Effect of yohimbine-trazodone on psychogenic impotence: a randomized, double-blind, placebo-controlled study

Effects of Trazodone on Sleep: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVES

Sleep problems and insomnia are common, challenging to treat, and transcend specific diagnoses. Although trazodone is a popular choice, robust meta-analytic evidence is lacking. This systematic review and meta-analysis investigates the efficacy and safety of trazodone for sleep disturbances, reflecting recent updates in insomnia diagnosis and treatment.

METHODS

We searched Medline, Embase, APA PsycINFO, the Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) up to 1 May 2024, for Randomized Controlled Trials (RCTs) comparing trazodone with placebo and reporting sleep-related outcomes. The minimum pharmacotherapy duration was 5 days. Included were all RCTs regardless of blinding (open-label or single- or double-blind), while quasi-randomized studies were excluded. The Cochrane Risk of Bias Tool for Randomized Trials assessed bias. Analyses used a random-effects model on an intention-to-treat (ITT) basis. Risk ratio (RR) was used for dichotomous outcomes and weighted mean difference (WMD) for continuous outcomes. When different units or scales were used, Hedge's adjusted g standardized mean difference (SMD) was calculated. Subgroup and preplanned sensitivity analyses explored heterogeneity and evaluated findings' strength and consistency.

RESULTS

In total, 44 RCTs with 3935 participants were included. Trazodone did not significantly impact subjective total sleep time (TST) [WMD = 0.73 min, 95% confidence interval (CI) - 24.62; 26.07, p = 0.96] but improved sleep quality (SQ) (SMD = - 0.58, 95% CI - 0.87; - 0.28, p < 0.01) and secondary outcomes. These included the number of nocturnal awakenings (SMD = - 0.57, 95% CI - 0.85; - 0.30], p < 0.01), nocturnal time awake after sleep onset (WMD = - 13.47 min, 95% CI - 23.09; - 3.86], p < 0.01), objective TST by polysomnography (WMD = 27.98 min, 95% CI 4.02; 51.95, p = 0.02), and sleep efficiency (WMD = 3.32, 95% CI 0.53; 1.57, p = 0.02). Tolerability issues included more dropouts owing to adverse effects (RR = 2.30, 95% CI 1.45; 3.64, p < 0.01), any sleep-related adverse effects (RR = 3.67, 95% CI 1.07; 12.47, p = 0.04), more adverse effects in general (RR = 1.18, 95% CI 1.03; 1.33, p = 0.02), and more sleep-related adverse effects (RR = 4.31, 95% CI 2.29; 8.13, p < 0.01).

CONCLUSION

Trazodone extends total sleep time but does not affect perceived sleep duration. It may improve sleep quality and continuity but has minor effects on sleep latency, efficiency, and daytime impairment. Trazodone is associated with adverse effects, necessitating a careful risk-benefit assessment. Limited data restrict generalizability, underscoring the need for more research.

REGISTRATION

PROSPERO registration number,CRD42022383121.

Multi-target strategies for the improved treatment of depressive states: Conceptual foundations and neuronal substrates, drug discovery and therapeutic application

Major depression is a debilitating and recurrent disorder with a substantial lifetime risk and a high social cost. Depressed patients generally display co-morbid symptoms, and depression frequently accompanies other serious disorders. Currently available drugs display limited efficacy and a pronounced delay to onset of action, and all provoke distressing side effects. Cloning of the human genome has fuelled expectations that symptomatic treatment may soon become more rapid and effective, and that depressive states may ultimately be "prevented" or "cured". In pursuing these objectives, in particular for genome-derived, non-monoaminergic targets, "specificity" of drug actions is often emphasized. That is, priority is afforded to agents that interact exclusively with a single site hypothesized as critically involved in the pathogenesis and/or control of depression. Certain highly selective drugs may prove effective, and they remain indispensable in the experimental (and clinical) evaluation of the significance of novel mechanisms. However, by analogy to other multifactorial disorders, "multi-target" agents may be better adapted to the improved treatment of depressive states. Support for this contention is garnered from a broad palette of observations, ranging from mechanisms of action of adjunctive drug combinations and electroconvulsive therapy to "network theory" analysis of the etiology and management of depressive states. The review also outlines opportunities to be exploited, and challenges to be addressed, in the discovery and characterization of drugs recognizing multiple targets. Finally, a diversity of multi-target strategies is proposed for the more efficacious and rapid control of core and co-morbid symptoms of depression, together with improved tolerance relative to currently available agents.

