Can Tagamet (cimetidine) and spironolactone be used to treat hypersexuality due to their potential to decrease sex drive?

Use of Cimetidine and Spironolactone for Hypersexuality

You are correct that both cimetidine (Tagamet) and spironolactone can decrease sex drive through their anti-androgenic effects, but spironolactone is the more evidence-based option for treating hypersexuality when pharmacotherapy is indicated, while cimetidine's role is primarily limited to drug interactions rather than therapeutic use.

Spironolactone's Sexual Side Effects

Spironolactone reliably causes decreased libido and sexual dysfunction in both men and women due to its anti-androgenic properties. 1

• In men, spironolactone causes gynecomastia, impotence, and decreased sexual function through decreased testosterone production and competitive inhibition of testosterone and dihydrotestosterone binding to androgen receptors 2, 1
• In women, the drug causes menstrual irregularities, decreased arousal, and sexual dysfunction 1, 3
• Decreased libido occurs in more than 10% of patients treated with spironolactone 1
• The sexual side effects are dose-dependent, with gynaecomastia occurring in 6.9% at 50 mg/day versus 52.2% at doses of 150 mg or more per day 4

Cimetidine's Limited Role

Cimetidine is mentioned in guidelines only as a drug that causes pharmacokinetic interactions with serotonin reuptake inhibitors (SRIs), not as a primary treatment for hypersexuality 2

• The AUA guidelines note that cimetidine can cause clinically significant pharmacokinetic interactions when used with SRIs, especially in elderly patients 2
• There is minimal evidence supporting cimetidine as a therapeutic agent for hypersexuality in modern practice 5

Evidence-Based Treatment of Hypersexuality

Selective serotonin reuptake inhibitors (SSRIs) are the first-line pharmacological treatment for sexual addiction and hypersexuality, not spironolactone or cimetidine 6

• SSRIs cause reduced libido as a common side effect, with rates varying by agent 2
• Paroxetine shows the highest rates of sexual dysfunction among SSRIs 7
• Sertraline at higher doses may be associated with increased frequency of erectile dysfunction and decreased libido, though studies have been too small to substantiate dose-related effects conclusively 2

Clinical Algorithm for Hypersexuality Treatment

When pharmacotherapy is needed for hypersexuality:

1. First-line: Consider SSRIs (particularly paroxetine or sertraline) as they have the most evidence for treating sexual addiction 6
2. Second-line: Naltrexone may be another therapeutic option 6
3. Off-label consideration: Spironolactone could be used in specific cases where anti-androgenic effects are desired, particularly in men, starting at 50-100 mg daily 2, 4
4. Avoid: Cimetidine has insufficient evidence and significant drug interaction concerns 2

Important Caveats

Spironolactone carries significant risks that must be weighed:

• In women of childbearing age, spironolactone should not be used in pregnancy as it crosses the placenta and may cause feminization of male fetuses 2
• Potassium monitoring is essential, particularly in patients with comorbidities or those taking medications affecting renal, adrenal, or hepatic function 2
• The sexual side effects, while potentially therapeutic for hypersexuality, can significantly impair quality of life and may not be reversible immediately upon discontinuation 2, 3

Psychotherapy, preferentially cognitive-behavioral therapy, should be used in association with any pharmacotherapy for sexual addiction 6