Hypertension medications and erectile dysfunction

[madman]

Sexual health is an integral part of overall health, and an active and healthy sexual life is an essential aspect of a good life quality. Cardiovascular disease and sexual health share common risk factors (arterial hypertension, diabetes mellitus, dyslipidemia, obesity, and smoking) and common mediating mechanisms (endothelial dysfunction, subclinical inflammation, and atherosclerosis). This generated a shift of thinking about the pathophysiology and subsequently the management of sexual dysfunction. The introduction of phosphodiesterase type 5 inhibitors revolutionized the management of sexual dysfunction in men. This article will focus on erectile dysfunction and its association with arterial hypertension. This update of the position paper was created by the Working Group on Sexual Dysfunction and Arterial Hypertension of the European Society of Hypertension. This working group has been very active during the last years in promoting the familiarization of hypertension specialists and related physicians with erectile dysfunction, through numerous lectures in national and international meetings, a position paper, newsletters, guidelines, and a book specifically addressing erectile dysfunction in hypertensive patients. It was noted that erectile dysfunction precedes the development of coronary artery disease. The artery size hypothesis has been proposed as a potential explanation for this observation. This hypothesis seeks to explain the differing manifestation of the same vascular condition, based on the size of the vessels. Clinical presentations of the atherosclerotic and/or endothelium disease in the penile arteries might precede the corresponding manifestations from larger arteries. Treated hypertensive patients are more likely to have sexual dysfunction compared with untreated ones, suggesting a detrimental role of antihypertensive treatment on erectile function. The occurrence of erectile dysfunction seems to be related to undesirable effects of antihypertensive drugs on the penile tissue. Available information points toward divergent effects of antihypertensive drugs on erectile function, with diuretics and beta-blockers possessing the worst profile and angiotensin receptor blockers and nebivolol the best profile.

CONCLUSION

Assessment of sexual function should be part of routine history taking by all physicians treating patients with arterial hypertension, not only as a part of a holistic approach of the patient but in the effort to pursue significant and tangible benefits. The essential first step for the treating physician is to initiate the discussion about sexual function and function to engage in an open dialogue with the patient and the sexual partner. In this, the patient (couple) shall be informed about the magnitude of the problem and ensured that effective and safe treatment is available. Finally, a realistic plan in co-operation with the couple in terms of shared-decision making should be developed.

 

[madman]

TABLE 1. Prognostic biomarkers of cardiovascular disease in patients with erectile dysfunction

 

[madman]

TABLE 2. The effect of different antihypertensive drug classes on erectile function

 

[madman]

FIGURE 1 Management of erectile dysfunction patients with and without cardiovascular disease. Modified with permission from Vlachopoulos et al. [53]. *Low-risk patients include those with complete revascularization (e.g. via coronary artery bypass grafting, stenting, or angioplasty), patients with asymptomatic controlled hypertension, those with mild valvular disease, and patients with left ventricular dysfunction/heart failure (NYHA classes I and II) who achieved five metabolic equivalents of the task (METS) without ischemia on recent exercise testing. **Indeterminate risk patients include diabetic patients, those with mild or moderate stable angina pectoris, past myocardial infarction (2–8 weeks) without intervention awaiting exercise electrocardiography, congestive heart failure (NYHA class III), and noncardiac sequelae of atherosclerotic disease (e.g. peripheral artery disease and a history of stroke or transient ischemic attack); this patient with erectile dysfunction may require assessment for additional vascular disease using carotid intima-media thickness or ankle-brachial index and subsequent reclassification to low or high risk. ***High-risk patients include those with unstable or refractory angina pectoris, uncontrolled hypertension, congestive heart failure (NYHA class IV), recent myocardial infarction without intervention (2 weeks), high-risk arrhythmia (exercise-induced ventricular tachycardia, implanted internal cardioverter defibrillator with frequent shocks, and poorly controlled atrial fibrillation), obstructive hypertrophic cardiomyopathy with severe symptoms, and moderate-to-severe valve disease, particularly aortic stenosis. Where appropriate CVD, cardiovascular disease; FRS, Framingham risk score; NYHA, New York Heart Association; PDE5i, phosphodiesterase type 5 inhibitors; RF, risk factor; Tth, testosterone therapy.

