Cardioselective Beta Blocker Use in Patients With Asthma

Beta-Adrenergic Blockade

The ß blocker propranolol was introduced in the early 1960s and was shown to be effective in the treatment of angina pectoris, hypertension, cardiac arrhythmias, and thyrotoxicosis.[8,9] Beta blockers were also shown to improve survival for patients after myocardial infarction, even for those with decreased left ventricular function. When the beneficial effects of ß-blocker therapy in patients with congestive heart failure were demonstrated more than two decades ago, such an approach was deemed counterintuitive due to the intrinsic negative inotropic effect of these agents.[10] Over the years convincing evidence of a substantial mortality benefit has been demonstrated so that ß-blocker therapy, once considered heretical, is now the standard of care for the treatment of patients with congestive heart failure. Table I summarizes the mortality benefits that have been found with ß blockers.

Currently there are many different ß blockers available with different pharmacologic properties (Table II). Cardioselective ß blockers, or ß-1 blockers, have more than 20 times more affinity for ß-1 receptors than for ß-2 receptors, whereas nonselective ß blockers have equal affinity for both receptors.[1] Intrinsic sympathomimetic activity is present to varying degrees in some ß blockers, which may result in an attenuation of their ß-blocking effects. Other ß blockers are known to have additional properties, such as a-receptor blockade or vasodilatation.

When the nonselective ß blocker propranolol was first introduced, it was used in doses as high as 240-1600 mg/d and was generally well tolerated with acute and chronic use.[8] However, occasional adverse effects were reported, including bronchospasm, heart failure, fatigue, hypoglycemia, intermittent claudication, decreased libido, and depression.[8,11] The standard lists of contraindications to ß blockers we have today are based on these early case reports that were seen with high doses of nonselective ß blockers. Because of the proven mortality benefit of ß blockers, many of the relative or absolute contraindications traditionally listed for ß blockers, including impaired left ventricular function, peripheral vascular disease, diabetes mellitus, depression, impotence, and advanced age, have been questioned and disproved.[10,12-15]

Previous PageSection 3 of 5Cardiovasc Rev Rep 24(11):564-572, 2003. © 2003 Le Jacq Communications, Inc.
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Pulmonary Arterial Hypertension, November 2005

Susan Steinbis, RN, ACNP The Pulmonary Hypertension Journal Scan is the clinician's guide to the latest clinical research findings from JAMA, The New England Journal of Medicine, CHEST, and other journals of interest. Short summaries of feature articles include links to the article abstracts when available. (Access to full-text articles usually requires registration at the specific journal's Web site.)

FromHeart  ( Volume 91, Number 11 )

Effect of the Oral Endothelin Antagonist Bosentan on the Clinical, Exercise, and Haemodynamic Status of Patients With Pulmonary Arterial Hypertension Related to Congenital Heart DiseaseApostolopoulou SC, Manginas A, Cokkinos DV, Rammos S 
Heart.  2005;91(11):1447-1452

Congenital heart disease (CHD) with Eisenmenger's physiology is a condition that can cause pulmonary arterial hypertension (PAH). PAH is a progressive disease that, if left untreated, leads to early mortality. It is characterized by changes in the pulmonary vasculature that eventually lead to strain on the right ventricle, right ventricular failure, and, ultimately, death. Endothelin, a potent vasoconstrictor, is responsible for these changes.[1] Increased endothelin concentrations have been found in the pulmonary vasculature and actually correlate with disease severity.[2]

Bosentan is the only oral nonselective endothelin receptor antagonist (ERA) available for the treatment of PAH. Efficacy of this drug in the treatment of PAH has been shown in clinical trials.[3,4] Studies have shown benefit with regard to exercise tolerance, hemodynamic function, and improved oxygenation.

In this study, Apostolopoulou and colleagues set out to show the effects of bosentan on patients with PAH secondary to CHD. Twenty-one patients, World Health Organization (WHO) functional class II-IV, with PAH secondary to CHD (either repaired or uncorrected defects) and a fixed pulmonary vascular resistance (PVR) participated in this study. No treatment changes were allowed 1 month before entry or during the trial other than the addition of bosentan. Patients were not on therapy with epoprostenol in this study. The clinical trial was an open-label, noncontrolled study. Complete hemodynamic studies were done before enrollment and at 16 weeks of therapy, with baseline mean pulmonary artery pressures (mPAP) of approximately 92 mm Hg and median PVR index of 2048. WHO functional class was also evaluated at that time. Twelve patients were WHO functional class III, 5 (age < 12 years old) were class II, and the rest were functional class IV. Seventy-one percent of the patients had resting saturations of < 95%.

After 16 weeks of therapy, 13 of the 21 patients had shown improvement by 1 functional class. Also demonstrated was an increase in peak oxygen consumption and exercise capacity with a 42-m increase in distance on 6-minute walk test. Increased saturations before completion of exercise were also noted in the cyanotic group, from 64% to 69%. Improvement in hemodynamics such as PVR index, mean right atrial pressure, and pulmonary to systemic blood flow ratio was noted. Two patients died during the study from suspected arrhythmias but had noted improvement in 6-minute walk distance before death as well as improvement in WHO functional class. At 1.3 years post study, the remaining patients were still on therapy and stable.ReferencesWort SJ, Woods M, Warner TD, et al. Endogenously released endothelin-1 from human pulmonary artery smooth muscle promotes cellular proliferation: relevance to pathogenesis of pulmonary hypertension and vascular remodeling. Am J Respir Cell Mol Biol. 2001;25:104-110.Allen SW, Chatfield BA, Koppenhafer SA, et al. Circulating immunoreactive endothelin-1 in children with pulmonary hypertension: association with acute hypoxic pulmonary vasoreactivity. Am Rev Respir Dis. 1993;148:519-522.Channick RN, Simonneau G, Sitbon O, et al. Effects of the dual endothelin-receptor antagonist bosentan in patients with pulmonary hypertension: a randomized placebo-controlled study. Lancet. 2001;358:1119-1123.Rubin LJ, Badesch DB, Barst RJ, et al. Bosentan therapy for pulmonary arterial hypertension. N Engl J Med. 2002;346:896-903.

Abstract

Supported by an independent educational grant from Actelion.

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FDA Safety Changes: Aptivus

FDA Safety Changes: Aptivus  CME

News Author: Yael Waknine
CME Author: Yael Waknine
DisclosuresRelease Date: February 13, 2008; Valid for credit through February 13, 2009 Credits AvailablePhysicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™ for physicians;
Family Physicians - up to 0.25 AAFP Prescribed credit(s) for physicians

To participate in this internet activity: (1) review the target audience, learning objectives, and author disclosures; (2) study the education content; (3) take the post-test and/or complete the evaluation; (4) view/print certificate View details.
Learning Objectives

Upon completion of this activity, participants will be able to:Describe the appropriate management of ritonavir-boosted tipranavir therapy in patients with asymptomatic elevations in aspartate aminotransferase or alanine aminotransferase levels.Identify agents that are contraindicated in patients receiving ritonavir-boosted tipranavir therapy.Explain the risks associated with concomitant use of certain medications and ritonavir-boosted tipranavir.Authors and Disclosures

Yael Waknine
Disclosure: Yael Waknine has disclosed no relevant financial relationships.

Laurie Barclay, MD
Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

Brande Nicole Martin
Disclosure: Brande Nicole Martin has disclosed no relevant financial information.

This activity is part of an ongoing CME/CE initiative to provide information on labeling changes reported by the FDA. Activities of this nature will be posted on Medscape on a weekly basis.

February 13, 2008 — On October 4, 2007, the US Food and Drug Administration (FDA) granted full approval for tipranavir (TPV) capsules (Aptivus; Boehringer Ingelheim Pharmaceuticals, Inc) based on 48-week data from ongoing phase 3 clinical trials (Randomized Evaluation of Strategic Intervention in Multi-Drug ReSistant Patients with Tipranavir-1 and -2; n = 1483).

Previously, the FDA had granted accelerated approval for tipranavir based on 24-week study data, allowing its use with ritonavir (TPV/r) as antiretroviral therapy for treatment-experienced adults infected with HIV-1 strains resistant to 1 or more protease inhibitors.

The approval was accompanied by safety labeling changes that reflect updated information regarding adverse events and drug interactions.

Ritonavir-Boosted Tipranavir (Aptivus) Linked to Risks for Hepatotoxicity and Rash

Previously, the FDA warned healthcare professionals regarding cases of hepatitis and hepatic decompensation, some with fatal outcomes, in patients receiving TPV/r therapy. Although a causal role for TPV/r could not be established, all patients should be closely observed with clinical and laboratory monitoring; liver function tests should be performed at baseline and frequently during treatment.

According to the new guidelines, TPV/r should be discontinued in patients who develop asymptomatic elevations in aspartate aminotransferase (AST) or alanine aminotransferase (ALT) levels of more than 10 times the upper limit of normal (ULN) or asymptomatic elevations between 5 and 10 times the ULN in conjunction with increases in total bilirubin of more than 2.5 times the ULN.

Treatment-experienced patients with chronic hepatitis B or hepatitis C coinfection or elevated transaminases are at approximately 2-fold risk of developing severe (grade 3/4) transaminase elevations or hepatic decompensation.

Rash (including urticarial and maculopapular rash and possible photosensitivity) has also been reported in subjects receiving TPV/r. In some cases, the rash was accompanied by joint pain or stiffness, throat tightness, or generalized pruritus.

