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ADMINISTRATION Vardenafil has not been evaluated in patients with severe Child-Pugh C hepatic impairment Pharmacodynamics Effects on Blood Pressure In a clinical pharmacology study of patients with erectile dysfunction single doses of vardenafil 20 mg caused a mean maximum decrease in supine blood pressure of 7 mmHg systolic and 8 mmHg diastolic compared to placebo accompanied by a mean maximum increase of heart rate of 4 beats per minute The maximum decrease in blood pressure occurred between 1 and 4 hours after dosing Following multiple dosing for 31 days similar blood pressure responses were observed on Day 31 as on Day 1 Vardenafil may add to the blood pressure lowering effects of antihypertensive agents see PRECAUTIONS Drug Interactions Effects on Blood Pressure and Heart Rate when Levitra is Combined with Nitrates A study was conducted in which the blood pressure and heart rate response to mg nitroglycerin NTG sublingually was evaluated in 18 healthy subjects following pretreatment with Levitra 20 mg at various times before NTG administration Levitra 20 mg caused an additional time-related reduction in blood pressure and increase in heart rate in association with NTG administration The blood pressure effects were observed when Levitra 20 mg was dosed 1 or 4 hours before NTG and the heart rate effects were observed when 20 mg was dosed or 8 hours before NTG

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Ultram above the recommended range Concomitant use of Ultram increases the seizure risk in patients taking Selective serotonin re-uptake inhibitors SSRI antidepressants or anorectics Tricyclic antidepressants TCAs and other tricyclic compounds e g cyclobenzaprine promethazine etc or Other opioids Administration of Ultram may enhance the seizure risk in patients taking MAO inhibitors see also WARNINGS - Use with MAO Inhibitors Neuroleptics or Other drugs that reduce the seizure threshold Risk of convulsions may also increase in patients with epilepsy those with a history of seizures or in patients with a recognized risk for seizure such as head trauma metabolic disorders alcohol and drug withdrawal CNS infections In Ultram overdose naloxone administration may increase the risk of seizure Anaphylactoid Reactions Serious and rarely fatal anaphylactoid reactions have been reported in patients receiving therapy with Ultram When these events do occur it is often following the first dose Other reported allergic reactions include pruritus hives

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