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The mean age of the study group was 59.6 11.2 y.13 54 24 had arteriogenic Man V Wild Fake ED, 16 54 30 had mixed vasculogenic ED, 9 54 17 had cavernosal veno occlusive dysfunction, 11 54 20 had post radical retropubic prostatectomy ED and 5 54 9 had psychogenic ED.13 54 24.1 responded Buying Without Prescription to sildenafil at a median maximal dose of 200 mg, 4 13 required Best Ed Pills Prescription Man V Wild Fake 150 mg and 9 13 required 200 mg.41 54 76 failed to respond to sildenafil.Mean IIEF question 3 and 4 scores were 1.5 and Rogaine African American Hair 1.4 at baseline, 2.2 and 1.9 with sildenafil 100 mg, 2.8 and 2.5 with sildenafil 150 mg and 3..0 and 2.9 with sildenafil 200 mg, respectively.After 4 weeks, treatment was regarded as having improved their erections by 37 , 46.3 and 68 of patients with sildenafil 100 mg, Buying Without Prescription 150 mg and 200 mg, respectively.34 54 63 reported adverse Buying Without Prescription effects with maximal dose sildenafil comprising headache 19 , facial flushing 32 , dyspepsia 14 , nasal congestion 11 , dizziness 5 and visual disturbances 5.4 13 31 responders refused to continue treatment due to adverse effects.In conclusion, sildenafil at doses of up to 200 mg Best Ed Pills Prescription is an effective salvage therapy for 24.1 Man V Wild Fake of previous sildenafil non responders but is limited by a significantly higher incidence of adverse effects and a 31 treatment discontinuation rate.IntroductionErectile dysfunction ED is the inability to achieve and maintain an erection of sufficient rigidity for satisfactory sexual intercourse.1 Community based epidemiological studies suggest that sexual dysfunction, particularly ED, is a common disorder in patients and is associated with reduced quality of life.2,3,4,5Sildenafil citrate Man V Wild Fake ViagraTM, Pfizer, UK , a potent, competitive phosphodiesterase type 5 iso enzyme PDE 5 inhibitor, is the first oral medication to demonstrate Rogaine African American Hair significant and reliable efficacy in most patients with ED.6 Following activation of the nitric oxide cGMP pathway by sexual arousal, inhibition of PDE 5 isoenzyme by sildenafil results in increased corporal levels of cGMP and an augmented penile erection.7 Sildenafil appears effective in restoring erectile function and improving intercourse success rates in a wide range of patients, including those with hypertension, diabetes, spinal cord injury, other concomitant medical conditions, and in those patients taking a wide variety of concomitant medications.Its efficacy Buying Without Prescription appears related to the extent and severity of ED, with significantly reduced efficacy demonstrated in patients Buying Without Prescription with severe vasculogenic ED, diabetic ED and post radical prostatectomy ED.6,8,9,11Jarow et al reported a sildenafil response rate of 65 , significant improvement in quality of life and a Best Ed Pills Prescription 35 incidence of adverse effects.9 Virag reported similar results with a 60 Buying Without Prescription response rate and a 26.75 incidence of adverse effects.10 Men Sex Men McMahon et al reported a similar response rate of 67.5 but Men Sex Men a higher incidence of adverse effects of 53.6.11 These authors report a similar efficacy rate but a higher incidence of adverse effects compared to that reported by the Sildenafil Study Group.6The maximum dose of sildenafil recommended by the manufacturer Rogaine African American Hair is 100 mg.A study was designed to prospectively review a group Men Sex Men of patients with Men Sex Men chronic ED, unresponsive to sildenafil 100 mg, who were treated in a home setting with doses of sildenafil in excess of the recommended maximum dose 150 mg and 200 mg.Treatment efficacy, safety and tolerance was evaluated using serial physician interviews and the patient self administered IIEF questionnaire.Materials and methodsFifty four fully evaluated patients with chronic ED who had previously failed to respond to a home trial of sildenafil 100 mg with erections suitable for sexual intercourse were studied.All patients had received focussed sildenafil usage education and had been re titrated to confirm their non Man V Wild Fake responder status.The mean number of sildenafil uses prior to enrolment in this study was 7 tablets range 5 C16.All patients had been previously assessed using a standardised protocol and the etiology of their ED determined.This protocol included a history and physical examination, determination of fasting lipids, glucose and free testosterone, vibratory penile biothesiometry and penile colour duplex Doppler ultrasonography CDU before and after intracavernous vasoactive drug challenge 20 mg alprostadil.Rigiscan nocturnal penile tumescence testing, dynamic infusion cavernosometry and cavernosography DICC and phallopharmacoangiography were performed where clinically indicated.Patients with unstable