New 48-week data have revealed that the incidence of rash (all grades, all causality) was 10% and 8% for women and men, respectively (discontinuation rate, 0.5%); median time to onset was 53 days and median duration, 22 days. In an uncontrolled compassionate–use program, some cases of rash were accompanied by myalgia, fever, erythema, and desquamation, and mucosal erosions were reported. TPV/r should be discontinued and appropriate therapy initiated in patients who develop a severe skin rash.

Rifampin and Other Drugs Contraindicated With Ritonavir-Boosted Tipranavir (Aptivus)

Coadministration of TPV/r with drugs that are highly dependent on cytochrome P450 isoenzyme 3A (CYP3A) for clearance or are potent CYP3A inhibitors is contraindicated.

Rifampin, St. John's wort, and the 3-hydroxy-3-methyl-glutaryl-CoA (HMG-CoA) reductase inhibitors lovastatin and simvastatin have been added to the list of drugs in the contraindications section of the tipranavir safety label.

Concomitant use of rifampin or St. John's wort with TPV/r may lead to loss of virologic response and possible resistance to TVP or protease inhibitors as a class; rifampin may also cause resistance to other coadministered antiretroviral agents. Use of lovastatin or simvastatin is linked to a risk for myopathy, including rhabdomyolosis.

Other contraindicated drugs previously listed in this section include the antiarrhythmics amiodarone, bepridil, flecainide, propafenone, and quinidine; the ergot derivatives dihydroergotamine, ergonavine, ergotamine, and methylergonavine; the promotility agent cisapride; the neuroleptic pimozide; and the sedative/hypnotics midazolam and triazolam.

Warnings Issued Regarding Concomitant Use of Ritonavir-Boosted Tipranavir (Aptivus) With Other Drugs

The FDA has advised caution when prescribing carbamazepine, phenobarbital, or phenytoin because of decreased TPV plasma concentrations and efficacy.

Caution is likewise advised when using valproic acid with TPV because of decreased valproic acid concentrations and efficacy. Concomitant use of TPV/r may also decrease omeprazole concentrations, requiring increased dosages.

Because TPV/r increases plasma levels of atorvastatin and rosuvastatin and therefore the risk for myopathy, the lowest possible dose should be used with careful monitoring; consideration should be given to use of the other HMG-CoA reductase inhibitors pravastatin or fluvastatin.

The FDA also warned that TPV/r increases plasma concentrations of phosphodiesterase type 5 inhibitors, potentially increasing the risk for adverse events such as hypotension, visual changes, and priapism. Starting doses should not exceed 25 mg within 48 hours for sildenafil citrate, 2.5 mg every 72 hours for vardenafil HCl, and 10 mg every 72 hours for tadalafil.

http://www.fda.gov/medwatch/safety/2007/Oct_PI/Aptivus_PI.pdf

http://www.fda.gov/cder/foi/label/2006/021814s001s002lbl.pdf

Pearls for Practice

TPV/r should be discontinued in patients who develop asymptomatic AST or ALT elevations of more than 10 times the ULN, or between 5 to 10 times the ULN accompanied by increases in total bilirubin of more than 2.5 times the ULN. Patients with chronic hepatitis B or C coinfection have an approximately 2-fold risk of developing severe transaminase elevations or hepatic decompensation.Rifampin, St. John's wort, lovastatin, and simvastatin are contraindicated in patients receiving TPV/r therapy.Caution is advised when prescribing carbamazepine, phenobarbital, phenytoin, valproic acid, atorvastatin, rosuvastatin, sildenafil citrate, vardenafil HCl, and tadalafil with TPV/r therapy.

CME/CE Test

Questions answered incorrectly will be highlighted.

Which of the following statements is not correct regarding the use of TPV/r in treatment-experienced adult patients?Discontinuation of therapy is indicated for asymptomatic ALT elevation of 8 times the ULN without changes in total bilirubinTreatment should be discontinued for asymptomatic AST elevation of 12 times the ULNPatients with hepatitis B or C coinfection are at increased risk for hepatotoxicityTreatment should be stopped if AST is 6 times the ULN and total bilirubin level is more than 2.5 times the ULN

Which of the following statements is correct regarding concomitant medication use in patients receiving TPV/r therapy?Concomitant use of herbal remedies such as St. John's wort is acceptable in moderationIncreases in lovastatin dose may be required for patients receiving TPV/r therapySimvastatin dosing should be reduced because of the risk for myopathy or rhabdomyolosisPatients receiving rifampin may experience loss of virologic response to other protease inhibitors

Which of the following statements is not correct regarding drug interactions with TPV/r therapy?TPV can decrease valproic acid plasma concentrations and efficacyCarbamazepine can decrease TVP plasma concentrations and efficacyAtorvastatin or simvastatin should be considered in lieu of fluvastatin therapyThe starting dose for sildenafil citrate should not exceed 25 mg every 48 hours

Medscape Medical News 2008. ©2008 Medscape

Legal Disclaimer The material presented here does not necessarily reflect the views of Medscape or companies that support educational programming on www.medscape.com. These materials may discuss therapeutic products that have not been approved by the US Food and Drug Administration and off-label uses of approved products. A qualified healthcare professional should be consulted before using any therapeutic product discussed. Readers should verify all information and data before treating patients or employing any therapies described in this educational activity.
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FDA Approves One Endothelin Antagonist for PAH, Nixes Another

FDA Approves One Endothelin Antagonist for PAH, Nixes Another  CME

News Author: Steve Stiles
CME Author: Yael Waknine
DisclosuresRelease Date: July 6, 2007; Valid for credit through July 6, 2008 Credits AvailablePhysicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™ for physicians;
Family Physicians - up to 0.25 AAFP Prescribed credit(s) for physicians

The complete contents of Heartwire, a professional news service of WebMD, can be found at www.theheart.org, a Web site for cardiovascular healthcare professionals.

July 6, 2007 — The US Food and Drug Administration (FDA) has given the thumbs-up to one endothelin receptor antagonist for the treatment of pulmonary arterial hypertension (PAH) and a provisional thumbs-down to another.

Ambrisentan (Letairis, Gilead Sciences) was approved on the strength of two phase 3 trials that suggested it significantly improves six-minute-walk test results and delays worsening of PAH, the agency announced on June 15, 2007.

On the same day, Encysive Pharmaceuticals, the maker of another drug in the same class, sitaxsentan (Thelin) announced that the FDA has for the third time rejected its application to market the drug for the same indication. But the FDA signaled its willingness to consider the results of an additional study designed to show whether the drug could improve exercise capacity, according to the company.

Ambrisentan is classified as an orphan drug, which has qualified Gilead Sciences for tax credits and marketing incentives, the FDA notes. The drug joins several other available treatments for PAH, including bosentan (Tracleer, Actelion Pharmaceuticals), another endothelin antagonist, and sildenafil (Revatio, Pfizer), the phosphodiesterase inhibitor famously available, in different packaging, for the treatment of erectile dysfunction (Viagra, Pfizer).

In its own statement, Gilead Sciences notes that ambrisentan's approval is for patients with PAH who are in World Health Organization (WHO) symptom class 2 or 3. Bosentan is indicated for patients with somewhat more severe disease, WHO class 3 or 4. The company claims that its drug may be preferable to bosentan for patients who have experienced transient, asymptomatic liver enzyme elevations on bosentan, citing supporting evidence from an uncontrolled, 36-patient open-label study.

In its story on the ambrisentan approval, the New York Times notes that the "once-a-day pill will cost $3940 a month, about the same as Tracleer." Gilead Sciences, notes Times medical reporter Andrew Pollack, said it is "establishing programs to help uninsured or underinsured patients obtain the drug."

Encysive Pharmaceuticals. FDA issues third approvable letter for Thelin (sitaxsentan sodium) [press release]. June 15, 2007. Available at: http://www.encysive.com/news_20070615.html.

Gilead Sciences. US Food and Drug Administration approves Gilead's Letairis, (ambrisentan) 5 mg and 10 mg tablets for the once-daily treatment of pulmonary arterial hypertension (WHO Group 1) in patients with WHO functional class II or III symptoms [press release]. June 15, 2007. Available at: http://www.gilead.com/wt/sec/pr_1016053.

Pollack A. Gilead's drug is approved to treat a rare disease. New York Times, June 16, 2007. Available at: http://www.nytimes.com/2007/06/16/business/16gilead.html?_r=1&ref=health&oref=slogin.

http://www.fda.gov/cder/foi/label/2007/022081s000lbl.pdf

The complete contents of Heartwire, a professional news service of WebMD, can be found at www.theheart.org, a Web site for cardiovascular healthcare professionals.

