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

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Consider a starting dose of 25 mg in patients > 65 years, patients with hepatic impairment (e.g., cirrhosis), and patients with severe renal impairment (creatinine clearance <30 mL/minute) because administration of VIAGRA in these patients resulted in higher plasma levels of sildenafil [see Use in Specific Populations (8.5, 8.6, 8.7) and Clinical Pharmacology (12.3)]. VIAGRA is supplied as blue, film-coated, rounded-diamond-shaped tablets containing sildenafil citrate equivalent to 25 mg, 50 mg, or 100 mg of sildenafil.

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Tablets are debossed with PFIZER on one side and VGR25, VGR50 or VGR100 on the other to indicate the dosage strengths. Consistent with its known effects on the nitric oxide/cGMP pathway [see Clinical Pharmacology (12.1, 12.2)], VIAGRA was shown to potentiate the hypotensive effects of nitrates, and its administration to patients who are using nitric oxide donors such as organic nitrates or organic nitrites in any form either regularly and/or intermittently is therefore contraindicated.

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Phosphodiesterase-5 (PDE5) Inhibitors In the Management of Erectile Dysfunction. The Efficacy and Safety of Avanafil During a Treatment of Male Erectile Dysfunction: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Therapeutics and Clinical Risk Management, 19, 629-644. The efficacy of fluoxetine in the treatment of premature ejaculation: a double-blind placebo controlled study. The Journal of Urology, 156(5), 1631–1632.

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Relative Efficacy of Minoxidil and the 5-α Reductase Inhibitors in Androgenetic Alopecia Treatment of Male Patients: A Network Meta-analysis. Atorvastatin efficacy in the primary and secondary prevention of cardiovascular events. Trends in Urology & Men's Health, 12(6), 19-22. Psychological Factors Related to Impotence as a Sexual Dysfunction in Young Men: A Literature Scan for Noteworthy Research Frameworks. Clinics and Practice, 12(4), 501-512.

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The role of cortisol in erectile function. Translational Andrology and Urology, 12(8), 1213-1214. People who Expect to Enter Psychotherapy are Prone to Believing that They Have Forgotten Memories of Childhood Trauma and Abuse. Mental Health Medications, U.S. Department of Health and Human Services. After patients have taken VIAGRA, it is unknown when nitrates, if necessary, can be safely administered. Although plasma levels of sildenafil at 24 hours post dose are much lower than at peak concentration, it is unknown whether nitrates can be safely co-administered at this time point [see Dosage and Administration (2.3), Drug Interactions (7.1), and Clinical Pharmacology (12.2)].

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

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There is a potential for cardiac risk of sexual activity in patients with preexisting cardiovascular disease. Therefore, treatments for erectile dysfunction, including VIAGRA, should not be generally used in men for whom sexual activity is inadvisable because of their underlying cardiovascular status. The evaluation of erectile dysfunction should include a determination of potential underlying causes and the identification of appropriate treatment following a complete medical assessment. VIAGRA has systemic vasodilatory properties that resulted in transient decreases in supine blood pressure in healthy volunteers (mean maximum decrease of 8.4/5.5 mmHg), [see Clinical Pharmacology (12.2)].

While this normally would be expected to be of little consequence in most patients, prior to prescribing VIAGRA, physicians should carefully consider whether their patients with underlying cardiovascular disease could be affected adversely by such vasodilatory effects, especially in combination with sexual activity.

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The maximum recommended dosing frequency is once per day. Based on effectiveness and toleration, the dose may be increased to a maximum recommended dose of 100 mg or decreased to 25 mg. VIAGRA was shown to potentiate the hypotensive effects of nitrates and its administration in patients who use nitric oxide donors such as organic nitrates or organic nitrites in any form is therefore contraindicated [see Contraindications (4.1), Drug Interactions (7.1), and Clinical Pharmacology (12.2)]. When VIAGRA is co-administered with an alpha-blocker, patients should be stable on alpha-blocker therapy prior to initiating VIAGRA treatment and VIAGRA should be initiated at 25 mg [see Warnings and Precautions (5.5), Drug Interactions (7.2), and Clinical Pharmacology (12.2)]. The recommended dose for ritonavir-treated patients is 25 mg prior to sexual activity and the recommended maximum dose is 25 mg within a 48 hour period because concomitant administration increased the blood levels of sildenafil by 11-fold [see Warnings and Precautions (5.6), Drug Interactions (7.4), and Clinical Pharmacology (12.3)]. Use with caution in patients with the following underlying conditions which can be particularly sensitive to the actions of vasodilators including VIAGRA – those with left ventricular outflow obstruction (e.g., aortic stenosis, idiopathic hypertrophic subaortic stenosis) and those with severely impaired autonomic control of blood pressure.

