Can losartan cause decreased libido or erectile dysfunction in a patient?

Losartan and Sexual Function

Losartan does not cause decreased libido or erectile dysfunction and may actually improve sexual function in hypertensive men. This represents a significant advantage over other antihypertensive drug classes, particularly beta-blockers and thiazide diuretics, which are well-established causes of sexual dysfunction.

Evidence Supporting Losartan's Favorable Sexual Profile

The most compelling evidence comes from a prospective interventional study demonstrating that losartan actively improved sexual function in hypertensive men with pre-existing erectile dysfunction 1. In this 12-week study of 82 men:

• Sexual satisfaction improved from 7.3% to 58.5% 1
• High-frequency sexual activity increased from 40.5% to 62.3% 1
• Quality of life improved in 73.7% of treated subjects 1

In men without baseline sexual dysfunction, losartan had no negative impact on sexual function 1, confirming its neutral-to-positive effect profile.

Comparative Risk Among Antihypertensive Classes

The sexual dysfunction risk varies dramatically by drug class, making medication selection clinically important:

• ACE inhibitors and ARBs (including losartan) show no increased incidence of erectile dysfunction compared to placebo 2 and may be protective 2
• Beta-blockers consistently cause sexual dysfunction, with propranolol specifically causing reduced libido and erectile dysfunction at therapeutic doses 3
• Thiazide diuretics carry the highest risk, with 17.1% incidence of erectile dysfunction versus 8.1% with placebo 2

The HEAAL trial specifically evaluated losartan and found no significant differences in kidney impairment, hyperkalemia, or hypotension between men and women, with no sexual dysfunction reported as a notable adverse effect 4.

Mechanistic Explanation

Losartan's favorable sexual profile relates to its blockade of angiotensin II, which has been recognized as an important mediator of detumescence and possibly erectile dysfunction 5. This mechanism distinguishes ARBs from other antihypertensive classes that may impair endothelial function or sympathetic tone.

Animal studies confirm this: spontaneously hypertensive rats treated with losartan for up to 90 days showed minimal impact on sexual behavior, whereas propranolol-treated rats demonstrated significant decreases in libido and erectile function 6.

Clinical Application Algorithm

When evaluating a patient on losartan who reports sexual concerns:

1. First, assess other contributing factors before attributing symptoms to losartan 2:

   • Progression of underlying vascular disease
   • Uncontrolled diabetes or metabolic syndrome
   • Depression or psychological factors
   • Other medications (particularly beta-blockers, diuretics, or antidepressants)

2. If sexual dysfunction predated losartan therapy, consider that losartan may actually improve the condition over 12 weeks of treatment 1

3. If dysfunction developed after starting losartan (which is uncommon), evaluate for:

   • Concurrent medications added around the same time
   • Worsening of underlying cardiovascular disease
   • New psychosocial stressors

4. Treatment options if erectile dysfunction persists:

   • PDE5 inhibitors (sildenafil, tadalafil) can be safely combined with losartan 2 as first-line treatment
   • Continue losartan given its cardiovascular benefits and lack of causative role
   • Avoid switching to beta-blockers or thiazide diuretics, which have higher sexual dysfunction risk 3, 2

Critical Clinical Pitfall

Do not discontinue or switch from losartan based on sexual complaints without thorough evaluation of alternative causes 2. Losartan represents one of the most sexually-favorable antihypertensive options available, and switching to other classes may worsen rather than improve sexual function 5, 7.

A meta-analysis of ARBs showed that valsartan improved sexual activity (MD: 0.71,95% CI 0.66-0.76), though erectile function improvement with losartan specifically did not reach statistical significance across pooled studies 8. However, individual trials demonstrate clear benefit 1, and the lack of harm is consistent across all studies.

Quality of Life Consideration

Sexual dysfunction is one of the most influential factors affecting antihypertensive medication compliance 1. Losartan's positive or neutral impact on sexual function represents a significant advantage for long-term blood pressure control and cardiovascular risk reduction 5, 7.