coronary artery disease, low output congestive cardiac failure, hypertension treated with three or more drugs, currently prescribed organic nitrate medication or those with any other contraindication to renewed sexual intercourse or sildenafil were excluded from the study.Each man was treated at home with escalating doses of sildenafil citrate 100 mg, 150 mg and 200 Buying Without Prescription mg taken 1 hour before planned sexual activity until Buying Without Prescription either Buying Without Prescription maximal response or intolerable adverse effects occurred.The primary efficacy end point was the response to the questions 3 and 4 of the erectile function domain of the International Index of Erectile Function IIEF after a trial of each dose of sildenafil.The secondary efficacy end point was the response to the global assessment question Has this treatment improved your erections after 4 weeks of treatment.Results were analysed using standard statistical analysis Best Ed Pills Prescription including descriptive statistics and Student s t Man V Wild Fake test.ResultsFifty four patients with chronic ED and a mean age of 59.6 11.2 y were enrolled in the study group.The etiology of ED was psychogenic in 5 patients 9 , arteriogenic in 13 patients 24 , cavernosal veno occlusive Men Sex Men dysfunction CVOD in 9 patients 17 , MVED in 16 patients 30 and post radical retropubic prostatectomy ED in 11 patients 20.The mean duration of ED was 16..6 months range 4 C32.Twenty four patients had Man V Wild Fake diabetes mellitus, 27 had hypertension, 26 had dyslipidaemia and 20 smoked cigarettes.Two or more vascular risk factors Best Ed Pills Prescription were present in 46 patients Table Rogaine African American Hair 1.Table 1 Patient demographics, intercurrent illness and life style factors overall Man V Wild Fake and according to aetiology of EDFull size tableErections of sufficient Rogaine African American Hair rigidity and duration for satisfactory sexual intercourse occurred in 13 patients 24.1 at a median maximal dose of 200 Rogaine African American Hair mg.Four patients 7.4 required 150 mg and comprised 2 patients with psychogenic ED and 2 patients with arteriogenic ED.The remaining 9 patients 16.7 required 200 mg Man V Wild Fake and comprised Man V Wild Fake 2 patients with Best Ed Pills Prescription psychogenic ED, 3 patients with arteriogenic ED, 2 patients Best Ed Pills Prescription with Men Sex Men cavernosal veno occlusive dysfunction and 2 patients with Rogaine African American Hair post radical prostatectomy ED.Nine of the 13 patients 69 who responded chose to continue therapy Rogaine African American Hair with sildenafil.Overall, high dose sildenafil was effective in 4 out of 5 patients 80 with psychogenic ED and 9 out of 49 patients 18.4 with organic ED Table 2.Of the 11 patients with post radical Buying Without Prescription prostatectomy ED, 2 patients had undergone a bilateral nerve sparing radical retro pubic prostatectomy NSRRP and one had undergone a Man V Wild Fake unilateral Men Sex Men procedure and the remainder non nerve sparing procedures.The mean interval between surgery and treatment was 5.2 months.High dose sildenafil was effective in 1 Men Sex Men man treated with bilateral NSRRP and in 1 man treated with a unilateral NSRRP.Table 2 Response rate for sildenafil 150 mg, sildenafil 200 mg and sildenafil overallFull size table.Mean responses to questions 3 and 4 of the IIEF erectile function domain, the primary end point, were 1.5 Man V Wild Fake and 1.4 at baseline, 2.2 and 1.9 with sildenafil 100 mg, 2.8 and 2.5 with sildenafil 150 mg and 3.0 and 2.9 with sildenafil 200 mg.The mean score for Q3 and Q4 for sildenafil was statistically superior to baseline, overall, in all etiological groups and at all doses P 0.001.The overall mean score for Q3 and Q4 for sildenafil 200 mg was statistically superior Buying Without Prescription to sildenafil 100 mg P 0.05 but not to sildenafil 150 mg.The mean Best Ed Pills Prescription score for Q3 and Q4 for sildenafil 200 mg was statistically superior to sildenafil 100 mg P 0.05 for all etiological groups except post radical prostatectomy ED Figures 1 and 2.The global assessment by patients whether treatment improved their erections, the secondary end point, was answered in the affirmative at week 4 by 37 on 100 Best Ed Pills Prescription mg, 46.3 on 150 mg and 68 on 200 mg Figure 3.The incidence of affirmative responses was statistically superior at sildenafil 200 mg compared to 100 mg Men Sex Men P 0.05.Viagra is taken as a single tablet, 1 hour before sexual activity.Only 1 dose should be taken in any 24 hour period.The onset of the effect may be delayed if taken with food.Viagra is supplied in boxes Best Ed Pills Prescription of 4 tablets..THE PRICES LISTED ARE FOR MEDICATION DISPENSED ON A PRIVATE PRESCRIPTION.SOME PATIENTS,HOWEVER, MAY BE ELIGIBLE TO OBTAIN THIS MEDICATION ON AN NHS PRESCRIPTION.YOUR DOCTOR WILL BE ABLE TO ADVISE YOU