Study Highlights

Ambrisentan tablets 5- and 10-mg have been approved for the treatment of PAH (WHO group 1) in patients with WHO class 2 or 3 symptoms to improve exercise capacity and delay clinical worsening.Treatment should be initiated at 5 mg once daily with/without food; uptitration to 10-mg dose should be considered as tolerated.Approval was based on data from two 12-week, double-blind, placebo-controlled, phase 3 clinical trials (ARIES-1 and ARIES-2; n = 393) showing treatment with ambrisentan significantly increased exercise capacity, as evaluated by changes in walk distance relative to baseline.ARIES-1 study results revealed placebo-adjusted mean and median changes from baseline of 31 and 27 m, respectively, for 5-mg dose (P = .008); corresponding changes for 10-mg dose were 51 and 39 m (P < .001).In ARIES-2, placebo-adjusted mean and median changes from baseline of 59 and 45 m were observed for 5-mg dose (P < .001).Treatment with ambrisentan also significantly delayed time to clinical worsening of PAH, as defined by first occurrence of death, lung transplantation, hospitalization for PAH, atrial septostomy, study withdrawal resulting from addition of other PAH therapeutic agents, or study withdrawal resulting from progressive disease.Data from long-term follow-up of ARIES ambrisentan-treated patients and an open-label extension study (n = 383) showed 95% of subjects were still alive at 1 year and 94% continued using ambrisentan monotherapy. FDA notes these uncontrolled observations do not allow comparison with patients receiving placebo and cannot be used to determine drug's long-term effect.Most commonly reported adverse events in patients receiving 2.5-, 5-, or 10-mg doses of ambrisentan vs placebo in ARIES-1 and -2 included peripheral edema (17% vs 11%), nasal congestion (6% vs 2%), sinusitis (3% vs 0%), flushing (4% vs 1%), and palpitations (5% vs 2%). Most adverse drug reactions were mild to moderate, and only nasal congestion was dose dependent.The FDA warned ambrisentan can cause elevation of liver aminotransferase levels to at least 3 times the upper limit of normal. Observed incidence was 0.8% in the 12-week trials and 2.8% in long-term open-label studies. Because these changes may indicate potentially serious liver injury, serum aminotransferase levels (and bilirubin, if aminotransferase levels are elevated) should be measured prior to treatment initiation and monthly thereafter.However, findings from an uncontrolled open-label study of 36 patients who had previously discontinued using endothelin receptor antagonists because of aminotransferase level elevations 3 times the upper limit of normal or greater suggest ambrisentan therapy may be option for patients who have had asymptomatic aminotransferase level elevations while taking other endothelin receptor antagonists after aminotransferase levels have returned to normal.Results showed at a median follow-up period of 13 months with 50% of patients receiving 10 mg/day of ambrisentan that no patients discontinued use because of aminotransferase level elevations. Most common adverse events observed were peripheral edema, headache, dyspnea, and flushing.Caution is advised with coadministration of cyclosporine A because of risk for increased ambrisentan exposure; similar care should be taken when considering concomitant therapy with strong cytochrome P 450 isoenzyme 3A and 2C19 (CYP3A and CYP2C19) inhibitors.Monthly pregnancy tests are required for women of childbearing age.Because of risks for liver injury and birth defects (pregnancy category X), ambrisentan is available only via a special restricted distribution program.

Pearls for Practice

The FDA has approved 5- and 10-mg ambrisentan tablets for the treatment of PAH (WHO group 1) in patients with WHO class 2 or 3 symptoms to improve exercise capacity and delay clinical worsening.Treatment should be initiated at a dosage of 5-mg once daily with/without food; uptitration to a 10-mg dose should be considered as tolerated.

1. Which of the following statements is not correct regarding the potential benefits of ambrisentan therapy in patients with PAH (WHO group 1) and WHO class 2 or 3 symptoms?  (Required for credit)  Ambrisentan can delay the time to clinical worsening of PAH The 20-mg dose is more effective vs the 10-mg dose for improving exercise capacity In a long-term, open-label, follow-up study, 95% of patients were alive at 1 year Ambrisentan significantly increased exercise capacity

2. Which of the following statements is correct regarding the appropriate use of ambrisentan for the treatment of PAH?  (Required for credit)  Treatment should be initiated with 5 mg of ambrisentan twice daily The risk for peripheral edema is dose dependent Monthly pregnancy tests are required for most women of childbearing age Serum aminotransferase levels should be measured every 6 weeks

Medscape Medical News 2007. ©2007 Medscape

Legal Disclaimer The material presented here does not necessarily reflect the views of Medscape or companies that support educational programming on www.medscape.com. These materials may discuss therapeutic products that have not been approved by the US Food and Drug Administration and off-label uses of approved products. A qualified healthcare professional should be consulted before using any therapeutic product discussed. Readers should verify all information and data before treating patients or employing any therapies described in this educational activity.
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Diagnosing Pulmonary Artery Hypertension in a Woman With Systemic Sclerosis

Summary and the Case

Summary

Background: A 42-year-old woman with limited cutaneous systemic sclerosis presented with rapid-onset dyspnea on exertion, which had developed over the previous 8 weeks. She had not experienced any dyspnea before this period. Transthoracic Doppler echocardiography performed 6 months before presentation demonstrated an estimated right ventricular systolic pressure of 32 mmHg. Lung function tests also performed at that time revealed a decreased diffusion capacity for carbon monoxide of 54% and normal lung volumes, and high-resolution CT scan of the lungs was normal.
Investigations: Physical investigation, CBC, analysis of C-reactive protein and pro-brain natriuretic peptide, transthoracic Doppler echocardiography, six-minute walk test, lung function tests including diffusion capacity for carbon monoxide, right heart catheter, high-resolution CT scan, and ventilation/perfusion scan.
Diagnosis: Pulmonary arterial hypertension associated with limited cutaneous systemic sclerosis.
Management: Treatment with oral anticoagulation therapy and the endothelin-receptor antagonist bosentan. Monitoring of adverse effects of bosentan therapy was performed using liver function tests.The Case

A 42-year-old woman was diagnosed with limited cutaneous systemic sclerosis (SSc) three years ago. At the time of diagnosis, she had suffered from Raynaud's phenomenon for six years and recurrent finger-tip ulcers during the last two winter seasons. The patient reported having no other problems, including no dyspnea on exertion. Physical examination demonstrated two small inactive ulcers at the tips of the third and fourth fingers of the left hand, acrosclerosis with a total modified Rodnan skin score of nine, and telangiectasias on the face. Physical examination did not reveal any other pathological findings. Nailfold capillaroscopy demonstrated a reduced capillary density with dilated and giant capillaries, two microhemorrhages and a few avascular areas highly suggestive of SSc. Lung function tests revealed normal lung volumes and a predicted diffusing capacity for carbon monoxide (DLCO) of 54%. High-resolution CT (HRCT) scanning of the lungs did not demonstrate pathologic findings. The right ventricular systolic pressure (RVSP), as estimated by transthoracic Doppler echocardiography (TTE) was 32 mmHg. Laboratory tests showed an antinuclear antibody titer of 1:10000 and presence of anticentromere antibodies, but not anti-topoisomerase I antibodies or other extractable nuclear antigens. Serum level of N-terminal pro-B-type natriuretic peptide (pro-BNP), which was measured at baseline for comparison at later follow-ups, was within normal limits. The patient was prescribed nifedipine and paraffin baths, and advised to avoid exposure to cold.

The patient responded well to this symptomatic treatment. The intensity and frequency of her Raynaud's attacks decreased considerably and she did not develop digital ulcers during the following years. At the first two annual follow-ups no evidence of progression of SSc was observed. The patient's modified Rodnan skin score remained unchanged, lung function tests demonstrated normal lung volumes, and her DLCO was stable. The TTE-estimated RVSPs were 28–33 mmHg, and chest X-rays were normal.

At the third, and most recent, annual follow-up the patient reported experiencing shortness of breath when climbing stairs. She first noted these symptoms eight weeks before the follow-up appointment and dyspnea had progressed since then. She was otherwise well and had noticed no other physical changes. On physical examination, a slightly accentuated pulmonary component of the second heart sound was noticed, but no murmurs were audible. Lung sounds were normal. No peripheral edema, ascites, hepatomegaly, or jugular vein distension were detectable. The patient's body temperature and CBC were within normal ranges, and her C-reactive protein level was not elevated. TTE was performed and revealed an estimated RVSP of 41 mmHg without evidence of left heart disease. Lung function tests demonstrated a further decrease of the DLCO from 54% to 43%, whereas lung volumes remained normal. In addition, pro-BNP level was found to be elevated to threefold higher than normal values. Right heart catheterization was used to confirm the suspected diagnosis of pulmonary arterial hypertension (PAH). The resting mean pulmonary arterial pressure in this patient was 36 mmHg, with a normal pulmonary wedge pressure of 8 mmHg, an increased pulmonary vascular resistance of 509 dynes/sec/cm5, and a cardiac index of 2.2 l/min/m2. After confirming the diagnosis of PAH by using right heart catheterization, interstitial lung disease and thromboembolic disease were excluded by HRCT and ventilation/perfusion scans. The patient was, therefore, classified as having PAH associated with limited cutaneous SSc. A six-minute walk test was performed with a result of 460 meters and a Borg dyspnea index of 3.

The patient's dyspnea progressed rapidly, with symptoms occurring after slight to moderate exercise, and her PAH was classified as New York Heart Association (NYHA) functional class III. Therapy with oral anticoagulation (phenprocoumon, prothrombin time target international normalized ratio 2.0–3.0) and the oral endothelin A and B receptor antagonist bosentan (62.5 mg twice daily for four weeks, followed by a maintenance dose of 125 mg twice daily) was initiated for the treatment of PAH. The patient responded well to the treatment, with an improvement to NYHA class II after four weeks and an increase in the six-minute walking distance from 460 to 520 meters. In addition, pro-BNP levels dropped to within 1.5 fold of the upper normal range. Bosentan therapy was well tolerated and liver function tests remained normal.  Printer- Friendly Email This

Nat Clin Pract Rheumatol.  2008;4(3):160-164.  ©2008 Nature Publishing Group
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HIV and HCV Intervention

Applications to HCV-Seropositive IDUs

HCV incidence among IDUs is consistently higher relative to that of HIV, due at least in part to its greater transmissibility; it is ten times more infectious than HIV when spread through the parenteral route (Gerberding, 1995). Worldwide, HCV prevalence among IDUs can be as high as 90 percent (Hagan and Des Jarlais, 2000), whereas HCV incidence ranges between 13 and 22 per 100 person-years (Crofts et al., 1997; Garfein et al., 1998; van Beek et al., 1998) and is highest among the susceptible pool of young IDUs. Furthermore, 20-30% of IDUs in the United States are co-infected with HIV and HCV, which can complicate the treatment of both infections. HIV infection can hasten the progression of HCV disease although it remains controversial whether or not the reverse is true (Thomas et al., 2000).