 

[Fernando Almaguer]

so metoprolol and Lisinopril will help erections. Please advise Madman

 

[madman]

so metoprolol and Lisinopril will help erections. Please advise Madman

Beta blockers and diuretics can cause the most sexual side effects. In contrast, sexual side effects less commonly occur with ACE inhibitors, angiotensin-receptor blockers, and calcium-channel blockers.

All beta-blockers (except selective β₁ receptor blocker nebivolol) can have a negative effect on erectile function and this includes the selective β₁ receptor blocker metoprolol.

ACE inhibitors can have a neutral/positive effect on erectile function and this includes lisinopril.

 

[madman]

I just posted the full paper.



Antihypertensive treatment

Drug effects
Treated patients with hypertension are more likely to have sexual dysfunction compared with untreated ones, suggesting a detrimental role of antihypertensive treatment on erectile function [43,105–109]. The occurrence of erectile dysfunction seems to be related to undesirable effects of antihypertensive drugs on the penile tissue. It remains to be clarified whether the lower blood pressure levels impair the blood supply towards the penile vasculature, thus resulting to erectile dysfunction. It should be highlighted that treated patients with hypertension usually suffer from more severe forms of the disease and target-organ damage of greater extent. Subsequently, the high prevalence of erectile dysfunction comes with no surprise [110]. The one-million-dollar question for the practicing physician is whether all antihypertensive drugs exert detrimental effects on erectile function or differences exist between the various drug categories. Accumulating evidence strongly indicates divergent effects of the various antihypertensive drugs on erectile function, pointing towards not only between-class differences but also within-class differences. Available data come from experimental, observational, and clinical studies. Collectively, available information points toward divergent effects of antihypertensive drugs on erectile function, with diuretics and beta-blockers possessing the worst profile and angiotensin receptor blockers (ARBs) and nebivolol the best profile (Table 2). Therefore, a more detailed description about the effects of ARBs and nebivolol on erectile function is provided.

 

[Fernando Almaguer]

Beta blockers and diuretics can cause the most sexual side effects. In contrast, sexual side effects less commonly occur with ACE inhibitors, angiotensin-receptor blockers, and calcium-channel blockers.

All beta-blockers (except selective β₁ receptor blocker nebivolol) can have a negative effect on erectile function and this includes the selective β₁ receptor blocker metoprolol.

ACE inhibitors can have a neutral/positive effect on erectile function and this includes lisinopril.

THANKS so looks like I'm good with metoprolol since its a selective b-1. Am I understanding you correctly?

 

[madman]

THANKS so looks like I'm good with metoprolol since its a selective b-1. Am I understanding you correctly?

No out of all the beta blockers whether selective or selective β₁ nebivolol is the only one shown to have a positive effect on erectile function.

 

[Golfboy307]

Madman, I wanted to give you a big thanks for posting this study. I have been on a Lisinopril 20mg/HCTZ 12.5mg (diuretic) combo for over 5 years. It does a great job keeping me at 120/80 or below. However, based on other health progress I have made, my Body Logic doctor has been urging me to consider dropping the diuretic (prescribed by my old doc). Well, after reading this article, I have finally made that change as of 3 weeks ago. The good news: my erections have been the strongest they have been in several years. Eye popping results really, very noticeable about 3 days after I stopped the HCTZ. The diuretic was definitely a negative factor sexually. Not as good news: my BP is back to averaging 125-135/75. Fine for now, but I may need to tweak my Lisinopril dosage a bit. As I move forward, I am going to use this study as a guide with my doctor.

(For reference, age 52, active runner/fitness athlete. Good diet. Hypertension in both parents. Currently on successful TRT regimen)

 

[Nelson Vergel]

What high blood pressure meds are the most erection friendly?

