Is Vortioxetine an Advantageous Choice for Erectile Dysfunction? A Case Report

Background

Antidepressants tend to worsen erectile dysfunction (ED). Phosphodiesterase inhibitors, the widely accepted choice for the treatment of ED may not be beneficial in certain cases due to adverse effects. The addition of vortioxetine to the existing range of antidepressant medications possibly opens up a new alternative, which is claimed to have minimal sexual adverse effects. ¹ Vortioxetine has multimodal action on serotonin receptors and better sexual tolerability profile. ² We encountered a unique benefit of vortioxetine in a male patient that helped in restoring ED.

Case Report

A 32-year-old, Mr M, a married businessman with poor erection and a dissatisfying sexual relationship with a wife for 4 years. The couple has been staying in a joint family of 6 members including parents and brothers in their own house with separate bedrooms for all. On evaluation, it was found that the patient had a heterosexual orientation and a monogamous relationship with his wife presented with a depressive episode for the past 1 year characterized by anhedonia, the sadness of mood, nonrefreshing sleep, and depressive ruminations. The patient was treated with sertraline 200 mg/day for 2 months and mirtazapine 30 mg/day for 3 months. On both occasions, his depressive symptoms remitted completely but continued to have ED. He has been prescribed sildenafil 50 mg and tadalafil 20 mg (phosphodiesterase inhibitors-PDE-5i), which failed to correct ED at the cost of an adverse effect of headache. The patient and spouse reported the persistence of ED even before the depressive symptoms began. All the necessary investigations carried out in the past including serum lipid profile, serum prolactin, serum testosterone, and penile Doppler were within normal limits. There were infrequent reports of early morning erections. Further history revealed no extramarital relationships, no exposure to drugs, surgery or trauma, and no medical ailments. No history of tobacco and alcohol consumption was noted. Premorbid personality was well adjusted. Physical examination was noted to have a body mass index of 24 and an associated history of involvement in regular physical activities since his graduation. Mental status examination revealed a depressed mood and worries about the ED. Routine investigations were within normal limits. There was nothing suggestive of marital disharmony before the beginning of ED. However, the marital conflicts were noted to have begun in the aftermath of ED and were revolving predominantly around sexual dissatisfaction. The patient had not benefitted from individual therapy including environmental modifications for ED in earlier consultations. He was diagnosed to have ED and moderate depressive episode with somatic symptoms. The couple was referred to the psychologist for addressing marital conflicts and reassessing sex therapy needs as one of the nonpharmacological management of ED while putting a serious consideration to start a novel antidepressant with the least sexual adverse effects. On a separate interview with a spouse, it was noted that both find their partner sexually attractive and get aroused adequately during intimacy. Besides, there was no discrepancy found between the sexual desires of both.

Considering the partial response to previous treatment, he was started on tablet vortioxetine 5 mg/day to 15 mg/day. Arizona sexual experience scale (ASEX) and Hamilton depression rating scale (HAM-D) was applied at baseline, day 7, and day 14. After 2 weeks of treatment with vortioxetine, the patient reported a strong sense of optimism in sexual functioning with surprisingly regular morning erections in the absence of any hypomanic symptoms. ASEX scores on day 1, 7, and 14 were noted to drop as 26, 15, and 5 while HAM-D scores were noted to improve as 18, 14, and 12. The patient was noted under remission from MDD as well as ED during the next 4 months of the follow-up period.

Discussion

ED is a very common and concurrent presence of MDD worsens ED twofold. ³ PDE-5i is chosen as the first step in the management of ED but it has limitations as seen in our case. The use of antidepressants is challenging especially in a case like ours where ED predated the onset of MDD.^3,4 Vortioxetine is an antagonist at 5-HT3 and 5-HT7 receptors, a partial agonist at 5-HT1B, and an agonist at 5-HT1A receptors. ⁵ Vortioxetine is equally efficacious to existing antidepressants without causing sexual dysfunction. ² The most common adverse effect of vortioxetine leading to discontinuation is nausea, which was not reported in our case. ⁶ There are no isolated trials or reports to implicate the use of vortioxetine in ED without associated MDD. It has been claimed that vortioxetine may be safer in subjects with sexual dysfunction as compared to traditional antidepressants. ⁷ In a recent study, it was reported that vortioxetine uniquely appears safe and effective treatment as well as an effective add on alternative for ED associated with MDD. ¹ Another review conducted on 2 years of published papers, revealed that vortioxetine was comparable to placebo and favorable over other selective serotonin reuptake inhibitors or serotonin norepinephrine reuptake inhibitors in terms of causing sexual dysfunction. ⁸ Recent evidence also favors norepinephrine dopamine reuptake inhibitor (Bupropion) ⁹ and 5-HT1A receptor agonists (vortioxetine and vilazodone) in facilitating sexual performance among patients with MDD. However, no research data are available to suggest the possible role of vortioxetine to improve ED independently. The mechanism of vortioxetine in humans is yet to be uncovered fully ¹⁰ ; however, an additional 5-HT7 activity could potentially be implicated in restoring sexual dysfunction supported by data from animal studies.^11-13 In our case, MDD improved on 3 different classes of antidepressants but ED seems to have responded uniquely and exclusively to vortioxetine. Possible improvement of ED with MDD cannot be ruled out completely. However subjective as well as objective improvement of ED on vortioxetine without other medications, the clear-cut difference in duration of ED and MDD, previously failed response to sertraline and mirtazapine (without 5-HT 7 activity) and a trail of improvement of ED faster than MDD suggests the possible independent role of vortioxetine in improving ED. Further research is required to study the role of vortioxetine in ED.