SILDENAFIL

Sildenafil is used in the treatment of erectile dysfunction in male adults (Prod Info VIAGRA(R) oral tablets, 2015). It is also used for the treatment of pulmonary arterial hypertension (Prod Info REVATIO oral tablets, suspension, intravenous injection, 2015).
Sildenafil has been used as a recreational drug by both men and women for enhancing libido. Often it is used in combination with other illicit drugs, including amyl nitrite. Serious adverse drug interactions are a potential hazard (Aldridge & Measham, 1999).

FORMS

Sildenafil is available as 20 mg, 25 mg, 50 mg, 100 mg tablets, 10 mg/mL oral powder for suspension, and 10 mg/12.5 mL intravenous solution (Prod Info REVATIO oral tablets, suspension, intravenous injection, 2015; Prod Info VIAGRA(R) oral tablets, 2015).
ADULTERATED PRODUCTS

In April 2012, the FDA confirmed that "African Black Ant", a product sold on the internet for sexual enhancement, contained sildenafil and tadalafil. This agent is sold as a "natural sexual enhancer" with no known side effects. The FDA advised consumers to stop taking the product (U.S. Food and Drug Administration, 2012).
CASE REPORT: A man developed persistent priapism after taking African Black Ant for erectile dysfunction and methamphetamine; symptoms resolved following treatment on 2 separate days. Laboratory analysis of the product detected sildenafil (96 mg/capsule; the maximum recommended dose is 100 mg/day according to the manufacturer) (Coralic et al, 2013).

-CLINICAL EFFECTS

GENERAL CLINICAL EFFECTS

USES: Smooth muscle relaxant used for erectile dysfunction and pulmonary hypertension. Sildenafil is also abused, often in conjunction with other drugs to enhance sexual performance.

PHARMACOLOGY: Inhibition of cGMP specific phosphodiesterase type-5 (PDE5) in smooth muscle in the pulmonary vascular bed in the lungs and the corpus cavernosum of the penis.

TOXICOLOGY: Overdose causes excessive vasodilatation resulting in hypotension, tachycardia, headache, priapism, facial flushing, dizziness, and general weakness.

EPIDEMIOLOGY: Poisoning is uncommon and rarely severe.

WITH POISONING/EXPOSURE

MILD TO MODERATE TOXICITY: Headache, facial flushing, dizziness, general weakness, priapism and vertigo.
SEVERE TOXICITY: Severe effects may include significant hypotension, tachycardia, and generalized weakness. Theoretically, CNS depression, cerebral ischemia, and other end organ ischemia are possible after severe overdose, but have not been reported. A young adult developed recurrent tonic-clonic seizures after misusing sildenafil (100 mg).

WITH THERAPEUTIC USE

Facial flushing, rash, diarrhea, dyspepsia, dizziness/vertigo, headache, abnormal vision, nasal congestion, hypotension, tachycardia, myocardial infarction, non-arteritic ischemic optic neuropathy, priapism (rare), and musculoskeletal pain have been reported.

Editor's Note: An ERG guide with information appropriate to this material does not exist.

-FIRST AID

FIRST AID AND PREHOSPITAL TREATMENT

ACTIVATED CHARCOAL

PREHOSPITAL ACTIVATED CHARCOAL ADMINISTRATION

Consider prehospital administration of activated charcoal as an aqueous slurry in patients with a potentially toxic ingestion who are awake and able to protect their airway. Activated charcoal is most effective when administered within one hour of ingestion. Administration in the prehospital setting has the potential to significantly decrease the time from toxin ingestion to activated charcoal administration, although it has not been shown to affect outcome (Alaspaa et al, 2005; Thakore & Murphy, 2002; Spiller & Rogers, 2002).

In patients who are at risk for the abrupt onset of seizures or mental status depression, activated charcoal should not be administered in the prehospital setting, due to the risk of aspiration in the event of spontaneous emesis.
The addition of flavoring agents (cola drinks, chocolate milk, cherry syrup) to activated charcoal improves the palatability for children and may facilitate successful administration (Guenther Skokan et al, 2001; Dagnone et al, 2002).

CHARCOAL DOSE

Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005).

Routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasionally hypotension (None Listed, 2004).

ADVERSE EFFECTS/CONTRAINDICATIONS

Complications: emesis, aspiration (Chyka et al, 2005). Aspiration may be complicated by acute respiratory failure, ARDS, bronchiolitis obliterans or chronic lung disease (Golej et al, 2001; Graff et al, 2002; Pollack et al, 1981; Harris & Filandrinos, 1993; Elliot et al, 1989; Rau et al, 1988; Golej et al, 2001; Graff et al, 2002). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).

-RANGE OF TOXICITY

MAXIMUM TOLERATED EXPOSURE

ADULT

Acute exposures in healthy male adults of up to 800 mg produced adverse effects similar to those seen at lower doses, except with increased incidence rates (Prod Info Viagra(TM), sildenafil citrate, 1998).
Healthy male volunteers given single oral doses of 100 mg experienced an average decrease of approximately 10 mmHg from baseline blood pressure levels (Prod Info Viagra(TM), sildenafil citrate, 1998).
CASE REPORT: An acute overdose of 2000 mg in a 42-year-old woman resulted in general weakness, palpitation, headache, dizziness, flushing, fine tremor of the upper extremities, tachycardia (heart rate, 101 bpm), nonspecific ST-T changes on ECG, and mild leukocytosis. The patient was discharged 12 hours after decontamination and supportive therapy (Hung & Yang, 2001).
CASE REPORT: A 54-year-old man developed vision loss in his left eye due to nonarteritic anterior ischemic optic neuropathy several hours after ingesting 200 mg of sildenafil. He had been taking sildenafil therapeutically at a dose of 100 mg 2 to 3 times per week over a period of a few months (Akash et al, 2005).
CASE REPORT/ADULTERATED PRODUCT: A man developed persistent priapism after taking African Black Ant for erectile dysfunction and methamphetamine; symptoms resolved following treatment on 2 separate hospital admissions. Laboratory analysis of the product detected sildenafil (96 mg/capsule; the maximum recommended dose is 100 mg/day according to the manufacturer) (Coralic et al, 2013). In April 2012, the FDA confirmed that "African Black Ant", a product sold on the internet for sexual enhancement, contained sildenafil and tadalafil. This agent is sold as a "natural sexual enhancer" with no known side effects. The FDA advised consumers to stop taking the product (U.S. Food and Drug Administration, 2012).
CASE REPORT/LACK OF SEVERE SYMPTOMS: A 56-year-old man intentionally ingested 65 sildenafil citrate tablets (100 mg each; total: 6500 mg) and initially developed severe vomiting and blurred vision, but no priapism. Upon admission 24 hours later, his laboratory studies were within normal limits with a minor decrease in kidney function (ie, glomerular filtration rate) and an increase in inflammatory parameters (ie, elevated C-reactive protein and leukocytosis). His serum sildenafil level was 22.2 mcg/mL (about 3 times higher than a previously reported fatal case with a serum concentration of 6.3 mcg/mL). It was estimated that his initial serum concentration was approximately 900 mcg/mL. His serum concentration gradually declined to 9.2 and 2.3 mcg/mL, respectively about 5 and 14 hours later. The estimated half-life was thought to be 4.2 hours. The patient remained stable without developing significant toxicity and recovered with supportive care (Matheeussen et al, 2015).
CASE REPORT/MISUSE: An 18-year-old developed recurrent tonic-clonic seizures approximately one hour after intentionally ingesting 100 mg of sildenafil (obtained without a prescription) to enhance his sexual performance. The seizures were witnessed by his girlfriend. Upon admission, his neurologic examination and head CT were essentially normal. He reported marijuana use about once per week. A urine drug screen was positive for tetrahydrocannabinol (THC) only. An EEG obtained the following day was normal and he was discharged without being prescribed any medications. About a month later, the patient tried sildenafil again and developed another episode of tonic-clonic seizure and was going to seek help from a therapist for his situational ED (Calabro et al, 2015).
CASE REPORT/CHRONIC MISUSE: A 49-year old man, with a history of sildenafil misuse for sexual enhancement for 2 years, took 300 mg of sildenafil (usual dose, 50 mg daily per the manufacturer) on the morning of admission and developed hemiparesthesia of the right side, neck pain and ataxia of the right arm. He had no family history of stroke or cerebral vascular events, but he smoked half a pack of cigarettes daily. Duplex sonography demonstrated a dissection of the right vertebral artery. A cerebral MRI showed similar findings, as well as an infarct of the right posterior inferior cerebellar artery territory. The patient was treated with intravenous heparin for 6 days that was followed by clopidogrel (75 mg daily) orally. Upon follow-up, a Doppler ultrasound study showed resolution of the dissection (Dersch et al, 2013).
CASE REPORT/RHABDOMYOLYSIS: A 45-year-old healthy man was admitted approximately 10 hours after taking 250 mg (five 50 mg tablets) of sildenafil that was obtained illegally after failing to achieve the desired sexual response with complaints of myalgia, in particular, in the lower extremities, darkish urine, and changes in visual perception. He reported taking sildenafil on a routine basis. Physical examination was positive for muscle tenderness only. Laboratory studies revealed a CPK of 25,325 International Units/L and elevated transaminases. Urine microscopy showed 3 to 5 red blood cells. Several ocular studies were performed and found to be normal. Following IV hydration and urine alkalization to prevent kidney injury, laboratory levels gradually returned to normal. Symptoms of myalgia and visual changes slowly resolved over several days. The patient was discharged on day 5 with no permanent sequelae (Oh, 2014).
CASE REPORT/INTRACEREBRAL HEMORRHAGE: A 35-year-old man with no prior medical history developed a severe headache approximately 2 hours after taking sildenafil 50 mg. He had been taking sildenafil 2 to 3 times daily for about a month without medical supervision. Upon admission, his vitals signs, neurologic examination and laboratory studies were within normal limits. A cranial CT scan showed a hemorrhage in the right nucleus caudatus, which opened in the lateral and third ventricles. Diagnostic studies revealed no vascular pathology. A cardiology exam was also normal. The patient was monitored for several days and discharged to home on day 5 with normal neurologic function (Ayberk et al, 2014).

