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From 24 to 48 hours after use of sildenafil, nitrate may be administered if no associated conditions increasing plasma concentration or delaying metabolism of sildenafil, such as age above 65 years, severe renal or hepatic failure, or simultaneous use of inhibitors of cytochrome P450 3A4, exist. In such instances, nitrates should only be used if conditions for the treatment of a possible severe hypotensive crisis exist. For the treatment of precordial pain no data about drug interactions are available contraindicating the use of sildenafil with aspirin, beta-blockers, calcium channel antagonists, or narcotics. Patients with acute myocardial

infarction

Unstable angina ? The same guidelines and warnings in relation to the use of nitrates and other medications commonly used in the treatment of this condition apply. Treatment of the hypotension resulting from the interaction of sildenafil with nitrates. The following measures should be employed in sequence: 1) place the patient in the Trendelenburg's position; 2) administer intravenous fluids rapidly; 3) use intravenous alpha-adrenergic agonists, such as phenylephrine, ethylephrine, or metaraminol; 4) if necessary, use an alpha or beta agonist, such as norepinephrine to support blood pressure, but one should be aware of the risk of worsening or inducing myocardial ischemia; 5) install auxiliary support through the intra-aortic balloon. The recommendations here expressed result from a still limited experience in regard to some of the multiple clinical situations of patients with cardiovascular disease, who intend to use sildenafil.

Therefore, the risk in face of these not yet tested situations is presumed based on what is known in regard to the pharmacokinetics and pharmacodynamics of the medication. This can be applied to situations such as heart failure, the first 6 months after an acute myocardial infarction or after a stroke, and uncontrolled hypertension, which are situations absent in the published studies.

In addition, some other pending questions should be remembered due to their importance and to a better comprehensiveness of this study: a) interaction with platelet antiaggregating agents other than aspirin; b) interaction with other phosphodiesterase inhibitors, including specific (milrinone, vesnarinone, enoximone) and nonspecific (theophylline, dipyridamole, papaverine, and pentoxifylline) inhibitors; c) effects of sildenafil on the central nervous system (PDE5 is present in the brain); d) the isolated hypotensive effect of sildenafil in high-risk patients with heart disease (severe heart failure); e) effect on skeletal muscles (thoracic muscle pains that may be mistaken for angina); f) simultaneous use of alcoholic beverages, especially with antihypertensive agents. Sildenafil has proved to be an effective and well-tolerated medication; these characteristics may be extended to patients with ischemic heart disease.

Therefore, the number of patients with cardiovascular disease willing to try the drug has been increasing. These patients, however, have two potential risks in relation to the use of sildenafil. The first is an indirect risk and relates to the ability to accomplish coitus, which is an activity associated with an increase in energy consumption and with varied degrees of psychological stress. The second is the risk of developing severe hypotension, which is directly linked to sildenafil-nitrate interaction.

In such circumstances, it is up to the cardiologist to decide and guide the patient in regard to the safe use of sildenafil. This study, based on the existing scientific data, on recommendations of a working group of the American College of Cardiology and of the American Heart Association, and on our initial experience, aims to provide to physicians in general and more specifically to cardiologists the necessary information so that sildenafil can be used as safely as possible in patients with cardiovascular disease.

Sociedade Brasileira de Urologia - I Consenso Brasileiro de Disfuncao Eretil.

Does severity of ischemic coronary diseasecorrelate with erectile dysfunction? Muller JE, Mittelman MA, Maclure M, Sherwood JB, Tofler GH. Triggering miocardial infarction by sexual activity - low absolute risck and prevention by regular physical exertion. Sexual activity triggering miocardial infarction - one less thing to worry about.

Oral sidenafil in the treatment of erectile dysfuncion.

Morales A, Gingell C Collins M, Wicker PA, Osterloh IH.

Clinical safety of oral citrate (VIAGRA) in the treatment of erectile dysfunction.

Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB.

Impotence and its medical and psychosocial correlates: results of the Massachusets male aging study.

Sildenafil: na orally active type 5 cyclic GMP-specific phosphodiesterase inhibtor for the treatment of erctile penile dysfunction.

Rajfer J, Aronson WJ, Bush PA, Dorey FJ, Ignarro LJ.

Nitric oxid as a mediator of relaxation of the corpus cavernosum in response to nondrenergic, noncholinergic neurotransmission.

