Year : 2018 | Volume
: 27 | Issue : 1 | Page : 154--157
Flibanserin: A controversial drug for female hypoactive sexual desire disorder
Rashmi Baid1, Rakesh Agarwal2,
1 Department of Obstetrics and Gynecology, IPGME and R and SSKM Hospital, Kolkata, West Bengal, India, Kolkata
2 Department of Cardiology, IPGME and R and SSKM Hospital, Kolkata, West Bengal, India, Kolkata
Dr. Rakesh Agarwal
IPGME and R and SSKM Hospital, AJC Bose Road, P.S-Bhowanipur, Kolkata - 700 020, West Bengal
Sexual functioning is an integral part of human life. Female sexual dysfunction (FSD) adversely affects quality of life and general well-being. The Food and Drug Administration recently approved flibanserin, for treatment of female hypoactive sexual desire disorder (HSDD), regarded as the most common FSD, amid great controversy. A novel multifunctional serotonin agonist and antagonist, flibanserin, has been shown to be efficacious in treating HSDD but with a rather tenacious side effect profile. We review this interesting drug in its entirety. Data for the article were collected by reviewing articles on PubMed, the drug (Addyi) website, and related websites on the internet.
|How to cite this article:|
Baid R, Agarwal R. Flibanserin: A controversial drug for female hypoactive sexual desire disorder.Ind Psychiatry J 2018;27:154-157
|How to cite this URL:|
Baid R, Agarwal R. Flibanserin: A controversial drug for female hypoactive sexual desire disorder. Ind Psychiatry J [serial online] 2018 [cited 2019 Jun 19 ];27:154-157
Available from: http://www.industrialpsychiatry.org/text.asp?2018/27/1/154/243306
Sexual functioning is an integral part of human life and has been shown in research to be important to both men and women  In the Study of Women's Health across the Nation, more than 75% of women reported sex to be moderately to extremely important.
Around 43% of women report sexual problems with 22.2% reporting sexually related personal distress. Hypoactive sexual desire disorder (HSDD) has been regarded to be the most common female sexual dysfunction (FSD) and affects nearly 1 in 10 women., It is a persistent or recurrent absence of deficiency of sexual desire or receptivity to sexual activity that causes marked distress or interpersonal difficulty. For a diagnosis of HSDD, the desire problem must not be better accounted for by another psychiatric disorder such as depression, substance abuse, or medical condition. Not only does FSD negatively affect health-related quality of life but also general well-being.,
HSDD was removed from the fifth edition of Diagnostic and Statistical Manual of Mental Disorder (DSM-V). Its symptoms were established as a criterion for female sexual interest/arousal disorder. However, ACOG recognizes HSDD as a separate entity.
Originally developed as an antidepressant, with a potentially rapid onset of action, flibanserin was approved by the Food and Drug Administration (FDA) for HSDD in August 2015 despite the removal of HSDD from DSM-V., The approval came with the caveat that the drug be dispensed through a special risk management program. It is the first FDA-approved drug for treatment of premenopausal women with acquired, generalized HSDD. We review this drug in its entirety, controversies surrounding its approval, dosage, pharmacokinetics, indications, adverse effects, and contraindications.
Mechanism of Action
Flibanserin is a novel multifunctional serotonin agonist and antagonist.
Libido is positively regulated by synaptic dopamine and also other microcircuits where norepinephrine, testosterone, and estrogen act. Libido is negatively modulated by microcircuits where prolactin and serotonin act.,, It implies relative deficiency of microcircuit dopamine and norepinephrine, or a relative excess of microcircuit serotonin can lead to disorder of sexual interest and desire.
Flibanserin has two principal pharmacological actions in neural microcircuits: it acts as a full agonist at postsynaptic 5HT1A receptors and an antagonist at postsynaptic 5HT2A receptors., Exclusive binding at these receptors differentiates flibanserin from buspirone and bupropion. This action in the prefrontal cortex causes the downstream release of dopamine and norepinephrine and reduction of serotonin, consistent with sites of abnormal neuroimaging described in patients with reduced sexual interest and desire.,, Flibanserin acts selectively on pyramidal neurons that excite brainstem 5HT neurons yet also selectively on pyramidal neurons that inhibit brainstem Norepinephrine and Dopamine neurons.
Flibanserin shows linear and dose proportional kinetics following a single oral dose (5–150 mg) and multiple oral doses (total daily dose ranging from 60 to 300 mg). It is 90% absorbed and has mean half-life of ~ 11 h. With mild hepatic impairment, half-life increases to 26 h. Taking the drug with food increases its absorption. It has 98% protein binding, primarily to albumin. Its oral bioavailability is 33%. Steady state of flibanserin is achieved only after 3 days of dosing and so it is incorrect to call it “female Viagra” because Viagra is used as needed.
