Is it safe for a 34-year-old male with controlled hypertension, taking Aztric CT (Olmesartan) 12.5 and Revelol XL (Metoprolol) 25, to take Dapoxetine and Sildenafil for premature ejaculation and erectile dysfunction?

Management of Erectile Dysfunction and Premature Ejaculation in a Hypertensive Patient

Sildenafil and dapoxetine can be safely used in this patient with controlled hypertension on Olmesartan and Metoprolol, but the beta-blocker may be contributing to his sexual dysfunction and should be considered for replacement with a different antihypertensive agent. 1

Assessment of Current Medication and Sexual Dysfunction

• The patient is currently on Olmesartan (Aztric CT 12.5) and Metoprolol (Revelol XL 25), which has adequately controlled his hypertension for five years 1
• Beta-blockers like Metoprolol are known to have negative effects on libido and erectile function, potentially contributing to the patient's sexual dysfunction 1
• Sexual dysfunction in hypertensive patients can be related to both the underlying vascular disease and the medications used to treat hypertension 1

Safety of Sildenafil in Hypertensive Patients

• Phosphodiesterase-5 (PDE5) inhibitors like sildenafil can be safely coadministered with most antihypertensive medications 1, 2
• Sildenafil may cause additive (but not potentiating) blood pressure-lowering effects when combined with antihypertensive medications 2
• The only absolute contraindication is concomitant use with nitrates, which this patient is not taking 1, 2
• Sildenafil is considered first-line therapy for erectile dysfunction according to guidelines 1

Safety of Dapoxetine in Hypertensive Patients

• Dapoxetine, a selective serotonin reuptake inhibitor (SSRI) developed specifically for premature ejaculation, has been studied in combination with PDE5 inhibitors 3, 4
• Studies show no clinically significant pharmacokinetic interactions between dapoxetine and sildenafil that would preclude their combined use 3
• The combination of dapoxetine and sildenafil has been shown to be effective and generally well-tolerated in men with both premature ejaculation and erectile dysfunction 4, 5

Recommended Management Approach

1. Consider medication adjustment for hypertension:

   • Since beta-blockers like Metoprolol can contribute to sexual dysfunction, consider switching to a different antihypertensive class 1
   • A calcium channel blocker or increasing the dose of the ARB (Olmesartan) could be considered as alternatives 1, 6
   • Maintain the hydrochlorothiazide component at 12.5mg as higher doses provide minimal additional BP benefit but increase side effects 6

2. For erectile dysfunction:

   • Sildenafil can be safely initiated at the standard dose (50mg, adjusted as needed) 1, 7
   • Monitor for potential additive blood pressure-lowering effects, especially within the first few hours after taking sildenafil 2
   • Advise the patient to take sildenafil 1 hour before planned sexual activity 7

3. For premature ejaculation:

   • Dapoxetine can be initiated at 30mg taken 1-3 hours before sexual activity 5
   • The dose can be increased to 60mg if needed and tolerated 4, 5
   • Common side effects to monitor include nausea, headache, and dizziness 4

Monitoring and Follow-up

• Monitor blood pressure after initiating these medications to ensure it remains controlled 1
• Assess for potential side effects including headache, flushing, and dizziness, which may be more common when combining these medications with antihypertensives 2, 4
• If the patient experiences symptomatic hypotension, consider adjusting the timing of medication administration or reducing doses 1

Important Caveats

• Ensure the patient understands that these medications treat symptoms but not the underlying causes of sexual dysfunction 1
• The patient should be informed about potential side effects and advised to seek medical attention if experiencing prolonged erection (>4 hours), sudden vision or hearing loss, or significant hypotension 1, 7
• Emphasize the importance of maintaining good control of hypertension, as uncontrolled hypertension itself can worsen erectile dysfunction through vascular damage 1