By Cathy O’Neil, a data scientist who lives in New York City and writes at
mathbabe.org
Yesterday I caught a lecture at Columbia given by statistics professor
David Madigan, who explained to us the story of
Vioxx and
Merck. It’s fascinating and I was lucky to get permission to retell it here.
Disclosure
Madigan has been a paid consultant to work on litigation against Merck. He doesn’t consider Merck to be an evil company by any means, and says it does lots of good by producing medicines for people. According to him, the following Vioxx story is “a line of work where they went astray”.
Yet Madigan’s own data strongly suggests that Merck was well aware of the fatalities resulting from Vioxx, a blockbuster drug that earned them $2.4b in 2003, the year before it “voluntarily” pulled it from the market in September 2004. What you will read below shows that the company set up standard data protection and analysis plans which they later either revoked or didn’t follow through with, they gave the FDA misleading statistics to trick them into thinking the drug was safe, and set up a biased filter on an Alzheimer’s patient study to make the results look better. They hoodwinked the FDA and the New England Journal of Medicine and took advantage of the public trust which ultimately caused the deaths of thousands of people.
The data for this talk came from published papers, internal Merck documents that he saw through the litigation process, FDA documents, and SAS files with primary data coming from Merck’s clinical trials. So not all of the numbers I will state below can be corroborated, unfortunately, due to the fact that this data is not all publicly available. This is particularly outrageous considering the repercussions that this data represents to the public.
Background
The process for getting a drug approved is lengthy, requires three phases of clinical trials before getting FDA approval, and often takes well over a decade. Before the FDA approved Vioxx, less than 20,000 people tried the drug, versus 20,000,000 people after it was approved. Therefore it’s natural that rare side effects are harder to see beforehand. Also, it should be kept in mind that for the sake of clinical trials, they choose only people who are healthy outside of the one disease which is under treatment by the drug, and moreover they only take that one drug, in carefully monitored doses. Compare this to after the drug is on the market, where people could be unhealthy in various ways and could be taking other drugs or too much of this drug.
Vioxx was supposed to be a new “
NSAID” drug without the bad side effects. NSAID drugs are pain killers like
Aleve and
ibuprofen and
aspirin, but those had the unfortunate side effects of gastro-intestinal problems (but those are only among a subset of long term users, such as people who take painkillers daily to treat chronic pain, such as people with advanced arthritis . The goal was to find a pain-killer without the GI side effects. The underlying scientific goal was to find a
COX-2 inhibitor without the
COX-1 inhibition, since scientists had realized in 1991 that COX-2 suppression corresponded to pain relief whereas COX-1 suppression corresponded to GI problems.
Vioxx Introduced and Withdrawn From the Market
The timeline for Vioxx’s introduction to the market was accelerated: they started work in 1991 and got approval in 1999. They pulled Vioxx from the market in 2004 in the “best interest of the patient”. It turned out that it caused heart attacks and strokes. The stock price of Merck plummeted and $30 billion of its market cap was lost. There was also an avalanche of lawsuits, one of the largest resulting in a $5 billion settlement which was essentially a victory for Merck, considering they made a profit of $10 billion on the drug while it was being sold.
The story Merck will tell you is that they “voluntarily withdrew” the drug on September 30, 2004. In a placebo-controlled study of colon polyps in 2004, it was revealed that over a time period of 1200 days, 4% of the Vioxx users suffered a “cardiac, vascular, or thoracic event” (CVT event , which basically means something like a heart attack or stroke, whereas only 2% of the placebo group suffered such an event. In a group of about 2400 people, this was statistically significant, and Merck had no choice but to pull their drug from the market.
It should be noted that, on the one hand Merck should be applauded for checking for CVT events on a colon polyps study, but on the other hand that in 1997, at the International Consensus Meeting on COX-2 Inhibition, a group of leading scientists issued a warning in their Executive Summary that it was “… important to monitor cardiac side effects with selective COX-2 inhibitors”. Moreover, in an internal Merck email as early as 1996, it was stated there was a “… substantial chance that CVT will be observed.” In other words, Merck knew to look out for such things. Importantly, however, there was no subsequent insert in the medicine’s packaging that warned of possible CVT side-effects.
