Buy Fluoxetine (Prozac) No Prescription

Generic Name: Fluoxetine HCl

Brand Name: Prozac, Sarafem

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Prozac common medical uses:
This medicine is in the class of drugs called selective serotonin reuptake inhibitors (SSRIs). Prozac, an antidepressant (mood elevator), is indicated for the treatment of depression, obsessive-compulsive disorders, panic disorder and eating disorders (bulimia nervosa). Prozac also is used occasionally to treat alcoholism, attention-deficit disorders, borderline personality disorders, sleep disorders, headaches, premenstrual syndrome, irregular heartbeat, schizophrenia, Tourette's syndrome, anxiety, and phobias.

Prozac contraindications:

• Hypersensitivity to fluoxetine. During premarketing testing of more than 5600 patients given fluoxetine, approximately 4% developed a rash and/or urticaria.
• MAOI. Not to be used with an MAOI or within 14 days of discontinuing MAOI therapy.

Prozac dosage:

• Major Depressive Disorder:
  Initial Treatment, Adults: 20 mg/day, administered in the morning, is recommended as the initial dose. Increase after several weeks if insufficient clinical improvement noted (max, 80 mg/day). Weekly dosing (90 mg delayed-release capsule) may be started 7 days after last 20 mg/day dose. If response is not satisfactory, consider reestablishing daily dosage regimen. Studies comparing fluoxetine 20, 40, and 60 mg/day to placebo indicate that 20 mg/day is sufficient to obtain a satisfactory response in major depressive disorder in most cases.
  Pediatric (Children and Adolescents): 10 mg/day; increase after 1 week if insufficient clinical improvement noted (max, 20 mg/day).
• Obsessive Compulsive Disorder:
  Initial Treatment, Adults: 20 mg once daily in the morning; increase after several weeks if insufficient clinical improvement noted (max, 80 mg/day).
  Children 7 years of age and older: Initial: 10 mg/day; increase after 2 wk (several weeks in lower weight children) if insufficient clinical improvement noted (max, 60 mg/day).
• Bulimia Nervosa:
  Initial Treatment, Adults: 60 mg daily in the morning; for some patients it may be advisable to titrate up to this target dose over several days.
• Panic Disorder:
  Initial Treatment, Adults: 10 mg/day; increase to 20 mg/day after 1 wk. Further dose increases may be considered after several wk if no clinical improvement noted (max, 60 mg/day).
• Premenstrual Dysphoric Disorder:
  Initial Treatment, Adults: 20 mg/day continuously (every day of menstrual cycle) or intermittently (starting 14 days prior to anticipated onset of menstruation through first full day of menses and repeating with each new cycle); dose may be increased if no clinical improvement noted (max, 80 mg/day).
  

Prozac side effects:

• Allergic or Toxic:
  Frequent: Rash, pruritus.
  Infrequent: Chills and fever, urticaria, maculopapular rash.
• Dermatologic:
  Infrequent: Acne, alopecia, dry skin, herpes simplex.
• Neurologic:
  Frequent: Headache, tremor, dizziness or lightheadedness, asthenia.
  Infrequent: Abnormal gait, ataxia, akathisia, buccoglossal syndrome, hyperkinesia, hypertonia, incoordination, neck rigidity, extrapyramidal syndrome, convulsions, photophobia, myoclonus, vertigo, migraine, tinnitus, hypesthesia, neuralgia, neuropathy, acute brain syndrome.
• Behavioral:
  Frequent: Insomnia, anxiety, nervousness, agitation, abnormal dreams, drowsiness and fatigue.
  Infrequent: Confusion, delusions, hallucinations, manic reaction, paranoid reaction, psychosis, depersonalization, apathy, emotional lability, euphoria, hostility, amnesia, increased libido.
• Autonomic:
  Frequent: Excessive sweating.
  Infrequent: Dry mouth, constipation, urinary retention, vision disturbance, diplopia, mydriasis, hot flushes.
• Cardiovascular:
  Infrequent: vasodilatation, hemorrhage, palpitations, chest pain, syncope, hypotension (including postural hypotension), angina pectoris, arrhythmia, tachycardia.
• Gastrointestinal:
  Frequent: Nausea, disturbances of appetite, diarrhea.
  Infrequent: Vomiting, stomatitis, dysphagia, eructation, esophagitis, gastritis, gingivitis, glossitis, melena, thirst, abnormal liver function tests. ce, pancreatitis.
• Respiratory:
  Frequent: Bronchitis, rhinitis, yawn.
  Infrequent: Asthma, dyspnea, hyperventilation, pneumonia, hiccups, epistaxis.
  Rare: Apnea, lung edema, hypoxia, pleural effusion, hemoptysis.
• Endocrine:
  Frequent: Weight loss.
  Infrequent: Generalized edema, peripheral edema, face edema, tongue edema, hypoglycemia, hypothyroidism, weight gain.
• Hematologic:
  Infrequent: Anemia, lymphadenopathy, hemorrhage.
• Musculoskeletal:
  Frequent: Muscle pain, back pain, joint pain.
  Infrequent: Arthritis, bone pain, bursitis, tenosynovitis, twitching.
• Urogenital:
  Frequent: Painful menstruation, sexual dysfunction, urinary tract infection, frequent micturition.
  Infrequent: Abnormal ejaculation, impotence, menopause, amenorrhea, menorrhagia, ovarian disorder, vaginitis, leukorrhea, fibrocystic breast, breast pain, cystitis, dysuria, urinary urgency, urinary incontinence.
• Miscellaneous:
  Frequent: Chills.
  Infrequent: Amblyopia, conjunctivitis, cyst, ear pain, eye pain, jaw pain, neck pain, pelvic pain, hangover effect, malaise.

