Flibanserin for hypoactive sexual desire disorder: place in therapy

Sexuality after breast cancer, how to provide a global and contemporary approach

Patients' sexuality is one of the major and most neglected impact of breast cancer (BC) and its treatment. Even though research is ongoing on the subject, sexuality issues are rarely taken into account and efficiently dealt with in clinical practice. The objective is to review the impact of BC and its treatment on modern women sexuality. In the literature, a heterogeneous level of advancement is notable in the different publishing countries depending on the cultural background; some countries simply do not publish on the matter, others mainly discuss the male partners and practicians experience, and lastly, the most progressive countries have moved up to studying niches of patients such as sexual and gender minorities. A multidisciplinary approach, including pharmacologic and nonpharmacologic management, appears most efficient. There is a need for greater inclusion of partners and for providing a specific training to first-line health care providers. This review provides a general contemporary worldwide overview of the state of the art in sexuality issues in BC patients and survivors.

Spanlastics as a Potential Platform for Enhancing the Brain Delivery of Flibanserin: In Vitro Response-Surface Optimization and In Vivo Pharmacokinetics Assessment

Flibanserin was licensed by the United States Food and Drug Administration (FDA) as an oral non-hormonal therapy for pre-menopausal women with inhibited sexual desire disorder. However, it suffers from susceptibility to first-pass metabolism in the liver, low aqueous solubility, and degradation in the acidic stomach environment. Such hurdles result in a limited oral bioavailability of 33%. Thus, the aim of the study was to utilize the principles of nanotechnology and the benefits of an intranasal route of administration to develop a formulation that could bypass these drawbacks. A response-surface randomized D-optimal strategy was used for the formulation of flibanserin spanlastics (SPLs) with reduced size and increased absolute zeta potential. Two numerical factors were studied, namely the Span 60: edge activator ratio (w/w) and sonication time (min), in addition to one categorical factor that deals with the type of edge activator. Particle size (nm) and zeta potential (mV) were studied as responses. A mathematical optimization method was implemented for predicting the optimized levels of the variables. The optimized formulation was prepared using a Span: sodium deoxycholate ratio of 8:2 w/w; a sonication time of 5 min showed particle sizes of 129.70 nm and a zeta potential of -33.17 mV. Further in vivo assessment following intranasal administration in rats showed boosted plasma and brain levels, with 2.11- and 2.23-fold increases (respectively) compared to raw FLB. The aforementioned results imply that the proposed spanlastics could be regarded as efficient drug carriers for the trans-nasal delivery of drugs to the brain.

Clitoral Therapy Device in Alleviating Sexual Dysfunction After Female Genital Mutilation: a randomized controlled trial. (Preprint)

BACKGROUND

Female genital mutilation is considered a crime but is still practiced today in Africa and the Middle East, despite all the laws that make this procedure illegal due to the long-term physical and psychological harm it causes to women. Millions of girls and women living today have undergone genital mutilation, which involves removing the external female genitalia either partially or totally, based on the belief that it restricts feminine sexuality, thereby "saving" a girl for marriage. For girls and women, the surgery offers no health advantages. Girls' right to control critical decisions regarding their sexual and reproductive health is violated because genital mutilation is frequently done against their will and frequently without their consent, leading to lifelong psychic trauma in addition to sexual dysfunction and lack of satisfaction due to distortion of the genitalia that threatens marital stability.

OBJECTIVE

To determine the effect of a clitoral therapy device on improving sexual domains in women suffering from sexual dysfunction after female genital mutilation.

METHODS

This study examined 80 married women aged from 20 to 45 years who were referred from the gynecology outpatient clinic of the Faculty of Medicine, Suez University, for sexual dysfunction resulting from female genital mutilation. The women were divided into 2 equal groups: the study group received a clitoral therapy device and traditional psychosexual education and were closely followed for 3 months, while the control group received only traditional psychosexual education for 3 months. The Arabic version of the Female Sexual Function Index (FSFI) questionnaire was used to assess sexual outcomes pre- and posttreatment in the 2 groups.

RESULTS

Our findings revealed a significant increase in the 6 domains of the FSFI pretreatment in both groups compared to posttreatment (P>.001), except the orgasm domain in the control group, which showed only a nonsignificant increase (P=.16).