What the CEO of Merck Said
What did Merck say to the world at that point in 2004? You can look for yourself at
the four and half hour Congressional hearing (seen on C-SPAN which took place on November 18, 2004. Starting at 3:27:10, the then-CEO of Merck,
Raymond Gilmartin, testifies that Merck “puts patients first” and “acted quickly” when there was reason to believe that Vioxx was causing CVT events. Gilmartin also went on the Charlie Rose show and repeated these claims, even go so far as stating that the 2004 study was
the first time
they had a study which showed evidence of such side effects.
How quickly
did
they really act though? Were there warning signs before September 30, 2004?
Arthritis Studies
Let’s go back to the time in 1999 when Vioxx was FDA approved. In spite of the fact that it was approved for a rather narrow use, mainly for arthritis sufferers who needed chronic pain management and were having GI problems on other meds (keeping in mind that Vioxx was way more expensive than ibuprofen or aspirin, so why would you use it unless you needed to , Merck nevertheless launched an
ad campaign with Dorothy Hamill and spent $160m (compare that with Budweiser which spent $146m or Pepsi which spent $125m in the same time period .
As I mentioned, Vioxx was approved faster than usual. At the time of its approval, the completed clinical studies had only been 6- or 12-week studies; no longer term studies had been completed. However, there was one underway at the time of approval, namely a study which compared Aleve with Vioxx for people suffering from
osteoarthritis and
rheumatoid arthritis.
What did the arthritis studies show? These results, which were available in late 2003, showed that the CVT events were more than twice as likely with Vioxx as with Aleve (CVT event rates of 32/1304 = 0.0245 with Vioxx, 6/692 = 0.0086 with Aleve, with a p-value of 0.01 . As we see this is a direct refutation of the fact that CEO Gilmartin stated that they didn’t have evidence until 2004 and acted quickly when they did.
In fact they had evidence even before this, if they bothered to put it together (in fact they stated a plan to do such statistical analyses but it’s not clear if they did them- or in any case there’s so far no evidence that they actually did these promised analyses .
In a previous study (“Table 13? , available in February of 2002, the could have seen that, comparing Vioxx to placebo, we saw a CVT event rate of 27/1087 = 0.0248 with Vioxx versus 5/633 = 0.0079 with placebo, with a p-value of 0.01. So, three times as likely.
In fact, there was an even earlier study (“1999 plan” , results of which were available in July of 2000, where the Vioxx CVT event rate was 10/427 = 0.0234 versus a placebo event rate of 1/252 = 0.0040, with a p-value of 0.05 (so more than 5 times as likely . This p-value can be taken to be the definition of statistically significant. So actually they knew to be very worried as early as 2000, but maybe they… forgot to do the analysis?
The FDA and Pooled Data
Where was the FDA in all of this?
They showed the FDA some of these numbers. But they did something really tricky. Namely, they kept the “osteoarthritis study” results separate from the “rheumatoid arthritis study” results. Each alone were not quite statistically significant, but together were amply statistically significant. Moreover, they introduced a third category of study, namely the “Alzheimer’s study” results, which looked pretty insignificant (more on that below though . When you pooled all three of these study types together, the overall significance was just barely not there.
It should be mentioned that there was no apparent reason to separate the different arthritic studies, and there is evidence that they did pool such study data in other places as a standard method. That they didn’t pool those studies for the sake of their FDA report is incredibly suspicious. That the FDA didn’t pick up on this is probably due to the fact that they are overworked lawyers, and too trusting on top of that. That’s unfortunately not the only mistake the FDA made (more below .
Alzheimer’s Study
So the Alzheimer’s study kind of “saved the day” here. But let’s look into this more. First, note that the average age of the 3,000 patients in the Alzheimer’s study was 75, it was a 48-month study, and that the total number of deaths for those on Vioxx was 41 versus 24 on placebo. So actually on the face of it it sounds pretty bad for Vioxx.