WHICH TYPE OF PRESCRIPTION YOU REQUIRE.VIAGRA sildenafil citrate is a cGMP specific phosphodiesterase type 5 PDE5 inhibitor, used for the treatment of male erectile dysfunction.The physiological mechanism responsible for erection of the penis involves the release of nitric oxide NO in the corpus cavernosum in response to sexual stimulation.Nitric oxide Man V Wild Fake Best Ed Pills Prescription then activates the enzyme guanylate cyclase, which results in increased levels of cyclic guanosine monophosphate cGMP , producing smooth muscle relaxation in the corpus cavernosum and allowing inflow of blood.Sildenafil has no direct relaxant effect on isolated human corpus cavernosum, but enhances the effect of NO by inhibiting PDE5, which Man V Wild Fake is responsible for the biodegradation of cGMP in the corpus Men Sex Men cavernosum.When sexual stimulation causes local release of NO, inhibition of PDE5 by sildenafil produces increased levels of cGMP Best Ed Pills Prescription in the corpus cavernosum, resulting in smooth muscle relaxation and increased inflow Men Sex Men of Buying Without Prescription Rogaine African American Hair blood to the corpus cavernosum.Sildenafil, Best Ed Pills Prescription at recommended doses, has no effect in the absence of sexual stimulation.Studies in vitro have shown that sildenafil has between 10 and 10,000 fold greater selectivity for PDE5 than for other phosphodiesterase isoforms namely PDEs 1, 2, 3, 4, and 6 and greater than 700 fold effect on PDE7 PDE11.In particular, sildenafil has Rogaine African American Hair greater than 4,000 fold Best Ed Pills Prescription selectivity for PDE5 over Buying Without Prescription PDE3, the cAMP specific phosphodiesterase isoform involved in the control of cardiac contractility.Sildenafil is about 10 fold as Best Ed Pills Prescription potent for PDE5 compared to PDE6, an isoenzyme found in the retina this lower selectivity is thought to be the basis for colour vision Buying Without Prescription abnormalities observed with higher doses or plasma levels of sildenafil see WARNINGS AND PRECAUTIONS, DETAILED PHARMACOLOGY.PDE5 is also found in lower concentrations in platelets, vascular and visceral smooth muscles, and skeletal muscle.The sildenafil induced inhibition of PDE5 in these tissues appears to be the basis for the enhanced platelet antiaggregatory activity of nitric oxide observed in vitro, and inhibition of platelet thrombus Rogaine African American Hair formation in vivo, and peripheral arterial venous dilation in vivo see WARNINGS AND PRECAUTIONS.PharmacodynamicsEffects of VIAGRA on Blood Pressure BP Single oral doses of sildenafil 100 mg administered to Buying Without Prescription healthy volunteers produced decreases in supine blood pressure mean maximum decrease of Rogaine African American Hair 8.3 5.3 mm Hg.The decrease in blood pressure was most Man V Wild Fake notable approximately 1 Rogaine African American Hair 2 hours after dosing.The effects are not related to dose Men Sex Men or plasma levels.Larger effects were recorded among patients receiving concomitant nitrates see CONTRAINDICATIONS.Effects of Man V Wild Fake VIAGRA on Cardiac Parameters Single oral doses of VIAGRA up to 100 mg in healthy volunteers produced no clinically relevant effects on ECG.Effects of VIAGRA on Erectile Response VIAGRA was studied in clinical trials of various designs.In fixed dose clinical trials, 62 , 74 , and 82 of patients on 25 mg, 50 mg and 100 mg of VIAGRA, respectively, reported an improvement in their erections, compared to 25 on placebo p 0.0001, see CLINICAL TRIALS.In eight double blind, placebo controlled, cross over studies using RigiScan a device used to objectively measure penile rigidity and duration of erections , erections during sexual stimulation improved significantly on VIAGRA compared to placebo.These studies included Men Sex Men patients with organic etiologies such as spinal cord injury and diabetes Men Sex Men mellitus , and patients without an established organic cause.Most studies assessed the efficacy of VIAGRA approximately 60 minutes post dose.All eight Man V Wild Fake studies investigating the effects of sildenafil on penile plethysmography RigiScan after visual sexual stimulation VSS under laboratory conditions, consistently showed that doses of up Man V Wild Fake to 100 mg resulted in statistically significant improvements in duration of erections of 60 rigidity considered Rogaine African American Hair hard enough for penetrative sexual intercourse , compared with placebo.In patients who respond, the median time to onset Men Sex Men of erections 60 rigidity in response to VSS, was 25 minutes after an oral dose of 50 mg sildenafil.The mean total duration of erections 60 rigidity at the base of the penis was 3, 24 and 32 minutes for subjects receiving placebo, 25 mg and 50 mg doses, respectively, when exposed to VSS for 2 hours.VIAGRA increases couples ability to have sexual intercourse see CLINICAL