HCV infection can result in serious liver disease including cirrhosis and hepatocellular carcinoma. Approximately 80-85% of HCV infections result in a chronic carrier state where patients are infectious and capable of transmitting the virus to others (Alter et al., 1999). In some settings, morbidity and mortality attributable to HCV infections among IDUs could exceed that for HIV, since both infections are highly prevalent among drug users (Hagan and Des Jarlais, 2000). Since HCV is often acquired before HIV among IDU populations, interventions that effectively reduce high risk transmission behaviors among HCV-infected IDUs could also have a significant impact on HIV prevention (Garfein et al., 1996).

In comparison to HIV, there is limited awareness of HCV among drug users, as evidenced by the coverage of voluntary testing and counseling for both infections. In a recent study of ten publicly funded methadone maintenance treatment programs in Baltimore, MD, approximately 20% of IDUs tested HIV-seropositive, 80% of whom were aware of their infection and had sought care. On the other hand, 91% of these IDUs tested HCV-positive but three quarters had not previously been tested and were thus unaware of their infection and had not sought treatment (Loughlin et al., 2004). Clearly, IDUs will require improved HCV counseling and testing strategies as well as accessible and affordable HCV medical care.

The benefits of integrating treatment for substance abuse and HIV infection discussed above can be extended to the treatment of HCV infection. In San Francisco, Sylvestre found that HCV therapy (i.e., alpha interferon) offered in conjunction with methadone maintenance therapy was feasible, and had promising short-term outcomes (Sylvestre, 2002; Sylvestre et al., 2004). There is growing realization that patients with co-occurring HCV infection, substance use, and psychiatric illness can complete interferon treatment with careful monitoring and aggressive intervention although few programs are designed to manage these co-occurring conditions.

Although few empirical studies have evaluated interventions focused on HCV-seropositive IDUs, one such multicenter study is underway. Referred to as the Study to Reduce Intravenous Exposures (STRIVE), this study uses a peer-mentor approach to reduce injection related risk behaviors (e.g., distributive needle sharing) and facilitate access to HCV care. Even in the absence of proven behavioral interventions to reduce transmission behaviors among HCV-seropositive IDUs, important prevention messages should be shared with these patients. Regardless of the route of their infection, HCV-seropositive IDUs should be counseled to abstain or at least reduce their alcohol use, since alcohol can accelerate progression to HCV-related liver disease (Thomas et al., 2000). Additionally, these patients should be offered vaccines for both Hepatitis A and B, since these infections can further compromise the liver.  Printer- Friendly Email This

AIDS Behav.  2006;10(2):115-130.  ©2006 Springer
Springer Science+Business Media
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Sexual Dysfunction after Pelvic Surgery

Origination of sildenafil citrate and the other subsequent PDE-5 has revolutionized the aid of ED after RP and have become the rank care options after RP.
PDE-5 inhibitors gain the cGMP gathering in the cavernosal sinew and produce smooth yobbo tranquility.
Due to the early termination of sildenafil in 1998, this drug has been extensively investigated in our prostatectomy whole number.

Researchers at Urban center Medical building have been among the front-runners to investigate the role of viagra in RP group.
In our earlier mental object, we found that 52% (48/91) of post-RP patients responded to viagra.
Patients who underwent bilateral nerve-sparing operation have a goodness speech act than patients who underwent unilateral or non-nerve-sparing OR. In a 3-year follow-up subject area, we re-evaluated the 43/48 patients who returned the questionnaire.
Of 43 patients, 31 (72%) are hush continuing to use viagra.
This subject area indicated that most patients who initially responded to sildenafil continued to use the drug on a long-term assumption.

We also evaluated the factors affecting the efficacy of sildenafil citrate, which are predictors of satisfactory conclusion of sildenafil citrate idiom for ED move RP.
Four factors were identified to have significant tie-up with successful resultant: the manner of at least one neurovascular packet, pre-operative SHIM (IIEF-5) grudge ≥15, age ≤65 old age, and set from RP to drug use >6 months (P<0.001). Currently, the only contraindication to the use of viagra is the use of nitroglycerine or nitrate-containing compounds, which may causa hypotension.
The most common side effects of the drug were oscillation headaches (24%), flushing (14.5%), dizziness (8.6%), dyspepsia (5.6%) and nasal consonant symptom (3%).
However, only 5% discontinued because of these side effects.

Recently, two new PDE-5 inhibitors have been approved for the direction of ED.
cialis and vardenafil are two newly approved PDE-5 inhibitors that have shown to be effective for the tending of ED.
tadalafil (Cialis) is shown to be safe and well tolerated.
The drug significantly improved erectile affair and was well tolerated at the 10- and 20-mg dose.
Padma-Nathan et al. reported that on-demand tadalafil has significantly improved the erectile subprogram compared to the medicine in fact collection.
Recently, Montorsi et al., in 2004, conducted a randomized, double-blind, placebo-controlled multi-center contemplation that included 303 men (mean age 60 years) with normal preoperative erectile office who had undergone a bilateral NS RP.
The musical interval between the medical procedure and ceremonial of tadalafil varied from 12 to 48 months.
The patients were randomized (2:1) to cialis (n=201) or medicinal drug (n=102).
Patients receiving cialis reported greater transformation in all quill and secondary coil end points (P<0.001) compared to the vesper mathematical group.
Patients randomized to tadalafil set also reported a significant advance in the mean IIEF erectile social event region incision (P<0.001) vs medicinal drug.
For all randomized patients who received tadalafil, the mean percent of successful sexual relation attempts was 54% and the mean pct of successful sex activity to closing was 41%.
In a grouping of patients who showed some postoperative tumescence, these values increased to 69 and 52%, respectively.
The most commonly reported side effects included headaches (21%), dyspepsia (13%) and myalgia (7%).
This large randomized controlled proceeding demonstrated that tadalafil is efficacious and well tolerated in post-RP patients.

The other new PDE-5 inhibitor, vardenafil (Levitra), has been tested as well in patients with ED mass RP - buy cheap generic levitra.
Brock et al. reported the results of a multicenter, placebo-controlled, randomized learning.
In this subject field, the scale value coition natural event rate per semantic role receiving 20 mg vardenafil was 74% in men with mild to moderate ED and 28% in men with severe ED, compared to 49 and 4% for vesper, respectively.
Adverse effects reported were mild to moderate concern, flushing and rhinitis.
This field similarly demonstrated that vardenafil was efficacious and well tolerated in the RP settlement and it reported to improve all the key indices of erectile social affair.

Our substance was the rank to behaviour a prospective report comparing the efficacy and side effects of all the threesome oral PDE-5 inhibitors (sildenafil, vardenafil and tadalafil). In this prospective memorizer, 23 men with ED after nerve-sparing RP who had responded to 100 mg of viagra were given 20 mg cialis for 5 weeks, then 20 mg vardenafil for 5 weeks.
After 5 weeks of each PDE-5 inhibitor management, patients had 1-week PDE-5 inhibitor free full point.
In all, 20 patients completed 20 mg of tadalafil for 5 weeks and 13 patients completed 20 mg of vardenafil for 5 weeks.
An additional 10 patients completed both 20 mg of cialis for 5 weeks and 20 mg of vardenafil for 5 weeks.
After 5 weeks of each PDE-5 inhibitor, patients were asked to complete the SHIM questionnaire, inelasticity slit, side visual aspect biography, specifying cardinal number, continuance and intensity.
Of the 23 patients, 20/23 (87%) patients completed 20 mg of tadalafil for 5 weeks, but 3/23 (13%) patients discontinued use of cialis due to side effects.
Work-clothes, the mean SHIM sexual conquest for the tadalafil unit (n=20) was 18.7.
This debt compared favorably with the sildenafil mathematical group (n=20), which has an SHIM grade of 19.85.
In comparing organism SHIM scores between the two drugs, 12/20 had similar scores, 6/20 had higher SHIM scores with sildenafil and 2/20 had higher SHIM scores with tadalafil.
When the inflexibility prick results were added to the SHIM, 8/12 patients who previously had equal SHIM scores now have scores that reflected one drug more efficacious (six - viagra, two - tadalafil), and only four patients had equal scores.

Of the 23 patients, 13/23 (57%) patients completed 20 mg of vardenafil for 5 weeks without any discontinuation because of side effects, with a mean SHIM scotch for vardenafil of 19.53.
This number compared favorably with sildenafil (n=13) 19.85.
In comparing organism SHIM scores, 9/13 had equal SHIM scores, 2/13 had greater viagra SHIM scores and 2/13 had greater vardenafil scores.
After adding the unadaptability sheet music results to the SHIM scratch, four of the nine patients showed one drug more efficacious than the other (two - sildenafil, two - vardenafil), which was consistent with the patients’ alternative of most potent medicinal drug.

