What alternative antidepressant can I switch to for a patient experiencing sexual side effects from Selective Serotonin Reuptake Inhibitors (SSRIs)?

From the Guidelines

Bupropion (Wellbutrin) is the preferred alternative antidepressant for patients experiencing sexual side effects from SSRIs, due to its lower rate of sexual adverse events compared to fluoxetine and sertraline 1. When considering a switch, it's essential to weigh the benefits and risks of each medication. Bupropion can be prescribed at 150-300 mg daily, typically starting at 150 mg once daily for a week before increasing to 150 mg twice daily if needed. Some key points to consider when switching to bupropion include:

• Bupropion works differently from SSRIs by primarily affecting dopamine and norepinephrine rather than serotonin, which explains its lower rate of sexual dysfunction 1.
• A cross-taper approach is generally recommended when switching from an SSRI - gradually reducing the SSRI while introducing bupropion.
• Other alternatives with lower sexual side effect profiles include mirtazapine (15-45 mg at bedtime) and vortioxetine (5-20 mg daily).
• For some patients, adding bupropion to a reduced dose of their current SSRI may preserve antidepressant efficacy while reducing sexual side effects.
• It's crucial to monitor for potential side effects of bupropion, which can include insomnia, agitation, dry mouth, and seizure risk (contraindicated in patients with seizure disorders or eating disorders) 1. The choice of alternative should be individualized based on the patient's specific symptoms, comorbidities, and previous treatment responses.

From the FDA Drug Label

FULL PRESCRIBING INFORMATION: 1 INDICATIONS AND USAGE 1.1 Major Depressive Disorder (MDD) 12.1 Mechanism of Action

The patient can be switched to bupropion, as it has a different mechanism of action compared to SSRIs and may have a lower risk of sexual side effects 2.

• Bupropion is an antidepressant that works as a norepinephrine-dopamine reuptake inhibitor (NDRI).
• It is approved for the treatment of Major Depressive Disorder (MDD).
• The dosage and administration instructions for bupropion can be found in sections 2.1-2.5 of the drug label.

From the Research

Alternative Antidepressants for Patients Experiencing Sexual Side Effects from SSRIs

• Bupropion is consistently reported to have a lower risk of sexual dysfunction compared to SSRIs, with studies suggesting it may be a suitable alternative 3, 4, 5.
• Mirtazapine and nefazodone are also associated with lower rates of sexual dysfunction, although the evidence is not as extensive as for bupropion 3, 4.
• Other potential alternatives include vilazodone, vortioxetine, and serotonin-norepinephrine reuptake inhibitors, although more research is needed to fully understand their effects on sexual function 5.
• Reboxetine and moclobemide have also been identified as having lower rates of sexual dysfunction, but their use may be limited by other factors, such as availability and side effect profiles 6, 7.

Management Strategies for Antidepressant-Induced Sexual Dysfunction

• Switching to a different antidepressant, such as those listed above, may be an effective strategy for managing sexual dysfunction 6, 7, 5.
• Adding a medication to treat the sexual dysfunction, such as sildenafil for erectile dysfunction, may also be considered 7.
• Dose reduction or a "drug holiday" may be tried, although the evidence for these approaches is limited 7.
• Patient education and awareness of potential sexual side effects are crucial for promoting medication adherence and managing expectations 5.