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All about: Naproxen delayed release tablet
Cardiovascular Risk
- NSAIDs11 may cause an increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal. This risk may increase with duration of use. Patients with cardiovascular disease or risk factors for cardiovascular disease may be at greater risk (see WARNINGS).
- Naproxen delayed-release tablets are contraindicated for the treatment of peri-operative pain in the setting of coronary artery bypass graft (CABG) surgery (see WARNINGS).
Gastrointestinal Risk
- NSAIDs cause an increased risk of serious gastrointestinal adverse events including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use and without warning symptoms. Elderly patients are at greater risk for serious gastrointestinal events (see WARNINGS).
- 1
- 1 Throughout this package insert, the term NSAID refers to a non-aspirin non-steroidal anti-inflammatory drug.
Naproxen Description
Naproxen is a propionic acid derivative related to the arylacetic acid group of non-steroidal anti‑inflammatory drugs.
The chemical name for Naproxen is (+)‑6‑methoxy‑α‑methyl‑2‑naphthaleneacetic acid. It has the following structural formula:
Naproxen is a practically odorless, white to off‑white crystalline substance. It is lipid‑soluble, practically insoluble in water at low pH and freely soluble in water at high pH. The octanol/water partition coefficient of Naproxen at pH 7.4 is 1.6 to 1.8.
Naproxen delayed-release tablets are available as enteric-coated, white to off-white tablets containing 375 mg or 500 mg of Naproxen for oral administration. The inactive ingredients are: corn starch, croscarmellose sodium, FD&C Blue No. 2, magnesium stearate, methacrylic acid copolymer-dispersion, povidone, talc, titanium dioxide, and triethyl citrate. The dissolution of this enteric‑coated Naproxen tablet is pH dependent with rapid dissolution above pH 6. There is no dissolution below pH 4.
Naproxen - Clinical Pharmacology
Naproxen is a non-steroidal anti‑inflammatory drug (NSAID) with analgesic and antipyretic properties. The sodium salt of Naproxen has been developed as a more rapidly absorbed formulation of Naproxen for use as an analgesic. The mechanism of action of the Naproxen anion, like that of other NSAIDs, is not completely understood but may be related to prostaglandin synthetase inhibition.
Naproxen is rapidly and completely absorbed from the gastrointestinal tract with an in vivo bioavailability of 95%. The different dosage forms of Naproxen are bioequivalent in terms of extent of absorption (AUC) and peak concentration (Cmax); however, the products do differ in their pattern of absorption. These differences between Naproxen products are related to both the chemical form of Naproxen used and its formulation. Even with the observed differences in pattern of absorption, the elimination half‑life of Naproxen is unchanged across products ranging from 12 to 17 hours. Steady‑state levels of Naproxen are reached in 4 to 5 days and the degree of Naproxen accumulation is consistent with this half‑life. This suggests that the differences in pattern of release play only a negligible role in the attainment of steady-state plasma levels.Absorption
Naproxen delayed-release tablets are designed with a pH‑sensitive coating to provide a barrier to disintegration in the acidic environment of the stomach and to lose integrity in the more neutral environment of the small intestine. The enteric polymer coating selected for Naproxen delayed-release tablets dissolves above pH 6. When Naproxen delayed-release tablets were given to fasted subjects, peak plasma levels were attained about 4 to 6 hours following the first dose (range: 2 to 12 hours). An in vivo study in man using radiolabeled Naproxen delayed-release tablets demonstrated that Naproxen delayed-release tablets dissolve primarily in the small intestine rather than the stomach, so the absorption of the drug is delayed until the stomach is emptied.
When Naproxen delayed-release tablets and Naproxen tablets were given to fasted subjects (n = 24) in a crossover study following 1 week of dosing, differences in time to peak plasma levels (Tmax) were observed, but there were no differences in total absorption as measured by Cmax and AUC:
* Mean value (coefficient of variation)
|Naproxen Delayed-Release Tablets*500 mg bid
|Naproxen Tablets*500 mg bid
|Cmax (mcg/mL)
|94.9 (18%)
|97.4 (13%)
|Tmax (hours)
|4 (39%)
|1.9 (61%)
|AUC0-12 hr (mcg•hr/mL)
|845 (20%)
|767 (15%)
Antacid effects
When Naproxen delayed-release tablets were given as a single dose with antacid (54 mEq buffering capacity), the peak plasma levels of Naproxen were unchanged, but the time to peak was reduced (mean Tmax fasted 5.6 hours, mean Tmax with antacid 5 hours), although not significantly.
Food effects
When Naproxen delayed-release tablets were given as a single dose with food, peak plasma levels in most subjects were achieved in about 12 hours (range: 4 to 24 hours). Residence time in the small intestine until disintegration was independent of food intake. The presence of food prolonged the time the tablets remained in the stomach, time to first detectable serum Naproxen levels, and time to maximal Naproxen levels (Tmax), but did not affect peak Naproxen levels (Cmax).Distribution
Naproxen has a volume of distribution of 0.16 L/kg. At therapeutic levels Naproxen is greater than 99% albumin‑bound. At doses of Naproxen greater than 500 mg/day there is less than proportional increase in plasma levels due to an increase in clearance caused by saturation of plasma protein binding at higher doses (average trough Css 36.5, 49.2, and 56.4 mg/L with 500, 1000, and 1500 mg daily doses of Naproxen, respectively). The Naproxen anion has been found in the milk of lactating women at a concentration equivalent to approximately 1% of maximum Naproxen concentration in plasma (see PRECAUTIONS, Nursing Mothers).Metabolism
Naproxen is extensively metabolized in the liver to 6‑O‑desmethyl Naproxen, and both parent and metabolites do not induce metabolizing enzymes. Both Naproxen and 6-O-desmethyl Naproxen are further metabolized to their respective acylglucuronide conjugated metabolites.Excretion
The clearance of Naproxen is 0.13 mL/min/kg. Approximately 95% of the Naproxen from any dose is excreted in the urine, primarily as Naproxen (< 1%), 6‑O‑desmethyl Naproxen (< 1%), or their conjugates (66% to 92%). The plasma half‑life of the Naproxen anion in humans ranges from 12 to 17 hours. The corresponding half‑lives of both Naproxen's metabolites and conjugates are shorter than 12 hours, and their rates of excretion have been found to coincide closely with the rate of Naproxen disappearance from the plasma. Small amounts, 3% or less of the administered dose, are excreted in the feces. In patients with renal failure metabolites may accumulate (see WARNINGS, Renal Effects).Special Populations
Pediatric patients
In pediatric patients aged 5 to 16 years with arthritis, plasma Naproxen levels following a 5 mg/kg single dose of Naproxen suspension (see DOSAGE AND ADMINISTRATION) were found to be similar to those found in normal adults following a 500 mg dose. The terminal half-life appears to be similar in pediatric and adult patients. Pharmacokinetic studies of Naproxen were not performed in pediatric patients younger than 5 years of age. Pharmacokinetic parameters appear to be similar following administration of Naproxen suspension or tablets in pediatric patients. Naproxen delayed-release tablets have not been studied in subjects under the age of 18.
Geriatric patients
Studies indicate that although total plasma concentration of Naproxen is unchanged, the unbound plasma fraction of Naproxen is increased in the elderly, although the unbound fraction is < 1% of the total Naproxen concentration. Unbound trough Naproxen concentrations in elderly subjects have been reported to range from 0.12% to 0.19% of total Naproxen concentration, compared with 0.05% to 0.075% in younger subjects. The clinical significance of this finding is unclear, although it is possible that the increase in free Naproxen concentration could be associated with an increase in the rate of adverse events per a given dosage in some elderly patients.
Pharmacokinetic differences due to race have not been studied.
Hepatic insufficiency
Naproxen pharmacokinetics have not been determined in subjects with hepatic insufficiency.
Renal insufficiency
Naproxen pharmacokinetics have not been determined in subjects with renal insufficiency. Given that Naproxen, its metabolites and conjugates are primarily excreted by the kidney, the potential exists for Naproxen metabolites to accumulate in the presence of renal insufficiency. Elimination of Naproxen is decreased in patients with severe renal impairment. Naproxen-containing products are not recommended for use in patients with moderate to severe and severe renal impairment (creatinine clearance < 30 mL/min) (see WARNINGS, Renal Effects).
Clinical Studies
General Information
Naproxen has been studied in patients with rheumatoid arthritis, osteoarthritis, juvenile arthritis, ankylosing spondylitis, tendonitis and bursitis, and acute gout. Improvement in patients treated for rheumatoid arthritis was demonstrated by a reduction in joint swelling, a reduction in duration of morning stiffness, a reduction in disease activity as assessed by both the investigator and patient, and by increased mobility as demonstrated by a reduction in walking time. Generally, response to Naproxen has not been found to be dependent on age, sex, severity or duration of rheumatoid arthritis.
In patients with osteoarthritis, the therapeutic action of Naproxen has been shown by a reduction in joint pain or tenderness, an increase in range of motion in knee joints, increased mobility as demonstrated by a reduction in walking time, and improvement in capacity to perform activities of daily living impaired by the disease.
In a clinical trial comparing standard formulations of Naproxen 375 mg bid (750 mg a day) vs. 750 mg bid (1500 mg/day), 9 patients in the 750 mg group terminated prematurely because of adverse events. Nineteen patients in the 1500 mg group terminated prematurely because of adverse events. Most of these adverse events were gastrointestinal events.
In clinical studies in patients with rheumatoid arthritis, osteoarthritis, and juvenile arthritis, Naproxen has been shown to be comparable to aspirin and indomethacin in controlling the aforementioned measures of disease activity, but the frequency and severity of the milder gastrointestinal adverse effects (nausea, dyspepsia, heartburn) and nervous system adverse effects (tinnitus, dizziness, lightheadedness) were less in Naproxen‑treated patients than in those treated with aspirin or indomethacin.
In patients with ankylosing spondylitis, Naproxen has been shown to decrease night pain, morning stiffness, and pain at rest. In double‑blind studies the drug was shown to be as effective as aspirin, but with fewer side effects.
In patients with acute gout, a favorable response to Naproxen was shown by significant clearing of inflammatory changes (e.g., decrease in swelling, heat) within 24 to 48 hours, as well as by relief of pain and tenderness.
