Online Levitra

Buy Bayer Levitra & Generic Levitra At Low Prices Free consultation & fast shipping. Levitra (Vardenafil) information, the powerful Viagra/Cialis alternative. Works faster, lasts longer. Great prices & service. 4 for $69. 30 for $119. http://www.bigonlinepharmacy.com/levitra.html [today's views: 5] Levitra 20 Mg 8 Pills ?149 Save on your prescription medications. Visit our pharmacy for convenient and cost-effective way of buying drugs. We offer free prescription and delivery worldwide. http://www.europeanrxdrugs.com/levitra.htm [today's views: 4] Levitra Farm - We compare Levitra prices worldwide We compare companies worldwide to bring you the cheapest Levitra prices! http://www.lovepillstore.com [today's views: 2] The Best levitra Directory on the Web Looking for levitra? Webdirectory about levitra, and related topics. Only top levitra websites listed. Great comparisons, great deals http://www.giantexplorer.com [today's views: 2] All about levitra. Best levitra Directory Looking for levitra? We have sorted out the best websites about levitra available on the web! Find the best sites about levitra and levitra related topics at giantexplorer.com! http://www.giantexplorer.com [today's views: 1] Ultimate Source For Gen. Viagra 90/$139 Best Source online for ED Meds. Generic Viagra: 30/$99, 60/$119, 90/$139. Cialis: 30/$149, 60/$239, 90/$269. Levitra: 20/$79, 30/$119, 60/$199. WorldWide Discreet Shipping. http://edmeds.medextreme.com/ [today's views: 1] Selected and Reviewed levitra websites Check out the best levitra websites. Find a lot of information about levitra. The listed levitra websites all safe and secure. Top reviewed levitra websites http://www.giantexplorer.com [today's views: 1] BUY DISCOUNTED PRESCRIPTIONS NOW!!! Save up to 60% on prescription medications. Get Viagra, Cialis, Levitra, Tamiflu, Nexium, Zyrtec, Alegra and many more brand name medications at a fraction of the cost. http://www.consumersdiscountrx.com/hope4 [today's views: 1] Buy Levitra Online Save money on Levitra and other medications with these online pharmacies. http://www.the-info-planet.com [today's views: 1] Generic LEVITRA $119 for 30 tablets Generic Levitra $89 for 20 tablets or $199 for 60 tablets - FREE Shipping worldwide http://www.seypharma.com [today's views: 1] Generic LEVITRA $119 for 30 tablets Generic LEVITRA (Vardenafil) $113 for 30 pills or $199 for 60 pills - $256 for 90 pills. Worldwide delivery - FREE shipping http://www.generic-pharmacy.net [today's views: 1] levitra on The Best Broadband Site on the Internet Heavy.com is the best broadband site on the internet, offering the best free videos, music and so much more. Check it out! http://www.heavy.com [today's views: 1] Facts about levitra at Answers.com Get smart about levitra at Answers.com. We collect facts from name-brand reference titles for you, for free. http://www.answers.com [today's views: 1] Levitra Alternatives Compared Compare Levitra with popular non-prescription impotence treatments and save today. impotenceguide.info MedXLife - Buy Levitra Online Order Levitra for $11.80 per pill, USA based licensed pharmacy, overnight shipping available. www.medxlife.com Get Levitra Benefits for Less Discover how to get Levitra benefits for less. Learn more about Levitra, its side effects, cost and its all natural alternative, Stamina-Rx. www.levitrabenefits.com Levitra® Alternative Today Compare Levitra® to the other leading brands. Learn about Vipra® for men. www.vipra.us Levitra Discount Price $46.94 5mg x5 $46.94, x10 $93.94 FedEx free. Processing fee. U.S. licensed pharmacy. 24 hour phone support. scriptsatdiscount.com Compare Levitra and VigRX Read a comparison of Levitra and VigRX and decide which product is right for you. VigRX is safe and effective. Order now and get free shipping plus a free gift. www.penispill.org Buy Levitra Online and Save Buy Levitra and other popular medications through our secure order process. Free, discreet shipping. sell.bestwebmeds.com Levitra Sold at Cost - $46.94 5mg x5 $46.94. , x10 $93.94. Free overnight FedEx shipping plus a processing fee. Order from a US licensed pharmacy and get FDA-approved prescription medicines. atcostpharma.com Order Levitra Online and Save Save up to 85% on 3000 FDA approved meds, like Levitra, from trusted, licensed pharmacies. 100% legal, safe and secure. Order now. www.bestmedvalues.com Buy Levitra We can help you find lower prices on all of your prescriptions online. We are affiliated with many online pharmacies to bring you a large selection of prescriptions at lower prices. www.emedsaver.com Next 10 websites for levitra>> Where do I get cheap Levitra online? The comparison! ATTENTION! In order to optain Levitra you need a prescription and an online consultation, which is offered on the websites listed here! Please find detailed information on Levitra on the featured websites. Read carefully and order afterwards! We keep this website always up to date with all packages and prices available. If you come across other Levitra offering websites please send us an email and we will review and add the website as soon as possible to the database. Product description: Levitra is a prescription medication that helps arteries in the penis relax and widen during sexual stimulation. As a result, men who suffer from impotence find it easier to achieve erections. Levitra works similarly to the popular impotence drug Viagra. But unlike Viagra, Levitra stays in the body for up to 16 hours, which means a man can engage in multiple encounters with his partner without having to take another dose. How to use this product: Levitra is available in 10 mg and 20 mg tablets. Only your doctor can decide which dose is right for you. The normal prescribed dose for most men is one 10 mg tablet at least 25 to 60 minutes before engaging in sexual activity. Side effects: Most side effects are mild to moderate. They include headache, flushing, indigestion, nausea, dizziness, and blocked or runny nose. Less common side effects associated with Levitra include sensitivity of the eye to sunlight, high or low blood pressure, fainting, stiffness in muscles, effects on vision, and painful or spontaneous erections. In clinical studies these side effects were rare and occurred in less than 10% of patients. Precautions: You can take Levitra with or without food. However, taking Levitra with meals high in fat content may delay the reaction time. Also, DO NOT drink grapefruit juice when you use Levitra. It may interfere with the effects of the drug. Levitra might make some people feel dizzy or affect their vision. If you feel dizzy or if your vision is affected, DO NOT drive or perform potentially hazardous activities until your symptoms are gone. Before you take Levitra, tell your doctor if you have heart trouble, sick cell disease, multiple myeloma, leukaemia, stomach ulcers, bleeding disorder (such as haemophilia), and/or any physical condition that affects the shape of the penis. DO NOT take Levitra if you: Are allergic to vardenafil or any of the other ingredients in Levitra. Take nitrates for angina. Have severe heart or liver problems. Are receiving kidney dialysis treatments Have recently had a stroke or heart attack. Have low pressure. Have a history of degenerative eye diseases (such as retinitis pigmentosa) Drug interactions:Drugs that may interfere with Levitra include the following: Nitrates (medicines for angina) Retonavir or Indinavire (medicines for HIV) Ketoconazole or Itraconazole (anti-fungal medicines) Erythromycin (antibiotic) Alpha-blockers (blood pressure medications) Those who have had success with Viagra should achieve better results with Levitra. Evidence suggests that Levitra starts acting sooner that Viagra (within 20 minutes) and lasts longer (up to 20 hours)! In addition, according to a recent news release by Bayer/GSK, ninety percent (90%) of men reported improved erections. Levitra also appears to have fewer side effects. This means that use of Levitra will lead to a safer, more spontaneous sex life for people on this type of treatment. Click here for precautions and how to take this medication! No Medical Consultation Fees, Fast - Easy Online Ordering, Discreet Shipping! A Board Certified Physician will complete your prescription online for FREE! (No hidden costs!) Click Here for full information about your Free Online Medical Consultation. Levitra is an FDA approved medication and can be shipped internationally! (see below) HUGE SAVINGS! - Up to 35% for you ! "Yellow" = most popular or lowest price! -------------------------------------------------------------------------------- Generic Levitra contains the same exact chemical ingredient (20mg of Vardenafil) as Brand name Bayer Levitra! Works the same as Levitra at prices 70% lower than the brand name! SeyPharma - Lowest Prices Online for Levitra! FREE Shipping to US & All Countries ! Medical Fees Shipping Qty. Medication Price Euros $ per dose* FREE FREE 10 Tablets 20 mg. Levitra $59.00 ORDER € 47 $5.90 FREE FREE 20 Tablets 20 mg. Levitra $89.00 ORDER € 71 $4.45 ! FREE FREE 30 Tablets 20 mg. Levitra $119.00 ORDER € 95 $3.97 FREE FREE 60 Tablets 20 mg. Levitra $199.00 ORDER € 159 $3.32 ! Generic Pharmacy.net - Great Prices for Levitra! FREE Shipping to US & All Countries ! Medical Fees Shipping Qty. Medication Price Euros $ per dose* FREE FREE 30 Tablets 20 mg. Levitra $113.00 ORDER € 90 $3.77 ! FREE FREE 60 Tablets 20 mg. Levitra $199.00 ORDER € 159 $3.32 FREE FREE 90 Tablets 20 mg. Levitra $256.00 ORDER € 205 $2.84 ! Budget Medicines - Featuring Discount Pricing, Free Shipping & ED Sampler Packs! Fast, Reliable, Worldwide FREE Shipping to US, Europe & All Countries ! Medical Fees Shipping Qty. Medication Price Euros $ per dose* HARD SAMPLER PACK! - Can't decide? Try them all! 10 20mg Levitra, 10 20mg Cialis & 10 100mg Viagra all for 1 low price of $145 - FREE Shipping! Limited time only! Click Here! FREE FREE 10 Tablets 20 mg. Levitra $ 69.95 ORDER € 56 $6.99 FREE FREE 20 Tablets 20 mg. Levitra $125.00 ORDER € 96 $6.25 ! FREE FREE 30 Tablets 20 mg. Levitra $145.00 ORDER € 111 $4.83 ! FREE FREE 60 Tablets 20 mg. Levitra $229.00 ORDER € 175 $3.82 Generic4U - Great Prices & Superior Service for Generic Levitra! FREE International Shipping to Every Country included in listed price !!! Pharmacy Med. Fees Shipping 20 mg. Generic Levitra Euros $ per dose* ED MINI SAMPLER PACK! - Learn what works best for you! 10 100mg Viagra, 10 20mg Levitra & 10 20mg Cialis all for only $159 - Limited time only - Free Shipping! Click Here! Generic4U FREE FREE 30 Tablets $149.00 ORDER € 121 $4.97 Generic4U FREE FREE 50 Tablets $179.00 ORDER € 145 $3.58 ! Generic4U FREE FREE 66 Tablets $219.00 ORDER € 177 $3.32 ! Generic4U FREE FREE 100 Tablets $299.00 ORDER € 242 $2.99 Generic4U FREE FREE 150 Tablets $379.00 ORDER € 307 $2.53 -------------------------------------------------------------------------------- GENUINE BRAND NAME LEVITRA BrandPills - Great Prices for Genuine Brand Name Levitra! US, European & INTERNATIONAL Customers Welcome! FREE WORLDWIDE SHIPPING ! FREE CONSULTATION ! NO HIDDEN CHARGES ! Med. Fees Shipping 20 mg. Brand Name Levitra Euros $ per dose * FREE! FREE! 8 Pills $109.00 ORDER € 86 $13.63 FREE! FREE! 12 Pills $129.00 ORDER € 101 $10.75 FREE! FREE! 22 Pills $239.00 ORDER € 186 $10.86 FREE! FREE! 26 Pills $269.00 ORDER € 210 $10.35 FREE! FREE! 35 Pills $319.00 ORDER € 249 $9.11 Mini Pack! - Can't decide? Try all 3 Brand Name ED Meds! 4 100mg Viagra, 4 20mg Cialis & 4 20mg of Levitra all for 1 low price of $219 - Limited time only - Free Shipping! Click Here! Pharmacy Author: Omudhome Ogbru, Pharm.D. Medical Editor: Jay Marks, M.D. Generic Name: vardenafil Brand Name: Levitra Drug Class And Mechanism: Vardenafil is an oral drug that is used to treat impotence (the inability to attain or maintain a penile erection.). It is a phosphodiesterase inhibitor that is similar to sildenafil (Viagra). Penile erection is caused by the engorgement of the penis with blood. This engorgement occurs when the blood vessels delivering blood to the penis increase in size and increase the delivery of blood to the penis. At the same time, the blood vessels carrying blood away from the penis decrease in size and decrease the removal of blood from the penis. Sexual stimulation that leads to the engorgement and erection causes the production and release of nitric oxide in the penis. Nitric oxide then activates the enzyme, guanylate cyclase to produce cyclic guanosine monophosphate (cGMP). The cGMP is primarily responsible for increasing and decreasing the size of the blood vessels carrying blood to and from the penis, respectively. Vardenafil prevents an enzyme called phosphodiesterase-5 from destroying cGMP so that cGMP persists longer. The longer cGMP persists, the more prolonged the engorgement of the penis. Vardenafil was approved by the FDA in August, 2003. Prescription: Yes Generic Available: No Preparations: Tablets: 2.5, 5, 10 and 20 mg Storage: Vardenafil should be stored at room temperature between 15-30°C (59-86°F). Prescribed For: Vardenafil is used for the treatment of impotence. Dosing: For most individuals, the recommended dose of vardenafil is 10 mg per day taken 60 minutes before intercourse. If there is no response or side effects, the dose may be increased to 20 mg or, if there are side effects, it may be reduced to 5 mg. Individuals 65 years of age or older should begin therapy with 5 mg. Individuals who are taking medications that increase the blood levels of vardenafil should start treatment with 2.5 to 5 mg of vardenafil. (See drug interactions.) Drug Interactions: The breakdown and elimination of vardenafil from the body is inhibited by erythromycin, ketoconazole (Nizoral), itraconazole (Sporanox), indinavir (Crixivan) and ritonavir (Norvir). Therefore, these drugs increase the concentration of vardenafil in the blood. If these drugs are being used at the same time as vardenafil, the dose of vardenafil should be reduced in order to avoid side effects from vardenafil. Vardenafil reduces the concentration of ritonavir and indinavir and may reduce the effect these drugs. Related Links on MedicineNet.com Page 2 of this Article The Doctor's Response Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider. Statements and information regarding dietary supplements have not been evaluated or approved by the Food and Drug Administration. Please consult your healthcare provider before beginning any course of supplementation or treatment. Buy Levitra Today Low price guarantee on Levitra. A safe and licensed US pharmacy. www.drugstore.com/pharmacy ED Meds -Free FedEx ED Rx Meds - 20mg x5 $47, x30 $270 All orders processed. USA Pharmacy SafeUSmeds.com Wikipedia vardenafil Vardenafil Molecular weight 488.6 Bioavailability 15% Metabolism hepatic (CYP3A4) Elimination half-life 4-5 hours Excretion biliary Pregnancy category B3 Legal status Schedule 4 (Aust) Routes of administration oral Vardenafil (Levitra) is a PDE5 inhibitor used in the treatment of erectile dysfunction. It can assist men with this disorder in achieving and maintaining an erection during sexual activity. As a PDE5 inhibitor, vardenafil is closely related in both function and marketing to sildenafil and tadalafil; it has a relatively short effective time, comparable to sildenafil. History Vardenafil was co-marketed by Bayer Pharmaceuticals and GlaxoSmithKline (GSK) under the trade name Levitra. As of 2005, the co-promotion rights of GSK on Levitra have been "transferred back" to Bayer in many markets outside of the United States. In Italy, Bayer markets the product as Levitra and GSK markets the product as Vivanza. Due to European Union trade rules, Parallel Imports made result in the Vivanza branded packs being seen alongside Levitra packs in pharmacies in other EU member states. Clinical use Main article: PDE5 inhibitor Indications and contraindications are as for other PDE5 inhibitors. Adverse drug reactions More common adverse drug reactions (ADRs) are as per other PDE5 inhibitors and are listed on that page. Common vardenafil-specific ADRs include: nausea. Infrequent ADRs include: abdominal pain, back pain, photosensitivity, abnormal vision, eye pain, facial oedema, hypertension, palpitation, tachycardia, arthralgia, myalgia, rash, itch, priapism. (Rossi, 2004) Dose forms It is available in 2.5 mg, 5 mg, 10 mg, and 20 mg doses in round orange tablets. The normal starting dose is 10 mg (roughly equivalent to 50 mg of sildenafil). Vardenafil should be taken 25-60 minutes prior to sexual activity, with a maximum dose frequency of once per day. In some territories, such as the UK, only certain doses may be available, i.e. 5 mg, 10 mg, and 20 mg. Reference Rossi S (Ed.) (2004). Australian Medicines Handbook 2004. Adelaide: Australian Medicines Handbook. ISBN 0-9578521-4-2 See also PDE5 inhibitor Sildenafil (Viagra) Tadalafil (Cialis) External links Official Levitra website FDA's Consumer Information PubChem Information This entry is from Wikipedia, the leading user-contributed encyclopedia. It may not have been reviewed by professional editors (see full disclaimer) Donate to Wikimedia Buy Vardenafil Now Compare. Vardenafil 20mg 10 for $79 Free shipping for all orders. www.planetdrugsdirect.com ED Rx Meds Free Shipping Meds - 20mg x5 $47, x30 $270 All orders processed. 