My doctor keeps telling me my blood pressure is borderline high or a bit high side he first asked me to try and reduce my salt intake now talking about maybe putting me on some meds I've never taken any blood pressure meds before and really don't know much about the different drugs they...

www.excelmale.com

Several classes of antihypertensive medications are associated with a lower risk of erectile dysfunction. These include:

1. Angiotensin II receptor blockers (ARBs): As mentioned earlier, ARBs work by blocking the effects of angiotensin II, a hormone that constricts blood vessels and increases blood pressure. They are less likely to cause erectile dysfunction compared to other antihypertensive medications. Some examples of ARBs include losartan, valsartan, and olmesartan.
2. Calcium channel blockers (CCBs): These medications work by preventing calcium from entering the smooth muscle cells of the heart and blood vessels, leading to relaxation and dilation of blood vessels. This helps lower blood pressure. CCBs are also considered to have a lower risk of erectile dysfunction. Some examples of CCBs are amlodipine, nifedipine, and diltiazem.
3. Alpha-blockers: These medications work by relaxing the smooth muscle in blood vessels and the prostate gland, improving blood flow and lowering blood pressure. Alpha-blockers are less likely to cause erectile dysfunction and may even improve erectile function in some cases. Examples of alpha-blockers include doxazosin, terazosin, and tamsulosin.
4. Nebivolol (Bystolic): This is a beta-blocker that works by reducing the workload on the heart and dilating blood vessels. Unlike some other beta-blockers, nebivolol is associated with a lower risk of erectile dysfunction due to its vasodilatory properties.

Angiotensin receptor blockers (ARBs) are a class of medications that are commonly used to treat hypertension (high blood pressure). They work by blocking the effects of angiotensin II, a hormone that constricts blood vessels and increases blood pressure. By inhibiting the action of angiotensin II, ARBs help to relax blood vessels, which lowers blood pressure. Here is a list of some common ARBs along with their details:

1. Losartan (Cozaar)

• Brand name: Cozaar
• Initial dose: 50 mg daily
• Maintenance dose: 25-100 mg daily, taken once or in two divided doses
• Common side effects: Dizziness, upper respiratory infection, fatigue, and nasal congestion

1. Valsartan (Diovan)

• Brand name: Diovan
• Initial dose: 80-160 mg daily
• Maintenance dose: 80-320 mg daily, taken once or in two divided doses
• Common side effects: Headache, dizziness, fatigue, and diarrhea

1. Irbesartan (Avapro)

• Brand name: Avapro
• Initial dose: 150 mg daily
• Maintenance dose: 75-300 mg daily, taken once or in two divided doses
• Common side effects: Dizziness, fatigue, and diarrhea

1. Candesartan (Atacand)

• Brand name: Atacand
• Initial dose: 16 mg daily
• Maintenance dose: 8-32 mg daily, taken once or in two divided doses
• Common side effects: Headache, dizziness, and upper respiratory infection

1. Telmisartan (Micardis)

• Brand name: Micardis
• Initial dose: 40 mg daily
• Maintenance dose: 20-80 mg daily, taken once
• Common side effects: Upper respiratory infection, sinusitis, diarrhea, and back pain

1. Olmesartan (Benicar)

• Brand name: Benicar
• Initial dose: 20 mg daily
• Maintenance dose: 20-40 mg daily, taken once
• Common side effects: Dizziness, nausea, and upper respiratory infection

1. Eprosartan (Teveten)

• Brand name: Teveten
• Initial dose: 600 mg daily
• Maintenance dose: 400-800 mg daily, taken once or in two divided doses
• Common side effects: Fatigue, headache, and dizziness

1. Azilsartan (Edarbi)

• Brand name: Edarbi
• Initial dose: 40 mg daily
• Maintenance dose: 40-80 mg daily, taken once
• Common side effects: Diarrhea, nausea, and dizziness

Please note that this list is not exhaustive, and that there may be other ARBs available.

