Metformin medscape

Discussion in 'Prescription Pricing' started by renkom, 29-Aug-2019.

  1. A1388 Guest

    Metformin medscape


    Indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus when treatment with both empagliflozin and metformin is appropriate Individualize the starting dose based on the patient’s current drug regimen Not to exceed 25 mg/2000 mg per day Empagliflozin is also indicated to reduce the risk of cardiovascular death in adults with type 2 diabetes mellitus and established cardiovascular disease; however, the effectiveness of empagliflozin/metformin on reducing the risk of cardiovascular death in adults with type 2 diabetes mellitus and cardiovascular disease has not been established Correct volume depletion before initiating if not previously treated with empagliflozin Monitor renal function more frequently after initiating drug in elderly patients, and then adjust dose based on renal function Renal function abnormalities can occur after initiating empagliflozin, metformin is substantially excreted by the kidney, and aging can be associated with reduced renal function Urinary tract infection (7.6-9.3%) Decreased vitamin B12 levels (7%) Increased LDL-C (4.6-6.5%) Female genital mycotic infections (5.4-6.4%) Dyslipidemia (2.9-3.9%) Increased urination (3.2-3.4%) Male genital mycotic infections (1.6-3.1%) Nausea (1.1-2.3%) Hypoglycemia, with monotherapy (1.4-1.8%) Lactic acidosis is a metabolic complication that can occur due to metformin accumulation during treatment and is fatal in ~50% of cases (see Black Box Warnings) Necrotizing fasciitis of the perineum (Fournier gangrene) reported with SGLT2 inhibitors; signs and symptoms include tenderness, redness, or swelling of the genitals or the area from the genitals back to the rectum, and have a fever above 100.4 F or a general feeling of being unwell; if suspected, discontinue SGLT2 inhibitor and start treatment immediately with broad-spectrum antibiotics and surgical debridement if necessary Fatal cases of ketoacidosis reported in patients taking empagliflozin Assess patients who present with signs and symptoms of metabolic acidosis for ketoacidosis, regardless of blood glucose level; consider risk factors for ketoacidosis prior to initiating therapy; patients may require temporary discontinuation of therapy in clinical situation that may predispose to ketoacidosis Empagliflozin causes intravascular volume contraction; symptomatic hypotension may occur after initiating, particularly in patients with renal impairment, elderly patients, patients with low systolic blood pressure, or patients taking diuretics Withholding of food and fluids during surgical or other procedures may increase risk for volume depletion, hypotension and renal impairment; therapy should be temporarily discontinued while patients have restricted food and fluid intake Cardiovascular collapse (shock), acute myocardial infarction, sepsis, and other conditions associated with hypoxemia have been associated with lactic acidosis and may also cause prerenal azotemia; when such events occur, discontinue therapy Hypoglycemia risk increased with insulin and insulin secretagogues (eg, sulfonylureas); a lower dose of insulin or the insulin secretagogue may be required Genital mycotic infections may occur with empagliflozin; patients with history of genital mycotic infections and uncircumcised males are more susceptible Empagliflozin increases the risk for urinary tract infections Metformin associated with decreased vitamin B12 levels Alcohol is known to potentiate metformin’s effect on lactate metabolism; warn patients against excessive alcohol intake while in therapy Cardiovascular collapse (shock) from whatever cause is associated with lactic acidosis and may also cause prerenal azotemia; discontinue drug immediately Empagliflozin may increase LDL-C Unknown if distributed in human breast milk As individual components, both empagliflozin and metformin were secreted in the milk of lactating rats Consider the developmental and health benefits of breastfeeding along with the mother’s clinical need for the drug, and any potential adverse effects on the breastfed infant from the drug or from the underlying maternal condition Empagliflozin: Selective sodium-glucose transporter-2 (SGLT2) inhibitor; SGLT2 is expressed in the proximal renal tubules and is responsible for the majority of the reabsorption of filtered glucose from the tubular lumen; SGLT2 inhibitors reduce glucose reabsorption and lower the renal threshold for glucose, thereby increasing urinary glucose excretion Metformin: Decreases hepatic glucose production; decreases GI glucose absorption; increases target cell insulin sensitivity The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information. Indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus who are not adequately controlled on a regimen containing metformin or canagliflozin or in patients already being treated with both canagliflozin and metformin, individualize dose based on the patient’s current regimen Canagliflozin is also indicated to reduce risk of major adverse cardiovascular events (cardiovascular death, nonfatal MI and stroke) in adults with type 2 diabetes mellitus and established cardiovascular disease Take BID daily with meals, with gradual dose escalation to reduce the adverse GI effects due to metformin Patients on metformin: Switch to tablet containing canagliflozin 50 mg with a similar total daily dose of metformin Patients on canagliflozin: Switch to tablet containing metformin 500 mg with a similar total daily dose of canagliflozin Patients already treated with canagliflozin and metformin: Switch to combination products containing the same total daily doses of each component Adjust dose based on effectiveness and tolerability; not to exceed daily dose of 300 mg/2000 mg Assess renal function before initiating and periodically thereafter Correct volume depletion before initiating in patients not previously treated with canagliflozin Not for treatment of type 1 diabetes or diabetic ketoacidosis Therapy may need to be