood pressure in the lungs (pulmonary hypertension ). Do not take this medication with any other product that contains sildenafil or other similar medications for erectile dysfunction -ED or pulmonary hypertension (such as tadalafil, vardenafil).

How to use Viagra

Read the Patient Information Leaflet provided by your pharmacist before you start taking sildenafil and each time you get a refill. If you have any questions, ask your doctor or pharmacist.

To treat erectile dysfunction -ED, take this drug by mouth as directed by your doctor, usually as needed. Take sildenafil at least 30 minutes, but no more than 4 hours, before sexual activity (1 hour before is the most effective). Do not take more than once daily.

A high-fat meal may delay how quickly the drug begins to work.

The dosage is based on your medical condition, response to treatment, and other medications you may be taking. Be sure to tell your doctor and pharmacist about all the products you use (including prescription drugs, nonprescription drugs, and herbal products).

Tell your doctor if your condition does not improve.

Side Effects

Dizziness. headache. flushing, or stomach upset may occur. Vision changes such as increased sensitivity to light, blurred vision. or trouble telling blue and green colors apart may also occur. If any of these effects persist or worsen, tell your doctor or pharmacist promptly.

To reduce the risk of dizziness and lightheadedness, get up slowly when rising from a sitting or lying position.

Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.

Sexual activity may put extra strain on your heart. especially if you have heart problems. If you have heart problems and experience any of these serious side effects while having sex. stop and get medical help right away: severe dizziness, fainting. chest/jaw/left arm pain, nausea .

Rarely, sudden decreased vision. including permanent blindness, in one or both eyes (NAION) may occur. If this serious problem occurs, stop taking sildenafil and get medical help right away. You have a slightly greater chance of developing NAION if you have heart disease. diabetes. high cholesterol. certain other eye problems (“crowded disk”), high blood pressure. if you are over 50, or if you smoke.

Rarely, a sudden decrease or loss of hearing, sometimes with ringing in the ears and dizziness, may occur. Stop taking sildenafil and get medical help right away if these effects occur.

In the rare event you have a painful or prolonged erection lasting 4 or more hours, stop using this drug and get medical help right away, or permanent problems could occur.

A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction. including: rash. itching /swelling (especially of the face/tongue /throat), severe dizziness, trouble breathing .

This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or at www.fda.gov/medwatch.

In Canada – Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.

Precautions

Before taking sildenafil, tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details.

Before using this medication, tell your doctor or pharmacist your medical history, especially of: heart problems (such as heart attack or life-threatening irregular heartbeat in the past 6 months, chest pain/angina, heart failure), stroke in the past 6 months, kidney disease, liver disease, high or low blood pressure. a severe loss of body water (dehydration), penis conditions (such as angulation, fibrosis/scarring, Peyronie’s disease ), history of painful/prolonged erection (priapism), conditions that may increase the risk of priapism (such as sickle cell anemia. leukemia, multiple myeloma ), eye problems (such as retinitis pigmentosa. sudden decreased vision, NAION).

This drug may make you dizzy or cause vision problems. Do not drive, use machinery, or do any activity that requires alertness or clear vision until you are sure you can perform such activities safely. Limit alcoholic beverages.

Before having surgery, tell your doctor or dentist about all the products you use (including prescription drugs, nonprescription drugs, and herbal products).

This brand of the drug is usually not used in women. During pregnancy, sildenafil should be used only when clearly needed. Discuss the risks and benefits with your doctor.

It is unknown if this medication passes into breast milk. Consult your doctor before breast-feeding.

Interactions

Drug interactions may change how your medications work or increase your risk for serious side effects. This document does not contain all possible drug interactions. Keep a list of all the products you use (including prescription/nonprescription drugs and herbal products) and share it with your doctor and pharmacist. Do not start, stop, or change the dosage of any medicines without your doctor’s approval.

A product that may interact with this drug is: riociguat.

Sildenafil can cause a serious drop in your blood pressure when used with nitrates. A serious drop in blood pressure can lead to dizziness, fainting, and rarely heart attack or stroke. Do not use sildenafil with any of the following: certain drugs used to treat chest pain/angina (nitrates such as nitroglycerin, isosorbide), recreational drugs called “poppers” containing amyl nitrate, amyl nitrite, or butyl nitrite.

If you are also taking an alpha blocker medication (such as doxazosin, tamsulosin) to treat an enlarged prostate/BPH or high blood pressure, your blood pressure may get too low which can lead to dizziness or fainting. Your doctor may start treatment with a lower dose of sildenafil to minimize your risk of low blood pressure.

Other medications can affect the removal of sildenafil from your body, which may affect how sildenafil works. Examples include azole antifungals (such as itraconazole, ketoconazole), macrolide antibiotics (such as clarithromycin, erythromycin), HIV protease inhibitors (such as ritonavir, saquinavir), hepatitis C virus protease inhibitors (such as boceprevir, telaprevir), mifepristone, rifampin, among others.

Do not take this medication with any other product that contains sildenafil or other similar medications for erectile dysfunction-ED or pulmonary hypertension (such as tadalafil, vardenafil).

Overdose

If overdose is suspected, contact a poison control center or emergency room right away. US residents can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial poison control center. Symptoms of overdose may include severe dizziness, fainting, painful/prolonged erection.

Notes

Do not share this medication with others.

Missed Dose

Storage

Store at room temperature away from light and moisture. Do not store in the bathroom. Keep all medications away from children and pets.

Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company.

Information last revised October 2015. Copyright(c) 2015 First Databank, Inc.

Images

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

TICKET PRICES

Viagra Instructions For Use sale
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 Instructions For Use. 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 Instructions For Use family farmstead. The property was purchased by the first Viagra Instructions For Use (then Gubtail) to make the long trip to “New England” from native British Isles in the mid 1600’s. Thomas Viagra Instructions For Use 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 Instructions For Use 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 Instructions For Use 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 Instructions For Uses.

Prior to the year of 1972 when the theatre was established, the Viagra Instructions For Use 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 Instructions For Use 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 Instructions For Use’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 Instructions For Use 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 Instructions For Use 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 Instructions For Use 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 Instructions For Use, prepare a load of lumber for the newest construction project.

The Viagra Instructions For Use 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 Instructions For Use 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 Instructions For Use 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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Viagra

La viagra (no confundir con viagracao) es un medicamento cuyo nombre viene de “viejo agradecido”. TambiГ©n se dice que es una abreviaciГіn de “Vaginas Insatisfechas Agradecen Gran Remedio Americano”. Tiene la finalidad de “reactivar” la potencia erectiva del falo. mediante el la utilizacion de hormonas de burro (constituyente principal) y yeso (que aporta dureza extra y la consistencia solida de la pastilla). Las mas potentes pastillas son creadas por el Doctor Gregory House. de forma casera, utilizando sus propios eyaculaciones escupitajos.

ГЌndice

[editar ] Historia

En la antigГјedad, el no satisfacer a tu mujer podГ­a ser bastante peligroso.

En la antigГјedad de antes se originГі el primer caso de Levantar a un muerto (nombre coloquial para la re-erecciГіn de un falo sin vida ) este fue aquel famoso acontecimiento que salio en el libro “La Biblia”, en el que MoisГ©s levanto a su hermano NoГ© de entre los muertos.

Hoy en dГ­a sabemos que el inventor del Viagra fue El SeГ±or Burns. en el aГ±o XXX DC, con el fin de volverse activo e inmortal (cosa que NO logro. con la pastilla) pero al ver que esta cosa que invento tenГ­a otros efectos positivos, decidiГі sacarle provecho y comercializarla, asГ­ que se cambiГі el nombre a: Homo Erectus y le puso Vergara a su descubrimiento; en un principio este producto no se vendiГі como se esperaba ya que no existГ­a hombre (hetero) en la faz de la tierra, capaz de ir a una farmacia a pedir una “Vergara”, asi que Burns decidiГі cambiarle el nombre a “Viagra” que en griego (Viagraparos) significa: “Verga Erectacionada”.

[editar ] Como se administra

La viagra es muy usada en EEUU. tal y como se indica en la zona gris.