 

[Nelson Vergel]

Effect of Blood Pressure Medications on erections

The Effect of Antihypertensive Drugs on Erectile Function: A Proposed Management Algorithm - By Michael Doumas MD, Stella Douma Blood pressure medications are among the most common causes of drug-induced decrease in sex drive and erectile function. This great paper reviews known data on the...

www.excelmale.com

 

[Nelson Vergel]

Beta blockers and diuretics can cause the most sexual side effects.

It seems that non-MRA diuretics may not be as bad, as shown on that table in post #3

 

[MarcoFL]

I just started 60mg ER Propranolol and find it better for heart rate control. I have not checked by BP yet. I had been on Metoprolol and felt it was not working anymore.

 

[Nelson Vergel]

I still strongly believe that using non-MRA diuretics like amiloride is the best way to deal with TRT or anabolic-induced water retention without affecting erectile function on insulin sensitivity. Amiloride plus losartan or telmisartan would also work if blood pressure is an issue.

 

[xcpatr922]

No out of all the beta blockers whether selective or selective β₁ nebivolol is the only one shown to have a positive effect on erectile function.

my own experience. With carvedilol, very bad ED for at least 2-3 days. Change to Nebivolol: still bad sometimes, bad not as bad as carvedilol. If I add Cialis plus Nebivolol: whoa, the morning wood is there and strong.

I ask my own doctor to change from carvedilol to Nebivolol. Reason the latter is helping (or minimum ED) is because Nebivolol is creating more NO syntesis. Also it doesnt have much effect on limiting HR like carvedilol.

I used to be in carvedilol for too long (before TRT), and becoming too "calm person" as almost has zero adrenaline.

 

[Chroniclowe]

my own experience. With carvedilol, very bad ED for at least 2-3 days. Change to Nebivolol: still bad sometimes, bad not as bad as carvedilol. If I add Cialis plus Nebivolol: whoa, the morning wood is there and strong.

I ask my own doctor to change from carvedilol to Nebivolol. Reason the latter is helping (or minimum ED) is because Nebivolol is creating more NO syntesis. Also it doesnt have much effect on limiting HR like carvedilol.

I used to be in carvedilol for too long (before TRT), and becoming too "calm person" as almost has zero adrenaline.

For me nebivolol actually boosted erections atleast at beginning those first 2-4 weeks, but at the moment i dont see difference. i have been using it many months now 10mg daily for high blood pressure and high heart rate. The downside is that i have slowly gaining weight on nebivolol which i hate. It keeps my resting heart rate little bit too low 50-60/beats per minute. Which sure causes weight gain. Without nebivolol my resting heart rate was always 100, and i was always naturally ripped, but thats horrible on your heart on longterm to have that high HR. I would like to have resting HR somewhere around 70-75. Im Thinking to drop my dosage down to 5mg daily, and see if weight gain stops, let my HR to increase 70’s and still allows my blood pressure to stay on good ranges.

Have you got any weight gain on nebivolol?

And i can agree with you that those other not so selective beta blockers/unselective can have that zero adrenaline effect. I used 4 weeks propranolol 20mg day, it made me also zero adrenaline, despite i had been stopped it, i stayed about 3 months afterward too calm. I still not get the same type adrenal affect than before, and i had naturally too high adrenaline.
I also saw one post on ray peat forum where someone used 40mg/day propranolol 2-weeks and became permanently ”too calm”.

 

[Chroniclowe]

[Level of hormones of pituitary-gonadal axis, penile blood flow and sexual function in men with arterial hypertension during monotherapy with bisoprolol and nebivolol] - PubMed

Measurement of levels of hormones of the pituitary-gonadal system, dopplerography of penile arteries and questioning after Vasiltchenko were carried out in 30 men (age 35-55 years) with I-II degree arterial hypertension who received monotherapy with bisoprolol and nebivolol for 2 months...

pubmed.ncbi.nlm.nih.gov

Bisoprolol and nebivolol significantly increased concentration of testosterone (by 82 and 85%, respectively) and prolactin (by 77 and 83%, respectively), lowered levels of estradiol and follicle-stimulating hormone, improved vascular blood flow in penile arteries, and did not worsen sexual function.

