リスクマネジメントのコツ

筆者は多くの製薬企業や医療機器企業でリスクマネジメントに関するコンサルテーションを実施してきた。
リスクマネジメントを実施する中で、多くの勘違いや思い込みや間違いがあることに気付いた。
今回はリスクマネジメントを実施する際のコツを紹介したい。

リスクとは

リスクとは「危害の発生の確率とそれが発生したときの重大性の組合せ」(ISO/IEC Guide 51)である。
私たちは普段生活している中で、上記の掛け算をしばしば行っている。
例えば、飛行機で旅行することになったとしよう。飛行機が墜落すればほぼ助からない。「破局的」(重大)であることは誰でも知っている。しかしながら、「飛行機はほぼ墜落しない」(発生確率≒0)と考えている。
重大性と発生確率を掛け合わせた場合、ほぼ0に近いのである。
つまりどれだけ大きな事故が発生するとしても、発生確率が極めて低ければ、リスクをとる(飛行機に乗る)のである。それでも怖い人は新幹線を使用するであろう。

最初は重大性に注目する

ICH-Q9「品質リスクマネジメント」やISO-14971「医療機器リスクマネジメント」では、初期リスクを求める際に上記の掛け算(重大性×発生確率)を実施することとなっている。
ここで多くの人がつまずいてしまうことは、重大性はほぼ推定できるが、発生確率が求まらないということである。
しかしである。筆者はコンサルテーションを実施する際に、初期の発生確率は正確に求める必要はないと説明している。
初期リスクアセスメントでは、発生確率はあまり重要ではない。
発生確率を求めることが難しければ最大値である”1”としておけば良い。(発生確率は少数であらわされる。0.0~1.0)
なぜならば、リスクは試せないのであって、発生してみなければ発生確率は計算できないのからである。

特に、ソフトウェアエラーやヒューマンエラーに関しては、発生確率を求めない。
ソフトウェアにバグは付きもの(100%発生する)であり、ヒューマンエラーは必ず発生するのである。

最後は発生確率に注目する

多くのリスクマネジメントの規格やガイドラインなどでは、重大性と発生確率のどちらかまたは両方を低減させることを求めている。
ISO-14971では、「リスクコントロール手段は、危害の重大さ若しくは危害の発生確率又はその両者を減少させることができる」との記載がある。
しかしながら、重大性についてはリスクコントロール実施後も変化しない(危害の重大性は不変)という認識が一般的である。
つまり、重大性を下げることは極めて困難なのである。

例えば、墜落しても死亡しない飛行機は造れない。しかしながら、極めて墜落しない飛行機は設計できるのである。(ちなみに、あらゆる輸送手段の中で航空機が最も安全(発生確率が最も低い)である。)

リスクマネジメントを実施して、重大性を下げようと苦心している人をしばしば見かけるが、ほとんど困難であることを説明する。
リスクマネジメントにおいては、重大性を下げるのではなく、発生確率を下げるのである。

起きてしまったことはリスクとは言わない

市場で実際に事故が発生した場合、多くの企業では再度リスクマネジメントを実施している。
その際に、また発生確率を掛けているケースを見かける。
起きてしまった事故はもはや「リスク」ではなく「問題」である。そもそもリスクは起きるか起きないかが不明であるため、発生確率を想定するのである。事故が起きてしまった場合は、重大性のみで判断しなければならない。

また再発を防止するためにリスクマネジメントではなく、CAPA(是正・予防処置)を実施しなければならない。
たとえば、重大な航空機事故や列車事故が発生したとしよう。多くの場合、事故調査委員会が開かれ根本的原因の徹底した追及と再発防止策を検討するであろう。

有名な話として、少女が猫を洗った後に寒いだろうと思って電子レンジに入れたといった事故が発生した。
製造業者はまさか生き物を電子レンジに入れるとは想定していなかったのである。しかしながら、実際に猫を電子レンジに入れたケースが発生したので、以降は取り扱い説明書に「生き物を入れないこと」と必ず明記(以降の発生確率は1と推定)しているのである。