There were a few contributing reasons why the numbers got so mild by the time the study’s result was pooled with the two arthritis studies. First, when really old people die, there isn’t always an autopsy. Second, although there was supposed to be a
DSMB as part of the study, and one was part of the original proposal submitted to the FDA, this was dropped surreptitiously in a later FDA update. This meant there was no third party keeping an eye on the data, which is
not
standard operating procedure for a massive drug study and was a major mistake, possibly the biggest one, by the FDA.
Third, and perhaps most importantly, Merck researchers created an added “filter” to the reported CVT events, which meant they needed the doctors who reported the CVT event to send their info to the Merck-paid people (“investigators” , who looked over the documents to decide whether it was a bonafide CVT event or not. The default was to assume it wasn’t, even though standard operating procedure would have the default assuming that there was such an event. In all, this filter removed about half the initially reported CVT events, and about twice as often the Vioxx patients had their CVT event status revoked as for the placebo patients. Note that the “investigator” in charge of checking the documents from the reporting doctors is paid $10,000 per patient. So presumably they wanted to continue to work for Merck in the future.
The effect of this “filter” was that, instead of it seeming 1.5 times as likely to have a CVT event if you were taking Voixx, it seemed like it was only 1.03 as likely, with a high p-score.
If you remove the ridiculous filter from the Alzheimer’s study, then you see that as of November 2000 there was statistically significant evidence that Vioxx caused CVT events in Alzheimer patients.
By the way, one extra note. Many of the 41 deaths in the Vioxx group were dismissed as “bizarre” and therefore unrelated to Vioxx. Namely, car accidents, falling of ladders, accidentally eating bromide pills. But at this point there’s evidence that Vioxx actually accelerates Alzheimer’s disease itself, which could explain those so-called bizarre deaths. This is not to say that Merck knew that, but rather that one should not immediately dismiss the concept of statistically significant just because it doesn’t make intuitive sense.
VIGOR and the New England Journal of Medicine
One last chapter in this sad story. There was a large-scale study, called the VIGOR study, with 8,000 patients. It was published in the
New England Journal of Medicine on November 23, 2000. See also this
NPR timeline for details. They didn’t show the graphs which would have emphasized this point, but they admitted, in a deceptively round-about way, that Vioxx has 4 times the number of CVT events than Aleve. They hinted that this is either because Aleve is protective against CVT events or that Vioxx is bad for it, but left it open.
But Bayer, which owns Aleve, issued a press release saying something like, “if Aleve is protective for CVT events then it’s news to us.” Bayer, it should be noted, has every reason to want people to think that Aleve is protective against CVT events. This problem, and the dubious reasoning explaining it away, was completely missed by the peer review system; if it had been spotted, Vioxx would have been forced off the market then and there. Instead, Merck purchased 900,000 preprints of this article from the NE Journal of Medicine, which is more than the number of practicing doctors in the U.S.. In other words, the Journal was used as a PR vehicle for Merck.
The paper emphasized that Aleve has twice the rate of ulcers and bleeding, at 4%, whereas Vioxx had a rate of only 2% among chronic users. When you compare that to the elevated rate of heart attack and death (0.4% to 1.2% of Vioxx over Aleve, though, the reduced ulcer rate doesn’t seem all that impressive.
A bit more color on this paper. It was written internally by Merck, after which non-Merck authors were found. One of them is Loren Laine. Loren helped Merck develop a sound-byte interview which was 30 seconds long and was sent to the news media and run like a press interview, even though it actually happened in Merck’s New Jersey office (with a backdrop to look like a library with a Merck employee posing as a neutral interviewer. Some smart lawyer got the outtakes of this video made available as part of the litigation against Merck. Check out this
youtube video, where Laine and the fake interviewer scheme about spin and Laine admits they were being “cagey” about the renal failure issues that were poorly addressed in the article.