24/7 Support. DrugStoreScripts.com Mentioned In levitra is mentioned in these AnswerPages: Levitra (Shopping) Levitra Bayer Buy (Shopping) weekend pill cGMP specific phosphodiesterase type 5 Makin' a Livin' Fishin' (Album by J.S. "Largemouth" Weeden) Dapoxetine AOL TopSpeed Super Bowl XXXVIII Halftime Show List of drugs: Le Temozolomide Schering-Plough More> Buy ED Meds Online Secure order, low prices and fast, discreet shipping worldwide. www.bestwebmeds.com/ Erection Drug Blindness The blue pill may cause NAION. Get legal help if you are blind. class-action-lawsuits.com/blindness How To Get Free Rx Drugs How Can People Who Can't Afford Their Medicines Get Them? Read This www.FreeMedicineFoundation.com What is the most important information I should know about vardenafil? A small number of patients have lost eyesight in one eye after taking vardenafil. This type of vision loss is called non-arteritic anterior ischemic optic neuropathy (NAION). NAION causes a sudden loss of eyesight because blood flow is blocked to the optic nerve. It is not clear at this time if vardenafil causes NAION. NAION also happens in patients who do not take this medicine. People who have a higher chance for NAION include those who: have heart disease; are over 50 years old; have diabetes; have high blood pressure; have high cholesterol; smoke; or have certain eye problems. Stop using vardenafil if you have any loss in your eyesight and seek medical help right away. Do not take vardenafil if you are taking any of the following medicines: a nitrate such as nitroglycerin (Nitrostat, Nitrolingual, Nitro-Dur, Nitro-Bid, Minitran, Deponit, Transderm-Nitro, others), isosorbide dinitrate (Dilatrate-SR, Isordil, Sorbitrate), isosorbide mononitrate (Imdur, ISMO, Monoket), and others; a recreational drug such as amyl nitrate or nitrite ("poppers"); or an alpha blocker such as doxazosin (Cardura), guanadrel (Hylorel), prazosin (Minipress), terazosin (Hytrin), alfuzosin (Uroxatral), tamsulosin (Flomax), and others. Taking vardenafil with any of these medications may cause very low blood pressure, possibly resulting in dizziness, fainting, stroke, or heart attack Contact your doctor or seek emergency medical attention for any erection that lasts longer than 4 hours. A sustained erection can damage the penis. Refrain from further sexual activity and notify your doctor it you develop dizziness, nausea, or angina (pain, tightness, discomfort, numbness, or tingling in the chest, arms, neck, or jaw) during sexual activity. Do not take vardenafil more than once a day. In some cases, use of vardenafil may be restricted to once every 72 hours (3 days). Follow your doctor's instructions. (back to top) What is vardenafil? Vardenafil relaxes muscles within the penis. This allows increased blood flow into the penis which is necessary to achieve and maintain an erection. Vardenafil is used to treat erectile dysfunction (impotence). Vardenafil may also be used for purposes other than those listed in this medication guide. (back to top) What should I discuss with my healthcare provider before taking vardenafil? A small number of patients have lost eyesight in one eye after taking vardenafil. This type of vision loss is called non-arteritic anterior ischemic optic neuropathy (NAION). NAION causes a sudden loss of eyesight because blood flow is blocked to the optic nerve. It is not clear at this time if vardenafil causes NAION. NAION also happens in patients who do not take this medicine. People who have a higher chance for NAION include those who: have heart disease; are over 50 years old; have diabetes; have high blood pressure; have high cholesterol; smoke; or have certain eye problems. Stop using vardenafil if you have any loss in your eyesight and seek medical help right away. Do not take vardenafil if you are taking any of the following medicines: a nitrate such as nitroglycerin (Nitrostat, Nitrolingual, Nitro-Dur, Nitro-Bid, Minitran, Deponit, Transderm-Nitro, others), isosorbide dinitrate (Dilatrate-SR, Isordil, Sorbitrate), isosorbide mononitrate (Imdur, ISMO, Monoket), and others; a recreational drug such as amyl nitrate or nitrite ("poppers"); or an alpha blocker such as doxazosin (Cardura), guanadrel (Hylorel), prazosin (Minipress), terazosin (Hytrin), alfuzosin (Uroxatral), tamsulosin (Flomax), and others. Taking vardenafil with any of these medications may cause very low blood pressure, possibly resulting in dizziness, fainting, stroke, or heart attack Before taking vardenafil, tell your doctor if you currently have or have ever had a heart attack, stroke, irregular heartbeats, angina (chest pain), or congestive heart failure; have high or low blood pressure; have a personal or family history of a rare heart condition known as prolongation of the QT interval (long QT syndrome); have liver problems; have kidney problems; have ever had blood problems, including sickle cell anemia, multiple myeloma, or leukemia; have a bleeding or blood clotting disorder; have a stomach ulcer; a family history of degenerative eye disease (e.g., retinitis pigmentosa); or have a physical deformity of the penis such as Peyronie's disease. You may not be able to take vardenafil, or you may require a dosage adjustment or special monitoring during treatment if you have any of the conditions listed above. Although vardenafil is not indicated for use by women, it is in the FDA pregnancy category B. This means that vardenafil is not expected to be harmful to an unborn baby. Vardenafil should not be taken by women. It is not known whether vardenafil passes into breast milk. Vardenafil should not be taken by women. If you are over 65 years of age, you may be more likely to experience side effects from vardenafil. Your doctor may prescribe a lower dose of the medication. (back to top) How should I take vardenafil? Take vardenafil exactly as directed by your doctor. If you do not understand these directions, ask your pharmacist, nurse, or doctor to explain them to you. Take each dose with a full glass of water. Vardenafil can be taken with or without food. Vardenafil is usually taken when needed. Generally, it is taken about 1 hour before sexual activity. The medication can help achieve an erection when sexual stimulation occurs. An erection will not occur just by taking a pill. Follow your doctor's instructions. Vardenafil should not be taken with grapefruit or grapefruit juice. Vardenafil can interact with grapefruit and grapefruit juice, and the interaction may have dangerous effects. You should discuss the use of grapefruit and grapefruit juice with your doctor. Do not take vardenafil more than once a day. In some cases, use of vardenafil may be restricted to once every 72 hours (3 days). Follow your doctor's instructions. If you develop dizziness, nausea, or angina (pain, tightness, discomfort, numbness, or tingling in the chest, arms, neck, or jaw) during sexual activity, refrain from further sexual activity and notify your doctor. Contact your doctor or seek emergency medical attention for any erection that lasts longer than 4 hours. A sustained erection can damage the penis. Store this medication at room temperature away from moisture and heat. (back to top) What happens if I miss a dose? Vardenafil is used as needed, so you are not likely to miss a dose. (back to top) What happens if I overdose? Seek emergency medical attention if an overdose is suspected. Symptoms of a vardenafil overdose are not known, but are likely to include chest pain, back pain, dizziness, an irregular heartbeat, abnormal vision, and swelling of the ankles or legs. (back to top) What should I avoid while taking vardenafil? Do not take any other drug used to treat impotence, such as alprostadil (Caverject, Muse, Edex) or yohimbine (Yocon, Yodoxin, others), without first talking to your doctor. Vardenafil should not be taken with grapefruit or grapefruit juice. Vardenafil can interact with grapefruit and grapefruit juice, and the interaction may have dangerous effects. You should discuss the use of grapefruit and grapefruit juice with your doctor. (back to top) What are the possible side effects of vardenafil? If you experience any of the following serious side effects, stop taking vardenafil and seek emergency medical attention or contact your doctor immediately: an allergic reaction (difficulty breathing; closing of the throat; swelling of the lips, tongue, or face; or hives); chest pain or an irregular heartbeats; swelling of the ankles or legs; shortness of breath; prolonged or severe dizziness; fainting; a prolonged (lasting longer than 4 hours) or painful erection; dizziness, nausea, or angina (pain, tightness, discomfort, numbness, or tingling in the chest, arms, neck, or jaw); or back pain. Other, less serious side effects may be more likely to occur. Continue to take vardenafil and talk to your doctor if you experience flushing; mild dizziness; headache; nasal congestion; stomach upset; sensitivity of the eyes to light; or temporary blue tint in vision or other vision abnormalities. Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome. (back to top) What other drugs will affect vardenafil? Do not take vardenafil if you are taking any of the following medicines: a nitrate such as nitroglycerin (Nitrostat, Nitrolingual, Nitro-Dur, Nitro-Bid, Minitran, Deponit, Transderm-Nitro, others), isosorbide dinitrate (Dilatrate-SR, Isordil, Sorbitrate), isosorbide mononitrate (Imdur, ISMO, Monoket), and others; a recreational drug such as amyl nitrate or nitrite ("poppers"); or an alpha blocker such as doxazosin (Cardura), guanadrel (Hylorel), prazosin (Minipress), terazosin (Hytrin), alfuzosin (Uroxatral), tamsulosin (Flomax), and others. Taking vardenafil with any of these medications may cause very low blood pressure, possibly resulting in dizziness, fainting, stroke, or heart attack Before taking vardenafil, tell your doctor if you are taking any of the following medications: any other drug used to treat impotence, such as alprostadil (Caverject, Muse, Edex) or yohimbine (Yocon, Yodoxin, others); the antibiotic drug erythromycin (E-Mycin, Eryc, Ery-Tab, others); an antifungal medication such as itraconazole (Sporanox) or ketoconazole (Nizoral); a medication used to treat irregular heartbeats such as quinidine (Quinaglute, Quinidex, Quin-Release), procainamide (Procan SR, Procanbid, Pronestyl), amiodarone (Cordarone, Pacerone), or sotalol (Betapace, Sorine); or the HIV medications indinavir (Crixivan) or ritonavir (Norvir). You may not be able to take vardenafil, or you may require a dosage adjustment or special monitoring during treatment if you are taking any of the medicines listed above. Drugs other than those listed here may also interact with vardenafil or affect your condition. Talk to your doctor or pharmacist before taking any prescription or over-the-counter medicines, including vitamins, minerals, and herbal products. (back to top) Where can I get more information? Your pharmacist has additional information about vardenafil written for health professionals that you may read. (back to top) What does my medication look like? Vardenafil is available with a prescription under the brand name Levitra. Other brand or generic formulations may also be available. Ask your pharmacist any questions you have about this medication, especially if it is new to you. Levitra 2.5 mg-orange, round, film-coated tablets Levitra 5 mg-orange, round, film-coated tablets Levitra 10 mg-orange, round, film-coated tablets Levitra 20 mg-orange, round, film-coated tablets (back to top) Remember, keep this and all other medicines out of the reach of children, never share your medicines with others, and use this medication only for the indication prescribed. Every effort has been made to ensure that the information provided by Cerner Multum, Inc. ('Multum') is accurate, up-to-date, and complete, but no guarantee is made to that effect. Drug information contained herein may be time sensitive. Multum information has been compiled for use by healthcare practitioners and consumers in the United States and therefore Multum does not warrant that uses outside of the United States are appropriate, unless specifically indicated otherwise. Multum's drug information does not endorse drugs, diagnose patients or recommend therapy. Multum's drug information is an informational resource designed to assist licensed healthcare practitioners in caring for their patients and/or to serve consumers viewing this service as a supplement to, and not a substitute for, the expertise, skill, knowledge and judgment of healthcare practitioners. The absence of a warning for a given drug or drug combination in no way should be construed to indicate that the drug or drug combination is safe, effective or appropriate for any given patient. Multum does not assume any responsibility for