Effex Sildenafil pills 50mg, 6pcs

Composition

Sildenafil citrate (in terms of sildenafil),1 tablet (50 mg) – 70.25 mg (50.00 mg).

Pharmacological action

Sildenafil is a potent selective inhibitor of cyclic guanosine monophosphate (cGMP)-specific phosphodiesterase type 5 (PDE5).

The physiological mechanism of erection is based on the release of nitric oxide (NO) in the cavernous body during sexual stimulation. This, in turn, leads to an increase in the level of cGMP, resulting in relaxation of the smooth muscle tissue of the cavernous body and increased blood flow in the cavernous body.

Sildenafil does not have a direct relaxing effect on the isolated cavernous body, but increases the relaxing effect of nitric oxide, causing inhibition of PDE5, which is responsible for the breakdown of cGMP in the cavernous body.

The pharmacological effect is achieved only in the presence of sexual stimulation.

In vitro studies have shown that sildenafil is selective for PDE5. Its activity against other known isoenzymes is much lower: PDE6-10 times, PDE1-more than 80 times, PDE2, PDE4, PDE7-11-more than 700 times. Sildenafil is 4000 times more active against PDE5 compared to PDE5, which is of great importance, since PDE5 is one of the key enzymes in the regulation of myocardial contractility.

A prerequisite for the effectiveness of sildenafil is sexual stimulation.

The use of sildenafil in doses up to 100 mg resulted in a slight short-term decrease in blood pressure. The hypotensive effect is associated with the vasodilating effect of sildenafil, which is associated with an increase in the level of cGMP in vascular smooth muscle cells.

In some patients,1 hour after taking the drug at a dose of 100 mg, the Farnsworth-Munsel 100 test revealed a slight and transient violation of the ability to distinguish shades of color (blue/green). After two hours, color perception was restored. Color vision disorders are caused by inhibition of PDE6, which is involved in retinal light transmission. Sildenafil does not affect visual acuity, contrast perception, electroretinogram values, intraocular pressure, or pupil diameter. Pharmacokinetics:

Suction

After ingestion, it is rapidly absorbed. The maximum concentration in blood plasma is reached within 30-120 minutes (an average of 60 minutes) when taken orally on an empty stomach. Bioavailability varies from 25 to 63%. When taken in combination with fatty foods, the absorption rate decreases: Cmax decreases by an average of 29%, and the time to reach the maximum concentration (Tmax) increases by 60 minutes, but the degree of absorption does not change significantly (the area under the pharmacokinetic curve concentration-time (AUC) decreases by 11%).

Distribution

The volume of distribution of sildenafil at steady state averages 105 liters. The plasma protein binding of sildenafil and its main circulating N-demethyl metabolite is approximately 96% and does not depend on the total concentration of the drug. Less than 0.0002% of the dose (average 188 ng) was detected in semen 90 minutes after taking sildenafil.

Metabolism

Sildenafil is mainly metabolized in the liver by microsomal cytochrome P 450 isoenzymes: CYP3A4 (major pathway) and CYP2C9 (minor pathway). The main circulating metabolite formed as a result of N-demethylation of sildenafil undergoes further metabolism. The selectivity of this metabolite on PDE is comparable to that of sildenafil, and its activity against PDE5 in vitro is about 50% of that of sildenafil. The concentration of the metabolite in the blood plasma is about 40% of the concentration of sildenafil. The N-demethyl metabolite undergoes further metabolism; its final elimination half-life is about 4 hours.

Deduction

The total clearance of sildenafil is 41 l / h, and the final half-life is 3-5 hours. After oral use, sildenafil is excreted as metabolites, mainly by the intestine (approximately 80% of the oral dose) and, to a lesser extent, by the kidneys (approximately 13% of the oral dose).

Pharmacokinetics in special patient groups

Elderly patients

In healthy elderly patients (65 years and older), the clearance of sildenafil is reduced, and the concentration of free sildenafil in plasma is approximately 40% higher than in young patients (18-45 years). Age does not have a clinically significant effect on the incidence of side effects.