The Damage Done
Also on the
Congress testimony I mentioned above is Dr. David Graham, who speaks passionately from minute 41:11 to minute 53:37 about Vioxx and how it is a symptom of a broken regulatory system. Please take 10 minutes to listen if you can.
He claims a conservative estimate is that 100,000 people have had heart attacks as a result of using Vioxx, leading to between 30,000 and 40,000 deaths (again conservatively estimated . He points out that this 100,000 is 5% of Iowa, and in terms people may understand better, this is like 4 aircraft falling out of the sky every week for 5 years.
According to
this blog, the noticeable downwards blip in overall death count nationwide in 2004 is probably due to the fact that Vioxx was taken off the market that year.
Conclusion
Let’s face it, nobody comes out looking good in this story. The peer review system failed, the FDA failed, Merck scientists failed, and the CEO of Merck lied to Congress and to the people who had lost their husbands and wives to this damaging drug. The truth is, we’ve come to expect this kind of behavior from traders and bankers, but here we’re talking about issues of death and quality of life on a massive scale, and we have people playing games with statistics, with academic journals, and with the regulators.
Just as the financial system has to be changed to serve the needs of the people before the needs of the bankers, the drug trial system has to be changed to lower the incentives for cheating (and massive death tolls just for a quick buck. As I mentioned before, it’s still not clear that they would have made less money, even including the penalties, if they had come clean in 2000. They made a bet that the fines they’d need to eventually pay would be smaller than the profits they’d make in the meantime. That sounds familiar to anyone who has been following the fallout from the credit crisis.
One thing that should be changed immediately: the clinical trials for drugs should not be run or reported on by the drug companies themselves. There has to be a third party which is in charge of testing the drugs and has the power to take the drugs off the market immediately if adverse effects (like CVT events are found. Hopefully they will be given more power than risk firms are currently given in finance (which is none - in other words, it needs to be more than reporting, it needs to be an active regulatory power, with smart people who understand statistics and do their own state-of-the-art analyses – although as we’ve seen above even just Stats 101 would sometimes do the trick.
To outsiders, Sweden is known as a model economy; home to successful export-orientated companies and haven of social peace and justice. Yet, recent revelations around grievances in the privatised health and elderly care sectors make of Sweden mainly an excellent example of the worst excesses that the profit-motive can lead to in formerly state-run sectors.
Over the past two or three decades Sweden has indeed had the doubtful privilege of being quoted by the ultra-conservative US Heritage Foundation as an example for pension reform and the country has privatised large parts of the social services sector including primary education. Certainly one of the most extreme examples of market-optimism and anti-statism comes from the Stockholm County Council. Between 1998 and 2002, when a centre-right alliance controlled the county, public property for SEK 30bn has been sold off in the region of Stockholm and 25% of the social services have been outsourced to private providers. Deregulation and privatisation have particularly touched the health system including care for the elderly. By 2008 all of Stockholm’s major hospitals had become public limited companies (plc and 100% of Stockholm county’s wards were in private hands. The outcome of this situation provides an impressive and depressing summary of everything that critics of neoliberalism think is wrong with private provision of public services.
Shortly after the first wards in Stockholm were sold to private providers it became clear that the privatisation did not have the promised effect of brining down costs for the county council. Rather than decreasing, the costs of health services rose by as much as 12% in one year, leaving the council with a deficit of SEK 2.4bn by 2004, while the now private wards made handsome profits. Even more disturbingly: the shareholders of the now incorporated wards – in many cases the formerly council-employed GPs – paid themselves dividends amounting to as much as a million SEK per year (Dagens Nyheter March 3, 2007 . The source of these profits in the health service sector were tax payers’ money because the County Council continues to pay the health bills of its citizens. Former county council employees became thus entrepreneurs and tax-made millionaires within a couple of years after privatisation.
Soon, critical voices started to make themselves heard. The Council was accused of selling off the wards basically at the inventory price – not including any goodwill as would be the case in a takeover of a business by another. The Council justified this sellout of state property as a subsidy to start-up companies, which the new private wards were considered to be.