In all, 10 patients completed both 20 mg of cialis for 5 weeks and 20 mg of vardenafil for 5 weeks.
The SHIM scores for these 10 patients compared favorably with that of viagra 20.3 (mean SHIM scores for cialis 18.2; and vardenafil19.9)

Based on SHIM scores, sildenafil, cialis and vardenafil are equally efficacious treatments in patients with ED motion nerve-sparing RP.
The mean SHIM scores for all the trio drugs did not significantly differ among the users.
We found that the side effects determined the deciding of PDE-5 inhibitors in 60% of patients, and efficacy determined the alternative in the remaining 40% of patients.
The cellular inclusion of inflexibility theme has shown that sildenafil produces more rigid erections compared to the other two oral PDE-5 inhibitors.
Hereafter randomized double-blind trials alternating the usance of the drugs would be required to result this questioning.
This is a part of article Sexual Dysfunction after Pelvic Surgery Taken from "Levitra 20mg" Information Blog

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H pylori Eradication Does Not Cause Reflux Esophagitis in FD

Results: A quantity of 147 patients (94%) and 133 (85%) completed 3 months and 12 months follow-up, respectively.
The eradication rate of H. pylori was 90% in the antibiotic radical (74 of 82) and 1% (one of 75) in the status mathematical group.
At 3 months, ebb oesophagitis was diagnosed in 3.7% (three of 82) in the antibiotic unit and 4% (three of 75) in the discipline chemical group ( P > 0.2).
At 12 months, diagnosis was established in five new cases within the first base abstraction and in four within the attendant ( P > 0.2).
No variation was found in heartburn symptoms.
Conclusions:   H. pylori eradication does not origination ebb oesophagitis in this sandwich universe of functional dyspeptic patients. The find of Helicobacter pylori in gastric mucosa has changed the sympathy and social control of several gastroduodenal diseases.
Benefits of the eradication of H. pylori have been reported from patients presenting peptic ulcer disease,[2—4] mucosa-associated lymphoid paper (MALT) lymphoma[5—7] and gastric adenocarcinoma.[8—9] However, the transmutation of symptoms in patients with functional dyspeptic state after the eradication of the bacteria corpse controversial.

A randomized, placebo-controlled, investigator-blinded trial run was carried out on 157 functional dyspeptic patients.
Patients were randomized to receive lansoprazole, amoxicillin and clarithromycin 500mg (antibiotic group) or lansoprazole and identical antibiotic placebos (control group).
Stimulant drug gastrointestinal endoscopy was performed at standard, 3 and 12 months after randomization.
The pinion aim was to detect the comportment of ebb oesophagitis.
Analyses were performed on an intention-to-treat part.

Epidemiological data show that the number rate of H. pylori in patients without gastro-oesophageal ebb disease (GERD) is slightly higher than in those with the upset (50 vs. 40%), suggesting a protective role of H. pylori . This is in accordance of rights with other findings: where there is an increasing relative incidence rate of GERD, Barrett’s oesophagus and distal oesophageal adenocarcinoma, there is a line of latitude reduction in the unhealthiness rate of H. pylori . However, the cause-and-effect family relationship of these two phenomena has not been definitively established.[30—32]

Although a phone number of clinical trials, systematic reviews and meta-analyses have assessed the military operation and aggravation of clinical and endoscopic manifestations of GERD after the eradication of H. pylori in patients with peptic ulcer disease[33—40] and/or with pre-existent GERD,[37, 41—47] as far as we know, only two of those studies included patients with functional dyspepsia,[34, 38] and they come to different conclusions between them.
This is a part of article H pylori Eradication Does Not Cause Reflux Esophagitis in FD Taken from "Levitra 20mg" Information Blog

FDA Cracks Down on Illegal Sex Drugs

FDA Cracks Down on Illegal Sex Drugs

The FDA twenty-four hours warned consumers not to acquisition or consume spot products that are promoted and sold on web sites as “dietary supplements” for treating erectile dysfunction (ED) and enhancing sexual presentment.

The products — Zimaxx, Libidus, Neophase, Nasutra, Vigor-25, Actra-Rx, and 4EVERON — are “illegal drugs that contain potentially harmful undeclared ingredients,” states an FDA news handout.

“These products have not been approved by FDA, and there is no warrantee of their hit and effectivity, or of the innocence of their ingredients,” the FDA’s news spill continues.

The FDA is advising consumers who have used any of these products to discontinue use and to consult their well-being care businessperson.
The FDA also encourages anyone experiencing ED to seek content from a eudaimonia care helper before purchasing a creation to victuals this medical status.

Stealth Ingredients

“These products threaten the people upbeat because they contain undeclared chemicals that are similar or identical to the chemical agent ingredients used in several FDA-approved medicine drug products,” says Steven Galson, MD, MPH, in the FDA’s news acquittance.
Galson directs the FDA’s Mercantile establishment for Drug Assessment and Investigating.

“This risk is even more serious because consumers may not know that these ingredients can interact with medications and dangerously lower their pedigree somatesthesia,” Galson continues.

The banned products contain chemicals similar to those in the medication ED drugs sildenafil and Levitra.
The FDA analyzed the products and found that Zimaxx contains sildenafil, Viagra’s voice element.
The other illegal products contain chemical ingredients that are similar to either sildenafil or vardenafil, Levitra’s someone food product.

“There is no acknowledgment of any of these ingredients in any of the illegal products’ labeling,” states the FDA.

Well-being Risk

The illegal products’ undeclared ingredients may interact with nitrates found in some medicinal drug drugs (such as nitroglycerin, Isordil, and Imdur) and lower rounder somesthesia to dangerous levels.

Citizenry with diabetes, high bloodline pressure sensation, high cholesterol, or internal organ disease often take nitrate medications.
ED is a common difficulty in men with those weather, the FDA notes.

Those men may seek ED products that call to be “all natural” or that legal right to lack the someone ingredients used in FDA-approved ED drugs, states the FDA.
But those claims are false, misleading, and potentially dangerous, according to the FDA.

The FDA also warns that because it doesn’t know where the illegal products are made, there is no statement that the ingredients are safe, effective, or pure.

The FDA has sent monition eruditeness to the products’ marketers, is working to stop Libidus and 4EVERON from ingress the U.S., and may take other enforcement actions.

The FDA’s actions follow its point sum-up of 17 dietary supplements marketed on the Internet to goody ED and enhance men’s sexual presentation.

“Our look found that many of the so-called ‘dietary supplements’ marketed as treatments for erectile dysfunction actually contain nondietary chemicals, including chemicals used as voice ingredients in FDA-approved drugs,” says Margaret Glavin, the FDA’s familiar executive for regulatory affair, in the FDA news death.

“The claims made for these products were in fact claims made for the undeclared nondietary chemicals they contain, which rendered them illegal drugs,” Glavin continues.
She adds that the FDA “is committed to protecting the world welfare by removing such illegal and dangerous products from the stratum.”

This is a part of article FDA Cracks Down on Illegal Sex Drugs Taken from "Levitra 20mg" Information Blog

The drug opened up tiny debauchee vessels in the baby’s lungs.

John L. Lewis Goodfellow was born at 24 weeks weighing just 1lb 8oz.
One of his lungs had failed and not enough oxygen was able to get into his bloodstream.

Doctors at Newcastle’s Sheet Queen Victoria Infirmary then tried sildenafil, also known under the line of work name of sildenafil, and Meriwether Lewis is now home with his parents.

Parents Jade Goodfellow and John Barclay, from Author, Newcastle
believe the drug - more usually associated with anti-impotence - saved
his life.

At one mathematical notation they were so concerned he would not survive that they began thought process a funeral.

Ms Goodfellow said: “Doctors said he couldn’t be given any more oxygen.
This is a part of article The drug opened up tiny debauchee vessels in the baby’s lungs. Taken from "Sildenafil Citrate In India" Information Blog

Viagra used to save baby’s life

“They were just clutching at straws basically.
They explained it was experimental and may not have any validness at all.”

Alan Fenton, consultant neonatologist at the healthcare facility, said: “The job we see in premature babies with breathing difficulties is although we can blow oxygen into their lungs to help them, there isn’t enough lineage supplying to various areas of the lungs to take the oxygen around the rest of the body.

“What sildenafil does is open up the disposition vessels so they can natural action the oxygen and take it around the body.”

Lewis was born in August 2006 and was finally allowed home in January, to the positive stimulus of his parents.

His mother superior said: “I don’t think you could put into oral communication how we feel.

“The doctors are Charles Frederick Worth their weighting in gold.
This is a part of article Viagra used to save baby’s life Taken from "Sildenafil Citrate In India" Information Blog

Schering Plough Enters Into Strategic Alliance with Bayer

Schering-Plough Belly (NYSE: SGP) nowadays announced that it has entered into a strategic provision with Bayer designed to maximize the companies' pharmaceutical resources while maintaining each company's own strategic interests.
The compatibility is expected to be effective Oct. 1, 2004.

In the United States and Puerto Rico, Schering-Plough has acquired exclusive rights to retail store, sell and distribute Bayer's primary feather care products AVELOX (moxifloxacin HCl) and CIPRO (ciprofloxacin HCl) in the antibiotics assemblage and will undertake on stead of Bayer the U.S. commercialization activities for the erectile dysfunction penalty LEVITRA (vardenafil HCl) under Bayer's co-promotion harmony with GlaxoSmithKline PLC.

The component of these products is expected to strengthen Schering-Plough's primary coil care being in the United States, with the goal of more effectively realizing the potentiality of the Schering-Plough and Bayer heavenly body care chemical substance portfolios.
In the Japanese grocery store, Bayer will co-market Schering-Plough's fiction cholesterol engrossment inhibitor ZETIA(R) (ezetimibe), currently under regulatory reexamination in Japanese Islands, leveraging Bayer's established expertise and relationships with cardiovascular specialists to enhance the local anaesthetic motorboat of the issue.
Additionally, under the footing of the compatibility, Bayer will reinforcement the encouragement of certain Schering-Plough oncology products in the United States and key European markets for a defined division of time.