医療機器の設計においてFMEAは使用してはならない

FMEA(IEC-60812)は医療機器規制では参照されていない。
FMEAの特徴は、リスクに検出可能性を掛け合わせていることである。これをリスク優先度(RPN:Risk Priority Number)と呼ぶ。

RPN=危害の発生の確率×重大性×検出可能性

機器の設計においてFMEA(検出可能性)は使用してはならない。リスク優先度は、患者、ユーザには無関係だからである。
医療機器のリスクマネジメントはISO-14971に従い、リスク(重大性×発生確率)を受容可能なまで低減しなければならない。つまり検出可能性に関係なく、医療機器設計においては、リスクコントロールが必要である。
FMEAは、工程設計において使用すれば良い。

改正GMP省令におけるリスクマネジメント

今般改正が予定されているGMP省令においては、ICH-Q9「品質リスクマネジメントに関するガイドライン」に従い、品質リスクマネジメントの実施が要求される。

PMDAのホームページでは、参考資料として「リスクマネジメントシート」の記載例が掲載されている。
https://www.pmda.go.jp/files/000218642.pdf
しかしである。この資料では業界をミスリードしてしまう。

「ユーザ要求仕様書(URS)を作成していない」「DQを実施していない」「IQ、OQ、PQを実施していない」などといった例が記載されている。
果たしてこれらはリスクマネジメントの対象であろうか。リスクとは、業務手順を遵守していても起きるかも知れない問題のことである。
「~を実施していない」は不作為であり、規制要件違反である。規制要件は遵守しなければならないものであり、リスクとして取り上げるべきものでは決してない。もしそれらがリスクであるとすれば、発生確率はどの程度あると思っているのであろうか?
当局には適切な模範の掲示を強く要望したい。

関連商品

[blogcard url=”https://ecompliance.co.jp/SHOP/191121P.html” title=”医療機器企業におけるリスクマネジメントセミナー” content=”医療機器企業にとって、リスクを管理することは非常に重要です。しかしながら、リスクマネジメントは難解です。
医療機器業界では、欧州が先行し、90年代からIOS-14971が制定されました。

医療機器には何がしかのリスクが潜んでいます。リスク分析の結果は、設計管理のインプットとなります。
医療機器事故は、ユーザの意図した利用と設計者の思想のギャップによって起こるとされています。

昨今では、ユーザビリティを含め、合理的な誤使用を予測したリスク分析が求められています。
演者は多くの医療機器企業においてリスクマネジメントの指導を行ってきましたが、各社ともに我流で実施していることが多いようです。
それでは、医療機器の安全が確保できず、また回収(改修)も減少しません。
そのためには、リスクマネジメントの基本的な考え方と規制当局の期待を十分に理解しなければなりません。

本セミナービデオでは、難解なリスクマネジメントを初心者にもわかりやすく解説いたします。”]

[blogcard url=”https://ecompliance.co.jp/SHOP/EL-008.html” title=”【セミナービデオ】医療機器企業におけるリスクマネジメントセミナー” content=”医療機器企業にとって、リスクを管理することは非常に重要です。しかしながら、リスクマネジメントは難解です。
医療機器業界では、欧州が先行し、90年代からIOS-14971が制定されました。

医療機器には何がしかのリスクが潜んでいます。リスク分析の結果は、設計管理のインプットとなります。
医療機器事故は、ユーザの意図した利用と設計者の思想のギャップによって起こるとされています。

昨今では、ユーザビリティを含め、合理的な誤使用を予測したリスク分析が求められています。
演者は多くの医療機器企業においてリスクマネジメントの指導を行ってきましたが、各社ともに我流で実施していることが多いようです。
それでは、医療機器の安全が確保できず、また回収(改修)も減少しません。
そのためには、リスクマネジメントの基本的な考え方と規制当局の期待を十分に理解しなければなりません。

本セミナービデオでは、難解なリスクマネジメントを初心者にもわかりやすく解説いたします。”]

[blogcard url=”https://ecompliance.co.jp/SHOP/MD-QMS-026.html” title=”【ISO 14971:2019対応】リスクマネジメント規程・手順書・様式” content=”ISO14971:2019に沿った形のリスクマネジメント規程・手順書・様式です。
医療機器設計におけるリスク分析は、ISO-14971に従って実施されています。
リスクマネジメント実施のための手順や様式を整えておかなければなりません。”]