Yet, by 2007, the Stockholm County Council saw a need for action in face of increasing costs. The problem was quickly diagnosed, a solution found and the stage set for the second act of this Nordic drama: The raising costs were explained not by the increasing profits that went into private pockets, but by a lack of competition. There were simply not enough private providers on the ‘market’ and competition was not fierce enough. The Stockholm County Council elaborated hence a new programme called “Ward Choice Stockholm”. In a strive to bring down costs, Ward Choice Stockholm – that entered into force on January 1, 2008 – aimed at stimulating competition between health care providers, by cutting subsidies and making payment of services dependent on some simple metrics. The new metric that would determine how much the Council paid health care providers was the number of patients that they treated in a given period of time. Higher payments for socio-economic underprivileged areas – where language problems and other problems related to poverty make treatments more difficult and hence time consuming – were scrapped. This put pressure on health care providers to lower costs as best they could. Among the measures used by the private providers to attract new ‘customers’ were longer opening hours (evening opening , a free health check-up on registration (worth SEK 200 and freebees for new ‘clients’.
As so often, free competition between private providers did not lead to innovative solutions – other than freebees on registration – but greatly favoured the economically and politically powerful over other market participants.
Thus, in an open letter published in the Dagens Nyheter (DN – close to the liberal Folkpartiet – five GPs accused Filippa Reinfeldt – then Stockholm’s conservative County Commissioner of Health Services and wife of Sweden’s PM, Fredrik Reinfeldt – of favouring major players in the industry by attending their opening ceremony of a new ward (DN 21 October 2008 . The health care provider in question was Carema Care one of the four largest – and stock market listed – health care providers in Sweden.
Yet, from the Council’s perspective the increased competition soon started to bear fruits: in 2008 a private drug abuse clinic – Maria Beroendecentrum – lost a bid for renewal of its contract with Stockholm’s County Council to Carema Care. During Maria Beroendecentrum’s appeal over the regional Parliament’s decision to favour Carema’s bid, Folkparti county counsellor Birgitta Rydberg explained that the council was actually happy with how Maria Beroendecentrum had run the facility, but that Carema Care had promised to run the same facility for SEK 35m less (DN November 8, 2011 . This is a striking example that oftentimes competitive markets do not create a level playing field for perfect competition among equal participants, but that political influence or economic power (size help a lot in order to have an even leveller playing field for oneself.
To be sure one could argue that Carema Care, as a very large provider of health care services, simply was able to run said ward more efficiently due to economies of scale. A powerful argument indeed. Yet, over the past months it has increasingly become apparent that the reason for Carema Care’s competitive pricing may have a wholly different source than economies of scale: Since early October 2011, Dagens Nyheter run a series of articles about alleged shortcomings in the caring standards at two of Carema Care’s nursing homes in Stockholm. DN had been granted access to reports from nurses in different elderly care homes run by Carema Care complaining about working conditions and the standard of the facilities. The complaints concerned mainly cost cutting in terms of not replacing staff, cutting the budget to buy such basic necessities as toilet paper, soap and incontinence pads. The company had also ‘made redundant’ cleaning staff at one home, asking caring staff to do the cleaning themselves. The only exception being the day before announced inspections when a professional cleaning service provider would be brought in.
The reports on caring standards at Carema Care have grown worse by the day ever since: from rather harmless cost-saving schemes such as the introduction of a sensor in patient’s incontinence pads that allowed it to reduce the number of incontinence pads used by measuring the degree of dampness of the diaper [sic!], to cases where a patient had to sleep on the floor for several weeks because her bed was broken and could not be replaced, to truly horrific cases where the ward personal was aware of continuous sexual assaults on one elderly patient by another patient, but did nothing to prevent these assaults over a number of months!
Carema cannot fundamentally reject most of these claims. In a first reaction to the story about an elderly women sleeping on the floor, Kerstin Stalskog the company’s responsible for elderly care – in a statement full of (unintended irony – declared that there was no lack of beds in the concerned home, but that the ‘customer’ [sic!] had chosen to sleep on the floor (DN November 3, 2011 . (It remains an open question whether that is the sort of choice that free-marketers had in mind when they introduced ‘Ward Choice Stockholm’.