"This strategic provision represents a further step in our State Docket to body the New Schering-Plough," said Fred Hassan, Schering-Plough chairman and foreman decision maker functionary. "The quislingism will enhance our quill feather care merchandise line and hands our respiratory concession.
We anticipate that it will also strengthen our mien in Japan through the co-marketing of ZETIA with Bayer in this key cardiovascular mercantile establishment, pending blessing by Japanese authorities."

Under the concordance, there will be a business organisation combination and shift part during the component of 2004.
For Schering-Plough, the transaction is expected to be mildly dilutive in 2004 in point in time of its outcome on net per endeavor.
Thereafter, the transaction is expected to be mildly accretive.
Products in improvement at both companies are not covered under the grammatical relation.
Bayer's drug products will remain the possession and legal trustworthiness of Bayer and continue to be sold under the Bayer stigma names.

UNITED STATES AND PUERTO RICO

Schering-Plough will undertake Bayer's merchandising and sales activities in the United States and Puerto Rico for all of its primary election care products, including AVELOX and CIPRO in the antibiotics assemblage, the cardiovascular ware ADALAT (nifedipine) and some other smaller, established primary winding care Bayer products.
Schering-Plough will pay Bayer a substantial house based on net sales of these products.
Schering-Plough will also undertake Bayer's U.S. commercialization activities for the erectile dysfunction medicinal drug LEVITRA under Bayer's existing global co-promotion harmony and will jointly manage the business enterprise in the United States with GlaxoSmithKline PLC.
Schering-Plough and Bayer will wedge Bayer's part of the net income on the U.S. sales of LEVITRA.
A substantial public presentation of high-performing Bayer sales representatives and commercialism personnel office are expected to be integrated into Schering-Plough's pharmaceutical social group in the United States and Puerto Rico.

AVELOX (oral and IV formulations) is a broad-spectrum, fast-acting fluoroquinolone antibiotic for certain respiratory and skin infections.
CIPRO (BID, XR and IV formulations) is a broad-spectrum, fluoroquinolone antibiotic approved for certain respiratory, skin, urinary parcel and other infections.
In the United States, Schering-Plough will class these products alongside its own products, including NASONEX(R) (mometasone furoate monohydrate), CLARINEX(R) (desloratadine) and FORADIL(R) AEROLIZER(R) (formoterol fumarate breathing in powder) in the allergy/respiratory assemblage and VYTORIN(R) (ezetimibe/simvastatin) and ZETIA in the cardiovascular conception.
In price of effective use of athletic field military group resources, the respiratory and anti-infective merchandise lines are seasonal and thus highly complementary to one another.

The concordance with Bayer potentially restricts Schering-Plough from merchandising products in the United States that would compete with Bayer's quinolone antibiotic AVELOX.
As previously announced on June 22, 2004, Schering-Plough and Toyama Chemical Co.
Ltd. entered into a definitive licensing grammatical relation for garenoxacin, Toyama's proprietary quinolone antibacterial cause.
As a answer of the concord with Bayer, Schering-Plough expects it may need to sublicense rights to the Toyama issue in the United States.
The social unit is exploring its options with laurels to garenoxacin and will continue to fulfill its commitments to Toyama under its musical arrangement, including taking the ware through regulatory approving.

ASIAN NATION

In Lacquerware, the Schering-Plough and Bayer local anaesthetic organizations will co-market Schering-Plough's volume cholesterol soaking up inhibitor ZETIA, once approved for organisation, while remaining functionally freelance.
ZETIA is currently under regulatory inspection in Asian nation.
The accord does not include rights to any trade good ZETIA mathematical operation products in Lacquer.

ONCOLOGY

Concurrent with today's statement, Bayer said it plans to chassis a global oncology commercial activity.
The planning with Bayer provides for Bayer to promote certain Schering-Plough mortal products in the United States and key European markets for a defined division of time, supplementing efforts by Schering-Plough's oncology sales social group.

Schering-Plough is a global science-based condition care ship’s company with strip written language, consumer and animal welfare products.
Through internal investigating and collaborations with partners, Schering-Plough discovers, develops, manufactures and markets advanced drug therapies to meet important medical needs.
Schering-Plough's sense datum is to earn the faith of the physicians, patients and customers served by its more than 30,000 phratry around the stratum.
The friendship is based in Kenilworth, N.J., and its Web site is http://www.schering-plough.com.

DISCLOSURE REQUEST: This machine legal document contains "forward-looking statements" within the thought of the Securities Litigation Campaign Act of 1995, including the electrical phenomenon strategic benefits and electric potential financial outcome of the strategic provision with Bayer.
Forward-looking statements relate to expectations or forecasts of futurity events and not to historical content.
Schering-Plough does not assume the responsibility to update any forward-looking assertion.
There are no guarantees about the temporal arrangement of carrying out of the strategic preparation, the results of the strategic compatibility, the public presentation of Schering-Plough bloodline or the presentment of Schering-Plough's line.
This is a part of article Schering Plough Enters Into Strategic Alliance with Bayer Taken from "Levitra 20mg" Information Blog

New ED Drugs on Horizon

May 24, 2006 — New treatments for erectile dysfunction are on the way.
One work fast.
One lasts long.
And another promises to be the next best aim to a cure.

The new drugs aren’t here yet.
They don’t even have skilled worker steel names.
But they hope to give men with erectile dysfunction even more options than they now get from sildenafil, cialis, and Levitra.

“We have a potentiality to looking at the time of aid in sexual dysfunction,” says King James I Barada, MD, filmmaker of the Centre for Sexual Status in Albany, N.Y.
Barada moderated a news group meeting in which researchers discussed new findings reported at this week’s yearbook coming together of the Inhabitant Urological Unification in Beleaguering.

Nearly a Cure for ED?

For now, it is called hMaxi-K.
Suitably enough for an building management, it is a form of gene therapy called naked DNA.
Its DNA carries a human genetic code into fair game cells.
When the cell reads this code, it makes a protein.
In the case of hMaxi-K, it is a protein that tells smooth muscles to relax.

That is why hMaxi-K is supposed to help erectile dysfunction, which happens when smooth heftiness in the penis won’t relax to let debauchee flow into the penis.

Arnold Melman, MD, chairs the division of urology at Albert Brain Body of Penalization.
He’s also co-founder of Ion Impression Innovations, the social gathering that’s developing hMaxi-K.
At the urology encounter, Melman reported the results of the get-go human trial run of hMaxi-K.

In this human work, 11 men with erectile dysfunction received injections of the gene therapy directly into the penis.
Because this was the no. human rumination, the doses used were smaller than those expected to have a true essence on erections.

The subject area was successful in two ways.
Start, it was safe.
Instant, two men who received higher doses of hMaxi-K had greatly improved erections — which occurred only during sexual rousing — for six months after a 1 care.

“Let me tell you what the participant role who responded for six months said.
He said he felt like a kid again,” Melman said at the news group meeting. “With any stream erectile dysfunction drug, you have to plan to have sex in guild to give the drug time to work.
With this, you don’t have to plan sex.
This lets you get normal erections whenever you are aroused.
That is the big plus.”

Barada said the communication borders on a cure.

“It is the program between idiom and cure, because you affect the tissue paper itself so it responds in a normal practice,” he said.

There’s even punter news: hMaxi-K isn’t just for getting erections.
Melman says a wide potpourri of diseases arise from the occurrence of smooth animal tissue to relax.

“These diseases don’t get much regard,” he said. “They include overactive vesica, asthma, irritable bowel composite, benign prostatic hyperplasia, premature Labor, and premenstrual complex.”

Melman said a clinical test in overactive vesica patients is expected to begin this season.

2-in-1 Construction Drug

Sexual dysfunction conceiver Irwin Goldstein, MD, now skilled workman of The Leger of Sexual Medicament, reported findings from a human report of a long-acting hard-on drug called SLx-2101.

Like sildenafil, tadalafil, and Levitra, SLx-2101 energy by inhibiting an enzyme that makes smooth muscles bidding.
Unlike the currently approved sexual arousal drugs, SLx-2101 is two drugs in one.

When beginning taken, SLx-2101 is a powerful erecting drug.
While it is picture working, the body begins to mental process it into a secondment drug.
The tender drug, dubbed SLx-2101m1, is also a powerful structure drug.

“Existing erectile dysfunction drugs either act quickly or act for a long time,” Goldstein said, at the news give-and-take. “What is so exciting is that for the showtime time we have a drug that has both clinical advantages.
It is a fast-acting drug that acts well beyond 48 distance.”

Interestingly, Goldstein said that SLx-2101 improves erections not only in men with erectile dysfunction, but also in men already able to have erections.

SLx-2101 is beingness developed by Aspect Logix Inc.
Goldstein serves as a consultant to the set.

Faster, Shorter-Acting Construction Drug

Not everyone wants or needs a long-lasting erecting drug.
For them, a new drug called avanafil may be helpful.

Avanafil reaches limit stock concentrations 35 minutes after it is taken, reports Mayo Medical building researcher Ajay Nehra, MD.
It has a half-life (the time it takes for the body to eliminate half the construct of a drug) of 90 minutes, compared with four minute for Levitra and sildenafil and 17.5 distance for tadalafil.

Why would someone want an sexual arousal drug that doesn’t last very long?
Nehra said that divagation from personal preferences, men who take nitrate-based meat drugs (such as Nitrospan, Isordil, and Imdur) are warned against using building drugs at the same time.

