What is the best medication for a 33-year-old patient with anxiety that has minimal sexual side effects?

Bupropion Is the Best Medication for Anxiety with Minimal Sexual Side Effects

For a 33-year-old patient with anxiety, bupropion is the best medication choice due to its significantly lower rates of sexual adverse events compared to SSRIs and other antidepressants. 1, 2, 3

Medication Options for Anxiety with Sexual Side Effect Considerations

First-Line Option: Bupropion

• Mechanism: Dopamine-norepinephrine reuptake inhibitor 3
• Sexual side effect profile: Lowest among antidepressants 3, 4
  • Only 15% of men and 7% of women experience sexual dysfunction (compared to 63% of men and 41% of women on sertraline) 4
• Starting dose: 37.5 mg every morning, then increase by 37.5 mg every 3 days 1
• Target dose: 150 mg twice daily 1
• Administration timing: Give second dose before 3 pm to minimize insomnia risk 1

Alternative Options (If Bupropion Is Contraindicated)

1. Mirtazapine

   • Well-tolerated with fewer sexual side effects than SSRIs 1, 2
   • Starting dose: 7.5 mg at bedtime 1
   • May cause increased appetite and weight gain 1

2. Buspirone

   • Low impact on libido 2
   • Can be used as monotherapy or as augmentation to existing treatment 2
   • 58% of patients show improvement in sexual function when added to SSRIs 2

Medications to Avoid Due to Sexual Side Effects

1. SSRIs (Selective Serotonin Reuptake Inhibitors)

   • Paroxetine: Higher rates of sexual dysfunction than other SSRIs 1
   • Sertraline: Associated with significant sexual dysfunction (63% in men, 41% in women) 4
   • Fluoxetine: Significant sexual side effects 1, 4

2. SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)

   • Venlafaxine: Associated with sexual dysfunction 1

Important Considerations for Bupropion Use

Benefits

• Activating (reduces apathy) 1, 3
• Rapid improvement in energy levels 1
• Effective for anxiety when depression is comorbid 3, 5
• Can be used as augmentation therapy for patients with partial response to SSRIs 3

Precautions

• Should not be used in patients with:
  • Seizure disorders 1
  • Agitation 1
  • Eating disorders with purging behaviors
• Common side effects: nervousness and insomnia 3
• Monitor for behavioral activation/agitation, especially early in treatment 1
• Minimal drug interactions compared to SSRIs 2, 6

Monitoring and Follow-up

• Assess baseline sexual function before starting medication 2
• Evaluate for common side effects: insomnia, nervousness, dry mouth, headache 3
• Schedule follow-up within 2-4 weeks to assess response and side effects
• Titrate dose gradually to minimize side effects 1

Clinical Pearl

While SSRIs and SNRIs are traditionally considered first-line for anxiety disorders 7, the significant impact on sexual function makes them poor choices for patients concerned about sexual side effects. Bupropion provides an effective alternative with minimal sexual dysfunction risk, making it the optimal choice for this 33-year-old patient with anxiety concerned about sexual side effects.