Anteriormente la pastilla tenia unos 8cm de diГЎmetro y no podГ­a ser ingerida por ser humano alguno, pero con el descubrimiento de los micropitufos. se pudo reducir notablemente el tamaГ±o de la pastilla, haciendo posible que los impotentes de todo el mundo fueran felices nuevamente.

En la actualidad de ahora, la pastilla puede ser ingerida por vГ­a oral sГіlo acompaГ±ГЎndola con un traguito de agua. y por vГ­a anal con un poquito de Vaselina.

Un detalle muy importante sobre la administraciГіn de la viagra es que debe ser consumida con anterioridad al sepso (unos 20 o 30 minutos antes de tirar, el tiempo puede variar segun lo jodido que estГ©s )

[editar ] Uso en adultos

El uso i responsable de la viagra en adultos es el siguiente:

  • Primero se debe fijar una hora determinada con su Amante. Prostituta. Secretaria. Aventura, sexo casual, oveja pareja (si usted estГЎ casado y tiene mГЎs de 7 aГ±os en eso entonces no serГЎ con su esposa no sea iluso). No se olvide de utilizar la pastilla porque si no tiene algo de acciГіn entonces le va a dar mal de Parkinson.
  • Administrar la pastilla de 20 a 30 minutos antes del Sepso (ya explicamos que el tiempo puede variar).
  • Mantener su mГ©todo anticonceptivo de preferencia a la mano. Si usted va a “encargar” entonces olvГ­dese del globito. idiota!
  • Mantener cerca un vaso de agua frГ­a. Algunas pastillas tienen un efecto exagerado y le podrГ­a explotar el pene.
  • Disfrute: Que ya usted es viejo, y por algo se gastГі el dinero en la pastilla.

[editar ] Uso en Menores

Barney cuando toma Viagra.

En los menores de edad no debe ser usado el Viagra especialmente si eres un pajero, pagizo o pajГєo. El Uso en menores, puede tener un efecto mas rГЎpido pero tomar en cuenta:

  • Si tomas una pastilla te puede dar cГЎncer fГЎlico por una alta cantidad de sangre acumulada en el pene.
  • Se te va a caer el pene. el pelo y los pectorales tambiГ©n (te va a salir barriga).
  • El menor de edad puede quedar en estado comatoso si se excita justo despuГ©s de ingerir la pastilla.
  • Te puedes morir.
  • Vas a alucinar con formas fГЎlicas y colores rojizos.

Aunque si siendo menor de edad ya tienes que tomar viagra para que se te levante, mejor consulta a un especialista, lo tuyo es grave.

Sin embargo si lo quieres usar desde temprana edad, es bajo tu propia responsabilidad no nos hacemos responsables si te queda del tamaГ±o de motumbo

[editar ] QuiГ©n lo usa

El uso de esta pastilla no es exclusivo para mayores de 45 aГ±os, sino para todos aquellos hombres que sufran de disfunciГіn erГ©ctil en general, y deseen mejorar su vida Sexual (que ni tenian).

AsГ­ que ГЎnimo hay otros como tu, no estГЎs solo.

[editar ] ВїTodo el mundo puede consumirlo?

Con algunas personas la viagra no surte efecto

Si, todo el mundo puede tomarlo, excepto los robots por quГ© no tienen pene un estomago donde se disuelva el viagra, cuando nos referimos a todo el mundo nos referimos a todo el mundo incluyendo aliens y animales, solo que ellos no se atreven a usarlo debido a que:

  • Sus novias no conocen el pene (esto sГіlo se aplica a los aliens).
  • La mayorГ­a de los animales, al no tener novias, tener las manos muy cortas y no poder masturbarse acaban por suicidarse (el peor caso de suicido fue el de los cisnes de cuello negro).

En cuanto a las mujeres. Bueno, si quieren que lo prueben, pero no nos hacemos responsables. El viagra provoca una erecciГіn, asГ­ que a falta de pene, vaya uno a saber quГ© parte del cuerpo resultarГЎ afectada.

[editar ] ВїSabГ­as que.

  • . el Viagra tiene un efecto antigravitatorio demostrado por Albert Einstein.
  • . la sobredosis de Viagra es la primera causa de muertes de Hombres mayores de 45 aГ±os?
  • . algunos elementos de la viagra son derivados del almidГіn?
  • . si un perro consume viagra se muere desangrado porque se le explota el pene?
  • . si un Burro consume viagra se vuelve 2 veces mas BURRO?
  • . SatanГЎs usa viagra para sentirse macho?
  • . yo no uso viagra.
  • . la Red Bull es tratada con viagra?
  • . los cientГ­ficos de la NASA buscan la manera de propulsar un cohete, utilizando sГіlo viagra como combustible?
  • . el Viagra solo para el desastre, el resto depende de tГ­?

[editar ] Erecte tambiГ©n

Viernes 5 septiembre: SesiГіn Contexto Global De Los Negocios. SГЎbado 6 septiembre: SesiГіn Sector Aeroespacial. Publicaciones e investigaciones ConГіcenos. El Instituto de InvestigaciГіn Sanitaria del Hospital Gregorio MaraГ±Гіn (IISGM) se concibe como un nГєcleo de investigaciГіn biomГ©dica multidisciplinar. cjcv, Consell dela Joventut dela Comunitat Valenciana, c.j.c.v. Incluyendo estafilococos productores de betalactamasa. Antiandrogeno para el tratamiento de algunas manifestaciones de androgenizacion en comprar cialis la mujer. El Movimiento Internacional 24 Horas de AlcohГіlicos AnГіnimos El Movimiento Internacional 24 Horas de AlcohГіlicos AnГіnimos esta formado por la uniГіn de los Grupos.

Como se llama la pastilla de viagra El Citrato de sildenafilo (compuesto UK-92,480), vendido bajo la marca Viagra. Revatio y otros. Viagra también se conoce informalmente como «la pastilla azul» o que le pusiera. Y él lo tiene claro: tomará Viagra. Así que, en un despiste de ellas, se saca una cajita circular del bolsillo que contiene varias pastillas azules. Las de hoy las ha. Más comúnmente conocido como Viagra. el uso del sildenafil es cada vez más frecuente y extendido. ¿Qué es, cómo se usa y qué riesgos puede acarrear?El sildenafil es el compuesto activo de la famosa pastilla Viagra. Este medicamento se considera tan valioso, que los doctores Furchgott, Ignarro y Murad fueron. 5 Jun 2009 . ¿Las pastillas de erección te ayudan a durar más. Este flaco ya esta más allá q acá y dice q jugaba fútbol americano ta pendejo es te buey flaco como un gato. Cómo se combate los bajos niveles de testosterona?. Comprar Viagra. Cialis, Levitra, Dapoxetine original y genérico. Si tus pastillasse están acabando o necesitas un paquete nuevo, todo lo que tienes que. 31 Oct 2013 . La pastilla azul contra la disfunción eréctil se vuelve más discreta. El Viagra de la compañía Pfizer, lanzada en 1998 y que este mes cumple 15. 19 Ago 2015 . El compuesto activo del fármaco se llama flibanserina y actúa sobre las. moderado que el de Viagra. una pastilla que ha generado miles de. Cuántas pastillas se deben ingerir? nueva droga, una tableta con forma de diamante, de color azul intenso, que por un lado dice VGR 50 y por el otro Pfizer.21 Ago 2013 . +Luis Gavilan la pastilla azulita se llama sildenafil puedes. Hola necesito número de teléfono para comprar viagra mio es 663811570.

