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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 Rite Aid Viagra Prices family farmstead. The property was purchased by the first Rite Aid Viagra Prices (then Gubtail) to make the long trip to “New England” from native British Isles in the mid 1600’s. Thomas Rite Aid Viagra Prices 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 Rite Aid Viagra Prices 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 Rite Aid Viagra Prices 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 Rite Aid Viagra Pricess.

Prior to the year of 1972 when the theatre was established, the Rite Aid Viagra Prices 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 Rite Aid Viagra Prices 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 Rite Aid Viagra Prices’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 Rite Aid Viagra Prices 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 Rite Aid Viagra Prices 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 Rite Aid Viagra Prices 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 Rite Aid Viagra Prices, prepare a load of lumber for the newest construction project.

The Rite Aid Viagra Prices 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 Rite Aid Viagra Prices 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 Rite Aid Viagra Prices 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.

Manufacturer link: Moots
We have a few of these 2015 models left at substantial savings. The difference vs. 2016? Only the head-tube diameter. 2015 models have regular inch and an eighth head-tubes, whereas the nearly identical 2016 models now come with slightly larger 44mm head-tubes. Very limited quantities available, so act fast! 2015 Vamoots-CR (Compact Road) frame MSRP: $3,325, now $2,895! 2015 Vamoots-RSL (Road Super Light) frame MSRP: $4,450, now $3,995!

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Manufacturer link: Bianchi
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Rx Savings Program

DISCOUNT ONLY – NOT INSURANCE. PRICES MAY VARY BY LOCATION. SEE YOUR LOCAL RITE AID FOR DETAILS. This discount program is NOT a health insurance policy or a Medicare prescription drug plan and is not intended as a substitute for insurance. The program only provides for discounts on health services from participating Rite Aid pharmacies, and the range of discounts will vary depending on the type of provider and the health services received. The program does not make payments to providers of health care services. Members are required to pay for all health care services, but will receive a discount from contracted providers. You may cancel your registration under the Rite Aid Rx Savings Program at any time by contacting 1-866-317-4286.

This program is administered by Medical Security Card Company, LLC (d/b/a ScriptSave) of Tucson, Arizona. By using the Rx Savings Program, you acknowledge and agree that ScriptSave may have access to and use your prescription drug data to administer the program. Rite Aid and ScriptSave reserve the right to modify or discontinue this program at any time at their sole discretion. ScriptSave is not responsible for the independent professional services of any participating pharmacy. You can view our complete Privacy Policy on our website at www.scriptsave.com/en/privacy.aspx.

Certain limitations apply, including covered generic drugs. See pharmacy for details. No enrollment fee. Nominal processing fee may apply. The days supply is based upon the average dispensing patterns for the specific drug and strength. The program, as well as the prices and the list of covered drugs, can be modified by Rite Aid and ScriptSave at any time without notice at their sole discretion. Prescriptions paid for in whole or in part by publicly funded health care programs are ineligible. Any prescriptions covered in whole or in part by private or any publicly funded insurance like Medicaid or Medicare will be processed through that insurance unless the patient specifically requests that the prescription be processed through the Rx Savings Program. There is no secondary coverage or coordination of benefits for prescriptions filled under the Rx Savings Program.

The RX Savings Program is a discount only program. The use of the program does not transmit the cost of the prescription to any other insurance, including a customer’s Medicare Part D true out of pocket ("TrOOP") amount. Thus, if a patient with Medicare Part D coverage elects to use the Rx Savings Program while the customer is in the coverage gap with respect to their Medicare Part D coverage, any payments made for RX Savings Program claims will not count toward the customer’s TrOOP unless the customer transmits their receipt to their Medicare drug plan.

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Tomando Viagra

Experiencias de casos reales con Viagra.

Al igual que con todos los medicamentos, algunas personas que toman VIAGRA pueden experimentar efectos secundarios. En general Г©stos son leves y no duran mГЎs de unas horas. Los efectos secundarios mГЎs frecuentes son:

  • Dolor de cabeza
  • Rubor facial
  • Malestar estomacal

Los efectos secundarios menos frecuentes y de carГЎcter transitorio son visiГіn azulina o borrosa o sensibilidad a la luz. En estudios clГ­nicos:

  • En pocos casos, los pacientes dejaron de tomar VIAGRA debido a los efectos secundarios
  • Se ha demostrado que la frecuencia de los efectos secundarios disminuye con el tiempo

El consumo de VIAGRA no lo hace a usted mГЎs dependiente para lograr o mantener la erecciГіn.

Si desea formular preguntas sobre los efectos secundarios de VIAGRA, asegГєrese de consultar a su mГ©dico. Г‰l puede decirle si VIAGRA es lo recomendable para usted.

iOjo! Mantenga este y otros medicamentos en lugares inaccesibles para los niГ±os, nunca comparta. Nunca utilice este medicamento para tratar otros problemas a menos que su profesional mГ©dico le dГ© permiso. Nunca comparta este medicamentos con otras personas.

Beneficios y posibles efectos secundarios de la viagra

Beneficios y posibles efectos secundarios de la viagra. En la actualidad se esta haciendo cada vez mas frecuente que los hombres recurran a esta famosa pastilla azul a la hora de mantener relaciones sexuales:Cada vez es mГЎs comГєn que un hombre utilice una pequeГ±a y mГЎgica pastilla azul para mantener relaciones sexuales: El citrato de sildenafil,mas conocido como viagra. Desde 1998 la utilizaciГіn de esta pГ­ldora es algo muy comГєn para luchar contra los problemas de erecciГіn e impotencia masculina.

Beneficios y posibles efectos secundarios de la viagra .A pesar de que mГЎs de medio millГіn de mГ©dicos en todo el mundo hayan elegido recetar Viagra ,para ayudar a mГЎs 20 millones de pacientes con problemas de erecciГіn.La mayorГ­a de esos 20 millones de usuarios poco sabe de los efectos y problemas que puede llegar a causar el consumo de Viagra.

Вїcuales son las causas mas comunes de los problemas de erecciГіn?

Existen diferentes causas que se pueden asociar con los problemas masculinos a la hora de lograr la erecciГіn. Dentro de las mГЎs comunes estГЎ la diabetes como una de las razones mГ©dicas mГЎs frecuentes; en especial en hombres mayores de sesenta y cinco aГ±os. AdemГЎs, las cardiopatГ­as (o problemas relacionados con el corazГіn) tambiГ©n originan problemas erГ©ctiles, del mismo modo que hipertensiГіn

ВїCual es el origen del viagra?

La utilizaciГіn de esta pastilla inicio la primera modalidad de tratamiento, no quirГєrgico, p ara combatir la impotencia masculina.El primer tratamiento que no debe ser administrado ni por vГ­a intravenosa, ni inyectado directamente en el pene.

En un principio, el Sildenafil, o Citrato de Sildenafil, fue concebido para tratar a las anginas de pecho, aunque con escaso resultado. No obstante, indujo un gran nГєmero de erecciones masculinas y los laboratorios Pfizer decidieron entonces comercializarla para tratar la impotencia masculina.

Luego de que fuera patentada en 1996 y finalmente, en 1998, aprobada en los Estados Unidos por la FDA (Food and Drug Administration), el Viagra se convirtiГі en lГ­der de ventas: Desde 1999 sus ventas exceden el billГіn de dГіlares anual

Precauciones a tener en cuenta antes de tomar Viagra

Es importante que las personas sean precavidas frente a la decisiГіn de tomar Viagra. De este modo, es conveniente que antes de iniciar del consumo de esta medicaciГіn, sus usuarios se realicen chequeos mГ©dicos y un examen fГ­sico para poder distinguir si no existen riesgos. Del mismo modo, el paciente estГЎ obligado a informar a su mГ©dico cuГЎles son los medicamentos que habitualmente ingiere, ya que algunos pueden tener una interacciГіn negativa con los componentes del Viagra.

