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special instructions With extreme caution and only in case of emergency it is possible to use tadalafil in patients with severe renal failure (CC ≤ 30 ml / min) and severe liver failure. During treatment with tadalafil, patients with moderate renal insufficiency (CC from 31 to 50 ml / min) were more likely to have back pain compared with patients with mild renal insufficiency (CC from 51 to 80 ml / min) or healthy volunteers . In patients with CC ≤ 50 ml / min, tadalafil should be used with caution. Therefore, the treatment of erectile dysfunction, including with tadalafil should not be used in men with heart diseases in which sexual activity is not recommended. The potential risk of complications due to sexual activity in patients with diseases of the cardiovascular system should be considered: myocardial infarction in the last 90 days; unstable angina or angina that occurs during intercourse; chronic heart failure (NYHA functional class II and above), which has developed over the past 6 months; uncontrolled heart rhythm disturbances; arterial hypotension (blood pressure less than 90/50 mm Hg) or uncontrolled arterial hypertension; stroke suffered in the last 6 months. With caution, tadalafil should be used in patients with a predisposition to priapism (for example, with sickle cell anemia, multiple myeloma or leukemia) or in patients with anatomical deformation of the penis (for example, during angulation, cavernous fibrosis or Peyronie's disease). The patient should be informed of the need to immediately consult a doctor in case of an erection lasting 4 hours or more. Untimely treatment of priapism leads to damage to the tissues of the penis, as a result of this, a long-term loss of potency may occur. With the use of tadalafil, no cases of priapism have been reported. It is not recommended to use tadalafil in combination with other types of treatment for erectile dysfunction.