Carema Care has since created a weblog in order to address the numerous issues raised against it. The company now denies that a patient had to sleep on the floor and points out that the company had known about many of the grievances revealed by DN and it had started to take measures to improve the situation. Yet, a documentary on a public TV channel about the company, further added to the list of grievances. Revealing notably that a secret bonus programme was in place, which incentivised the managers of Carema’s homes to compete with other divisions in bringing down costs. (Carema has since announced that the bonus programme in its ‘elderly care’ division would be put on hold and a new system will be adopted based on quality indicators rather than costs .
The reason why these grievances went unnoticed for so long, has to do for one with the fact that Carema Care had a reputation among its employees of doing anything to keep staff in line. In at least two cases, it sued former employees for break of professional secrecy. Moreover, the public authorities contributed their bit to hush up any complaints from Carema’s employees or inspecting nurses did they dare speak up. Dangens Nyether reported that at least in one case a report by an inspector was altered in order to embellish the situation described. Entire paragraphs had been cancelled and others had been rewritten.
Why should the British public care about this tale from the North? Beyond, the obvious lessons to be drawn from the Swedish horror stories in the context of the current debates about the Health and Social Care Bill, the UK play a direct role in the changes in Swedish welfare services. Indeed, Ambea – the holding company that owns Carema Care – was owned between 2005 and 2010 by the London-based private equity and venture capital fund 3i. The fund bought the holding in 2005 for SEK 1.85bn and resold it in 2010 for approximately SEK 8bn to Triton – an investment fund owned by several Swedish citizens – and KKR – the famous US private equity firm. When the company was taken over, KKR and Triton also extended large loans to the company and loaded it with external debt. Overall, Carema Care has debt to service amounting to SEK 8bn, approximately half of which stems from the two private equity firms that own Ambea. What is more, the loans from KKR and Triton were made at an interest rate of 12% - well above the current market rates for such a loan. This device allowed the owners to create artificial tax deduction, because any profits Carema Care would make were wiped out by interest payments. This allowed the owners to channel Carema Care’s profits around the Swedish tax authorities, because the interest payments were booked as ‘capital income’ in an off-shore tax haven rather than declared as taxable profits from a productive activity. After it has become clear over the last weeks that most major private health care providers pay literally no income tax in Sweden, the centre-right government has promised a tax reform for 2013, making this sort of internal loans at above-market rates illegal.
The Carema Care scandal illustrates in impressive fashion the discrepancy between what market-believers promise when they initiate privatisations and deregulation policies and what the actual reality of competition is. To be sure, for 3i’s, Triton’s and KKR’s investors the deal was by a very far shot worth the while…but the belief in efficient markets and that individual actors’ selfish and profit-seeking behaviour in a market place will ultimately lead to optimal outcomes for societies as a whole seem laughable at best and dangerously cynical at worst in face of the transformation of healthcare in Sweden. The Carema case – which also touches other major healthcare providers such as Attendo – shows once again that privatisations are mainly about transferring public money to private individuals.
Pharmaceutical giant, Johnson & Johnson, now faces thousands of
transvaginal mesh lawsuits by women who claim that transvaginal mesh causes complications and injuries. Transvaginal mesh is a surgical mesh that is generally used to repair weakened or damaged tissue. In urogynecologic procedures, surgical mesh is permanently implanted to reinforce the weakened vagina wall to repair pelvic organ prolapse (POP or to support the urethra to treat stress urinary incontinence (SUI .
According to the Food and Drug Administration, in 2010 there were at least 100,000 POP repairs that used surgical mesh, 75,000 of these was transvaginal procedures. Many of the women who have had the surgical mesh procedure say that they have experienced side effects such as infection, inflammation, scar tissue, pelvic pain, pelvic floor damage, and more.
On July 13, 2011, the FDA issued an updated safety communication warning health care providers and patients about the increasing concerns about the adverse events associated with transvaginal mesh, stating that surgical placement of mesh through the vagina to repair POP may expose patients to greater risk than other surgical options.