discontinued at time of, or prior to, iodinated contrast imaging procedures Therapy causes intravascular volume contraction and can cause renal impairment; acute kidney injury, some requiring hospitalization and dialysis reported Fatal cases of ketoacidosis reported in patients taking canagliflozin An approximately 2-fold increased risk of lower limb amputations associated with canagliflozin use was observed in 2 large clinical trials; lower limb infections, gangrene, and diabetic foot ulcers were the most common precipitating medical events leading to the need for an amputation; risk of amputation was highest with baseline history of prior amputation, peripheral vascular disease, and neuropathy (see Black Box Warnings) Lactic acidosis; risk increases with degree of renal dysfunction and age (see Black Box Warnings) Metformin use in patients with impaired hepatic function has been associated with some cases of lactic acidosis The postmarketing metformin-associated lactic acidosis cases primarily occurred in patients with significant renal impairment; the risk of metformin accumulation and metformin-associated lactic acidosis increases with severity of renal impairment because metformin is substantially excreted by the kidney Metformin-associated lactic acidosis have resulted in death, hypothermia, hypotension, and resistant bradyarrhythmias; onset of metformin-associated lactic acidosis is often subtle, accompanied only by nonspecific symptoms such as malaise, myalgias, respiratory distress, somnolence, and abdominal pain; if metformin lactic acidosis suspected, discontinue therapy immediately and institute general supportive measures in hospital setting; prompt hemodialysis recommended Alcohol is known to potentiate the effect of metformin on lactate metabolism Shock from various causes (eg, acute CHF, acute MI, and other conditions characterized by hypoxemia) has been associated with lactic acidosis and may also cause prerenal azotemia Renal impairment; canagliflozin increases serum creatinine and decreases e GFR; metformin is known to be substantially excreted by the kidney and risk of metformin accumulation and lactic acidosis increases with the degree of renal impairment; ensure normal renal function before initiating and at least annually thereafter Before initiating therapy, consider factors that may predispose patients to acute kidney injury including hypovolemia, chronic renal insufficiency, congestive heart failure, and concomitant medications (diuretics, ACE inhibitors, ARBs, NSAIDs); consider temporarily discontinuing therapy in any setting of reduced oral intake (such as acute illness or fasting) or fluid losses (such as gastrointestinal illness or excessive heat exposure) Withholding of food and fluids during surgical or other procedures may increase risk for volume depletion, hypotension and renal impairment Before initiating therapy, obtain an estimated glomerular filtration rate and obtain an e GFR at least annually; assess more frequently in patients at increased risk for development of renal impairment Consider temporarily discontinuing in settings of reduced oral intake or fluid losses; if acute kidney injury occurs, discontinue and promptly treat; monitor renal function during therapy Hyperkalemia reported with canagliflozin; monitor potassium levels in patients with impaired renal function and in patients predisposed to hyperkalemia Dose-related increases in LDL‑C reported with canagliflozin; monitor LDL-C and treat as indicated Canagliflozin increases risk for genital mycotic infections; treat if indicated Increases risk of urinary tract infections (UTIs), including life-threatening urosepsis and pyelonephritis that started as UTIs; evaluate patients for signs and symptoms of urinary tract infections and treat promptly, if indicated Necrotizing fasciitis of the perineum (Fournier gangrene) reported with SGLT2 inhibitors; signs and symptoms include tenderness, redness, or swelling of the genitals or the area from the genitals back to the rectum, and have a fever above 100.4 F or a general feeling of being unwell; if suspected, discontinue SGLT2 inhibitor and start treatment immediately with broad-spectrum antibiotics and surgical debridement if necessary Ketoacidosis associated with SGLT2 inhibitors reported; monitor for signs of ketoacidosis and advise patients to seek immediate medical attention for symptoms (eg, difficulty breathing, nausea, vomiting, abdominal pain, confusion, unusual fatigue or sleepiness); assess patients who present with signs and symptoms of metabolic acidosis for ketoacidosis, regardless of blood glucose level; consider risk factors for ketoacidosis prior to initiating therapy; patients may require temporary discontinuation of therapy in clinical situations that may predispose to ketoacidosis Metformin may lower vitamin B12 levels without manifestations; monitor hematologic parameters annually Increased risk of bone fracture, occurring as early as 12 weeks after treatment initiation, reported; consider factors that contribute to fracture risk prior to initiating therapy Hypersensitivity reactions, including angioedema and anaphylaxis reported with canagliflozin; these reactions generally occurred within hours to days after initiating canagliflozin; if hypersensitivity reactions occur, discontinue therapy; treat and monitor until signs and symptoms resolve Canagliflozin: Selective sodium-glucose transporter-2 (SGLT2) inhibitor; SGLT2 is expressed in the proximal renal tubules and is responsible for the majority of the reabsorption of filtered glucose from the tubular lumen; SGLT2 inhibitors reduce glucose reabsorption and lower the renal threshold for glucose, thereby increasing urinary glucose excretion Metformin: Biguanide; acts by decreasing endogenous hepatic glucose production, decreases intestinal absorption of glucose, and improves insulin sensitivity by increasing peripheral glucose uptake and utilization; improves glucose tolerance and lowers both basal and postprandial plasma glucose The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