Trazodone for erectile dysfunction: a systematic review and meta-analysis

OBJECTIVE

To determine the efficacy and safety of trazodone in the treatment of erectile dysfunction (ED) in a meta-analysis.

METHODS

The data sources used were Medline and the Cochrane Library databases (January 1966 to May 2002), bibliographies of retrieved articles and review articles, and conference proceedings and abstracts. Trials were eligible for inclusion in the review if they included men with ED, compared trazodone with a control, were randomized, of > or = 7 days' duration and assessed clinically relevant outcomes. Two reviewers independently evaluated study quality and extracted data in a standardized fashion.

RESULTS

Six trials (comprising 396 men) met the inclusion criteria; they consisted of heterogeneous populations, were small, brief and in some cases methodologically weak. Three of the six trials showed an apparently clinically meaningful benefit of trazodone for ED compared with placebo, the differences being statistically significant in two. In pooled results, trazodone monotherapy appeared more likely than placebo to lead to a 'positive treatment response', although this difference was not statistically significant (37% vs 20%; relative benefit increase, 1.6; 95% confidence interval, CI, 0.8-3.3). Subgroup analyses suggested that men with psychogenic ED might be more likely to benefit from trazodone than those with mixed or physiological ED. The efficacy of trazodone also appeared greater at higher doses (150-200 vs 50 mg/day). Men randomized to trazodone were not significantly more likely than those receiving placebo to withdraw for any reason or for an adverse event, or to have specific adverse events, but wide CIs could not exclude a greater risk of these adverse outcomes with trazodone. Specific adverse events with trazodone included dry mouth (19%), sedation (16%), dizziness (16%) and fatigue (15%).

CONCLUSION

Trazodone may be helpful in men with ED, possibly more so at higher doses, and in men with psychogenic ED. Future high-quality trials should compare trazodone with placebo and other therapies in men with depression and psychogenic ED.

Pharmacological aspects of erectile dysfunction

Erectile dysfunction (ED) is a common problem with a prevalence of approximately 50% in men aged 40 to 70. There are several etiologies for ED including vasculogenic, neurogenic, hormonal and/or psychogenic factors; one-fourth of ED cases can be drug-related. Penile erection involves a complex interaction between the CNS and local factors. It is a neurovascular event modulated by psychological and hormonal factors. Pharmacologically, neural modulation and endocrine status are very important to attaining penile erection. There have been several significant advances for the pharmacologic treatment of ED. Treatments include agents that are not only orally effective, but possess either local or central acting mechanisms of action. Apomorphine, a centrally-acting agent, is effective in the treatment of ED. Sildenafil, another orally effective agent, acts by inhibiting cyclic GMP-specific phosphodiesterase Type V. Testosterone can be effective transdermally. Non-orally active agents include alprostadil and papaverine. Phentolamine and trazodone are effective in selected cases. Some agents can interact with other medications. Several pharmacological agents, some with central-acting mechanisms and some with Iocally-acting vascular effects, are therapeutically useful in the treatment of ED.