any aspect of healthcare administered with the aid of information Multum provides. The information contained herein is not intended to cover all possible uses, directions, precautions, warnings, drug interactions, allergic reactions, or adverse effects. If you have questions about the drugs you are taking, check with your doctor, nurse or pharmacist. Levitra Levitra Prescription Levitra Brand Name Levitra Generic Levitra Names Vardenafil, Generic Levitra, Levitra Description Active Ingredient: vardenafil_HCl LEVITRA is an FDA-approved oral prescription medication for the treatment of erectile dysfunction (ED) in men. It is available in 2.5 mg, 5 mg, 10 mg, and 20 mg tablets and is taken only when needed. Take LEVITRA no more than once a day. What LEVITRA does LEVITRA helps increase blood flow to the penis and may help men with ED get and keep an erection satisfactory for sexual activity. Once a man has completed sexual activity, blood flow to his penis should decrease and his erection should go away. LEVITRA has been clinically shown to improve erectile function even in men who had other health factors, like diabetes or prostate surgery. LEVITRA provided first time success and reliable improvement of erection quality for many men. Men reported having harder erections and improved overall sexual experiences. Most Common Levitra Side Effects Headache, Runny or stuffy nose, flushing Levitra (Vardenafil HCI) helps increase blood flow to the penis and may help men with ED (Erectile Dysfunction) get and keep an erection satisfactory for sexual activity Levitra If you order Levitra at our site, you have a list of advantages against general online consumers that buy Levitra at other online resources. One of those advantages is that if you order Levitra at our online pharmacy you get sensible discounts on the same drug, offered by hundreds of different resources. Order Levitra at our online pharmacy. All our order pages are SSL secured so if you order Levitra at Canadian pharmacy you are protected by best technologies available nowadays. The other advantage while you order Levitra at our site is that all the transactions are absolutely secure. Relaxes Muscles Levitra can also be used for purposes other than those listed. This allows increased blood flow into the penis which is necessary to achieve and maintain an erection. Levitra is used to treat erectile dysfunction (impotence). Levitra relaxes muscles within the penis. All our products including Levitra are of the highest quality, we don't save on the rank of our meds- your health is the main objective for us. Our Levitra is cheap enough to be considered an affordable pill for general customer, still it's of the best quality. We strongly recommend to consult your doctor before starting Levitra therapy. Do not follow advices of unqualified advisors about Levitra tablet. Even for non-prescription drugs it's better to consult your medical-man before taking any kind of medicine, and Levitra is not an exception. Levitra tablet became really popular recently, thanks to its low price, loyal contamination and simple usage. All the information provided in this section about Levitra is intended for educational aim only; do not consider this information to be as valuable as your doctor's advice about Levitra therapy. Do not forget to consult your healer about potential Levitra precautions and Levitra medication interactions, this information could be really important for you. Levitra dosages and terms of usage can be corrected by your doctor. We deliver our Levitra worldwide, so wherever you are you can get your high-quality Levitra for low charge in short terms. It is important to be well informed about the medications you buy and use. Understanding what medications do, how best to use them, and how they could potentially interact with other medications are critical factors in being an informed consumer. All of the medications available at CliniCareRx are accompanied by a comprehensive drug facts page, access the drug facts to the left or below. Levitra is a medication for men only. Levitra is a medication that is available only with a prescription, but you can now get your prescription online with our streamlined ordering process. You can get your prescription easily online after completing the online medical form. The medical history form takes just minutes to complete, and it is used for protection when ordering Levitra online. No orders for Levitra can be processed without the online medical form being completed. What is Levitra? Levitra is used to promote an erection for men who have erectile dysfunction or problems keeping an erection. Levitra is one of the newest prescription medications available for the man?s sexual needs. If you are ready to order, you can click on the order button now, and you will be taken to the streamlined prescription writing forms. After you have completed the form and the online consultants have reviewed your answers (which only takes a few moments) your prescription will be written and you can order Levitra fast and discreetly. Save money by ordering Levitra online from your home or office, without having to be embarrassed! Levitra prescriptions are available when you have the time, day, or night, because we realize that your busy schedule does not enable you to reach our site during most regular business hours. We have the best prices on Levitra possible. Our online pharmacy strives to keep your prices on medications low. We can offer you these great prices on Levitra because our overhead is much lower than in the pharmacy store. You can place an order for Levitra, and your order will be on its way to you within just twenty four hours using express shipping so that you don?t have to wait long at all when you need a new prescription filled for Levitra. Check out our low prices on Levitra by clicking on the order button. LEVITRAO is an oral therapy for the treatment of erectile dysfunction. This monohydrochloride salt of vardenafil is a selective inhibitor of cyclic guanosine monophosphate (cGMP)-specific phosphodiesterase type 5 (PDE5). Vardenafil HCl is designated chemically as piperazine, 1-[[3-(1,4-dihydro-5-methyl-4-oxo-7-propylimidazo[5,1-f ][1,2,4]triazin-2-yl)-4-ethoxyphenyl]sulfonyl]-4-ethyl-, monohydrochloride and has the following structural formula: Vardenafil HCl is a nearly colorless, solid substance with a molecular weight of 579.1 g/mol and a solubility of 0.11 mg/mL in water. LEVITRA is formulated as orange, round, film-coated tablets with "BAYER" cross debossed on one side and "2.5", "5", "10", and "20" on the other side corresponding to 2.5 mg, 5 mg, 10 mg, and 20 mg of vardenafil, respectively. In addition to the active ingredient, vardenafil HCl, each tablet contains microcrystalline cellulose, crospovidone, colloidal silicon dioxide, magnesium stearate, hypromellose, polyethylene glycol, titanium dioxide, yellow ferric oxide, and red ferric oxide. FDA ALERT [07/2005]: A small number of men have lost eyesight in one eye some time after taking Levitra, Viagra, or Cialis. This type of vision loss is called non-arteritic anterior ischemic optic neuropathy (NAION). NAION causes a sudden loss of eyesight because blood flow is blocked to the optic nerve. We do not know at this time if Levitra, Viagra, or Cialis cause NAION. NAION also happens in men who do not take these medicines. People who have a higher chance for NAION include those who: have heart disease are over 50 years old have diabetes have high blood pressure have high cholesterol smoke have certain eye problems FDA has approved new labels for Levitra, Viagra, and Cialis to include information on possible eyesight loss (NAION). Stop using Levitra, Viagra, or Cialis if you have a loss in your eyesight. Get medical help right away. This information reflects FDA’s current analysis of data available to FDA concerning this drug. FDA intends to update this sheet when additional information or analyses become available. -------------------------------------------------------------------------------- What is Levitra? Levitra is a medicine taken by mouth for the treatment of erectile dysfunction (ED) in men. ED is a condition where the penis does not harden and expand when a man is sexually excited, or when he cannot keep an erection. Levitra may help a man with ED get and keep an erection when he is sexually excited. Levitra must be used only under a doctor's care. Levitra does not: cure ED increase a man’s sexual desire protect a man or his partner from sexually transmitted diseases, including HIV. Speak to your healthcare professional about ways to guard against sexually transmitted diseases. serve as a male form of birth control Levitra is only for men with ED. Levitra is not for women or children. Levitra must be used only under a healthcare professional’s care. Who Should Not Take Levitra? Do not take Levitra if you: take any medicines called “nitrates” use recreational drugs called "poppers" like amyl nitrate and butyl nitrate have been told by your healthcare professional not to have sexual activity because you have health problems What are The Risks? The following are the major possible risks and side effects of Levitra therapy. This list is not complete. Levitra can cause your blood pressure to drop suddenly to an unsafe level if it is taken with certain other medicines such as nitrates and alpha-blockers, and recreational drugs that contain nitrates called "poppers". A sudden drop in your blood pressure could cause you to become dizzy, faint, or have a heart attack or stroke. Tell all your healthcare professionals that you take Levitra. If you need emergency medical care for a heart problem, it will be important for your healthcare professionals to know when you last took Levitra. Levitra may uncommonly cause: an erection that won’t go away (priapism) vision changes, such as seeing a blue tinge to objects or having difficulty telling the difference between the colors blue and green Some common side effects with Levitra include: headache flushing stuffy or runny nose indigestion upset stomach dizziness What Should I Tell My Healthcare Professional? Tell your healthcare professional if you: have or had heart problems have low blood pressure or have high blood pressure that is not controlled have had a stroke or any family members have a rare heart condition known as prolongation of the QT interval (long QT syndrome) have liver problems have kidney problems and require dialysis have ever had severe vision loss have retinitis pigmentosa, a rare genetic (runs in families) eye disease have stomach ulcers have a bleeding problem have a deformed penis shape or Peyronie’s disease have had an erection that lasted more than 4 hours take any medicines called “alpha blockers” (alpha blockers are sometimes prescribed for prostate problems or high blood pressure) have blood cell problems, such as sickle cell anemia, multiple myeloma, or leukemia Can Other Medicines or Food Affect Levitra? Levitra and certain other medicines can interact with each other. Tell your healthcare professional about all the medicines you take including prescription and non-prescription medicines, vitamins, and herbal supplements. Know the medicines you take. Keep a list of them with you to show your healthcare professional. Levitra FDA Approved 2003 Patient Information Sheet Revised 07/2005 Levitra is a new impotence drug that treats male erectile dysfunction, ED. According to a recent news release by Bayer/GlaxoSmithKline, ninety percent (90%) of men reported improved erections. Each Levitra pill may work in as quickly as 25 minutes and may work for up to 24 hours. Levitra acts in the same way as Viagra, by blocking an enzyme called phosphodiesterase-5, or PDE-5. This helps the smooth muscles in the penis to relax, which effectively increases blood flow. Thus, allowing the penis to become and stay harder longer Your doctor will have suggested a suitable dose for you. Always take Levitra exactly as your doctor has instructed you, and check with the doctor if you are unsure. Tell the doctor if you think Levitra is too strong or too weak. He or she may suggest a different dose, depending on your condition. Take a Levitra tablet about 25 to 60 minutes before sexual activity. With sexual stimulation you may achieve an erection anywhere from 25 minutes up to four to five hours after taking Levitra. Swallow one tablet with a glass of water. You can take Levitra with or without food - but preferably not after a heavy or high-fat meal. Taking Levitra can cause side effects, although not everybody gets them. Most of the effects are mild or moderate. Very common side effects (These may affect 1 in 10 people or more) Headaches Flushing Common side effects (These may affect between 1 in 10 and 1 in 100 people) Indigestion Feeling sick (nausea) Dizziness Blocked or runny nose Uncommon side effects (These may affect less than 1 in 100 people) Sensitivity of the eye to sunlight High or low blood pressure Fainting Stiffness in muscles Effects on vision Erectile disturbances (such as spontaneous or painful erections) If any of these affects you badly, or doesn’t go away as you carry on taking Levitra, tell your doctor. If you notice any side effects not mentioned in this leaflet, please tell your doctor. Levitra (Vardenafil HCI) helps increase blood flow to the penis and may help men with ED (Erectile Dysfunction) get and keep an erection satisfactory for sexual activity. Levitra is a medication for men only. Levitra is a medication that is available only with a prescription, but you can now get your prescription online with our streamlined ordering process. You can get your prescription easily online after completing the online medical form. The medical history form takes just minutes to complete, and it is used for protection when ordering Levitra online. No orders for Levitra can be processed without the online medical form being completed. What is Levitra? Levitra is used to promote an erection for men who have erectile dysfunction or problems keeping an erection. Levitra is one of the newest prescription medications available for the man?s sexual needs. If you are ready to order, you can click on the order button now, and you will be taken to the streamlined prescription writing forms. After you have completed the form and the online consultants have reviewed your answers (which only takes a few moments) your prescription will be written and you can order Levitra fast and discreetly. Save money by ordering Levitra online from your home or office, without having to be embarrassed! Levitra prescriptions are available when you have the time, day, or night, because we realize that your busy schedule does not enable you to reach our site during most regular business hours. We have the best prices on Levitra possible. Our online pharmacy strives to keep your prices on medications low. We can offer you these great prices on Levitra because our overhead is much lower than in the pharmacy store. You can place an order for Levitra, and your order will be on its way to you within just twenty four hours using express shipping so that you don?t have to wait long at all when you need a new prescription filled for Levitra. Check out our low prices on Levitra by clicking on the order button