    Ciprofloxacin yogurt Buy amoxicillin online overnight delivery Sertraline bipolar

    Metformin is a prescription drug used to treat type 2 diabetes. Learn about. Metformin. https//reference.medscape.com/drug/glucophage-metformin-342717. Treat polycystic ovarian syndrome with Glucophage / Metformin Alone Metformin Dosing and Protocol. Metformin is taken in a dose that the woman can tolerate. Most people can tolerate 500 mg three times daily, if they build up to that dose gradually. Medscape - Type 2 diabetes mellitus dosing for Synjardy, Synjardy XR empagliflozin/metformin, frequency-based adverse effects, comprehensive interactions.

    Indicated as adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus who are already treated with sitagliptin or metformin and have inadequate glycemic control on sitagliptin or metformin alone Individualize starting dose based on patient’s current regimen Adjust dose according to effectiveness and tolerability; not to exceed daily dose of 5 mg/2000 mg Administer q Day with evening meal Contraindicated in patients with renal impairment, carefully monitor renal function in the elderly and use with caution as age increases Initial and maintenance dosing of metformin should be conservative in patients with advanced age due to the potential for decreased renal function in this population Controlled clinical studies of metformin did not include sufficient numbers of elderly patients to determine whether they respond differently from younger patients Saxagliptin: In the 6, double-blind, controlled clinical safety and efficacy trials of saxagliptin, 634 (15.3%) of the 4148 randomized patients were 65 years or older, and 59 (1.4%) patients were 75 years or older No overall differences in safety or effectiveness were observed between patients 65 years or older and younger patients 5 mcg/m L) is a rare but potentially severe consequence; if it occurs, mortality is ~50% Incidence is rare (~0.03 cases/1000 patient-years with 0.015 fatal cases/100 patient-years) Patients with CHF requiring pharmacologic management, in particular those with unstable or acute CHF who are at risk of hypoperfusion and hypoxemia, are at an increased risk of lactic acidosis Risk of lactic acidosis increases with the degree of renal dysfunction and age Do not start in patients aged 80 years or older unless Cr Cl demonstrates that renal function is not reduced because these patients are more susceptible to developing lactic acidosis Promptly withhold metformin with hypoxemia, dehydration, or sepsis Avoided with clinical or laboratory evidence of hepatic disease Caution against excessive alcohol intake, either acute or chronic, during metformin therapy because alcohol potentiates the effects of metformin on lactate metabolism Should be temporarily discontinued prior to any intravascular radiocontrast study and for any surgical procedure The onset of lactic acidosis often is subtle and accompanied by nonspecific symptoms (eg, malaise, myalgias, respiratory distress, increasing somnolence, nonspecific abdominal distress) DPP-4 inhibitors may cause joint pain that can be severe and disabling; resolves within a month upon discontinuing the drug Once stabilized on any dose level of metformin, GI symptoms, which are common during initiation of therapy, are unlikely to be drug related; later occurrences of GI symptoms could be due to lactic acidosis or other serious disease Gradual increase of metformin dose may reduce GI side effects Metformin may decrease serum vitamin B12 concentration Do not exceed saxagliptin 2.5 mg/day when coadministered with strong cytochrome P450 3A4/5 (CYP3A4/5) inhibitors (eg, ketoconazole, atazanavir, clarithromycin, indinavir, itraconazole, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin) Coadministration of saxagliptin with thiazolidinediones (eg, rosiglitazone, pioglitazone) increases risk for peripheral edema Inactive tablet ingredients (ie, ghost tablet) may be eliminated in the feces as a soft, hydrated mass Pancreatitis reported with saxagliptin; monitor for signs and symptoms and discontinue if pancreatitis suspected Serious hypersensitivity