What is the most effective Selective Serotonin Reuptake Inhibitor (SSRI) for treating premature ejaculation?

From the Guidelines

Paroxetine is the most effective SSRI for premature ejaculation, with daily treatment exerting the strongest ejaculation delay, increasing ejaculatory latency time (ELT) a mean of 8.8-fold over baseline 1.

Key Points

• Selective serotonin reuptake inhibitors (SSRIs) are recommended as first-line agents for the treatment of premature ejaculation, with paroxetine, sertraline, and fluoxetine being effective options 1.
• Daily treatment with paroxetine 10-40mg is often considered most effective, with treatment typically starting at 10mg daily and potentially increasing to 20mg after 1-2 weeks based on response.
• On-demand administration of clomipramine, paroxetine, sertraline, and fluoxetine 3-6 hours before intercourse is modestly efficacious and well tolerated but is associated with substantially less ejaculatory delay than daily treatment in most studies 1.
• Treatment with SSRIs should be avoided in men with a history of bipolar depression due to the risk of mania, and caution is suggested in prescribing SSRIs to adolescents with premature ejaculation and to men with premature ejaculation and a co-morbid depressive disorder, particularly when associated with suicidal ideation 1.

Considerations

• Patients should be advised to avoid sudden cessation or rapid dose reduction of daily dosed SSRIs as this may precipitate SSRI withdrawal syndrome 1.
• The use of off-label SSRIs is favored over the tricyclic antidepressant clomipramine because of a better side effect profile 1.
• A systematic review did not identify a significant difference in suicidal ideation in adult men treated with anti-depressants versus placebo, but a small increase in the risk of suicidal ideation or suicide attempts was noted in patients under age 18 1.

From the FDA Drug Label

Male and Female Sexual Dysfunction with SSRIs Although changes in sexual desire, sexual performance and sexual satisfaction often occur as manifestations of a psychiatric disorder, they may also be a consequence of pharmacologic treatment. In particular, some evidence suggests that selective serotonin reuptake inhibitors (SSRIs) can cause such untoward sexual experiences Table 5 below displays the incidence of sexual side effects reported by at least 2% of patients taking sertraline in placebo-controlled trials Table 5 Adverse EventSertraline Hydrochloride TabletsPlacebo Ejaculation Failure1(Primarily Delayed Ejaculation) 14% 1% Decreased Libido26%1% Denominator used was for male patients only (N=1118 sertraline: N=926 placebo)

The best SSRI for premature ejaculation is not explicitly stated in the provided drug label. However, sertraline is noted to cause ejaculation failure, primarily delayed ejaculation, in 14% of male patients, which could be beneficial for patients with premature ejaculation.

• Key points:
  • Sertraline may cause delayed ejaculation.
  • The incidence of ejaculation failure is 14% in male patients taking sertraline.
  • Sertraline may be considered as an option for patients with premature ejaculation, but this is not a direct indication in the drug label 2.

From the Research

Treatment Options for Premature Ejaculation

• Premature ejaculation is a common form of sexual dysfunction among men, and its treatment can involve various modalities, including medications, behavioral modifications, and diet alterations 3.
• Selective serotonin reuptake inhibitors (SSRIs) have emerged as effective new treatments for patients with premature ejaculation, whether or not these patients suffer from depression 4.

SSRIs for Premature Ejaculation

• Clomipramine, fluoxetine, paroxetine, and sertraline seem to be safe treatment options for patients with premature ejaculation, especially in cases of failed psychological treatment, rejection of psychological treatment, and when partners are unwilling to cooperate in treatment 4.
• Fluoxetine is an effective agent for the treatment of premature ejaculation, with significant improvement realized in intravaginal ejaculatory latency time (IELT), ejaculatory control, and distress levels for both men and their partners 5.
• Paroxetine hydrochloride appears to be a useful agent in the pharmacological treatment of premature ejaculation when administered on a chronic or 'on-demand' basis 6.

Comparison of SSRIs

• Paroxetine was found to be more effective than placebo, fluoxetine, and escitalopram at increasing IELT, although there existed a high level of heterogeneity in the paroxetine vs. fluoxetine groups and the paroxetine vs. placebo groups 7.
• The combination of paroxetine with other treatments, such as tadalafil or behavior therapy, was found to be more efficacious than paroxetine alone 7.

Side Effects and Compliance

• Common side effects of SSRIs for premature ejaculation include nausea, muscle soreness, palpitation, and flushing, which are generally mild and tolerable 7.
• Compliance with SSRIs is a well-described problem, and dropout rates at 6 and 12 months were found to be 56% and 72%, respectively, in one study 5.