Can Abilify (aripiprazole) affect a man's ability to maintain an erection?

Can Abilify Cause Erectile Dysfunction?

Yes, Abilify (aripiprazole) can cause erectile dysfunction, though it is actually less likely to cause this problem compared to most other antipsychotic medications. The FDA drug label lists erectile dysfunction as an "infrequent" adverse reaction, and research shows aripiprazole may actually improve sexual function when switched from other antipsychotics 1, 2.

Understanding Aripiprazole's Sexual Side Effects

Documented Incidence

• The FDA label for aripiprazole classifies erectile dysfunction as an infrequent adverse reaction (occurring in less than 1% of patients), which is notably lower than many other antipsychotics 1.
• A systematic review found that aripiprazole showed lower odds for erectile or ejaculatory dysfunction compared to other atypical antipsychotics like risperidone 3.

Why Aripiprazole is Different

• Unlike most antipsychotics that block dopamine receptors, aripiprazole acts as a partial agonist at dopamine D2 and D3 receptors, which typically results in fewer sexual side effects 4.
• Aripiprazole reduces prolactin levels rather than raising them (as most antipsychotics do), and elevated prolactin is a major cause of sexual dysfunction with antipsychotic medications 2.

What to Do If Erectile Dysfunction Occurs

First: Confirm the Cause

• Sexual dysfunction occurs in 30-60% of patients taking antipsychotic medications overall, so it's important to determine if aripiprazole is truly the culprit 5.
• Consider other contributing factors: relationship issues, hormonal abnormalities, other medications, excessive alcohol use, cardiovascular disease, diabetes, or inadequate sexual stimulation 6, 7.

Treatment Options

Option 1: Add a PDE5 Inhibitor (First-Line)

• Sildenafil, tadalafil, vardenafil, or avanafil are FDA-approved first-line treatments for erectile dysfunction and can be safely used alongside aripiprazole 6.
• These medications improve erections in 73-88% of men compared to 26-32% with placebo 7, 8.
• Critical safety screening required: Ensure the patient is not taking nitrates (absolute contraindication), can perform moderate physical activity, and has no high-risk cardiovascular conditions 9.
• Provide proper instructions: sexual stimulation is necessary, may require 5 separate attempts at maximum dose before declaring failure, and timing/food intake matters 6, 7.

Option 2: Consider Adjunctive Aripiprazole (If on Another Antipsychotic)

• If the patient is taking a different antipsychotic that's causing erectile dysfunction, adding or switching to aripiprazole may actually improve sexual function 2, 10.
• One study showed significant improvement in erectile difficulties (P=0.04) and ejaculatory function (P=0.017) at 12 weeks after switching to aripiprazole 2.

Option 3: Dose Adjustment

• Consider whether the current aripiprazole dose can be reduced while maintaining psychiatric stability 5.

Important Caveats

• Paradoxical hypersexuality: In rare cases, aripiprazole can cause the opposite problem—compulsive sexual behavior and hypersexuality due to its dopamine agonist properties, particularly in young males with previous risk behaviors 4.
• The FDA label notes rare cases of priapism (prolonged painful erection), which requires immediate medical attention 1.

Practical Management Algorithm

1. Verify the timeline: Did erectile dysfunction begin after starting aripiprazole or was it pre-existing?
2. Screen for other causes: Check testosterone levels, assess cardiovascular risk factors, review all medications, evaluate relationship factors 6.
3. If aripiprazole is the likely cause and psychiatric stability allows: Consider dose reduction 5.
4. If dose reduction isn't feasible: Prescribe a PDE5 inhibitor (sildenafil 50-100mg, tadalafil 10-20mg as needed, or tadalafil 5mg daily) after cardiovascular screening 6, 7, 9.
5. Ensure proper PDE5 inhibitor use: Sexual stimulation required, try at least 5 times at maximum dose, avoid heavy meals with sildenafil, wait 24 hours after sildenafil or 48 hours after tadalafil before any nitrate use 7, 9.
6. If PDE5 inhibitors fail: Refer to urology for alternative treatments (intraurethral prostaglandin, intracavernosal injection, vacuum device, or penile prosthesis) 6.