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Clinical Interventions in Aging, 4, 463-472. Avanafil for treatment of erectile dysfunction: review of its potential. Vascular Health and Risk Management, 8, 517-523. Cross-Study Review of the Clinical Efficacy of Apomorphine SL 2 and 3 mg: Pooled Data from Three Placebo-Controlled, Fixed-Dose Crossover Studies. European Urology Supplements, 1(3), 12-20.

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Apomorphine: an update of clinical trial results. International Journal of Impotence Research, 12 Suppl 4, S67–S73. A single-centre result of two courses of low-intensity shockwave therapy (Li-SWT) in erectile dysfunction. Effect of oral administration of high-dose nitric oxide donor L-arginine in men with organic erectile dysfunction: results of a double-blind, randomized, placebo-controlled study. Treatment of erectile dysfunction with pycnogenol and L-arginine.

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Journal of Sex & Marital Therapy, 29(3), 207–213. Red ginseng for treating erectile dysfunction: a systematic review. British Journal of Clinical Pharmacology, 66(4), 444-450. The World Journal of Men's Health, 36(3), 183-191. Efficacy and safety of long-term tadalafil 5 mg once daily combined with sildenafil 50 mg as needed at the early stage of treatment for patients with erectile dysfunction. There are no controlled clinical data on the safety or efficacy of VIAGRA in the following groups; if prescribed, this should be done with caution.

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Penile Entrapment With Thick Penile Ring: A Case Report and Literature Review. Vacuum therapy in erectile dysfunction—Science and clinical evidence. International Journal of Impotence Research, 22(4), 211-219. The science of vacuum erectile device in penile rehabilitation after radical prostatectomy. Translational Andrology and Urology, 2(1), 61–66.

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The role of vacuum pump therapy to mechanically straighten the penis in Peyronie’s disease. Maca (L. meyenii) for improving sexual function: a systematic review. BMC Complementary and Alternative Medicine, 10, 44. Effect of Tongkat Ali on stress hormones and psychological mood state in moderately stressed subjects.

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Journal of the International Society of Sports Nutrition, 10(1), 28. An investigation into the stress-relieving and pharmacological actions of an ashwagandha (Withania somnifera) extract: A randomized, double-blind, placebo-controlled study. A Randomized, Double-Blind, Placebo-Controlled, Crossover Study Examining the Hormonal and Vitality Effects of Ashwagandha ( Withania somnifera) in Aging, Overweight Males. American Journal of Men's Health, 13(2), 1557988319835985. Effect of standardized root extract of ashwagandha (Withania somnifera) on well-being and sexual performance in adult males: A randomized controlled trial. Patients who have suffered a myocardial infarction, stroke, or life-threatening arrhythmia within the last 6 months; Patients with resting hypotension (BP <90/50 mmHg) or hypertension (BP >170/110 mmHg); Patients with cardiac failure or coronary artery disease causing unstable angina.

Prolonged erection greater than 4 hours and priapism (painful erections greater than 6 hours in duration) have been reported infrequently since market approval of VIAGRA.

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Subjective effects of Lepidium meyenii (Maca) extract on well-being and sexual performances in patients with mild erectile dysfunction: a randomised, double-blind clinical trial. Comprehensive Intersystemic Assessment Approach to Relieve Psychogenic Erectile Dysfunction: viagra sildenafil price A Review. Open Access Macedonian Journal of Medical Sciences, 9(F), 189–196. Erectogenic and neurotrophic effects of icariin, a purified extract of horny goat weed (Epimedium spp.) in vitro and in vivo. The Journal of Sexual Medicine, 7(4 Pt 1), 1518–1528.

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Oxytocin in the Treatment of Psychiatric Disorders. Efficacy and safety of fixed-dose oral sildenafil in the treatment of erectile dysfunction of various etiologies. Efficacy and safety of avanafil for treating erectile dysfunction: results of a multicentre, randomized, double-blind, placebo-controlled trial. VIAGRA- sildenafil citrate tablet, film coated Pfizer Laboratories Div Pfizer Inc For most patients, the recommended dose is 50 mg taken, as needed, approximately 1 hour before sexual activity. However, VIAGRA may be taken anywhere from 30 minutes to 4 hours before sexual activity. In the event of an erection that persists longer than 4 hours, the patient should seek immediate medical assistance.