Related post

Comment

  1. alternatives to allergy medication allergy medications for itching skin non drowsy allergy medication canada

  2. sleeping pills non prescription uk meloset 3 mg uk

  3. buy generic prednisone 10mg purchase prednisone online cheap

  4. pain relief without stomach upset buy coversyl generic

  5. best pimple medication for teenagers omnacortil canada best dermatologist treatment for acne

  6. how long do antihistamines take to work triamcinolone over the counter prescription vs over the counter

  7. medicine for stomach acid problems lincocin 500mg generic

  8. accutane 10mg sale order isotretinoin 10mg online cheap isotretinoin 20mg cost

  9. amoxil 1000mg sale order amoxil 1000mg buy amoxil 250mg online cheap

  10. sleeping prescription sleeping pills online where can i buy meloset

  11. azithromycin 500mg pills zithromax for sale purchase zithromax online cheap

  12. order gabapentin generic buy gabapentin 800mg online

  13. order azithromycin 500mg for sale azithromycin 250mg over the counter buy azithromycin for sale

  14. cheap lasix 100mg buy lasix without prescription

  15. prednisolone sale order omnacortil 5mg online cheap prednisolone price

  16. order amoxicillin sale buy amoxil 250mg sale amoxicillin price

  17. doxycycline over the counter monodox us

  18. albuterol inhaler order albuterol pills order albuterol sale

  19. buy clavulanate sale clavulanate sale

  20. buy levothroid generic synthroid tablet buy generic levothyroxine for sale

  21. order vardenafil sale purchase vardenafil without prescription

  22. buy clomid 50mg online purchase serophene online cheap order clomiphene 50mg online

  23. tizanidine online order buy tizanidine 2mg generic order tizanidine generic

  24. buy rybelsus 14mg rybelsus 14 mg without prescription buy semaglutide 14mg online

  25. order deltasone 40mg generic prednisone 10mg for sale prednisone 20mg without prescription

  26. order isotretinoin 40mg sale order generic isotretinoin isotretinoin 20mg over the counter

  27. order rybelsus 14mg pills buy rybelsus 14 mg generic buy semaglutide online

  28. cost albuterol 4mg ventolin 2mg oral order albuterol 4mg inhaler

  29. order amoxicillin 250mg pills amoxicillin 250mg us purchase amoxil pill

  30. augmentin without prescription order augmentin without prescription buy augmentin tablets

  31. azithromycin us buy azithromycin 250mg sale azithromycin 250mg price

  32. synthroid 150mcg generic levothyroxine tablet buy levothyroxine generic

  33. omnacortil 20mg brand prednisolone brand brand prednisolone 40mg

  34. order clomiphene 100mg for sale order clomid pill generic clomid

  35. gabapentin 800mg us order neurontin 800mg generic neurontin over the counter

  36. buy lasix generic diuretic how to get lasix without a prescription buy generic furosemide 100mg

  37. viagra online order cheapest viagra sildenafil 100mg tablet

  38. monodox buy online acticlate brand order vibra-tabs pills

  39. You could definitely see your skills in the work you write. The sector hopes for more passionate writers such as you who are not afraid to mention how they believe. At all times go after your heart.

  40. rybelsus 14 mg oral cheap semaglutide cost semaglutide

  41. real money casino online casino for real cash play slots

  42. buy levitra online buy vardenafil without prescription buy levitra paypal

  43. pregabalin 75mg without prescription order lyrica 75mg for sale brand pregabalin

  44. plaquenil 200mg cheap buy hydroxychloroquine 400mg sale order plaquenil 400mg

  45. But wanna state that this is extremely helpful, Thanks for taking your time to write this.

  46. aristocort medication order triamcinolone 4mg pills where to buy aristocort without a prescription

  47. cialis 5mg cost cialis 20mg us cialis 5mg over the counter

  48. clarinex canada desloratadine cost where can i buy clarinex

  49. buy cenforce 100mg online order cenforce online cheap buy cenforce sale

  50. claritin buy online oral loratadine how to buy claritin

  51. aralen 250mg sale where to buy aralen without a prescription buy chloroquine 250mg online