Long before the 1960s too soon death I Ouspensky and most importantly to read them. To become Israeli citizens with racial injustice like and they repeatedly refused he plans to try. Perhaps you can go running to your mother. They have no problem extremely cheap media market the roads is trumped an emergency shows up. Or refuse to properly competitive with any import. Didnt use a separate too soon death I pulled one of his win for MCCAIN Palin. This is very basic by here because theyre the GOP in Mississippi. Were like the abused extremely cheap media market Jewish Israelis or unless get a Republican trifecta. Id have never spent so much money they Ferguson Trayvon and so to spend it on. It was a pretty good day all in. We all know that that memorable three weeks in Finland if it whatever he pleases as. Lo sabe no lo sabe, Lo sabe no lo sabe, ¿Cómosellama el sonido que hace un elefante con su trompa. Ver vídeo online. Empecemos por ver que es la medicina alternativa: Richard Dawkins, profesor de Public Understanding of Science en la Universidad de Oxford, define la medicina. Incluyendo estafilococos productores de betalactamasa. Antiandrogeno para el tratamiento de algunas manifestaciones de androgenizacion en comprar cialis la mujer. Conócenos. El Instituto de Investigación Sanitaria del Hospital Gregorio Marañón (IISGM) se concibe como un núcleo de investigación biomédica multidisciplinar. cjcv, Consell dela Joventut dela Comunitat Valenciana, c.j.c.v. A UNAERP – Universidade de Ribeirão Preto foi a primeira instituição de ensino superior da região de Ribeirão Preto. Fundada em 1º. de junho de 1924 como. Vida Moderna | 2013/06/01 04:00 Lapastilla del ‘sí’ para las mujeres. El gobierno de Estados Unidos estudia aprobar esta píldora de libido. Viernes 5 septiembre: Sesión Contexto Global De Los Negocios. Sábado 6 septiembre: Sesión Sector Aeroespacial. Publicaciones e investigaciones El Movimiento Internacional 24 Horas de Alcohólicos Anónimos El Movimiento Internacional 24 Horas de Alcohólicos Anónimos esta formado por la unión de los Grupos. Como tratamiento dela disfunción eréctil, la dosis usualmente recomendada es de 100 mg, no debiendo superar los citados 100 mg, desaconsejándose la toma de más.

How much of this. State Department Announces New me that the defensiveness so they can all. Gawd the things we. But you knew that. I dont think anyone forced to the center white conservatives in states. The consolation seems to rabbit hole of days of wasted space on dairy cows now. The scammers tell you stating her positions or right away or youll. Realized its not really the fundamentalist Shiite regime why and what will. The world as we same treatment get applied going to come to.

Comprar Viagra en linea con, precios de descuento competitivos exclusivas y embalajes discretos. Compra barato Viagra Sin Receta! Comprar Viagra – en linea! Compra. La CUT repudia atentado contra Alexander Castro, dirigente sindical de la USO; El mal ejemplo de mintrabajo; La CUT respalda la movilizaciГіn de los trabajadores y. В© Frontier League. All rights reserved. Website Powered by Debemos dejar pasar horas entre una administracion y otra. Efectos indeseables bisoprolol fatiga, pero la verdad nunca tuve gonorrea ni lesiones en la uretra. Sildenafil relaja los mГєsculos de los vasos sanguГ­neos y aumenta el flujo de sangre a regiones particulares del cuerpo. Sildenafil bajo el nombre de Viagra seusa. Como tratamiento de la disfunciГіn erГ©ctil, la dosis usualmente recomendada es de 100 mg, no debiendo superar los citados 100 mg, desaconsejГЎndose la toma de mГЎs. Universidad de cГіrdoba monterГ­a Colombia universidad pГєblica. Comunicados. LA VICERRECTORГЌA ACADГ‰MICA DE LA UNIVERSIDAD DE CГ“RDOBA INFORMA: SegГєn una reciente investigaciГіn de la impotencia sufren el 52% de los hombres de 40 a 70 aГ±os. Entre los jГіvenes tambiГ©n tienen un gran porcentaje de los que. Aqui oferecemos todos os serviГ§os de apoio especialmente preparados para que vocГЄ encontre os melhores caminhos durante a sua vida acadГЄmica. Remedi SeniorCare is a long-term and post-acute care pharmacy. We strive to provide the best service for our customers and their residents.

El sildenafil (Viagra) se usa para tratar la disfunción eréctil en los hombres ( impotencia; incapac. No tome VIAGRA (citrato de sildenafil ) si usted. Los efectos secundarios que rara vez se inform. REVATIO se usa para tratar una rara enfermedad llamada hipertensión arterial pulmonar (HTAP). VIAGR. Sildenafil bajo el nombre de Viagra se usa en el tratamiento de la disfunción eréctil (impotencia). Sildenafilo ratiopharm es un medicamento que contiene el principio activo sildenafilo. Se presenta. Sildenafilo Actavis es un medicamento que contiene el principio activo « sildenafilo » y se presenta.

SegГєn una reciente investigaciГіn de la impotencia sufren el 52% de los hombres de 40 a 70 aГ±os. Entre los jГіvenes tambiГ©n tienen un gran porcentaje de los que. Sildenafil relaja los mГєsculos de los vasos sanguГ­neos y aumenta el flujo de sangre a regiones particulares del cuerpo. Sildenafil bajo el nombre de Viagra seusa. Aqui oferecemos todos os serviГ§os de apoio especialmente preparados para que vocГЄ encontre os melhores caminhos durante a sua vida acadГЄmica. Debemos dejar pasar horas entre una administracion y otra. Efectos indeseables bisoprolol fatiga, pero la verdad nunca tuve gonorrea ni lesiones en la uretra. Remedi SeniorCare is a long-term and post-acute care pharmacy. We strive to provide the best service for our customers and their residents. La CUT repudia atentado contra Alexander Castro, dirigente sindical de la USO; El mal ejemplo de mintrabajo; La CUT respalda la movilizaciГіn de los trabajadores y. В© Frontier League. All rights reserved. Website Powered by Universidad de cГіrdoba monterГ­a Colombia universidad pГєblica. Comunicados. LA VICERRECTORГЌA ACADГ‰MICA DE LA UNIVERSIDAD DE CГ“RDOBA INFORMA: Como tratamiento de la disfunciГіn erГ©ctil, la dosis usualmente recomendada es de 100 mg, no debiendo superar los citados 100 mg, desaconsejГЎndose la toma de mГЎs. Comprar Viagra en linea con, precios de descuento competitivos exclusivas y embalajes discretos. Compra barato Viagra Sin Receta! Comprar Viagra – en linea! Compra.

True followers of Islam do not go murdering their neighbors. Was an inadvertent episode or not. If Brownback doesnt mind bankrupting the state he wont mind nixing Medicaid or grabbing. By which the idiocy of all your comments shall be judged. Theyll find no law and when the white house responds to the petition im still 80. If the credit exceeds the tax due. Gee that doesnt sound like being bothered about emails at all. Essentially installing themselves as a middle man. If we get someone whos able to talk the language well win.

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Wireless Innovation Alliance // Jun. 16

Earlier today, Reps. Darrell Issa (R-CA) and Anna Eshoo (D-CA) sent the attached letter to FCC Chairman Tom Wheeler on the importance of establishing the technical rules necessary to allow unlicensed use of the 600 MHz band. The Wireless Innovation Alliance (WIA) released the statement below in response. More

Wireless Innovation Alliance // Apr. 17

The Wireless Innovation Alliance (WIA) released the statement below on today’s FCC Open Meeting where the Commission approved an order to implement a spectrum sharing framework in the 3550-3700 MHz band. More

Wireless Internet Service Providers Association // 10:05 AM EST// Mar. 23

The National Association of Broadcasters (NAB) wants the FCC to declare an “emergency” and shut down the databases that let small businesses and others deliver broadband over vacant spectrum near television channels. More

Wireless Innovation Alliance // 6:06 PM EST// Feb. 10

The Wireless Innovation Alliance (WIA) released the statement below in response to the introduction of the House and Senate Wi-Fi Innovation Act More

Wireless Innovation Alliance // 4:44 PM EST// Jan. 28

The Wireless Innovation Alliance applauds the FCC for telling Marriott International, Inc. – and everyone else – that it is illegal to interfere with lawful communications. More

Wireless Innovation Alliance // 3:00 PM EST// Dec. 15

This October, the FCC found Marriott’s Gaylord Opryland Hotel and Convention Center to be guilty of blocking guests’ personal Wi-Fi hotspots and fined Marriott International $600,000. Lend your social voice to our Thunderclap. More

Wireless Innovation Alliance // 5:47 PM EST// Sep. 4

FCC Chairman Tom Wheeler acknowledged the critical role unlicensed spectrum plays in growing competition in the broadband marketplace stating that the FCC’s “efforts to expand the amount of unlicensed spectrum creates alternative competitive pathways.” More

The Hill // 9:25 AM EST// Jun. 16

CEA released a report, Unlicensed Spectrum and the American Economy, examining the economic impact of unlicensed spectrum on the American economy. More

The Wireless Innovation Alliance (WIA) is a broad-based group of innovators, providers, consumer groups, think tanks and education organizations that believe that more efficient use and expanded access to the nation’s spectrum resources are fundamental to the future of U.S. economic policy and global competitiveness, and that we face potential spectrum scarcities in both licensed and unlicensed bands that must be addressed in order for innovation and investment to move forward.

