Frågedatum: 2018-11-23
RELIS database 2018; id.nr. 151, ULIC
www.svelic.se
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Betablockerare och sexuella biverkningar



Fråga: Finns det tydligare indikationer kring vilken/vilka betablockerare som har lägst frekvens av biverkningar i form av sexuella/potens störningar och som i så fall vore att rekommendera till unga patienter?

Svar: Sammanfattning
We have found no study that has directly compared the risk of sexual dysfunction associated with different types of beta-blockers. Most experts appear to agree that treatment with older, non-selective beta-blockers carries a higher risk of sexual dysfunction than with newer, selective beta-blockers. Based on indirect comparisons between reported incidences of sexual dysfunction for different beta-blockers on the Swedish market, the risk appears to be higher for propranolol, pindolol and sotalol (non-selective beta-blockers) as compared with selective beta-blockers (metoprolol, atenolol, bisoprolol, nebivolol and carvedilol). Whether there are differences in risk between different selective beta-blockers is uncertain.

Svar

When searching the literature via PubMed (1) we have found no study that has directly compared the risk of sexual dysfunction associated with different types of beta-blockers. Solid evidence for a difference in risk between different beta-blockers are therefore lacking. However, some data are available, and we have found some publications discussing the risk and whether or not there are differences between different beta-blockers, as follows:

In the pharmacological database Micromedex (4) it is stated that sexual dysfunction (SD) appears to occur less often in beta-blockers with cardioselectivity and low lipid solubility (5). Nebivolol, a third-generation selective beta-blocker has the highest cardioselectivity of the currently available beta -blockers (5). Other selective beta-blockers include metoprolol, atenolol and bisoprolol, nebivolol and carvedilol (2, 6). Non-selective betablockers on the Swedish market include propranolol, pindolol and sotalol.

Summaries of Product Characteristics (7) for selective beta-receptor blockers; metoprolol, atenolol and bisprolol report impotence and decreases in libido as rare side effects with a frequency of =1/10 000, <1/1000 (0.01-0.1%). Impotence is reported as a less common adverse reaction (=1/1000, £1/100) for nebivolol and carvedilol. For the non-selective beta-blockers, propranolol adversely affects both libido (1% to 4%) and erectile function (1). The incidence of impotence is dose-related and varies from 6% to 15% at dosages of 120 to 140 mg/day to 30% to 40% at dosages of 480 mg/day (1, 2). For sotalol, sexual dysfunction (non-specified) is reported as a common adverse reaction (= 1/100, < 1/10) (6). An incidence of 2% is reported for erectile dysfunction, decreased libido, and impotence (4). The incidence of erectile dysfunction associated with pindolol is stated to be less than 2%, and reduced libido 1-2% (2).

A recent systematic review (3) evaluated 30 sets of guidelines for hypertension management in adults that address sexual dysfunction. The results of this review showed that the guidelines never use terms such as loss of libido, ejaculatory dysfunction, lack of orgasm, and priapism. Therapeutic issues such as exploring SD in clinical history, assessing SD prior to and during treatment with antihypertensives, substituting the offending agents with alternatives that possess a better safety profile are superficially addressed by most guidelines. The European Society of Hypertension (ESH) guidelines (8) state that “older beta-blockers exert negative effects on erectile dysfunction, whereas newer drugs such as nebivolol have neutral or beneficial effects.” The American College of Cardiology Foundation/American Heart Association (9) state that “Although earlier beta blockers have been associated with depression, sexual dysfunction, /../ these side effects are less prominent or absent with newer agents”. However, this statement lacks references.

Referenser:
  1. PubMed. US National Library of Medicine/National Institutes of Health [sökning gjord 2018-10-25]. http://www.ncbi.nlm.nih.gov/pubmed
  2. Micromedex, “Drug-Induced Sexual Dysfunction”, 2016.
  3. Al Khaja KA, Sequeira RP, Alkhaja AK, Damanhori AH. Antihypertensive Drugs and Male Sexual Dysfunction: A Review of Adult Hypertension Guideline Recommendations. J Cardiovasc Pharmacol Ther. 2016 May;21(3):233-44. doi: 10.1177/1074248415598321.
  4. Micromedex. Truven Health Analytics, Greenwood Village, Colorado, USA. Available at: http://www.micromedexsolutions.com/ [hämtat 2018-10-26].
  5. Smith PF &amp; Talbert RL: Sexual dysfunction with antihypertensive and antipsychotic agents. Clin Pharm 1986; 5:373-384.
  6. Weber M. The role of the new b-blockers in treating cardiovascular disease. Am J Hypertens. 2005;18(12 pt 2):169S-176S.
  7. Produktresumeer. www.FASS.se
  8. Reappraisal of European guidelines on hypertension management. A European Society of Hypertension Task Force document. J Hypertens. 2009;27(11):2121–2158.
  9. ACCF/AHA 2011 Expert consensus document on hypertension in the elderly . A report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus document. Circulation. 2011;123:2434–2506