Yohimbine treatment of organic erectile dysfunction in a dose-escalation trial

Yohimbine has had questionable effects in men with organic erectile dysfunction. We conducted this study to better define the population of men responsive to yohimbine, because tobacco was thought to affect a regimen of yohimbine more than other risk factors. We measured nocturnal penile tumescence with the RigiScan monitor, hormone profiles, answers to the Florida Sexual Health Questionnaire, and clinical responses at baseline and after two different doses of yohimbine in 18 nonsmoking men with erectile dysfunction. Of the 18 men, nine (50%) were successful in completing intercourse in more than 75% of attempts. The yohimbine responders were men with less severe erectile dysfunction as manifested by improved increased rigidity on RigiScan testing, higher Florida Sexual Health Questionnaire scores, and slightly higher levels of serum testosterone. Yohimbine is an effective therapy to treat organic erectile dysfunction in some men with erectile dysfunction.

A risk-benefit assessment of sildenafil in the treatment of erectile dysfunction

Sildenafil is an oral treatment for erectile dysfunction (ED). It acts as an inhibitor of 3',5'-cyclic guanosine monophosphate-phosphodiesterase type 5. An effective treatment for ED is required to produce an erectile response sufficient for satisfactory sexual performance. This has been documented for sildenafil in men with ED of differing aetiologies and baseline severity in various types of clinical trials. Sildenafil treatment is characterised by a good tolerability profile and low treatment digcontinuation rate caused by treatment-related adverse effects. Most of the adverse effects associated with sildenafil are extensions of the pharmacological action of the drug. There is no significant difference in the adverse effect profile (headache, flushing, dyspepsia, nasal congestion and abnormal vision) of this agent as assessed by clinical data obtained either in the pre- and postlaunch periods. Because of its acceptable risk-benefit ratio, sildenafil can be prescribed to a very large group of patients with ED. The reports of serious cardiovascular events associated with the use of sildenafil (including anecdotal reports of deaths) have been very thoroughly analysed. A number of studies have not shown any difference in the risk of serious cardiovascular events in sildenafil- and placebo-treated patients. However, when making a risk-benefit evaluation, certain subgroups of patients need to be considered separately. In particular, sildenafil is contraindicated in patients receiving nitrate therapy. In some other subgroups of patients, the risks and benefits of treatment need to be assessed on an individual basis and it is hoped that additional data will clarify any possible risks associated with sildenafil administration such patients. It is helpful to compare the risk-benefit profile of sildenafil with the characteristics of other oral drugs for ED. According to the preliminary data, apomorphine and phentolamine are possible future options for the treatment of ED; however, there needs to be further clinical evaluation of these agents. Initial data have shown that sildenafil can be successfully combined with intracavernosal injection in patients nonresponders to either therapy. In conclusion, favourable characteristics make sildenafil suitable for the first-line therapy for a substantial proportion of patients with ED.

Yohimbine: a clinical review

Although yohimbine (YOH) has been available for the treatment of male erectile dysfunction (ED) for longer than Viagra, there is a perception that little is known about the clinical performance of the drug. This review attempts, by comprehensive analysis of the literature, to cover the clinical, pharmacological, and therapeutic profiles of YOH, relevant to its potential utility in the management of patients with ED. Relatively few well-designed studies have been completed. From these, however, it can be concluded that YOH as monotherapy possesses only modest efficacy in ED patients. In acute and chronic (long-term) studies, YOH has been found to be relatively free of side effects over the dose range predicted to be effective in ED. At much higher doses, the most frequently observed effects, consistent with the primary pharmacological action of the drug, are elevation of blood pressure, a slight anxiogenic action, and increased frequency of urination. These side effects are all easily reversible on termination of YOH therapy. There is increasing evidence that the erectogenic action of YOH can be augmented by concomitant administration of agents that augment the release and/or action of nitric oxide in the corpus cavernosum. YOH has yet to be studied in female sexual dysfunction. Overall, the benefit risk profile of YOH would indicate that it has potential, more probably as part of a combination strategy, e.g., with a drug that enhances the nitric oxide pathway, in the treatment of ED.