Prozac precautions:

• Children: Safety and efficacy has not been established in pediatric patients less than 8 yr of age with depression, or less than 7 yr of age with OCD.
• Geriatrics: Elderly patients should initially receive fluoxetine in low dosage with slow progressive increases only if required and tolerated. Patients who have concomitant systemic illnesses or who are receiving other drugs concomitantly should be under careful observation at all dosage levels.
• Allergic events and rash: Fluoxetine use has been associated with occurrences of significant rash and allergic events, including vasculitis, lupus-like syndrome, laryngospasm, anaphylactoid reactions, and pulmonary inflammatory disease. Discontinue if underlying cause of rash cannot be identified.
• Anxiety and Insomnia: During premarketing clinical trials, anxiety, nervousness and insomnia were reported by 10 to 15% of patients treated with fluoxetine.
• Weight change: Significant weight loss, especially in underweight depressed patients, may be an undesirable result of treatment with fluoxetine.
• Cardiovascular disease: Use with caution in patients with a history of MI or unstable heart disease; use in these patients is limited.
• Bipolar disorder: Fluoxetine may increase likelihood of precipitation of a mixed/manic episode or mania/hypomania in these patients; prior to initiating fluoxetine treatment, patient should be adequately screened to determine if they are at risk for bipolar disorder; such screening should include a detailed psychiatric history, including a family history of suicide, bipolar disorder, and depression.
• Hepatic function impairment: Metabolism of fluoxetine is delayed; lower doses or less frequent dosing is recommended in patients with liver disease.
• Seizure disorders: Fluoxetine should be used with caution in patients with a history of convulsive disorders.
• Hypokalemia: Self-induced vomiting often leads to hypokalemia which may lower seizure threshold and/or may lead to cardiac conduction abnormalities.
• Diabetes: In patients with diabetes, fluoxetine may alter glycemic control. Hypoglycemia has occurred during therapy with fluoxetine and hyperglycemia has developed following discontinuation of the drug. As is true with many other types of medication when taken concurrently by patients with diabetes, insulin and/or oral hypoglycemic dosage may need to be adjusted when therapy with fluoxetine is instituted or discontinued.
• Hyponatremia: Several cases of hyponatremia (some with serum sodium lower than 110 mmol/L) have been reported. The hyponatremia appeared to be reversible when fluoxetine was discontinued.

Drug interactions:

• 5-HT 1 agonists (triptans): Weakness, hyperreflexia, and incoordination have been reported rarely.
• Alcohol: Potentiation of impairment of mental and motor skills. Coadministration is not recommended.
• Amphetamines: SSRIs may increase the sensitivity to amphetamines, and amphetamines may increase the risk of serotonin syndrome.
• Benzodiazepines: Coadministration of alprazolam and fluoxetine has resulted in increased alprazolam levels and decreased psychomotor performance. Half the initial alprazolam dose and titrate to lowest effective dose. Diazepam t 1/2 may be prolonged.
• Beta-blockers: Fluoxetine may inhibit the metabolism of metoprolol and propranolol resulting in cardiac toxicity; monitor for bradycardia, hypotension, and heart failure if combination is used; not established for all beta-blockers (unlikely with atenolol or nadolol due to renal elimination).
• Buspirone: Effects of buspirone may be decreased.
• Carbamazepine: Increased carbamazepine levels, causing toxicity.
• Clozapine: Elevated serum clozapine levels have occurred. Closely monitor patients on coadministration.
• Cyclosporine: Concentrations of cyclosporine may be elevated, increasing the risk of toxicity.
• Cyproheptadine: Decreased or reversed effects of fluoxetine.
• Digoxin: The pharmacologic effects of digoxin may be increased, possibly because of displaced protein binding.
• Haloperidol: Serum concentrations of haloperidol may be increased.
• HMG-CoA reductase inhibitors: Fluoxetine may inhibit the metabolism of lovastatin and simvastatin resulting in myositis and rhabdomyolysis; these combinations are best avoided.
• Hydantoins (eg, phenytoin): Increased hydantoin levels, causing toxicity.
• Lithium: Lithium levels may be increased or decreased by fluoxetine with possible neurotoxicity and increased serotonergic effects.
• Loop diuretics: Fluoxetine may cause hyponatremia; additive hyponatremic effects may be seen with combined use of a loop diuretic (bumetanide, furosemide, torsemide); monitor for hyponatremia.
• MAO Inhibitors: Combination may lead to serious, possibly fatal, reactions. Discontinue MAO inhibitor at least 14 days before starting fluoxetine; discontinue fluoxetine at least 5wk before starting MAO inhibitor.
• Nefazodone: May increase the risk of serotonin syndrome with SSRIs; monitor.
• NSAIDs (eg, aspirin, ibuprofen): The risk of GI bleeding may be increased.
• Pimozide: A case of life-threatening sinus bradycardia has been reported.
• Propafenone: Fluoxetine may inhibit the metabolism of propafenone, elevating propafenone levels and increasing the pharmacologic and adverse effects.
• Sibutramine: May increase the risk of serotonin syndrome with SSRIs; avoid coadministration.
• Sympathomimetics: May increase the risk of serotonin syndrome with SSRIs.
• Thioridazine: Concurrent use is contraindicated because of risk of prolongation of QTc interval and development of serious ventricular arrhythmias (eg, torsades de pointes) and sudden death.
• Trazodone: Plasma levels may be increased by fluoxetine.
• Tramadol: Fluoxetine combined with tramadol (serotonergic effects) may cause serotonin syndrome; monitor.
• Tricyclic antidepressants: Increased toxic effects of tricyclic antidepressant. Dosage of tricyclic antidepressants may need to be reduced and plasma concentrations may need to be monitored when fluoxetine is coadministered or has been recently discontinued.
• Tryptophan: The risk of CNS symptoms and peripheral toxicity may be increased.
• Valproic acid: Fluoxetine may increase serum levels of valproic acid; monitor.
• Venlafaxine: Fluoxetine may increase the risk of serotonin syndrome.
• Warfarin: The anticoagulant effects of warfarin may be increased, possibly because of displaced protein binding.