Naltrexone is an opioid receptor antagonist used primarily in the management of alcohol dependence and opioid dependence. It is marketed as its hydrochloride salt, naltrexone hydrochloride, under the trade name Revia. In some countries, an extended-release formulation is marketed under the trade name Vivitrol. Contents [hide] 1 Chemical Structure 2 Pharmacology 3 Rapid detoxification 4 Alcohol dependence 5 Safety 6 Low-dose naltrexone (LDN) 6.1 In multiple sclerosis 7 External links 8 References [edit] Chemical Structure Naltrexone can be described as a substituted oxymorphone – here the tertiary amine methyl-substituent is replaced with methylcyclopropane. [edit] Pharmacology Naltrexone, and its active metabolite 6-?-naltrexol, are competitive antagonists at ?- and ?-opioid receptors, and to a lesser extent at ?-opioid receptors. This blockade of opioid receptors is the basis behind its action in the management of opioid dependence—it reversibly blocks or attenuates the effects of opioids. Its use in alcohol (ethanol) dependence has been studied and has been shown to be effective. Its mechanism of action in this indication is not fully understood, but as an opioid-receptor antagonist is likely to be due to the modulation of the dopaminergic mesolimbic pathway which ethanol is believed to activate. [edit] Rapid detoxification Naltrexone is sometimes used for rapid detoxification ("rapid detox") regimens for opioid dependence. The principle of rapid detoxification is to induce opioid-receptor blockade while the patient is in a state of impaired consciousness so as to attenuate the withdrawal symptoms experienced by the patient. Rapid detoxification under general anaesthesia involves an unconscious patient and requires intubation and external ventilation. Rapid detoxification is also possible under sedation. The rapid detoxification procedure is followed by oral naltrexone daily for up to 12 months for opioid dependence management. There are a number of practitioners who will use a naltrexone implant placed in the lower abdomen, and more rarely, in the posterior to replace the oral naltrexone. This implant procedure has not been shown scientifically to be successful in "curing" the subject of their addiction, though it does provide a better solution than oral naltrexone for medication compliance reasons. Naltrexone implants are made by at least three companies (Wedgewood/Australian, ???[New Jersey]/USA, and Fidelity Capital/Russian), though none are FDA approved. There is currently scientific disagreement as to whether this procedure should be performed under local or general anesthesia, due to the rapid, and sometimes severe, withdrawal that occurs from the naltrexone displacing the opiates from the receptor sites. Rapid detoxification has been criticised by some for its questionable efficacy in long-term opioid dependence management. Rapid detoxification has often been misrepresented as a one-off "cure" for opioid dependence, when it is only intended as the initial step in an overall drug rehabilitation regimen. Rapid detoxification is effective for short-term opioid detoxification, but is approximately 10 times more expensive than conventional detoxification procedures. Aftercare can also be an issue, since at least one well-known center (check before you assume they will take you) in the United States reported that they will remove an implant from any patient arriving in their facility before admission. [edit] Alcohol dependence Depot injectable naltrexone (Vivitrol ®, formerly Vivitrex, but changed after a request by the FDA) was approved by the FDA on April 13, 2006 for the treatment of alcoholism. This version is made by Alkermes, and will be jointly marketed by Cephalon, Inc.. The preparation will be injected into the posterior and lasts for up to 30 days. Clinical trials for this medication were done with a focus on alcohol, presumably due to the larger number of alcoholics that it could be used to treat; however, Alkermes was asked to run a safety study for the off-label use of the injection for opiate addicts. This was found to be a successful use of the medication in patients who were single drug abusers, though multi-drug abusers would generally decrease their opiate use and increase their use of other drugs (i.e. cocaine) while on the injection. Other studies (Schmitz et al., 2001), however, provide evidence that naltrexone with the right protocol can be effective in treating cocaine addiction. [edit] Safety There has been some controversy regarding the use of opioid-receptor antagonists, such as naltrexone, in the long-term management of opioid dependence due to the effect of these agents in sensitising the opioid receptors. That is, after therapy, the opioid receptors continue to have increased sensitivity for a period during which the patient is at increased risk of opioid overdose. This effect reinforces the necessity of monitoring of therapy and provision of patient support measures by medical practitioners. [edit] Low-dose naltrexone (LDN) Low Dose Naltrexone (LDN), where the drug is used in doses approximately one-tenth those used for drug/alcohol rehabilitation purposes, is being used by some as an "off-label" experimental treatment for certain immunologically-related disorders. Evidence of safety and efficacy are currently lacking, with no published data from randomised controlled trials in humans. The use of LDN for such diseases as cancer was discovered and developed by Ian Zagon and championed by Bernard Bihari. There is some in vitro data that indirectly suggest the potential benefits of LDN therapy. Anecdotal accounts and case reports have also been cited in favour of LDN therapy. Some of the conditions where LDN has been reported as beneficial include multiple sclerosis, Crohn's disease, HIV/AIDS, chronic fatigue syndrome, fibromyalgia, AD in children (Elchaar GM, et al. 2006) and cancer. Several clinical trials have been planned. [edit] In multiple sclerosis Specifically in multiple sclerosis, LDN has been theorized to work in multiple modalities. Without formal studies, there is no formal conclusion as of yet, but the generally accepted theory posited originally by Dr. Bihari is as follows. Dr. Bihari generally observed that multiple sclerosis patients have lower levels of beta-endorphins than healthy controls. Beta-endorphins, in turn, are important regulators of the immune system. The Low Dose Naltrexone dose causes an artificial blockade of the endorphin receptors in the brain. The normal dose of Naltrexone for addiction (~50mg) maintains this blockade continuously, preventing any derived pleasure from taking the forbidden drugs, but the Low Dose of Naltrexone (~3 - 6mgs) is only effective for a short duration. During that time, the body cannot get endorphins to attach to the receptors and apparently overcompensates by creating more. Once the Low Dose Naltrexone dose has been metabolized, the body is left with a "normal" amount of endorphins as compared to healthy controls, which consequently normalizes the immune function. [1] naltrexone Drug information Generic Name: naltrexone (injection) (nal TREX own) Brand Names: Vivitrol What is the most important information I should know about naltrexone injection? • Do not use narcotic drugs or alcohol while you are being treated with naltrexone injection. Never try to overcome the effects of the medication by using large doses of narcotic drugs or alcohol. Doing so could result in dangerous effects, including coma and death. Ask your doctor before using any prescription or over-the-counter medicine to treat a cold, cough, diarrhea, or pain during your treatment with naltrexone injection. These medicines may contain narcotics or alcohol. • Naltrexone injection can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert. • Carry an ID card or wear a medical alert bracelet stating that you are being treated with naltrexone, in case of emergency. Any doctor, dentist, or emergency medical care provider who treats you should know that you are receiving this medication. • Additional forms of counseling and/ or monitoring may be recommended during treatment with naltrexone injection. What is naltrexone injection? • Naltrexone injection is an special narcotic drug that blocks the effects of other narcotic medicines and alcohol. • Naltrexone injection is used to treat narcotic drug or alcohol addiction.. • Naltrexone injection may also be used for purposes other than those listed in this medication guide. What should I discuss with my health care provider before receiving naltrexone injection? • Do not receive naltrexone injection if you have: · an addiction to narcotics; · a history of alcohol or narcotic drug use within the past 7-10 days; or · drug or alcohol withdrawal symptoms. • Before receiving naltrexone, talk to your doctor if you have: · kidney disease; · liver disease; or · a bleeding disorder such as hemophilia (if you are using naltrexone injection injection). • If you have any of these conditions, you may not be able to receive naltrexone injection or you may need a dosage adjustment or special tests during treatment. • FDA pregnancy category C. This medication may be harmful to an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant during treatment. • It is not known whether naltrexone injection passes into breast milk or if it could harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby. How is naltrexone injection used? • Naltrexone injection injection (Vivitrol) is given as a shot into a muscle. This injection is usually given once a month (every 4 weeks) and can be given only by a doctor or nurse in a clinic. • It is important to receive your naltrexone injections regularly to get the most benefit. • Carry an ID card or wear a medical alert bracelet stating that you are being treated with naltrexone, in case of emergency. Any doctor, dentist, or emergency medical care provider who treats you should know that you are receiving this medication. • Additional forms of counseling and/ or monitoring may be recommended during treatment with naltrexone injection. What happens if I miss a dose? • If you miss an appointment to have your naltrexone injection, make another appointment as soon as possible. What happens if I overdose? • Seek emergency medical attention if you think you have received too much of this medicine. • Symptoms of a naltrexone injection overdose may include nausea, stomach pain, dizziness, or seizure (convulsions). What should I avoid while using naltrexone injection? • Naltrexone injection can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert. • Do not use narcotic drugs or alcohol while receiving naltrexone injection. Never try to overcome the effects of the medication by using large doses of narcotic drugs or alcohol. Doing so could result in dangerous effects, including coma and death. Ask your doctor before using any prescription or over-the-counter medicine to treat a cold, cough, diarrhea, or pain while you are being treated with naltrexone injection. These medicines may contain narcotics or alcohol. What are the possible side effects of naltrexone injection? • Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. • Call your doctor at once if you have any of these serious side effects: · blurred vision or eye problems; · fast heartbeat; · mood changes, hallucinations (seeing or hearing things), confusion, thoughts of hurting yourself; · nausea, stomach pain, low fever, loss of appetite, dark urine, clay-colored stools, jaundice (yellowing of the skin or eyes); · ear pain, ringing in your ears; · skin rash or itching; or · wheezing, difficulty breathing. • Other less serious side effects are more likely to occur, such as: · feeling anxious, nervous, restless, or irritable; · feeling light-headed, fainting; · increased thirst; · muscle or joint aches; · weakness or tiredness; · sleep problems (insomnia); · decreased sex drive, impotence, or difficulty having an orgasm; or · pain, tenderness, itching, or a hard lump where the naltrexone injection is given. • Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome. What other drugs will affect naltrexone injection? • The pain-relieving effects of any narcotic pain medications you use will be blocked if you use them during your treatment with naltrexone injection. Harmful side effects could also occur. • Before receiving naltrexone injection, tell your doctor if you use any of the following drugs: · buprenorphine (Buprenex, Subutex); · butorphanol (Stadol); · codeine (Tylenol with codeine); · hydrocodone (Lortab, Vicodin); · dezocine (Dalgan); · hydromorphone (Dilaudid); · levorphanol (Levo-Dromoran); · meperidine (Demerol); · methadone (Dolophine, Methadose); · morphine (Kadian, MS Contin, Roxanol); · nalbuphine (Nubain); · nalmefene (Revex); · naloxone (Narcan); · oxycodone (OxyContin, Roxicodone, Percocet); · oxymorphone (Numorphan); or · propoxyphene (Darvon, Darvocet). • There may be other drugs not listed that can affect naltrexone injection. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor. Where can I get more information? • Your doctor has additional information about naltrexone injection written for health professionals that you may read. • Every effort has been made to ensure that the information provided by Cerner Multum, Inc. ('Multum') is accurate, up-to-date, and complete, but no guarantee is made to that effect. Drug information contained herein may be time sensitive. Multum information has been compiled for use by healthcare practitioners and consumers in the United States and therefore Multum does not warrant that uses outside of the United States are appropriate, unless specifically indicated otherwise. Multum's drug information does not endorse drugs, diagnose patients or recommend therapy. Multum's drug information is an informational resource designed to assist licensed healthcare practitioners in caring for their patients and/ or to serve consumers viewing this service as a supplement to, and not a substitute for, the expertise, skill, knowledge and judgment of healthcare practitioners. The absence of a warning for a given drug or drug combination in no way should be construed to indicate that the drug or drug combination is safe, effective or appropriate for any given patient. Multum does not assume any responsibility for any aspect of healthcare administered with the aid of information Multum provides. The information contained herein is not intended to cover all possible uses, directions, precautions, warnings, drug interactions, allergic reactions, or adverse effects. If you have questions about the drugs you are taking, check with your doctor, nurse or pharmacist. Naltrexone is a medication that blocks the effects of drugs known as opioids (a class that includes morphine, heroin or codeine). It competes with these drugs for opioid receptors in the brain. It was originally used to treat dependence on opioid drugs but has recently been approved by the FDA as treatment for alcoholism. In clinical trials evaluating the effectiveness of naltrexone, patients who received naltrexone were twice as successful in remaining abstinent and in avoiding relapse as patients who received placebo-an inactive pill. 2. Why does naltrexone help for alcoholism? While the precise mechanism of action for naltrexone's effect is unknown, reports from successfully treated patients suggest three kinds of effects. First, naltrexone can reduce craving, which is the urge or desire to drink. Second, naltrexone helps patients remain abstinent. Third, naltrexone can interfere with the tendency to want to drink more if a recovering patient slips and has a drink. 