CONCLUSIONS

Clitoral therapy devices may be an effective, safe, noninvasive rehabilitation method for sexual dysfunction following female genital mutilation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05039775; https://clinicaltrials.gov/ct2/show/NCT05039775.

Cognitive-behavioral group therapy for women with hypoactive sexual desire: A pilot randomized study

BACKGROUND

Hypoactive Sexual Desire Disorder (HSDD) is a very prevalent sexual problem, with limited options for treatment. Given that psychological factors are major contributors to the disorder, a therapy such as Cognitive-Behavioral Therapy (CBT) may be useful to treat HSDD.

OBJECTIVE

To evaluate the effects of group CBT on women with HSDD.

METHOD

Clinical trial randomized study with 106 women diagnosed with HSDD, who were divided as follows: Group 1 (n = 53) underwent group CBT for 8-weeks, and Group 2 (n = 53), were put on a waiting list and used as a control group. Sexual function was assessed by the Female Sexual Quotient (FSQQ) at the initial interview and after 6-months. Mann Whitney test was used for group comparison.

MAIN OUTCOME MEASURES

demographics, education, sexual history, FSQQ and its domains for sexual function assessment.

RESULTS

Both groups had similar characteristics regarding sexual response, self-image, and relationship with a partner at the initial interview. Women undergoing therapy showed significant improvement in sexual function when compared with the control group. The overall FSQQ result showed an average growth of 18.08 points (95% CI 12.87‒23.28) for the therapy group against a decrease of 0.83 points (95% CI 3.43‒1.77) for controls (p < 0.001). The five domains of the questionnaire also exhibited significant improvement in the therapy group: desire and interest (p = 0.003), foreplay (p = 0.003), excitation and tuning (p < 0.001), comfort (p < 0.001), and orgasm and satisfaction (p < 0.001).

CONCLUSION

Group CBT was shown to be an effective tool for treating HSDD.

A systematic UHPLC-Q-TOF-MS/MS based analytical approach for characterization of flibanserin metabolites and establishment of biotransformation pathway

A systematic metabolite profiling approach has paramount importance in detecting, identifying, and characterizing drug metabolites. Till date, there is no report published on the comprehensive metabolic fate of flibanserin (FLB). In this study, the structure of entire potential metabolites of FLB has been elucidated by execution of in silico tool and high resolution mass spectrometry based metabolite profiling strategy employing data-dependent and data-independent approaches. In vitro metabolism profile was investigated after incubating FLB with liver microsomes (rat and human) and S9 fractions in presence of their respective co-factors. In vivo metabolites were identified from rat plasma, urine, feces, and brain tissue samples. An efficient extraction technique was developed that made it possible to identify the metabolites generated even in extremely low concentrations. Extraction was carried out by precipitating protein and thereafter solid-phase extraction to enrich their concentration in the sample before analysis. Fourteen new metabolites have been identified and characterized. Most of the metabolites of FLB were generated due to hydrolysis and oxidation followed by glucuronide, sulfate, and methyl conjugation. Additionally, a spiking study was employed to confirm the presence of N-oxide metabolite in human liver S9 fraction and rat urine samples. Moreover, we have established the probable biotransformation pathway of FLB and successfully analyzed the toxicity potential of the metabolites using Pro Tox-II software.

Management of hypoactive sexual desire disorder in transgender women: a guide for clinicians

Hypoactive sexual desire disorder (HSDD) represents a common condition among transgender women. However, to date no specific guidelines for the management of HSDD in transgender persons are available. The aim of the present narrative Review is to evaluate evidence-based treatment for HSDD and to suggest treatment options for HSDD in transgender women. Clinically relevant publications on the management of HSDD (from 1985 to 2020) were searched in PubMed and Medline databases, using the following terms: "sexual desire", "sexual health", "HSDD", "transgender", "gender-affirming treatment", "sexual therapy", "testosterone treatment", "Central nervous system-active medications", and variants. Since sexual desire could be affected by several factors, a comprehensive assessment of HSDD- exploring biological, psychological, and social domains- is recommended, in order to identify possible predisposing, precipitating and maintaining factors. Among treatment options, transgender women may benefit of different sex therapy strategies and/or central nervous system-active medications-such as flibanserin, bremelanotide, bupropion and buspirone-and transdermal testosterone, bearing in mind that this option could be poorly accepted by patients due to the risk of virilizing effects. The lack of data regarding the efficacy of HSDD treatment options in transgender women emphasize the need for literature to focus more on this topic in the future.

