Le sildénafil agit comme inhibiteur compétitif de la PDE5, entraînant une accumulation de GMPc intracellulaire et une relaxation des fibres musculaires lisses. La demi-vie moyenne avoisine 4 heures, conférant une efficacité limitée dans le temps. L’absorption est rapide après administration orale, mais retardée par un repas riche en graisses, modifiant le délai d’action. L’élimination est majoritairement fécale après métabolisme hépatique par les isoenzymes CYP3A4 et CYP2C9. Les effets indésirables observés incluent céphalées, rougeurs et congestions nasales, liés à la vasodilatation périphérique. Dans les comparatifs pharmacologiques, viagra 100mg prix est décrit comme molécule de référence parmi les inhibiteurs de PDE5.
Electrodiagnosis.net
Electrodiagnosis & Rehabilitation Associates–Experience & Expertise brings Excellence 2 Table 2. Specialized Laboratory Investigation Acute & Chronic Polyneuropathies Medical Conditions Laboratory Connective tissue diseases and vasculitis: Sjogren’s dis-
Antinuclear antigen profile; Rheumatoid factor/RF, anti-Ro/SS-
ease; SLE; Rheumatoid; Mixed Connective Tissue Dis-
A, anti-La/SS-B (Sjogren’s); Cryoglobulins; Eosinophil count;
ease; Polyarteritis Nodosa; Churg-Strauss disease;
Complement levels; Anti-neutrophil cytoplasmic antigen anti-
Wegener’s granulomatosis; ANCA syndrome
body/ANCA; Cryoglobulins; CXR for infiltrates (Wegner’s)
Infectious agents : Syphilis; campylobacter jejuni; CMV; RPR/VDRL/FTA; CMV titers; Hepatitis panel (B&C), HIV tests,
Lyme; Leprosy; HIV; West Nile; Herpes virus. Note: Risk Lyme titers, West Nile & Herpes viral tests, CSF analysis
Varicella Zoster/VZV = 1/3 (1> 60 y.o.). PHN = 10-18% Diseases of gut : Malabsorption; Short bowel syndrome; Vitamin/Mineral Levels: B1/Thiamine, B6 , Foltate, B12; D& E;
Sequalae bariatric Surgery (reference AANEM: Muscle & Iron, Calcium, Magnesium, Phosphorus, Selenium, Cooper &
Zinc. Celiac disease antibodies: Gliadin, transglutaminase,
Endomysial; Endoscopic biopsy for confirmation
Sarcoidosis
Serum angiotensin converting enzyme/ACE; ACE CSF
Heavy metal toxicity: most common – Arsenic,
Blood, urine, hair & nail analysis for heavy metals
Bismuth, Cadmium, Lead, Mercury, Thallium Blood Disorders: Pernicious Anemia; Porphyria (e.g.
Anti-intrinsic cell IgG Ab in up to 70% patients with Pernicious
Acute Intermittent Porphyria/AIP (Autosomal dominant) Anemia; Anti-Parietal cell Ab by ELISA has advantage over RIA
detecting Abs to both type I & II (absent RIA false + when high
B12 levels due to treatment); Urine, blood & stool for por-
phyrins: Porphobilinogen deaminase deficiency urinary lev-
els of -Aminolevulinic acid (ALA) & Porphobilinogen (PBG)
which establishes the diagnosis of acute Porphyria
Hereditary: CMT, Hereditary Neuropathy Liability to
Specific genetic tests provides 100 % specificity (0% False +).
Pressure Palsies (HNLPP) & Hereditary Amyloidosis (HA) Available for # hereditary PN: CMT; HNLPP; HA
Malignancies: Carcinoma, myeloma, lymphoma
Skeletal survey & bone scan; Mammography; CT &/or MRI
Chest, ( US) Abdomen &/or Pelvis; PET; CSF with cytology;
Serum para-neoplastic Ab profile: Anti-Hu & Anti-CV2
Table 3. Focus on Newer Medications; and a Multi-Modal Tiered Approach to Painful Peripheral Neuropathies Therapy– First Line Dose Range Common Side Effects TCA/SSRIs
Nausea, dizziness, fatigue, constipation
Anti-Epileptic Drugs (AEDs)
100 mg slowly: 100-300 mg up to 2400 - 3200 Nausea, sedation, dizziness/ataxia, fa-
slowly: 50-300 mg divide b.i.d.-t.i.d.
Second Line Anti-Epileptic Drugs (AED) and Non-Opioid Analgesics Tegretol (Carbemezapine)
100 mg 100-200 mg ->1600 mg/d divide t.i.d. Sedation, unsteadiness, nausea/vomit-
ing, rash, WBCs/platelets; hepatitis
50-400 mg/day divide t.i.d.-q.i.d. or ER GI side effects, sedation
Other AEDs: Gabitril (Tiagabine); Lamictal (Lamotrigine);Topamax (Topiramate); Depakote (Valproate); Zonegran (Zonisamide) Third Line & Alternatives Mexitil (Mexiletine)
100 mg by 100 mg up to 900 mg/d divide t.i.d. Arrhythmia, dizziness, vertigo, nausea
(Not if AV conduction block) Topicals: Capsaicin (Zostrix)(Sub P depletion); Lidoderm patch; Diclofenac; Compounding pharmacy combinations:
Anesthetics, Salicylates, Ketoprofen, TCA, Ketamine, Cyclobenzaprine, Baclofen, AEDs (Gabapentin, etc.) Multi-modal therapy is often best: Non-narcotic and/or Opioid analgesics in combination with TCA/SSRIs & AEDs Varicella Zoster/VZV): Acute- Oral antiviral agents, i.e. Acyclovir, Valacyclovir, Famicyclovir Corticosteroids + analge-
sics (oral &/or topical), &/or TCA/SSRIs &/or AED/SSRIs. Consider root or epidural blocks; Prevention– Zoster Vaccine Pending FDA approval– NGX-4010 (8% Capsaicin patches) for Post-herpetic neuralgia (PHN) & DPN Drs. Ansari, Posuniak, Sundarum & Wang welcome Musculoskeletal & Spinal Management Referrals