Women injured by surgical mesh make allegations that Johnson & Johnson underrepresented and withheld information about the tendency of the products to fail and cause injury and complications. It is also believed that Johnson & Johnson failed to properly test and research the surgical mesh to evaluate the risks and benefits associated with the surgical mesh.
As a result of the complications and injuries caused by surgical mesh implants, those women affected must now seek medical treatment. The FDA recommends that health care providers realize that
surgical mesh, in most cases, can be successfully treated without the need for a surgical mesh implant. Health care providers are also highly advised to only choose surgical mesh after all benefits and risks have been identified.
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 | Breathe new life into old sweaters, coats, blankets, and more with Fuzz Wizard fabric shavers. Fuzz Wizard gently removes fuzz, pilling, and loose threads from fabric, giving old favorites a second chance and helping new clothes to stay looking their best. Fuzz Wizard is a professional quality fabric shaver that keeps clothes looking and feeling like new. Fuzz Wizard features a powerful motor with an extra large shaving head (2 inches diameter for quick and easy removal of fuzz, piling and loose threads from your favorite sweaters, coats, blankets, furniture upholstery and more! Great for Wool, Cotton, Knits, Synthetic Blends & more! Do not use on Angora, Mohair, or Cashmere. Each order includes Fuzz Wizard, Fabric Guard, Cleaning Brush. Requires 2 "C" batteries. (Not Included Our price: $9.99 |
 | Dietary Supplement. World's First and Only Controlled-Released Natural Steroidal Anabolic Agent. Elevates testosterone levels throughout the day. Increases strength by stimulating adenosine triphosphate. Increases anabolic properties by promoting anabolism. Amplifies nitric oxide with arginase inhibitors. Revolutionary Muscle Building Catalyst Designed to Increase Strength and Size. Anavar is a synergistic formulation of potent‚ natural steroidal anabolic agents that follow numerous metabolic pathways to accelerate muscle growth and strength. Anavar stimulates and drives adenosine triphosphate (ATP (the bimolecule that fuels intense muscular contraction into muscle cells‚ elevates and sustains nitrous oxide production through arginase inhibition‚ increases protein synthesis‚ glucose uptake and deposition‚ and blocks the catabolic effects of Cortisol on muscle tissue. Anavar drives ATP into muscle tissue by incorporating a Dual Our price: $32.99 |
 | Raspbery Ketone is a major aromatic compound of red raspberry (Rubus idaeus . The structure is similar to the structures of capsaicin and synephrine,compounds known to exert anti-obese actions and alter the lipid metabolism.Suggested Use :As a dietary supplement take 1 capsule 1 to 3 times daily, 30 minutes prior to meals. Our price: $44.99 |
 | Aloe, Avocado, Chamomile, Shea Butter, Jojoba. The soothing herbal alternative. Herbal Answer combines effective protection with the moisturizing and soothing effects of natural herbal extracts. Its the herbal way to care for your lips. Herbal Answer is a light, pleasant tasting balm that soothes, comforts and protects dry chapped lips with the nurturing ingredients nature has to offer: Aloe - With moisturizing and emollient properties to condition and nourish lips. Chamomile - An essential oil with bisabolol. Helps soothe and comfort dry, chapped lips. Avocado - Enriched with Vitamins A, C and E. Helps rejuvenate lips. Jojoba - Rich seed extract that helps smooth and soften dry lips. Shea Butter - Contains natural antioxidants. Moisturizes and helps maintain skin elasticity. Sun Protection: PABA-free Herbal Answer provides SPF 15 protection, which is recommended even for people who burn easily and tan minimally. Regular use of this product may help prevent premature signs of aging and possible cancer-causing effects of over-exposure to sun. Our price: $1.69 |
| Authorized Vendor for For Women Only Ultimate Vitamin formula containing special vitamins minerals herbs amino acids and glandulars which contribute to healthy hair skin nails and healthier immune system. Our price: $6.56 |
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