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Viagra® (Sildenafil) information for patients; Avoid getting ripped off when you buy Viagra online from the perspective of a pharmacist; Viagra cost, price comparison; anti counterfeiting measures; also Viagra mechanism of action, discovery timeline, and other interesting Viagra trivia

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Fig. 1: Comparative images; real Viagra, so-called "generic Viagra"

Pill A: Picture of an authentic 100 mg pill of Pfizer Viagra® tablet.

Pill B: Picture of so-called generic Viagra 100mg purchased from an internet pharmacy.  Manufacturing source unknown.  Note the darker blue color and the round shape of the generic pill.

Buying Viagra Online - Pharmacist's Perspective

My name is Corey Nahman.  I've been a licensed  pharmacist since 1983.  Whenever I am at a party or a wedding, etc., people always ask me about buying Viagra on the internet.  Is it safe?  How much does it cost?  How do you know you're getting the real thing?  What is the difference between fake Viagra, counterfeit Viagra and generic Viagra?  So I figured that since there is such an interest in this topic I would put together a web page to help out the millions of men who are curious about buying erectile dysfunction drugs on the internet.

The difference Between Generic, Counterfeit and Fake Viagra

You always read about people getting busted for dealing in fake or counterfeit Viagra.  Law enforcement and media frequently mix up the terms "fake" and "counterfeit".  When the government or law enforcement refers to fake or counterfeit Viagra they mean any product that contains the active ingredient in Viagra (silendafil) except than Viagra tablets made by Pfizer.  Period.  Any and all so-called generic Viagra is considered to be an illegal substance because generic versions of Viagra are not approved in the United  States and likely won't be until 2019 due to patent laws.

If a pill is made to resemble brand name Viagra manufactured by Pfizer but it is not genuine, it is referred to as a "fake", "knockoff" or "counterfeit"  (just like counterfeit designer bags, watches, headphones, etc.)  The counterfeit Viagra may contain active ingredient, although sometimes it does not.

Generic Viagra:

Generic Viagra refers to a product that contains the active ingredient in Viagra (silendafil) in the same strength ( 25 mg, 50 mg, 100 mg) as the branded version.  It does not pretend to be Viagra brand silendafil although most of the time so-called generic Viagra will be colored blue and may have the characteristic diamond shape associated with the real thing.  Generic Viagra is usually labeled as silendafil. 

Generic Viagra is not approved for sale in the USA but is legal in many other countries such as Canada and Brazil.  Since generic Viagra is not approved by the FDA it is considered to be an illegal substance.

The retail price of generic Canadian Viagra is 1/4 of what you'd pay in the USA.

The loophole is that you are allowed to purchase small quantities of generic Viagra for personal use in countries where it is legal and bring it home.  I have done so myself while visiting Mexico.

It is illegal to buy or sell generic Viagra on the internet and ship it across the US border.  If postal authorities catch it they will confiscate it and destroy it.   Law enforcement never goes after the buyers.  They focus on the sellers. 

If they do get arrested and prosecuted, people who selling unapproved versions of Viagra to Americans face criminal for violating the Prescription Drug Marketing A of 1987.  Charges associated  with the violation of this law include Federal prison sentences of up to 10 years in a federal prison.

Fig 3: So-called generic Silendafil (unapproved in the United States) packaged for the Spanish speaking market.  Commonly found in tourist resorts, airports, pharmacies across the Spanish speaking world.

Fig 2: So-called Generic Viagra pills from India.  Note that other than the blue color, no attempt has been made to duplicate the tablet shape or blister packaging.

Fig 5: Generic version of Viagra manufactured by Teva, a multinational drug company.  The above silendafil tablets are labeled in Czech. 

Although Teva markets hundreds of products in the United States, the above product is not allowed to be sold in the USA.

Fig 4: Generic version of Viagra with the brand name Suhagra, manufactured in India by Cipla, a well known drug company. 

While Suhagra is approved for sale in India and many other countries.  It is not approved for use in the United States.  FDA and law enforcement consider it to be an illegal substance.