Impaired renal function

In mild (creatinine clearance 50-80 ml/min) and moderate (creatinine clearance 30-49 ml/min) renal insufficiency, the pharmacokinetics of sildenafil after a single oral dose of 50 mg do not change. In severe renal insufficiency (CC

Liver function disorders

In patients with cirrhosis of the liver (stages A and B according to the Child-Pugh classification), the clearance of sildenafil decreases, which leads to an increase in AUC (84%) and Cmax (47%) compared to those with normal liver function in patients of the same age group. The pharmacokinetics of sildenafil in patients with severe hepatic impairment (Child-Pugh stage C) have not been studied.

Indications

Treatment of erectile dysfunction, characterized by the inability to achieve or maintain a penile erection sufficient for satisfactory sexual intercourse.

EFFEX Sildenafil is effective only with sexual stimulation.

Contraindications

Hypersensitivity to sildenafil or any other component of the drug.

Use in patients receiving continuous or intermittent nitric oxide donors, organic nitrates or nitrites in any form, as EFFEX Sildenafil enhances the hypotensive effect of nitrates). The safety and efficacy of EFFEX Sildenafil when co-administered with other treatments for erectile dysfunction have not been studied, so the use of such combinations is not recommended.

Co-use with ritonavir.

Liver function disorders.

Severe chronic renal failure.

Severe heart failure, unstable angina, stroke or myocardial infarction in the last 6 months, life-threatening arrhythmias, hypertension (BP > 170/100 mm Hg) or hypotension (BP >

According to the registered indication, EFFEX Sildenafil is not intended for use in children under 18 years of age. According to the registered indication, EFFEX Sildenafil is not intended for use in women. With caution:

Anatomical deformity of the penis (angulation, cavernous fibrosis, or Peyronie’s disease).

Diseases predisposing to the development of priapism (sickle cell anemia, multiple myeloma, leukemia, thrombocythemia).

Diseases accompanied by bleeding.

Exacerbation of gastric ulcer and duodenal ulcer.

Hereditary retinitis pigmentosa.

Side effects

The most common side effects were headache and hot flashes.

Usually, the side effects of EFFEX Sildenafil are mild to moderate and transient.

Fixed-dose studies have shown that the frequency of some adverse events increases with increasing dose.

From the immune system:  infrequently – hypersensitivity reactions (including skin rash), allergic reactions.

From the side of the visual organ:  often – blurred vision, visual impairment, cyanopsia; infrequently – eye pain, photophobia, photopsia, chromatopsia, redness of the eyes/sclera injections, changes in the brightness of light perception, mydriasis, conjunctivitis, hemorrhage in the eye tissue, cataracts, disruption of the lacrimal apparatus; rarely – swelling of the eyelids and adjacent tissues, dryness in the eyes, the presence of iridescent circles in the field of vision around the light source, increased eye fatigue, vision of objects in yellow (xanthopsia), vision of objects in red (erythropsia) hyperemia of the conjunctiva, irritation of the eye mucosa, unpleasant sensations in the eyes; frequency unknown-non-arteritic anterior ischemic neuropathy of the optic nerve (NPINZ), retinal vein occlusion, visual field defect, diplopia*, temporary loss of vision or decreased visual acuity, increased intraocular pressure, retinal edema, retinal vascular diseases, vitreous detachment/vitreous traction.

From the side of the hearing organ:  infrequently – sudden loss or loss of hearing, tinnitus, pain in the ears.

From the cardiovascular system:  often-hot flashes; infrequently-tachycardia, palpitation, decreased blood pressure, increased heart rate, unstable angina, atrioventricular block, myocardial ischemia, cerebral thrombosis, cardiac arrest, heart failure, abnormalities in electrocardiogram readings, cardiomyopathy; rarely – atrial fibrillation.

Blood and lymphatic system disorders:  infrequently-anemia, leukopenia.

From the side of metabolism and nutrition: infrequently-thirst, edema, gout, uncompensated diabetes mellitus, hyperglycemia, peripheral edema, hyperuricemia, hypoglycemia, hypernatremia.

Respiratory system disorders: often – nasal congestion; infrequently-nosebleeds, rhinitis, asthma, dyspnoea, laryngitis, pharyngitis, sinusitis, bronchitis, increased sputum volume, increased cough; rarely – a feeling of tightness in the throat, dryness of the nasal mucosa, swelling of the nasal mucosa.

From the gastrointestinal tract: often – nausea, dyspepsia; infrequently gastroesophageal reflux disease, vomiting, abdominal pain, dry oral mucosa, glossitis, gingivitis, colitis, dysphagia, gastritis, gastroenteritis, esophagitis, stomatitis, deviation of “liver” functional tests from the norm, rectal bleeding; rarely – hyposthesia of the oral mucosa.

