Cardiovascular Disease Management

Medication-Related Sexual Dysfunction

• The steroidal mineralocorticoid receptor antagonist spironolactone has been associated with sexual dysfunction, unlike losartan 1
• Certain antihypertensive medications, including diuretics, can have negative effects on libido and erectile function, with thiazide diuretics like HCTZ being among the most commonly associated with sexual dysfunction, as acknowledged by the American College of Cardiology 2
• Erectile dysfunction affects approximately 5-20% of men with diabetes and is more common in those with hypertension, with drugs associated with erectile dysfunction including diuretics, beta-blockers, central sympathomimetics, and ganglion blockers 3
• The following hierarchy of antihypertensive medications for the risk of erectile dysfunction has been suggested, from highest to lowest risk:
• Phosphodiesterase-5 inhibitors can be safely co-administered with most antihypertensive medications, including ACE inhibitors like perindopril, and are not contraindicated with most antihypertensives (except nitrates) 5, 6
• The American College of Cardiology recommends considering alternative antihypertensive medications with lower risk of erectile dysfunction, such as ACE inhibitors, ARBs, or calcium channel blockers, when treating patients with hypertension who experience erectile dysfunction 2, 4
• If a patient experiences erectile dysfunction while taking antihypertensive medication, evaluate for other causes of erectile dysfunction, such as hypertension, diabetes, obesity, and smoking, and consider medication timing and switching to an alternative medication or adding a PDE-5 inhibitor if appropriate 6, 7
• Lifestyle modifications, such as physical activity, weight management, and smoking cessation, can help lower the risk of erectile dysfunction, as recommended by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and the Princeton Consensus recommendations 6, 7
• Erectile dysfunction may be an early marker of vascular disease rather than a medication side effect, emphasizing the importance of incorporating sexual function into cardiovascular risk assessment for all men, as recommended by the Princeton Consensus recommendations 7

Assessment and Management

• The absolute risk of erectile dysfunction with ACE inhibitors, including perindopril, is low compared to other antihypertensive classes, and these medications have not been observed to increase the incidence of erectile dysfunction 6, 4
• Encourage patients to report any sexual dysfunction symptoms, and consider the potential impact of antihypertensive medications on sexual function when selecting a treatment plan 2, 4