Flibanserin undergoes oxidative metabolism by CYP3A4 and to a lesser extent by CYP2D6 cytochrome P450 isoenzymes. Concomitant CYP3A4 inhibitors may increase flibanserin exposure and are contraindicated. Flibanserin may be used 2 weeks after the last dose of a moderate or strong CYP3A4 inhibitor. A moderate or strong CYP3A4 inhibitor may be initiated 2 days after the last dose of flibanserin. Strong CYP3A4 inhibitors include ketoconazole, itraconazole, clarithromycin, nefazodone, ritonavir, indinavir, and conivaptan. Moderate CYP3A4 inhibitors include atazanavir, ciprofloxacin, diltiazem, verapamil, erythromycin, fluconazole, and grapefruit juice. Weak CYP3A4 inhibitors such as oral contraceptive pills, cimetidine, fluoxetine, Ginkgo biloba, and ranitidine may be associated with increased risk for hypotension, syncope, and central nervous system (CNS) depression.,
Furthermore, CYP3A4 inducers can substantially reduce flibanserin concentrations and are not recommended with it. These include etravirine, carbamazepine, phenobarbital, phenytoin, rifampin, and St. John's wort.
The use of flibanserin in patients who are CYP2C19 poor metabolizers results in increased flibanserin concentrations and may increase the risk of hypotension and syncope. These patients should be closely monitored for adverse reactions. These include drugs such as proton-pump inhibitors, selective serotonin reuptake inhibitors, benzodiazepines, and antifungals.
Flibanserin inhibits P-glycoprotein. Increased monitoring of concentrations of drugs transported by P-glycoprotein that have a narrow therapeutic index such as digoxin and sirolimus is indicated.
Flibanserin is excreted mostly through bile and the kidneys as inactive metabolites.
100 mg PO once daily at bedtime.
Administration during waking hours increases risk of hypotension, syncope, accidental injury, and depression. It is discontinued after 8 weeks if no improvement occurs.,,
In case of missed dose, the patient should take the next dose at bedtime the next day. Doses should not be doubled.
Currently, it is not indicated in postmenopausal women or in men. Neither is it indicated to enhance sexual performance.
Alcohol use – associated with severe hypotension and syncopeUse of moderate or strong CYP3A4 inhibitorsHepatic impairment.,
Flibanserin may cause CNS depression with somnolence and sedation. Fatigue, insomnia, and dry mouth can also occur. Patients should not drive or engage in other activities requiring full alertness until at least 6 h after taking flibanserin. Concomitant use of CNS depressants such as diphenhydramine, opioids, hypnotics, and benzodiazepines may increase this risk.
Flibanserin by itself can cause hypotension and syncope.
Mice studies have shown dose-related increase in the incidence of malignant mammary tumors in female mice at exposures 3 and 10 times the recommended clinical dose. This was not seen in male mice or in male or female rats. However, clinical implications of these findings are unknown at present.
Pregnancy and Lactation
Adverse events were observed in some animal reproduction studies. It should be avoided in pregnancy. Flibanserin is excreted in rat milk. However, human data are not available and it is not recommended during breastfeeding at present.,
Controversies Plaguing Flibanserin
Does HSDD at all exist? Considering that it was no more included as a separate entity in DSM-V, is drug treatment the right way forward?Is flibanserin safe enough to recommend its use? Safety and adverse effect date of flibanserin are still accumulating. According to meta-analysis by Jaspers et al., premenopausal and postmenopausal women taking flibanserin experienced 0.5 more satisfying sexual encounters a month and scored 0.3 points higher on a 5-point sexual desire scale. They concluded that these modest benefits did not outweigh harms.,, According to FDA, flibanserin increased somnolence, sedation, or fatigue compared with placebo: 21% versus 8%!Approval controversy: In 2009, Boehringer Ingelheim applied for approval of flibanserin to treat HSDD in premenopausal women. However, the FDA's clinical reviewers and an external advisory committee voted unanimously against the drug 11-0. This was because the drug was noted to cause substantial somnolence and dangerous interactions with alcohol and other drugs and having failed to improve sexual desire measured with a daily electronic diary. Boehringer sold the rights of flibanserin to Sprout which resubmitted it for FDA approval in 2013 and was rejected yet again. The FDA concluded that only “numerically small treatment differences compared to placebo” were obtained with the drug which “do not clearly outweigh safety concerns.” In 2015, Sprout resubmitted flibanserin to the FDA and the drug was approved. However, the resubmission included no new benefit data! Within 48 h of the FDA approval, flibanserin was sold to Valeant Pharmaceuticals for about billion 1$ in cash 
A coalition of women's groups, even the score, had actively campaigned for the drug's approval, emphasizing that several approved drugs for male sexual dysfunction exist but not so for women. Quite ironically, the campaign was managed by blue engine message and media, a public relations firm, and received funding from Sprout.