  52. buy priligy 60mg misoprostol 200mcg generic order misoprostol without prescription

  53. order glucophage pill metformin 500mg cheap metformin 500mg generic

  54. orlistat 60mg over the counter xenical 60mg uk diltiazem 180mg cost

  55. norvasc 5mg over the counter order norvasc 5mg generic norvasc oral

  56. buy generic acyclovir for sale order zyloprim 300mg without prescription buy allopurinol for sale

  57. buy rosuvastatin cheap buy cheap crestor zetia 10mg cheap

  58. lisinopril usa buy prinivil online cheap cost prinivil

  59. motilium 10mg generic buy cheap motilium order generic tetracycline

  60. order omeprazole order prilosec 20mg without prescription order omeprazole 10mg sale

  61. Thankyou for helping out, great information.

  62. order flexeril 15mg buy flexeril 15mg baclofen 10mg price

  63. oral metoprolol lopressor 50mg us metoprolol over the counter

  64. buy ketorolac without a prescription order colchicine online cheap buy generic gloperba for sale

  65. tenormin 50mg generic tenormin 100mg sale tenormin over the counter

  66. medrol over the counter methylprednisolone without prescription order medrol sale

  67. inderal over the counter propranolol drug order plavix 75mg pills

  68. academic writing services uk buy essays for college buy essay online uk

  69. order generic methotrexate 5mg buy methotrexate online coumadin 5mg brand

  70. mobic drug oral mobic 15mg buy celebrex generic

  71. buy metoclopramide 20mg without prescription order reglan 10mg sale generic losartan 50mg

  72. generic tamsulosin 0.2mg buy celecoxib medication buy cheap generic celecoxib

  73. esomeprazole 40mg pills order topiramate how to buy topamax

  74. ondansetron brand generic ondansetron order aldactone 100mg without prescription

  75. order imitrex sale order levaquin 500mg online levofloxacin for sale

  76. zocor price simvastatin online order valtrex oral

  77. cheap avodart oral avodart 0.5mg purchase ranitidine

  78. acillin ca amoxil generic order amoxicillin

  79. propecia 5mg without prescription order finpecia generic buy generic forcan online

  80. buy generic ciprofloxacin – augmentin pills order augmentin 625mg sale

  81. ciprofloxacin 500mg oral – purchase keflex online cheap purchase amoxiclav pills

  82. ciprofloxacin uk – doxycycline brand buy cheap generic erythromycin

  83. order flagyl sale – buy zithromax 500mg sale brand azithromycin 500mg

  84. stromectol without prescription – order sumycin pill buy tetracycline 500mg generic

  85. buy ivermectin 12mg for humans – ciplox usa tetracycline 250mg pill

  86. order valacyclovir 1000mg sale – valacyclovir 500mg us order acyclovir 400mg generic

  87. buy acillin tablets penicillin order amoxil uk

  88. order metronidazole 400mg generic – metronidazole 200mg us zithromax for sale online

  89. order lasix 40mg without prescription – order captopril 25 mg buy cheap captopril

  90. metformin 1000mg uk – bactrim price buy cheap generic lincomycin

  91. oral zidovudine 300 mg – order roxithromycin 150 mg sale buy generic zyloprim 100mg

  92. buy clozapine 50mg online cheap – coversyl ca order famotidine 40mg for sale

  93. quetiapine 100mg uk – fluvoxamine 100mg pill cheap eskalith generic

  94. clomipramine for sale – cymbalta 40mg over the counter buy doxepin 75mg generic

  95. F*ckin’ tremendous issues here. I’m very glad to see your post. Thanks a lot and i am looking ahead to contact you. Will you please drop me a mail?

  96. brand atarax 25mg – buy nortriptyline 25mg generic purchase endep

  97. I am often to blogging and i really appreciate your content. The article has really peaks my interest. I am going to bookmark your site and keep checking for new information.

  98. I believe this site holds some real excellent info for everyone. “A sense of share is not a bad moral compass.” by Colin.

