Medication Summary
The goals of pharmacotherapy are to reduce morbidity and prevent complications. Agents employed in the management of paraphilic disorders include antidepressants, antiandrogens, phenothiazines, anxiolytics, long-acting gonadotropin-releasing hormone (GnRH) agonists, and mood stabilizers.
Selective serotonin reuptake inhibitor (SSRI) antidepressants
Class Summary
Serotonergic antidepressants such as SSRIs may be used off-label to decrease sexual obsessions and compulsive/impulsive sexual behavior, and/or induce sexual side effects.
Fluoxetine (Prozac)
Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used to treat impulse-control problems or underlying illness. It selectively inhibits presynaptic serotonin reuptake, with minimal or no effect on the reuptake of norepinephrine or dopamine.
Paroxetine (Paxil, Pexeva)
Paroxetine is a potent selective inhibitor of neuronal serotonin reuptake; it also has a weak effect on norepinephrine and dopamine neuronal reuptake. Paroxetine is not FDA-approved for use in children.
Citalopram (Celexa)
Citalopram appears to have the most benign side effect profile, with fewer sexual adverse effects than other SSRIs. It is not FDA-approved for children.
Sertraline (Zoloft)
Selective inhibitor of neuronal serotonin reuptake; it also has a weak effect on norepinephrine and dopamine neuronal reuptake.
Fluvoxamine
Fluvoxamine is a potent selective inhibitor of neuronal serotonin reuptake. It does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors and thus has fewer adverse effects than TCAs do.
Escitalopram (Lexapro)
This agent is an SSRI and an S-enantiomer of citalopram that is used for the treatment of depression. Escitalopram enhances serotonin activity because of selective reuptake inhibition at the neuronal membrane. Its mechanism of action is thought to be the potentiation of serotonergic activity in the central nervous system (CNS) through the inhibition of CNS neuronal reuptake of serotonin.
Anxiolytics
Class Summary
Non-benzodiazepine anxiolytics may help induce impulse control (off-label).
Buspirone
Buspirone is a unique anxiolytic that differs from benzodiazepines in that it does not exert anticonvulsant or muscle-relaxing effects for generalized anxiety disorder (GAD). It is a serotonin agonist with serotonergic neurotransmission and some dopaminergic effects in the central nervous system (CNS). It has an anxiolytic effect, but may take as long as 2-3 weeks to achieve full efficacy.
Luteinizing Hormone-Releasing Hormone Analog
Class Summary
Long-acting GnRH agonists are used to reduce release of gonadotropin hormones.
Triptorelin (Trelstar, Triptodur)
Triptorelin is a synthetic decapeptide agonist analogue of GnRH, also known as luteinizing hormone (LH)-releasing hormone (LHRH). By reducing LH, follicle-stimulating hormone (FSH), and testosterone, it may lead to reduced sex drive.
Leuprolide (Eligard, Fensolvi, Lupron)
Leuprolide is a synthetic nonapeptide analogue of GnRH. When continuously administered, it acts as a potent inhibitor of gonadotropin secretion.
Mood stabilizers
Class Summary
These agents are used to treat bipolar disorder and may have off-label benefit for aggression and impulse control.
Valproic acid (Depakote)
Valproic acid is indicated for manic episodes associated with bipolar disorder. Valproic acid is the most widely used agent in its class. It is modestly effective and generally well tolerated. It is chemically unrelated to other drugs that treat seizure disorders. Although its mechanism of action is not established, its activity may be related to increased brain levels of gamma-aminobutyric acid (GABA) or enhanced GABA action. It also may potentiate postsynaptic GABA responses, affect potassium channels, or have a direct membrane-stabilizing effect. The recommended plasma concentration is 50-125 µg/mL.
Antimanic agents
Class Summary
These agents are used to treat bipolar disorder and may have off-label benefit for aggression and impulse control.
Lithium (Lithobid)
Lithium is indicated to treat bipolar disorder. The specific mechanism of action is unknown, but the drug alters sodium transport in nerve and muscle cells and influences reuptake of serotonin, norepinephrine, or both at cell membranes.
Progestin
Class Summary
Antiandrogenic agents are given to reduce androgen serum levels.
Medroxyprogesterone (Depo-Provera, Provera)
Medroxyprogesterone may reduce the secretion of LH and FSH from the pituitary by decreasing the amount of GnRH secreted by the hypothalamus. This suppression in turn suppresses sex characteristics in males and may be used to reduce sex drive.
Antipsychotics, Phenothiazine
Class Summary
Phenothiazines may act through their effects in the dopaminergic mesolimbic system. Sometimes used off-label for treatment of aggression.
Fluphenazine
Fluphenazine is a high-potency typical antipsychotic with pharmacology similar to that of haloperidol. Used to treat underlying illness or decrease aggression.
