Which medication has the least risk of erectile dysfunction (ED) and what is the percentage of patients experiencing it?

Medication with Lowest Risk of Erectile Dysfunction

Bupropion has the lowest risk of erectile dysfunction among antidepressants, with only 7-15% of men experiencing ED compared to 41-63% with SSRIs. 1

Comparison of Medications and ED Risk

Antidepressants

• Bupropion (Wellbutrin): Lowest risk of sexual dysfunction among antidepressants with only 7-15% of men experiencing erectile dysfunction 1, 2
• Mirtazapine: Associated with a low rate of sexual adverse effects (≤10% of patients) 2
• Nefazodone: Low risk of sexual dysfunction (≤10% of patients), though it is no longer available for clinical use 3, 2
• SSRIs (sertraline, fluoxetine, paroxetine, etc.): Highest rates of sexual dysfunction, affecting 30-60% of patients 2
  • Paroxetine has higher rates of sexual dysfunction than fluoxetine, fluvoxamine, nefazodone, or sertraline 4

PDE5 Inhibitors (for ED treatment)

• All FDA-approved PDE5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil) have similar efficacy profiles for treating ED 4
• Most common side effects include dyspepsia, headache, flushing, back pain, nasal congestion, myalgia, visual disturbance, and dizziness 4
• Side effect differences:
  • Avanafil: Lowest rates of dyspepsia 4
  • Tadalafil: Lowest rates of flushing 4
  • Vardenafil and avanafil: Lowest rates of myalgia 4

Mechanism Behind Lower ED Risk with Bupropion

• Bupropion lacks the anticholinergic and antiadrenergic effects common to many other antidepressants 5
• It works primarily on dopamine and norepinephrine systems rather than serotonin, which appears to be responsible for its lower impact on sexual function 5
• In clinical studies, bupropion has demonstrated the ability to reverse sexual dysfunction caused by SSRIs in approximately 66% of patients 6

Clinical Applications

• For patients requiring antidepressant therapy who are concerned about sexual dysfunction, bupropion should be considered as a first-line option 1, 2
• For patients already experiencing sexual dysfunction from SSRIs, adding bupropion (75-150mg taken 1-2 hours before sexual activity) may help ameliorate these effects 6
• If p.r.n. (as needed) use is insufficient, a scheduled dose of up to 75mg three times daily may be more effective 6

Important Considerations

• Sexual dysfunction is often underreported in clinical trials and may be more common in real-world practice than indicated in product information 2
• Absolute rates of sexual dysfunction are probably underreported in clinical studies 4
• When selecting an antidepressant, clinicians should balance efficacy for depression with the risk of side effects including sexual dysfunction 2
• Sexual side effects may compromise a patient's lifestyle and result in poor medication compliance 3

Monitoring and Management

• Physicians should actively monitor patients for antidepressant-induced sexual adverse effects 2
• For patients experiencing ED from medications, PDE5 inhibitors (sildenafil, tadalafil) have been shown to be effective management strategies 3
• For women with antidepressant-induced sexual dysfunction, the addition of bupropion at higher doses appears to be the most promising approach 3

Remember that sexual dysfunction can significantly impact quality of life and medication adherence, making the selection of medications with lower ED risk an important consideration in treatment planning.