  99. cost augmentin – ampicillin generic brand ciprofloxacin

  100. buy amoxil tablets – keflex 250mg oral buy cipro pills for sale

  101. buy azithromycin 500mg without prescription – order azithromycin sale ciprofloxacin canada

  102. brand cleocin – order cefixime for sale chloromycetin order

  103. I would like to thnkx for the efforts you have put in writing this blog. I am hoping the same high-grade blog post from you in the upcoming as well. In fact your creative writing abilities has inspired me to get my own blog now. Really the blogging is spreading its wings quickly. Your write up is a good example of it.

  104. ivermectin 3 mg online – oral ivermectin cost where can i buy cefaclor

  105. buy allergy tablets – purchase promethazine generic where to buy theo-24 Cr without a prescription

  106. methylprednisolone 8mg oral – buy cetirizine 10mg without prescription azelastine 10ml oral

  107. Very well written story. It will be helpful to anybody who utilizes it, including myself. Keep up the good work – for sure i will check out more posts.

  108. desloratadine 5mg ca – clarinex 5mg without prescription buy generic albuterol over the counter

  109. I love your writing style genuinely enjoying this website .

  110. Thanks for sharing superb informations. Your website is so cool. I am impressed by the details that you have on this blog. It reveals how nicely you perceive this subject. Bookmarked this website page, will come back for extra articles. You, my friend, ROCK! I found simply the information I already searched all over the place and simply couldn’t come across. What a great site.

  111. buy glucophage online – glycomet buy online precose brand

  112. buy glyburide generic – glipizide usa buy forxiga 10 mg online cheap

  113. You really make it seem really easy with your presentation however I find this topic to be really one thing which I feel I might never understand. It seems too complex and very extensive for me. I’m looking forward for your next submit, I will attempt to get the grasp of it!

  114. order prandin 1mg sale – prandin 1mg pill jardiance brand

  115. I’ve learn a few good stuff here. Definitely value bookmarking for revisiting. I surprise how a lot effort you set to make any such fantastic informative website.

  116. buy generic semaglutide – buy glucovance without a prescription how to get DDAVP without a prescription

  117. buy lamisil 250mg without prescription – diflucan 100mg over the counter grifulvin v cheap

  118. Thank you for the auspicious writeup. It in reality was once a enjoyment account it. Look complicated to more delivered agreeable from you! By the way, how could we keep up a correspondence?

  119. buy generic ketoconazole 200mg – buy nizoral no prescription itraconazole order online

  120. buy famciclovir tablets – famciclovir 500mg sale generic valcivir 1000mg

  121. You made some good points there. I looked on the internet for the issue and found most people will agree with your site.

  122. You actually make it appear really easy together with your presentation however I to find this topic to be actually one thing which I believe I’d never understand. It seems too complex and very huge for me. I’m taking a look ahead on your subsequent put up, I will attempt to get the hang of it!

  123. buy generic digoxin – buy generic dipyridamole online furosemide 40mg generic

  124. purchase metoprolol pill – buy adalat 30mg without prescription adalat 10mg pill

  125. microzide 25 mg for sale – buy norvasc sale bisoprolol order

  126. buy nitroglycerin no prescription – valsartan ca diovan 80mg generic

  127. simvastatin note – lipitor hook atorvastatin colour

  128. rosuvastatin pills need – ezetimibe online coast caduet buy drift

  129. viagra professional online woman – malegra seldom levitra oral jelly vein

  130. priligy cover – sildigra trace cialis with dapoxetine relative

  131. cenforce appeal – cialis cost brand viagra pills camp

  132. Have you ever thought about adding a little bit more than just your articles? I mean, what you say is important and all. But imagine if you added some great graphics or videos to give your posts more, “pop”! Your content is excellent but with images and video clips, this blog could certainly be one of the best in its field. Very good blog!

  133. brand cialis still – viagra soft tabs favourite penisole widow

  134. Hello! I know this is kinda off topic but I was wondering which blog platform are you using for this site? I’m getting fed up of WordPress because I’ve had problems with hackers and I’m looking at alternatives for another platform. I would be great if you could point me in the direction of a good platform.

  135. Its superb as your other content : D, thanks for putting up. “In the spider-web of facts, many a truth is strangled.” by Paul Eldridge.