ASSESS-3: a randomised, double-blind, flexible-dose clinical trial of the efficacy and safety of oral sildenafil in the treatment of men with erectile dysfunction in Taiwan

The efficacy and safety of sildenafil were evaluated in a randomised, double-blind, placebo-controlled, flexible-dose study in Taiwanese men aged 26 to 80 y with erectile dysfunction (ED) of broad-spectrum aetiology and more than 6 months' duration. A total of 236 patients were randomised at six medical centres in Taiwan to receive either sildenafil (50 mg initially increased if necessary to 100 mg or decreased to 25 mg depending on efficacy and toleration) (n=119) or matching placebo (n=117) taken on an 'as needed' basis 1 h prior to anticipated sexual activity for a period of 12 weeks. At the end of 12 weeks, the primary efficacy variables relating to the achievement and maintenance of erections sufficient for sexual intercourse, and the secondary efficacy variables, which included: (1) the five separate domains of sexual functioning of the IIEF (International Index of Erectile Function) scale, (2) the percentage of successful intercourse attempts; and (3) a global assessment of erections, were all statistically significantly improved by sildenafil in comparison with placebo (P<0.0001). Treatment-related adverse events occurred in 43.7% of patients receiving sildenafil and 18.8% receiving placebo. The most common adverse events with sildenafil were flushing, dizziness and headache (25.2, 6.7 and 5.9% of patients, respectively), and most were mild in nature. The efficacy and safety of sildenafil in the population of Taiwanese men appears similar to that reported in other studies in western populations.

Male sexual function and its disorders: physiology, pathophysiology, clinical investigation, and treatment

This review is designed to help the reproductive endocrinologist integrate his or her professional activity with those of other disciplines including urology, radiology, neurology, and psychology in order to successfully manage all of the inseparable aspects of male sexual and reproductive functioning. Significant advances in the field of male sexual physiology and pathophysiology and new methods of investigation and treatment of male sexual disorders are outlined. The review synthesizes available data on the following: norms of sexual organs, aging and sexuality, role of central and peripheral neurochemicals in each stage of the sexual cycle, role of corporeal smooth muscles in the hemodynamic control of erection and detumescence, influence of psychological factors, drugs, and disease on all aspects of sexual functioning, and use of nocturnal penile tumescence monitoring, imaging investigations, and neurophysiologic studies in the diagnostic workup of males with sexual dysfunction. Clinical algorithms are presented where appropriate. Extensive discussions on newly developed strategies in psychological and behavioral counseling, drug therapy, tissue engineering, nonsurgical devices, and surgical treatments for all forms of sexual disorders are also provided. Lastly, the effect of sexual dysfunction and its treatment on quality of life in affected men is addressed, along with recommendations for future research endeavors.

Pharmacology of erectile function and dysfunction

Central regulation of the erectile process involves several transmitters, including dopamine, serotonin, noradrenaline, and nitric oxide, and peptides, such as oxytocin and ACTH/alpha-MSH. These systems may be targets for future drugs designed to treat erectile dysfunction. Peripherally, the different steps involved in neurotransmission, impulse propagation, and intracellular transduction of neural signals in penile smooth muscles need further investigation. Continued studies of the interactions between different transmitters/modulators may reveal new combination therapies. Increased knowledge of the changes in penile tissues associated with erectile dysfunction may explain the pathogenetic mechanisms and help to prevent the disorder.

VIAGRA : IS IT A WONDER DRUG ?

