Can Abilify (aripiprazole) cause erectile dysfunction?

Abilify and Erectile Dysfunction

Yes, Abilify (aripiprazole) can cause erectile dysfunction, though it appears to have a lower risk compared to other antipsychotics, particularly those that significantly elevate prolactin levels. 1, 2, 3

Evidence from FDA Labeling

The FDA-approved drug label for aripiprazole explicitly lists erectile dysfunction as an adverse reaction observed during clinical trials, categorized as "infrequent" in the reproductive system and breast disorders section. 1 This official designation confirms that ED is a recognized side effect, though it occurs less commonly than some other adverse events.

Comparative Risk Among Antipsychotics

Aripiprazole demonstrates a more favorable sexual side effect profile compared to first-generation antipsychotics and prolactin-elevating atypical antipsychotics like risperidone. 2, 3

• Systematic review evidence shows that aripiprazole has lower odds of causing erectile or ejaculatory dysfunction compared to other atypical antipsychotics. 2
• The mechanism differs from high-risk antipsychotics: first-generation agents and risperidone primarily cause sexual dysfunction through prolactin elevation, while aripiprazole is actually dopamine-partial agonist that typically does not significantly raise prolactin. 2
• In fact, adjunctive aripiprazole has been studied as a treatment for antipsychotic-related sexual dysfunction caused by other agents, with one RCT showing reduction in sexual dysfunction when added to prolactin-elevating antipsychotics. 3

Clinical Management Algorithm

If erectile dysfunction develops on aripiprazole:

1. First, verify the temporal relationship - confirm ED began after aripiprazole initiation and was not pre-existing. 1

2. Rule out other contributing medications - approximately 25% of ED cases are drug-related, and patients may be on multiple agents (antihypertensives, SSRIs, etc.) that have higher ED risk than aripiprazole. 4

3. Consider dose reduction if clinically feasible for the psychiatric indication, as sexual dysfunction with psychotropics can be dose-dependent. 5

4. Add a PDE5 inhibitor (sildenafil, tadalafil, vardenafil, or avanafil) as first-line ED treatment unless contraindicated (particularly nitrate use). 6, 7 This approach allows continuation of necessary psychiatric medication while addressing the sexual dysfunction.

5. Switch to another antipsychotic only if the above strategies fail and the psychiatric condition allows, recognizing that most antipsychotics carry sexual dysfunction risk. 5, 3

Critical Caveats

• Do not assume aripiprazole is the culprit without systematic evaluation - the drug has one of the better sexual side effect profiles among antipsychotics, so other causes (cardiovascular disease, diabetes, other medications, relationship factors) should be thoroughly assessed. 6, 2

• Sexual dysfunction is vastly underreported - patients rarely volunteer this information spontaneously, so direct questioning is essential. 5

• Untreated sexual dysfunction leads to medication non-adherence - this is one of the most common reasons patients discontinue psychiatric medications, potentially destabilizing their mental health condition. 5

Treatment with PDE5 Inhibitors

If PDE5 inhibitors are prescribed:

• Screen for nitrate use (absolute contraindication due to potentially fatal hypotension) and assess cardiovascular risk before prescribing. 7, 8
• Provide proper instructions - sexual stimulation is required for efficacy, and incorrect use accounts for many treatment failures. 7, 8
• Titrate to optimal dose - ensure at least 5 separate attempts at maximum dose before declaring treatment failure. 7, 9
• All four FDA-approved PDE5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil) have similar efficacy; choice should be based on patient preference, cost, and side effect profile. 8