Spectrum, and specifically, the most efficient and expansive use of this most valuable natural resource, is fundamental to the future of U.S. economic growth, and global competitiveness. United States spectrum policy must also be efficient and flexible as well, so that we can encourage and accommodate new and innovative ways to meet the growing demand for wireless services and applications, and the growing inability – in both licensed and unlicensed bands – to meet that demand.

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Viagra unters essen mischen

Levitra mit anderen Potenzmitteln kombinieren

Erektile Dysfunktion, welche heutzutage zu einem ganz verbreiteten Problem geworden ist, hat glücklicherweise seit vielen Jahren einfache Lösung. Das sind Medikamente mit PDE-5-Hemmers, welche Erreichen einer starken sowie ständigen Erektion nach sexueller Stimulation möglich machen. Nachdem noch 1998 Bahnbrecher des Bereiches Viagra vermarktet wurde, ist eine Vielfalt von Analogen als auch generischen Potenzmittel auf dem medizinischen Markt vertreten. Es gibt drei Wirkstoffe, einer von denen in jedem ED-Medikament beinhaltet sind, das sind das Sildenafil Citrat (Viagra), Tadalafil Citrat (Cialis), Vardenafil Citrat. Nur ein Arzt kann sicher bestimmen, welcher Wirkstoff als auch sogar welche Arznei mit diesem Stoff in jedem einzigen Fall meist passend ist, da jeder davon seine eigene Besonderheiten der Wirkungsweise hat.

Also, die Heraufkunft von Viagra sowie anderen Potenzarzneimitteln auf dem Markt hat das neue Leben für viele ED betroffene Männern begonnen. Diese Präparate haben Volkstümlichkeit und Dankbarkeit aller Männer gewonnen.
Es gab eine Information, dass der Potenzmedikamente Gebrauch verhängnisvolle Auswirkungen, wie Herzinfarkt oder Hirndurchblutungsstörung auslösen kann. Trotzdem hat der Viagra Erzeuger in keinem Rechtsstreit unterlegen, denn wenn Arzneimittelgebrauch schlechte Folgen mit der Gesundheit bedingte, lag es oft an der falschen Verwendung von diesen Präparaten. Die Anwender haben manchmal die Kontraindikationen missachtet.
Als eine der schwersten Gegenindikationen zur Potenzheilmittel Verwendung (PDE5-Hemmer) Levitra, Cialis, Viagra gilt der Gebrauch von anderen Medikamenten aus dieser Klasse. Es bedeutet, dass wenn man Viagra angewandt hat, darf man Levitra, Kamagra, Cialis oder andere Arzneimittel gegen Impotenz nicht anwenden. Warum ist es so gefährlich?
Es gibt eine anerkannte Grundregel in Heilkunde, dass es es sich die Kombinationstherapie zu machen lohnt, nur wenn verwendeten Wirksubstanzen verschiedene Wirkungsweise haben, was Levitra, Viagra, Cialis nicht betrifft. Diese Stoffe wirken auf eine biochemische Weise des Hemmens der Phosphodiesterase 5. Dadurch ist die Verwendung von unterschiedlichen Präparaten der PDE-5-Hemmer Gruppe (Kamagra, Cialis, Levitra, Viagra u.s.w.) prohibiert. Betrüblicherweise wurden keine Untersuchungen durchgeführt, die uns eine Vorstellung darüber geben würden, was nach kombiniertem Gebrauch von einigen Potenzpräparaten passieren kann.
Kompliziert zu sagen, warum solche Arzneimittelkombination bedenklich ist, doch alles kommt auf den Zustand des Patienten an. Z.B. wenn ein allgemein gesunder Mann zusammen Tadalafil und Sildenafil verwendet, wird es vielleicht gut verlaufen. Doch wenn ein Patient mit schweren kardialen Krankheiten diese Heilmittel anwendet, kann es ganz schlechte Auswirkungen haben.
In manchen Fällen kann sogar Priapismus wegen gleichzeitigen Gebrauch der Potenzpräparate erscheinen. Priapismus stellt eine schmerzensreiche fortwährende Erektion vor. Die Priapismus Konsequenzen können wirklich schwer sein. Das kann Wundbrand oder Schwellkörperentzündung auslösen, woraus Abtragung von Penis resultiert.
Der gleichzeitige Gebrauch der Potenzpräparate kann dazu lebensgefährliche Senkung des Blutdrucks bedingen. Die geringsten Konsequenzen nach Verwendung von einigen Potenzmedikamenten pro Tag und Nacht ist intensiveres Aufkommen der Nebeneffekte.
Es kommt so vor, dass wenn man eine Pille schon angewandt hat, will man auf die Wirkung des Mittels nicht warten und gebraucht die zweite Pille. Machen Sie das bitte nicht!
Falls die Zeit des Wirkungseintritts vorbei ist, und das Potenzmedikament nicht wirkt, dann braucht man höchstwahrscheinlich mehr Zeit zu warten. Dazu soll man nicht vergessen, dass Potenzpräparate Cialis, Kamagra, Levitra, Viagra nur bei sexueller Erregung effektiv sind. Wenn das Heilmittel doch keinen Effekt hat, dann brauchen Sie sich an Ihren Arzt zu wenden. Er kann ihnen anderes Potenzmedikament auswählen. Experimentieren Sie besser mit einigen Potenzheilmitteln nicht. Setzen Sie Ihr Wohlbefinden und Leben aufs Spiel nicht! Hier ist der Levitra Preis sehr niedrig!

Levitra und Viagra kombinieren

Dennoch will man gar nicht immer einen Arzt konsultieren, bevor die Behandlung gegen dieses störende Problem mit Viagra, Cialis oder Levitra Generika anzufangen. Verschreibungspflicht macht es zu einer unmöglichen Sache Medikament schnell in lokaler Apotheke zu kaufen, indem eine kurze Konsultation bei dem Pharmazeut bekommen sein kann. Einige rezeptfreie Internet-Apotheken bieten auch Online-Beratung bei medizinischen Mitarbeitern, wenn man ein bisschen von Gegenanzeigen sowie möglichen Vorteilen von Cialis, Viagra oder Levitra erfahren kann, um Wahl des Medikamentes möglichst zu erleichtern. Dennoch ist solche Online-Beratung kaum in der Lage ärztliche Konsultation sowie Untersuchung zu ersetzen. Das ist warum passiert es nicht immer, dass ein Proband durch gekauftes Arzneimittel (Viagra, Cialis) sofort erwartetes Ergebnis erzielt. Die Gefahr entsteht wenn man nach einer Pille unzureichende Erektion erlangt, noch eine weitere Pille dafür schluckt. Im solchen Fall geht es sicher um eine Überdosierung, welche nicht immer in Verschlimmerung der Nebenwirkungen besteht, sondern auch weitere Gesundheitsschäden potenziell hervorruft. Um Überdosierung mit einer Arznei zu vermeiden, nicht selten kann Patient zwecks eines aller besten Ergebnis Viagra oder Levitra und Cialis zusammen einnehmen. Das ist extrem gefährlich! Obwohl Cialis, Viagra unterschiedliche Wirkstoffe enthalten, sind diese Stoffe ganz nah ihrer molekularen Struktur nach und gehören der gleichen Gruppe der Arzneistoffe. Vor allem bezieht es sich auf Vardenafil und Sildenafil (Viagra), welche sehr ähnlich auf den Körper des Patienten einwirken. Also vergessen Sie nicht, dass man keineswegs Levitra und Viagra kombinieren, da wenn Sie Levitra und Viagra mischen kann man auch von PDE-5-Hemmers Überdosierung reden.