  136. brand cialis strict – viagra soft tabs smart penisole against

  137. cialis soft tabs online await – valif online anybody viagra oral jelly halt

  138. I dugg some of you post as I thought they were very helpful very beneficial

  139. Hi there! This post couldn’t be written any better! Reading through this post reminds me of my previous room mate! He always kept talking about this. I will forward this article to him. Pretty sure he will have a good read. Thank you for sharing!

  140. What Is Potent Stream? Potent Stream is a male health formula that helps to maintain healthy urinary and prostate health by killing off all the toxins in the body

  141. cialis soft tabs online spin – cialis oral jelly pills drive viagra oral jelly online off

  142. dapoxetine meat – cialis with dapoxetine comment cialis with dapoxetine show

  143. cenforce scrooge – levitra professional dusk brand viagra pills stride

  144. of course like your website but you need to check the spelling on several of your posts. Many of them are rife with spelling problems and I find it very bothersome to tell the truth nevertheless I will certainly come back again.

  145. asthma treatment stool – asthma medication rabbit asthma treatment anyway

  146. Would you be thinking about exchanging hyperlinks?

  147. I like what you guys are up also. Such smart work and reporting! Carry on the excellent works guys I¦ve incorporated you guys to my blogroll. I think it will improve the value of my site 🙂

  148. prostatitis medications born – pills for treat prostatitis resolve prostatitis treatment enjoy

  149. uti antibiotics chant – treatment for uti idiot uti antibiotics hey

  150. I’m still learning from you, but I’m making my way to the top as well. I certainly liked reading everything that is written on your website.Keep the stories coming. I liked it!

  151. It’s actually a nice and useful piece of info. I am glad that you just shared this helpful info with us. Please keep us informed like this. Thank you for sharing.

  152. loratadine unconscious – claritin pills mom claritin pills oh

  153. valacyclovir online everything – valtrex pills savage valacyclovir pills carry

  154. priligy snort – priligy staff dapoxetine slip

  155. claritin escape – claritin pills dangerous claritin pills axe

  156. What Is LeanBiome? LeanBiome, a new weight loss solution, includes beneficial strains of gut bacteria that work fast for weight loss.

  157. You got a very fantastic website, Gladiolus I detected it through yahoo.

  158. It’s actually a nice and useful piece of information. I’m glad that you simply shared this useful information with us. Please stay us informed like this. Thank you for sharing.

  159. ascorbic acid better – ascorbic acid waist ascorbic acid art

  160. promethazine rank – promethazine offer promethazine kitchen

  161. Very interesting info!Perfect just what I was searching for!

  162. clarithromycin beautiful – albenza card cytotec pills america

  163. hi!,I like your writing very much! share we communicate more about your post on AOL? I require an expert on this area to solve my problem. Maybe that’s you! Looking forward to see you.

  164. florinef third – nexium pills rest lansoprazole passage

  165. Rattling good info can be found on website.

  166. Great write-up, I am regular visitor of one?¦s blog, maintain up the excellent operate, and It is going to be a regular visitor for a long time.

  167. buy rabeprazole 20mg online cheap – buy rabeprazole 20mg online domperidone us

  168. buy cheap generic dulcolax – oxytrol canada liv52 ca

  169. The next time I read a blog, I hope that it doesnt disappoint me as much as this one. I mean, I know it was my choice to read, but I actually thought youd have something interesting to say. All I hear is a bunch of whining about something that you could fix if you werent too busy looking for attention.

  170. order bactrim 480mg pills – buy cotrimoxazole no prescription tobra online buy

  171. hydroquinone us – purchase duphaston online dydrogesterone 10mg pill

  172. F*ckin¦ tremendous things here. I¦m very happy to see your article. Thanks a lot and i’m taking a look forward to touch you. Will you please drop me a e-mail?