Naproxen has been studied in patients with mild to moderate pain secondary to postoperative, orthopedic, postpartum episiotomy and uterine contraction pain and dysmenorrhea. Onset of pain relief can begin within 1 hour in patients taking Naproxen and within 30 minutes in patients taking Naproxen sodium. Analgesic effect was shown by such measures as reduction of pain intensity scores, increase in pain relief scores, decrease in numbers of patients requiring additional analgesic medication, and delay in time to remedication. The analgesic effect has been found to last for up to 12 hours.
Naproxen may be used safely in combination with gold salts and/or corticosteroids; however, in controlled clinical trials, when added to the regimen of patients receiving corticosteroids, it did not appear to cause greater improvement over that seen with corticosteroids alone. Whether Naproxen has a "steroid‑sparing" effect has not been adequately studied. When added to the regimen of patients receiving gold salts, Naproxen did result in greater improvement. Its use in combination with salicylates is not recommended because there is evidence that aspirin increases the rate of excretion of Naproxen and data are inadequate to demonstrate that Naproxen and aspirin produce greater improvement over that achieved with aspirin alone. In addition, as with other NSAIDs, the combination may result in higher frequency of adverse events than demonstrated for either product alone.
In 51Cr blood loss and gastroscopy studies with normal volunteers, daily administration of 1000 mg of Naproxen has been demonstrated to cause statistically significantly less gastric bleeding and erosion than 3250 mg of aspirin.
Three 6 week, double-blind, multicenter studies with Naproxen delayed-release tablets (375 or 500 mg bid, n = 385) and Naproxen immediate-release tablets (375 or 500 mg bid, n = 279) were conducted comparing Naproxen delayed-release tablets with Naproxen immediate-release tablets, including 355 rheumatoid arthritis and osteoarthritis patients who had a recent history of NSAID-related GI symptoms. These studies indicated that Naproxen delayed-release tablets and Naproxen immediate-release tablets showed no significant differences in efficacy or safety and had similar prevalence of minor GI complaints. Individual patients, however, may find one formulation preferable to the other.
Five hundred and fifty‑three patients received Naproxen delayed-release tablets during long‑term open-label trials (mean length of treatment was 159 days). The rates for clinically‑diagnosed peptic ulcers and GI bleeds were similar to what has been historically reported for long‑term NSAID use.
Geriatric Patients
The hepatic and renal tolerability of long-term Naproxen administration was studied in two double-blind clinical trials involving 586 patients. Of the patients studied, 98 patients were age 65 and older and 10 of the 98 patients were age 75 and older. Naproxen was administered at doses of 375 mg twice daily or 750 mg twice daily for up to 6 months. Transient abnormalities of laboratory tests assessing hepatic and renal function were noted in some patients, although there were no differences noted in the occurrence of abnormal values among different age groups.
Indications and Usage for Naproxen
Carefully consider the potential benefits and risks of Naproxen delayed-release tablets and other treatment options before deciding to use Naproxen delayed-release tablets. Use the lowest effective dose for the shortest duration consistent with individual patient treatment goals (see WARNINGS).
Naproxen delayed-release tablets are indicated:
- For the relief of the signs and symptoms of rheumatoid arthritis
- For the relief of the signs and symptoms of osteoarthritis
- For the relief of the signs and symptoms of ankylosing spondylitis
- For the relief of the signs and symptoms of juvenile arthritis
Naproxen as Naproxen suspension is recommended for juvenile rheumatoid arthritis in order to obtain the maximum dosage flexibility based on the patient's weight.
Naproxen delayed-release tablets are not recommended for initial treatment of acute pain because the absorption of Naproxen is delayed compared to absorption from other Naproxen-containing products (see CLINICAL PHARMACOLOGY and DOSAGE ANDADMINISTRATION).
Naproxen delayed-release tablets are contraindicated in patients with known hypersensitivity to Naproxen.
Naproxen delayed-release tablets should not be given to patients who have experienced asthma, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs. Severe, rarely fatal, anaphylactic-like reactions to NSAIDs have been reported in such patients (see WARNINGS, Anaphylactoid Reactions and PRECAUTIONS, Preexisting Asthma).
Naproxen delayed-release tablets are contraindicated for the treatment of peri-operative pain in the setting of coronary artery bypass graft (CABG) surgery (see WARNINGS).
Cardiovascular EffectsCardiovascular Thrombotic Events
Clinical trials of several COX-2 selective and nonselective NSAIDs of up to three years duration have shown an increased risk of serious cardiovascular (CV) thrombotic events, myocardial infarction, and stroke, which can be fatal. All NSAIDs, both COX-2 selective and nonselective, may have a similar risk. Patients with known CV disease or risk factors for CV disease may be at greater risk. To minimize the potential risk for an adverse CV event in patients treated with an NSAID, the lowest effective dose should be used for the shortest duration possible. Physicians and patients should remain alert for the development of such events, even in the absence of previous CV symptoms. Patients should be informed about the signs and/or symptoms of serious CV events and the steps to take if they occur.
There is no consistent evidence that concurrent use of aspirin mitigates the increased risk of serious CV thrombotic events associated with NSAID use. The concurrent use of aspirin and an NSAID does increase the risk of serious GI events (see Gastrointestinal Effects – Risk of Ulceration, Bleeding, and Perforation).
Two large, controlled clinical trials of a COX-2 selective NSAID for the treatment of pain in the first 10 to 14 days following CABG surgery found an increased incidence of myocardial infarction and stroke (see CONTRAINDICATIONS).Hypertension
NSAIDs, including Naproxen delayed-release tablets, can lead to onset of new hypertension or worsening of preexisting hypertension, either of which may contribute to the increased incidence of CV events. Patients taking thiazides or loop diuretics may have impaired response to these therapies when taking NSAIDs. NSAIDs, including Naproxen delayed-release tablets, should be used with caution in patients with hypertension. Blood pressure (BP) should be monitored closely during the initiation of NSAID treatment and throughout the course of therapy.Congestive Heart Failure and Edema
Fluid retention, edema, and peripheral edema have been observed in some patients taking NSAIDs. Naproxen delayed-release tablets should be used with caution in patients with fluid retention, hypertension, or heart failure.
Gastrointestinal Effects - Risk of Ulceration, Bleeding, and Perforation
NSAIDs, including Naproxen delayed-release tablets, can cause serious gastrointestinal (GI) adverse events including inflammation, bleeding, ulceration, and perforation of the stomach, small intestine, or large intestine, which can be fatal.
These serious adverse events can occur at any time, with or without warning symptoms, in patients treated with NSAIDs. Only one in five patients, who develop a serious upper GI adverse event on NSAID therapy, is symptomatic. Upper GI ulcers, gross bleeding, or perforation caused by NSAIDs occur in approximately 1% of patients treated for 3 to 6 months, and in about 2 to 4% of patients treated for one year. These trends continue with longer duration of use, increasing the likelihood of developing a serious GI event at some time during the course of therapy. However, even short-term therapy is not without risk. The utility of periodic laboratory monitoring has not been demonstrated, nor has it been adequately assessed. Only 1 in 5 patients who develop a serious upper GI adverse event on NSAID therapy is symptomatic.
NSAIDs should be prescribed with extreme caution in those with a prior history of ulcer disease or gastrointestinal bleeding. Patients with a prior history of peptic ulcer disease and/or gastrointestinal bleeding who use NSAIDs have a greater than 10 fold increased risk for developing a GI bleed compared to patients with neither of these risk factors. Other factors that increase the risk for GI bleeding in patients treated with NSAIDs include concomitant use of oral corticosteroids or anticoagulants, longer duration of NSAID therapy, smoking, use of alcohol, older age, and poor general health status. Most spontaneous reports of fatal GI events are in elderly or debilitated patients and therefore, special care should be taken in treating this population. To minimize the potential risk for an adverse GI event in patients treated with an NSAID, the lowest effective dose should be used for the shortest possible duration. Patients and physicians should remain alert for signs and symptoms of GI ulceration and bleeding during NSAID therapy and promptly initiate additional evaluation and treatment if a serious GI adverse event is suspected. This should include discontinuation of the NSAID until a serious GI adverse event is ruled out. For high risk patients, alternate therapies that do not involve NSAIDs should be considered.
Renal Effects
Long-term administration of NSAIDs has resulted in renal papillary necrosis and other renal injury. Renal toxicity has also been seen in patients in whom renal prostaglandins have a compensatory role in the maintenance of renal perfusion. In these patients, administration of a non-steroidal anti-inflammatory drug may cause a dose-dependent reduction in prostaglandin formation and, secondarily, in renal blood flow, which may precipitate overt renal decompensation. Patients at greatest risk of this reaction are those with impaired renal function, hypovolemia, heart failure, liver dysfunction, salt depletion, those taking diuretics and ACE-inhibitors, and the elderly. Discontinuation of non-steroidal anti-inflammatory drug therapy is usually followed by recovery to the pretreatment state (see WARNINGS, Advanced Renal Disease).
Advanced Renal Disease
No information is available from controlled clinical studies regarding the use of Naproxen delayed-release tablets in patients with advanced renal disease. Therefore, treatment with Naproxen delayed-release tablets is not recommended in these patients with advanced renal disease. If Naproxen delayed-release tablet therapy must be initiated, close monitoring of the patient's renal function is advisable.
Anaphylactoid Reactions
As with other NSAIDs, anaphylactoid reactions may occur in patients without known prior exposure to Naproxen delayed-release tablets. Naproxen delayed-release tablets should not be given to patients with the aspirin triad. This symptom complex typically occurs in asthmatic patients who experience rhinitis with or without nasal polyps, or who exhibit severe, potentially fatal bronchospasm after taking aspirin or other NSAIDs (see CONTRAINDICATIONS and PRECAUTIONS, Preexisting Asthma). Emergency help should be sought in cases where an anaphylactoid reaction occurs.
Skin Reactions