PEDIATRIC

CASE REPORT (PEDIATRIC): A 19-month-old healthy toddler ingested up to 6 (50 mg) sildenafil tablets and developed mild facial flushing, tachycardia (140 beats/min), and priapism with no apparent pain. The patient was observed for 24 hours; decontamination was not performed. All symptoms completely resolved within 24 hours (Wills et al, 2007).
CASE REPORT (PEDIATRIC): A 2-year-old toddler experienced persistent facial flushing, painful transient penile engorgement, bilateral rhonchi, and diarrhea after ingesting approximately 1.5 pills (75 mg) of sildenafil. He recovered completely with no permanent sequelae (Cantrell, 2004).

Carcinogenicity Ratings for CAS139755-83-2 :

ACGIH (American Conference of Governmental Industrial Hygienists, 2010): Not Listed
EPA (U.S. Environmental Protection Agency, 2011): Not Listed
IARC (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004): Not Listed
NIOSH (National Institute for Occupational Safety and Health, 2007): Not Listed
MAK (DFG, 2002): Not Listed
NTP (U.S. Department of Health and Human Services, Public Health Service, National Toxicology Project ): Not Listed

TOXICITY AND RISK ASSESSMENT VALUES

EPA IRIS

EPA Risk Assessment Values for CAS139755-83-2 (U.S. Environmental Protection Agency, 2011):

Not Listed

-STANDARDS AND LABELS

WORKPLACE STANDARDS

ACGIH TLV Values for CAS139755-83-2 (American Conference of Governmental Industrial Hygienists, 2010):

Not Listed

AIHA WEEL Values for CAS139755-83-2 (AIHA, 2006):

Not Listed

NIOSH REL and IDLH Values for CAS139755-83-2 (National Institute for Occupational Safety and Health, 2007):

Not Listed

OSHA PEL Values for CAS139755-83-2 (U.S. Occupational Safety, and Health Administration (OSHA), 2010):

Not Listed

OSHA List of Highly Hazardous Chemicals, Toxics, and Reactives for CAS139755-83-2 (U.S. Occupational Safety and Health Administration, 2010):

