Pharmacological strategies for sexual recovery in men undergoing antipsychotic treatment

ABSTRACT

Introduction

First- and second-generation antipsychotics are highly accountable for causing a plethora of medical side effects, ranging from metabolic imbalances to sexual dysfunction (SD), that frequently undermine patient-doctor relationships. Nevertheless, to date antipsychotics are one of the best treatment options for dealing with numerous either acute or chronic conditions like agitation, suicidality, depression, dementia, and of course psychosis. For these reasons, clinicians need to handle them wisely to preserve patients’ sexual health, avoid poor therapeutic adherence and prevent high rates of therapy drop-out.

Areas covered

This article reviews the literature on pharmacologic approaches for management strategies in men who are administered with antipsychotics and developed SD. The etiology of antipsychotic-induced SD is also discussed.

Expert opinion

Clinicians must consider sexual life as a major health domain. To do so, a first step would be to measure and monitor sexual function by means of psychometric tools. Secondly, primary prevention should be conducted when choosing antipsychotics, i.e. picking sex-sparing compounds like aripiprazole or brexpiprazole. Thirdly, if sexolytic compounds cannot be dismissed, such as first-generation antipsychotics, risperidone, paliperidone, or amisulpride, then aripiprazole 5–20 mg/day adjunctive therapy has proven to be most effective in normalizing prolactin levels and consequently treating antipsychotic-induced SD.

KEYWORDS:

• brexpiprazole
• antipsychotic
• aripiprazole
• sexual dysfunction
• prolactin
• dopamine
• schizophrenia
• drug treatment
• management strategies
• compliance

Article highlights

• Antipsychotics, especially first-generation antipsychotics (FGAs), risperidone or paliperidone, act by severely affecting sexual functioning.

• The sexolytic effect is mostly mediated by a dopamine D₂ antagonism, which eventually results in high levels of prolactinemia, a peripheral marker of sexual dysfunction. However, other mechanisms may be involved in this process, such as histaminergic, cholinergic, and alpha-adrenergic sedation, as well as serotonin-mediated sexual demotivation.

• In order to preserve sexuality, clinical psychiatrists need to measure and monitor sexual function by means of psychometric tools.

• Primary prevention should be conducted when choosing antipsychotics, i.e. by avoiding sexolytic compounds, such as FGAs, risperidone, paliperidone, and amisulpride, and picking sex-sparing compounds like aripiprazole or brexpiprazole.

• If sexolytic compounds cannot be dismissed, then aripiprazole 5-20 mg/day adjunctive therapy has proven to be most effective in normalizing prolactin levels and consequently treating antipsychotic-induced sexual dysfunction.

This box summarizes key points contained in the article.

Declaration of Interest

EA Jannini is has been a paid speaker and/or consultant for Bayer, IBSA, Lundbeck, Otsuka, Merck Serono, Menarini, Pfizer and Schionogi and Viatris. G Di Lorenzo has meanwhile received personal fees from Angelini, FB Health, Lundbeck, Neuraxpharm and Otsuka for speaking. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

EA Jannini and A Sansone are partially supported by the PRIN (Research Projects of National Relevance) grant #2017S9KTNE_002.