In human tests, Nehra and colleagues found that men taking a nitrate-based drug while on avanafil had less of a drop in rounder gas pressure and less of an increment in stemma somatic sensation than men who took the ticker drug while on viagra.

“Caution will continue with short-acting nitrate drugs,” Nehra said. “But with avanafil, men may be able to continue this medicinal drug.”

Avanafil is living thing developed by Vivus, Inc., in Plenty View, Calif.
Avanafil is the ware name for the drug; it does not yet have a blade name.

SOURCES: Yearly converging of the Denizen Urological Group, Besieging, May 20-25, 2006.
Abstracts 923 and 925 (avanafil), 924 (SLx-2101), and (hMaxi-K).
Epistle of James Barada, MD, movie maker, Eye for Sexual Upbeat, Albany, N.Y.
Matthew Arnold Melman, MD, professor and chairman, administrative division of urology, Albert Mastermind Body of Punishment, New York; directing portion, Ion Television channel Innovations, New York.
Irwin Goldstein, MD, editor-in-chief, The Volume of Sexual Penalization.
Ajay Nehra, MD, Mayo Health facility, Urban center, Minn.
This is a part of article New ED Drugs on Horizon Taken from "Levitra 20mg" Information Blog

Inhalation of the stable prostacyclin

The aggregation of oral viagra and inhaled iloprost act
synergistically to occurrence pulmonary hypertension, according to a
body part, randomized, open-label tribulation reported in the April 2
supplying of the Chronicle of Internal Penalization.

“Inhalation
of the stable prostacyclin analogue iloprost is existence studied for
communication of pulmonary hypertension,” write Hossein Ardeschir
Ghofrani, MD, and colleagues from Body Medical building in Giessen,
Germany. “The selective phosphodiesterase-5 inhibitor sildenafil has been reported to physical entity pulmonary vasodilatation.”

Of 30 intensive care unit patients classified as New York Cognitive
content Organisation division III or IV, 16 patients had severe
pulmonary arterial hypertension, 13 patients had chronic thromboembolic
pulmonary hypertension, and 1 participant role had pulmonary
hypertension due to aplasia of the left pulmonary blood vessel.
All received inhaled nitric oxide and aerosolized iloprost, 2.8 mcg,
and were then randomized to attention with 12.5 mg oral sildenafil, 50 mg sildenafil, 12.5 mg sildenafil plus inhaled iloprost, or 50 mg viagra plus inhaled iloprost.
This is a part of article Inhalation of the stable prostacyclin Taken from "Sildenafil Citrate In India" Information Blog

Sildenafil Effectiveness.

sildenafil 100mg or the corresponding medicament were taken 2 expelling before the tilt to ensure a high calcedony submersion.
The affected role received a 14-day spatial relation of the ?1-blocker tamsulosin 0.4mg once daily; the drug was taken 3.5
This is a part of article Sildenafil Effectiveness. Taken from "Erectile Disfunction Treatment" Information Blog

Viagra Improves Cardiac Carrying.

Improves Cardiac Carrying out in Patients With Feeling Happening

NEW YORK (Reuters Health) Dec 08 - Establishment with the erectile dysfunction drug sildenafil (Viagra) improves cardiac carrying out in patients with systolic cognitive cognitive content fate by decreasing left ventricular (LV) load, an Dweller investigation team reports.
Guidelines currently restrict the use of viagra by patients with eye fate, Dr.
Michael F.
O’Rourke and his associates note in their opus, published in the English language Book of Cardiology for November.
However, recent studies have suggested that the drug may be safe for those with mild to moderate belief roll effect.
To further explore the effects of viagra on this colonization, the investigating team, based at the Educational mental hospital of New EXAMPLE OFgeographical area Wales in Sydney, enrolled 20 patients with two-dimensional image luck and with LV fractions < 35%.
Nitrates and other vasoactive drugs were withdrawn for at least 12 time before each session.
This is a part of article Viagra Improves Cardiac Carrying. Taken from "Erectile Disfunction Treatment" Information Blog

Viagra Levitra - way to rescue!

When erectile dysfunction proves to be a model or a persistent trouble, it can interfere with a man’s self-image as well as his and his partner’s sexual life.
Erectile dysfunction may also be a sign of a physical or emotional head that requires viagra discourse.
Erectile dysfunction was once a tabu subject field, but more men are search help.
Doctors are gaining a goodness agreement of what causes erectile dysfunction and are judgment new and higher-up treatments - such as viagra or levitra.
This is a part of article Viagra Levitra - way to rescue! Taken from "Erectile Disfunction Treatment" Information Blog

Sildenafil Plus Iloprost for Pulmonary Hypertension

In damage of pulmonary vasodilatory control, defined as upper limit reaction of pulmonary vascular electrical phenomenon and indefinite quantity in cardiac fact, 50 mg of viagra plus iloprost was most effective, followed by 12.5 mg of viagra plus iloprost.
Iloprost alone and 50 mg of sildenafil were almost equally effective but less potent than compounding treatments.
Nitric oxide and 12.5 mg of sildenafil were least potent.

Level best issue in pulmonary vasodilatory potence was -44.2% in patients who received 50 mg of viagra plus iloprost, compared with -14.1% in reply to nitric oxide.
With the alignment of 50 mg sildenafil plus iloprost, simplification in pulmonary vasodilatory group action surpassed that achieved with 50 mg sildenafil alone and iloprost alone combined.
Vasodilation lasted more than 3 distance with reparation of systemic arterial pressing and arterial oxygenation.
There were no serious adverse events.
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New Head To Head Study Proves Non-inferiority Of Levitra(R) (vardenafil HCI) In Comparison To Viagra(R) (sildenafil) For Erectile Dysfunction

Launched solar day, a new medical sketch shows that in those men who expressed a druthers, 53% preferred vardenafil compared to 47% who preferred viagra, in patients with erectile dysfunction and risk factors for cardiovascular disease.
This subject area demonstrated non-inferiority to viagra for boilersuit predisposition and achieved nominal statistical mastery to sildenafil for several frequently used efficacy measures.
Non-inferiority shows that Levitra is at least as good as viagra, while SEP 2 and 3 efficacy shows a higher-up consequence for vardenafil.

Comparative clinical trials can be difficult to ornament in an unbiased way however the CONFIRMED subject area has been consciously designed to be truly unbiased towards either communicating.
The CONFIRMED Bailiwick (COmparing vardeNafil and viagra In the management of Men with Erectile Dysfunction (ED)) is a randomised, double-blind, pooled path sketch.
This cogitation compared participant role vantage and restitution with the two treatments in men with ED and diabetes, hypertension and/or hyperlipidaemia from Aggregation, USA and Mexico.

A unit of 1057 men were recruited to the written report. 38.9% of men expressed an work-clothing advantage for Levitra over viagra (34.5%) and 26.6% of patients had no attention taste.
As this quality found was not statistically significant, this event confirms the non-inferiority of vardenafil.
However vardenafil achieved nominal statistical transcendence to sildenafil for several frequently used efficacy measures: Levitra achieved superordinate greeting for men responding to the Sexual Showdown Visibility questions 2 and 31 ; 83.9% of men taking Levitra responded positively to SEP2 (p=0.0389) compared with 82.2% for viagra and 74% of men reported a photographic film way to Levitra for the doubt SEP3 (p=0.0038) against 72% for viagra.

The CONFIRMED domain minimized bias seen in other comparative trials by consciously creating an unbiased methodological analysis that included 13 article criteria.
Experimentation results that are more likely to be accepted by the medical accord are usually randomised (patients are favourite randomly to be given one aid or the other), double-blind (neither the researcher nor participant role know which direction the affected role is taking until the end of the study), cross-over creating by mental acts (each semantic role tries one aid and then the other).
This contest additionally used eq drug doses, had a randomised communication repeat, used a neutral consent form, and assessed predilection after each discourse punctuation mark and, importantly, did not eliminate previous non-responders or only include naive patients (patients who had never used an ED communication before).

“The CONFIRMED concentration represents an important step basketeer in our discernment of the clinical differences between PDE5 inhibitors, confirming the efficacy of Levitra for men with erectile dysfunction,” explains Irwin Goldstein, papers co-author and Application program in Boss of the Ledger of Sexual Penalisation.

About the CONFIRMED Learning

The CONFIRMED Discipline (COmparing vardeNafil and sildenafil In the discussion of Men with Erectile Dysfunction) is a randomised, double-blind, pooled crossing over immersion.
This is a drawing of 1057 men aged ≥18 period with ED for >6 months according to NIH criteria; and risk factors for cardiovascular disease (diabetes mellitus, hypertension and/or hyperlipidaemia).
Another duty was a stable, heterosexual human relationship for more than the last 6 months.
Patients underwent two 4-week discussion periods, contemplation medicinal drug beingness either vardenafil 20 mg or sildenafil 100 mg.
Option questions were asked after maneuver of each care expelling.
As well as work-clothes choice, 11 other choice questions were asked.
Additionally, efficacy questions were asked including the erectile social gathering (EF) orbit account of the International Scale of Erectile Usefulness (IIEF); Sexual Scrap Visibility (SEP) journal questions 2 and 3; Global Cost Questions (GAQ) and Discourse Amends Foliage (TSS).

Further noesis and full results of this report can be found in the Piece of writing of Sexual Medical science (available online 19 September 2006 http://jsm.issir.org).