Intranasal Niosomal In Situ Gel as a Promising Approach for Enhancing Flibanserin Bioavailability and Brain Delivery: In Vitro Optimization and Ex Vivo/In Vivo Evaluation

Flibanserin (FLB) is a multifunctional serotonergic agent that was recently approved by the FDA for the oral treatment of premenopausal women with hypoactive sexual desire disorder. FLB is a centrally acting drug that has a low oral bioavailability of 33% owing to its exposure to the hepatic first-pass effect, as well as its pH-dependent solubility, which could be an obstacle hindering the drug dissolution and absorption via mucosal barriers. Thus, this work aimed at overcoming the aforementioned drawbacks and promoting the nose-to-brain delivery of FLB via the formulation of an intra-nasal in situ niosomal gel. The Box-Behnken design was employed to study the impact of Span® 85 concentration (X1), hydration time (X2), and pH of the hydrating buffer (X3) on the vesicle size and drug entrapment. The optimized formulation exhibited a spherical shape with a vesicular size of 46.35 nm and entrapment efficiency of 92.48%. The optimized FLB niosomes integrated into gellan gum-based in situ gel exhibited enhanced ex vivo permeation and improved plasma and brain concentrations after nasal administration in rats compared to raw FLB. These findings highlight the capability of the proposed intra-nasal FLB niosomal in situ gel to boost the drug bioavailability and to promote its direct delivery to the brain.

Mass Spectrometry-Based Rapid Quantitative Bioanalysis of Flibanserin: Pharmacokinetic and Brain Tissue Distribution Study in Female Rats

Flibanserin (FLB) is the first United States Food and Drug Administration (USFDA) approved serotonin modulator recently marketed to treat acquired generalized women hypoactive sexual desire disorder. The scope of this study was to develop and validate a sensitive, selective and reliable ultra-performance liquid chromatography–mass spectroscopy/mass spectroscopy-based quantification method for FLB in rat plasma as well as brain tissue samples. The method includes a simple liquid–liquid sample extraction procedure. FLB was subjected to chromatographic separation using a poroshell C18 column with the mobile phase comprising a mixture of acetonitrile (ACN), 10 mM ammonium acetate and acetic acid (90:10:0.1, v/v/v). Detection and quantification of FLB after positive electrospray ionization were carried out in selective ion monitoring mode. The fragment ions (m/z) of FLB (parent ion: 391.1741) and IS (parent ion: 448.1550) were monitored at 161.0704 and 285.0917, respectively. A linear response of FLB was observed over a concentration range of 2.5–600 ng/mL in plasma and 5–500 ng/mL in brain tissue homogenate. The intra- and inter-day precision and accuracy of the method met the acceptable limits specified in the USFDA bioanalytical method validation guideline. The analyte was found to be stable in benchtop, freeze-thaw, auto-injector and dry extract stability studies. The developed method was used to quantitate FLB in the plasma and brain tissue of a single-dose oral pharmacokinetic and brain tissue distribution study in female rats. Maximum FLB concentration in plasma and brain was achieved within an hour; however, the total amount of the drug that reached the brain was significantly less than in plasma. Rate of elimination of FLB from brain was also faster resulting in a lesser half-life in brain compared to the plasma.

A validated UPLC–MS/MS method for flibanserin in plasma and its pharmacokinetic interaction with bosentan in rats

Aim: The purpose of this study was development, validation and application of ultra-performance liquid chromatography (UPLC)–ESI–MS/MS method for quantitation of flibanserin in plasma samples.Method & results: After extraction of analyte from plasma by diethyl ether, separation was performed on UPLC C18 column using mobile phase composition of 10 mM ammonium formate-acetonitrile (30:70, v/v) by isocratic elution of 0.3 ml/min. The multiple reaction monitoring transitions of m/z 391.13 → 161.04 and 384.20 → 253.06 were used for detection of analyte and internal standard (quetiapine), respectively. The calibration curves were linear (r ≥ 0.995) between 0.22 and 555 ng/ml concentration and all validation results were within the acceptable range as per US FDA guidelines. Conclusion: The assay procedure was fully validated and successfully applied in pharmacokinetic interaction study of flibanserin with bosentan in rats.