Counterfeit Viagra

Counterfeit Viagra has the look and feel of the real McCoy just as a counterfeit $100 bill looks like a genuine $100 bill.  Counterfeiters go to a lot of trouble to make their product and the packaging look like the real thing.  Many times it takes an expert to tell the two apart.  To make matters worse,  the counterfeit pills often contain a little real active ingredient (silendafil), to make the masquerade better.   

Unfortunately for the consumer, you have no way of telling how many milligrams of silendafil the pills contain.  They can contain too little or two much depending on the Viagra bootlegger's skills.

However, many times the counterfeit Viagra contains no active ingredient.  Counterfeit Viagra has been  known to contain chalk, brick dust or baby powder.

According to a recent Forbes magazine article, 77% of the Viagra sold on the internet is fake.  Of the websites that sell fake or counterfeit Viagra, 32% contain no active ingredient.  Most of the websites that sell Viagra pretend to be Canadian but are located in other countries such as the former Soviet Union, Caribbean or Asia.

In 2008, Bloomberg.com reported that illegal Viagra was responsible for a large portion of counterfeit medicine seizures.  Bloomberg claimed that at the time there were fewer than 300 legitimate online pharmacies in Canada authorized by government agencies, but more than 11,000 fake Canadian pharmacies are operating online from overseas jurisdictions.  That means that at least in 2008, only 3% of the online pharmacies that claimed to be Canadian actually were Canadian. 

How Does Pfizer Deter Counterfeit Viagra?

Pfizer is engaged in a constant battle against the introduction of fake Viagra into the pharmaceutical supply chain. Pfizer uses redundant high tech security features to make it easy to detect counterfeit Viagra pills and packaging:

Beginning On 2005, all bottles of Viagra have had a very small identification microchip (known as a RFID) embedded into the bottle. The bottles are embedded with a Tagsys Flexible Module passive high-frequency (13.56 MHz) tag. This means that every bottle of Viagra has a special electronic fingerprint so that pharmacists and wholesalers can track the pedigree of the tablets inside to ensure that they are authentic and obtained legally.

Each Viagra label also contains a special two-dimensional barcode that works hand in hand with the RFID chip so that pharmacists and wholesalers can track the Viagra from the factory, through the supply chain down to the individual consumer.

The labels on the Viagra bottles (as well as many other Pfizer products such as Lipitor and Celebrex) are printed with a color shift ink bar which is hard to fake but easy to recognize with the naked eye, similar to what you see with paper money.

Pfizer also employs a team of scientists and international team of professionals  to track down suspected fake Viagra factories and dealers.   Pfizer Global Security, a group comprised of former law-enforcement pros. The company placed its chief security officer front and center to detail the hazards of fake drugs and highlight Pfizer's activity to combat them.

Fig. 6: Counterfeit Viagra: Example of counterfeit Viagra tablets and packaging compared to genuine Pfizer product

Fig 7: High quality counterfeit Viagra.  In this example, it is very difficult to tell the counterfeit from the genuine Viagra. 

The tablet imprint on genuine Viagra is "VGR".  The tablet imprint on the counterfeit is "VGP".

The counterfeit imprinting is lighter than on the real Viagra.

The counterfeit tablets appear to have slightly thicker edges.

Fig. 8: Counterfeit Viagra Factory
Counterfeit Viagra factory; Guangzhou, China; Circa 2010

Bottom Line

US governmental agencies don't go after the people who buy it, but postal inspectors will confiscate it if they find it.  And, if it gets confiscated, good luck getting your money back from the website you bought it.

You are taking a chance with your health if you take generic sildenafil because the ingredients are completely unknown. If you are unsure where to buy Viagra, see my recommendation above.

Red Flags Regarding Buying Viagra Online:

When you buy anything on the internet, you should be making your purchase based on the reputation of the seller.  Trustworthy seller = trustworthy product.  I call this the ebay principle.  This applies to buying anything on the internet, especially medicines. 

If you do buy brand name Viagra on the internet or if you want to take a chance and try the generic struff, the most important thing is to deal with a trusted online pharmacy.

- Make sure there is a physical address on the website selling the Viagra. It should be a real address, not a P.O. box. If there is no address that is a bad sign.