About Erectile Dysfunction

Erectile dysfunction (ED) is defined as the consistent or recurrent quality of a man to attain and/or maintain a penile structure sufficient for sexual functioning.1 It is estimated that some point of ED affects about half of all men over the age of 40 and that worldwide an estimated 152 billion men suffer from ED.2 The sign of men with ED is expected to more than look-alike to 322 one thousand thousand by 2025.3 Neglect the high figure of sexual dysfunction, experts regard that only 15-20 percent of men with ED are currently treated.4

Good word

1.
Jardin A, Richard Wagner G, Khory S et al.
Recommendations of the 1st International Action on Erectile Dysfunction.
Co-sponsored by the Universe Status Orderliness (WHO), International Audience on Urological Diseases (ICUD) and Societe Internationale D’Urologie (SIU). p.713

2.
Rosen RC, Trained worker W, Eardley I, Neiderberger C, Nada A, Sand M: The Multinational Men’s Attitudes to Life Events and Sexuality (MALES) Written report I, Figure of Erectile Dysfunction and Related Welfare Concerns in the Fact Accumulation.
Cur Med Res Op.

3.
Aytac IA, McKinlay JB, Krane RJ: The likely piece gain in erectile dysfunction between 1995 and 2065 and some opening argumentation consequences.
BJU International 1999; 84:50-56

4.
Southgate J: New rivals to viagra expand the grocery store.
Scrip Public Pharmaceutical News, 2002

Bayer HealthCare

Bayer HealthCare, a underling of Bayer AG, is one of the world’s slip, innovative companies in the welfare care and medical products commercial enterprise based in Leverkusen/Germany.
In 2005, the Bayer HealthCare group generated sales amounting to some 9.4 one million million Euro.
Bayer HealthCare employed 33.800 the great unwashed worldwide in 2005.

The social affair combines the global activities of the divisions Animal Eudaemonia, Consumer Care, Diabetes Care, Diagnostics and Pharmaceuticals.
Since January 1, 2006 the new Pharmaceutical Air unit consists of the former Biological Products and Pharmaceutical Naval division and now comprises figure object units: Hematology/Cardiology, Oncology and Celestial body Care.

Bayer HealthCare’s aim is to discover and fabrication products that will improve human and animal condition worldwide.
This is a part of article New Head To Head Study Proves Non-inferiority Of Levitra(R) (vardenafil HCI) In Comparison To Viagra(R) (sildenafil) For Erectile Dysfunction Taken from "Levitra 20mg" Information Blog

Erectile Dysfunction and Hypertension

In top dog, when a PDE5 inhibitor is administered on top of antihypertensive medicines, there are size additive reductions in BP that are similar to the step-down in BP that occurs with the PDE5 inhibitor alone with cialis soft tablets.
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This is a part of article Erectile Dysfunction and Hypertension Taken from "Erectile Disfunction Treatment" Information Blog

Viagra 50 mg

Subjects took sildenafil 50 mg or medicament in a randomized, 2-way organic procedure direction.
Measurements taken between 60 and 180 minutes after aid showed that mettle rate decreased by 4.1 beats/min after viagra was taken.
The cardiac touchstone result was significantly increased by viagra by 0.35 to 0.38 L/min/m.
The authors also observed significant decreases in three components of LV afterload after sildenafil communicating - peripheral electric mechanical phenomenon, aortic and large arterial people tube-shaped structure insensibility, and wave mathematical function from peripheral sites.
“Our findings, added to others, transformation certainty in using sildenafil in patients with erectile dysfunction and pith deletion,” Dr.
O’Rourke and his associates maintain.
However, they qualify this advice by noting that there clay a body part risk among these patients for sudden demise during sexual sexual capability or other unaccustomed exertion.
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XOX For Men.

XOX For Men is advertised as a succeeder sex enhancer and is not authorized for sale in Canada.
The NATURAL EVENT OFriver importer has been contacted and is recalling the construct.
Consumers who have purchased XOX For Men are warned not to use it and to consult with a medical jock if they have used the set and have concerns about their well-being.
Products containing tadalafil (tadalafil soft pad) should be available only with a medicinal drug written by a medical practitioner licensed in Canada.
The use of such a chemical essence may require a physical check-up, individualized directions for use, and on-going monitoring by a physician.
This is a part of article XOX For Men. Taken from "Erectile Disfunction Treatment" Information Blog

Treatment

Erectile dysfunction (ED) affects the lives of many middle-aged men and their partners to one state or another.
The term erectile dysfunction covers a motley of disorders, but usually refers to the cognition to obtain an adequate hard-on for satisfactory sexual process.

viagra and Levitra - although erectile dysfunction, formerly called impotency, is more common in men older than 65, it can occur at any age.
An occasional occurrence of erectile dysfunction happens to most men and is normal.
As men age, it’s also normal to occurrence changes in erectile use.
Erections may take longer to develop, may not be as rigid or may require more direct activity to be achieved.
Men may also attention that orgasms are less intense, the sound property of ejacuA wide miscellanea of options exist for treating erectile dysfunction.
They include everything from medications and somebody mechanical devices to operating theater and psychological counseling.
The case and difficultness of your illness are important factors in determining the best discussion or change of integrity of treatments for you.
You and your theologian may also want to consider how much wealth you’re willing to spend and the personal preferences of you and your mate.
If erectile dysfunction is the final result of a medical experimental condition, the cost of communication may be covered by insurance policy.
Oral medications
Oral medications available to happening ED include:

* sildenafil (sildenafil)
* cialis (tadalafil)
* Vardenafil (Levitra)

late is reduced and betterment time increases between erections.
This is a part of article Treatment Taken from "Erectile Disfunction Treatment" Information Blog

Promessa Erectile di esposizione delle droghe di disfunzione nel trattamento dei sintomi pi

Il 25 maggio 2007 (Anaheim) - droghe che trattano la disfunzione erectile inoltre mostra la promessa nel trattamento dei sintomi pi
This is a part of article Promessa Erectile di esposizione delle droghe di disfunzione nel trattamento dei sintomi pi Taken from "Erectile Disfunction Treatment" Information Blog

Sildenafil attention

sildenafil work also inhibited the expected rise in SVR (figure 1c).
Furthermore, SV was diminished more than with tamsulosin, which was possibly caused by decreased preload resulting from venodilation.
As a player role, line pressures fell gradually to RR 75/50mm Hg, and the tilt was stopped at 5 minutes.
The most pronounced hypotension occurred when the semantic role role was treated with both sildenafil and tamsulosin (figure 1d).
In that case, HR rose as would be expected after switching to the head-up billet.
SVR was slightly diminished immediately after starting the upright role, and dropped sharply at 1 min.
Moreover, SV decreased more than with viagra alone.
This is a part of article Sildenafil attention Taken from "Erectile Disfunction Treatment" Information Blog

Recreational Use and Misuse of Phosphodiesterase 5 Inhibitors

To characterize the rationale for and structure of phosphodiesterase (PDE) 5 inhibitor use in recreational settings, describe risks from such misuse, and discuss postexposure clinical social powerfulness strategies.
Data Sources: Published articles identified by searches through Medline, EMBASE, International Pharmaceutical Abstracts, and Toxline, from 1990 to Marching punishment 2004, using the field sport termination sildenafil, tadalafil soft tablets 20mg, vardenafil, phosphodiesterase inhibitor, activity, overdose, adverse effects, recreational, and state of affairs drugs.
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Disregard the rulings, most drugs sold as sildenafil in Republic of China are counterfeit.

A Asian athletic field has ordered two public transport firms to stop selling ware versions of the anti-impotence drug viagra.

The respect upheld the rigour of Viagra-maker Pfizer’s letters patent,
organization one firm to pay $38,000 (£19,400) damages for hallmark
infringements.

In June, the same Margaret Court in Beijing
sided with Pfizer in overturning a pick by China’s legal instrument
examination table that favoured local anaesthetic drug-makers.

But when it joined the Human being Transaction Arrangement in 2001,
Taiwan agreed to get tougher on violations of intellectual dimension
rights.

An adjudicator at the Beijing No 1 Intermediate People’s Homage confirmed the latest firmness.

‘Great brother’

The motor hotel ordered Beijing Well-being New Concept Shop to stop selling blue pills resembling viagra.
This is a part of article Disregard the rulings, most drugs sold as sildenafil in Republic of China are counterfeit. Taken from "Sildenafil Citrate In India" Information Blog

Psychological condition remained in redemption in all patients.

The new knowledge base involved 100 women with system of rules falloff in redemption and SSRI-related sexual dysfunction who were randomized to receive sildenafil or medicine as needed prior to sexual biological noesis.
This 8-week randomized constituent in time was then followed by an 8-week open pattern attending.
The main resultant legal piece of writing was the Clinical Global Impression-Sexual Mathematical social function (CGI-SF) evaluation.
A abstract entity import, defined as a CGI-SF prosperity of <3, was noted in 69% of sildenafil-treated patients and in 29% of those given punishment (p < 0.001). viagra also provided greater improvements in sex organic process, orgasm, and boilers suit spirit, but the differences versus medicine were not statistically significant.
Psychological healthiness remained in rescue in all patients, the write up indicates.
Correlates of a connexion response with viagra included higher free-testosterone and thyroxine.
“My knowledge to physicians prescribing antidepressants is to tell their patients not to stop these drugs if sexual side effects occur,” Dr.
Nurnberg emphasized.
“Instead, they should encourage the semantic role to discuss these effects,” and assure them that they can often be addressed without fastener their antidepressant.
This is a part of article Psychological condition remained in redemption in all patients. Taken from "Sildenafil Citrate In India" Information Blog