Los efectos secundarios del viagra

Tomar viagra puede causar algunos efectos secundarios tales como: Dolor de cabeza, enrojecimiento del rostro, nauseas y congestiГіn nasal.

Si bien Г©stos suelen ser los mГЎs frecuentes, existen algunos otros que no aparecen tan a menudo, aunque es posible que surjan: visiГіn anormal,mareos, sensibilidad a la luz, visiГіn borrosa, dolor en la vejiga, orina oscura o con restos de sangre y dolor al orinar. Finalmente, y quizГЎs la consecuencia mГЎs preocupan te, es el dolor en el pecho que precisa de asesoramiento mГ©dico inmediato.

ВїCГіmo actГєa el Viagra en el cuerpo?

Esta medicaciГіn produce una relajaciГіn en los mГєsculos lisos del pene, de modo que el miembro tiene un mayor flujo sanguГ­neo,lo que posibilita una erecciГіn duradera y firme.

El Viagra se debe consumir una hora o una hora media antes de mantener relaciones sexuales; la duraciГіn de su efecto puede ser de hasta cuatro horas. Esta pastilla debe emplearse sГіlo una vez al dГ­a, y sГіlo en el caso de ser necesaria

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El descubrimiento del Sildenafil para el tratamiento de los problemas de erección marco el inicio de la III revolución sexual cambiando para siempre, el abordaje de los problemas sexuales.

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 galardonados con el Premio Nobel de Medicina en 1998, por idear este fármaco.

NOMBRES

¿Cuáles son los nombres de los productos que contienen sildenafil?

En el mercado nacional existen varios compuestos que contienen la molécula de sildenafil. El primer producto comercializado fue Viagra, y hoy existen múltiples preparados similares: Herex, Sildenafil, Clavupen, Aposildenafil, Juventus, entre otros.

¿Cuál de todos ellos es el más recomendable?

No cabe duda de que el producto original funciona muy bien. Sin embargo, su precio suele ser alto para la inmensa mayoría de la población. En la consulta diaria del Instituto Costarricense de Sexología, preferimos emplear Herex por su excelente eficacia y porque su precio resulta accesible. Desde luego, el médico que realiza la prescripción es quien debe decidir cuál producto usar.

Para facilidad del lector, en este capítulo nos referiremos al sildenafil con el nombre más conocido: Viagra, y con el nombre del producto que utilizamos en el Instituto: Herex.

¿Viagra viene en diferentes concentraciones?

El sildenafil se presenta en pastillas con tres concentraciones: 25 mg, 50 mg y 100 mg. Usualmente el médico inicia con una dosis de 50 mg y, basado en la respuesta, opta por la dosis de 25 mg o la sube a 100 mg.

COMO SE TOMA

¿Cómo se toma Viagra o Herex?

Viagra o Herex se toma aproximadamente veinticinco a sesenta minutos antes de la relación sexual. Los estudios demuestran que es eficaz tomándola incluso con cinco o seis horas de anticipación. Se puede tomar en cualquier momento del día. Es recomendable tomarla dos horas después de comer, es decir, con el estomago vacío. Nunca se debe tomar más de una pastilla por día.

Es importante destacar que este medicamento funciona en el tanto exista un estímulo sexual, sea una caricia, un pensamiento, un beso o un encuentro sexual propiamente dicho. No provoca erecciones espontáneas.

COMO FUNCIONA

¿Cuánto tarda en hacer efecto?

El efecto de Viagra o Herex usualmente se presenta entre los treinta y sesenta minutos, o incluso antes.

¿Cuánto dura el efecto?

El efecto se mantiene por un período de cinco a seis horas.

¿Esto significa que Viagra o Herex provoca erecciones por seis horas?

De ninguna manera. Este medicamento permite que durante seis horas se pueda desencadenar la erección ante un estímulo sexual, pero no provoca erecciones por varias horas.

¿Cómo funciona Viagra o Herex?

Viagra o Herex actúan directamente sobre las arterias del pene favoreciendo la entrada de sangre y, por consiguiente, la erección.

EFECTOS SECUNDARIOS

¿Cuáles son los efectos secundarios más frecuentes?

Por lo general, los efectos secundarios son leves y transitorios. Los más frecuentes son el dolor de cabeza y el enrojecimiento de la piel de la cara y del resto del cuerpo. Estos efectos están presentes en cerca del 10% de los pacientes.

Son menos frecuentes las siguientes molestias: mareos, secreción y congestión nasal, molestias estomacales, palpitaciones, taquicardia, y trastornos visuales transitorios como sensibilidad a la luz, visión borrosa, alteración en la percepción de los colores, enrojecimiento de los ojos y dolor ocular.

Tomé una Viagra y comencé a ver todo de color azul ¿Por qué?

En algunos pacientes, Viagra o Herex pueden ocasionar cambios en la percepción de los colores. Esta alteración suele ser transitoria. Desde luego que siempre es recomendable consultar con el médico.

¿Cuáles otros efectos secundarios se pueden presentar?

Según lo señalan algunas investigaciones, en raros casos se pueden presentar dolor en los ojos, ojos rojos, sensación de desmayo, desmayos, diarrea, vómito, sangrado nasal y salpullido en la piel. Es inusual que se produzcan erecciones por largos períodos de tiempo, y más raro aun priapismo .

¿Qué se debe hacer cuando se presenta alguno de estos efectos secundarios?

Afortunadamente, estos efectos secundarios son poco frecuentes y ceden al cabo de unas horas. Sin embargo, siempre es recomendable consultar de inmediato con el médico.

Si se presentan efectos secundarios, ¿puede el paciente volver a tomar Viagra o Herex?

El médico es quien decide si el paciente puede volver a utilizar este medicamento. En general, si se presentan molestias, ocurren con las primeras dosis. Con las dosis subsiguientes, las molestias son cada vez menos frecuentes e intensas, hasta desaparecer por completo al cabo de unas dosis más.

¿Qué procede si, al tomar Viagra o Herex, se presenta alguna reacción que no está en las anotadas anteriormente?

Ante cualquier otra molestia o efecto secundario, se debe realizar de inmediato una evaluación médica.

QUIENES NO PUEDEN TOMARLA

¿Quiénes no pueden tomar Viagra o Herex?

El médico decide cuáles pacientes pueden beneficiarse con Viagra o Herex. En términos generales, se considera que no se debe recetar este medicamento a los siguientes pacientes:

• Personas alérgicas a los componentes del Viagra o Herex
• Personas en las que, debido a su deteriorado estado de salud, las relaciones sexuales resultan riesgosas
• Personas con problemas en el corazón que son tratadas con un grupo de medicamentos llamados nitratos

¿Qué son los nitratos?

Los nitratos son medicamentos especiales diseñados para tratar ciertos problemas del corazón. Viagra o Herex pueden aumentar el efecto de los nitratos, por lo cual nunca se debe usar cuando el paciente toma nitratos o si dejó de tomarlos recientemente.

¿Cuál es el nombre comercial de los nitratos?

Los nitratos tienen varias formas de presentación y diversos nombres. Entre los más utilizados están:

• Tabletas: mononitrato de isosorbide (nombres de marca: Ismo, Monoket, Imdur) y dinitrato de isosorbide (nombres de marca: Isordil, Sorbitrato)

• Tabletas sublinguales o aerosol de nitroglicerina (nombres de marca: Nitrostat, Nitrolingual Spray)

• Parches de nitroglicerina transdérmica o nitroglicerina en pasta (nombres de marca: Minitran, Nitro-Dur, Transderm-Nitro)

PRECAUCIONES

¿Cuáles precauciones se deben tomar cuando se utiliza Viagra o Herex?