Why would someone want to hide their address? No address means that they are deliberately making it hard for you to track them down in case there is a problem.

- The website where you buy Viagra should have a toll free telephone number. If something goes wrong you want to be able to speak to a real live person. It is very frustrating to only be able to communicate by e-mail when you have a problem.

Test the telephone number before you place your order. Ask the person who answers the phone where the Viagra is shipped from. If they don't answer to your satisfaction, it's a bad sign.

- Do they have a 24-hour chat or IM customer service? The reliable, established internet pharmacies all have this service integrated into their sites. If they have such a service, test drive it.

- How long does it take for the person on the other end to respond? Ask them some questions such as: "How long have you been in business? Who is the manufacturer of your Viagra (it should be Pfizer)? Where is it shipped from? How long does it take to get my shipment. What is the cost of Viagra?

- Ask them if they do the shipping and handling or if they only do the billing.

- There is a good chance that the person on the other end of the phone is just a go-between; a clerk in front of a credit card machine, doing the billing for hundreds of Viagra websites.

In many instances, they have no idea who the Viagra merchant is; all they know is that once a month they get a commission check from someone they have never seen or met in person.

Their job is answering the phone and ringing up your sale. After your credit card has been charged, the relationship is over.

- You get what you pay for. If it seems too good to be true, it probably is too good to be true. The price of Viagra can be deceiving. You are better off paying $40.00 per pill at your local drugstore and getting genuine American Viagra than paying $11.00 for a so-called generic Viagra on the internet and getting a fake or harmful pill. Your Viagra cost is not the most important thing to consider.

- Your first purchase should be for a small quantity of pills. Don't start off with thirty tablets. Buy five or ten. Make sure the Viagra is legit and the shipping and billing goes smoothly before you make a large purchase.

- You should never deal with a site from Russia or Nigeria, places where identity theft is common. Scammers in these countries have been known to set up sham Viagra web sites just so they could steal your credit card information.

Where does fake Viagra come from?

Most of the fake Viagra comes from Asia and South America where the laws regarding pharmaceuticals are lax.

Most of the Viagra selling websites are fly-by-night operations looking to make a quick buck with a low price of Viagra. They often masquerade as American or Canadian internet pharmacies but they are usually located outside the law in countries such as China, Japan, Cambodia or Bulgaria.


How much should it cost?

GoodRX.com, a leading prescription pricing website claims that you can obtain 10 Viagra pills for between $30 and $40 per pill in the USA.  Another popular online pharmacy site - RxUSA.com sells Viagra 100 mg for  $36 per pill.  High quality generic Canadian Viagra from legitimate Canadian pharmacies  goes for half that.  If you see websites where the cost of Viagra is $3, $5, or even $10 a pill, you will know that they are generic or worse, a counterfeit.

Who does this site recommend?

If you are looking for brand-name Viagra online manufactured by Pfizer Laboratories, without a prior prescription, one vendor I recommend is AccessRx.com, a division of Secure Medical LLC. They have been in business since 1998, are located in the USA in Tempe Arizona, and even offer overnight shipping. They have an A+ rating from the Arizona Better Business Bureau.

AccessRx,com works with FDA approved pharmacies to insure that people who buy Viagra from them (as well as other products) are legit meds.  I called them up.  AccessRx is run by a gentleman named Jerry Rao.  He has a brick and mortar location located at 5801 S. McClintock Drive Suite 107, Tempe AZ 85283, USA.  They have been online since 1998. 

No Prescription needed? Welcome To Internet Enabled Telemedicine:

With Access RX you do not need a previous prescription to get the Viagra.  They do this via telemedicine.  (You also have the option to do a video consultation with a medical professional).

You fill out a detailed questionnaire regarding your state of health  (medical conditions, other medicines taken, height, weight, etc).  One of their licensed physicians evaluates your information.  If appropriate, they will contact your physician for further information. If everything checks out, the physician writes you a prescription for the Viagra and they ship it out to you.

Their prices are competitive with large chain drugstores and you are assured of getting brand-name, American, FDA-Approved Viagra delivered to your door in a couple of days without having to go to a doctor. Expect to pay  $23.75 dollars per pill.  The icing on the cake is that you save the time and money associated with a visit to a doctor's office.  This is especially fantastic if you do not have medical insurance or if your insurance does not cover Viagra. 