3. Does this mean that naltrexone will "sober me up" if I drink? No, naltrexone does not reduce the effects of alcohol that impair coordination and judgement. 4. If I take naltrexone, does it mean that I don't need other treatment for alcoholism? No, naltrexone is only one component of a program of treatment for alcoholism including counseling, help with associated psychological and social problems and participation in self-help groups. In both studies where naltrexone was shown to be effective, it was combined with treatment from professional psychotherapists. 5. How long does naltrexone take to work? Naltrexone's effects on blocking opioids occurs shortly after taking the first dose. Findings to date suggest that the effects of naltrexone in helping patients remain abstinent and avoid relapse to alcohol use also occur early. 6. Are there some people who should not take naltrexone? Naltrexone should not be used with pregnant women, individuals with severe liver or kidney damage or with patients who cannot achieve abstinence for at least 5 days prior to initiating medications. Also, people who are dependent on opioid drugs, like heroin or morphine must stop their drug use at least 7 days prior to starting naltrexone. 7. What does it feel like to be on naltrexone? Aside from side effects, which are usually short-lived and mild, patients usually report that they are largely unaware of being on medications. Naltrexone usually has no psychological effects and patients don't feel either "high" or "down" while they are on naltrexone. It is not addicting. While it does seem to reduce alcohol craving, it does not interfere with the experience of other types of pleasure. 8. What are the side effects of naltrexone? In the largest study, the most common side effect of naltrexone affected only a small minority of people and included the following: nausea (10%), headache (7%), dizziness (4%), fatigue (4%), insomnia (3%), anxiety (2%), and sleepiness (2%). These side effects were usually mild and of short duration. As treatment for alcoholism, naltrexone side effects, predominantly nausea, have been se vere enough to discontinue the medication in 5-10% of the patients starting it. For most other patients side effects are mild or of brief duration. One serious possibility is that naltrexone can have toxic effects on the liver. Blood tests of liver function are performed prior to the onset of treatment and periodically during treatment to determine whether naltrexone should be started and whether it should be discontinued if the relatively rare side effect of liver toxicity is taking place. 9. Do I need to get blood tests while I'm on naltrexone? How often? To ensure that naltrexone treatment is safe, blood tests should be obtained prior to initial treatment. Following that, retesting generally occurs at monthly intervals for the first three months, with less frequent testing after that point. More frequent testing may be requested depending on the health of your liver prior to beginning treatment. Blood tests are needed to make sure that liver function is adequate prior to taking naltrexone and to evaluate whether naltrexone is having adverse effects on the liver. 10. Can I take other medications with naltrexone? The major active effect of naltrexone is on opioid drugs, which is one class of drugs used primarily to treat pain but is also found in some prescription cough preparations. Naltrexone will block the effect of normal doses of this type of drug. There are many non-narcotic pain relievers that can be used effectively while you are on naltrexone. Otherwise, naltrexone is likely to have little impact on other medications patients commonly use such as antibiotics, non-opioid analgesics (e.g., aspirin, acetaminophen, ibuprofen), and allergy medications. You should inform your physician of whatever medication you are currently taking so that possible interactions can be evaluated. Because naltrexone is broken down by the liver, other medications that can affect liver function may affect the dose of naltrexone. 11. Will I get sick If I drink while on naltrexone? No. Naltrexone may reduce the feeling of intoxication and the desire to drink more, but it will not cause a severe physical response to drinking. 12. Will I get sick If I stop naltrexone suddenly? Naltrexone does not cause physical dependence and it can be stopped at any time without withdrawal symptoms. In addition, available findings regarding cessation do not show a "rebound" effect to resume alcohol use when naltrexone is discontinued. 13. What should I do If I need an operation or pain medication? You should carry a card explaining that you are on naltrexone and that also instructs physicians on pain management. Many pain medications that are not opioids are available for use. If you are going to have elective surgery, naltrexone should be discontinued at least 72 hours beforehand. 14. What Is the relationship of naltrexone to AA? There is no contradiction between participation in AA and taking naltrexone. Naltrexone is not addictive and does not produce any "high" or pleasant effects. It can contribute to achievement of an abstinence goal by reducing the craving or compulsion to drink, particularly during early phases of recovery. It is most likely to be effective when the patient's goal is to stop drinking altogether. 15. How long should I stay on naltrexone? If naltrexone is tolerated and the patient is successful in reducing or stopping drinking, the recommended initial course of treatment is 3 months. At that time the patient and clinical staff should evaluate the need for further treatment on the basis of degree of improvement, degree of continued concerns about relapse and level of improvement in areas of functioning other than alcohol use. FDA-approved naltrexone, in a low dose, can boost the immune system — helping those with HIV/AIDS, cancer, autoimmune diseases, and central nervous system disorders. In May 2006, clinical trial researchers at Pennsylvania State University College of Medicine reported: "LDN therapy offers an alternative safe, effective, and economic means of treating subjects with active Crohn's disease." What is low-dose naltrexone and why is it important? > Low-dose naltrexone holds great promise for the millions of people worldwide with autoimmune diseases or central nervous system disorders or who face a deadly cancer. > In the developing world, LDN could provide the first low-cost, easy to administer, and side-effect-free therapy for HIV/AIDS. Naltrexone itself was approved by the FDA in 1984 in a 50mg dose for the purpose of helping heroin or opium addicts, by blocking the effect of such drugs. By blocking opioid receptors, naltrexone also blocks the reception of the opioid hormones that our brain and adrenal glands produce: beta-endorphin and metenkephalin. Many body tissues have receptors for these endorphins and enkephalins, including virtually every cell of the body's immune system. In 1985, Bernard Bihari, MD, a physician with a clinical practice in New York City, discovered the effects of a much smaller dose of naltrexone (approximately 3mg once a day) on the body's immune system. He found that this low dose, taken at bedtime, was able to enhance a patient's response to infection by HIV, the virus that causes AIDS. [Note: Subsequently, the optimal adult dosage of LDN has been found to be 4.5mg.] In the mid-1990's, Dr. Bihari found that patients in his practice with cancer (such as lymphoma or pancreatic cancer) could benefit, in some cases dramatically, from LDN. In addition, people who had an autoimmune disease (such as lupus) often showed prompt control of disease activity while taking LDN. -------------------------------------------------------------------------------- How does LDN work? > LDN boosts the immune system, activating the body's own natural defenses. Up to the present time, the question of "What controls the immune system?" has not been present in the curricula of medical colleges and the issue has not formed a part of the received wisdom of practicing physicians. Nonetheless, a body of research over the past two decades has pointed repeatedly to one's own endorphin secretions (our internal opioids) as playing the central role in the beneficial orchestration of the immune system, and recognition of the facts is growing. Witness these statements from a review article of medical progress in the November 13, 2003 issue of the prestigious New England Journal of Medicine: "Opioid-Induced Immune Modulation: .... Preclinical evidence indicates overwhelmingly that opioids alter the development, differentiation, and function of immune cells, and that both innate and adaptive systems are affected.1,2 Bone marrow progenitor cells, macrophages, natural killer cells, immature thymocytes and T cells, and B cells are all involved. The relatively recent identification of opioid-related receptors on immune cells makes it even more likely that opioids have direct effects on the immune system.3" The brief blockade of opioid receptors between 2 a.m. and 4 a.m. that is caused by taking LDN at bedtime each night is believed to produce a prolonged up-regulation of vital elements of the immune system by causing an increase in endorphin and enkephalin production. Normal volunteers who have taken LDN in this fashion have been found to have much higher levels of beta-endorphins circulating in their blood in the following days. Animal research by I. Zagon, PhD, and his colleagues has shown a marked increase in metenkephalin levels as well. [Note: Additional information for Dr. Zagon can be found at the end of this page.] Bihari says that his patients with HIV/AIDS who regularly took LDN before the availability of HAART were generally spared any deterioration of their important helper T cells (CD4+). In human cancer, research by Zagon over many years has demonstrated inhibition of a number of different human tumors in laboratory studies by using endorphins and low dose naltrexone. It is suggested that the increased endorphin and enkephalin levels, induced by LDN, work directly on the tumors' opioid receptors — and, perhaps, induce cancer cell death (apoptosis). In addition, it is believed that they act to increase natural killer cells and other healthy immune defenses against cancer. In general, in people with diseases that are partially or largely triggered by a deficiency of endorphins (including cancer and autoimmune diseases), or are accelerated by a deficiency of endorphins (such as HIV/AIDS), restoration of the body's normal production of endorphins is the major therapeutic action of LDN. Naltrexone is a prescription drug, so your physician would have to give you a prescription after deciding that LDN appears appropriate for you. Naltrexone in the large 50mg size, originally manufactured by DuPont under the brand name ReVia, is now sold by Mallinckrodt as Depade and by Barr Laboratories under the generic name naltrexone. LDN prescriptions are now being filled by hundreds of local pharmacies, as well as by some mail-order pharmacies, around the US. Some pharmacists have been grinding up the 50mg tablets of naltrexone to prepare the 4.5mg capsules of LDN; others use naltrexone, purchased as a pure powder, from a primary manufacturer. One of the first pharmacies to do so was Irmat Pharmacy in Manhattan. Their recent price for a one-month's supply of 4.5mg LDN (30 capsules) was $38. Irmat does monthly quality control testing on its LDN, accepts prescriptions from any licensed physician, checks for insurance coverage, and includes shipment anywhere in the US or to other countries. In contrast, Gideon’s Drugs charges $15 for a one month’s supply of 4.5mg LDN but it does not accept insurance and it will charge for shipment. > Pharmacies that are known to be reliable compounders of LDN: Pharmacy Phone Fax Irmat Pharmacy, New York, NY (212) 685-0500 (800) 975-2809 (212) 532-6596 Gideon's Drugs, New York, NY (212) 575-6868 (212) 575-6334 The Compounder Pharmacy, Aurora, IL (630) 859-0333 (800) 679-4667 (630) 859-0114 The Medicine Shoppe, Canandaigua, NY (585) 396-9970 (800) 396-9970 (585) 396-7264 Skip's Pharmacy, Boca Raton, FL (561) 218-0111 (800) 553-7429 (561) 218-8873 Smith's Pharmacy, Toronto, Canada (416) 488-2600 (800) 361-6624 (416) 484-8855 > IMPORTANT: Make sure to specify that you do NOT want LDN in a slow-release form. Reports have been received from patients that their pharmacies have been supplying a slow-release form of naltrexone. Pharmacies should be instructed NOT to provide LDN in an "SR" or slow-release or timed-release form. Unless the low dose of naltrexone is in an unaltered form, which permits it to reach a prompt "spike" in the blood stream, its therapeutic effects may be inhibited. Fillers. Capsules of LDN necessarily contain a substantial percentage of neutral inactive filler. Experiments by the compounding pharmacist, Dr. Skip Lenz, have demonstrated that the use of calcium carbonate as a filler will interfere with absorption of the LDN capsule. Therefore, it is suggested that calcium carbonate filler not be employed in compounding LDN capsules. He recommends either Avicel, lactose (if lactose intolerance is not a problem), or sucrose fillers as useful fast-release fillers. > IMPORTANT: Make sure to fill your Rx at a compounding pharmacy that has a reputation for consistent reliability in the quality of the LDN it delivers. The FDA has found a significant error rate in compounded prescriptions produced at randomly selected pharmacies. Dr. Bihari has reported seeing adverse effects from this problem. Please see our report, Reliability Problem With Compounding Pharmacies. Please see the above list of recommended pharmacies for some suggested sources. -------------------------------------------------------------------------------- What dosage and frequency should my physician prescribe? The usual adult dosage is 4.5mg taken once daily at night. Because of the rhythms of the body's production of master hormones, LDN is best taken between 9pm and 3am. Most patients take it at bedtime. People who have multiple sclerosis that has led to muscle spasms are advised to use only 3mg daily and to maintain that dosage. Rarely, the naltrexone may need to be purchased as a solution — in distilled water — with 