What can be added to Vraylar (cariprazine) to mitigate sexual dysfunction?

Treatment Options to Add to Vraylar for Sexual Dysfunction

For sexual dysfunction while on Vraylar (cariprazine), add a PDE5 inhibitor (sildenafil, tadalafil, or vardenafil) as first-line treatment, starting at the lowest dose and titrating as needed. 1

Treatment Algorithm for Male Sexual Dysfunction

First-Line Pharmacologic Intervention

• Start with oral PDE5 inhibitors (sildenafil, tadalafil, vardenafil) on an as-needed basis, beginning conservatively at the lowest dose and titrating to maximum dose if needed 1
• Daily low-dose PDE5 inhibitors can be used as an alternative to on-demand dosing and have demonstrated effectiveness 1
• Critical contraindication: Do not use PDE5 inhibitors if the patient is taking oral nitrates, as this combination can cause dangerous hypotension 1

Assess and Treat Hypogonadism

• Check morning total testosterone level; if <300 ng/dL, diagnose hypogonadism 1
• Testosterone therapy can relieve erectile dysfunction, ejaculatory problems, and orgasm difficulties in hypogonadal patients 1
• Adding testosterone to PDE5 inhibitor therapy in men with low serum testosterone improves erectile dysfunction beyond PDE5 inhibitors alone 1
• Monitor periodically for efficacy, side effects, and changes in health status 1

Problem-Specific Treatments

For premature ejaculation or ejaculatory problems:

• SSRIs (paroxetine, sertraline, citalopram, or fluoxetine) dosed daily 1
• Clomipramine dosed on-demand 1
• Pelvic physical therapy 1

For orgasm difficulties (reduced intensity, difficulty achieving):

• Vibratory therapy 1
• PDE5 inhibitors if not already prescribed 1
• Pelvic physical therapy 1

Non-Pharmacologic Interventions (Should Be Implemented Concurrently)

Lifestyle Modifications

• Smoking cessation 1
• Weight loss if obese 1
• Increased physical activity (one study showed PDE5 inhibitors combined with aerobic exercise were more effective than PDE5 inhibitors alone) 1
• Reduction of alcohol consumption 1

Psychological and Behavioral Interventions

• Referral to sex therapy or couples counseling, as sexual dysfunction often has a psychological overlay that may be more pronounced in psychiatric patients 1
• Pelvic floor muscle training/pelvic physical therapy has shown benefit in improving sexual function 1

Monitoring and Follow-Up

• Re-evaluate at regular intervals for efficacy, side effects, and any significant changes in health status 1
• Monitor for treatment adherence and adjust therapy based on response 1

Common Pitfalls to Avoid

• Do not prescribe PDE5 inhibitors to patients on nitrates - this is an absolute contraindication due to risk of severe hypotension 1
• Do not prescribe testosterone to men actively trying to conceive, as it causes short-term suppression of sperm production 1
• Do not assume sexual dysfunction will resolve spontaneously - it requires active intervention with a multidimensional treatment plan 1
• Start PDE5 inhibitors at conservative doses and titrate up rather than starting at maximum doses 1