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 Table of Contents  
CASE SERIES
Year : 2020  |  Volume : 4  |  Issue : 1  |  Page : 81-83

Risperidone-Induced sexual dysfunction reverted with aripiprazole: Experience from two cases


Department of Psychiatry, Smt. NHL Municipal Medical College and SVPIMSR Hospital, (Affiliated under Gujarat University), Ahmedabad, Gujarat, India

Date of Submission12-Nov-2019
Date of Decision30-Nov-2019
Date of Acceptance09-Apr-2020
Date of Web Publication30-May-2020

Correspondence Address:
Dr. Shreyasee S Bhowmick
D 194, Sant Vihar Society, Behind Raneshwar Temple, Vasna Road, Vadodara - 390 007, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_78_19

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  Abstract 


Antipsychotic agents are effective in schizophrenia by alleviating positive and negative symptoms, but also have the potential for inducing sexual dysfunction by causing hyperprolactinemia. This may have a negative impact on treatment compliance. Risperidone is associated with a high rate of sexual dysfunction compared to olanzapine, clozapine, quetiapine, and aripiprazole. However, the partial dopaminergic agonism of aripiprazole at D2receptor may explain why its use does not usually cause this side effect and may even revert it when added to another antipsychotic. We present here two cases of schizophrenia, who were treated with risperidone, and complained of sexual dysfunction during follow-up. After the addition of aripiprazole and reducing the dose of risperidone, this side effect reverted without a negative impact on treatment adherence or therapeutic efficacy.

Keywords: Aripiprazole, hyperprolactinemia, risperidone, sexual dysfunction


How to cite this article:
Bhowmick SS, Darji VM, Parikh NC, Shah ND. Risperidone-Induced sexual dysfunction reverted with aripiprazole: Experience from two cases. Ann Indian Psychiatry 2020;4:81-3

How to cite this URL:
Bhowmick SS, Darji VM, Parikh NC, Shah ND. Risperidone-Induced sexual dysfunction reverted with aripiprazole: Experience from two cases. Ann Indian Psychiatry [serial online] 2020 [cited 2020 Oct 1];4:81-3. Available from: http://www.anip.co.in/text.asp?2020/4/1/81/285515




  Introduction Top


Risperidone is a potent second-generation antipsychotic drug used in the treatment of schizophrenia. However, it is associated with sexual side effects in both men and women, which is found to be associated with dose-dependent hyperprolactinemia. Studies report sexual dysfunction in the range of 67%–96% in patients treated with risperidone.[1],[2],[3] Most of these patients present with decreased sexual desire, while difficulty in arousal, erectile dysfunction, and ejaculatory dysfunction are other common symptoms reported. Among those having risperidone-induced sexual dysfunction, almost all of the patients are found to have elevated prolactin levels.[2],[3] Dopamine inhibits prolactin release and so dopamine antagonists such as risperidone used in the treatment of schizophrenia are expected to increase plasma prolactin level. In order to treat such sexual dysfunction and associated hyperprolactinemia, switching to an antipsychotic with a lower propensity for prolactin elevation is usually the first choice, although this carries risks of relapse and destabilizing the illness. An alternative option is to add aripiprazole to the existing treatment.[4] We share our experience from two cases of schizophrenia who experienced sexual dysfunction after starting risperidone which was dealt with by dose reduction and addition of aripiprazole.


  Case Reports Top


Case 1

History

A 25-year-old man presented with persecutory delusions since the past 1-year that people from his neighborhood were plotting against him and his family members and planning to force his mother and sister into prostitution. He also had auditory hallucinations with derogatory and threatening content about the same neighborhood. He used to remain socially withdrawn throughout the day, had frequent impulsive anger-outbursts and maintained a poor self-hygiene. Based on these features, he was diagnosed with schizophrenia according to the criteria published in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). The treatment was started with risperidone up to 4 mg/day. The patient responded to treatment, and gradually, the psychotic features started abating. After about 2 months of continuing the same treatment, he started complaining of sexual dysfunction in the form of decreased sexual desire and difficulty in maintaining erection. This was quite distressing for him because he was planning to get married soon. He did not have a history of epilepsy, brain tumor, or another medical condition.