Flibanserin is a controversial drug approved for a controversial disorder amid huge controversy. While it may serve as the lamp in the light in the long search for female sexual problems, it has still a long way to go. Women taking this drug must well be educated about the adverse events associated with this drug and the possible interactions. Until further data are available, a cautious use of the drug is warranted.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
|1||Tan HM, Marumo K, Yang DY, Hwang TI, Ong ML. Sex among Asian men and women: The global better sex survey in Asia. Int J Urol 2009;16:507-14.|
|2||Cain VS, Johannes CB, Avis NE, Mohr B, Schocken M, Skurnick J, et al. Sexual functioning and practices in a multi-ethnic study of midlife women: Baseline results from SWAN. J Sex Res 2003;40:266-76.|
|3||Shifren JL, Monz BU, Russo PA, Segreti A, Johannes CB. Sexual problems and distress in United States women: Prevalence and correlates. Obstet Gynecol 2008;112:970-8.|
|4||Dhanuka I, Simon JA. Flibanserin for the treatment of hypoactive sexual desire disorder in premenopausal women. Expert Opin Pharmacother 2015;16:2523-9.|
|5||Lodise NM. Hypoactive sexual desire disorder in women: Treatment options beyond testosterone and approaches to communicating with patients on sexual health. Pharmacotherapy 2013;33:411-21.|
|6||American College of Obstetricians and Gynecologists Committee on Practice Bulletins-Gynecology. ACOG practice bulletin No. 119: Female sexual dysfunction. Obstet Gynecol 2011;117:996-1007.|
|7||American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Text Revision. 4th ed. Washington, DC: American Psychiatric Press; 2000. p. 1-943.|
|8||Biddle AK, West SL, D'Aloisio AA, Wheeler SB, Borisov NN, Thorp J, et al. Hypoactive sexual desire disorder in postmenopausal women: Quality of life and health burden. Value Health 2009;12:763-72.|
|9||Davison SL, Bell RJ, LaChina M, Holden SL, Davis SR. The relationship between self-reported sexual satisfaction and general well-being in women. J Sex Med 2009;6:2690-7.|
|10||D'Aquila P, Monleon S, Borsini F, Brain P, Willner P. Anti-anhedonic actions of the novel serotonergic agent flibanserin, a potential rapidly-acting antidepressant. Eur J Pharmacol 1997;340:121-32.|
|11||Borsini F, Cesana R, Kelly J, Leonard BE, McNamara M, Richards J, et al. BIMT 17: A putative antidepressant with a fast onset of action? Psychopharmacology (Berl) 1997;134:378-86.|
|12||Stahl SM. Mechanism of action of flibanserin, a multifunctional serotonin agonist and antagonist (MSAA), in hypoactive sexual desire disorder. CNS Spectr 2015;20:1-6.|
|13||Bancroft J, Graham CA, Janssen E, Sanders SA. The dual control model: Current status and future directions. J Sex Res 2009;46:121-42.|
|14||Pfaus JG. Pathways of sexual desire. J Sex Med 2009;6:1506-33.|
|15||Stahl SM, Sommer B, Allers KA. Multifunctional pharmacology of flibanserin: Possible mechanism of therapeutic action in hypoactive sexual desire disorder. J Sex Med 2011;8:15-27.|
|16||Woodard TL, Nowak NT, Balon R, Tancer M, Diamond MP. Brain activation patterns in women with acquired hypoactive sexual desire disorder and women with normal sexual function: A cross-sectional pilot study. Fertil Steril 2013;100:1068-76.|
|17||Arnow BA, Millheiser L, Garrett A, Lake Polan M, Glover GH, Hill KR, et al. Women with hypoactive sexual desire disorder compared to normal females: A functional magnetic resonance imaging study. Neuroscience 2009;158:484-502.|
|18||Addyi (flibanserin) [Prescribing Information]. Raleigh, NC: Sprout Pharmaceuticals; August, 2015.|
|19||Robinson K, Cutler JB, Carris NW. First pharmacological therapy for hypoactive sexual desire disorder in premenopausal women: Flibanserin. Ann Pharmacother 2016;50:125-32.|
|20||2016. Available from: https://www.addyi.com/files/Addyi-PI-9-28-15.pdf. [Last accessed on 2016 Mar 31].|
|21||Sathyanarayana Rao TS, Andrade C. Flibanserin: Approval of a controversial drug for a controversial disorder. Indian J Psychiatry 2015;57:221-3.|
|22||Jaspers L, Feys F, Bramer WM, Franco OH, Leusink P, Laan ET, et al. Efficacy and safety of flibanserin for the treatment of hypoactive sexual desire disorder in women: A Systematic review and meta-analysis. JAMA Intern Med 2016;176:453-62.|
|23||Woloshin S, Schwartz LM. US food and drug administration approval of flibanserin: Even the score does not add up. JAMA Intern Med 2016;176:439-42.|