Not Listed

ENVIRONMENTAL STANDARDS

EPA CERCLA, Hazardous Substances and Reportable Quantities for CAS139755-83-2 (U.S. Environmental Protection Agency, 2010):

Not Listed

EPA CERCLA, Hazardous Substances and Reportable Quantities, Radionuclides for CAS139755-83-2 (U.S. Environmental Protection Agency, 2010):

Not Listed

EPA RCRA Hazardous Waste Number for CAS139755-83-2 (U.S. Environmental Protection Agency, 2010b):

Not Listed
Editor's Note: The D, F, and K series waste numbers and Appendix VIII to Part 261 -- Hazardous Constituents were not included. Please refer to 40 CFR Part 261.

EPA SARA Title III, Extremely Hazardous Substance List for CAS139755-83-2 (U.S. Environmental Protection Agency, 2010):

Not Listed

EPA SARA Title III, Community Right-to-Know for CAS139755-83-2 (40 CFR 372.65, 2006; 40 CFR 372.28, 2006):

Not Listed

DOT List of Marine Pollutants for CAS139755-83-2 (49 CFR 172.101 - App. B, 2005):

Not Listed

EPA TSCA Inventory for CAS139755-83-2 (EPA, 2005):

Not Listed

LABELS

NFPA

NFPA Hazard Ratings for CAS139755-83-2 (NFPA, 2002):

Not Listed

-PERSONAL PROTECTION

SUMMARY

Editor's Note: An ERG guide with information appropriate to this material does not exist.

PROTECTIVE CLOTHING

CHEMICAL PROTECTIVE CLOTHING. Search results for CAS 139755-83-2.

Specific recommendations and test data for this chemical were not found in the available manufacturers' product literature. A complete list of consulted manufacturers and references is presented below.

-PHYSICAL HAZARDS

FIRE HAZARD

SUMMARY

Editor's Note: An ERG guide with information appropriate to this material does not exist.

FLAMMABILITY CLASSIFICATION

NFPA Flammability Rating for CAS139755-83-2 (NFPA, 2002):

Not Listed

FIRE CONTROL/EXTINGUISHING AGENTS

Editor's Note: An ERG guide with information appropriate to this material does not exist.

NFPA Extinguishing Methods for CAS139755-83-2 (NFPA, 2002):

Not Listed

EVACUATION PROCEDURES

SUMMARY

Editor's Note: An ERG guide with information appropriate to this material does not exist.

AIHA ERPG Values for CAS139755-83-2 (AIHA, 2006):

Not Listed

DOE TEEL Values for CAS139755-83-2 (U.S. Department of Energy, Office of Emergency Management, 2010):

Not Listed

AEGL Values for CAS139755-83-2 (National Research Council, 2010; National Research Council, 2009; National Research Council, 2008; National Research Council, 2007; NRC, 2001; NRC, 2002; NRC, 2003; NRC, 2004; NRC, 2004; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2005; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2005; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; United States Environmental Protection Agency Office of Pollution Prevention and Toxics, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2009; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2009; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2009; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2009; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2009; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2009; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2009; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2009; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2009; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2009; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2009; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2009; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2009; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2008; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2005; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2005; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2005; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2005; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2005; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2005; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2005; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2005; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2007; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2005; National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, 2006; 62 FR 58840, 1997; 65 FR 14186, 2000; 65 FR 39264, 2000; 65 FR 77866, 2000; 66 FR 21940, 2001; 67 FR 7164, 2002; 68 FR 42710, 2003; 69 FR 54144, 2004):

Not Listed

NIOSH IDLH Values for CAS139755-83-2 (National Institute for Occupational Safety and Health, 2007):

Not Listed

CONTAINMENT/WASTE TREATMENT OPTIONS

SUMMARY

Editor's Note: An ERG guide with information appropriate to this material does not exist.

SMALL LEAK/SPILL

Editor's Note: An ERG guide with information appropriate to this material does not exist.

LARGE LEAK/SPILL

Editor's Note: An ERG guide with information appropriate to this material does not exist.