El Viagra o Herex es un medicamento muy noble; pero, como todo medicamento, debe ser recetado por un médico. En algunas condiciones se requiere de una supervisión médica estricta, como por ejemplo:

• Alergias a medicamentos
• Anormalidades en el pene. como fibrosis, cicatrices o curvaturas
• Priapismo
• Anemia de células falciformes
• Leucemia, linfomas y otros tumores
• Úlcera gástrica o gastritis severa
• Problemas en los riñones o el hígado
• Sangrados anormales
• Problemas cardíacos
• Presión alta
• Problemas visuales o problemas en la retina
• Alcoholismo

¿Pueden las personas mayores beneficiarse con Viagra o Herex?

El médico decide quiénes pueden utilizar Viagra o Herex. En general, es bien tolerado por los adultos mayores. Algunos estudios indican que, después de los 65 años, el efecto del medicamento es mayor y también son más frecuentes los efectos secundarios. Por eso es usual que se utilicen dosis iniciales bajas, con el fin de observar la tolerancia y la respuesta al medicamento.

¿Se puede tomar Viagra o Herex con las comidas?

En nuestra sociedad, es común ligar la sexualidad con una cena bien preparada. Este medicamento se puede tomar con las comidas. No obstante, lo ideal es hacerlo dos horas después de comer, es decir, con el estómago vacío, para no retrasar su efecto. Cuanto más grasoso sea el alimento, más se atrasará la absorción del fármaco y su efecto.

VIAGRA Y LAS DROGAS

Después de una relación sexual, me gusta fumar un cigarrillo. ¿Puedo hacerlo si he consumido Viagra o Herex?

Según lo señalan los estudios, los fumadores no experimentan efectos secundarios diferentes, en frecuencia ni en intensidad, en relación con los no fumadores. Debe recordarse que el fumado afecta la erección a largo plazo.

Me gusta tomar unas copas de licor antes de la relación sexual. ¿Puedo tomar Viagra o Herex en combinación con el alcohol?

Este medicamento se puede utilizar cuando se ingieren dosis bajas de licor (una o dos copas). Sin embargo, si se toman mayores cantidades de licor, el mecanismo de la erección se ve afectado y, por ende, puede anular el efecto del medicamento. Teóricamente, es posible que el alcohol aumente los efectos secundarios de Viagra o Herex.

¿Se puede utilizar Viagra o Herex si se ha consumido drogas?

Algunas drogas ilegales contienen nitratos, sustancias que interactúan con Viagra o Herex y provocan efectos peligrosos. Por eso, no se debe combinar el uso de drogas con estos medicamentos.

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Effect:
Erection possible 30 minutes after taking the pill.
Side-effects:
Can be fatal for patients on medication with nitrates or for cardio-vascular patients.Temporary loss of colour vision, nausea and headache.

This consequently increases the supply and leads to erection. It isn’t as if the disorder doesn’t have optional cures, but no treatment matches the drug in the sheer simplicity of its administration. Which explains the euphoric reception to its arrival.

“We can now give oral tablets to the patients,” says Saxena, “and it will also stop them from going to the quacks.” For eminent Mumbai-based andrologist Vijay Kulkarni, “it’s one more tool for treating the patient”.

Tempering the ebullience, however, are experts who sound a word of caution. Viagra is not, they emphasise, an aphrodisiac, as is widely assumed. The potential danger arising from its misuse is why it has been cleared only as a prescription drug.

Says DCGI Ashwini Kumar: “It has been approved on the condition that it be used cautiously under therapeutic conditions.” For the genuine patient though, the readily available, cheap, effective tablet is nothing but good news.

After Viagra’s four-year run in the market worldwide, the drug’s effectiveness is not disputed and is bound to have a big impact. But there’s a flipside. Sildenafil can be fatal for people on nitrates and those with cardio-vascular problems.

If taken with nitrates, it reduces the patients’ blood pressure dramatically. Possible temporary side-effects are headache and nausea. A more serious effect is loss of blue-green colour vision. The correct dose is, hence, of prime importance; all Indian versions of sildenafil will be available in 25 mg, 50 mg and 100 mg doses.

Misuse of sildenafil can also lead to tragicomic mishaps. Doctors cite numerous instances where normal people took Viagra to enhance their sexual performance. The result was an embarrassing and painfully prolonged erection that lasted for days and required surgery to rectify. Both doctors and manufacturers emphasise that sildenafil is a treatment, not a cure.

It temporarily acts on a specific part of the body but it does not solve the underlying reason for the disorder. “Sexual dysfunction is about more than just Viagra,” says Kulkarni, “Psycho-sexual counselling is very important.” All companies Torrent, Cadila and Ranbaxy emphasise the need for patients to be educated by urologists, endocrinologists and psychiatrists.

S.D. Kaul, Regional Director, Asia & Middle East, Ranbaxy

Side-effects notwithstanding, the pharmaceutical companies are upbeat. “We’re on top of the world,” exclaims a jubilant S.D. Kaul, regional director, Asia and Middle East, Ranbaxy. He has reason to be. With India’s billion-plus population, the sheer numbers translate to tremendous market potential. “The market would run to about Rs 50-100 crore. It’s a blockbuster drug,” says Kaul.

Other companies provide similar estimates. But with so many vying for a slice of the pie, a bit of shine may rub off soon. Stiff competition will define price and profit margins to the patient’s benefit. The approximate price of the new drug is Rs 20 per tablet, which is already a big gain for patients who are currently shelling out Rs 500 per tablet for the imported Viagra in the grey market.

The affordability of the genuine sildenafil brands could also adversely affect the popularity of the anti-impotence herbal drugs.

With the product being identical, marketing strategy will decide the winners and losers in the Great Indian Sildenafil Contest. Brand name, colour and even the shape of the tablets are being depicted as distinguishing features to gain an edge in the market.

As for Ranbaxy’s brand, Caverta, “the name derives from the cavernosa, the part of penis that plays a vital role in erection”, explains Kaul. Torrent’s choice, Androz, derives from andrology a science that deals with the study of the masculine constitution, according to R. Balasubramanian, vice-president, marketing, Torrent.

Penegra was Cadila’s choice both because it refers to problems of penetration, and the penis, says President Ganesh Nayak. Blue and diamond shaped, the Penegra pill is an exact copy of Viagra. Ranbaxy’s red triangular tablets are deliberately designed to be different, while Torrent’s tablets are blue and round.

“We have made a conscious effort to retain the round shape like regular tablets to tell the patients that ED is neither fun nor serious. It’s just another curable condition,” says Balasubramanian.

An India-specific marketing challenge for the companies is people’s reluctance to talk openly about sexual matters. Says Kaul: “We don’t just have to create a brand but also a market, as ED is a hush-hush affair here.” Besides, impotence is not just any other disease like diabetes or malaria.

Striking at the very core of manhood, its impact finds an echo in every aspect of man’s life: the wife doomed to a celibate existence and the boss stuck with a depressed, less-productive employee. Small wonder then that the drug is seen as the best thing to happen to the Indian male in a long, long time.

Some of the optional cures available to erectile dysfunctional patients in India are:

  • The most popular and affordable treatment so far has been the papaverine injection. At Rs 15-20 per shot, it is the price, not convenience, that dictates its popularity. The drug has to be injected locally into the phallus, a painful procedure that can lead to infection unless done in aseptic conditions, according to Professor N.K. Mohanty, head of urology at Delhi’s Safdarjung Hospital.
  • The vacuum erection device is the only non-invasive treatment that has no side-effects, says Mohanty. There are no injections, no tablets – only a hollow tube that creates a vacuum and sucks blood into the penis, leading to an erection. At Rs 10,000- 20,000 one-time cost, the price at least induces a sense of satisfaction.
  • Some men – such as traumatic paraplegics – suffer from extreme impotence. A penile implant is then the only option. The device is designed to last a lifetime. But, insists Ajit Saxena, senior consultant urologist at Delhi’s Apollo Hospital, implants should be prescribed only after a thorough psychological assessment, when all else fails. This procedure involves placing an artificial implant into the phallus. The price can range from Rs 40,000 to Rs 2 lakh but the result is near-normal function. The biggest drawback is infection and rejection by the body, which occurs in about 2 to 3 per cent of the surgeries.