Male erectile dysfunction is common and frustrating after the age of forty years. Erectile dysfunction is a cause of misery, relationship difficulties, and significantly reduced quality of life. Sildenafil citrate (Viagra) has shown promising results in recently published clinical trials. Sildenafil is a potent and competitive inhibitor of cGMp specific phosphodiesterase-5, predominant isoenzyme in the human corpus cavernosum. It is effective in erectile dysfunction of diverse origin, however it requires a patent vascular system to be effective. It is not effective in patients with endocrinal impotence, loss of libido, premature ejaculation or infertility. Its main adverse effects are headache, flushing, dyspepsia, diarrhoea, nasal congestion, indigestion, visual disturbances, dizziness and rash. Ventricular tachycardia and acute myocardial infraction have been reported in patients of ischaemic heart disease after consumption of sildenafil. Six deaths have been reported in patients taking nitrates. In India it is likely to be prescribed by a primary care physician without complete evaluation of patient on complaint of impotence. Hence the ethical question of who should prescribe this drug should be addressed by medical fraternity and proper guidelines formulated to avoid misuse of sildenafil. Phosphodiesterase is distributed in nerve, central nervous system, and systemic vasculature, hence long-term effects of drug on these tissues has to be ascertained. It should be made mandatory to report all adverse drug reactions to ADR monitoring centres. It is a wonder for those who require it, but has potentially dangerous adverse effects and drug interactions and hence is and not a wonder pill for all kinds of impotence.

Oral and injectable medications for the treatment of erectile dysfunction

The treatment of erectile dysfunction has changed dramatically over the past two decades. The introduction of the oral agent sildenafil 2 years ago has revolutionized the treatment of men with compromised erections and has met with expected success and low morbidity. Sildenafil is effective in most men with erectile dysfunction in the general population and in select populations, such as men with spinal cord injury, diabetes mellitus, and patients who have had nerve-sparing radical prostatectomy. It is safe in the general population as well as in many men with cardiac disease. Other newer medications are in trial and may soon be available to supplement treatment with sildenafil. Oral phentolamine, apomorphine, newer phosphodiesterase type-5 inhibitors, and topical agents are currently in phase 3 trials. These agents, in addition to newer intraurethral and indictable agents, may assist men with erectile dysfunction and rescue those in whom sildenafil is ineffective or in whom untoward side effects of sildenafil reduce its effectiveness. The 21st century will witness many additional agents designed for specific patients with specific conditions causing erectile dysfunction. We can expect these oral agents, assisted by topical and injectable agents, to successfully restore erectile function in the majority of men suffering from erectile dysfunction.

Asian sildenafil efficacy and safety study (ASSESS-1): a double-blind, placebo-controlled, flexible-dose study of oral sildenafil in Malaysian, Singaporean, and Filipino men with erectile dysfunction. The Assess-1 Study Group

OBJECTIVES

To evaluate the efficacy, safety, and tolerability of oral sildenafil in Asian men with erectile dysfunction of various causes (organic, psychogenic, or mixed) and of more than 6 months' duration.

METHODS

In this double-blind, parallel-group trial conducted at eight centers in Malaysia, the Philippines, and Singapore, 254 men, 26 to 78 years old, were randomized to 12 weeks of sildenafil or placebo taken as needed 1 hour before anticipated sexual activity. Initially, the sildenafil (n = 127) or matching placebo (n = 127) dose was 50 mg but could be increased to 100 mg or decreased to 25 mg because of a lack of efficacy or intolerance, respectively. Efficacy was assessed by the 15-question International Index of Erectile Function, patients' event logs of sexual activity, and a global efficacy question about erections.

RESULTS

The two primary efficacy variables relating to achievement and maintenance of an erection sufficient for sexual intercourse, as assessed by the mean scores for International Index of Erectile Function question 3 (4.22 versus 2.59) and question 4 (4.15 versus 2.41), were both significantly higher with sildenafil than with placebo (P <0.0001). In addition, the five separate International Index of Erectile Function domains of sexual function, the percentage of successful intercourse attempts, and the global efficacy assessment of erections revealed significantly greater treatment effects in favor of sildenafil (P <0.0001 versus placebo for all variables). Treatment-related adverse events occurred in 22.8% of patients who received sildenafil and in 10.2% of those who received placebo.