Interesting study on nebivolol. Increased prolactin that much, but still didnt worsened sexual function.
But its little bit suspicious russian study, lol. Tried to find more data on that study but i cant find anything.

 

[xcpatr922]

[Level of hormones of pituitary-gonadal axis, penile blood flow and sexual function in men with arterial hypertension during monotherapy with bisoprolol and nebivolol] - PubMed

Measurement of levels of hormones of the pituitary-gonadal system, dopplerography of penile arteries and questioning after Vasiltchenko were carried out in 30 men (age 35-55 years) with I-II degree arterial hypertension who received monotherapy with bisoprolol and nebivolol for 2 months...

pubmed.ncbi.nlm.nih.gov

Bisoprolol and nebivolol significantly increased concentration of testosterone (by 82 and 85%, respectively) and prolactin (by 77 and 83%, respectively), lowered levels of estradiol and follicle-stimulating hormone, improved vascular blood flow in penile arteries, and did not worsen sexual function.

Interesting study on nebivolol. Increased prolactin that much, but still didnt worsened sexual function.
But its little bit suspicious russian study, lol. Tried to find more data on that study but i cant find anything.

exactly, nebivolol "still" has some negative side effect me hence use cialis to counteract.

 

[xcpatr922]

For me nebivolol actually boosted erections atleast at beginning those first 2-4 weeks, but at the moment i dont see difference. i have been using it many months now 10mg daily for high blood pressure and high heart rate. The downside is that i have slowly gaining weight on nebivolol which i hate. It keeps my resting heart rate little bit too low 50-60/beats per minute. Which sure causes weight gain. Without nebivolol my resting heart rate was always 100, and i was always naturally ripped, but thats horrible on your heart on longterm to have that high HR. I would like to have resting HR somewhere around 70-75. Im Thinking to drop my dosage down to 5mg daily, and see if weight gain stops, let my HR to increase 70’s and still allows my blood pressure to stay on good ranges.

Have you got any weight gain on nebivolol?

And i can agree with you that those other not so selective beta blockers/unselective can have that zero adrenaline effect. I used 4 weeks propranolol 20mg day, it made me also zero adrenaline, despite i had been stopped it, i stayed about 3 months afterward too calm. I still not get the same type adrenal affect than before, and i had naturally too high adrenaline.
I also saw one post on ray peat forum where someone used 40mg/day propranolol 2-weeks and became permanently ”too calm”.

I complained to my cardiologist long time ago that since I'm taking regular carvedilol, I become too calm and my HR max is only at 130 and I can't exercise that much.

I know carvedilol is extremely good though, I have very bad 'anxiety feeling' before an MI event but after carvedilol that feeling is gone. Also very stable LVEF and very minimal effect after MI. With regular carvedilol I'm gaining weight .........fast. Although I'm at Keto. Then I slowly not taking it and do more HIIT (this is prior TRT). Weight stablizes and going down.

Best time for me to take BB is:
-before sleep
- after exercise
-after sex

I then research a lot on BB and found Nebivolol could be the answer. Before I use Nebivolol I already in TRT. With TRT I gained lot of muscle, like losing 8 percent of boday fats just like that. Impressive. Eating carb a bit has no effect now, whoa...this is like 19 feeling. So I add cardiologist to switch me to nebivolol, I took it on demand only and again trial-and-error for few days. I still feel it has an impact to ED for 1-2 days. Then I add Cialis to counteract, things are okay now.

Many of these studies, regardless what they say, it really doesn't matter. What matter is whether it work in our body and whether there's tip/trick to manage the side effect. Same like TRT. The min. dose and every day injection is when I feel the best.