What is the best blood pressure (BP) medication for a male patient with erectile dysfunction (ED)?

Best Blood Pressure Medication for Males with Erectile Dysfunction

Angiotensin receptor blockers (ARBs) are the optimal first-line antihypertensive choice for men with erectile dysfunction, as they may actually improve sexual function while effectively controlling blood pressure. 1

Primary Recommendation: ARBs

• ARBs (particularly losartan, valsartan, and telmisartan) are less likely to cause ED than other antihypertensive classes and may improve erectile function. 1, 2
• Valsartan specifically demonstrated improvement in sexual activity scores (mean difference 0.71,95% CI 0.66-0.76) in hypertensive men. 2
• ARBs should be strongly considered when initiating antihypertensive therapy in any man concerned about sexual function. 3, 4

Alternative Options

ACE Inhibitors

• ACE inhibitors have neutral effects on erectile function and represent a reasonable alternative if ARBs are not tolerated. 4
• Both ACE inhibitors and ARBs work through the renin-angiotensin system without the negative sexual side effects of older agents. 4

Calcium Channel Blockers

• Calcium antagonists have neutral effects on erectile function and can be used safely in men with ED. 4

Nebivolol (Selective Beta-Blocker)

• If a beta-blocker is required, nebivolol with its direct vasodilating properties is less likely to cause ED than traditional beta-blockers. 1
• Traditional beta-blockers should be avoided as they negatively affect libido and erectile function. 1

Medications to Avoid

• Traditional beta-blockers (except nebivolol) have negative effects on erectile function and should be avoided when possible. 1, 4
• Thiazide diuretics are associated with higher rates of ED compared to ARBs. 1, 4
• Mineralocorticoid receptor antagonists (spironolactone) can negatively affect libido and erectile function. 1
• Central-acting agents (clonidine, methyldopa) negatively affect erectile function. 4

Concurrent ED Management

PDE5 inhibitors (sildenafil, tadalafil, vardenafil, or avanafil) should be offered as first-line ED treatment regardless of which antihypertensive is chosen, as they make drug class distinctions for ED less relevant. 1

• All four FDA-approved PDE5 inhibitors have similar efficacy (60-65% success rate for intercourse completion). 1, 5, 6
• PDE5 inhibitors can be safely coadministered with antihypertensive medications and have additive BP-lowering effects. 1
• Absolute contraindication: PDE5 inhibitors must never be prescribed to patients taking nitrates due to risk of dangerous hypotension. 1, 5
• Caution is needed when combining PDE5 inhibitors with alpha-blockers due to additive hypotensive effects. 4

Clinical Algorithm

1. Screen for nitrate use and assess cardiovascular risk before any ED treatment. 1
2. Switch current antihypertensive to an ARB (losartan, valsartan, or telmisartan) if patient is on a beta-blocker, diuretic, or other ED-causing agent. 3, 4
3. Simultaneously initiate a PDE5 inhibitor with proper dosing instructions and titration to optimal dose. 1, 7
4. If ARBs are contraindicated, use ACE inhibitors or calcium channel blockers as alternatives. 4
5. Provide instructions to maximize PDE5 inhibitor efficacy, as incorrect use accounts for many treatment failures. 1, 5

Important Caveats

• ED itself is a strong independent risk marker for cardiovascular disease, equivalent to smoking or family history of MI. 1
• This cardiovascular risk should be communicated to the patient and his primary care provider for comprehensive risk assessment. 1
• Men with diabetes or post-prostatectomy typically have more severe ED and respond less robustly to treatment, requiring higher PDE5 inhibitor doses. 1, 5
• At least 5 separate attempts at maximum PDE5 inhibitor dose should be completed before declaring treatment failure. 7