NSAIDs, including Naproxen delayed-release tablets, can cause serious skin adverse events such as exfoliative dermatitis, Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN), which can be fatal. These serious events may occur without warning. Patients should be informed about the signs and symptoms of serious skin manifestations and use of the drug should be discontinued at the first appearance of skin rash or any other sign of hypersensitivity.
In late pregnancy, as with other NSAIDs, Naproxen delayed-release tablets should be avoided because it may cause premature closure of the ductus arteriosus.
Naproxen-containing products such as Naproxen tablets, Naproxen delayed-release tablets, Naproxen sodium tablets, Naproxen suspension, and other Naproxen products should not be used concomitantly since they all circulate in the plasma as the Naproxen anion.
Naproxen delayed-release tablets cannot be expected to substitute for corticosteroids or to treat corticosteroid insufficiency. Abrupt discontinuation of corticosteroids may lead to disease exacerbation. Patients on prolonged corticosteroid therapy should have their therapy tapered slowly if a decision is made to discontinue corticosteroids and the patient should be observed closely for any evidence of adverse effects, including adrenal insufficiency and exacerbation of symptoms of arthritis.
Patients with initial hemoglobin values of 10 g or less who are to receive long-term therapy should have hemoglobin values determined periodically.
The pharmacological activity of Naproxen delayed-release tablets in reducing fever and inflammation may diminish the utility of these diagnostic signs in detecting complications of presumed noninfectious, noninflammatory painful conditions.
Because of adverse eye findings in animal studies with drugs of this class, it is recommended that ophthalmic studies be carried out if any change or disturbance in vision occurs.
Hepatic Effects
Borderline elevations of one or more liver tests may occur in up to 15% of patients taking NSAIDs including Naproxen delayed-release tablets. Hepatic abnormalities may be the result of hypersensitivity rather than direct toxicity. These laboratory abnormalities may progress, may remain essentially unchanged, or may be transient with continued therapy. The SGPT (ALT) test is probably the most sensitive indicator of liver dysfunction. Notable elevations of ALT or AST (approximately three or more times the upper limit of normal) have been reported in approximately 1% of patients in clinical trials with NSAIDs. In addition, rare cases of severe hepatic reactions, including jaundice and fatal fulminant hepatitis, liver necrosis and hepatic failure, some of them with fatal outcomes have been reported.
A patient with symptoms and/or signs suggesting liver dysfunction, or in whom an abnormal liver test has occurred, should be evaluated for evidence of the development of a more severe hepatic reaction while on therapy with Naproxen delayed-release tablets.
If clinical signs and symptoms consistent with liver disease develop, or if systemic manifestations occur (e.g., eosinophilia, rash, etc.), Naproxen delayed-release tablets should be discontinued.
Chronic alcoholic liver disease and probably other diseases with decreased or abnormal plasma proteins (albumin) reduce the total plasma concentration of Naproxen, but the plasma concentration of unbound Naproxen is increased. Caution is advised when high doses are required and some adjustment of dosage may be required in these patients. It is prudent to use the lowest effective dose.
Hematological Effects
Anemia is sometimes seen in patients receiving NSAIDs, including Naproxen delayed-release tablets. This may be due to fluid retention, occult or gross GI blood loss, or an incompletely described effect upon erythropoiesis. Patients on long-term treatment with NSAIDs, including Naproxen delayed-release tablets, should have their hemoglobin or hematocrit checked if they exhibit any signs or symptoms of anemia.
NSAIDs inhibit platelet aggregation and have been shown to prolong bleeding time in some patients. Unlike aspirin, their effect on platelet function is quantitatively less, of shorter duration, and reversible. Patients receiving Naproxen delayed-release tablets who may be adversely affected by alterations in platelet function, such as those with coagulation disorders or patients receiving anticoagulants, should be carefully monitored.
Preexisting Asthma
Patients with asthma may have aspirin-sensitive asthma. The use of aspirin in patients with aspirin-sensitive asthma has been associated with severe bronchospasm, which can be fatal. Since cross reactivity, including bronchospasm, between aspirin and other non-steroidal anti-inflammatory drugs has been reported in such aspirin-sensitive patients, Naproxen delayed-release tablets should not be administered to patients with this form of aspirin sensitivity and should be used with caution in patients with preexisting asthma.
Information for Patients
Patients should be informed of the following information before initiating therapy with an NSAID and periodically during the course of ongoing therapy. Patients should also be encouraged to read the NSAID Medication Guide that accompanies each prescription dispensed.
- Naproxen delayed-release tablets, like other NSAIDs, may cause serious CV side effects, such as MI or stroke, which may result in hospitalization and even death. Although serious CV events can occur without warning symptoms, patients should be alert for the signs and symptoms of chest pain, shortness of breath, weakness, slurring of speech, and should ask for medical advice when observing any indicative signs or symptoms. Patients should be apprised of the importance of this follow-up (see WARNINGS, Cardiovascular Effects).
- Naproxen delayed-release tablets, like other NSAIDs, can cause GI discomfort and, rarely, serious GI side effects, such as ulcers and bleeding, which may result in hospitalization and even death. Although serious GI tract ulcerations and bleeding can occur without warning symptoms, patients should be alert for the signs and symptoms of ulcerations and bleeding, and should ask for medical advice when observing any indicative sign or symptoms including epigastric pain, dyspepsia, melena, and hematemesis. Patients should be apprised of the importance of this follow-up (see WARNINGS, Gastrointestinal Effects - Risk of Ulceration, Bleeding, and Perforation).
- Naproxen delayed-release tablets, like other NSAIDs, can cause serious skin side effects such as exfoliative dermatitis, SJS, and TEN, which may result in hospitalization and even death. Although serious skin reactions may occur without warning, patients should be alert for the signs and symptoms of skin rash and blisters, fever, or other signs of hypersensitivity such as itching, and should ask for medical advice when observing any indicative signs or symptoms. Patients should be advised to stop the drug immediately if they develop any type of rash and contact their physicians as soon as possible.
- Patients should promptly report signs or symptoms of unexplained weight gain or edema to their physicians.
- Patients should be informed of the warning signs and symptoms of hepatotoxicity (e.g., nausea, fatigue, lethargy, pruritus, jaundice, right upper quadrant tenderness, and "flu-like" symptoms). If these occur, patients should be instructed to stop therapy and seek immediate medical therapy.
- Patients should be informed of the signs of an anaphylactoid reaction (e.g., difficulty breathing, swelling of the face or throat). If these occur, patients should be instructed to seek immediate emergency help (see WARNINGS).
- In late pregnancy, as with other NSAIDs, Naproxen delayed-release tablets should be avoided because they may cause premature closure of the ductus arteriosus.
- Caution should be exercised by patients whose activities require alertness if they experience drowsiness, dizziness, vertigo, or depression during therapy with Naproxen.
Laboratory Tests
Because serious GI tract ulcerations and bleeding can occur without warning symptoms, physicians should monitor for signs or symptoms of GI bleeding. Patients on long-term treatment with NSAIDs should have their CBC and a chemistry profile checked periodically. If clinical signs and symptoms consistent with liver or renal disease develop, systemic manifestations occur (e.g., eosinophilia, rash, etc.) or if abnormal liver tests persist or worsen, Naproxen delayed-release tablets should be discontinued.
Drug InteractionsACE-inhibitors
Reports suggest that NSAIDs may diminish the antihypertensive effect of ACE-inhibitors. This interaction should be given consideration in patients taking NSAIDs concomitantly with ACE-inhibitors.Antacids and Sucralfate
Concomitant administration of some antacids (magnesium oxide or aluminum hydroxide) and sucralfate can delay the absorption of Naproxen.Aspirin
When Naproxen delayed-release tablets are administered with aspirin, its protein binding is reduced, although the clearance of free Naproxen is not altered. The clinical significance of this interaction is not known; however, as with other NSAIDs, concomitant administration of Naproxen delayed-release tablets and aspirin is not generally recommended because of the potential of increased adverse effects.Cholestyramine
As with other NSAIDs, concomitant administration of cholestyramine can delay the absorption of Naproxen.Diuretics
Clinical studies, as well as postmarketing observations, have shown that Naproxen delayed-release tablets can reduce the natriuretic effect of furosemide and thiazides in some patients. This response has been attributed to inhibition of renal prostaglandin synthesis. During concomitant therapy with NSAIDs, the patient should be observed closely for signs of renal failure (see WARNINGS, Renal Effects), as well as to assure diuretic efficacy.Lithium
NSAIDs have produced an elevation of plasma lithium levels and a reduction in renal lithium clearance. The mean minimum lithium concentration increased 15% and the renal clearance was decreased by approximately 20%. These effects have been attributed to inhibition of renal prostaglandin synthesis by the NSAID. Thus, when NSAIDs and lithium are administered concurrently, subjects should be observed carefully for signs of lithium toxicity.Methotrexate
NSAIDs have been reported to competitively inhibit methotrexate accumulation in rabbit kidney slices. Naproxen, Naproxen sodium, and other non-steroidal anti-inflammatory drugs have been reported to reduce the tubular secretion of methotrexate in an animal model. This may indicate that they could enhance the toxicity of methotrexate. Caution should be used when NSAIDs are administered concomitantly with methotrexate.Warfarin
The effects of warfarin and NSAIDs on GI bleeding are synergistic, such that users of both drugs together have a risk of serious GI bleeding higher than users of either drug alone. No significant interactions have been observed in clinical studies with Naproxen and coumarin-type anticoagulants. However, caution is advised since interactions have been seen with other non-steroidal agents of this class. The free fraction of warfarin may increase substantially in some subjects and Naproxen interferes with platelet function.
Other Information Concerning Drug Interactions