1mg per ml dispensed with a 5ml medicine dropper. If LDN is used in a liquid form, it is important to keep it refrigerated. The therapeutic dosage range for LDN is from 1.75mg to 4.5mg every night. Dosages below this range are likely to have no effect at all, and dosages above this range are likely to block endorphins for too long a period of time and interfere with its effectiveness. > IMPORTANT: Make sure to specify that you do NOT want LDN in a slow-release form (see above). -------------------------------------------------------------------------------- Are there any side effects or cautionary warnings? > Side effects: LDN has virtually no side effects. Occasionally, during the first week's use of LDN, patients may complain of some difficulty sleeping. This rarely persists after the first week. Should it do so, dosage can be reduced from 4.5mg to 3mg nightly. > Cautionary warnings: Because LDN blocks opioid receptors throughout the body for three or four hours, people using medicine that is an opioid agonist, i.e. narcotic medication — such as Ultram (tramadol), morphine, Percocet, Duragesic patch or codeine-containing medication — should not take LDN until such medicine is completely out of one's system. Patients who have become dependant on daily use of narcotic-containing pain medication may require 10 days to 2 weeks of slowly weaning off of such drugs entirely (while first substituting full doses of non-narcotic pain medications) before being able to begin LDN safely. LDN should probably not be taken during pregnancy until research into that question is completed. Full-dose naltrexone (50mg) carries a cautionary warning against its use in those with liver disease. This warning was placed because of adverse liver effects that were found in experiments involving 300mg daily. The 50mg dose does not apparently produce impairment of liver function nor, of course, do the much smaller 3mg and 4.5mg doses. People who have received organ transplants and who therefore are taking immunosuppressive medication on a permanent basis are cautioned against the use of LDN because it may act to counter the effect of those medications. -------------------------------------------------------------------------------- When will the low-dose use of naltrexone become FDA approved? > Although naltrexone itself is an FDA-approved drug, the varied uses of LDN still await application to the FDA after related scientific clinical trials. The FDA approved naltrexone at the 50mg dosage in 1984. LDN (in the 3mg or 4.5mg dosage) has not yet been submitted for approval because the prospective clinical trials that are required for FDA approval need to be funded at the cost of many millions of dollars. The successful results of the first US medical center research on LDN, an open-label trial that tested the use of LDN in Crohn’s disease (details here), was presented in May 2006 by Professor Jill Smith of the Pennsylvania State University College of Medicine. The National Institutes of Health has granted $500,000 for Dr. Smith's group to continue the study as a larger placebo-controlled scientific trial of LDN in Crohn's disease. All physicians understand that appropriate off-label use of an already FDA-approved medication such as naltrexone is perfectly ethical and legal. Because naltrexone itself has already passed animal toxicity studies, one could expect that once testing is able to begin, LDN could complete its clinical trials in humans and receive FDA approval for one or more uses within two to four years. -------------------------------------------------------------------------------- What You Can Do > Talk to your doctor. If you are suffering from HIV/AIDS, cancer, or an autoimmune disease, LDN could help. In AIDS and cancer therapy, LDN is often used in conjunction with other medications. Cancer. Anyone with cancer or a pre-cancerous condition should consider LDN. Many use LDN as a preventive treatment. Post-treatment, others have been using LDN to prevent a recurrence of their cancer. LDN has been shown in many cases to work with virtually incurable cancers such as neuroblastoma, multiple myeloma, and pancreatic cancer. HIV/AIDS. As an AIDS drug, LDN leads to far fewer side effects than the standard "AIDS cocktail." When used in conjunction with HAART therapies, LDN can boost T-cell populations, prevent disfiguring lipodystrophy, and lower rates of treatment failure. Do not be afraid to approach your doctors — physicians today are increasingly open to learning about new therapies in development. Tell your doctors about this website, or print out and hand them the information, and let them weigh the evidence. > Tell others. If someone you know has HIV/AIDS, cancer, an autoimmune disease, or one of the aforementioned central nervous system disorders, LDN could save them from a great deal of suffering. If they use e-mail, send them the address of this website (www.lowdosenaltrexone.org). Or, print out the site and mail them the information. > Help spread the word to the media, the medical community, and to developing countries. Low-dose naltrexone has the potential to reduce the terrible human loss now taking place throughout the globe. It is a drug that could prevent millions of children from becoming AIDS orphans. It is a drug that could be a powerful ally in the war against cancer. If you or someone you know has connections in the media, the medical community, or to those in developing countries involved in AIDS policy or treatment, please let them know about LDN. > Raise funds to help run clinical trials. Following the First Annual LDN Conference in June 2005, several of those who attended decided to begin a fundraising effort in the US to further research into the effectiveness of LDN for MS, the LDN for MS Research Fund. The plan is to collect $20,000 as "seed money" from the LDN MS community—those who have already benefited from it, but want to know how it works. Research is the only way to determine why LDN has garnered so many positive anecdotal reports, to find ways to improve its use, and perhaps benefit even more people with MS. The Accelerated Cure Project for MS, a nonprofit organization, has offered to receive, hold, and disburse the monies on the fund's behalf to allow contributions to be tax-deductible. All funds will be held in a separate account, and refunded to the donors should the trial not launch for some reason. For further information, please see the linked page LDN Research Funding. -------------------------------------------------------------------------------- About This Website > This is a not-for-profit website. This website is sponsored by Advocates For Therapeutic Immunology. The purpose of this website is to provide information to patients and physicians about important therapeutic breakthroughs in advanced medical immunology. The authors of this site do not profit from the sale of low-dose naltrexone or from website traffic, and are in no way associated with any pharmaceutical manufacturer or pharmacy. > Consult your doctor. This website is not intended as a substitute for professional medical help or advice. A physician should always be consulted for any medical condition. > Contact us. For information on how to contact us with questions or comments, click here. Please note that no response can be given to individual questions concerning medical symptoms or treatment. -------------------------------------------------------------------------------- Additional Information Bernard Bihari, MD, is the discoverer of the major clinical effects of low dose naltrexone. A private practitioner in Manhattan, Dr. Bihari is a Board-certified specialist in Psychiatry and Neurology. Dr. Bihari's curriculum vitae and contact info. David Gluck, MD, is the editor of this website, ldninfo.org. He is a Board-certified specialist in both Internal Medicine and Preventive Medicine. Dr. Gluck has served as medical director for JCPenney and MetLife, and is now semi-retired, living and working in New York City. Ian S. Zagon, PhD, has spent over two decades in doing basic research concerning endorphins. He is Professor of Neural and Behavioral Sciences, Pennsylvania State University, Dept. of Neural and Behavioral Sciences, H-109, Hershey Medical Center, Hershey, PA 17033; office phone: (717) 531-6409; email: isz1@psu.edu; website. Naltrexone is a drug prescribed to help people maintain abstinence after they have withdrawn (detoxified) from heroin or other opioids . It is also used in an experimental treatment to bring about rapid withdrawal from opioids. Naltrexone has also been used as a treatment to support abstinence for people who are dependent on alcohol. This information explains the use of naltrexone to assist people in maintaining abstinence from heroin use. What does naltrexone do? Naltrexone is classed as an opioid antagonist . It works by blocking the opioid receptors in the brain and therefore blocking the effects of heroin and other opioids. It can assist in maintaining abstinence from heroin because the person is aware that they cannot achieve a ‘high’ from using heroin. Therefore, any money spent on heroin will be wasted. It does not directly stop a person wanting to use heroin, although it may reduce or prevent cravings in some people. You cannot become physically dependent on naltrexone and it does not produce any euphoric effects. How effective is naltrexone? There have been a lot of media reports on naltrexone, often describing it as a ‘miracle cure’ for heroin. There is, however, general agreement from drug professionals that the effectiveness of naltrexone treatment is very much dependent on: the person’s particular situation, including their level of commitment to staying off heroin and the level of support available to them; and it being one part of a comprehensive treatment program, which includes regular counselling. In fact, recent studies have suggested that many clients do not remain on naltrexone treatment and will often return to heroin use. More studies are currently being conducted that may provide a clearer picture of naltrexone’s effectiveness. It is important to recognise that naltrexone treatment may be effective for some people, but will not suit everyone. How do you know if naltrexone maintenance treatment is right for you? Naltrexone is one of a number of treatments for heroin dependence. Other treatments include: Methadone maintenance Withdrawal/detoxification (residential or home-based/medical or non-medical) Counselling (outpatient or as part of residential rehabilitation). It is strongly recommended that a person wanting to remain abstinent from heroin engages in a treatment program that addresses both the physical and psychological aspects of drug dependency. This usually includes combining various treatments, such as methadone maintenance with counselling, or progressing from withdrawal to counselling/rehabilitation. A doctor or drug counsellor that spends time assessing the person’s situation and explaining the different treatment options will more likely recommend a program that is appropriate for that person. If applying for the naltrexone program, see a doctor who is experienced in this treatment (your statewide drug phone service can provide an appropriate referral). To be eligible for naltrexone treatment, the following needs to be considered: The person must be free of heroin and other opioids for 7 - 10 days, or 10 days for methadone, before commencing naltrexone maintenance treatment, otherwise there is a risk that the individual may experience acute, instant withdrawal. Existing liver conditions, such as acute hepatitis, may exclude a person from naltrexone treatment. If a woman is pregnant or breastfeeding further advice should be sought, as it has not been established that using naltrexone during pregnancy is completely safe. People who are highly motivated to be opioid free and have support from family and/or friends are more likely to benefit from the treatment. Other considerations Having the right support and environment is crucial in helping the person give up and, perhaps more importantly, stay off heroin. Support. The support of family, friends, doctor and/or drug counsellor (practical and emotional support) is very important to help the person through the process of withdrawal. To be away from drugs. To be out of the environment in which drugs are readily available (this may mean giving up old friends, moving to a different area) To understand his or her drug use. To understand why the person uses a particular drug, what might trigger them to using, what other emotional and practical issues they might be facing (a drug counsellor can help the person through this). What are the side effects? Naltrexone is generally well tolerated, however some side effects have been reported. Most of these symptoms occur very early in treatment — the first week or so. It is important to note that some of these effects may be due to the combined experience of withdrawal from opioids and taking naltrexone. Most commonly reported: Difficulty in sleeping, anxiety, nervousness, abdominal pain/cramps, nausea and/or vomiting, low energy, joint and muscle pain and headache. Less commonly reported: Loss of appetite, diarrhoea, constipation, increased thirst, increased energy, feeling depressed, irritability, dizziness, skin rash, delayed ejaculation, decreased potency, and chills. What does the treatment involve? Treatment involves taking a prescribed amount of naltrexone for as long as it is perceived to be required; the length of the program depends on the individual’s situation. The tablets are taken orally, once a day, the usual dose being 50mg, or every couple of days at a higher dose (e.g. 100mg on alternate days or 150mg every three days). Daily doses are often recommended in order for the person to develop a routine, and to keep a stable level of naltrexone in the blood. Often a carer, family member, doctor or pharmacist supervises the administration of the dose. The Naloxone (Narcan) Challenge Test (NCT) Following abstinence from opioids for a period of 7-10 days, and after a negative urine test has been achieved for opioids, a naloxone (Narcan) challenge test is usually administered by a doctor to determine the remaining degree of physical dependence on opioids. Naloxone is injected into the individual and they are then monitored for approximately 20 minutes to assess any signs of withdrawal. If moderate to severe withdrawal symptoms are identified, the test can be undertaken again 24 hours later. If the symptoms indicate only mild withdrawal, the first dose of naltrexone can be provided. Agitation, parathesia (temporary numbness/pins and needles) has been infrequently reported with the use of naloxone. Risks The greatest risk associated with naltrexone is when heroin is used either after a naltrexone dose has been skipped or if a person stops taking naltrexone altogether. While the person is on naltrexone, tolerance to heroin decreases. Therefore, if heroin is used (and the effects of naltrexone are either diminished or worn