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Stomatitis and oral ulcers, mild alopecia and hair thinning, and GI upset may occur and are related to folic acid antagonism. These side effects can be improved with folic acid supplementation. Folic acid given at a dose of 1mg daily does not diminish the efficacy of methotrexate and is routinely given with methotrexate to decrease these side effects. Some patients complain of GI upset nausea or diarrhea with oral methotrexate. This may be lessened when methotrexate is taken at night. In most cases this is completely eliminated when methotrexate is given by subcutaneous administration. Before starting methotrexate, baseline studies should include complete blood count, liver chemistries, serum creatinine, hepatitis B and C serologies, and chest X-ray. Routine toxicity monitoring should include a CBC, liver profile, serum albumin and serum creatinine every 4-8 weeks. Methotrexate can be combined safely with nearly every other FDA-approved DMARDs for RA, including sulfasalazine, hydroxychloroquine, TNF inhibitors, abatacept, rituximab, tocilizumab, anakinra, and leflunomide.

Erectile dysfunction affects 30 million men in the United States. The problem can occur at any age, but the older a man gets, the greater the chance that he will have a health problem that results in ED. According to the National Institutes of Health, approximately 5 of 40-year-old men and between 15 and 25 of 65-year-old men experience ED on a long-term basis. In young men, erectile dysfunction is less common and when it does occur is more likely to have a psychological cause such as stress or performance anxiety. Still, young men are seeking treatment for this and other sexual problems in increasing numbers. The use of Viagra increased 312 among men aged 18-45 between 1998 and 2002. For an erection to occur, several parts of the body must work together. The brain sends messages to control the nerves, hormone levels, blood flow and muscles that cause an erection. If anything interferes with these messages, or if any part of the system doesnt function correctly, an erection wont occur. The penis has two sponge-like cylindrical structures that run along its length, parallel to the urethra (the tube that carries semen and urine). During sexual arousal, these cylinders become engorged with blood, straightening and stiffening the penis. Continued sexual arousal maintains the higher rate of blood flow into the penis and limits the flow out of the penis, keeping the erection firm. After ejaculation or when the sexual excitement passes, the excess blood drains out of the spongy tissue and the penis returns to its non-erect size and shape. What are the psychological causes of erectile dysfunction. A number of things can interfere with sexual feelings and lead to or exacerbate erectile dysfunction. These can include anxiety history of physical, emotional, or sexual abuse stress fatigue poor communication or conflict with your partner Erectile dysfunction as a result of a psychological cause tends to develop rapidly and be related to a recent situation or event. You may find you are able to have an erection in some circumstances but not in others. If you are generally able to experience or maintain an erection when you first wake up in the morning this can suggest that the problem is psychological rather than physical.

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