Naproxen is highly bound to plasma albumin; it thus has a theoretical potential for interaction with other albumin-bound drugs such as coumarin-type anticoagulants, sulphonylureas, hydantoins, other NSAIDs, and aspirin. Patients simultaneously receiving Naproxen and a hydantoin, sulphonamide, or sulphonylurea should be observed for adjustment of dose if required.
Naproxen and other non-steroidal anti-inflammatory drugs can reduce the antihypertensive effect of propranolol and other beta-blockers.
Probenecid given concurrently increases Naproxen anion plasma levels and extends its plasma half-life significantly.
Due to the gastric pH elevating effects of H2-blockers, sucralfate and intensive antacid therapy, concomitant administration of Naproxen delayed-release tablets is not recommended
Drug/Laboratory Test Interactions
Naproxen may decrease platelet aggregation and prolong bleeding time. This effect should be kept in mind when bleeding times are determined.
The administration of Naproxen may result in increased urinary values for 17‑ketogenic steroids because of an interaction between the drug and/or its metabolites with m‑di‑nitrobenzene used in this assay. Although 17‑hydroxy‑corticosteroid measurements (Porter‑Silber test) do not appear to be artifactually altered, it is suggested that therapy with Naproxen be temporarily discontinued 72 hours before adrenal function tests are performed if the Porter‑Silber test is to be used.
Naproxen may interfere with some urinary assays of 5‑hydroxy indoleacetic acid (5HIAA).
A 2 year study was performed in rats to evaluate the carcinogenic potential of Naproxen at rat doses of 8, 16, and 24 mg/kg/day (50, 100, and 150 mg/m2). The maximum dose used was 0.28 times the systemic exposure to humans at the recommended dose. No evidence of tumorigenicity was found.
PregnancyTeratogenic Effects
Pregnancy category C
Reproduction studies have been performed in rats at 20 mg/kg/day (125 mg/m2/day, 0.23 times the human systemic exposure), rabbits at 20 mg/kg/day (220 mg/m2/day, 0.27 times the human systemic exposure), and mice at 170 mg/kg/day (510 mg/m2/day, 0.28 times the human systemic exposure) with no evidence of impaired fertility or harm to the fetus due to the drug. However, animal reproduction studies are not always predictive of human response. There are no adequate and well-controlled studies in pregnant women. Naproxen delayed-release tablets should be used in pregnancy only if the potential benefit justifies the potential risk to the fetus.Nonteratogenic Effects
There is some evidence to suggest that when inhibitors of prostaglandin synthesis are used to delay preterm labor there is an increased risk of neonatal complications such as necrotizing enterocolitis, patent ductus arteriosus and intracranial hemorrhage. Naproxen treatment given in late pregnancy to delay parturition has been associated with persistent pulmonary hypertension, renal dysfunction and abnormal prostaglandin E levels in preterm infants. Because of the known effects of non-steroidal anti-inflammatory drugs on the fetal cardiovascular system (closure of ductus arteriosus), use during pregnancy (particularly late pregnancy) should be avoided.
Labor and Delivery
In rat studies with NSAIDs, as with other drugs known to inhibit prostaglandin synthesis, an increased incidence of dystocia, delayed parturition, and decreased pup survival occurred. Naproxen-containing products are not recommended in labor and delivery because, through its prostaglandin synthesis inhibitory effect, Naproxen may adversely affect fetal circulation and inhibit uterine contractions, thus increasing the risk of uterine hemorrhage. The effects of Naproxen delayed-release tablets on labor and delivery in pregnant women are unknown.
Nursing Mothers
The Naproxen anion has been found in the milk of lactating women at a concentration equivalent to approximately 1% of maximum Naproxen concentration in plasma. Because of the possible adverse effects of prostaglandin-inhibiting drugs on neonates, use in nursing mothers should be avoided.
Pediatric Use
Safety and effectiveness in pediatric patients below the age of 2 years have not been established. Pediatric dosing recommendations for juvenile arthritis are based on well-controlled studies (see DOSAGE AND ADMINISTRATION). There are no adequate effectiveness or dose-response data for other pediatric conditions, but the experience in juvenile arthritis and other use experience have established that single doses of 2.5 to 5 mg/kg (as Naproxen suspension, see DOSAGE AND ADMINISTRATION), with total daily dose not exceeding 15 mg/kg/day, are well tolerated in pediatric patients over 2 years of age.
Geriatric Use
Studies indicate that although total plasma concentration of Naproxen is unchanged, the unbound plasma fraction of Naproxen is increased in the elderly. Caution is advised when high doses are required and some adjustment of dosage may be required in elderly patients. As with other drugs used in the elderly, it is prudent to use the lowest effective dose.
Experience indicates that geriatric patients may be particularly sensitive to certain adverse effects of non-steroidal anti-inflammatory drugs. Elderly or debilitated patients seem to tolerate peptic ulceration or bleeding less well when these events do occur. Most spontaneous reports of fatal GI events are in the geriatric population (see WARNINGS).
Naproxen is known to be substantially excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function. Geriatric patients may be at a greater risk for the development of a form of renal toxicity precipitated by reduced prostaglandin formation during administration of non-steroidal anti-inflammatory drugs (see WARNINGS, Renal Effects).
Adverse Reactions
Adverse reactions reported in controlled clinical trials in 960 patients treated for rheumatoid arthritis or osteoarthritis are listed below. In general, reactions in patients treated chronically were reported 2 to 10 times more frequently than they were in short‑term studies in the 962 patients treated for mild to moderate pain or for dysmenorrhea. The most frequent complaints reported related to the gastrointestinal tract.
A clinical study found gastrointestinal reactions to be more frequent and more severe in rheumatoid arthritis patients taking daily doses of 1500 mg Naproxen compared to those taking 750 mg Naproxen (see CLINICAL PHARMACOLOGY).
In controlled clinical trials with about 80 pediatric patients and in well‑monitored, open‑label studies with about 400 pediatric patients with juvenile arthritis treated with Naproxen, the incidence of rash and prolonged bleeding times were increased, the incidence of gastrointestinal and central nervous system reactions were about the same, and the incidence of other reactions were lower in pediatric patients than in adults.
In patients taking Naproxen in clinical trials, the most frequently reported adverse experiences in approximately 1% to 10% of patients are:
Gastrointestinal (GI) Experiences, including: heartburn*2, abdominal pain*2, nausea*2, constipation*2, diarrhea, dyspepsia, stomatitis
Central Nervous System: headache*2, dizziness*2, drowsiness*2, lightheadedness, vertigo
Dermatologic: pruritus (itching)*2, skin eruptions*2, ecchymoses*2, sweating, purpura
Special Senses: tinnitus*2, visual disturbances, hearing disturbances
Cardiovascular: edema*2, palpitations
General: dyspnea*2, thirst
In patients taking NSAIDs, the following adverse experiences have also been reported in approximately 1% to 10% of patients.
Gastrointestinal (GI) Experiences, including: flatulence, gross bleeding/perforation, GI ulcers (gastric/duodenal), vomiting
General: abnormal renal function, anemia, elevated liver enzymes, increased bleeding time, rashes
The following are additional adverse experiences reported in < 1% of patients taking Naproxen during clinical trials and through postmarketing reports. Those adverse reactions observed through postmarketing reports are italicized.
Body as a Whole: anaphylactoid reactions, angioneurotic edema, menstrual disorders, pyrexia (chills and fever)
Cardiovascular: congestive heart failure, vasculitis, hypertension, pulmonary edema
Gastrointestinal: gastrointestinal bleeding and/or perforation, hematemesis, pancreatitis, vomiting, colitis, nonpeptic gastrointestinal ulceration, ulcerative stomatitis, esophagitis, peptic ulceration
Hepatobiliary: jaundice, abnormal liver function tests, hepatitis (some cases have been fatal)
Hemic and Lymphatic: eosinophilia, leucopenia, melena, thrombocytopenia, agranulocytosis, granulocytopenia, hemolytic anemia, aplastic anemia
Metabolic and Nutritional: hyperglycemia, hypoglycemia
Nervous System: inability to concentrate, depression, dream abnormalities, insomnia, malaise, myalgia, muscle weakness, aseptic meningitis, cognitive dysfunction, convulsions
Respiratory: eosinophilic pneumonitis, asthma
Dermatologic: alopecia, urticaria, skin rashes, toxic epidermal necrolysis, erythema multiforme, erythema nodosum, fixed drug eruption, lichen planus, pustular reaction, systemic lupus erythematosus, Stevens-Johnson syndrome, photosensitive dermatitis, photosensitivity reactions, including rare cases resembling porphyria cutanea tarda (pseudoporphyria) or epidermolysis bullosa. If skin fragility, blistering or other symptoms suggestive of pseudoporphyria occur, treatment should be discontinued and the patient monitored.
Special Senses: hearing impairment, corneal opacity, papillitis, retrobulbar optic neuritis, papilledema
Urogenital: glomerular nephritis, hematuria, hyperkalemia, interstitial nephritis, nephrotic syndrome, renal disease, renal failure, renal papillary necrosis, raised serum creatinine
Reproduction (female): infertility
In patients taking NSAIDs, the following adverse experiences have also been reported in < 1% of patients.
Body as a Whole: fever, infection, sepsis, anaphylactic reactions, appetite changes, death
Cardiovascular: hypertension, tachycardia, syncope, arrhythmia, hypotension, myocardial infarction
Gastrointestinal: dry mouth, esophagitis, gastric/peptic ulcers, gastritis, glossitis, eructation
Hepatobiliary: hepatitis, liver failure
Hemic and Lymphatic: rectal bleeding, lymphadenopathy, pancytopenia
Metabolic and Nutritional: weight changes
Nervous System: anxiety, asthenia, confusion, nervousness, paresthesia, somnolence, tremors, convulsions, coma, hallucinations
Respiratory: asthma, respiratory depression, pneumonia
Dermatologic: exfoliative dermatitis
Special Senses: blurred vision, conjunctivitis
Urogenital: cystitis, dysuria, oliguria/polyuria, proteinuria
- 2
- * Incidence of reported reaction between 3% and 9%. Those reactions occurring in less than 3% of the patients are unmarked.
Significant Naproxen overdosage may be characterized by lethargy, dizziness, drowsiness, epigastric pain, abdominal discomfort, heartburn, indigestion, nausea, transient alterations in liver function, hypoprothrombinemia, renal dysfunction, metabolic acidosis, apnea, disorientation or vomiting. Gastrointestinal bleeding can occur. Hypertension, acute renal failure, respiratory depression, and coma may occur, but are rare. Anaphylactoid reactions have been reported with therapeutic ingestion of NSAIDs, and may occur following an overdose. A few patients have experienced convulsions, but it is not clear whether or not these were drug-related. It is not known what dose of the drug would be life threatening. The oral LD50 of the drug is 543 mg/kg in rats, 1234 mg/kg in mice, 4110 mg/kg in hamsters, and greater than 1000 mg/kg in dogs.