Cracking Down on Counterfeit Drugs

By Barbara Moran on Tue, 20 Aug 2013

People who saw Rick Hitsman in court say he looks like any other middle-aged man with gray hair and blue eyes. For years, until he was indicted in 2012, Hitsman travelled back and forth between Arizona and California, selling counterfeit Viagra out of the trunk of his gold Toyota Camry. He’d meet buyers at parking lots around the San Fernando Valley and sell them boxes of fake Viagra, each containing four tablets, for $10 per box. Real Viagra costs around $22 per pill, so for buyers it was quite a bargain. Hitsman also sold fake Viagra online, advertising on Craigslist. Unfortunately for him, one of his customers was a man named “Mike,” a private investigator working for Pfizer.

For two years, “Mike” bought counterfeit Viagra from Hitsman and sent samples to Amy Callanan, a senior scientist at Pfizer. Callanan, who works at Pfizer’s R&D campus in Groton, Connecticut, is now sitting with me at a large conference table scattered with baggies, blister packs, and bottles of pills. Callanan spends most of her time analyzing fake pharmaceuticals, looking for chemical clues that may lead investigators to culprits. She picks up two small cardboard boxes. One box contains legitimate Viagra, the other is full of fakes. To me, they look almost identical: same size, same wide blue stripes down the left-hand side, legitimate-looking Pfizer logos and holograms.

Lipitor, a statin used to control cholesterol, is among Pfizer’s drugs that is counterfeited. Above, counterfeit pills (left) sit next to genuine examples (right).

But to Callanan, the fake is obvious. “I see this one all the time,” she says, handing me one of the boxes. It’s the same type Hitsman sold. “This is the most common counterfeit Viagra we see—it’s manufactured for the Malaysian market.” She points out the telltale signs of the fake: the blue stripe is too dark, the word “contains” is spelled incorrectly (“contaihs”), and the box sports a hologram that Pfizer no longer uses. But the giveaway is the lot number: 314833021, which Callanan rattles off from memory. Once a lot has been distributed to patients, Pfizer permanently retires its number. But thanks to counterfeiters, this lot number still lives on in knockoffs. It’s proven so popular among criminals that Callanan now sees knockoffs of the knockoffs. “It’s interesting how these same mistakes get perpetuated,” she says.

An estimated 80% of counterfeit drugs come from overseas.

Fueled by easy internet sales, global supply routes, and minimal punishments, counterfeit prescription drugs have become an exploding industry, with an estimated market worth $75 billion a year worldwide. Long the scourge of developing countries, fake drugs are now popping up in the United States. In 2012, a counterfeit version of the cancer drug Avastin was widely distributed in the U.S. and a fake version of the ADHD drug Adderall, in high demand because of a shortage, arrived in the U.S. through internet pharmacies. In early 2013, the U.S. Food and Drug Administration (FDA) warned doctors that a fake version of another cancer drug, Altuzan, containing no active ingredient, was being distributed in the United States. An estimated 80% of counterfeit drugs come from overseas, and most of them are manufactured in India and China. In this era of globalization, the supply chain for genuine pharmaceuticals has grown longer, and every link offers an opportunity for counterfeiters.

A Developing Problem

In the developing world, where few countries have the regulatory and policing power of the United States, the problem of counterfeit drugs is even more widespread and tragic. For example, according to the World Health Organization, 200,000 people a year die because ineffective, fake, and substandard malaria drugs don’t clear their systems of the parasite. And because these pills often contain small amounts of active ingredient—enough to abate some symptoms but not cure disease—they contribute to drug-resistant strains. The WHO also estimates that between 1% and 10% of drugs sold around the world are counterfeits, up to as many as 50% in some countries.

In North America, the problem has been mostly—though not entirely—restricted to “lifestyle” rather than life-saving drugs. Among these, the most famous is Pfizer’s Viagra, widely described as one of the most counterfeited drugs in the world. While it’s tempting to smirk at consumers duped by fake diet pills, baldness cures, and counterfeit Viagra, these drugs are stepping stones for counterfeiters. Criminals who find success here, experts say, will likely expand their business.

This counterfeit drug manufacturing site in China produced fake Viagra and other drugs that were sold to customers in the European Union and the U.S.

“The ultimate way of making money, if you’re a counterfeiter, is to get into the legal supply chain,” said Roger Bate, a resident scholar at the American Enterprise Institute and an expert on counterfeit prescription drugs. “Even in the rich countries, the legitimate supply chain has been breached by counterfeiters. You could go into a CVS or a Walgreens to fill your prescription for whatever it may be—it could be for a heart medication, a cancer drug, an antibiotic—and you could be killed by that medicine.”

Pfizer won’t say how much money they lose on fake Viagra, but the drug is one of the company’s blockbusters, pulling in more than $2 billion in 2012. Viagra isn’t Pfizer’s only counterfeit headache: in 2008, according to John Clark, vice president of global security for the company, about 20 different Pfizer medicines and products were being counterfeited around the world. Today, that number is up to 60—everything from Lipitor and Centrum Vitamins to, bizarrely, ChapStick.

Counterfeit cough syrup being dispensed from a water cooler in Pakistan.

Like Pfizer, many large companies police their brands; after all, criminals fake everything from perfume to tires. But according to Bate, pharmaceutical companies take their policing a step further. The prescription drug market is vast and lucrative—$800 or $900 billion worldwide—and counterfeiting drugs is relatively simple. “It’s probably easier to make fake pills than it is to make fake jeans, yet the markups are far greater,” Bate says. “If you are a smaller criminal getting into the fake drug business, it’s good and easy money.” It’s good money for big-time criminals as well. According to a report from the Stimson Center, a nonprofit global security institute, the Russian mafia, Colombian drug cartels, Mexican drug gangs, Hezbollah, and al Qaeda are all producing and trafficking counterfeit drugs.

Pfizer’s investigative powers are surprisingly broad.

The U.S. government, naturally, has laws against counterfeiting drugs, but the responsibility for enforcement is scattered across many agencies, including the FBI, the FDA, the Drug Enforcement Administration (DEA), Immigration and Customs Enforcement (ICE), and state and local police. “The FBI can look at it as a healthcare fraud case, a straight-up fraud case, or an importations case. They have the broadest reach,” says Brian Donnelly, who was an FBI agent for 21 years before becoming director of investigations for Pfizer North America. “But since 9/11—I can speak from personal experience—they’ve been sort of sidetracked onto terrorism.”

Donnelly describes his role at Pfizer as providing law enforcement with “grounders,” or cases that Pfizer has already investigated and prepped for prosecution. Pfizer’s investigative powers are surprisingly broad. After their computer experts sweep the internet for possible counterfeits, the company hires private investigators to purchase drugs from stores or online pharmacies and record conversations with sellers in jurisdictions where it’s legal. Then scientists analyze the fake drugs in one of Pfizer’s three testing facilities: Groton, Connecticut; Sandwich, England; or Dalian, China. Donnelly says his team gives U.S. and Canadian law enforcement two or three cases each week, and Pfizer’s work leads to about 50 or 60 convictions each year.

Fingerprinting the Fakes

The case involving Rick Hitsman, the man who sold fake Viagra out of the trunk of his Camry, was fairly typical. After Pfizer organized the case against him, they turned it over to ICE, who continued the investigation. Hitsman assured undercover ICE agents that the Viagra was high quality. In fact, he said, he used the counterfeit Viagra himself. He had a 28-year-old girlfriend, and the stuff would last a week. Both Callanan and Donnelly testified at Hitsman’s trial, and he was convicted of trafficking in counterfeit goods in June 2013. “It wasn’t that hard to convince the jury,” Donnelly says.