-PHYSICAL/CHEMICAL PROPERTIES

MOLECULAR WEIGHT

666.7 (sildenafil)

DESCRIPTION/PHYSICAL STATE

SILDENAFIL: White to off-white crystalline powder with a solubility of 3.5 mg/mL in water (Prod Info Viagra(TM), sildenafil citrate, 1998).

SILDENAFIL: A 50 mg Viagra(TM) tablet dissolved in 10 mL of distilled water was found to be acidic (pH = 4.4) (Higuchi et al, 2001).

-REFERENCES

GENERAL BIBLIOGRAPHY

40 CFR 372.28: Environmental Protection Agency - Toxic Chemical Release Reporting, Community Right-To-Know, Lower thresholds for chemicals of special concern. National Archives and Records Administration (NARA) and the Government Printing Office (GPO). Washington, DC. Final rules current as of Apr 3, 2006.

40 CFR 372.65: Environmental Protection Agency - Toxic Chemical Release Reporting, Community Right-To-Know, Chemicals and Chemical Categories to which this part applies. National Archives and Records Association (NARA) and the Government Printing Office (GPO), Washington, DC. Final rules current as of Apr 3, 2006.

49 CFR 172.101 - App. B: Department of Transportation - Table of Hazardous Materials, Appendix B: List of Marine Pollutants. National Archives and Records Administration (NARA) and the Government Printing Office (GPO), Washington, DC. Final rules current as of Aug 29, 2005.

62 FR 58840: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 1997.

65 FR 14186: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2000.

65 FR 39264: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2000.

65 FR 77866: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2000.

66 FR 21940: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2001.

67 FR 7164: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2002.

68 FR 42710: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2003.

69 FR 54144: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2004.

AIHA: 2006 Emergency Response Planning Guidelines and Workplace Environmental Exposure Level Guides Handbook, American Industrial Hygiene Association, Fairfax, VA, 2006.

Akash R, Hrishikesh D, Amith P, et al: Association of combined nonarteritic anterior ischemic optic neuropathy (NAION) and obstruction of cilioretinal artery with overdose of Viagra(R). J Ocular Pharmacol Ther 2005; 21:315-317.

Alaspaa AO, Kuisma MJ, Hoppu K, et al: Out-of-hospital administration of activated charcoal by emergency medical services. Ann Emerg Med 2005; 45:207-12.

Aldridge J & Measham F: Sildenafil (Viagra) is used as a recreational drug in England (letter). Br Med J 1999; 318:669.

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Arora RR, Timoney M, & Melilli L: Acute myocardial infarction after the use of sildenafil (letter). New Engl J Med 1999; 341:700.

Arruda-Olson AM, Mahoney DW, & Nehra A: Cardiovascular effects of sildenafil during exercise in men with known or probable coronary artery disease - A randomized crossover trial. JAMA 2002; 287:719-725.

Ayberk G, Ozveren MF, Yaman ME, et al: Intracerebral hemorrhage after sildenafil citrate use: an incidental association?. Urol J 2014; 11(2):1524-1526.

Boolell M, Allen MJ, & Ballard SA: Sildenafil: an orally active type 5 cyclic GMP-specific phosphodiesterase inhibitor for the treatment of penile erectile dysfunction. Intn J Impotence Res 1996; 8:47-52.

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Calabro RS, De Luca R, Balletta T, et al: Seizure-induced by phosphodiesterase-5 inhibitors for recreational use: an emerging problem among young people!. Subst Use Misuse 2015; 50(1):137-138.

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Feenstra J, van Drie-Pierik RJ, & Lacle CF: Acute myocardial infarction associated with sildenafil. Lancet 1998; 352:957-958.

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Golej J, Boigner H, Burda G, et al: Severe respiratory failure following charcoal application in a toddler. Resuscitation 2001; 49:315-318.

Graff GR, Stark J, & Berkenbosch JW: Chronic lung disease after activated charcoal aspiration. Pediatrics 2002; 109:959-961.

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Herrmann HC, Chang G, & Klugherz BD: Hemodynamic effects of sildenafil in men with severe coronary artery disease. New Engl J Med 2000; 342:1622-1626.

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Classification | Information to evaluate chemical incidents

Information to evaluate chemical incidents

Information to evaluate chemical incidents

Information to evaluate chemical incidents