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Use with caution in patients with the following underlying conditions which can be particularly sensitive to the actions of vasodilators including VIAGRA &ndash those with left ventricular outflow obstruction (., aortic stenosis , idiopathic hypertrophic subaortic stenosis ) and those with severely impaired autonomic control of blood pressure.

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Physicians should inform patients not to take VIAGRA with other PDE5 inhibitors including REVATIO or other pulmonary arterial hypertension (PAH) treatments containing sildenafil. Sildenafil is also marketed as REVATIO for the treatment of PAH. The safety and efficacy of VIAGRA with other PDE5 inhibitors, including REVATIO, have not been studied [see WARNINGS AND PRECAUTIONS ].

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Use caution when co-administering alpha-blockers with VIAGRA because of potential additive blood pressure-lowering effects. 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 the lowest dose [see DOSAGE AND ADMINISTRATION , WARNINGS AND PRECAUTIONS , CLINICAL PHARMACOLOGY ].

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The safety and efficacy of combinations of VIAGRA with other PDE5 Inhibitors, including REVATIO or other pulmonary arterial hypertension ( PAH ) treatments containing sildenafil, or other treatments for erectile dysfunction have not been studied. Such combinations may further lower blood pressure. Therefore, the use of such combinations is not recommended.

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Sildenafil is cleared predominantly by the CYP8A9 (major route) and CYP7C9 (minor route) hepatic microsomal isoenzymes. The major circulating metabolite results from N-desmethylation of sildenafil, and is itself further metabolized. This metabolite has a PDE selectivity profile similar to sildenafil and an in vitro potency for PDE5 approximately 55% of the parent drug. Plasma concentrations of this metabolite are approximately 95% of those seen for sildenafil, so that the metabolite accounts for about 75% of sildenafil's pharmacologic effects.

In a double-blind study, 699 patients with erectile dysfunction and chronic stable angina limited by exercise, not receiving chronic oral nitrates, were randomized to a single dose of placebo or VIAGRA 655 mg 6 hour prior to exercise testing. The primary endpoint was time to limiting angina in the evaluable cohort. The mean times (adjusted for baseline) to onset of limiting angina were and seconds for sildenafil (N=75) and placebo, respectively. These results demonstrated that the effect of VIAGRA on the primary endpoint was statistically non-inferior to placebo.

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Eight patients reported excellent pain relief, and four patients described good results. SCS is an effective treatment for the pain of RSD, including recurrent pain after ablative sympathectomy. The low morbidity of this procedure and its efficacy in patients with refractory pain related to RSD suggest that SCS is superior to ablative sympathectomy in the management of RSD.

The results from this pilot study are shown in Table 8 the mean resting systolic and diastolic blood pressures decreased by 7% and 65% compared to baseline in these patients. Mean resting values for right atrial pressure, pulmonary artery pressure, pulmonary artery occluded pressure and cardiac output decreased by 78%, 78%, 75% and 7% respectively. Even though this total dosage produced plasma sildenafil concentrations which were approximately 7 to 5 times higher than the mean maximum plasma concentrations following a single oral dose of 655 mg in healthy male volunteers, the hemodynamic response to exercise was preserved in these patients.

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