From the musculoskeletal system: often-back pain; infrequently – myalgia, pain in the extremities, arthritis, osteoarthritis, tendon rupture, tenosynovitis, bone pain, myasthenia gravis, synovitis.

From the genitourinary system: infrequently – cystitis, nocturia, breast enlargement, urinary incontinence, hematuria, ejaculation disorders, genital edema, anorgasmia, hematospermia, penile tissue damage; rarely-prolonged erection and / or priapism.

Central and peripheral nervous system disorders: very often-headache; often-dizziness; infrequently-drowsiness, migraine, ataxia, hypertonia, neuralgia, neuropathy, paresthesia, tremor, vertigo, depressive symptoms, insomnia, unusual dreams, increased reflexes, kinesthesia; rarely-convulsions*, repeated convulsions*, fainting.

Skin and subcutaneous tissue disorders: infrequently – skin rash, urticaria, herpes simplex, pruritus, increased sweating, skin ulceration, contact dermatitis, exfoliative dermatitis; frequency unknown-Stevens-Johnson syndrome, toxic epidermal necrolysis.

Other services: infrequently – a feeling of heat, swelling of the face, photosensitivity reaction, shock, asthenia, increased fatigue, pain of various localization, chills, accidental falls, chest pain, accidental injuries; rarely-irritability.

*Side effects identified during post-marketing studies.

Cardiovascular complications

Adverse events such as severe cardiovascular events (including myocardial infarction, unstable angina, sudden cardiac death, ventricular arrhythmia, hemorrhagic stroke, transient ischemic attack, hypertension, and hypotension) that were temporarily associated with the use of sildenafil have been reported during post-marketing use of sildenafil for the treatment of erectile dysfunction. Most of these patients, but not all of them, had risk factors for cardiovascular events. complications.

Many of these adverse events were observed shortly after sexual activity, and some of them were observed after taking sildenafil without subsequent sexual activity. It is not possible to establish a direct link between the observed adverse events and these or other factors.

Visual impairments

In rare cases, post-marketing use of all PDE5 inhibitors, including sildenafil, reported non-arteriitic anterior ischemic neuropathy of the arthelic nerve (NPINZN), a rare disease and cause of reduced or lost vision. Most of these patients had risk factors, such as a decrease in the ratio of excavation diameters to the optic disc (“congestive disc”), age over 50 years, diabetes mellitus, hypertension, coronary heart disease, hyperlipidemia, and smoking. An observational study evaluated whether recent use of PDE5 inhibitors was associated with acute onset of NSAID.

The results indicate an approximately 2-fold increase in the risk of NSAIDs within 5 half-lives after the use of a PDE5 inhibitor. According to published literature data, the annual incidence of NPINZD is 2.5-11.8 cases per 100,000 men aged > 50 years in the general population.

Patients with sudden vision loss should be advised to discontinue sildenafil therapy and consult their doctor immediately. Individuals who have already had a case of NSAIDs have an increased risk of recurrence of NSAIDs. Therefore, the doctor should discuss this risk with these patients, as well as discuss with them the potential for adverse effects of PDE5 inhibitors. PDE5 inhibitors, including sildenafil, should be used with caution in such patients and only in situations where the expected benefit outweighs the risk.

Interaction

The metabolism of sildenafil occurs mainly under the action of cytochrome CYP3A4 (main pathway) and CYP2C9 isoenzymes, so inhibitors of these isoenzymes can reduce the clearance of sildenafil, and inducers, respectively, increase the clearance of sildenafil.

A decrease in the clearance of sildenafil was observed with the simultaneous use of inhibitors of the cytochrome CYP3A4 isoenzyme (ketoconazole, erythromycin, cimetidine).

Cimetidine (800 mg), a non-specific inhibitor of the cytochrome CYP3A4 isoenzyme, when co-administered with sildenafil (50 mg) causes an increase in the concentration of sildenafil in plasma by 56%.

A single dose of 100 mg of sildenafil together with erythromycin (500 mg / day 2 times a day for 5 days), a moderate inhibitor of the cytochrome CYP3A4 isoenzyme, against the background of achieving a constant concentration of erythromycin in the blood, leads to an increase in the AUC of sildenafil by 182%.