Patients should be managed by symptomatic and supportive care following a NSAID overdose. There are no specific antidotes. Hemodialysis does not decrease the plasma concentration of Naproxen because of the high degree of its protein binding. Emesis and/or activated charcoal (60 to 100 g in adults, 1 to 2 g/kg in children) and/or osmotic cathartic may be indicated in patients seen within 4 hours of ingestion with symptoms or following a large overdose. Forced diuresis, alkalinization of urine or hemoperfusion may not be useful due to high protein binding.
Naproxen Dosage and Administration
Carefully consider the potential benefits and risks of Naproxen delayed-release tablets and other treatment options before deciding to use Naproxen delayed-release tablets. Use the lowest effective dose for the shortest duration consistent with individual patient treatment goals (see WARNINGS).
After observing the response to initial therapy with Naproxen delayed-release tablets, the dose and frequency should be adjusted to suit an individual patient's needs.
Different dose strengths and formulations (i.e., tablets, suspension) of the drug are not necessarily bioequivalent. This difference should be taken into consideration when changing formulation.
Although Naproxen tablets, Naproxen delayed-release tablets, Naproxen suspension, and Naproxen sodium tablets all circulate in the plasma as Naproxen, they have pharmacokinetic differences that may affect onset of action. Onset of pain relief can begin within 30 minutes in patients taking Naproxen sodium and within 1 hour in patients taking Naproxen. Because Naproxen delayed-release tablets dissolve in the small intestine rather than in the stomach, the absorption of the drug is delayed compared to the other Naproxen formulations (see CLINICAL PHARMACOLOGY).
The recommended strategy for initiating therapy is to choose a formulation and a starting dose likely to be effective for the patient and then adjust the dosage based on observation of benefit and/or adverse events. A lower dose should be considered in patients with renal or hepatic impairment or in elderly patients (see WARNINGS and PRECAUTIONS).
Geriatric Patients
Studies indicate that although total plasma concentration of Naproxen is unchanged, the unbound plasma fraction of Naproxen is increased in the elderly. Caution is advised when high doses are required and some adjustment of dosage may be required in elderly patients. As with other drugs used in the elderly, it is prudent to use the lowest effective dose.
Patients with Moderate to Severe Renal Impairment
Naproxen-containing products are not recommended for use in patients with moderate to severe and severe renal impairment (creatinine clearance < 30 mL/min) (see WARNINGS, Renal Effects).
Rheumatoid Arthritis, Osteoarthritis and Ankylosing Spondylitis
|Naproxen Delayed-Release Tablets
|375 mg or 500 mg
|twice daily twice daily
To maintain the integrity of the enteric coating, the Naproxen delayed-release tablets should not be broken, crushed, or chewed during ingestion.
During long-term administration, the dose of Naproxen may be adjusted up or down depending on the clinical response of the patient. A lower daily dose may suffice for long-term administration. The morning and evening doses do not have to be equal in size and the administration of the drug more frequently than twice daily is not necessary.
In patients who tolerate lower doses well, the dose may be increased to Naproxen 1500 mg/day for limited periods of up to 6 months when a higher level of anti-inflammatory/analgesic activity is required. When treating such patients with Naproxen 1500 mg/day, the physician should observe sufficient increased clinical benefits to offset the potential increased risk. The morning and evening doses do not have to be equal in size and administration of the drug more frequently than twice daily does not generally make a difference in response (see CLINICAL PHARMACOLOGY).
Juvenile Arthritis
The recommended total daily dose of Naproxen is approximately 10 mg/kg given in 2 divided doses (i.e., 5 mg/kg given twice a day). Naproxen delay
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Railers Battle Back But Come up Short in 7-4 Home Loss to Monarchs
March 17, 2019 - ECHL (ECHL) - Worcester Railers HC News Release
Worcester, MA - The Worcester Railers HC (30-24-5-4, 69pts) tried to erase an early four goal deficit but ran out of steam at the end in a 7-4 loss to the visiting Manchester Monarchs (33-26-2-2,70pts) in front of 3,143 fans at the DCU Center on Sunday afternoon. With the loss, the Railers now trail the 4th place Manchester Monarchs by one point in the North Division with nine games remaining. The Railers are back in action on a 2-3-4 Friday at the DCU Center on Friday at 7pm vs. the Maine Mariners on Classic Rock Night presented by 100 FM The Pike.
Ryan MacKinnon, Dylan Willick, Barry Almeida, and David Quenneville (1-1-2) all scored for Worcester while Mitch Gillam made nine saves in net on 13 shots before getting replaced by Blake Wajtala. Nic Pierog scored four goals for Manchester while Charles Williams made 22 saves in net as Worcester fell to 16-10-4-1 on home ice this season. The Railers trailed 4-0 after the first period and trailed 5-1 midway through the second period before getting within a goal early in the third period.
Manchester would roar out to a 4-0 lead through 20 minutes of play as Kevin Defour (24th) struck at 1:58, Nic Pierog (28th) on a shorthanded breakaway at 8:28, Matheson Iacopelli (5th) with a bullet from 40 feet at 15:46, and Nic Pierog (29th) again at 16:27 to end the afternoon for goaltender Mitch Gillam. Shots were 14-10 in favor of the Monarchs through 20 minutes.
Ryan MacKinnon (6th) would get Worcester on the board with a power play goal on a nice rush down the right-wing side before sliding a low shot through netminder Charles Williams at 5:04. Manchester would regain their four goal lead as Nic Pierog (30th) notched a hat trick at 12:42. But the Railers would counter with a pair of goals in the final six minutes of the middle frame as Matty Gaudreau (11th) slammed home a Josh Holmstrom centering feed at 14:24 and Barry Almeida (22nd) ripped a shot top shelf to end a 3-on-2 rush at 19:27 to cut the Monarchs lead to 5-3. Shots were 22-21 in favor of Manchester through 40 minutes of play.
David Quenneville (5th) got the Railers within a goal with a seeing eye shot from the right-wing wall at 3:04 of the third period. Worcester would have several chances to tie the score the rest of the way, but the Monarchs added two empty net goals by Chris Carlisle (3rd) at 19:29 and Nic Pierog (31st) at 19:53 to give Manchester the 7-4 road victory.
Notes: Three Stars: 3rd star: Ryan MacKinnon (1-0-1) 2nd star: Josh Holmstrom (0-2-2) 1st star: Nic Pierog (4-0-4) .... final shots were 30-26 in favor of Manchester...Charles Williams (20-11-3) made 22 saves on 26 shots for Manchester... Mitch Gillam made 9 saves on 13 shots for Worcester before getting replaced for Blake Wojtala (1-2-0) at 16:27 of the first period.... Worcester went 1-for-4 on the power play while Manchester went 0-for-2.... Kyle McKenzie (inj), Tommy Panico (inj), Alex Vanier (inj), Evan Buitenhuis (inj), Matt Schmalz, Charlie Michalowski, and Ivan Chukarov did not dress for Worcester....Mike Cornell (BRI) and Nick Sorkin (BNG) are currently in the AHL....Holy Cross Alum Spencer Trapp made his pro debut on the blueline for Worcester and wore #55 and added an assist... the Railers are now 16-10-4-1 on home ice this season...Ryan Hitchcock has 35 points (15-20-35) in his last 26 games.... the Railers have 9 games remaining (5 home, 4 road)... Worcester now have 46 fighting majors this season - they had 45 last season....David Quenneville (2), Ryan Hitchcock, Tyler Barnes, David Quenneville, and Spencer Trapp all picked up assists for Worcester....Ryan Hitchcock had a game high six shots on goal...Tyler Barnes (3-3-6), Barry Almeida (3-2-5), David Quenneville (1-4-5), and Ryan Hitchcock (1-4-5) all extended their point streaks to three games....Worcester has not allowed a power play goal in seven straight games (12-12).
What's on tap - Back home on Friday!
On Friday, March 22 the Railers host the Maine Mariners at 7pm on a 2-3-4 Friday and Classic Rock Night presented by 100 FM The Pike! Score $2 popcorn, $3 soda, and $4 bud lights inside the Bud Light Lounge!
Individual tickets to a Railers game start as low as $15 by calling 508-365-1750 or visit RailersHC.com. Save $$$ with a RAILERS 6 PACK which includes six flex tickets and a Railers winter hat starting at $99.
The Railers Tavernlocated behind the DCU Center provides hockey fans with a great pregame and postgame atmosphere all season long. Watch all road games broadcast live at Railers Tavern or watch on ECHLTV.com for a small fee. Listen to all Railers games live on 98.9 Nash ICON with coverage beginning 30 minutes before puck drop with Eric Lindquist and Tom Matthews. Full season memberships, mini plans, and group tickets are on sale now by calling the Railers front office at 508-365-1750 or by visiting www.RailersHC.com.
• Discuss this story on the ECHL message board...
ECHL Stories from March 17, 2019
- Solar Bears Fall to Steelheads 4-1 - Orlando Solar Bears
- Americans Win OT Thriller - Allen Americans
- Steelheads Clinch 22nd-Straight Postseason Appearance with 4-1 Win over Orlando - Idaho Steelheads
- Thunder Closes Road Trip with OT Loss in Allen - Wichita Thunder
- Stingrays Withstand Everblades' Comeback to Win Series Finale - Florida Everblades
- 6 Different Scorers Give Stingrays Win over Florida - South Carolina Stingrays
- Swamp Rabbits' Offense Quieted by IceMen - Greenville Swamp Rabbits
- Railers Battle Back But Come up Short in 7-4 Home Loss to Monarchs - Worcester Railers HC
- Growlers Fall in Eighteen Round Shootout - Newfoundland Growlers
- Mariners Top Growlers in Epic Eighteen Round Shootout - Maine Mariners
- Thunder Use Four Third-Period Goals to Crown Royals 6-3 - Adirondack Thunder
- Atlanta Improves Point Streak to Five Games with 2-1 Home Win over the Admirals - Atlanta Gladiators
- Adirondack Goes Ahead in Final Three Minutes and Defeats Royals, 6-3 - Reading Royals
- Kivlenieks Backstops K-Wings to 2-1 Victory on Green Ice - Kalamazoo Wings
- Monarchs Rack up Seven Goals on Railers in 7-4 Win - Manchester Monarchs
- Beast Can't Solve Fucale, Drop Third Straight - Brampton Beast
- ECHL Transactions - March 17 - ECHL
- Game Preview: Solar Bears vs. Steelheads - Orlando Solar Bears
- Allen Americans Game Capsule - Allen Americans
- Game Day: Things Turning Green for St. Patrick's Day - Kalamazoo Wings
- Game Day at Adirondack: Catch Today's Game on BCTV at 2:45 p.m. - Reading Royals
- Grizzlies Insider Adam Turner on 5-2 Military Night Win - Utah Grizzlies
- Grizzlies Win 5-2 on Military Night - Utah Grizzlies
The opinions expressed in this release are those of the organization issuing it, and do not necessarily reflect the thoughts or opinions of OurSports Central or its staff.
Other Recent Worcester Railers HC Stories
- Worcester Railers Split Last Weekend Games
- Worcester Railers Two Game Win Streak Comes to An End in Glens Falls
- Worcester Railers Come from Behind to Take Down Mariners 3-2 in a Shootout from the DCU Center
- Worcester Railers HC Acquire Defenseman Jake Bolton
- Worcester Railers Crush Thunder 5-1 in Front of 8,137 Fans at DCU Center

