Background: A growing number of prescription medicines such as Viagra(R) are offered and sold directly to consumers on the Internet. Little is known about the structure and "quality" of these "virtual pharmacies" in terms of how responsibly "online-prescriptions" are actually issued. Objective: To determine to what extent Viagra is sold on the Internet despite clear contraindications. Methods: The World Wide Web was searched for companies who offer to issue prescriptions for Viagra online or sell Viagra without prescription. We pretended to be a patient in which the ordered drug (Viagra) is clearly contraindicated, and tried to obtain an online prescription for this drug on the Internet. Our test case was as a 69-year-old woman giving a sexual history of having "no orgasm," with obesity (165cm/78kg), coronary artery disease, and hypertension, and taking captopril, pravachol, atenolol, and erythromycin. Results: Twenty-two distinct companies were identified, consisting of three different types: 2 required a written prescription by a "real" physician, 9 dispensed the drug without any prescription at all, and 11 issued an "online prescription" after an alleged physician reviewed the online order form containing medical questions. We tested 10 of the latter type, among them 8 based in the USA. We ordered a total of 66 pills worth US$ 1,802.84. Three companies, among them both European companies, delivered within 6, 10, and 34 days respectively, despite Viagra being clearly contraindicated. In 80% no complete history was taken, in 70% inappropriate medical terminology was used, and in only 2 cases was the order form reviewed by a physician who identified himself. Conclusions: Although a surprisingly high number of Internet pharmacies declined delivery, the public should be alerted to the risks involved with prescription drug prescribing and dispensing via the Internet.