Potencial roles of conserved amino acids in the catalic domain of the cGMP-binding cGMP-specific phosphodiesterase (PDE5). Use of sildenafil (Viagra) in patients with cardiovascular disease.

[ Links ] Forca-Tarefa para o Uso do Sildenafil e Doencas Cardiovasculares (Task Force for the Use of Sildenafil and Cardiovascular Diseases) Mailing Adress: Armenio Costa Guimaraes - Av.

Garibaldi, 1555 - 40210-070 - Salvador, BA - Brazil. All the contents of this journal, except where otherwise noted, is licensed under a Creative Commons Attribution License.

Marechal Camara, 160 - 3? Andar - Sala 330 20020-907, Centro, Rio de Janeiro, RJ - Brazil Tel.: +55 21 3478-2700 Fax: +55 21 3478-2770.

About sildenafil Key facts Who can and can't take sildenafil Where to get sildenafil How and when to take it Side effects Pregnancy and breastfeeding Cautions with other medicines Common questions.

Sildenafil is a medicine used to treat erectile dysfunction. It increases blood flow to the penis to help men get an erection.

At least two-thirds of men have improved erections after taking it.

Sildenafil is also sometimes used to treat pulmonary hypertension (high blood pressure in the blood vessels that supply the lungs). This medicine is available on prescription and can also be bought from most pharmacies.

It comes as tablets that you swallow, chewable tablets, and as a liquid that you drink. It usually takes 30 to 60 minutes for sildenafil to work for erectile dysfunction.

You can take it up to 4 hours before you want to have sex. Taking sildenafil alone will not cause an erection. The most common side effects are headaches, feeling sick, hot flushes and dizziness.

It can be dangerous to take sildenafil if you also take medicines called nitrates (often given for chest pain).

The combination can cause a dangerous fall in your blood pressure. If you're not sure if you're taking a nitrate, ask your doctor or pharmacist.

Sildenafil is called by the brand names Viagra (for erectile dysfunction) and Revatio (for pulmonary hypertension). Sildenafil for erectile dysfunction (Viagra) can be taken by men aged 18 and over.

Sildenafil for pulmonary hypertension (Revatio) can be taken by adults and children aged 1 and over.

Do not take sildenafil if you: have had an allergic reaction to sildenafil (Viagra) or any other medicines in the past are taking medicines called nitrates for chest pain have a serious heart or liver problem have recently had a stroke or a heart attack have low blood pressure have a rare inherited eye disease, such as retinitis pigmentosa. Check with your doctor before taking sildenafil if you: have sickle cell anaemia (an abnormality of red blood cells), leukaemia (cancer of blood cells) or multiple myeloma (cancer of bone marrow) have a deformity of your penis or Peyronie's disease (curved penis) have a heart problem.

Your doctor should carefully check whether your heart can take the additional strain of having sex.

have a stomach ulcer or a bleeding problem like haemophilia.

You can get sildenafil on the NHS if you have erectile dysfunction or pulmonary hypertension. Branded versions of sildenafil such as Viagra are not available on the NHS, except in special circumstances.

You can also get sildenafil on a private prescription from your doctor. This means you'll need to pay the full cost of the medicine. Prices vary, but on average 4 tablets costs around ?20.

You can buy sildenafil from a pharmacy following a discussion with the pharmacist. They'll ask you some questions about your general health to make sure sildenafil is safe for you to take. If the pharmacist has any concerns about whether sildenafil is safe for you, they may advise you to see your doctor.

Be very careful if you do this as many websites sell fake medicines. Online medicines are not always regulated and the ingredients in them can vary from one pack to another. They can cause unpleasant side effects or may not be suitable for you. It's best to see your doctor before buying medicines online.

They know your medical history and can discuss whether you might benefit from treatment. If you choose to buy sildenafil/Viagra over the internet, make sure: any online pharmacy is registered with the General Pharmaceutical Council (GPhC) any online doctor service is registered with the Care Quality Commission (CQC) all doctors are registered with the General Medical Council (GMC) 5.

It's important to take it as advised by your doctor or pharmacist. Sildenafil tablets for erectile dysfunction come in different strengths ranging from 25mg to 100mg. The usual dose is 50mg, when you need it (no more than once a day).

The dose can be increased to 100mg or decreased to 25mg depending on its effect. Take sildenafil up to 4 hours before you want to have sex.

For sildenafil to work properly, you'll need to be sexually excited.

