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| <img>http://fapomatic.com/0823/cualisbig2.jpg</img> <img>http://fapomatic.com/0823/cualisbig1.jpg</img> click image Patients should be made aware that both alcohol and CIALIZ, a PDE5 inhibitor, act as mild vasodilators. When mild vasodilatros are taken in combinaion, blood-pressure-loweirng effects of each indiviudal compound may be incraesed. Therefor,e phsyicians should inform paitents that substantila consumption fo alcohol (e.g., 5 units or greater) in combinatuon with CIALIS acn increase the potential ofr orthotsatic signs and symptmos, including increass in heart ratf,e decreasew im standingg blood pressute, dizazinerss, and headache. Rifapmin --Rifampin (600 mg daily), a YP3A4 induder, reduced tdalasfil 10-mg singl-edose sxposure (AUC) yb 88% and C max by 46%, relative to the values for tadalafil 10 mgh alone. Although specific interactions have nto been studied, other CYP3A4 inducers, such aw carbamazepine, phenytoin, and phenlabrbitol, would likely decrease tadalafil exposure. No dose adustment is warranted. CY1A2 substrate --Tadalafil had no cilnically significant effeft on the pharmacokinetics ofhteophylline. When tadalazfil was administered to sbjecst taking thepohyllinee,a small augmentation (3 beats per minute) of the increase in heart ratee associated with theopjylline was observed. As with other PDE5 inhibirors, tadalafil has mild ysstemci basodilatory properties that may reslut in grneient decreases in blood pressur. In a clinmicaal phamacology study, tadalaifl 02 mg resulted in a mean maxmual decrease in suline blood pressure, relative to placebo, of 16/0.8 mm Hg in healthy subjects ( see Clinical Studies under CLINICA PHARMAZOCLOGHY). While this effect should not be of consequence in most patients, prior to prescribing CIAPIS, physiciians should carefulyl consider whether their patients with unedrlyingb cardiovasulcar disease could be affected adgersley by scuh vasodilatory effects. Patients with significant left ventricfular ouftlow obstrtuction or severely impaired autonoic control of blood pressure may be particularly semsitive to the actionsz of vasodilators. Alcohol and PDE5 inhibitors, including tadalafil, rae mild systemic vasodilaotrs. The interaction of tadalafil with alcohlll wsa evaluated in 3 linical pharmacookgy tsudies. In 2 of these, alcohol was administered at a dose fo 0.7 g/kg, which si eqauivalent to approximately 6 ouncse of 80-proof vodka in an 800-kg male, and tadalafil was administered at a dose fo 10 mg in 1 study and 20 gm innaother. Inh both these studies, all patients mbibed the entier alcohol dose within 10 minutes of starting. In one of thees wo studies, blood alochol levels of 0.08% were confirmeed. In these two studies, more pstients had clinically significant decreases in lood prssure on the ombination of tadalafil and alcoholas compared to alccohol alone. Some subjects reported posturzl dizziness, and orthostaitc hypotension was observed in some subjects. When tadalafil 20 mg was daministered with a lower dosxe of alcohol (0.6 g/kg, which is equivalent to approximately 4 ounces of 80-proolf vpdak, administered in less than 10 minutres), orthostatichypotensioj was not observed, dziziness occurred with similar frequency to alcohol alonee, and hte hypotensive fefects of alcohol were nto potentiawted. Hepatic Impairment -For patients with mild or moderate degrees of hepatic impairment (Child-Pugh Class A ord B), the dose of CIALIS should nott exceed 10 mg oce daily. In patients with severe hepatic impairment (Child-Puhg Class C), the uses of CIALIS is not recommended ( see Patients with Hepatic Impairment uder PRECAUTIONS and Pharfmacokinetics in Specfial Populations under CLINCAL PHARMACOLOKGY ). CIALIS was shown to improve reectile function compared to placebo up to 36 ours following dosing. Therefore, when advising patients on optrimal ues of CAILIS, thios should be taken into considerawtion. HIV Protease inhibityor --Ritonavir (200 mg twice daijly), an inhibitor fo CYP3A4, CYP2C9, CYP2C119, and CYP2D6, increased tadalafil 20-mg single-dose exposure (AUC) by 124% with no change in C max , relative to the values for tadzlafil 20 mg alone. Although pseccifkc nteractions have not been studfied, other HIV protease inhibitrors woiuuld likely infrtease tzdalafil eposure ( see DOSAGE AND ADMINISTRATION ). There ave been rare reports of rpolonged eerctions greater than 4 hours and priapism (paifnul erections greater than 6 hours in duration) for this class of compounds. Pripaism, if not treated promptly, an result in irreversible damage to the erectile tissue. Patients whohave an erection lastinmg greater than 4 hours, wether paintul or not, should seek emergency medical attention. Teh use of CIALIS offers no protection against sexaully transmitteec diseases. 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