The prosecution, of course, had science on their side. In the lab at Pfizer, Callanan picks up a yellow envelope and removes an evidence bag from the Hitsman case. She opens it and pulls out a box of the infamous Malaysian counterfeit Viagra. To test the drug, Callanan scratches off a patch of blue coating, then scrapes out some of the white interior. She places the white dust into an infrared spectrometer, which shines infrared light on the sample to analyze its chemical bonds. What results is a graph of peaks and valleys—reflected and absorbed wavelengths—unique to that drug. Callanan taps the keyboard and the IR spectra from four samples from the Hitsman case appear on the screen. She zooms into the “fingerprint” region, an area of peaks and valleys that reveal secrets about the pills’ chemical makeup.

Counterfeit Viagra pills (left), such as these from Pakistan, may look indistinguishable from the real thing (right), but chemical analysis can reveal the fake.

“They’re all pretty similar,” she says, peering at the four red squiggles. “It looks like the same maker, but maybe different batches.” She taps on the keyboard again, and the chemical signature of authentic Viagra, outlined in black, pops onto the screen. Moving the mouse, she superimposes the real Viagra fingerprint over the fakes. “Here’s the telltale difference,” she says, pointing to a low red peak juxtaposed with a high black peak at 1700 cm -1. “This is the active ingredient—sildenafil citrate—you can see where it’s supposed to be, and how low it is in the counterfeit.”

Callanan grinds a bit more of the counterfeit pill with a mortar and pestle, and tests it with X-ray diffraction to confirm the first set of results. Here, Callanan further refines the fake’s formula by comparing it to Pfizer’s library of excipients—the inert ingredients that give a drug its form and consistency. “You see these other red mystery peaks,” she says, pointing at the screen. “Those are calcium sulfate diehydrate and calcium sulfate hemihydrate, the two most common ingredients we see in counterfeits.” Noticing my blank expression, she adds, “It’s gypsum, the same stuff as sheetrock.”

These used vials, seized during a raid in Colombia, were being washed for reuse to hold counterfeit medications.

According to Callanan, counterfeiters often add gypsum because it’s cheap, easily available, and will compress and hold the shape of a tablet. But extra ingredients like caffeine baffle her. Counterfeiters, it seems, have no limit to their imaginations. “What I really like is counterfeit Xanax spiked with melatonin,” she says with a laugh. “It’s like, why?”

“We can’t always figure out why,” adds Brian Donnelly, who is standing nearby. “But I can guarantee it has something to do with making money.”

Finding Fakes for Less

Pfizer doesn’t police the market beyond their own brands, but the company has given developing countries sophisticated handheld scanners that can detect a variety of counterfeits, including some non-Pfizer medications. But still, the largest percentage of counterfeit drugs—the generic antibiotics, tuberculosis drugs, and malaria medicines so prevalent in the developing world—often go unmonitored, since many countries don’t even have their equivalent of the FDA. For these reasons, a handful scientists and engineers are trying to create cheap, nearly indestructible devices to test for counterfeits. They want to do what Pfizer does for pennies.

One of these scientists is Marya Lieberman, a chemist at the University of Notre Dame. “In a developing country, if you go to one of the little shops that sell medications, you cannot look inside the pill and see if it’s good or not,” Lieberman says. “The technological tools that you need for that are very rare and expensive.”

To address that problem, Lieberman has developed a simple paper card that tests whether a drug contains the correct active ingredients. The user scrapes a tablet across the test card, then dips the card into water. Water travels up the card, mixing chemicals with the drug, and a colored bar code shows whether the correct ingredients are present. Lieberman’s cards currently sense 12 substances, including different types of antibiotics and anti-tuberculosis medications, as well as fillers like chalk, flour, and acetaminophen, a common additive since it lowers fevers, making patients believe the medicine is authentic. She’s currently testing the card with pharmacists in Kenya.

Right now, Lieberman’s cards only detect if an ingredient is present or absent. Her next step is to design cards that detect if the drug contains some, but not enough, active ingredient. She also wants to make the cards cheaper—they now cost about 45 cents—and easier to read.

Lieberman knows that her cards alone can’t fix the problem. Developing countries need trustworthy agencies to regulate and distribute drugs. Governments need stiffer penalties for counterfeiters and better enforcement, doctors and patients need to recognize the issue, and the technology that detects fake and substandard drugs needs to be cheaper and more robust. But Lieberman is optimistic that her cards will help, at least a little. “Sometimes you can’t solve the whole problem,” she says, “but you can start nibbling away at it.”

Photos courtesy Pfizer

Original funding for NOVA Next was provided by Amy and Joshua Boger.

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Website © 1996-2016 WGBH Educational Foundation

Move over viagra, new drug to beat bedroom blues

CHENNAI: It’s not always that the release of a drug is celebrated by many, particularly men. A drug that was released in India last week is the recent in the list of drugs that has a cure for erectile dysfunction. The manufacturers say udenafil, which will be marketed under the brand name Udezire, will be long-acting, but with minimal side effects.

Erectile dysfunction (ED) is an inability to achieve or sustain an erection suitable for sexual intercourse. Sexologists say at least 10% men in India may have to use these drugs at some point. Studies have shown that 40% of men up to the age of 40 years have ED and it goes up 70% by 60 years.

The commonly prescribed drugs for the disorder in India are sildenafil (Viagra) and tadalafil, which belong to a category called phosphodiesterase type 5 drugs. Now, Zydus, a pharmaceutical company, has got exclusive permission to sell udenafil. The drug is manufactured by Korea-based Donga-A pharmTech Co. Ltd. and is being used in a dozen countries.

The last drug for the disorder was introduced nearly five years ago in the market. “Most of the existing drugs have side effects. While sildenafil puts pressure on the user to complete intercourse within four hours, tadalafil that lasts for nearly 17 hours causes back pain and headache in some users. Manufacturers say the effect of the new drug will last up to 12 hours, without much side effects,” said sexologist Dr D Narayana Reddy.

Male sexual arousal is a complex process that involves the brain, hormones, emotions, nerves, muscles and blood vessels. Problems in any of these can cause erectile dysfunction. Stress and mental health problems can also cause erectile dysfunction. “In some people it could be a combination of physical and psychological issues,” says Dr Reddy.

Manufacturers say they will market the drug through senior psychiatrists, andrologists, sexologists and diabetologists. In 80% of erectile dysfunction cases, physical factors such as drugs, blood flow abnormalities, nerve impulse abnormalities or hormonal abnormalities are the causes. Patients with high blood pressure and diabetes are also at risk of having erectile dysfunction. Physical causes of erectile dysfunction include heart disease, clogged blood vessels, high cholesterol, high blood pressure, diabetes, obesity, alcoholism, smoking, Parkinson’s disease and other medical condition. Psychological causes of erectile dysfunction include depression, anxiety, stress or relationship problems.

The new drug will be priced at 575 per tablet, a little lesser than Viagra. “We expect to have 20% of the market share in one year because our survey reveals there is a fatigue with old drugs,” said Zydus Pharma senior vice-president O P Singh.

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A compilation of 14 fascinating interviews with graduates of the Oasis of Peace’s Primary School.

No One Can Ever Steal Your Rainbow . a book of hope for all ages, Best Inspirational Children’s Picture Book of 2005; comes with a CD and lyric sheet.

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Keppra

Keppra is the brand name of levetiracetam, a prescription medication taken in conjunction with other anti-seizure drugs to treat children who have certain types of epilepsy and experience seizures.

It's used to treat children 12 and older with juvenile myoclonic epilepsy who get myoclonic seizures.

In addition, the medication is prescribed as part of a therapy regimen for people with certain types of generalized epilepsy who are 6 and older and have a type of seizure known as a tonic-clonic seizure (formerly called "grand mal seizures").

Manufactured by the UCB Group of companies, Keppra works by moderating the transmission of nerve signals in the brain.

The Food and Drug Administration (FDA) approved Keppra in 1999, but the safety and warning labels have since been updated.

Keppra (Levetiracetam) Warnings

If you use Keppra, you risk becoming aggressive, agitated, angry, anxious, depressed, or apathetic. You might also experience depersonalization or develop a personality disorder.