Evaluation

The organic conditions that could lead to sexual dysfunction were ruled out by performing routine laboratory investigations such as complete blood count, blood glucose level, thyroid profile, liver function tests, renal function tests, and magnetic resonance imaging of the brain. Any other psychological cause was also ruled out. Serum testosterone level was within normal limits, but the serum prolactin level was found to be more than twice the upper limit of normal (39.65 ng/ml; normal 3–14.7 ng/ml). Thus, it was very likely that the patient had sexual dysfunction induced by risperidone.

Management

We added aripiprazole (up to 10 mg/day) to the on-going treatment, and the dose of risperidone was reduced to 2 mg/day. The patient started improving and had no difficulty in maintaining erection and sexual desire by the end of 1-month. There was no re-emergence of psychotic features. Repeat serum prolactin level after 3 months was within normal limits (2.64 ng/ml).

Case 2

History

A 42-year-old married man suffered from auditory hallucinations, persecutory delusions, negative symptoms (apathy, alogia), and disorganized behavior such as muttering, gesturing, inappropriate laughing for about 10 years with multiple exacerbations. These symptoms led to the diagnosis of schizophrenia according to the DSM-5 criteria. During the third exacerbation, risperidone was started up to 3 mg/day. His symptoms improved, but 3 months later, he started complaining of reduced sexual desire and difficulty in maintaining erection.

Evaluation

The organic causes were ruled out with the help of investigations, as in the first case. Serum testosterone was within normal limits, but serum prolactin level was more than twice the upper limit of normal (44.79 ng/ml; normal 3–14.7 ng/ml) suggesting risperidone-induced sexual dysfunction.

Management

The dose of risperidone was reduced to 2 mg/day, and aripiprazole was added up to 10 mg/day. The patient had a significant improvement in his sexual function within 2 months. Repeat serum prolactin levels after 2 months dropped to normal limits (8.2 ng/ml). With regular follow-up and therapeutic compliance, his psychotic and sexual features remained stable.


  Discussion Top


There are well-designed clinical trials regarding risperidone-induced hyperprolactinemia.[5],[6] Sexual dysfunctions secondary to hyperprolactinemia have been discussed in a few observational studies and case reports.[1],[2],[3] The sexual side effects related to antipsychotic-induced hyperprolactinemia are one of the main factors that lead patients (especially young) to abandon treatment, which is a determinant of relapse and hence overall functionality and prognosis.[4] Furthermore, reports suggest that with improvement in hyperprolactinemia, sexual function may or may not improve.[7],[8],[9] Hence, it is important to look at effective treatments that not only lower the serum prolactin levels but also bring about clinical improvement in the sexual side effect.

The various pharmacological management strategies for risperidone-induced sexual dysfunction reported in the literature have been discussed in [Table 1].
Table 1: Pharmacological management strategies of risperidone-induced sexual dysfunction in literature

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There have been studies which have led to the improvement in sexual dysfunction by augmenting or switching over to aripiprazole. The latter strategy, i.e., switching to aripiprazole and stopping the offending agent, has led to re-emergence of psychotic features in some case reports/studies.[6] Hence, we decided to go for cross-tapering of risperidone and aripiprazole as reported by Raghuthaman et al.[7] in his study. Although unlike in the study by Raghuthaman et al.,[7] we opted for tapering the dose of risperidone to minimum (i.e., 2 mg/day) along with augmentation with aripiprazole (10 mg/day), to achieve adequate control of symptoms and improve the sexual dysfunction at relatively low doses of risperidone and aripiprazole.

Aripiprazole is a functional antagonist of dopamine at D2 receptors under hyperdopaminergic conditions but exhibits functional agonist properties under hypodopaminergic conditions. Compared to risperidone, aripiprazole has a higher affinity for D2 receptors and acts as a partial dopamine agonist. Therefore, when aripiprazole is coadministered with risperidone, it may bind to D2 receptors more robustly and act as a dopamine agonist in an antipsychotic-induced hypodopaminergic state.[4],[5]

In both of our cases, after the introduction of aripiprazole and reducing the dose of risperidone, the patient's difficulty in erection and decreased sexual desire resolved, while maintaining adequate control of the psychotic symptoms and without an increase in the incidence of other side effects.