In Closing:

Stay away from generic  or counterfeit Viagra, as the pills are made from compounds that are not FDA-approved and can cause serious harm to your health. The cost of Viagra online should be about the same as you would get at your local pharmacy ($30 - $40 per 100 mg tablet) , but you can actually save money if you buy Viagra online because you won't have a co-pay like you would if you received a Viagra prescription from your local doctor.

Interesting Viagra Pharma Factoids:

When was Viagra discovered?

1989
Pfizer Scientists synthesize silendafil citrate and give it the code name UK-92, 480. The drug would not be known as Viagra until the mid-90s.
Experimental compound UK-92,480 is believed to be useful as a high blood pressure and angina treatment. The scientists hope it may act as a vasodilator and be useful in treating cardiovascular ailments such as hypertension and angina.

1991
Researchers at Pfizer's Sandwich, England research facility (Peter Ellis and Nick Terret) observe that drugs that inhibit the PDE5 enzyme may be helpful in reversing erectile dysfunction.
Early Phase 1 trials regarding the use of Viagra for angina are unremarkable.

1992
A second Phase 1 angina trial reveals that the drug has an unusual side effect; penile erections.
Phase 2 clinical study is conducted testing silendafil citrate's usefulness as an angina treatment.

1993
Pilot study using silendafil citrate as a treatment for erectile dysfunction is conducted in Bristol, England. Test subjects take it three times a day for a week. The studies had only 28 men involved.

1994
Second pilot study on silendafil as an Erectile dysfunction treatment demonstrates that a once per day dose is able to produce an erection.
Pfizer realizes it has something important; it accelerates the program examining silendafil citrate for erectile dysfunction.
1994 - 1997

21 clinical trials are conducted involving 4,500 men demonstrate that Viagra (as it is now known) is safe and effective.

1997
Pfizer files a New Drug Application for Viagra (NDA 020895) with the United States FDA. FDA agrees to give it a priority review.
1998

FDA approves Viagra as the first oral treatment for erectile dysfunction. It was approved with a starting dose of 50 mg with the option to increase the dose to 100mg or reduce it to 25 mg.
Misc:

Viagra Patents
FDA lists two patents for Viagra. Patent number 5250534 expires on March 27, 2012. Patent number 6469012 (patent use code U-155; TREATMENT OF ERECTILE DYSFUNCTION) is set to expire on Oct 22, 2019.
How did they come up with the name VIAGRA?

Viagra Name
The name Viagra is believed to be an amalgam of two words:

The "Vi-" part is associated with the words vigor (physical or mental strength, energy, or force) or "vital"  (necessary to the continuation of life; life-sustaining).

The "-agra" part of the name Viagra is associated with Niagara Falls, the iconic American waterfall; a metaphor for a massive powerful natural phenomenon.

Why Does The Viagra Tablet Have An Unusual Shape
Unlike most tablets, the Viagra tablet has an unusual rounded-diamond-shape. It is believed that one reason Pfizer employs this tablet design is to make it harder to split the tablet with common tablet splitters.

The wholesale cost of Viagra in a 100 mg tablet is $31.00, so your Viagra cost will be slightly more than that. The price of Viagra in a 50 mg tablet is approximately the same. When people buy 100 mg tablets and split them into two 50 mg portions, they save about 50% per dose. Some people even cut them into quarters, which will save you even more money. A pill cutter is recommended to cut the Viagra in half or quarters.

The diamond shaped Viagra tablet will not fit into the typical tablet splitter which is designed to split round tablets. Since its launch in 1998, specially designed Viagra tablet splitters have become available.

(Incidentally, another erectile dysfunction drug, Cialis also has an irregular shaped tablet that discourages pill splitting).

Viagra Information On The Internet:

Viagra.com
Official website; Geared to patients; all about Viagra and erections.

PfizerPro.com
Official Viagra website for healthcare professionals; How to start and maintain patients on Viagra, Multimedia presentation, prescribing information, etc. This site also has a section where you can report an adverse regarding Viagra.