off completely), the risk of overdosing from heroin is greatly increased. People who are planning to use heroin after being on naltrexone should consider themselves ‘new’ users. Overdose may occur if the person uses the same or even a smaller amount of heroin compared to what they did before being on naltrexone. In Australia, there have been a number of naltrexone-related deaths, due mainly to this reason. If a naltrexone dose is skipped, it is important to remember that the blocking effect wears off gradually (for example, the usual daily dose of 50mg will wear off in 24-72 hours). Therefore, if heroin is used in the meantime, a ‘high’ may not be achieved immediately and there may be a temptation to use again and/or increase the dosage. As the naltrexone slowly wears off, the ‘full’ effects of all of the heroin can be experienced, increasing the chances of overdose. Emergency cards Given that naltrexone blocks the effects of opioids, if painkillers are required which are opioid based, they will not be effective. It is important that doctors/medical staff are aware if an individual is taking naltrexone so that opioid-free drugs can be administered. An Emergency Card is a useful method of alerting medical staff that an individual is taking naltrexone. What does it cost? Currently naltrexone treatment for heroin is relatively expensive (approximately $200 - $370 per month). The cost of treatment can run into the thousands depending on the time the person is on the treatment, any other services utilised (such as counselling), and whether the service is privately run or a public service. How can I support someone who is on the naltrexone program? Supporting a friend or family member on the naltrexone program requires providing both emotional and practical support. If you take on this role you need to establish a clear agreement with the person on the naltrexone program about what this will (and will not) involve. You and your family member/friend should first discuss and agree on issues, such as the your role in informing the doctor if problems arise. You also need to think carefully about your limits regarding the type of support you can give to the person on treatment. Be careful not to overstep what you feel you are willing and able to give and remember to take care of yourself, which includes arranging support for you. Supporting your family member/friend on the naltrexone program may include: Being committed to supervising the naltrexone dose for the duration of the treatment Knowing what to do in the event of an overdose Encouraging your friend/family member to develop their friendships and support networks, to get involved in positive, healthy activities (such as taking a class, joining a support group, being active) Going with your friend/family member to appointments (doctors, counsellors) Attending couple or family counselling if appropriate. More on support for family members. How can I find out more? Before a person goes on any drug treatment program, it is important that all the information has been explained to them (and, where appropriate, carers, such as family, friends etc) by a doctor experienced in drug treatment and/or a drug counsellor. This includes the length of the program, how much it costs, what other supports are included or recommended, all the risks and side effects, and any other health issues to consider. Psychosocial treatments for alcoholism have been shown to increase abstinence rates and improve the quality of life for many alcoholics. Nonetheless, a significant proportion of alcoholics find it difficult to maintain initial treatment gains and eventually relapse to problematic drinking. Some of these individuals can now be helped with naltrexone, an opiate antagonist recently approved by the Food and Drug Administration (FDA) to treat alcohol abuse disorders. When used as an adjunct to psychosocial therapies for alcohol-dependent or alcohol-abusing patients, naltrexone can reduce The percentage of days spent drinking The amount of alcohol consumed on a drinking occasion Relapse to excessive and destructive drinking This TIP will help clinicians and treatment providers use naltrexone safely and effectively to enhance patient care and improve treatment outcomes. Naltrexone therapy improves treatment outcomes when added to other components of alcoholism treatment. For patients who are motivated to take the medication, naltrexone is an important and valuable tool. In many patients, a short regimen of naltrexone will provide a critical period of sobriety, during which the patient learns to stay sober without it. The Consensus Panel that developed this Treatment Improvement Protocol (TIP) made recommendations based on a combination of clinical experience and research-based evidence. Their guidelines are summarized below. Those supported by the research literature are followed by (1); clinically based recommendations are marked (2). Citations to the former are referenced in the body of this document, where the guidelines are presented in full detail. Concurrent Psychosocial Interventions Naltrexone has been approved as an adjunct to psychosocial treatment and should not be seen as a replacement for psychosocial interventions. Treatment is significantly more successful when the patient is compliant with both the medication and psychosocial programs. Psychosocial treatments are likely to enhance compliance with pharmacotherapy, and likewise, pharmacotherapies enhance psychosocial treatment by reducing craving and helping the patient remain abstinent. Pharmacological Management Eligibility for Treatment The following details some of the criteria for determining patients' eligibility for treatment with naltrexone: Individuals who have been diagnosed as alcohol dependent, are medically stable, and are not currently (or recently) using opioids (e.g., heroin, controlled pain medication) are suitable candidates for naltrexone therapy. Individuals with acute hepatitis or liver failure are not suitable candidates. Patients requiring narcotic analgesia also are not suitable candidates. Appropriate candidates should be willing to be in a supportive relationship with a health care provider or support group to enhance treatment compliance and work toward a common goal of sobriety. Patient interest and willingness to take naltrexone are important considerations. At the currently recommended dose of 50 mg daily, hepatic toxicity is very unlikely. Continued alcohol use is more likely than naltrexone to cause liver damage. Before determining a patient's eligibility for naltrexone therapy, clinicians should be aware that alcohol alone may be responsible for pretreatment elevated liver function test (LFT) results. In some cases, simply stopping the consumption of alcohol will immediately lower LFT values appreciably. When there is a question, the Consensus Panel recommends repeating LFTs after 5 to 7 days of abstinence. (2) If the levels dramatically improve, then the patient may be a suitable candidate for naltrexone. Providers should perform LFTs prior to treatment initiation and periodically during treatment. The Consensus Panel recommends caution in using naltrexone with patients whose serum aminotransferases results are five times above normal. (1) Because total bilirubin reflects more severe and potentially chronic liver dysfunction, the Consensus Panel recommends using total bilirubin to both evaluate and monitor the development of liver problems. Patients with an elevation of total bilirubin should be referred to an internist or hepatologist for a consultation prior to considering naltrexone therapy. The final decision to use naltrexone should be based on a risk-benefit analysis. Clinician and patient may choose to start naltrexone treatment in spite of the presence of medical problems because the potential benefits of reducing or eliminating alcohol consumption may outweigh the potential risk of naltrexone. Naltrexone and Other Substances The use of other substances during naltrexone treatment, particularly illegal opiates and opioid-containing medications, may pose the same level of concern and possible adverse consequences as the use of alcohol. Random urinalysis, collateral reports from family members or employer (with the patient's written consent), and self-reports from the patient can be used to evaluate the use of other substances. In addition to illegal substances, the use of both prescription and nonprescription medications should also be addressed. The patient's agreement or resistance to continuing treatment may indicate his or her level of willingness to consider other substance use as a problem. Interactions with opiates and opioids Because naltrexone may cause or worsen opiate withdrawal in subjects who are physiologically dependent on opiates or who are in active opiate withdrawal, it is contraindicated in these patients until after they have been abstinent from opiates for at least 5 to 10 days, or longer if they are withdrawing from methadone without benefit of buprenorphine (Buprenex) (once approved). (1) Naltrexone is absolutely contraindicated in patients currently maintained on methadone or LAAM (levo-alpha-acetyl-methadol) for the treatment of opiate dependence. (1) Naltrexone does not interfere with nonopioid pain medications such as ibuprofen, acetaminophen, and aspirin. (1) If at any time the need for opioid treatment becomes necessary, naltrexone therapy can be discontinued for 2 or 3 days, and the opioid can then be given in conventional doses. If opioids are needed to reduce pain in someone with recent naltrexone ingestion, pain relief can still be obtained but at higher than usual doses. These doses require close medical monitoring. (2) Patients should be warned that self-administration of high doses of opiates while on naltrexone is extremely dangerous and can lead to death from opioid intoxication by causing respiratory arrest, coma, or circulatory collapse. In emergency situations requiring opiate analgesia, a rapidly acting analgesic with minimal respiratory depression should be used and carefully titrated to the patient's responses. Interactions with other drugs Caution should be used when combining naltrexone with other drugs associated with potential liver toxicity, such as acetaminophen and disulfiram (Antabuse). Other interactions of which Consensus Panel members are aware include thioridazine (Mellaril) and oral hypoglycemics. The Consensus Panel recommends that clinicians be aware of all of the patient's medications and watch closely for naltrexone's interactions with other drugs. Clinicians should report adverse drug-drug interactions to the manufacturer(s) if they do occur. Concurrent use of antidepressants and naltrexone appears to be safe. Interaction with alcohol Unlike disulfiram, naltrexone does not appear to alter the absorption or metabolism of alcohol and does not have major adverse effects when combined with alcohol. Some patients, however, have noted increased nausea caused by drinking alcohol while taking naltrexone. Patients on naltrexone are less likely to relapse to heavy drinking following a lapse in abstinence. However, both patient and provider should know that naltrexone does not make people "sober up" and does not alter alcohol's acute effects on cognitive functioning. Starting Treatment Patient education comes first Patients must be taught how naltrexone works and what to expect while taking it. Treatment providers should tell patients that the medication is not a "magic bullet"; instead, naltrexone is likely to reduce the urge to drink and the risk of returning to heavy drinking. Providers should negotiate a treatment plan with the patient at each stage of therapy. Initial medical workup The pretreatment medical workup should include A complete physical examination, including the liver Various laboratory tests, including LFTs (e.g., serum aminotransferases, total bilirubin) A pregnancy test A urine toxicology screen A complete/updated medical history to rule out possible contraindications A substance abuse history that focuses on the use of other substances, especially opiates, as well as the patient's history of use, misuse, or abuse of prescribed medications A mental health/psychiatric status screening Positive mental health/psychiatric screens may necessitate more formal mental status examinations to determine the severity of the illness and the appropriate course of treatment. The Consensus Panel recommends focusing the psychiatric interview on anxiety symptoms, depression, psychosis, and cognitive functioning because these elements may complicate therapy. (1) Pretreatment abstinence Naltrexone should be initiated after signs and symptoms of acute alcohol withdrawal have subsided. The Consensus Panel recommends that patients be abstinent for 3 to 7 days before initiating naltrexone treatment. (2) Starting doses The FDA has established guidelines for the dosage and administration of naltrexone. Within general parameters, treatment with naltrexone must be individualized according to these factors as well as to the particular needs of each patient. The FDA guidelines recommend an initiation and maintenance dose of 50 mg/day of naltrexone for most patients, usually supplied in a single tablet. Because adverse events may make the patient reluctant to continue the medication, the starting dose can be reduced for several days or divided in two. (2) For example, treatment can begin with either one-quarter of a tablet (12.5 mg/day) or one-half of a tablet (25 mg/day) daily, with food, and eventually move to a full tablet daily (50 mg/day) within 1 to 2 weeks if tolerated. Management of common adverse effects Common adverse effects, which may include nausea, headache, dizziness, fatigue, nervousness, insomnia, vomiting, and anxiety, occur at the initiation of treatment in approximately 10 percent of patients. The Consensus Panel recommends the following strategies: Patient education. If patients are going to experience common adverse effects, these tend to occur early in treatment, and the symptoms generally resolve within 1 to 2 weeks. Support and reassurance can help patients better tolerate these transient adverse effects. Timing of doses. The Consensus Panel recommends morning dosing for most patients to establish a routine and ensure better compliance. (1) Naltrexone should ideally be taken after the "regular" morning routine, preferably with food. Individual patient needs can also guide the timing of doses. Split dosage. If there is a need to split the dose, then the patient should take half in the morning and half in the evening, preferably with dinner. Management of nausea. Nausea is a problem for approximately 10 percent of patients and may reduce compliance. To minimize nausea, patients can take naltrexone with complex carbohydrates such as bagels or toast and not take the medication on an empty stomach. (2) The use of simethicone (e.g., Maalox) or bismuth subsalicylate (e.g., Pepto-Bismol) before taking naltrexone may help. Strategies for controlling persistent nausea or other adverse