Suicidal Ideation and Suicidal Behavior as Rare Adverse Events of Antidepressant Medication: Current Report from the AMSP Multicenter Drug Safety Surveillance Project

BACKGROUND

Suicidal ideations, suicide attempts, and fatal suicides are rare adverse drug reactions to antidepressant drugs, but they essentially are clinically relevant. Drawing on a larger dataset of the European drug surveillance program, the present naturalistic study updates a previous contribution (Stübner et al., 2010).

METHODS

First an analysis of the comprehensive data collected in 81 psychiatric hospitals from 1993 to 2014 by the European drug surveillance program Arzneimittelsicherheit in der Psychiatrie was made. All documented single cases of suicidal ideations or behavior judged as adverse drug reactions to antidepressant drugs were carefully assessed as to their clinical features and drug prescriptions.

RESULTS

Among 219,635 adult hospitalized patients taking antidepressant drugs under surveillance, 83 cases of suicidal adverse drug reactions occurred (0.04%): 44 cases of suicidal ideation, 34 attempted suicides, and 5 committed suicides were documented. Restlessness was present in 42 patients, ego-dystonic intrusive suicidal thoughts or urges in 39 patients, impulsiveness in 22 patients, and psychosis in 7 patients. Almost all adverse drug reactions occurred shortly after beginning antidepressant drug medication or increasing the dosage. Selective serotonin reuptake inhibitors caused a higher incidence of suicidal ideation and suicidal behavior as adverse drug reactions than noradrenergic and specific serotonergic antidepressants or tricyclic antidepressants, as did monotherapy consisting of one antidepressant drug, compared to combination treatments.

CONCLUSIONS

The study supports the view that antidepressant drug-triggered suicidal ideation and suicidal behavior (primarily with selective serotonin reuptake inhibitors) are rare. Special clinical features (restlessness, ego-dystonic thoughts or urges, impulsiveness) may be considered as possible warning signs. A combination therapy might be preferable to antidepressant drug monotherapy when beginning treatment.

Ignorance Is Not Bliss: If We Don't Understand Hypoactive Sexual Desire Disorder, How Can Flibanserin Treat It? Commentary

BACKGROUND

Female sexual dysfunction (FSD) affects as many as 1 in every 3 women, with a significant portion of these with hypoactive sexual desire disorder (HSDD). These figures alone present significant psychological and pharmacologic challenges. Partly in response to this situation, in 2015 the US Food and Drug Administration approved flibanserin for the treatment of HSDD. This approval has drawn criticism on the grounds of efficacy and necessity.

AIM

To better inform potential consumers about FSD, flibanserin and other interventions for the treatment of HSDD, the importance of understanding the mechanism of FSD, and the efficacy of flibanserin and to review existing relevant knowledge.

METHODS

A literature review of extant clinic studies and theoretical discussion articles was performed.

OUTCOMES

Efficacy of flibanserin for addressing symptoms associated with HSDD in premenopausal women.

RESULTS

Extant literature and empirical evidence suggest that the efficacy of flibanserin for the treatment of HSDD in premenopausal women is at least questionable.

CLINICAL TRANSLATION

Clinicians considering the prescription of flibanserin would be well advised to appreciate some of the controversies concerning the efficacy of the drug.

STRENGTHS AND LIMITATIONS

The prohibitive usage guidelines, tenuous risk-benefit profile, and considerable cost of use of flibanserin are each worthy of consideration. Flibanserin thus far has been trialed in only a narrow patient range: premenopausal women in long-term relationships with acquired or generalized HSDD.

CONCLUSIONS

Although we acknowledge that the discovery and use of flibanserin constitute a compelling narrative, we conclude by questioning the specific efficacy and necessity of flibanserin in providing a treatment for HSDD in women. Anderson R, Moffatt CE. Ignorance Is Not Bliss: If We Don't Understand Hypoactive Sexual Desire Disorder, How Can Flibanserin Treat It?

COMMENTARY

J Sex Med 2018;15:273-283.