When co-administered with sildenafil (100 mg once) and saquinavir (1200 mg / day 3 times a day), an HIV protease inhibitor and cytochrome CYP3A4 isoenzyme, while achieving a constant concentration of saquinavir in the blood, the Cmax of sildenafil increased by 140%, and AUC increased by 210%. Sildenafil does not affect the pharmacokinetics of saquinavir. Stronger inhibitors of the cytochrome CYP3A4 isoenzyme, such as ketoconazole and itraconazole, can also cause stronger changes in the pharmacokinetics of sildenafil.

Simultaneous use of sildenafil (100 mg once) and ritonavir (500 mg twice daily), an HIV protease inhibitor and a strong cytochrome P450 inhibitor, while achieving a constant concentration of ritonavir in the blood leads to an increase in the Cmax of sildenafil by 300% (4 times), and AUC by 1000% (11 times). After 24 hours, the concentration of sildenafil in the blood plasma is about 200 ng / ml (after a single application of sildenafil alone-5 ng/ml).

If sildenafil is used at the recommended doses in patients receiving simultaneously strong inhibitors of the cytochrome CYP3A4 isoenzyme, the Cmax of free sildenafil does not exceed 200 nM, and the drug is well tolerated.

A single antacid dose (magnesium hydroxide/aluminum hydroxide) does not affect the bioavailability of sildenafil.

In studies involving healthy volunteers, concomitant use of an endothelin receptor antagonist, bosentan (an inducer of the CYP3A4 isoenzyme (moderate), CYP2C9, and possibly CYP2C19) at steady-state concentrations (125 mg twice daily) and sildenafil at steady-state concentrations (80 mg three times daily) decreased the AUC and Cmax of sildenafil by 62.6% and 52.4%, respectively. Sildenafil increased the AUC and Cmax of bosentan by 49.8% and 42%, respectively. It is suggested that the concomitant use of sildenafil with potent inducers of the CYP3A4 isoenzyme, such as rifampicin, may lead to a large decrease in the concentration of sildenafil in blood plasma. Inhibitors of the cytochrome CYP2C9 isoenzyme (tolbutamide, warfarin), cytochrome CYP2D6 isoenzyme (selective serotonin reuptake inhibitors, tricyclic antidepressants), thiazide and thiazide-like diuretics, ACE inhibitors and calcium antagonists do not affect the pharmacokinetics of sildenafil.

Azithromycin (500 mg / day for 3 days) has no effect on the AUC, Cmax, Tmax, elimination rate constant and T 1/2 of sildenafil or its main circulating metabolite.

Effect of sildenafil on other medications

Sildenafil is a weak inhibitor of cytochrome P450 isoenzymes-1A2,2C9,2C19,2D6,2E1 and 3A4 (IR 50> 150 mmol). When taking sildenafil at the recommended doses, its Cmax is about 1 micromol, so it is unlikely that sildenafil can affect the clearance of substrates of these isoenzymes.

Sildenafil enhances the hypotensive effect of nitrates both with prolonged use of the latter, and when they are prescribed for acute indications. In this regard, the use of sildenafil in combination with nitrates or nitric oxide donors is contraindicated.

When the alpha-blocker doxazosin (4 mg and 8 mg) and sildenafil (50 mg and 100 mg) were co-administered in patients with benign prostatic hyperplasia with stable hemodynamics, the average additional reduction in systolic / diatonic blood pressure in the supine position was 9/5 mm Hg and 8/4 mm Hg, respectively, and in the standing position-11/4 mm Hg and 4/5 mm Hg, respectively.

Rare cases of symptomatic postural hypotension, which manifested itself in the form of dizziness (without fainting), have been reported in such patients. In some sensitive patients receiving alpha-blockers, concomitant use of sildenafil may lead to symptomatic hypotension.

There were no signs of significant interaction with tolbutamide (250 mg) or warfarin (40 mg), which are metabolized by the cytochrome CYP2C9 isoenzyme.

Sildenafil (100 mg) does not affect the pharmacokinetics of HIV protease inhibitors, saquinavir and ritonavir, which are substrates of the cytochrome CYP3A4 isoenzyme, at constant blood levels.

