Initiated for a source unrelated to the underlying disease. Indeed, the decision of when to start therapy remains one of the most challenging issues physicians caring for patients with cll have to make. How to treat symptomatic cll? viagra how long it takes to work There has been considerable debate regarding what is the best initial therapeutic approach for symptomatic cll. discounted generic viagra Cll virtually always presents as a systemic disease and is generally treated with chemotherapy. Until recently, the goal of therapy has been one of palliation only, without hope of complete remission of the cll. cheap viagra pills Introduction of new therapies outlined below and novel combination approaches has begun shifting the therapeutic goal of cll to that of attaining a complete remission as defined by a recent consensus paper on response evaluation in cll. 21 a summary of different classes of therapies employed for the treatment of previously untreated, but symptomatic cll patients follows below. Alkylator therapy the initial treatment of patients with symptomatic cll has often involved therapy with chlorambucil. While this therapy is effective at palliating the majority of cll patients, no randomized studies have established its benefit relative to overall survival as compared to observation alone. Prednisone is often included with chlorambucil despite three randomized studies not demonstrating a survival advantage to its addition (reviewed in 13 ). buy viagra online cheap category Furthermore, a meta-analysis that included 424 patients from three separate trials randomized to receive chlorambucil versus chlorambucil and prednisone could not demonstrate a survival benefit. viagra and grapefruit juice side effects 13 prednisone and other corticosteroids as a single agent have a minimal response rate in cll, predispose to opportunistic infections, and can accentuate hyperleukocytosis. 22 outside of supportive therapy for autoimmune complications, there is little data to support including corticosteroids in the initial treatment of cll. Since the introduction of chlorambucil, a variety of studies have examined different schedules and dose intensities in previously untreated cll with varied results. The most promising regimen was a high-dose regimen (approximately 5 times the usual dosing) reported by jaksik and colleagues. 23 a fixed 15 mg daily dose of chlorambucil was administered until toxicity or complete remission. A control arm received standard dose chlorambucil. An alternative response assessment different than the nci criteria was utilized that did not require bone marrow evaluation. After attainment of cr, patients received a twice-weekly dose of 15 mg of chlorambucil for 3 years. buy viagra without prescription Even without the ability to directly compare these results to other regimens that used the nci response criteria, 21 this regimen was impressive. The treatment arm showed significantly higher cr rate (70% versus 31%, p < 0. 0001) and overall. viagra generic viagra no prescription fastest shipping us noggin 2009