Sildenafil tablets for pulmonary hypertension come in 10mg and 20mg

tablets

For erectile dysfunction, it's best to take sildenafil on an empty stomach. It may take longer to work if you take it with food.

If you or your child are taking sildenafil as a liquid, 1ml is usually the same as taking a 10mg tablet, but it's important to always check the medicine label.

Liquid sildenafil will usually be made up for you by your pharmacist.

The medicine will come with a plastic syringe or spoon to help you take the right amount.

If you do not have a plastic syringe or spoon, ask your pharmacist for one. Do not use a kitchen teaspoon as it will not give the right amount. If you have pulmonary hypertension and you forget to take a dose of sildenafil, take it as soon as you remember and then continue as usual.

Never take an extra dose to make up for a forgotten one. If you often forget doses, it may help to set an alarm to remind you. You could also ask your pharmacist for advice on other ways to help you remember to take your medicine.

Taking too much sildenafil by accident can cause unpleasant side effects, such as: headaches dizziness indigestion blocked nose altered vision. Talk to your doctor if you have taken too much sildenafil and you're worried about these side effects. Like all medicines, sildenafil can cause side effects in some people.

Many people have no side effects or only minor ones.

Common side effects happen in more than 1 in 100 people.

If you get these side effects, keep taking the medicine, but tell your doctor or pharmacist if these side effects bother you or do not go away: headaches feeling sick hot flushes, including facial flushing indigestion a colour

tinge

Serious side effects are rare and happen in less than 1 in 1,000 people.

Stop taking sildenafil and call a doctor straight away if you get : chest pains - if this happens during or after sex, get into a semi-sitting position and try to relax; do not use nitrates to treat your chest pain prolonged and sometimes painful erections - viagra tablet online order if you have an erection that lasts for more than 4 hours, contact a doctor immediately a sudden decrease or loss of vision a serious skin reaction - symptoms may include fever, severe peeling and swelling of the skin, blistering of the mouth, genitals and around the eyes seizures.

In rare cases, it's possible to have a serious allergic reaction (anaphylaxis) to sildenafil. Immediate action required: Call 999 or go to A&E if: you get a skin rash that may include itchy, red, swollen, blistered or peeling skin you're wheezing you get tightness in the chest or throat you have trouble breathing or talking your mouth, face, lips, tongue or throat start swelling.

You could be having a serious allergic reaction and may need viagra 25 mg tablet buy online immediate treatment in hospital. For a full list, see the leaflet inside your medicines packet.

You can report any suspected side effect to the UK safety scheme.

Sildenafil is not recommended in pregnancy and while breastfeeding.

Non-urgent advice: Tell your doctor if you're:

trying

Tell your doctor if you're taking these medicines before you start sildenafil : nitrates for chest pain riociguat for pulmonary hypertension recreational drugs called poppers, such as amyl nitrite.

Mixing sildenafil with herbal remedies and supplements. Some complementary therapies may have ingredients that could interfere with sildenafil and cause side effects. Tell your doctor or pharmacist if you're taking any other medicines, including herbal remedies, vitamins or supplements. Sildenafil belongs to a group of medicines called phosphodiesterase 5 (PDE5) inhibitors.

It works if you have erection problems by temporarily increasing blood flow to the penis when you get sexually excited.

It works in pulmonary hypertension by relaxing blood vessels in the chest. This increases the blood supply to the lungs and reduces the workload of the heart. In general, at least two-thirds of men say they have harder erections after taking it. If sildenafil does not work for you, it may be because: you have not waited long enough after taking it before trying to have sex you have waited too long after taking it to have sex the dose is not high enough you're not sexually aroused enough.

Sildenafil usually starts to work within 30 to 60 minutes.

It's triggered by sexual stimulation, so you need to be aroused for it to work. You should be able to get an erection at any time between 1 and 4 hours after taking sildenafil. Your erection should go away after you have had sex. If you're taking sildenafil for erectile dysfunction, do not take it more than once a day. If you're taking sildenafil (Revatio) for pulmonary hypertension, do not take it more than 3 times a day.

There do not seem to be any lasting harmful effects from taking it for many months and years. If sildenafil does not work, there are other tablets you could try that work in a similar way, such as: tadalafil (Cialis) - can be taken up to 36 hours before sex avanafil (Spedra) - can be taken up to around 4 hours before sex vardenafil (Levitra) - can be taken up to around 4 hours before sex.