CONCLUSIONS

Sildenafil is an effective and well-tolerated treatment for Asian men with erectile dysfunction of broad-spectrum etiology.

Efficacy and safety of fixed-dose and dose-optimization regimens of sublingual apomorphine versus placebo in men with erectile dysfunction. The Apomorphine Study Group

OBJECTIVES

A sublingual (SL) formulation of apomorphine has been developed and found effective in penile erectile dysfunction (ED). This study assessed the efficacy and safety of several doses of apomorphine SL in a dose-optimization schedule compared with placebo.

METHODS

In this 8-week, multicenter, double-blind clinical trial, 569 patients were randomized to four groups: a dose-optimization group in which patients began with 2 mg, increased or decreased the dosage as needed for 4 weeks, and thereafter maintained an optimal dose for 4 weeks; two fixed-dose groups of either 5 or 6 mg; and a placebo group. Efficacy was assessed by patient and partner responses to home-use questionnaires about sexual function and activity and by responses to the International Index of Erectile Function and the Brief Sexual Function Inventory.

RESULTS

In all apomorphine SL groups, a significantly higher percentage of patients compared with the placebo group achieved and maintained an erection firm enough for intercourse (48% to 53% versus 35% for placebo, P < or =0.001) and a significantly higher percentage of attempts resulted in intercourse (45% to 51% versus 33%, P < or =0.001). The responses to the questionnaires completed by the patients and partners were similar. Apomorphine SL was well tolerated; nausea, the most common side effect, was dose related and diminished substantially during the second 4-week period at all doses. The dose-optimization schedule resulted in fewer adverse events without impacting efficacy.

CONCLUSIONS

Apomorphine SL is an effective and safe treatment for ED, with 2 and 4 mg providing the most acceptable therapeutic index.

Medical treatment of erectile dysfunction

Erectile dysfunction (ED) is defined as the consistent inability to obtain or maintain an erection for satisfactory sexual relations. Data from the Massachusetts Male Aging Study have indicated that the prevalence of erectile dysfunction of any degree is 39% in 40-year old men, and 67% in those aged 70 years. Effective therapy has been available for some time, but it has commonly involved surgery, external devices or penile self-injection. For many men, these represent unacceptable barriers to seeking therapy. Recently, however, an effective oral medication has become available. This article reviews the physiology and pharmacology of ED. The literature currently available on the effectiveness and safety of various drugs used for ED is summarized, with particular attention to newly available oral agents. Guidelines for work-up and drug treatment of patients with ED are given. Detailed history and physical examination are crucial to the safe and effective treatment of men with erectile impotence. An extensive review of the literature shows that based on safety, effectiveness and ease of use, oral sildenafil citrate is an excellent choice for first-line therapy. Patients who use organic nitrates of any kind in any capacity should not be offered sildenafil. Based solely on effectiveness intracavernosal injection therapy remains the golden standard and should also be offered as an option for first-line therapy for the appropriate patients. Many alternatives are available for men who cannot use sildenafil or injection therapy. A thorough knowledge of existing medications is essential for proper treatment of ED.

Pharmacological treatment of erectile dysfunction

There is growing evidence that the field of pharmacotherapy, particularly oral drugs, will be dominant in the future management of sexual dysfunction. Basic research has led to the understanding of the intracellular mechanisms that control penile smooth muscle contractility and therefore erection, opening a vast area for pharmacological intervention. Moreover, the importance of central neurohormonal mechanisms has made these pathways the target for new centrally acting drugs. Given these trends most patients suffering from erectile dysfunction will respond to pharmacological agents in the not so distant future.

La Yohimbina nel deficit dell'erezione: Studio retrospettivo: Yohimbina in erectile deficit: Retrospective study

A brief literature review shows that Yohimbina gave 45-65% satisfactory results when used to treat erectile deficit. The author then makes a retrospective evaluation of 58 patients, comparing them with a control group of 12 patients treated with a placebo (vit. A+E). The effectiveness of Yohimbina, prescribed with magistral prescription, proved to be between 40 and 70%, depending on the patient's age and type of erectile deficit, and was certainly superior to the placebo.