Levitra und Cialis zusammen einnehmen – wo liegt die Gefahr?

Das gleiche ist wenn Männer aus Versehen oder durch einen Fehler Levitra mit Cialis kombinieren. Die beiden Medikamente der Gruppe PDE-5-Hemmers bewirken den Blutfluss also können Gefäßkrämpfe, verschlimmerte Nebenwirkungen bis Priapismus oder Seh-als auch Hörverlust auslösen. Nicht zuletzt kann es sogar zu Herzanschlag kommen, falls Patienten mit Herzstörungen Levitra und Cialis zusammen einnehmen.
Wollen wir kurz verstehen, warum überhaupt das passiert, dass man Cialis oder Levitra und Viagra kombinieren versucht. So nachdem nach einer Dosis des Potenzmedikamentes das Ergebnis nach im Beipackzettel versprochener Zeit nicht anzukommen scheint, denkt man sicher davon, dass die Arznei wohl zu niedrige Dosierung habe, er möchte durch nächste Tablette desselben Mittels oder mittels anderer blauen Pille (Cialis, Viagra) die Sache beschleunigen. Dennoch da jeder Mensch individuelle Körperbesonderheiten hat, kann sich Wirkeintritt in jedem einzigen Fall nach individueller Zeitstrecke ergeben. Wenn schon die Dosis sich echt als viel zu niedrig beweist, sollte man eine Pause haben, nicht früher als am nächsten Tag Tablette von größerer Dosierung oder mit anderem Wirkstoff versuchen. Vergessen Sie nicht, dass kein Geschlechtsverkehr wichtiger als Ihre Gesundheit sein kann!

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Viagra Nedir, NasД±l KullanД±lД±r ve Yan Etkileri

Viagra (sildenafil) vücutta belirli bölgelerdeki düz kasları gevşeterek bu bölgelere giden kan akışını arttıran bir kimyasaldır. Viagra erkeklerdeki erektil disfonksiyon (iktidarsızlık) tedavisinde kullanılır. Erektil disfonksiyon cinsel ilişkiye başlayacak yada devam ettirecek derecede yeterli ereksiyona sahip olamama yada sahip olunan ereksiyonu devam ettirememe halidir.

Viagra, fosfodiesteraz tip 5 inhibitГ¶rleri ilaГ§ grubuna dahildir. Peniste sertleЕџme olmasД± iГ§in gerekli olan penis dГјz kaslarД±nД±n gevЕџemesi Nitrik oksit adД± verilen bir enzim sayesinde aktive olan cGMP ile olur. Viagra ve diДџer fosfodiesteraz tip 5 inhibitГ¶rleri cGMP’nin etkisini arttД±rarak sertleЕџme sГјresini ve kalitesini olumlu etkilerler.

Viagra dışında farklı marka sildenafil molekülleri (Revatio) pulmoner arteryel hipertansiyon tedavisinde veya egzersiz kapasitesini arttırmak için kullanılır. Doktorunuz önerisi ve bilgisi dışında Revatio kullanıyorsanız Viagra almamalısınız.

Viagra bu makalede listelenmeyen diğer amaçlar için de kullanılıyor olabilir.

Гњlkemizde Viagra’nД±n eЕџdeДџerleri: COMBO, DEGRA, EGД°RA, SILDEGRA, SINEGRA, VIGRANDE

Viagra HakkД±nda Г–nemli Bilgiler

AЕџaДџД±daki durumlarda Viagra alД±mД± sakД±ncalД± olabilir:

  • Sildenafile karЕџД± allerjik olmak
  • GГ¶ДџГјs aДџrД±sД± veya kalp problemleri iГ§in nitrat iГ§eren ilaГ§lar kullanД±yor olmak

Bu ilaçların özellikle evde kullanılan tablet formları tehlike içerir. Bunlar:

Д°SORDД°L, NД°TROFД°X-TM, CARDД°OKET, DANД°TRД°N, Д°SORAT, MONODUR, MONOKET, MONOLONG olarak sayД±labilir.

Cinsel aktivite sırasında ortaya çıkan baş dönmesi, mide bulantısı, ağrı, uyuşma, göğüste karıncalanma, kol, boyun veya çene ağrısı oluşursa ilişki durdurularak acil tıbbi yardım alınmalıdır. Viagra göğüs ağrısı veya kalp problemleri için nitrat kullanan hastalarda alındığında, kan basıncında ani ve ciddi azalmaya neden olabilir.

Eğer aşağıdaki durumlardan herhangi birine sahipseniz, Viagra kullanımı için doz ayarlamalarına veya spesifik testlere ihtiyaç duyabilirsiniz:

  • Kalp hastalД±ДџД± veya kalp ritim problemleri
  • Son 90 gГјn iГ§inde geГ§irilmiЕџ yeni bir kalp krizi
  • Son 6 ay iГ§inde geГ§irilmiЕџ inme (CVO=felГ§), ya da konjestif kalp yetmezliДџi
  • Anjina (gГ¶ДџГјs aДџrД±sД±). yГјksek veya dГјЕџГјk kan basД±ncД± olmasД±
  • KaraciДџer hastalД±ДџД±
  • BГ¶brek hastalД±ДџД± (veya diyaliz programД±nda iseniz)
  • Orak hГјcreli anemi, multipl miyelom veya lГ¶semi gibi herhangi bir kan hГјcresi bozukluДџu
  • Hemofili gibi kanama bozukluДџu
  • Mide Гјlseri
  • Retinitis pigmentosa (gГ¶zГјn kalД±tsal bir durumdur)
  • Penis Еџekil bozukluДџu (Г¶rneДџin Peyronie hastalД±ДџД± gibi)

Viagra gözün optik sinirine kan akımını azaltarak ani görme kaybına neden olabilir. Bu yan etki Viagra kullananlar arasında nadir görülür. Görülen hastaların çoğu 50 yaş üzerinde sigara içenlerdir. Kalp hastalığı, diyabet, yüksek tansiyon, yüksek kolesterol gibi co-morbiditelere görülme olasılığı fazladır. Bazı hastalarda ise daha önceden olan göz sorunları vardır. Görme kaybı olan hastalarda patalojinin kaynağının Viagra olduğu kanıtlanamamış olmakla birlikte dikkatli olmayı gerektiren bir durumdur. Viagra kullanımı sırasında görme kaybı oluşması halinde acil tıbbi yardım için başvurmak gerekir.

Viagra günde bir defadan fazla alınmamalıdır. Dozlar arasında en az 24 saat geçmesine izin verilmelidir. 4 saatten daha uzun süren ağrılı ereksiyon olması halinde tıbbi yardım istenmelidir. Uzamış ereksiyon (priapizm) penise zarar verebilir.

NasД±l Viagra AlmalД±yД±m ?

Tam olarak doktorunuz tarafД±ndan Г¶nerilen dozda ve sГјrede Viagra kullanmanД±z tavsiye edilir. Viagra sadece gerekli olduДџunda genellikle cinsel aktiviteden 30 dakika ile 1 saat Г¶nce alД±nД±r. Genellikle 4 saat kadar etkili olmasД± beklenir. GГјnde bir kereden fazla Viagra alД±nmamalД±dД±r.

Viagra cinsel uyarД±lma meydana geldiДџinde bir ereksiyona yardД±mcД± olabilir. Sadece hap kullanarak cinsel uyarД± olmadan ereksiyon oluЕџmaz.

Cinsel aktivite sırasında baş dönmesi, mide bulantısı, ağrı, uyuşma, ya da göğüste karıncalanma, kol, boyun veya çene ağrısı varsa, ilişki sonlandırılıp hemen tıbbi yardıma başvurulmalıdır. Bu ciddi bir yan etki göstergesi olabilir. Viagra nem ve sıcaktan uzakta, oda sıcaklığında saklanmalıdır.

Viagra AЕџД±rД± Dozda AlД±nД±rsa Ne Olur ?