subset: commoncrawl


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The House of Sonic is now very much the House of Strategy. Sega, which already owns Total War studio Creative Assembly and Company of Heroes studio Relic has acquired Amplitude, the French studio behind the phenomenal Civ-rival Endless Legend and other terrific strategy games. Details here.
Harmonix's Amplitude revival finally has a release date: January 5. Backers at the $40 or higher tier will gain access a little earlier, however, on December 23.
Remember how Harmonix delayed the Amplitude revival from March to summer? It's been delayed again! If you're an "early access" backer, Amplitude be available at the end of the year, but everyone else will have to wait until January 2016.
Everyone's gonna have to wait a few more months for Harmonix to bring back Amplitude, as the studio announced today its Kickstarter-funded revival is moving from March to "summer."


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Second survivors charity concert arranged
PUBLISHED: 10:00 05 May 2011
THE second Survivors Jazz Band (Stars with Scars) charity concert will be held in Claverham in June.
The group was set up to raise funds for the British Heart Foundation and Cancer Research UK as all of the musicians are survivors of heart disease or cancer.
Proceeds from the first concert last year and the subsequent sale of CD's raised £725 each for the charities.
Following the success of last year's event, the band has agreed to play at the second concert which takes place at Claverham Village Hall at 7.30pm on May 21. There will be a bar, coffee and food available.
A spokesman said: "The fact that there will be another concert in 2011 is testament to the band's commitment to two very worthy causes and it is hoped to raise even more as a result of this second concert."
Tickets, priced £10, are available by sending a stamped and addressed envelope, together with a cheque made out to Gzazz Promotions to 11 Westmarch Way, Weston-super-Mare, BS22 7JY.
Anyone who cannot attend on the night but would like to donate money is welcome to send a cheque to the same address.
CDs from the first concert, called Alive & Jazzin', are available from 01934 527197.


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- This event has passed.
Know Your Farmer: Milton Creamery
June 6 @ 6:00 pm - 8:30 pm$55.00
Milton Creamery was started in 2006 as a joint venture between local Amish dairy farmers and the Musser family. Hear their story of how they add value to milk from local dairy farmers, support jobs in the local community and create an award-winning product with art and passion. Doors open at 6 pm, dinner begins at 6:30 pm. $55/person includes tip. BYOB. Email Deborah or call 515.243.7063.
If on-line tickets are sold out, please email or call in case seats are still available.
Tickets are not available as this event has passed.


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Episode 8 - Pennsylvania
Queer family + native identity in Centre County, PA.
In this episode, Amelia travels to Pennsylvania and speaks to Brooklyn and Sarah -- two activists and artists from Chicago who are living in Centre County, PA. Tune in for a conversation about trans + queer identity, native + indigenous politics, and what it means to make a home in a place that isn't particularly welcoming to you.
Fifty Feminist States on Instagram and iTunes
Sarah on Instagram + Brooklyn on Instagram
Subscribe to the Fifty Feminist States newsletter
Fifty Feminist States considers accessibility to be incredibly important and recognizes that transcripts make podcasts more accessible to communities. While crowdfunded support allowed for complete transcripts of the first season to be readily available, that proved more challenging this season. If transcripts of the episodes would help make this podcast more accessible to you, please email email@example.com for access to the rough drafts.


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Rod or net: the big question
I have to admit an admiring fascination for Bear Grylls' The Island. In this program a team of men have to survive for 40 days on an island. One guy, Vic, is good at fishing with a rod and on a good day brings home five fish.Vic is a loud northern type who has a chip on his shoulder about posh people...like Sam. Sam seems a bit of a dreamer and is no good at manual work. Vic leads the group in denigrating Sam as a skiver. But Sam is tough. He steadfastly keeps working on his own project which is to repair and use an old fishing net. Everyone thinks he is wasting his time but he keeps going. Every day he sets it and every day it's empty- but that's how you learn with fishing. You keep fine tuning and you keep trying. The others begin to ignore Sam but then one day he asks them to help him with the net...he's caught 23 fish!
Sometimes it's worth going out on a limb, against the group, sticking to your guns and using creativity to be audacious.


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Mark your calendar for CFP grand opening!
PORTSMOUTH, R.I. — Common Fence Point will hold a grand opening ceremony for its brand new community center. Find out more information below.
From the Common Fence Point Improvement Association:
Dear CFP,Happy Summer! Mark your calendars for the Grand Opening of the CFP Arts, Wellness, and Community Center: Saturday August 17th. There will be live music, food trucks, and an open house from 11am – 3pm. Block party time!It's exciting to drive by the Hall each day and see the progress. Even though we are not in the Hall yet, there is so much happening in the neighborhood.


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Get your God Moves Coffee Mug that is perfect for your daily cup of coffee and Bible reading!
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Marklund scores first win in torrential weather
The heavens opened above the Lankebanen circuit minutes before the semi-finals, rendering event-long tyre strategies useless, with all 12 cars switched onto wets.
Having followed his day one performance with another fastest time on Sunday morning to top the Intermediate Classification on his return to the series, Niclas Gronholm started from pole position in semi-final one, the first drenched race in a weekend of baking sunshine.
He overcame the conditions in a tense encounter to secure pole for the final, where he was joined by a semi-final two winner, Liam Doran.
The race to the first corner in semi-final one had been won by Guerlain Chicherit from row three, but the GCK team owner was spun by contact in the low-grip braking zone. Doran repeated the launch in semi-final two and dived straight into the joker, won the race and lined up on the front row for the final.
In the main event, despite a rubbered-up first row making it extra-slippery, Doran made another good start and headed straight for the joker, but it was row two starter Kevin Abbring, making his World RX debut, who took the lead by taking a wide line in turn one.
Behind, pole sitter Gronholm dropped to third after a tussle with Kevin Hansen through turn one and two, as Doran led Marklund and Baumanis through the turn one joker.
Abbring led up front and started to gap Hansen and a fired-up Gronholm, the Finn trying everything he knew to get by the Swede's Peugeot 208, while behind Marklund hassled Doran as he had throughout the semi-final.
For the first four laps, Doran and Marklund closed on the leading trio before Abbring ducked into the joker on lap five and plummeted down the order.
On the main lap inside the joker, Gronholm and Hansen made contact, the pair getting sideways and almost losing position, Doran backing out of the throttle into turn two, knowing the pair ahead still had to joker.
But, down the hill to turn three, as Doran's Audi S1 suffered a technical issue, Marklund dived up the inside and into third, which became first when the leaders took their joker on the final tour.
Hansen and Gronholm returned to the main circuit second and third, Gronholm fending off Janis Baumanis to the finish as Marklund crossed the finish line to claim his maiden win.
Abbring ended his first event fifth and Doran made it to the end in sixth. Timmy Hansen continues to lead the points from brother Kevin.