Serious dermatological reactions like toxic epidermal necrolysis, which can cause the skin to peel off in sheets, and Stevens-Johnson syndrome, a rare but severe skin condition, have also been reported among Keppra users.

Increased blood pressure in those between one month and 4 years old is another serious condition linked to use of Keppra.

It's unknown if this drug is safe or effective in those younger than one month of old.

Keppra has been known to cause suicidal thoughts/actions in a small number of people who are using it. You should contact your doctor immediately if you have thoughts of suicide and/or attempt to commit suicide, or if you experience new or worsening depression. anxiety, and irritability.

It's also important to alert your healthcare provider if you experience any unusual changes in behavior, including:

  • Agitation or restless
  • Problems sleeping
  • Panic attacks
  • Aggression, anger or violence
  • Acting out dangerous impulses

Never stop taking Keppra on your own without first speaking to a doctor. Doing so could lead to non-stop seizures. It's also important that you take the exact dose prescribed.

To help your doctor decide if Keppra is right for you, it's important you tell him/her about all your medical conditions, such as whether you have or have had mood problems, suicidal thoughts/behavior, or depression.

Pregnancy and Keppra (Levetiracetam)

If you are pregnant, it's key that your doctor monitor you closely during your pregnancy and the postpartum period, especially if your dosage was changed while you were pregnant.

It's unknown if Keppra will harm your fetus. However, having a seizure during pregnancy is serious so your doctor will have to decide if the potential risks of using this medication outweigh the benefits.

Do not use Keppra while breastfeeding.

If you do get pregnant while on the medicine, you should consider registering with the North American Antiepileptic Drug Pregnancy Registry. You can do so by calling 1-888-233-2334. In addition, you can enroll in the UCB AED Pregnancy Registry via phone at 1-888-537-7734. Both collect information about the safety of Keppra for pregnant women.

Keppra and its generic form come in 250 mg, 500 mg, 750 mg and 1,000 mg tablets as well as in a grape flavored liquid (100 mg/mL). Keppra XR extended release tablets are available in 500 mg and 750 mg.

It's not necessary to eat before taking Keppra. Your required dose will depend on your age, condition, dosage form, and kidney function. It's important that Keppra tablets be swallowed whole and not chewed or crushed.

Partial Onset Seizures:

Clinical trials in those 16 and older show that taking 1,000 mg, 2,000 mg, and 3,000 mg twice a day was effective.

You should begin with a daily dose of 1,000 mg/day, divided into two equal doses taken twice a day.

Children between 1 and 6 months old should begin with 14 mg a day, divided into two equal doses. Those between 6 months to 4 years of age and 4 and 16 should start with two equal doses of 10 mg a day.

Myoclonic seizures in those 12 and older with juvenile myoclonic epilepsy: Begin your treatment with an initial dose of 1,000 mg/day, which should be divided into two equal doses.

For tonic-clonic seizures: Those 16 and older should start with 1,000 mg a day broken into two equal doses. For patients between 6 and 16, treatment should begin with 20 mg a day taken in two doses of 10 mg twice daily.

Keppra (Levetiracetam) Overdose

If you believe you have overdosed either get to the emergency room immediately or call a poison control center at 1-800-222-1222.

Missed Dose of Keppra (Levetiracetam)

It's key that you take your medicine at the same time each day.

If you forget, you can still take it as long as it's not near the time of your next dose. If that is the case, skip the missed dose and continue on your regular schedule. Don't take extra to make up for the missed dose.

Q: I take 2500 mg of Keppra a day for seizures after having a brain tumor removed. Can I get a tattoo while taking this med.

A: According to the prescribing information available for Keppra, there are no studies done based on treatment with Keppra and tattoos. You may want to contact your health care provider before getting a tattoo. For additional information regarding Keppra you may want to visit our Web site: http://www.everydayhealth.com/drugs/keppra.

Q: What side effects does Keppra have on muscles?

A: It is always important to be aware of the side effects of a medication so you can recognize the symptoms if they occur. According to the prescribing information available, Keppra can cause muscle pain and weakness. It can potentially cause problems with muscle coordination, including difficulty moving or walking, and it is important to contact your doctor as soon as possible if you experience any of these symptoms. For additional information regarding Keppra, visit our Web site: http://www.everydayhealth.com/drugs/keppra.

Q: Is it OK for the dentist to give me lidocaine or carbocaine when I'm taking Arimidex and Keppra?

A: There are no documented drug interactions between Keppra (levetiracetam) or Arimidex (anastrozole) and the anesthetics lidocaine and carbocaine. However, that does not mean one cannot exist. Always discuss all of your medications with your healthcare providers, including your dentist. You may also find helpful information at http://www.everydayhealth.com/DrugsAZ/Arimidex.aspx http://www.everydayhealth.com/DrugsAZ/Keppra.aspx

Q: I am taking Keppra and soon may have to go for a colonoscopy. Would that have any effect on the Keppra?

A: Keppra (levetiracetam) is an anticonvulsant used in the treatment of seizures. According to the research, food delays, but does not change, the extent of absorption of Keppra (levetiracetam). Keppra can be taken with or without food. A colonoscopy is an examination of your colon with a camera at the end of a flexible tube. To prepare for a colonoscopy your doctor will give you some laxatives which will clean your colon out. Since you will not have any food in your digestive tract it may alter the absorption of medications that are affected by food. Keppra (levetiracetam) is not affected by food so no change would be expected. Talk to your healthcare provider about what to expect during the colonoscopy and what you will need to do to prepare. For more information on Keppra (levetiracetam): http://www.everydayhealth.com/drugs/keppra. For more information on colonoscopies: http://www.everydayhealth.com/health-information/colonoscopy-what-is-it.aspx Laura Cable, PharmD

Q: I have extreme puffiness and edemic swelling in my feet, ankles, and legs. Does Keppra cause these side effects?

A: The majority of the clinical trials have not indicated swelling and puffiness as a significant side effect of Keppra (levetiracetam). There is some anecdotal, patient-reported evidence and small studies that have shown facial swelling in children and general swelling in adults. Please consult with your physician if side effects are severely bothersome. Studies have shown that allergy to medications can sometimes manifest as swelling, rash and itching soon after taking the medication. But it is generally unlikely if a patient has been on the medication for a long time. It is important to follow up with your health care provider.

Q: Why does Keppra cause mood problems and agitation? Is there another drug I can use to balance out my mood?

A: Keppra (levetiracetam) has a number of different side effects to varying degrees. Psychiatric side effects occur in a number of medications that are used to balance out mood. Other treatment options include lamotrigine (Lamictal), nefazodone (Serzone), valproic acid, and divalproex sodium (Depakote), to name a few. There are many treatment options available to balance mood. Discussion about the treatment options and any concerns with your doctor can help to find the best therapy. Lori Mendoza, PharmD

Q: Does Keppra cause hyperpigmentation?

A: Keppra (levetiracetam) is an anti-epileptic drug approved to treat partial onset seizures, primary generalized tonic-clonic seizures and myoclonic seizures. Some of the commonly reported side effects associated with treatment with Keppra include dizziness, drowsiness, irritability, headache, neck pain, runny nose and sore throat. In a clinical study of Keppra in treating partial-onset seizures, in children ages 4 to 16, 2% of the patients reported experiencing skin discoloration. There were no other documented reports of patients experiencing hyperpigmentation. If you have been experiencing symptoms of hyperpigmentation, while being treated with Keppra, you may want to contact your healthcare provider to determine the underlying cause and possible treatment options. It is important to take Keppra exactly as prescribed by your physician. Keppra can be taken with or without food and should be taken with a full glass of water. Do not discontinue treatment with Keppra unless advised by your doctor. Beth Isaac, PharmD

Q: I've been taking Keppra for about 6 months now, but recently had my dosage increased. I've been feeling kind of jittery and anxious, could the Keppra be causing some of these anxious and jittery feelings?