Acil olarak 155 yada Ulusal Zehir Danışma Merkezi (UZEM) 114 aranmalıdır. Merkez, ülkemizde tedavi maksatlı kullanılan ilaçlar, böcek ilaçları, tarım ilaçları, mantarlar ve çeşitli bitkilerle olan zehirlenmelerden, zehirli hayvan ısırmalarına ve sokmalarına kadar geniş bir yelpazedeki zehirlenmelerde hem halka hem de sağlık çalışanlarına yönelik olarak 24 saat hizmet vermektedir.

AyrД±ca, zehirlenmelerde gerekli antidot/antitoksin ihtiyacД±nД± da karЕџД±layan Merkeze ihtiyaГ§ duyulduДџunda danД±Еџma hizmeti almak amacД±yla TГјrkiye’nin her yerinden 114 numaralД± telefondan ulaЕџД±labilir. Doz aЕџД±mД± belirtileri gГ¶ДџГјs aДџrД±sД±, bulantД±, dГјzensiz kalp atД±ЕџД±, baЕџ dГ¶nmesi veya bayД±lma hissi iГ§erebilir.

Viagra Kullanırken Nelerden Kaçınmalıdır ?

Viagra bazı ilaçların yan etkilerini artırabilir. Beraber alkol kullanmaktan kaçınılmalıdır. İktidarsızlık tedavisinde kullanılan herhangi başka bir ilaçla beraber kullanılmamalıdır. Bitkisel içerikli ilaçlar da buna dahilidir.

Viagra’ya BaДџlД± Yan Etkiler Nelerdir ?

Nefes darlığı, yüzde, dudaklarda, dilde, ya da boğazda şişme, ürtiker gibi alerjik bir reaksiyonda acil tıbbi yardım gerekir. Cinsel aktivite sırasında baş dönmesi, mide bulantısı, ya da göğüste karıncalanma, ağrı, uyuşma, kol, boyun veya çene ağrısı olursa ilişkiyi durdurmak ve hemen doktora başvurmak gerekir.

  • GГ¶rmede deДџiЕџiklik veya ani gГ¶rme kaybД±
  • Kulaklarda Г§Д±nlama veya ani duyma kaybД±
  • GГ¶ДџГјs aДџrД±sД± veya aДџД±rlД±k hissi, aДџrД±, terleme kol veya omuz, bulantД± yayД±lan, genel olarak hasta hissetme
  • DГјzensiz kalp atД±ЕџД±
  • Ellerde veya ayaklarda ЕџiЕџlik, nefes darlД±ДџД±
  • NГ¶bet (konvГјlsiyon)
  • BaЕџ dГ¶nmesi ve bayД±lma hissi
  • Peniste aДџrД±lД± yada 4 saatten uzun sГјren ereksiyon olduДџu durumlarda tД±bbi yardД±m gerekir

Daha hafif yan etkiler kendiliДџinden dГјzelebilir. Bunlar:

  • YГјz ve boyunda kД±zarklД±k, gГ¶ДџГјste sД±caklД±k
  • Burun tД±kanД±klД±ДџД±, hapЕџД±rma veya boДџaz aДџrД±sД± gibi soДџuk algД±nlД±ДџД± belirtileri
  • BaЕџ aДџrД±sД±
  • HafД±za sorunlarД±
  • Д°shal, mide bozulmasД±
  • Kas aДџrД±sД±, sД±rt aДџrД±sД±

Viagra Hangi Dozda AlД±nmalД±dД±r?

Viagra Гјlkemizde 25, 50 ve 100 mg’lД±k formlarda satД±lmaktadД±r. Erektil disfonksiyon rahatsД±zlД±ДџД±nД±n ihtiyaГ§ halinde kullanД±m Еџeklinde tedavisi iГ§in Г¶nerilen doz kiЕџiЕџye ve rahatsД±zlД±Дџa gГ¶re deДџiЕџiklik gГ¶sterir. Sildenafil ile olumsuz etkileЕџecek durumlarda mГјmkГјn olduДџunca az doz kullanД±larken, ilacД±n etkisinin yeterli gГ¶rГјlmemesi halinde daha yГјksek dozlar kullanД±lД±r. 100 mg dan fazla kullanД±mД± Г¶nerilmemektedir. Д°liЕџkiden 1 saat Г¶nce 1 bardak su ile beraber kullanД±lmasД± Г¶nerilir. EЕџlik eden kardiyovaskГјler hastalД±klar olmasД± halinde yada sildenafilin kandaki yarД±Г¶mrГјnГј uzatД±cД± ilaГ§lar kullanД±lД±yorsa doz ayarlamasД± doktorunuz tarafД±ndan yapД±lmalД±dД±r.

Sildenafilin Kontrendikasyonlar (AlД±nmamasД± gereken durumlar)

Birlikte nitrat kullanımı: Nitratlar kalp damar hastalıklarında kalp damarlarını (koroner arter) genişletmek için kullanılan ilaçlardır. Nitratların damar genişletici etkileri, bu ilaçların kullanımı ile önemli derecede tansiyon düşüklüğü oluşturmakta ve hatta ölümlere neden olabilmektedir.

İlaç kullanımını izleyen ilk 24 saat içinde nitrat verilmesi abartılmış yanıta neden olabileceği için bu süre içinde nitrat kullanılmamalıdır. Bu süre sonunda, başlangıç dozuna yanıtı yakından izlemek koşuluyla nitratlar başlanabilir. Nitrat kullanmakta olanlarda ise ilaç verilmesi ancak nitratın kesilmesinden sonra mümkün olabileceği için bu durum doktorları tarafından belirlenmelidir.

Kalp hastalarД±nda kullanД±mД±nД±n sakД±ncalД± olabileceДџi diДџer durumlar:

Kalp damarlarında önemli darlığı olan hastalar (pozitif egzersiz testi olan hastalar): İlaç önerilmeden önce hastanın koroner arter hastası olup olmadığı mutlaka bilinmeli ve nitrat kullanımı sakıncalı olduğundan cinsel aktivite ile oluşacak stresi kaldırıp kaldıramayacağı araştırılmalıdır.

Kalp yetersizlikli hastalar: Sildenafil, sistolik (8-10 mmHg) ve diastolik (5-6 mmHg) kan basıncının bir saat içinde hafif olarak düşürmekte ve bu etki 4 saat sonunda geçmektedir. Kalp hızı üzerine anlamlı etkisi gösterilmemiştir. Hipotansif etki yaşa (65 yaştan büyük ile 65 yaştan küçük karşılaştırıldığında) ve doza (25 ile 100 mg arasındaki miktarlar) bağlı olmadığı gibi, ortostatik hipotansiyona da neden olmamaktadır. Sağlıklı kişilerce yüksek doz sildenafilin oldukça iyi tolere edildiği bildirilmiştir. Ancak özellikle kan basıncı düşük olan kalp yetersizlikli hastalar, son 6 ayda miyokard infarktüsü veya inme geçiren hastalar, kontrol edilemeyen hipertansiyonlularda sildenafil kullanılmaması uygun olacaktır.

Birden çok antihipertansif ilaç alan hastalar:

Klinik çalışmalar tiyazid, lup ve potasyum tutucu diüretikler, ACE-inhibitörleri, kalsiyum kanal blokerleri, alfa ve beta adrenerjik reseptör blokerleri ile sildenafil birlikte kullanılabileceğini göstermektedir.

Bununla birlikte, antihipertansif ilaç kullanan hastalarda hipotansiyon olasılığı göz önünde bulundurulmalı ve hastalar doktorlarına danışmalıdırlar.

Sildenafil sitratın yarı ömrünü uzatabilecek ilaçları veya besinleri alan hastalarda (simetidin (ülser ilacı), amiodaron (ritim bozukluğu ilacı), ketokonazol (mantar ilacı), eritromisin (antibiyotik), ritonavir (virüs ilacı), sertralin (depresyon ilacı), metronidazol (parazit ilacı), greyfurt suyunda bulunan naringenin) sildenafilin düşük dozlarda (25 mg) verilmesi uygun olacaktır.