Concomitant use of sildenafil at steady state (80 mg three times a day) leads to an increase in the AUC and Cmax of bosentan (125 mg twice a day) by 49.8% and 12%, respectively.

Sildenafil (50 mg) does not cause an additional increase in bleeding time when taking acetylsalicylic acid (150 mg).

Sildenafil (50 mg) does not enhance the hypotensive effect of alcohol in healthy volunteers with a maximum blood alcohol concentration of 0.08% (80 mg/dl) on average.

In patients with arterial hypertension, there were no signs of interaction between sildenafil (100 mg) and amlodipine. The average additional reduction in blood pressure in the supine position is 8 mm Hg (systolic) and 7 mm Hg (diastolic). The use of sildenafil in combination with antihypertensive agents does not lead to additional side effects.

How to take, course of use and dosage

Inside.

The recommended dose for most adult patients is 50 mg of sildenafil approximately 1 hour before sexual activity.

Depending on the effectiveness and tolerability, the dose can be increased to 100 mg. The maximum recommended dose is 100 mg. The maximum recommended frequency of application is 1 time per day.

Elderly patients

No dose adjustment of EFFEX Sildenafil is required.

Impaired renal function

No dose adjustment is required in patients with mild to moderate renal impairment (creatinine clearance 30-80 ml / min).

Concomitant use with other medications

To minimize the risk of postural hypotension in patients taking alpha-blockers, sildenafil should be started only after hemodynamic stabilization has been achieved in these patients. Consideration should also be given to reducing the initial dose of sildenafil.

Overdose

When using EFFEX Sildenafil in doses higher than recommended, adverse events were similar to those noted above, but usually occurred more frequently. Treatment is symptomatic. Hemodialysis does not accelerate the elimination of the drug, since sildenafil is strongly bound to plasma proteins and is not excreted by the kidneys.

Special instructions

To diagnose erectile dysfunction, determine their possible causes, and choose appropriate treatment, it is necessary to collect a complete medical history and conduct a thorough physical examination.

Treatment of erectile dysfunction should be used with caution in patients with anatomical deformity of the penis (angulation, cavernous fibrosis, Peyronie’s disease), or in patients with risk factors for priapism (sickle cell anemia, multiple myeloma, leukemia, thrombocythemia).

Cases of prolonged erections and priapism have been reported in post-marketing studies. If your erection persists for more than 4 hours, seek immediate medical attention. If priapism therapy is not carried out immediately, it can lead to penile tissue damage and permanent loss of potency.

Drugs intended for the treatment of erectile dysfunction should not be prescribed to men for whom sexual activity is undesirable.

Sexual activity poses a certain risk in the presence of heart disease, so before starting any therapy for erectile dysfunction, the doctor should refer the patient for a cardiovascular examination. Sexual activity is undesirable in patients with heart failure, unstable angina, stroke or myocardial infarction in the last 6 months, life-threatening arrhythmias, arterial hypertension (BP > 170/100 mm Hg) or hypotension (BP >

Clinical studies have shown no differences in the incidence of myocardial infarction (1.1 per 100 people per year) or the incidence of cardiovascular mortality (0.3 per 100 people per year) in patients treated with sildenafil compared to patients treated with placebo.

Cardiovascular complications

Adverse events such as serious cardiovascular events (including myocardial infarction, unstable angina, sudden cardiac death, ventricular arrhythmia, hemorrhagic stroke, transient ischemic attack, hypertension, and hypotension) that were temporarily associated with the use of sildenafil have been reported during post-marketing use of sildenafil for the treatment of erectile dysfunction. Most of these patients, but not all of them, had risk factors for cardiovascular complications.

Many of these adverse events were observed shortly after sexual activity, and some of them were observed after taking sildenafil without subsequent sexual activity. It is not possible to establish a direct link between the observed adverse events and these or other factors.

Hypotension

Sildenafil has a systemic vasodilating effect, leading to a transient decrease in blood pressure, which is not a clinically significant phenomenon and does not lead to any consequences in most Nazis. However, before prescribing sildenafil, the doctor should carefully assess the risk of possible undesirable manifestations of vasodilating effects in patients with the corresponding diseases, especially against the background of sexual activity.

Increased susceptibility to vasodilators is observed in patients with obstruction of the left ventricular exit tract (aortic stenosis, hypertrophic obstructive cardiomyopathy), as well as with a rare syndrome of multiple systemic atrophy, manifested by a severe violation of blood pressure regulation by the autonomic nervous system.