Therapeutic effects of high dose yohimbine hydrochloride on organic erectile dysfunction

PURPOSE

We evaluated men with organic erectile dysfunction treated with placebo and high dose oral yohimbine hydrochloride.

MATERIALS AND METHODS

We selected 22 patients with organic erectile dysfunction (mean age 58 years) for treatment in the andrology outpatient clinic. These patients had been previously undergone neurological, vascular, hormonal and psychological testing, and were treated during an equal period of 30 days with placebo and daily single dose oral 100 mg. yohimbine. The response to treatment was evaluated via a questionnaire that comprised the outcome items of complete--normal penile rigidity enabling vaginal penetration, partial--erection improved but not sufficiently for appropriate vaginal penetration, none--no improvement and worse--erection deteriorated. The patients consented to treatment after being told of the severe adverse effects that might occur.

RESULTS

The most common side effects were anxiety, increase in cardiac frequency, increased urinary output and headache but in no case was treatment discontinued. Of the patients 3 (13.6%) and 12 (54.5%) reported complete or partial response to treatment, respectively. However, statistical analysis disclosed no significant difference when yohimbine was compared to placebo (p < 0.05).

CONCLUSIONS

Oral 100 mg. single dose daily yohimbine promotes no improvement in patients with organic erectile dysfunction.

Yohimbine elimination in normal volunteers is characterized by both one- and two-compartment behavior

We sought to determine the safety, pharmacodynamic response, and single- and multiple-dose pharmacokinetic profile of yohimbine hydrochloride. Thirty-two healthy volunteers received 6 days of yohimbine, 5.4 mg 3 times daily (t.i.d.), 10.8 mg t.i.d., 16.2 mg t.i.d., or 21.6 mg twice daily (b.i.d.), with determination of plasma catecholamine levels and mood/anxiety-inventory scores. The pharmacokinetic profile of yohimbine was determined after the first and last dose. Yohimbine exhibited one-compartment elimination in most subjects, with dose-dependent increases in maximal concentration (Cmax) and area under the curve (AUC) but no evidence of drug accumulation. At least two subjects in each cohort exhibited two-compartment elimination of yohimbine, with nonsignificant increases in day 7 AUC, Cmax, and terminal elimination half-life (t1/2beta). Plasma catecholamine levels increased significantly in relation to both average yohimbine AUC and Cmax, but there were no significant effects on heart rate, blood pressure, or anxiety/mood-inventory scores. The single- and multiple-dose pharmacokinetic profile of yohimbine exhibits a substantial degree of interpatient and intrapatient variability, possibly resulting from variability in first-pass and hepatic metabolism. There is a significant correlation between plasma norepinephrine levels and yohimbine AUC or Cmax. Further multiple-dose studies are warranted definitively to address the relation between yohimbine AUC or Cmax and pharmacologic effect.

Comparative sexual side effects of bupropion, fluoxetine, paroxetine, and sertraline

OBJECTIVE

To investigate patient reported prosexual side effects of the aminoketone antidepressant bupropion (INN, amfebutamone) and to compare directly the sexual side effects of bupropion and the selective serotonin reuptake inhibitor (SSRI) antidepressants fluoxetine, paroxetine, and sertraline.

METHODS

One hundred seven psychiatric outpatient respondents receiving current treatment with one of the above antidepressants anonymously completed questionnaires that allowed reporting of both decreases and increases in sexual function. The main outcome measures were antidepressant-associated changes in libido, arousal, duration of time from arousal to orgasm, intensity of orgasm, and duration of orgasm relative to that experienced before the onset of the patients' psychiatric illnesses.