reactions with saxagliptin reported (typically within the first 3 months of therapy) Caution with history of angioedema Severe and disabling arthralgia reported in patients taking DPP-4 inhibitors; consider as a possible cause for severe joint pain and discontinue drug if appropriate Limited available data in pregnant women are not sufficient to determine drug-associated risk for major birth defects and miscarriage; published studies with metformin use during pregnancy have not reported a clear association with metformin and major birth defect or miscarriage risk No adverse developmental effects independent of maternal toxicity observed when saxagliptin and metformin were administered separately or in combination to pregnant rats and rabbits during period of organogenesis Poorly controlled diabetes in pregnancy increases maternal risk for diabetic ketoacidosis, pre- eclampsia, spontaneous abortions, preterm delivery, stillbirth and delivery complications. Poorly controlled diabetes increases fetal risk for major malformations, still birth, and macrosomia related morbidity There is no information regarding presence of metformin or alogliptin in human milk, effects on breastfed infant, or effects on milk production; limited published studies report that metformin is present in human milk; however, there is insufficient information to determine effects of metformin on breastfed infant and no available information on effects of metformin on milk production; the developmental and health benefits of breastfeeding should be considered along with mother’s clinical need for therapy and any potential adverse effects on breastfed infant from therapy or from underlying maternal condition Saxagliptin: Dipeptidyl peptidase IV (DPP-4) inhibition that results in increased incretin hormones and enhanced glycemic control Metformin: Biguanide; acts by decreasing endogenous hepatic glucose production, decreases intestinal absorption of glucose, and improves insulin sensitivity by increasing peripheral glucose uptake and utilization; improves glucose tolerance and lowers both basal and postprandial plasma glucose Half-Life: saxagliptin 2.5-3.1 hr; metformin 6.2 hr (plasma) and 17.6 hr (blood) Peak Plasma Time: metformin extended-release 4-8 hr Peak Plasma Concentration: saxagliptin and active metabolite (24 ng/m L, 47 ng/m L) Protein Bound: negligible for both saxagliptin and metformin Metabolism: saxagliptin by CYP3A4/5; major active metabolite is also a DPP4 inhibitor (50% as potent); metformin is excreted unchanged in urine and does not undergo hepatic metabolism Excretion: feces (saxagliptin 22%), urine (saxagliptin 75%; metformin 90%) The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information. Not be used in patients with type 1 diabetes or for the treatment of diabetic ketoacidosis, as it would not be effective in these settings Has not been studied in patients with a history of pancreatitis; unknown whether patients with a history of pancreatitis are at an increased risk of developing pancreatitis when taking linagliptin Has not been studied in combination with insulin Acute pancreatitis, including fatal pancreatitis Rash Hypersensitivity reactions including anaphylaxis, angioedema, and exfoliative skin conditions Mouth ulceration, stomatitis Severe and disabling arthralgia Discontinue metformin at the time of or before an iodinated contrast imaging procedure in patients with an e GFR between 30-60 m L/minute/1.73 m²; in patients with a history of liver disease, alcoholism, or heart failure; or in patients who will be administered intra-arterial iodinate contrast Rare reports of lactic acidosis (see Black Box Warnings) Monitor hepatic and renal function; risk of metformin accumulation and lactic acidosis increases with renal impairment; hepatic impairment limits ability to clear lactate Avoid excessive alcohol intake; alcohol is known to potentiate effect of metformin on lactate metabolism Use of concomitant medications that may affect renal function or metformin disposition Use in combination with an insulin secretagogue (eg, sulfonylurea) was associated with a higher rate of