Has sexual dysfunction been reported as an adverse effect of lithium treatment?/nA 30-year-old man

Fråga: Has sexual dysfunction been reported as an adverse effect of lithium treatment? A 30-year-old man with affective disorders has been treated with Lithionit (lithium) 3+0+2 tablets for more than four years. He has from time to time suffered from impaired sexual function, in particular reduced libido and erectile function. The patient has also been treated with Cipramil (citalopram) for one and a half year. Citalopram treatment was stopped six months ago, due to an improvement in the depression. However, the side effects have still not subsided. The patient has no known other diseases or drug therapies.

Sammanfattning: Sexual dysfunction has been reported in relation to both lithium and citalopram therapy. In the present case neither lithium nor citalopram can be ruled out as a contributing to the development of sexual dysfunction. The time relationship primarily suggests lithium. Other causes of sexual dysfunction must be ruled out since sexual dysfunction is common in psychiatric patients.

Svar: A question concerning impotence as a side effect of lithium has been dealt with previously in Drugline (1). This document describes two cases of patients with loss of libido and impaired erection ability associated with lithium therapy and a study in which 5 out of 33 patients on lithium had difficulties in achieving and maintaining erection. Further documentation has been found in an updated literature search.

One 39-year-old man with schizophrenia suffered from impotence during treatment with lithium and neuroleptics (2). The neuroleptic drugs were progressively reduced and the patient was only treated with lithium. However, the erectile dysfunction did not subside until lithium was withdrawn. The symptoms reappeared after re-exposure to lithium.

More patients among 24 lithium treated manic-depressive patients were dissatisfied with their present sex life compared with 42 controls among surgical patients with no known psychiatric disease (3). In this study indication as a confounding factor is an obvious problem since sexual impairment is much more common in psychiatric patients than in patients subject to surgery.

Sexual function was assessed by self-rating scale in 104 outpatients (45 men and 59 women) with a bipolar disorder who were attending an affective disorder clinic (4). All patients were under treatment with lithium, either alone, or in combination with benzodiazepines, tricyclic antidepressants, neuroleptics or other drugs. Among patients on lithium monotherapy did not have a problem with sexual function, whereas in combination with benzodiazepines sexual dysfunction was reported by about half of the patients. Again, the effect of bensodiazepines may be due to the patients condition rather than the drug.

One case of ejaculation disturbances possibly related to lithium treatment is documented in the Swedish adverse drug registry (5). It concerns a 41-year-old male with recurrent depression who after initiation of the drug treatment suffered from this side effect. Lithium was not withdrawn and several years later the patient had still not recovered.

There are 46 reports of impotence and 3 of ejaculation dysfunction associated with lithium treatment in the WHO adverse drug reaction database (INTDIS) (6). It should be noted that the WHO database is not subject to a homogenous evaluation of the reports due to differences among reporting countries. This small number of reports of a widely used drug for many years does not support a causal relationship.

Sexual dysfunction related to citalopram or SSRI treatment is documented in the literature (5,7-11).

In the present case neither lithium nor citalopram can be ruled out as a contributing to the development of sexual dysfunction. The time relationship primarily suggests lithium. Other causes of sexual dysfunction must be ruled out since sexual dysfunction is common in psychiatric patients.