Official Viagra Prescribing Information
(Package Insert); dose, mechanism of action, side effects, precautions, warnings; patient information; very technical, don't get scared when you come to the section on warnings and side effects

Viagra Scientific Papers
National Library Of Medicine; automated Medline search; a listing of scientific papers in condensed form regarding Viagra.

Viagra Versus Levitra
From Forbes magazine; M. Herper and A. Lagorce; Side by side comparison of various characteristics; cost, pharmacokinetics, marketing tactics, etc.

Viagra Versus Cialis
From Forbes magazine; M. Herper; side by side comparison of various characteristics in slide show format.

Viagra News
(from Google) ; recently published news regarding Viagra.

Viagra mechanism of Action

All three of the erectile dysfunction drugs (Viagra, Levitra and Cialis) are similar in action. They block an enzyme that causes an erection to go flaccid. Although these drugs are similar in action, their dose, onset of action time and duration of action differ.

Viagra (Sildenafil) is a member of a family of drugs called PDE5 Inhibitors. Viagra was the first PDE5 inhibitor on the market. FDA was approved Viagra on March 27, 1998. The team of scientists who discovered Viagra won the Nobel Prize.

The BIG Discovery: cyclic guanosine monophosphate (cGMP)

Some very smart scientists discovered that cyclic guanosine monophosphate (cGMP) was the key to sustaining an erection.

They discovered that when a man gets sexually stimulated, a chain reaction occurs in the tissue of the penis that results in elevated levels of a substance called cyclic guanosine monophosphate (cGMP).

As long as there are sufficient levels of cGMP, the penis can remain erect. The more cGMP, the more robust and durable the erection.

If you inhibit the degradation (breakdown) of cGMP it stays around in the penis longer, producing a more durable erection.

Another way you can think of Viagra (and all other similar medicines) is that it preserves the elevated levels of cGMP that are created when a man is sexually stimulated for a stronger, more lasting erection.

That's how Viagra works - Viagra blocks the enzyme phosphodiesterase-5 (PDE5) which is responsible for the neutralization of cGMP. Viagra (Sildenafil) is a highly selective inhibitor of PDE5. (PDE5 is not the only phosphodiesterase involved in the erectile physiology but it appears to be the most important one).

The nice thing about Viagra and other PDE5 blockers is that they shouldn't cause erections at inappropriate times because they only block degradation of cGMP produced in reaction to sexual stimulation, such as thinking about something sexy.

If you are not being sexually stimulated, there is no cGMP to protect, so Viagra and similar drugs remain in the background.

The only bad news is that everyone's Viagra cost is going up, which means less men can take advantage of the powerful drug.

Absorption, Bioavailability
Viagra is rapidly absorbed. Maximum observed plasma concentrations of Viagra are reached within 30 to 120 minutes (median 60 minutes) of oral dosing in the fasted state. Viagra is about 40% biovailable. Viagra is highly protein bound (96%). When Viagra is taken with a high fat meal, the rate of absorption is reduced.

Metabolism, Half Life, Excretion

Viagra is mostly metabolized in the liver by an enzyme known as CYP3A4 and to a lesser extent CYPC229. Viagra breakdown products are excreted in the feces (80%) and in the urine (approximately 13%). Viagra's mean half life is about 4 hours.

If you are going to take any of the PDE5 inhibitors such as Viagra, it is very important that your doctor be aware if you have a liver condition (such as cirrhosis) or kidney condition (such as if you are on dialysis) because you may need a special dosage adjustment.

Likewise, if you try to obtain Viagra on the internet, please make sure that the person authorizing your prescription knows the true status of your liver function and your kidney function.

Dose:
For most patients, the recommended dose of Viagra is 50mg taken about 1 hour prior to anticipated sexual activity. However, the Viagra label states that it can be taken anywhere from 1/2 hour to 4 hours prior to sexual activity.

The dose of Viagra may be increased to 100mg or decreased to 25mg depending on efficacy and side effects. Sometimes people buy the 100mg tablets and break them in half to save money.

Viagra is available 25mg and 50mg and 100mg tablets.

The maximum recommended dose is one pill per day.

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