RESULTS

Bupropion-treated patients reported significant increases in libido, level of arousal, intensity of orgasm, and duration of orgasm beyond levels experienced premorbidly. The three SSRIs to an equal degree significantly decreased libido, arousal, duration of orgasm, and intensity of orgasm below levels experienced premorbidly. Overall, 27% of the SSRI-treated patients had no adverse sexual side effects; in contrast, 86% of patients treated with bupropion had no adverse sexual effects, and 77% of bupropion-treated patients reported at least one aspect of heightened sexual functioning.

CONCLUSIONS

SSRI-induced adverse sexual effects appear to be the rule rather than the exception and may be substantially underreported unless patients are specifically asked about the effects of these medications on various aspects of sexual function. In contrast, prosexual effects were reported by the majority of patients treated with bupropion. The findings are reviewed in light of the neurochemistry of these agents and the sexual response.

Is high-dose yohimbine hydrochloride effective in the treatment of mixed-type impotence? A prospective, randomized, controlled double-blind crossover study

OBJECTIVES

To determine the effectiveness and safety of high-dose yohimbine for the treatment of mixed-type impotence.

METHODS

Twenty-nine patients who had mixed-type impotence diagnosed on the basis of a sexual history, results of a physical examination, laboratory analysis, assessment of the sensory pain threshold of the dorsal nerve of the penis, and dynamic color Doppler sonography of the cavernosal arteries were entered into a randomized, double-blind, placebo-controlled, crossover comparison of a placebo with high-dose yohimbine hydrochloride (36 mg per day orally). The treatment consisted of two 25-day courses; after a 14-day washout period, the patients who initially received the placebo for 25 days were switched to yohimbine hydrochloride for 25 days. Erectile function, ejaculation, interest in sex, physical examination findings, blood pressure, pulse rate, weight, and audiovisual sexual stimulation test were investigated before treatment and at the end of each drug period. The Mann-Whitney test was used for the statistical analysis.

RESULTS

Twenty-seven patients (93%) completed the whole treatment schedule. Positive clinical results (complete and partial responses) were obtained in 12 cases (44%) at the end of the yohimbine phase and in 13 (48%) after the placebo period. No statistical difference was indicated. Drug-related adverse effects occurred in 2 patients in the yohimbine group (7%).

CONCLUSIONS

Yohimbine is no better than placebo as a first-line treatment for mixed-type impotence.

Intracavernosal Injection Therapy and Other Treatment Options for Erectile Dysfunction

In the United States, almost 30 million men have complete or partial erectile dysfunction. This disorder occurs in approximately 52% of men between 40 and 70 years of age; 70% of affected men younger than 35 years of age have psychogenic causes, and 85% of men older than 50 years of age have organic impotence. Furthermore, erectile dysfunction is exacerbated by the presence of such conditions as heart disease, diabetes, and hyperlipidemia and the medications used to manage them. Thus, a widespread segment of the population is in need of a safe and effective treatment strategy for restoration of normal sexual function. The technique of intracavernosal injection therapy was initially described in the early 1980s. During the subsequent decade, the effectiveness of various drug combinations and the associated side effects were demonstrated. In 1995, prostaglandin E(1) was approved for intra-cavernosal pharmacotherapy. It has proved highly effective for neurogenic, vasculogenic, and psychogenic erectile dysfunction, with reported response rates of 75 to 92%. The major side effect (albeit uncommon) is corporal fibrosis. Other options for treatment of erectile dysfunction are vacuum-erection devices and penile prostheses.

Treatment of antidepressant-induced sexual side effects

Sexual side effects of antidepressant medications are becoming more frequently encountered by patients who require pharmacotherapy. A MEDLINE search was conducted to generate articles that address methods of treating these iatrogenically induced clinical situations. We report here on treatment strategies to alleviate these adverse events. We conclude that clinicians should routinely ask about sexual side effects due to antidepressants and that they should be treated promptly to ensure patient compliance with antidepressant pharmacotherapy.