  173. buy generic fulvicin – gemfibrozil 300 mg price lopid 300 mg for sale

  174. purchase forxiga generic – sinequan 75mg usa precose ca

  175. order dramamine without prescription – pill prasugrel brand risedronate

  176. buy enalapril 5mg without prescription – zovirax canada zovirax price

  177. etodolac medication – etodolac 600mg over the counter order cilostazol 100 mg online

  178. where can i buy piroxicam – feldene over the counter rivastigmine 3mg price

  179. I just could not depart your site before suggesting that I extremely enjoyed the standard info a person provide for your visitors? Is gonna be back often to check up on new posts

  180. Hello there, I found your site by means of Google even as searching for a similar topic, your website came up, it seems great. I have bookmarked it in my google bookmarks.

  181. order piracetam generic – buy biltricide online sinemet 10mg tablet

  182. purchase hydroxyurea pill – buy disulfiram 500mg online cheap cost robaxin 500mg

  183. depakote 250mg cheap – where to buy topiramate without a prescription topamax 200mg tablet

  184. What Is FitSpresso? The effective weight management formula FitSpresso is designed to inherently support weight loss. It is made using a synergistic blend of ingredients chosen especially for their metabolism-boosting and fat-burning features.

  185. What Is Sugar Defender? Sugar Defender is a meticulously crafted natural health supplement aimed at helping individuals maintain balanced blood sugar levels. Developed by Jeffrey Mitchell, this liquid formula contains 24 scientifically backed ingredients meticulously chosen to target the root causes of blood sugar imbalances.

  186. cheap disopyramide phosphate pills – where to buy lamotrigine without a prescription thorazine canada

  187. FitSpresso: What Is It? FitSpresso is a natural weight loss aid designed for individuals dealing with stubborn weight gain. It is made using only science-backed natural ingredients.

  188. buy aldactone 100mg generic – cheap epitol naltrexone 50mg canada

  189. buy cheap cytoxan – antivert 25mg us trimetazidine price

  190. You are my inhalation, I have few blogs and rarely run out from post :). “No opera plot can be sensible, for people do not sing when they are feeling sensible.” by W. H. Auden.

  191. cyclobenzaprine pills – order prasugrel sale buy vasotec for sale

  192. order zofran 8mg pill – purchase eldepryl online cheap brand ropinirole

  193. ascorbic acid 500 mg pill – order ferrous sulfate without prescription purchase compro pills

  194. Glad to be one of many visitants on this amazing website : D.

  195. purchase durex gel – zovirax usa latanoprost medication

  196. I like what you guys are up also. Such clever work and reporting! Keep up the superb works guys I¦ve incorporated you guys to my blogroll. I think it’ll improve the value of my website 🙂

  197. What is Gluco6? Gluco6 is a revolutionary dietary supplement designed to help individuals manage their blood sugar levels naturally.

  198. cost rogaine – order proscar 1mg generic order finasteride generic

  199. What i do not realize is in truth how you are not actually a lot more well-appreciated than you may be now. You’re very intelligent. You know therefore significantly on the subject of this subject, produced me individually consider it from a lot of varied angles. Its like women and men aren’t involved until it’s something to do with Lady gaga! Your own stuffs great. Always care for it up!

  200. arava online – buy alfacalcidol tablets buy cartidin pills for sale

  201. buy calan pills for sale – calan 120mg price tenoretic order online

  202. buy cheap tenormin – buy carvedilol for sale carvedilol 6.25mg us

  203. Good write-up, I’m regular visitor of one’s blog, maintain up the nice operate, and It is going to be a regular visitor for a lengthy time.

  204. buy atorlip pill – order nebivolol 5mg generic buy bystolic pills for sale

  205. F*ckin’ amazing things here. I’m very happy to look your article. Thank you so much and i am looking ahead to contact you. Will you kindly drop me a mail?

  206. gasex brand – buy cheap generic gasex buy diabecon generic

  207. buy lasuna online – purchase diarex for sale how to get himcolin without a prescription

  208. buy generic norfloxacin online – purchase eulexin online cheap order confido sale

  209. order speman without prescription – buy himplasia for sale finasteride over the counter

  210. finax price – order cardura generic buy uroxatral without a prescription

  211. I have been exploring for a bit for any high-quality articles or weblog posts on this kind of space . Exploring in Yahoo I eventually stumbled upon this web site. Studying this info So i?¦m glad to express that I have an incredibly excellent uncanny feeling I found out just what I needed. I such a lot indubitably will make sure to do not overlook this web site and provides it a glance regularly.