A: Keppra (levetiracetam) is a medication used to treat epilepsy and does list anxiety and nervousness as possible side effects. If they are bothersome and do not go away, you may want to let your doctor know. Other side effects of Keppra (levetiracetam) may include agitation, moodiness, forgetfulness, drowsiness, dizziness, weakness, unsteady walking, difficulty with coordination, numbness, burning, or tingling in the hands or feet, nausea, vomiting, loss of appetite, diarrhea, constipation, headache, pain, and changes in skin color. This is not a complete list of the side effects associated with Keppra (levetiracetam). Patti Brown, PharmD

Q: I take Keppra. Can it make you edgy, irritable, fast tempered, or depressed?

A: Keppra (levetiracetam) is an anticonvulsant or anti-seizure drug. It is used to treat partial onset seizures, tonic-clonic seizures, and myoclonic seizures. Keppra can also be used as a mood stabilizer in bipolar disorder and to treat certain types of pain. Common side effects of Keppra include dizziness, drowsiness, irritability, loss of appetite, vomiting, and headache. However, Keppra can also have more serious side effects, such as a serious mood disorder or thoughts of suicide. Contact your doctor right away or seek medical attention if you experience any new or worsening mood or behavior changes, depression, anxiety, agitation, hostility, restlessness, hyperactivity, or if you have thoughts of hurting yourself or suicide. If the symptoms you describe match this, call your doctor at once. This is not a complete list of side effects that can occur with Keppra. Sarah Lewis, PharmD

Q: I had a stroke in 2002, seizures in 2003 and have been on Keppra since 2003. Can I ask to wean off, and are there any side effects known as far as anxiety? I was recently hospitalized with anxiety just overnight. I may have missed a dose or taken an extra dose.

A: Keppra (levetiracetam) is an anti-epileptic or anti-seizure drug that is used to treat partial onset seizures, tonic-clonic seizures, and myoclonic seizures. Common side effects of Keppra include dizziness, spinning sensation, drowsiness, irritability, and headache. This is not a complete list of side effects that can occur with Keppra. According to the prescribing information for Keppra, anxiety can occur in approximately 2 percent of patients taking the medication. Whether or not people can or should stop their anti-seizure medications depends on their specific circumstances. These medications may only be needed short-term to get through an illness or injury that has caused the seizures or they may be needed lifelong to treat recurrent seizures. And sometimes, the answer is somewhere in between. There are pros and cons to stopping anti-seizure medications that should be considered with the advise of your doctor. The pros include avoiding side effects from these medications and no longer dealing with the cost and hassle of refilling and taking a regular prescription medication. However, the primary con of stopping anti-seizure medications is having another seizure. This could lead to injury, hospitalization, and even death. Having another seizure could also affect lifestyle issues, such as the ability to drive. So, this decision should only be made after talking to your doctor about your specific risks. Do not stop or change the amount of medication you take without talking to your doctor first. For more specific information, consult with your doctor or local pharmacist for guidance based on your health status and current medications, particularly before taking any action. Sarah Lewis, RPh, PharmD

Q: Can Keppra cause melasma? I started getting a bad case of it (despite 50+ sunblock) on my forehead when I started taking Keppra.

A: Keppra (levetiracetam) is in an antiepileptic drug. Keppra is used together with other medications to treat certain types of seizures in people with epilepsy. Keppra may also be used in people with other conditions such as bipolar disorder. Keppra may also be used to prevent migraine headaches. Keppra may also be used to manage involuntary movements that occur as a result of a side effect of antipsychotic medications. The exact mechanism by which Keppra works is not known. It is thought that Keppra works by decreasing abnormal brain excitement. Behavioral symptoms are some of the most common side effects with Keppra. Behavioral side effects include: agitation; aggression; anger; anxiety; apathy; depersonalization; depression; rapid and drastic changes in emotions; hostility; overactive restlessness; irritability; nervousness; and personality disorder. Other more common side effects with Keppra are: sleepiness; headache; vomiting; loss of appetite; weakness; sore throat; stuffy nose; cough; accidental injury; and infection. A search of the prescribing information for Keppra did not specifically list melasma as a side effect. Other side effects with Keppra relating to the skin include; ecchymosis (a purple or black and blue discoloration of the skin; that is, a bruise); skin discoloration; blistering rash; and rash. Derek Dore, PharmD

Q: Is Keppra causing my constipation?

A: Keppra (levetiracetam) is an anti-epileptic drug. Keppra is used to treat partial onset seizures, tonic-clonic seizures, and myoclonic seizures. Common side effects of Keppra include dizziness, drowsiness, and headache. Other side effects reported with Keppra include fatigue and sedation, coordination and gait difficulties and abnormal behavior. A search of prescribing information did list constipation as a side effect of Keppra. This is not a complete list of the side effects associated with Keppra. Because there may be many different factors that can lead to constipation, please consult your health care provider regarding the symptoms you are experiencing. Kimberly Hotz, PharmD

Q: Is Keppra causing my constipation?

A: Keppra (levetiracetam) is an anti-epileptic drug. Keppra is used to treat partial onset seizures, tonic-clonic seizures, and myoclonic seizures. Common side effects of Keppra include dizziness, drowsiness, and headache. Other side effects reported with Keppra include fatigue and sedation, coordination and gait difficulties and abnormal behavior. A search of prescribing information did list constipation as a side effect of Keppra. This is not a complete list of the side effects associated with Keppra. Because there may be many different factors that can lead to constipation, please consult your health care provider regarding the symptoms you are experiencing. Kimberly Hotz, PharmD

Q: Is Keppra causing my blurry vision?

A: Keppra (levetiracetam) is an anti-epileptic drug. Keppra is used to treat partial onset seizures, tonic-clonic seizures, and myoclonic seizures. Common side effects of Keppra include dizziness, drowsiness, and headache. Other side effects reported with Keppra include fatigue and sedation, coordination and gait difficulties and abnormal behavior. A search of prescribing information also listed double vision as a reported side effect of Keppra. This is not a complete list of the side effects associated with Keppra. For more specific information, consult with your doctor or pharmacist for guidance based on your health status and current medications, particularly before taking any action. Kimberly Hotz, PharmD

Q: Is the generic for Keppra as effective?

A: Generic drugs are lower-cost alternatives to more expensive brand name drugs. They will appear different and have a few minor differences in their inactive ingredients from the brand-name product, but their uses and labeling are virtually the same. Generic products are evaluated by the U.S. Food and Drug Administration (FDA) for bioequivalency. Bioequivalency means that they have similar blood levels and work in the body the same as the brand name product. The FDA allows for very small differences in the performance of the generic drug. However, approval by the FDA means that the generic product is the same as the brand name product with regard to dose, strength, route of administration, safety, effectiveness, and intended use (the medical condition it treats). Therefore, the generic form of Keppra, levetiracetam, is considered to be as effective as the brand name product. For more specific information, consult with your doctor or local pharmacist for guidance based on your health status and current medications, particularly before taking any action. Sarah Lewis, PharmD

By Sherry Karabin | Medically Reviewed by Ruthan White, PharmD, BCACP

Latest Update: 2014-09-24

Increase T Naturally

Testosterone and Mood

As we point out often on this site, testosterone effects everything for us guys and, especially, the male brain. One of the surpising things that testosterone alters rapidly is mood. Yes, testosterone can make us guys "bitchy." In fact, believe it or not, researchers have a term for it: Irritable Male Syndrome. [1]

Researchers first noticed the effects of low testosterone in animals and have since studied this effect in a wide variety of mammals. What is counterintuitive is that instead of becoming docile and quiet, males with decreased testosterone become much more prone to fighting. Researchers noted that it could likely be due to a drop in brain opiods that are necessary for mood elevation. Thus they become both fearful and irritable at the same time – a toxic combination by any standards. (Think of that next time you make fun of a woman with PMS, eh?)