Since the combined use of sildenafil and alpha-blockers can lead to symptomatic hypotension in some sensitive patients, sildenafil should be prescribed with caution in patients taking alpha-blockers. To minimize the risk of postural hypotension in patients taking alpha-blockers, sildenafil should be started only after the hemodynamic parameters have stabilized in these patients. Consideration should also be given to reducing the initial dose of sildenafil. The doctor should inform patients about what actions should be taken in case of symptoms of postural hypotension.

Visual impairments

In rare cases, post-marketing use of all PDE5 inhibitors, including sildenafil, reported non-arteriitic anterior ischemic optic neuropathy ( NSAID), a rare disease and cause of reduced or lost vision. Most of these patients had risk factors, such as a decrease in the ratio of excavation diameters to the optic disc (“congestive disc”), age over 50 years, diabetes mellitus, hypertension, coronary heart disease, hyperlipidemia, and smoking.

An observational study evaluated whether recent use of PDE5 inhibitors was associated with acute onset of NSAID. The results indicate an approximately 2-fold increase in the risk of NSAIDs within 5 half-lives after the use of a PDE5 inhibitor. According to published literature data, the annual incidence of NPINZD is 2.5-11.8 cases per 100,000 men aged ≥ 50 years in the general population.

Patients with sudden vision loss should be advised to discontinue sildenafil therapy and consult their doctor immediately. Individuals who have already had a case of NSAIDs have an increased risk of recurrence of NSAIDs. Therefore, the doctor should discuss this risk with these patients, as well as discuss with them the potential for adverse effects of PDE5 inhibitors. PDE5 inhibitors, including sildenafil, should be used with caution in such patients and only in situations where the expected benefit outweighs the risk.

A small number of patients with hereditary retinitis pigmentosa have genetically determined disorders of retinal phosphodiseterase function. There is no information on the safety of sildenafil in patients with retinitis pigmentosa, so the drug should be used with caution (see the section “With caution”).

Hearing loss

Some post-marketing and clinical studies have reported cases of sudden hearing impairment or loss associated with the use of all PDE5 inhibitors, including sildenafil, and most of these patients had risk factors for sudden hearing impairment or loss. No causal relationship has been established between the use of PDE5 inhibitors and sudden hearing impairment or hearing loss. In case of sudden hearing loss or loss of hearing while taking sildenafil, you should immediately consult your doctor.

Bleeding issues

Sildenafil enhances the antiplatelet effect of sodium nitroprusside, a nitric oxide donor, on human platelets in vitro. There are no data on the safety of using sildenafil in patients with a tendency to bleeding or exacerbation of gastric and duodenal ulcers, so sildenafil should be used with caution in these patients.The incidence of nosebleeds in patients with pulmonary hypertension associated with diffuse connective tissue diseases was higher (sildenafil 12.9%, placebo 0%) than in patients with primary pulmonary hypertension (sildenafil 3.0%, placebo 2.4%). In patients treated with sildenafil in combination with a vitamin K antagonist, the incidence of nosebleeds was higher (8.8%) than in patients who did not take a vitamin K antagonist (1.7%).

Use in conjunction with other treatments for erectile dysfunction

The safety and efficacy of sildenafil in combination with other PDE5 inhibitors or other drugs for the treatment of pulmonary hypertension containing sildenafil (for example, Revazio® ) or other agents for the treatment of erectile dysfunction have not been studied, so the use of such combinations is not recommended. Influence on the ability to drive vehicles and mechanisms:

Since taking sildenafil may cause dizziness, a decrease in blood pressure, the development of chromatopsia, blurred vision, etc. side effects, caution should be exercised when driving vehicles and engaging in other potentially dangerous activities that require increased concentration and speed of psychomotor reactions. You should also pay close attention to the individual effect of the drug in these situations, especially at the beginning of treatment and when changing the dosage regimen.

Storage conditions

Store at a temperature not exceeding 25 °C.

Keep out of the reach of children.

Shelf

life is 3 years.

Do not use after the expiration date indicated on the package.

Active ingredient

Sildenafil

Conditions of release from pharmacies

By prescription

Dosage form

Tablets

Purpose

For men, For adults as prescribed by a doctor

Indications

Erectile Dysfunction