hypoglycemia compared with placebo in a clinical trial May lead to decreases levels of vitamin B12 without clinical manifestations (occurred in approximately 7% of patients) Cardiovascular collapse (shock) from whatever cause (eg, acute congestive heart failure, acute myocardial infarction, and other conditions characterized by hypoxemia) has been associated with lactic acidosis and may also cause prerenal azotemia; discontinue drug promptly Severe and disabling arthralgia reported in patients taking DPP-4 inhibitors; consider as a possible cause for severe joint pain and discontinue drug if appropriate No conclusive evidence of macrovascular risk reduction reported with antidiabetic drugs Serious hypersensitivity reactions reported including anaphylaxis, angioedema, and exfoliative skin conditions; discontinue therapy promptly, assess for other potential causes, institute appropriate monitoring and treatment, and initiate alternative treatment for diabetes Heart failure has been observed with two other members of the DPP-4 inhibitor class; consider risks and benefits of empagliflozin in patients with risk factors for heart failure; monitor for signs and symptoms; if heart failure develops, manage accordingly to standard of care and consider interrupting treatment Bullous pemphigoid reported with DPP-4 inhibitor use, which required hospitalization; in reported cases, patients recovered with topical or systemic immunosuppressive treatment and discontinuation of DPP-4 inhibitor; patients should report development blisters/erosions; discontinue DPP-4 therapy and consult a dermatologist if bullous pemphigoid suspected Limited data in pregnant women not sufficient to inform associated risk for major birth defects and miscarriage with product; published studies with metformin use during pregnancy have not reported a clear association with metformin and major birth defect or miscarriage risk; there are risks to mother and fetus associated with poorly controlled diabetes in pregnancy Poorly controlled diabetes in pregnancy increases maternal risk for diabetic ketoacidosis, pre-eclampsia, and delivery complications; poorly controlled diabetes increases fetal risk for major birth defects, still birth, and macrosomia-related morbidity There is no information regarding presence of product in human milk, effects on breastfed infant, or effects on milk production; however, linagliptin is present in rat milk; limited studies report that metformin is present in human milk; there is insufficient information to determine effects of metformin on breastfed infant and no available information on effects of metformin on milk production; therefore, developmental and health benefits of breastfeeding should be considered along with mother’s clinical need for therapy and any potential adverse effects on breastfed child from therapy or from underlying maternal condition Linagliptin: Dipeptidyl peptidase 4 (DPP-4) inhibitor; increases and prolongs incretin hormone activity from glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) which are inactivated by the DPP-4 enzyme; incretins increase insulin release and reduce glucagon secretion Metformin: Decreases hepatic glucose production; decreases GI intestinal glucose absorption; increases target cell insulin sensitivity; lowers both basal and postprandial plasma glucose and unlike sulfonylureas, does not typically produce hypoglycemia or hyperinsulinemia Half-life: 12 hr (linagliptin); 6.2 hr (metformin) Dialyzable: Removal of linagliptin by dialysis is unlikely and metformin is dialyzable (clearance of up to 170 m L/min under good hemodynamic conditions) Renal clearance: 70 m L/min (linagliptin) Excretion: Linagliptin enterohepatic system (80%) or urine (5%); metformin urine (90%) Take with a meal Dosing should be individualized on the basis of both effectiveness and tolerability, while not exceeding the maximum recommended dose for either prompt-release or extended-release tablets Prompt-release: When initiating, dose escalation should be gradual to reduce the GI side effects associated with metformin The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