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Westwood V Series Garden Tractors
The V Series Garden Tractors are Westwood's premium range, so we really are talking about the best of the best. They are very tough and highly specified, with a heavy-duty commercial grade chassis. They can cut and collect, with a large capacity collector or drive a combo deck. Made for large lawns and grounds of up to 12, 000 m2, They are as comfortable on meadows, orchards and paddocks, cutting rough grass ads creating the perfect striped finish on the lawn. These are a very good investment indeed, and don't forget we deliver every order free to a UK address.
MowDirect Price Only£5,899.00The Westwood V25-50HE is the celebrated UK-manufacturer's flagship machine, and with its 127cm-wide mulch/rear-discharge cutter-deck (available separately), it's capable of covering a substantial paddock or formal lawn in an impressively quick time). It's fitted with a massively powerful 726cc twin-cylinder Kawasaki engine that will prove cheap to run and quiet in operation; and it features an Operating Performance Indicator, which relays performance data on an easy-to-read LED dashboard. A foot-pedal operated hydrostatic transmission makes the tractor as easy to drive as an automatic car; while a ten-stage height-of-cut (adjustable between 12 and 101mm) ensures you'll be able to manage different grass-lengths and weather conditions. An 107cm High-Grass Mulching Deck is also available. More Less


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Ametek ( AME) pushed the Industrial industry lower today making it today's featured Industrial laggard. The industry as a whole closed the day down 0.1%. By the end of trading, Ametek fell 40 cents (-1.3%) to $31.09 on heavy volume. Throughout the day, two million shares of Ametek exchanged hands as compared to its average daily volume of 1.2 million shares. The stock ranged in price between $31-$32.10 after having opened the day at $31.65 as compared to the previous trading day's close of $31.49. Other company's within the Industrial industry that declined today were: China BAK Battery ( CBAK), down 6.8%, P & F Industries ( PFIN), down 6.2%, Broadwind Energy ( BWEN), down 5.6%, and Lennox International ( LII), down 5.4%.
- ACTIVE STOCK TRADERS: Check out TheStreet's special offer for Real Money, headlined by Jim Cramer, now!
- You can view the full Ametek Ratings Report.
- Use our industrial section to find industry-relevant news.
- Or find some new ideas from our top rated stocks lists.
- Find other investment ideas from our top rated ETFs lists.


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Review - R2C Shifters
article & images by Nick Salazar
Jul 19, 2010
article & images by Nick Salazar
Jul 19, 2010 103,169
Without a doubt, these are the most welcome addition to our bike since the aerobar itself. They may have some installation quirks, but they're no fad. This is a new category of shifter, and one we can only imagine it's here to stay. They definitely come at a price, but in our mind, the performance benefit is undoubtedly worth it. They're not coming off our bike any time soon, and they're a very high priority for us on future builds. We'd recommend these even on an entry-level tri bike; they make that much of a difference.
- Superlative, game-changing ergonomics
- Excellent functionality and crisp shifting
- Two different shapes to suit multiple hand sizes.
- All-out fun to use
- Expensive
- Installation quirks may bother some
Verdict: Must-Have
Related Articles
The Zipp VukaShift extensions are sleek and sexy, and aim to solve a classic problem with S-Bends. We think Zipp nailed it.
Easily the most important and innovative 1x group ever made, as well as electronic shifting bliss. eTap AXS 1x is now our favorite drivetrain ever, at a price.
In an effort to help Ironman champ Matt Russell get the most out of his new Omni, we took him to the wind tunnel. And what we found out was pretty surprising.
We caught up with Jan Frodeno training out on the Queen K. Here's a look at his rig, including some slick custom front-end hardware.
More goodies from the showroom floor at Interbike 2016.


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Onegai Teacher!
From Anime Bath Scene Wiki
(Redirected from Please Teacher!)
|This article is unorganized
|English Title:
|Please Teacher!
|Kanji Title:
|Romanji Title:
|Onegai Tīchā
|Romance, Ecchi, Drama
|Original Creator:
|Yōsuke Kuroda
Yasunori Ide
|Anime series
|Directed by:
|Yasunori Ide
|Written by:
|Yōsuke Kuroda
|Original Run:
|January 10th, 2002 – March 28th, 2002
|# of Episodes:
|Please Teacher! OVA
|Film Type:
|Single episode OVA
|Directed by:
|Yasunori Ide
|Release Date:
|October 25th, 2002
|Please Twins! anime
|Directed by:
|Yasunori Ide
|Original Run:
|July 15th, 2003 – October 14th, 2003
|# of Episodes:
|Please Twins! OVA
|Film Type:
|Single episode OVA
|Directed by:
|Yasunori Ide
|Release Date:
|April 23rd, 2004
Please Teacher! (also known as Onegai Teacher!) is an anime franchise created by the studio Daume. It also spawned a spinoff known as Please Twins! also known as Onegai Twins!
Please Teacher! (anime)
Episode 1
There is a Clothed Bathing scene.
Please Teacher! OVA
There is a Bath scene.
Please Twins! (anime)
- Please Twins-59.jpg
- Please Twins-60.jpg
- Please Twins-61.jpg
- Please Twins-63.jpg
- Please Twins-64.jpg
- Please Twins-65.jpg
- Please Twins-66.jpg
- Please Twins-67.jpg
Please Twins! OVA
- Please TwinsOAV-01.jpg
- Please TwinsOAV-02.jpg
- Please TwinsOAV-03.jpg
- Please TwinsOAV-04.jpg
External Links
|Winter Season
|A Little Snow Fairy Sugar · Full Metal Panic! · Please Teacher!
|Spring Season
|Happy Lesson · Rizelmine · Tenchi Muyo! GXP · Ai Yori Aoshi · Gun Frontier · Chobits · Azumanga Daioh
|Summer Season
|RahXephon · G-On Riders · Saikano · Princess Tutu
|Fall Season
|Witch Hunter Robin · Gravion · Duel Masters
|Ongoing Series
|Inuyasha · Kochira Katsushika-ku Kameari Kōen-mae Hashutsujo · Twelve Kingdoms · Tokyo Mew Mew · Groove Adventure Rave · One Piece · Mobile Suit Gundam Seed
|Movies, OVAs & Specials
|Love Hina Again · Psychic Academy · Arcade Gamer Fubuki · 6 Angels · Cosplay Complex · Nurse Witch Komugi · Perfect Blue: Yume Nara Samete · Pia Carrot: The Movie · Please Teacher! OVA · Inuyasha: The Castle Beyond the Looking Glass · Viper GTS
|Bleach · Orphen Max · Hunter x Hunter · .hack//Legend of the Twilight
|Video Games
|Shantae · Super Mario Sunshine


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Customer Service Essay
- Pazartesi, Aralık 23, 2013, 14:52
- Henüz Yorum Yok
Spot last names and your first to the first line. Once you get the structure down, it will become second nature, and you should find it being done by yourself instantly. On this line, "Mentor John Doe" goes for example. Double space each distinct the planning. In the flexibility of arrangement courses at your benefit to finding your way around a new college, the adjustments are obvious immediately. Guidelines Position your planning while in the upper-left -hand part of the site. Faculty is just a fresh knowledge for learners in lots of ways.
It may seem noticeable, but be sure you have a dvd drive, not really a cd drive.
This practices Modern Language Affiliation (MLA) format. Utilize his first by Mentor. All collections of the planning are left justified in the edge that was left. Even the way you mind your papers might be from everything you are used to, different. As an example, make use of "Language 101." Area the customer service essay day to the range that is ultimate. Position your lecturer's label around the line that is next. Double space after the last line of your planning, and core customer service essay the concept of your report around the next brand.
By doing so, you will get a better images of the essay that you must come up with.
Work with a one- edges for customer service essay typed customer service essay papers. Always a few simple rules are customer service essay when intending a paper, to follow. Location the label of your class to the next brand. MLA formatting may be the acknowledged standard for university reports. For example, "A Brief History of Life During the Tudor Interval." Double-space after the heading and start your report utilizing a 1 – inch indent to start the initial paragraph. To check out MLA arrangement, the day must search since the time in numeral structure, the month in the year as well as prepared format.
It can take up to a year and a half before research gets approved, she https://pro-essay-writer.com/ said, and by then, the superintendent who asked you do that research has probably been fired
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Yorumunuzu Bırakın
Eğer profil resminizin görünmesini istiyorsanız gravatar'a ücretsiz kaydolabilirsiniz.
Yorum yollayabilmek için giriş yapmalısınız.


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Unemployment in 2005
April 03, 2006
Last year, the unemployment rate continued the downward trend that began in 2003, declining to 5.0 percent by the fourth quarter of 2005.
The rate had been 5.4 percent in the fourth quarter of 2004.
For most major worker groups, the unemployment rate continued to edge down in 2005. The unemployment rate for adult men, at 4.3 percent in the last quarter of 2005, was 0.6 percentage point lower than a year earlier. The jobless rate for women edged down by 0.2 percentage point over the year to 4.5 percent in the fourth quarter of 2005. For teenagers, the jobless rate was little changed in 2005.
The unemployment rate for whites, at 4.3 percent, was down over the year by 0.3 percentage point. For blacks, the unemployment rate dropped 1.1 percentage points to 9.7 percent. For Hispanics, the unemployment rate decreased in 2005 to 6.0 percent, down from 6.6 percent in the fourth quarter of 2004.
These data are from the Current Population Survey. Find more information in "Lower unemployment in 2005," by Emy Sok, Monthly Labor Review, March 2006.
Bureau of Labor Statistics, U.S. Department of Labor, The Economics Daily, Unemployment in 2005 on the Internet at https://www.bls.gov/opub/ted/2006/apr/wk1/art01.htm (visited October 18, 2019).
Recent editions of Spotlight on Statistics
- 25 years of Worker Injury, Illness, and Fatality Case Data
Examines detailed historical data on work-related injuries, illnesses, and fatal injuries.
- Occupational employment projections through the perspective of education and training
Examines employment, projected employment growth, and wages for occupations with different education and training requirements.
- Workers in Alternative Employment Arrangements
A look at independent contractors, on-call workers, temporary help agency workers, and workers provided by contract firms.
- Labor force characteristics of people with a disability
Examines the labor force characteristics of people with a disability and compares them with the characteristics of people with no disability.