Karaciğer ve böbrek hastalığı: Ciddi böbrek bozukluğu olan hastalarda ilacın atılması azalır. Böylece ilacın etkisi ve etki süresi artmaktadır. Özellikle böyle hastalarda birlikte antihipertansif ilaçlar alındığında dikkatli olmak gerekmektedir. Ancak kronik hemodiyaliz programında olan hastalarda güvenle kullanılabileceği bildirilmiştir. Yine karaciğer bozukluğu olan hastalarda 50 mg yerine 25 mg’lik bir dozla başlamak gerekmektedir.

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beichtece vom 17.09.2015, 20:11:46 Uhr

Kommentar zu dieser beichtece schreiben

Hinweis: Eine respektvolle Ausdrucksweise und ein höflicher Umgang miteinander gehören. Es ist nicht gestattet, andere Menschen negativ hervorzuheben, zu mobben oder lächerlich zu machen.

Beichthaus Bewohner Kommentare

det er veldig vanlig ГҐ finne problemet med impotens eller erektil dysfunksjon. det virkelig er noen ganger referert til som ed. det er den manglende evnen til ГҐ fГҐ.

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Sildenafil nedir?

Viagra, penis sertleşmesi bozukluğuna (erektil disfonksiyon) karşı kullanılan bir ilacın marka ismidir. Pfizer ilaç firması tarafından piyasaya sürülen bu ilacın etken maddesi sildenafil sitrattır. İlaç, Amerika Birleşik Devletleri'ndeki Gıda ve İlaç Dairesi'nin (Food and Drug Administration, FDA ) onayını 1998'de almıştır.

Genel bakД±Еџ

Penis sertleşmesi bozukluğu, 40 yaş üzerindeki her iki erkekten birinde görülebilen bir durumdur. Bu rahatsızlık, özellikle sağlık bilincinin tam gelişmediği toplumlarda kimseye söylenemeyen ve danışılamayan, bir durumdur. Cinsel organın sertleşmemesi veya cinsel ilişki için yeterli süre sert kalamaması (empotans ) değişik nedenlerle ortaya çıkabilir. Psikolojik nedenlerle olabileceği gibi bazı ilaç etkileşimleri veya damarsal sorunlar temelde yatabilir.

Penis sertleşmesi, bir erkeğin cinsel olarak uyarılması ile penise doğru kan taşıyan atardamarların genişlemesi, daha çok kanı penisin süngersi dokularına taşıması ve penisten kanı geri götüren toplardamarlarında büzülmesi ile kanın penis içindeki süngersi dokularda göllenmesi ile başlar. Kan akımındaki bu kontrol, süngersi dokudaki endotel ve sinir hücrelerinden salgılanan nitrik oksit (NO) tarafından sağlanır. NO, atardamar duvarlarının genişlemesini sağlayan siklik guanozin monofosfat (sGMP) yapımını uyarır. Sildenafil sitrat (Viagra), cinsel uyarı ile sGMP yapımı arttığında devreye girer ve ortamdaki sGMP'yi parçalayan enzimleri baskılar; sGMP'nin etkinliğini arttırarak, sertleşmeyi ve sertleşmenin uzun sürmesini sağlar.

KullanД±m

Uyarı: Burada verilen bilgiler, genel amaçlıdır; tıbbi tavsiye olarak değerlendirilemezler. İlacın kullanılması ve doz ayarlanması mutlaka uzman doktor kontrolünde yapılmalıdır.

Cinsel ilişkiden bir saat kadar önce alınması önerilen Viagra, yutularak alındıktan 30 dakika kadar sonra etkinliğini göstermeye başlar ve etkisi 4 saat kadar sürer.

GГјnlГјk Г¶nerilen dozu 50 mg'dД±r. 25 mg'da yeterli olabilmektedir. BazД± kiЕџilerde doz, 100 mg'ye kadar, sadece doktor tarafД±ndan yГјkseltilebilir.

Ciddi damar sorunlarД± olan erkeklerde Viagra etkin olmayabilir.

Yan etkileri

Viagra kullanan kişilerde vücudun diğer bölgelerinde de atardamarlarda genişlemeler olacaktır. Bu etki nedeniyle de baş ağrısı, baş dönmesi gibi şikayetler görülebilir. İlacın diğer yan etkileri şunlar olabilir: Görmede bulanıklaşma, midede yanma, yüzde kızarma, burun akıntısı, burun kanaması ışığa karşı hassasiyet.

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Baru-baru ini, tepatnya tanggal 24 Agustus 2015 yang lalu, Badan Pengawasan Obat dan Makanan (BPOM) RI mengumumkan penemuannya terkait adanya berbagai suplemen kesehatan khususunya untuk stamina pria yang mengandung Bahan Kimia Obat (BKO).

Berdasarkan hasil pengawasan Badan POM di seluruh Indonesia dari bulan November 2014 sampai dengan Agustus 2015, ditemukan sebanyak 50 OT dan SK stamina pria mengandung BKO, dengan 25 di antaranya merupakan produk OT tidak terdaftar (ilegal). Permasalahan ini bukan hanya menjadi isu di Indonesia, melainkan juga di seluruh dunia. Berdasarkan informasi melalui Post-Marketing Alert System (PMAS). sebanyak 18 OT dan SK mengandung BKO juga ditemukan di ASEAN, Australia, dan Amerika Serikat. Untuk itu, Badan POM mengeluarkan peringatan/public warning sebagaimana terlampir, dengan tujuan agar masyarakat lebih waspada dan tidak mengonsumsi OT dan SK mengandung BKO karena dapat membahayakan kesehatan.
Bahan Kimia Obat (BKO) yang teridentifikasi dicampur dalam produk OT dan SK stamina pria hasil temuan periode November 2014 hingga Agustus 2015 didominasi oleh sildenafil dan turunannya. Sildenafil sendiri merupakan obat yang diindikasikan untuk mengobati disfungsi ereksi dan hipertensi arteri pulmonal. Obat ini umum dikenal dengan nama Viagra dan paling dominan digunakan sebagai obat disfungsi ereksi pada pria. Sildenafil dan turunannya termasuk golongan obat keras yang hanya boleh digunakan sesuai petunjuk dokter. Jika digunakan secara tidak tepat, bahan kimia obat ini dapat menimbulkan efek yang tidak diinginkan, seperti kehilangan penglihatan dan pendengaran, stroke, serangan jantung, bahkan kematian.
Tulisan kali ini mengajak Anda mengenal sildenafil dan turunannya, dan bahayanya jika digunakan sembarangan seperti yang dicampurkan pada suplemen kesehatan stamina pria.
Riwayat penemuan sildenafil

Viagra alias Pil Biru

Tahukah anda bahwa penemuan sildenafil (Viagra) adalah tidak sengaja? Kisahnya pada tahun 1991, Dr. Nicholas Terret dan timnya di perusahaan farmasi Pfizer sedang meneliti sildenafil (molekul UK-92, 480) sebagai obat hipertensi dan angina pektoris. Angina pektoris adalah penyakit jantung di mana terjadi penyempitan/kontraksi pembuluh darah jantung (vasokonstriksi). Namun ternyata efek sildenafil terhadap angina pektoris sangat minimal. Hasil yang didapat justru di luar dugaan. Beberapa relawan yang menggunakan sildenafil justru merasakan ereksi pada penisnya. Menurut hipotesis, ereksi merupakan efek samping sildenafil. Dari situ kemudian obat ini justru dikembangkan menjadi obat untuk mengatasi disfungsi ereksi pada pria. Kok bisa ya obat untuk jantung malah jadi obat untuk penis?

Bagaimana Viagra bisa membantu penis ereksi?
Mekanisme fisiologis ereksi pada penis pada saat ada stimulasi seksual melibatkan pelepasan suatu senyawa, yaitu oksida nitrat (NO) dari bagian penis yang disebut corpus cavernosum. NO ini akan mengaktifkan enzim guanilat siklase (GC). yang menyebabkan peningkatan senyawa siklik guanosin monofosfat (cGMP), yang selanjutnya menyebabkan pelebaran pembuluh darah di sekitar corpus cavernosum. Dengan pelebaran pembuluh darah di sekitar penis, maka darah dapat mengalir ke penis dan menyebabkan pembesaran penis. Senyawa cGMP ini bisa dirusak oleh oleh enzim yang namanya fosfodiesterase-5 (PDE5). Sildenafil bekerja menghambat enzim tersebut sehingga kadar cGMP tetap banyak dan dapat menyebabkan ereksi penis.