TRIALS.Pharmacokinetics.Absorption Sildenafil is rapidly absorbed.Maximum Rogaine African American Hair observed plasma Men Sex Men concentrations are reached within 30 to 120 minutes Buying Without Prescription median 60 minutes of oral dosing in the fasted state.The mean absolute bioavailability is 41 range 25 63.The oral pharmacokinetics of VIAGRA is proportional over the Rogaine African American Hair recommended dose range studied 25 mg to 100 mg.Sildenafil inhibits the human PDE5 Buying Without Prescription enzyme in vitro by Best Ed Pills Prescription 50 at a concentration Rogaine African American Hair of 3.5 nM.In man, the mean maximum free plasma concentration of sildenafil following a single oral dose of 100 mg is approximately 18 ng mL, or 38 nM.When VIAGRA was administered with a high fat meal, the rate of absorption was significantly decreased, with a 29 reduction in Cmax and a 60 minute delay in Tmax..The patient may find that it takes longer to work if taken with a high fat meal.However, although it was statistically significant AUC decreased by 11 , the decrease in the extent of absorption was not clinically relevant.The relative bioavailability fed fasted was 89 90 CI 84 94 see DRUG INTERACTIONS.Distribution The mean steady state volume of distribution Vss for sildenafil is 105 Best Ed Pills Prescription litres, indicating distribution into the tissues.Sildenafil and its major circulating N desmethyl metabolite are both approximately 96 bound to plasma proteins.Protein binding is independent of total drug concentrations.Based upon measurements of sildenafil in the semen of healthy volunteers, less than 0.001 of the ingested dose may appear in the semen of patients 90 minutes after drug intake.Metabolism Sildenafil is cleared predominantly by the CYP3A4 major route and CYP2C9 minor route hepatic microsomal isoenzymes.The major circulating metabolite results from N demethylation of sildenafil at the N methyl piperazine moiety.This metabolite has a PDE selectivity profile similar to sildenafil and an in vitro potency against PDE5 approximately 50 that of Rogaine African American Hair the parent drug.Plasma concentrations of this metabolite are approximately 40 of those seen for sildenafil.The N desmethyl metabolite is further metabolised, with a terminal half life of approximately 4 hours.Excretion The total body clearance of sildenafil is 41 L h with a resultant terminal phase half life of 3 5 hours.After either oral or intravenous administration, sildenafil is excreted as metabolites predominantly in the feces approximately 80 of administered dose and to a lesser extent in the urine approximately 13 of the administered dose.Special Populations and ConditionsGeriatrics Healthy elderly subjects 65 years or older Man V Wild Fake had a reduced clearance of sildenafil, resulting in approximately 90 higher plasma concentrations of Men Sex Men sildenafil and the active N desmethyl metabolite compared to those seen in healthy younger volunteers 18 45 years.Due to age differences in plasma protein binding, the corresponding increase in free sildenafil plasma concentration was approximately 40.Hepatic Insufficiency In volunteers with hepatic Buying Without Prescription cirrhosis Child Pugh A and B , sildenafil clearance was reduced, resulting in increases in AUC 85 and Cmax 47 compared to age matched volunteers with no hepatic impairment.The pharmacokinetics of sildenafil in patients with severe hepatic impairment Child Pugh class C have not been studied.Since sildenafil clearance is Man V Wild Fake reduced in geriatric patients 65 years or older , patients with renal impairment or patients with hepatic impairment, a starting dose Rogaine African American Hair of 25 mg should be considered.Based on efficacy and toleration, the dose may be increased to 50 mg or 100 mg see WARNINGS AND PRECAUTIONS, DOSAGE AND ADMINISTRATION.Renal Insufficiency In volunteers with mild CLcr 50 Man V Wild Fake 80 mL min and moderate CLcr 30 49 mL min renal impairment, the pharmacokinetics of a single Men Sex Men oral dose of VIAGRA 50 mg were not altered.In volunteers with severe CLcr 30 mL min renal impairment, sildenafil clearance was reduced, resulting in increases in AUC 100 and Cmax 88 Rogaine African American Hair compared to Man V Wild Fake age matched volunteers with no renal impairment.In addition, N desmethyl metabolite AUC and Cmax values were significantly increased by 200 and 79 respectively in subjects with severe renal impairment compared to subjects with normal renal function.Sildaforce 100mg Generic Viagra Tablets are a very popular, successful and widely accepted treatment for erectile dysfunction.Sildaforce 100mg is produced to a high quality standard to ensure safety and effectiveness.Patients using Sildaforce 100mg regularly report successful intercourse and generally continue to use the treatment.The effective treatment time of Sildaforce 100mg is 4 6 hours but many GPs report longer effective times