events include dose reduction, slow titration, and cessation of the medication for 3 or 4 days and then reinitiating it at a lower dose. (2) Withdrawal. Patients may not be able to discriminate between the common effects of withdrawal from alcohol and the common adverse effects caused by naltrexone. Patients should be reassured that their symptoms will get better with time. Alcohol withdrawal can be managed with support or benzodiazepines if indicated. Ongoing Treatment With Naltrexone Maintenance doses Low doses Maintenance doses of less than the standard 50 mg/day regimen may be considered in patients who do not tolerate the standard maintenance dose but who are otherwise good candidates for naltrexone. It is preferable to decrease the maintenance dose to 25 mg/day to avoid noncompliance and relapse due to common adverse effects rather than to rule out naltrexone as a treatment option for these patients. Some patients may ask to take naltrexone twice daily in order to experience subjective relief from craving. In these cases, the daily dose may be divided in two and given at those times of the day when craving is strongest. Higher doses Under certain circumstances, providers may increase the daily naltrexone dose to greater than 50 mg. Patients who may be considered for an increase include those who report persistent feelings of craving, discomfort, and even brief relapses, despite compliance with their treatment plan. In such cases, dosages of 100 mg/day are sometimes used, with appropriate medical monitoring. There is evidence that naltrexone is well tolerated, safe, and efficacious at these higher doses. Before adjusting dosage, providers should first consider intensification of other treatment interventions, particularly psychosocial components. The reason the medication is not working should be explored. Providers should view a patient's request for increased dose as a sign of engagement and motivation in treatment, not as drug-seeking behavior. In some outpatient treatment, higher doses of naltrexone have been given under observation either 2 days a week or 3 days a week. If this is necessary and the patient tolerates a higher dose, possible protocols are 100 mg on Monday and Wednesday, with 150 mg on Friday; 150 mg on Monday and 200 mg on Thursday; or 150 mg every third day. Duration of treatment Although FDA guidelines indicate that naltrexone should be used for up to 3 months to treat alcoholism, the Consensus Panel recommends that treatment providers individualize the length of naltrexone treatment according to each patient's needs. (2) Initially, the patient can be treated with naltrexone for 3 to 6 months, after which the patient and the therapist can reevaluate the patient's progress. At this time, the decision to extend treatment must be based on clinical judgment. The Consensus Panel concurs that certain patients may be appropriate candidates for long-term (e.g., up to 1 year) naltrexone treatment if they demonstrate evidence of compliance with medication and psychosocial treatment regimens. (2) Factors to be weighed in the clinical decision to extend treatment beyond 3 to 6 months include patient interest, recent dose adjustment, partial treatment response, and prophylaxis in high-risk situations. Other Clinical Considerations During Treatment Followup liver function tests After the initial screening, followup LFTs should be completed after 1 month of naltrexone treatment. If the results are acceptable, followup LFTs may then be conducted at 3 and 6 months after the initiation of treatment, depending on the severity of liver dysfunction at the start of treatment. More frequent monitoring is indicated for cases in which dose adjustments are being made, baseline LFTs are high, there is a history of hepatic disease, disulfiram or other potential hepatic-toxic medication is added to the treatment, or symptomatology indicates the need for monitoring. Pain management Because naltrexone blocks the effects of usual doses of therapeutic opioids, providers should use nonnarcotic methods of analgesia as first line of treatment for pain conditions. If narcotic pain relief is indicated, patients must discontinue naltrexone use for the period during which analgesics are required. If a painful event such as surgery is anticipated, then naltrexone should be discontinued 72 hours prior to the procedure. (1) If a patient is taken off naltrexone and put on an opioid analgesic, he or she should be abstinent from the narcotic for at least 3 to 5 days before resuming naltrexone treatment. (1) In emergencies such as cases of acute severe pain, higher doses of opioid analgesics may be used with extreme caution to override the blockade produced by naltrexone. The narcotic dose needs to be carefully titrated to achieve adequate pain relief without oversedation or respiratory suppression. Both the dose and the patient's vital signs (including respiratory rate, level of awareness, and level of analgesia) must be closely monitored. Respiratory assistance and support must be available, should this be necessary. The Consensus Panel recommends that patients on naltrexone always carry safety identification cards providing information that the patient is receiving naltrexone and instructions for treating patients in the event of an emergency. Continued drinking The continued or periodic drinking of alcohol may not be a sufficient reason to discontinue naltrexone: Some patients respond to naltrexone treatment at first by reducing rather than stopping their drinking. When a patient drinks during treatment, the treatment provider should evaluate whether the patient is taking his or her medication regularly and actively participating in treatment. The intensity of care along with the expectations placed on the patient may be increased. Dose adjustments may also be indicated. Abstinence should be a desired goal for the patient; however, reductions in drinking may be an acceptable intermediate outcome. Failure to maintain complete abstinence is not necessarily a failure of treatment because there are many other areas of a patient's life that can improve, such as job performance, social relationships, and general physical health. Use of naltrexone in conjunction with disulfiram The concomitant use of two potentially hepatotoxic medications is not ordinarily recommended unless the probable benefits outweigh the known risks. If naltrexone is used with disulfiram, then treatment providers should perform LFTs shortly after the initiation of combined use. Providers should retest patients every 2 weeks for 1 to 2 months and thereafter at regular intervals, such as monthly. (2) Combination therapy with disulfiram and naltrexone should not be used for very long periods, and generally, the two drugs should not be started simultaneously. Ending Naltrexone Therapy Successful termination of naltrexone Because naltrexone is not addicting, patients who stop taking the medication do not suffer from withdrawal symptoms, so naltrexone therapy can be discontinued without tapering the dose. Nonetheless, dose reductions may be psychologically useful to the patient. The treatment team should work with the patient in developing structured plans in the event of threatened or actual relapse. Scheduled followup visits ("booster visits") may also be helpful in providing support for the patient and opportunities for intervention based on identifying early signs of potential relapse. Naltrexone may be restarted if the patient and the treating clinicians feel that it may be helpful in preventing relapse. Monitoring the outcome of treatment In evaluating the outcome of naltrexone therapy, providers should expect to see evidence of positive improvement over time as evaluated by the treatment program's indicators of progress. Some of the possible criteria that can be used and selected to fit each program's needs and policies include Compliance with treatment plan Stable abstinence or significant reduction in the frequency and amount of drinking, as indicated by patient self-reports, collateral reports, and biological markers Markedly diminished craving Improvement in quality of life, including physical and mental health status, family and social relationships, work and/or vocational status, and legal status Abstinence from other substances of abuse Other Topics This TIP reviews the basic neurobiological and preclinical research supporting clinical investigations of naltrexone for treatment of alcohol dependence. An overview of neurological reinforcement systems and drug dependence for providers who do not have a medical background explains how naltrexone works. Also reviewed are the specific findings of the initial two clinical trials that established the efficacy of naltrexone in the treatment of alcohol dependence. This document describes the subsequent research to identify the patients most likely to benefit from naltrexone treatment, the differential subjective effects of naltrexone, the use of naltrexone for other patient populations, naltrexone in the context of other pharmacotherapies, and directions for future research. The TIP provides a brief overview of naltrexone as a medication, including its development and clinical role, its mechanism of action, its pharmacokinetic properties, its safety and common adverse effects, and some clinical considerations when prescribing this medication. Appendix B guides clinicians and administrators who are interested in adding naltrexone to the formulary of their health care organization. Included in this appendix is an extensive list of Federal and private Web sites for readers who may want to access additional information about substance abuse treatment through the Internet. Appendix C details the process by which innovations are adopted over time and outlines strategies that encourage technology transfer and research utilization. For the organization that would like to incorporate naltrexone as a potential treatment adjunct, this appendix offers suggestions about how to prepare the system for this change. Finally, Appendix D provides two instruments to help treatment providers who would like to monitor craving in their patients: The Obsessive Compulsive Drinking Scale and the Alcohol Urge Questionnaire. This TIP will give treatment providers the information they need, first to determine which patients can benefit from naltrexone and second to safely and effectively administer the medication. Although research on the use of naltrexone for alcohol abuse disorders is ongoing, this TIP presents the "state of the ur email, and even if

Since its launch in 1994 PharmWeb has developed into the premier online community of pharmacy, pharmaceutical and healthcare-related professionals with over 40,000 self-registered users. The first pharmaceutical portal on the Internet has developed into an invaluable directory of information, including a library of archives from over 100 moderated discussion forums. To browse the site either jump to a section using the pull-down menu or scroll down the home page to see what PharmWeb has to offer. PharmWeb is a registered trade mark. Full programs of major pharmacy, pharmaceutical and health-related conferences around the world plus the PharmWeb Conference Calendar. World Wide Pharmacy Colleges/Departments/Schools This is a comprehensive database of world wide pharmacy schools. The schools list is in the form of a searchable database and is regularly updated. The database includes contact names, addresses, telephone and FAX numbers, and Internet addresses where available. PharmWeb Discussion Forum The PharmWeb Discussion Forum is a collection of discussion groups and mailing lists specialising in specific aspects of medicine, pharmacy, pharmaceutical sciences and health-related issues. The discussion groups and mailing lists are designed to focus on specific areas and are moderated to ensure that discussions are within the scope of a particular discussion group. Patient Information Information on the drugs, medicines, diseases and conditions. PharmWeb Chat A real-time discussion forum for matters relating to pharmacy, pharmaceutical sciences, and health-related issues. Either drop in to see who is on-line, or arrange a meeting with colleagues on one of the 6 discussion rooms. It is even possible to have a private conversation. PharmWeb Virtual Library A repository of pharmaceutical information for educational and research purposes. Government and Regulatory Bodies Links to government and regulatory bodies around the world. PharmWeb Directory A directory of people in the health professions. Over 5,000 people are registered on the Directory. PharmWeb World Drug Alert Receive information about drugs and medicine via this mailing list. PharmWeb Yellow Web Pages Your directory to pharmaceutical information on the Internet. Includes companies, pharmacies, hospitals, plus much more. Each site is evaluated by our team of researchers before addition to the directory. Societies A directory of pharmaceutical and health-related societies around the world. Also included is a list of International Pharmaceutical Federation (FIP) member organisations (including addresses, telephone and FAX numbers). PharmWeb Appointments Job vacancies in science and the health professions, updated regularly. If you want to be the first to know about a new vacancy why not join the PharmWeb Appointments Alert? Newsgroups Links to various science and health-related newsgroups. Continuing/Further Education Links to pharmaceutical and health-related courses and teaching information. Special Interest Pages A resource of links to sites specialising in science, drugs and health-related subjects. A starting point for information other than pharmacy. PharmWeb Index An A to Z index of information held on PharmWeb. History of PharmWeb PharmWeb was the first hierarchical information resource on the Internet for pharmaceutical and health-related information. How did it all start? Pharmacy and the Internet This page contains information on pharmaceutical publications related to the Internet and considers the applications of the Internet to pharmacy. PharmWeb Internet Directory Links to some of the best sites on the Internet including search engines, news, weather, entertainment, and many other interesting sites. What's New on PharmWeb? Find out about the latest developments on PharmWeb. Access Statistics How many people use PharmWeb? Detailed access statistics for the main PharmWeb servers. How to Add/Edit Links Do you want to add or edit any link on PharmWeb, this tells you how to do it. PharmWeb and its Services What can PharmWeb do for you? A summary of the services that PharmWeb provides. Problem Solver Some of the common problems encountered using web browsers. Comments and Suggestions Let us know what you think of PharmWeb. Many developments have been the result of user feedback. PharmWeb Authors & Acknowledgements Who does all the work? Organisations on PharmWeb PharmWeb is here as a result of the support of major pharmaceutical and health-related organisations. Contact PharmWeb Th