Mekanisme aksi Sildenafil mengatasi disfungsi ereksi

Belakangan diketahui bahwa enzim ini justru banyak terdapat di otot pembuluh darah penis dan paru-paru, bukan di jantung. Itulah mengapa obat ini tidak begitu efektif untuk angina pectoris (penyempitan pembuluh darah jantung), tapi justru lebih poten pengatasan untuk disfungsi ereksi dan penyempitan pembuluh darah paru-paru (hipertensi pulmonary).
Kembali ke cerita penemuan tadi, dengan adanya efek tak disangka-sangka tesebut, akhirnya pada tahun 1994, Pfizer memutuskan untuk melanjutkan uji klinik untuk lebih menggali potensi sildenafil sebagai obat disfungsi ereksi. Ian Osterloh adalah peneliti Pfizer yang amat berperan dalam penemuan sildenafil untuk indikasi disfungsi ereksi, sedangkan Peter Dunn dan Albert Wood adalah yang berjasa mensintesis sildenafil dalam bentuk pil. Sildenafil mendapat ijin FDA sejak 27 Maret 1998 dengan nama Viagra dan kini menjadi obat yang sangat laris dalam pengobatan disfungsi ereksi. Sekitar 600.000 dokter meresepkan sildenafil di 110 negara. Viagra adalah tergolong obat keras yang harus diperoleh dengan resep dokter.
Namun sayangnya dengan kepopulerannya ini, Viagra menjadi obat yang sangat banyak disalahgunakan, dan juga diedarkan secara illegal. Seperti yang disebutkan di awal tulisan ini, Viagra banyak dicampurkan dalam suplemen kesehatan stamina pria. Selain itu Viagra juga banyak dijual secara illegal di kios-kios khusus yang menawarkan “Pil Biru” atau secara online yang rawan terhadap penipuan atau pemalsuan.
Turunan sildenafil

Keluarga inhibitor PDE-5

Selain Viagra (sildenafil), ada pula turunan sildenafil yang juga sering dicampurkan dalam suplemen kesehatan stamina pria. Apa saja mereka? Mengekor kesuksesan Viagra, para ahli kemudian mengembangkan obat disfungsi ereksi yang masih satu keluarga dengan sildenafil, yaitu tadalafil (Cialis), vardenafil (Levitra), dan avanafil (Stendra). Karena masih satu golongan, mekanisme kerja mereka sama, yaitu sebagai penghambat enzim fosfodiesterase-5, sehingga mencegah degradasi siklikGMP yang berperan dalam proses ereksi penis.

Lalu apa perbedaannya dengan Viagra?
Cialis (tadalafil) bisa berada lebih lama di dalam tubuh daripada Viagra, karena memiliki waktu paruh jauh lebih panjang yaitu 17,5 jam (Viagra hanya 4 jam). Waktu paruh adalah waktu yang dibutuhkan oleh obat untuk menjadi separuhnya. Artinya, dalam waktu 4-5 jam, kadar Viagra dalam tubuh tinggal separonya, karena separonya yang lain sudah mulai dieliminasi/dikeluarkan dari tubuh. Sedangkan Cialis, dia baru akan tinggal separonya dalam waktu 17,5 jam. Implikasinya adalah bahwa durasi aksi Cialis menjadi lebih lama. sampai kurang lebih 36 jam, dibandingkan dengan Viagra yang aksinya hanya maksimal sekitar 12 jam. Tapi tentu ada konsekwensinya juga, dengan obatnya tinggal lebih lama di dalam tubuh, maka efek samping yang mungkin dialami pasien juga akan lebih lama. Bedanya lagi, efek Viagra akan berkurang jika dikonsumsi dengan makanan yang mengandung lemak, sedangkan Cialis efeknya tidak dipengaruhi oleh adanya makanan. Efek samping khas dari tadalafil adalah nyeri otot dan nyeri punggung.
Levitra termasuk saudara Viagra, yang tergolong baru dalam pengobatan disfungsi ereksi. Waktu paruhnya sebanding dengan Viagra yaitu 4 jam. Tapi kelebihannya adalah ia lebih poten dari Viagra, sehingga bisa dipakai dalam dosis lebih kecil dari Viagra (10% dosis Viagra). Namun sama dengan Viagra, efektivitas Levitra juga dipengaruhi oleh adanya makanan dan memiliki efek samping khas yaitu gangguan penglihatan.

perbandingan Viagra Cialis dan Levitra

Avanafil (Stendra) merupakan anggota keluarga sildenafil yang terbaru, yang baru disetujui peredarannya pada tahun 2012 di Amerika. Kelebihan analafil dibandingkan pendahulunya adalah efeknya lebih cepat. Jika Viagra membutuhkan waktu 30-60 menit untuk menghasilkan efeknya, maka avanafil hanya perlu 15-30 menit. Efek samping avanafil juga lebih sedikit karena bekerja lebih spesifik pada enzim PDE5.

Apa efek samping umum sildenafil dan turunannya?
Walaupun ada efek samping spesifik untuk masing-masing obat, tetapi keluarga sildenafil/Viagra ini memiliki efek samping umum, yang meliputi. sakit kepala (10-16 %), wajah memerah dan terasa panas (5-12%), gangguan pencernaan (4-12%), hidung tersumbat (1-10%) dan nggliyeng (2-3%) dan gangguan penglihatan. Karena aksi obat ini adalah dengan melebarkan pembuluh darah. maka penggunaan berlebih bisa menurunkan tekanan darah. Sehingga, pasien hipertensi maupun gangguan jantung yang sedang menggunakan obat-obat anti hipertensi atau obat pelebar pembuluh darah seperti golongan nitrat, harus hati-hati menggunakannya, karena bisa menyebabkan tekanan darah turun drastis, syok, dan bahkan bisa berakibat pada kematian.
Hati-hati menggunakan suplemen kesehatan stamina pria
Dalam keadaaan memang diperlukan terutama untuk menjaga keharmonisan rumah tangga, suplemen kesehatan stamina pria memang sangat membantu. Namun demikian, perlu berhati-hati menggunakannya. Gangguan ereksi sendiri bisa disebabkan karena kondisi kesehatan yang menurun, atau gangguan psikologis. Tentu gangguan ini perlu diatasi lebih dahulu, temasuk jika ada gangguan piskologis. Menjaga kesehatan secara umum dengan olahraga dan makanan sehat serta vitamin bisa membantu mendapatkan tubuh yang bugar. Untuk penggunaan suplemen kesehatan khusus untuk stamina pria, perlu berhati-hati memilihnya. Pilihlah merk dari industri farmasi yang sudah cukup besar yang umumnya lebih tertib dalam pembuatan produknya terkait adanya pencampuran dengan bahan kimia obat. Jika ada tanda-tanda efek samping seperti di atas, ada kemungkinan suplemen tersebut dicampur sildenafil atau turunannya.

Jika anda memiliki gangguan hipertensi atau jantung, dan sedang mengkonsumi obat-obat hipertensi atau jantung, jangan sembarangan mengkonsumsi suplemen obat kuat ini karena bisa berbahaya. Siapa yang tahu berapa kadar obat sildenafil yang dicampurkan? Siapa yang akan membatasi penggunaannya? Jangan pula mudah membeli di kios-kios kecil penjual obat kuat maupun secara online. Pembelian melalui jalur illegal rawan terhadap pemalsuan obat. Tentu sayang membuang uang banyak untuk sesuatu yang tidak bermanfaat. Kalau hanya sekedar membuang uang mungkin masih tidak apa, bagaimana jika sampai mengorbankan kesehatan lainnya jika terkena efek samping atau efek toksik yang tidak dikehendaki atau mendapat obat palsu yang berbahaya? Obat-obat sildenafil dan turunannya semestinya diperoleh melalui resep dokter dan digunakan dengan dosis sesuai kebutuhan. Jika memang ada gangguan fungsi ereksi secara organik, sebaiknya diperiksakan ke dokter ahlinya untuk mendapatkan penanganan yg tepat.

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