  Conclusion Top


Risperidone has the potential of causing sexual dysfunction and hyperprolactinemia. Such sexual dysfunction secondary to hyperprolactinemia can be resolved by keeping the patient on low dose of risperidone (2 mg/day) and the addition of aripiprazole (10 mg/day). With this strategy, it is also possible to maintain adequate control of the symptoms of the underlying illness as shown in our two cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.[12]



 
  References Top

1.
Dossenbach M, Dyachkova Y, Pirildar S, Anders M, Khalil A, Araszkiewicz A, et al. Effects of atypical and typical antipsychotic treatments on sexual function in patients with schizophrenia: 12-month results from the Intercontinental Schizophrenia Outpatient Health Outcomes (IC-SOHO) study. Eur Psychiatry 2006;21:251-8.  Back to cited text no. 1
    
2.
Sathish Kumar SV, Sinha VK. Comparative study of sexual dysfunction and serum prolactin level associated with olanzapine, risperidone, and clozapine in patients with remitted schizophrenia. Indian J Psychiatry 2015;57:386-91.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Nagaraj AK, Pai NB, Rao S. A comparative study of sexual dysfunction involving risperidone, quetiapine, and olanzapine. Indian J Psychiatry 2009;51:265-71.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Taylor D, Barnes T, Young A. Hyperprolactinemia. In: Taylor D editor, editors. The Maudsley Prescribing Guidelines In Psychiatry. 13th ed. Hoboken NJ: John Wiley and Sons; 2018. p. 137-40.  Back to cited text no. 4
    
5.
Chen CK, Huang YS, Ree SC, Hsiao CC. Differential add-on effects of aripiprazole in resolving hyperprolactinemia induced by risperidone in comparison to benzamide antipsychotics. Prog Neuropsychopharmacol Biol Psychiatry 2010;34:1495-9.  Back to cited text no. 5
    
6.
Byerly MJ, Marcus RN, Tran QV, Eudicone JM, Whitehead R, Baker RA. Effects of aripiprazole on prolactin levels in subjects with schizophrenia during cross-titration with risperidone or olanzapine: Analysis of a randomized, open-label study. Schizophr Res 2009;107:218-22.  Back to cited text no. 6
    
7.
Raghuthaman G, Venkateswaran R, Krishnadas R. Adjunctive aripiprazole in risperidone-induced hyperprolactinaemia: Double-blind, randomised, placebo-controlled trial. BJPsych Open 2015;1:172-7.  Back to cited text no. 7
    
8.
Chen CY, Lin TY, Wang CC, Shuai HA. Improvement of serum prolactin and sexual function after switching to aripiprazole from risperidone in schizophrenia: A case series. Psychiatry Clin Neurosci 2011;65:95-7.  Back to cited text no. 8
    
9.
Kodesh A, Weizman A, Aizenberg D, Hermesh H, Gelkopf M, Zemishlany Z. Selegiline in the treatment of sexual dysfunction in schizophrenic patients maintained on neuroleptics: A pilot study. Clin Neuropharmacol 2003;26:193-5.  Back to cited text no. 9
    
10.
Ishitobi M, Kosaka H, Shukunami K, Murata T, Wada Y. Adjunctive treatment with low-dosage pramipexole for risperidone-associated hyperprolactinemia and sexual dysfunction in a male patient with schizophrenia. J Clin Psychopharmacol 2011;31:243-5.  Back to cited text no. 10
    
11.
Schmidt HM, Hagen M, Kriston L, Soares-Weiser K, Maayan N, Berner MM. Management of sexual dysfunction due to antipsychotic drug therapy. Cochrane Database Syst Rev 2012;11:CD003546.  Back to cited text no. 11
    
12.
Byerly MJ, Lescouflair E, Weber MT, Bugno RM, Fisher R, Carmody T, et al. An open-label trial of quetiapine for antipsychotic-induced sexual dysfunction. J Sex Marital Ther 2004;30:325-32.  Back to cited text no. 12
    



 
 
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