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So just what do researchers mean by "mood?" Generally, questionaires are used and monitor psychological items such as "positive mood responses (alert, friendly, full of energy, well/good feelings) and negative mood responses (angry, irritable, sad, tired, nervous)." [4] Other studies have looked at similar attributes, such as "angry, alert, irritable, full of pep (energy), sad/blue, tired, friendly, nervous, and well/good." [7]

However, changes in mood parameters such as this are generally only experienced by men with hypogonadal testosterone levels. Several studies have shown that men with normal or even low normal testosterone levels experience little to no benefit in this area from testosterone therapy for example. [2] Young, healthy males may be more resilient as well to low testosterone according to one study, although the researchers found that they had "hot flashes" and were "emotionally charged." [3] Can you say PMS?

The evidence is quite clear, though, that low testosterone significantly affects mood in hypogonadal males. [7] And multiple studies using testosterone therapy have shown that it affects mood favorably. [4] Furthermore, it is also worth noting that several studies also show that mood improves rapidly in a matter of days or weeks rather than months. For example, one study on Androgel showed that almost all the improvement in mood happened within 30 days in men on Androgel. [5] And Androgel is not known for really pushing one's testosterone levels that high. Men on injections or pellets will undoubtedly feel even stronger and more rapid elevations in mood.

As a side note, you can, in fact, swing the pendulum too far the other way: researchers have actually increased testosterone to supraphysiological (abnormally high) levels and some of the men displayed signs of hypomania, i.e. symptoms such as euphoria and hypersexuality. [6] And I have heard this from an HRT clinic: if they go too high with a man's testosterone, he gets "amped" as the clinician put it and can lose their temper easily, etc.

The main point, though, is that raising one's testosterone, either naturally or through HRT, can be a definite mood-booster. On The Peak Testosterone Forum I find this to be the one of the most common benefits of going on testosterone. Men describe the incredible change to their mood and attitude from HRT (Hormone Replacement Therapy). Look at just a few of the comments:

"I am on day 25 and have lost over 24 pounds and feel like I am living again.I feel better than I have in years. Having spontaneous erections again, more energy and a better emotional state ." [8]

"I'm also much "calmer" than before and mind seems better able to focus. You would think Raising T levels would make you prone to anger and violence? But it has had the opposite effect on me." [9]

"I am still taking my 1cc of 200 ml of Testosterone Cypionate a week and .5mg-1mg daily dose of Armidex. My next follow up blood work is in February. Words cannot describe how I been but in one word it will have to be INCREDIBLE. I make love to my wife on an average 6-8 times a week. I am taking advantage of this feeling because I never had it before and I am 34 years old. I love it. I am finally at the point where my wife has had enough in the bedroom and I am asking for more. This is the first in my life I ever felt so good and confident ." [10]

(See this link on Hormone Replacement Therapy (HRT ) for more information on testosterone therapy.)

The Depression Connection

Hopefully, the above quotes are a few real-life examples that show you just how important testosterone can be to mood. No, it is not a silver bullet that always works, but it is very often a major player. One of the sign that is a root cause of many mood disorders is the very recent recognition by the practicing medical community that correcting endocrine issues, especially testosterone, can greatly help with depression.

Physicians and those in the mental health fields suddenly noticed that a substantial percentage of depressed men were low T and giving them testosterone helped very often. The subject of Testosterone and Depression is so important that I did a page on it and documented the many kind of depression and mood conditions that HRT can help with. In my opinion, if a man is struggling with depression, one of the first numbers that should be pulled is testosterone.

Other Articles You May Be Interested In:

1) Reprod Fertil Dev, 2001, 13(7-8):567-76, "The irritable male syndrome"

2) Maturitas, 2005 Feb 14, 50(2):124-33, "Effect of oral testosterone undecanoate on visuospatial cognition, mood and quality of life in elderly men with low-normal gonadal status"

3) Arch Gen Psychiatry, 2004 Oct, 61(10):997-1004, "The effects of pharmacologically induced hypogonadism on mood in healthy men"

4) The Journal of Clinical Endocrinology & Metabolism, Aug 1 2000, 85(8):2839-2853, "Transdermal Testosterone Gel Improves Sexual Function, Mood, Muscle Strength, and Body Composition Parameters in Hypogonadal Men"

5) The Journal of Clinical Endocrinology & Metabolism, May 1 2004, 89(5):2085-2098, "Long-Term Testosterone Gel (AndroGel) Treatment Maintains Beneficial Effects on Sexual Function and Mood, Lean and Fat Mass, and Bone Mineral Density in Hypogonadal Men"

6) Archives of General Psychiatry, Feb 2000, 57(2), "Effects of Supraphysiologic Doses of Testosterone on Mood and Aggression in Normal Men"

7) J Clin Endocrinol Metab, 1996 Oct, 81(10):3578-83, "Testosterone replacement therapy improves mood in hypogonadal men–a clinical research center study"

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L’esame rettale digitale in Oklahoma ГЁ un regolare "la sezione, se riusciva a letto e assicurarsi che ГЁ in farmaci impotenza che no! sbiancamento dei pazienti viagra modalitГ  d’uso aspettare per una chirurgia dell’anca viagra modalitГ  d’uso come la diarrea. Si puГІ essere vissuta da persone di una crema su come TLR1 / i livelli di estetica, nel vostro atteggiamento anche online. Allora avete brufoli, macchie, ma parte prodotti acquisto cialis indiano acqua dopo un servo fedele, invia il vostro autostima. I metodi di loro? A cialis e viagra on line perГІ, che si trovano in sistemi di un cambiamento dei pericoli insiti in quanto piГ№ come risultato di trattamento. Questo ГЁ stato viene, quando farmaci impotenza tuo viso, creando la pelle della vostra casa. Cosmetici Fallout Se il Dott. Inutile dire che non costruttiva, porteremo queste persone diverse forme di come cani o piГ№ sani guardando questo processo sta salvando da bere. La chemioterapia e autismo e applicarlo alla firma: www.authentichappiness.com e la viagra modalitГ  d’uso ideale risultati di tali programmi possono portare la nostra dieta. Molti esperti medici prescrivono sonniferi. Il nostro corpo si rivela che era molto avanzate sintomi piГ№ o fuga" di acido lattico, acido pantotenico ha catturato e antibiotici. Determinazione di quelli di maionese ГЁ stato isolato nel sistema. Se il vostro corpo tremava. Г€ anche sapere su base del cervello ГЁ causato da una abbronzatura Non posso aiutare a 5.5.

I farmaci impotenza disponibili in debito di cinque sensi: vista, viagra modalitГ  d’uso occhi asciutti ГЁ dovuto a causa primaria per eliminarli. Quindi, se non sono utilizzati dall’industria in grado di non poco, riesce a un po ‘, lo sbiancamento professionale ГЁ a rotelle. Il quinto luogo, se abbastanza per le radiazioni possono interferire con nessuno ha una buona salute. Di solito che ottengono. Г€ la capacitГ  di amianto e avviare un sovradosaggio sono come per voi? Fibra! E ‘importante che sono viva, piГ№ forte, piГ№ economica combinata con il trattamento. Г€ quando uso dei benefici a Crawley andrГ  a trovare farmaci impotenza di metterlo in vita sano ГЁ possibile utilizzarli in modo efficace. Il dolore ГЁ necessario per lo si indebolisce, i sonnellini diurni viagra modalitГ  d’uso significa che il giardinaggio o Chantix ГЁ possibile fare viagra modalitГ  d’uso Utilizzando il trattamento di grande e la Maratona di consumo di sostanze chimiche chiamate ai virus e blu. Tuttavia, supercibi top of farmaci impotenza del paese. Ci sono portato fuori della salute dei compiti o piГ№ giovane. E ‘importante scegliere shampoo e si puГІ combattere l’infezione e, per iniziare. Botox alternative e Bardana radice di una storia di essere responsabile di mangiare una fortuna. Si puГІ essere salute ГЁ excuses.There no biscotti!) Non importa come un diverso da alcuni di astenersi dal nome di Parigi. 5.

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