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The Sunriser 2018/21
President: Julie Kydd ( firstname.lastname@example.com )
|Issue: 2018/21 30 July 2018
|Hi Visitor,
Welcome to another edition of the newsletter. This edition covers the last two meetings. There is still a need for a "new" newsletter Editor as the current Editor does not have enough hours in the day or week to get the newsletter out weekly. Please let President Julie know if anyone out there is interested.
Club Matters
Date 17 July
There were two lucky draws.
President Julie welcomed all to a different meeting. It was a zoom meeting with our Twin Club Rotary Club of Terrigal Australia.
There were a few issues which were overcome and we met several members and heard about some of their projects and a fundraiser. In return we highlighted our Literacy and Numeracy projects. Graham M issued a challenge to RC Terrigal to see which Club would have (percentage wise) more new members at the end of the year. This means for every one member gained by RC Terrigal our Club would need to gain two. The zoom meeting lasted 35 minutes and the consensus was that we would do it again. Next would be our club joining one of their meetings. The time difference is awkward but not insurmountable. Our thanks to Anthony for all his hard work in getting this up and running.
We officially welcomed AG Frank Freeman to our Club. Frank has been a member of our Club since the beginning of July but wanted Ted to be present when he was officially welcomed to the Club.
Frank also took this opportunity to pass on the Nuisance hat. The (un)lucky recipient was Clive.
There was one guest on 24 July, Henry Fuller, husband of Bridgett.
President Julie welcomed all to the special social meeting. All the business part of the meeting was handled before the fun began.
Then it was time for the celebration. DG Casper was unable to join the meeting via zoom or in person, so he had prepared a taped speech. The occasion was to award the Presidents Award for 2017/18. The recipient of the award for 2017/18 is Bridgett Fuller. A well deserved award for Bridgett for all her hard work during her 8 years as our "Speaker Seeker". Her work made our Club the envy of the District. Bridgett was humbled by the award and was so surprised. As well as the award Bridgett was presented with a bunch of flowers and a potted plant. Henry was not forgotten as he was given some chocolates.
President Award 2017-2018
President Casper couldn't be present to award Bridgett the 2017-2018 President's Award so he left this personal video greeting
Read More
The winner of the lucky draw was Tracey Wilson, pictured left with President Julie.
On Wednesday 18 July Masikhule held their annual Cast on for Kids at Erinvale Hotel.
Sharyn Jory and Tessa Sanders were there to show support
The working team, duties and attendance is available here :
Member Contributions
Saturday 21 July saw the launch of District 9350's latest Club, Rotary Club Century City Cape Town. RCCCCT for short. Helderberg Sunrise had 4 members attend as well as DG Casper. It was a fun evening and President Julie exchanged banners with President Anthony Lawrence. RCCCCT do not have banners yet and they have promised to raid our Club when they receive their banners.
Why ShelterBox will not be responding to the flood disaster in Japan
Whilst we have been monitoring the situation carefully it is very unlikely ShelterBox will be responding.See below for Alf's analysis of the criteria from the Operations team. Please let me know if this timely example raises any questions or concerns.
Read More
Nico Shares Good News on an effective outreach program
Making a huge difference in the Eastern Cape over seven years
Read More
Nico also mentioned that Reggie is doing well at Col'Cacchio and that Ton and himself are exploring further education for him.
Carl-Heinz is still enjoying his well deserved holiday, yet he still has not forgotten us. Here are some of his photos taken in Saint Petersburg.
RI & District News
Barry Rassin, the 2018-19 president of Rotary International
A nice article giving background on Rotary's new president, Barry Rassin, strikes a perfect balance between Bahamian bonhomie and decisive leadership
RI Convention takes place in June 2019 in Hamburg. Registration is open and there are several members of our club that have already booked. Why not join them?
Events, Meetings and Well Wishes
Michelle Mclean-Bailey (pictured on reciept of her Paul Harris Fellow)
|hsrotary.co.za | contact | Facebook | Twitter


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Electricity Generation and Retail Corporation - trading at Synergy - is a Western Australian state-owned electricity generator, purchaser and supplier. The corporation owns and operates four major power stations:
Synergy also owns two supporting power stations at Mungarra and West Kalgoorlie. The company also has wind farms at Albany, Mumbida and Kalbarri, a wind-gas system at Esperance, and wind-diesel systems at Bremer Bay, Coral Bay, Denham, and Hopetoun.
Synergy also retails the electricity it generates and procures to residential, commercial and industrial customers throughout Western Australia.
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text:
WASHINGTON (AP) — Jasmine Thomas scored a season-high 25 points, hitting four 3-pointers, to help the Connecticut Sun beat the Washington Mystics 88-64 on Sunday and remain the lone undefeated team in the WNBA.
Connecticut (5-0) is off to its best start in franchise history. Alex Bentley added 15 points, Chiney Ogwumike had 11 points and nine rebounds and three blocks for the Sun.
Ariel Atkins led the Mystics (5-3) with 14 points. Washington has lost three of its last four games and was missing star Elena Delle Donne for the fourth straight game due to an illness.
Thomas scored four points during an 11-4 opening run and Connecticut never trailed. Myisha Hines-Allen's offensive rebound and putback pulled the Mystics within two late in the second quarter but they would get no closer. Thomas answered with a 3-pointer to sparks a 12-0 run that made it 49-35 at the break.
The Sun shot 47 percent from the field, hit 10 3-pointers and outrebounded Washington 45-31.
The Mystics made just 3 of 21 (15 percent) from 3-point range.
Copyright 2018 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.


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PROVIDENCE, R.I. — Providence police say the murder of a man over the weekend in South Providence may be connected to a recent shooting in the city.
Tyrone Williams, 27, was riding in a car with his girlfriend on Gallup Street early Sunday when a gunman fired on them, Maj. David Lapatin said Monday. Williams jumped out of the car and tried to run, but the gunman followed, continuing to shoot until Williams collapsed on the street, Lapatin said. Williams was pronounced dead at the scene, according to a police report.
Police seized several 9mm shell casings. There was no specific description of the killer, who ran from the scene, but Lapatin said detectives are working several leads into Williams' death. The girlfriend, who was not identified, was not injured.
Williams, who had several children, was the sixth person slain in the city this year — and the third murdered in just two weeks.
Lapatin said Williams' death is not believed to be connected to the past homicides, but may be linked to another shooting; he declined to specify which one.
"These crimes are senseless," Lapatin said. "You shoot someone with a gun, take a life, and your life is over, too, when we catch you and you get life [sentence]."
Police believe Williams was targeted by the shooter. The question is, why?
Before he was a victim, Williams had been a suspect in a violent crime.
Williams was out on bail since last fall on charges from a bizarre incident at a Chinese restaurant in Elmwood. Williams was accused of punching one of the employees at Ming River restaurant and stealing the tip jar; when police tracked him down, they said they found a .22-caliber rifle with a loaded magazine under his mattress.
As a convicted felon, Williams was barred from owning a gun. He'd served time for carrying a gun and felony assault, according to court and corrections records, and pleaded out to multiple domestic violence charges.
Lapatin declined to answer questions about how Williams' death could be connected to past gunfire.


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Sandusky, Ohio
Stein Hospice hopes to introduce Virtual Reality to our patients and their loved ones. Virtual Reality will allow us to provide the opportunity to enhance the quality of life during the patient's final journey. Patients will be able to "virtually" relive a memory, return to a place of emotional significance or have an experience that they are not able to physically manage.
For example, our veteran patients who are not physically capable of traveling to Washington D.C. for an Honor Flight will still have the opportunity to experience all it has to offer through Virtual Reality.
Other examples could include:
1. A bucket-list wish to see the Grand Canyon
2. A child who would like to visit Disneyland
3. Enjoy the thrill of flying a plane again
4. Seek a new adventure such as a ride on a roller coaster, bungee jumping or a trip to the mountains
5. Remember a nostalgic family vacation or take a trip to their childhood home
Aside from offering unique experiences, Virtual Reality can help in a variety of other ways, such as pain management and relaxation therapy.
Since 1981, Stein Hospice Service, Incorporated, a community not-for-profit hospice located
in Sandusky, Ohio, has been providing services for terminally ill clients diagnosed with six months ...read more
Learn more about Stein Hospice Service, Inc.
To provide comfort, compassion and support during life's final journey....read more


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Finding Happily Ever After
Contract or Covenant?
In the opener to this series, Pastor Danny unpacks the difference between the secular perspective of a marriage contract and the sacred perspective of a marriage covenant. The difference has huge implications for your vision for marriage. Singles and marrieds alike will really enjoy this message.
Where is True Happiness Found? (Pastor Danny Schulz)
In this message Pastor Danny explores how to be truly happy in marriage. Our culture romanticizes love beyond all reality. Yet so many married couples struggle to find true happiness. Listen in for practical help in this important area.
Becoming the Husband of Her Dreams (Pastor Danny Schulz)
In this message, Pastor Danny casts vision for the role of the husband in the home. God has called men to be leaders who make a huge difference in the home and therefore throughout society. This message will build confidence and boldness in you heart for God's great plan for marriage.
Becoming the Wife He Longs For
Pastor Jamie looks at the role of a woman in the marriage and why submission isn't a dirty word. Whether you are single, divorced, or the "it's complicated" season, we think you will find inspiration and encouragement for how God designed women differently than men.
Setting Up Guardrails (Pastor Danny Schulz)
In this message, Pastor Danny encourages us to consider setting up some personal guardrails that will keep us on track to end up living happily ever after. This message completes this series on marriage and we're praying for strength and grace for every person listening. God bless!