Drugs other than those listed here may also interact with Prozac.

Pregnancy & Lactation
Pregnancy Category C.
In embryo-fetal development studies in rats and rabbits, there was no evidence of teratogenicity following administration of up to 12.5 and 15 mg/kg/day, respectively (1.5 and 3.6 times, respectively, the MRHD of 80 mg on a mg/m2 basis) throughout organogenesis. However, in rat reproduction studies, an increase in stillborn pups, a decrease in pup weight, and an increase in pup deaths during the first 7 days postpartum occurred following maternal exposure to 12 mg/kg/day (1.5 times the MRHD on a mg/m2 basis) during gestation or 7.5 mg/kg/day (0.9 times the MRHD on a mg/m2 basis) during gestation and lactation. There was no evidence of developmental neurotoxicity in the surviving offspring of rats treated with 12 mg/kg/day during gestation. The no-effect dose for rat pup mortality was 5 mg/kg/day (0.6 times the MRHD on a mg/m2 basis). Fluoxetine should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Nonteratogenic Effects
Neonates exposed to fluoxetine and other SSRIs or serotonin and norepinephrine reuptake inhibitors (SNRIs), late in the third trimester have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding. Such complications can arise immediately upon delivery. Reported clinical findings have included respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, hypotonia, hypertonia, hyperreflexia, tremor, jitteriness, irritability, and constant crying. These features are consistent with either a direct toxic effect of SSRIs and SNRIs or, possibly, a drug discontinuation syndrome. It should be noted that, in some cases, the clinical picture is consistent with serotonin syndrome.

Nursing Mothers
Because fluoxetine is excreted in human milk, nursing while on fluoxetine is not recommended. In one breast-milk sample, the concentration of fluoxetine plus norfluoxetine was 70.4 ng/mL. The concentration in the mother's plasma was 295.0 ng/mL. No adverse effects on the infant were reported. In another case, an infant nursed by a mother on fluoxetine developed crying, sleep disturbance, vomiting, and watery stools. The infant's plasma drug levels were 340 ng/mL of fluoxetine and 208 ng/mL of norfluoxetine on the second day of feeding.

Monitoring parameters

• mental status for depression
• suicidal ideation (especially at the beginning of therapy or when doses are increased or decreased)
• anxiety
• social functioning
• mania
• panic attacks
• akathisia
• sleep

Missed dose:
If a dose is missed, take it as soon as possible. If several hours have passed or if it is nearing time for the next dose, do not double the dose to catch up, unless advised by your doctor. If more than one dose is missed, contact your doctor or pharmacist.

Overdose:
Symptoms: Nausea and vomiting were prominent in overdoses involving higher fluoxetine doses. Other prominent symptoms of overdose included agitation, restlessness, hypomania, and other signs of CNS excitation, including seizures.

There are no specific antidotes for fluoxetine.

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Storage:
All dosage forms should be stored at controlled room temperature of 15°C to 30°C (50°F to 86°F). Oral liquid should be dispensed in a light-resistant container.

References:

• 1. U.S. Food and Drug Administration. Prozac (Fluoxetine) U.S. Prescribing Information. Available at (PDF format): Prescribing Information