    Metformin medscape

    Love Affair With Metformin Still Strong, or Time to Move. - Medscape, Polycystic Ovarian Syndrome Fertility Treatment with.

  2. Levitra vs viagra cost
  3. Amoxicillin for toddlers
  4. This site uses cookies. By continuing to browse this site you are agreeing to our use of cookies.

    • UpToDate.
    • Empagliflozin/metformin - Medscape Reference.
    • Metformin Remains Best First-line Therapy for Type 2. - Medscape.

    Dec 18, 2018. New evidence suggests that preventing vitamin B12 deficiency could reduce peripheral neuropathy in patients on metformin. Metformin oral tablet is a prescription drug that’s used along with diet and exercise to treat high blood sugar levels caused by type 2 diabetes. Tablets are available as generic drugs and as. Dec 12, 2014. Metformin is the first-line pharmacologic treatment for patients with T2D and can be useful in preventing or delaying diabetes in patients with.

     
  5. Quink Well-Known Member

    If you’ve been knocked out by sinus infection symptoms—stuffiness, face pain or pressure, nasal discharge—your doctor might recommend that you wait it out for a week or so before resorting to an antibiotic. And she or he might be right: Antibiotics are often not necessary for clearing up a sinus infection, according to recent research. As a result, many health experts, including Zara Patel, M. D., a sinus infection expert and assistant professor of otolaryngology at Stanford University in Stanford, Calif., are urging doctors to think twice before prescribing antibiotics for sinus and other respiratory infections. A 2016 study, published in JAMA, found that people who went to the doctor with a sinus infection were more likely to leave with a prescription for antibiotics than people seeing the doctor for any other reason (such as a sore throat or an ear infection). But some doctors, pointing to newer evidence, are starting to take a more cautious approach. “For acute sinusitis, there are very well-done studies indicating that antibiotics are not necessary in the vast majority of patients, and most people will be able to clear an infection on their own,” Patel says. Essential Oils for Sinus Infection and Sinus Congestion. Strong Home Remedies for Sinus Infection You have to Try Sinus Infection Sinusitis Sinus infection Symptoms.
     
  6. zane New Member

    Visit allieduniversaledge.now to see the best up-to-date Allied Universal EDGE Exceedlms content for India and also check out these interesting facts you probably never knew about allieduniversaledge.We analyzed Allieduniversaledge.page load time and found that the first response time was 52 ms and then it took 479 ms to load all DOM resources and completely render a web page. This is an excellent result, as only 5% of websites can load faster. HTML content can be minified and compressed by a website’s server. The most efficient way is to compress content using GZIP which reduces data amount travelling through the network between server and browser. It is highly recommended that content of this web page should be compressed using GZIP, as it can save up to 13.2 k B or 61% of the original size. Image size optimization can help to speed up a website loading time. The chart above shows the difference between the size before and after optimization. Allied Universal EDGE Exceedlms images are well optimized though. Allied Universal Client and Employee Login Portal Access Allied Universal EDGE Login. Allied Universal Employee Benefit Job Training Glassdoor
     
  7. uzrealtor User

    Does Propranolol Help Anxiety? Side Effects, Dosage & Warnings Does Propranolol Really Help Anxiety? Read How does It Works, Side Effects, Interactions, Uses, Over Dose Problems, Warning and Conclusion.

    Propranolol Side Effects, Dosage, Uses, and More
     
  8. TifsHeeseegop New Member

    Revatio, Viagra sildenafil dosing, indications, interactions. Medscape - Pulmonary hypertension, erectile dysfunction-specific dosing for Revatio, Viagra sildenafil, frequency-based adverse effects, comprehensive interactions.

    Side Effects of Sildenafil Citrate - Men Home Page