SANTA FE, N.M. — Psychiatrists underprescribe erectile dysfunction drugs, and primary care physicians prescribe them like aspirin to virtually any man who asks, H. George Nurnberg, M.D., said at a psychiatric symposium sponsored by the University of Arizona.
Men who suffer sexual dysfunction as a side effect of antidepressants should be given phosphodiesterase-5 inhibitors to alleviate the dysfunction and thereby help ensure they continue taking the antidepressants, advised Dr. Nurnberg, director of clinical research programs in the psychiatry department at the University of New Mexico, Albuquerque. Very few psychiatrists are doing so, he said.
If, however, a seemingly healthy young or middle-aged man asks for an erectile dysfunction drug, Dr. Nurnberg said the primary care physician's first response should not be to prescribe pills but to do a thorough work-up for underlying disease. “Sexual dysfunction is a sentinel marker,” he said, warning that “it actually may be an early manifestation or marker of very significant disease, of systemic disorder, coming down the pike.”
Advertisements for sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra) have obscured medical issues surrounding sexual dysfunction, Dr. Nurnberg said.
“There is a dangerous message in there. It is presented to us as a lifestyle issue,” he said. “This asymptomatic patient walking around … the assumption is he has this change in erectile dysfunction but everything else is fine.”
In most cases, this patient already has the beginnings of cardiovascular disease, he warned, predicting that as many as 30% are candidates for a myocardial infarction later in life.
Characterizing the new drugs as aspirin for erectile dysfunction, he said, “If you give the drug and they get better, that is good, but you have no idea what the etiology is. You have to think about the cause.”
Dr. Nurnberg summarized growing evidence that sexual dysfunction is a sentinel marker for endothelial dysfunction associated with major depression, medical disorders such as diabetes and cardiovascular disease, and medication side effects.
In the absence of underlying medical conditions, medications are the leading cause of sexual dysfunction, he continued. About 50% of patients discontinue antidepressants because of side effects; in patients with sexual side effects, the discontinuation rate is 90%.
Physicians ought to ask patients about any sexual consequences the patients experience while taking selective serotonin reuptake inhibitors, he said. Otherwise, “[patients] vote with their feet, and they stop taking the drug. That can be quite devastating in terms of treatment of a disorder. If we keep people on the drug, we can have better treatment outcomes.”
Some physicians choose antidepressants known to have fewer sexual side effects or augment them with bupropion, which Dr. Nurnberg said is not effective in preventing sexual dysfunction. Instead, he recommended treating the sexual side effect. Phosphodiesterase-5 inhibitors are not currently approved for women, but they might be helpful for the treatment of sexual dysfunction in females taking selective serotonin reuptake inhibitors, according to Dr. Nurnberg. With more than 4,000 women exposed to sildenafil so far, the studies have established safety but not efficacy.
He suggested the mixed results might reflect a lack of attention to women's hormone levels in most studies. In a recent trial, he reported finding significant differences over time in hormone levels of responders and nonresponders.
Previous studies did not control for hormone status. “They mixed menopausal and premenopausal women on contraceptive agents,” he said. “Estrogen status becomes very important in terms of female sexual dysfunction.”
Dr. Nurnberg disclosed receiving research support from and serving as a consultant or speaker for seven pharmaceutical companies, including Pfizer, GlaxoSmithKline, and Eli Lilly & Co., manufacturers of the three erectile dysfunction drugs.
He recommended the drug companies replace current advertisements with public service messages urging men who experience erectile dysfunction to ask their physicians for a physical examination.