  212. brand hytrin 1mg – buy dutasteride tablets dapoxetine 30mg brand

  213. oral trileptal 600mg – order generic pirfenidone synthroid 75mcg for sale

  214. I really treasure your work, Great post.

  215. buy cheap duphalac – order betahistine 16mg without prescription betahistine usa

  216. cyclosporine sale – cheap methotrexate 10mg purchase colchicine online cheap

  217. hi!,I like your writing very much! share we communicate more about your post on AOL? I require an expert on this area to solve my problem. Maybe that’s you! Looking forward to see you.

  218. Some really fantastic articles on this web site, appreciate it for contribution. “When he has ceased to hear the many, he may discern the One – the inner sound which kills the outer.” by H Hahn Blavatsky.

  219. deflazacort without prescription – brimonidine cheap buy brimonidine generic

  220. This design is steller! You certainly know how to keep a reader entertained. Between your wit and your videos, I was almost moved to start my own blog (well, almost…HaHa!) Fantastic job. I really enjoyed what you had to say, and more than that, how you presented it. Too cool!

  221. As a Newbie, I am continuously exploring online for articles that can be of assistance to me. Thank you

  222. besivance where to buy – besivance usa buy generic sildamax over the counter

  223. neurontin price – generic ibuprofen 600mg buy sulfasalazine pill

  224. buy benemid pills for sale – order probenecid 500mg online cheap carbamazepine 400mg usa

  225. order celecoxib online – buy celebrex 200mg online cheap indomethacin 75mg uk

  226. I have not checked in here for a while since I thought it was getting boring, but the last several posts are good quality so I guess I will add you back to my everyday bloglist. You deserve it my friend 🙂

  227. I have recently started a site, the information you offer on this site has helped me tremendously. Thank you for all of your time & work.

  228. mebeverine 135mg price – buy colospa 135 mg online buy generic cilostazol for sale

  229. order diclofenac 100mg generic – aspirin online order aspirin 75mg online

  230. Having read this I thought it was very informative. I appreciate you taking the time and effort to put this article together. I once again find myself spending way to much time both reading and commenting. But so what, it was still worth it!

  231. It’s a shame you don’t have a donate button! I’d certainly donate to this outstanding blog! I guess for now i’ll settle for book-marking and adding your RSS feed to my Google account. I look forward to brand new updates and will talk about this site with my Facebook group. Talk soon!

  232. buy rumalaya online cheap – rumalaya cost buy amitriptyline 50mg

  233. mestinon 60mg cost – order sumatriptan without prescription imuran for sale online

  234. Your home is valueble for me. Thanks!…

  235. Heya i’m for the primary time here. I came across this board and I find It really useful & it helped me out much. I’m hoping to offer one thing back and help others such as you aided me.

  236. Hello my friend! I wish to say that this article is awesome, great written and include almost all vital infos. I’d like to look extra posts like this.

  237. Yeah bookmaking this wasn’t a bad determination outstanding post! .

  238. cheap generic voveran – buy generic imdur over the counter where can i buy nimodipine

  239. order baclofen 10mg sale – order lioresal order feldene generic

  240. I really like what you guys are up too. This kind of clever work and reporting! Keep up the excellent works guys I’ve added you guys to blogroll.

  241. Keep working ,splendid job!

  242. I like this website its a master peace ! Glad I discovered this on google .

  243. meloxicam 15mg cheap – rizatriptan 10mg drug buy toradol pill

  244. cyproheptadine price – order periactin 4 mg online cheap order tizanidine online

  245. cheap trihexyphenidyl without prescription – artane where to buy purchase cheap voltaren gel

  246. buy omnicef without a prescription – buy cefdinir online cleocin medication

  247. I have been exploring for a little for any high quality articles or blog posts on this kind of space . Exploring in Yahoo I finally stumbled upon this site. Studying this information So i am glad to exhibit that I have a very good uncanny feeling I discovered just what I needed. I most indisputably will make certain to don?¦t omit this site and give it a glance regularly.

  248. order flagyl 400mg generic – cenforce without prescription purchase cenforce for sale

TOP