Finasteride [5ARI] Induced/Associated Effects

[Michael Scally MD]

[OA] Sexual Side Effects of 5-Alpha-Reductase Inhibitors Finasteride and Dutasteride

The 5-alpha-reductase inhibitors finasteride and dutasteride are frequently used in the treatment of androgenetic alopecia and benign prostatic hyperplasia.

These drugs are effective at reducing levels of dihydrotestosterone, the primary androgen responsible for the pathogenesis of both these conditions.

However, finasteride and dutasteride have also been shown to produce an increase in the incidence of sexual dysfunction, namely, impotence, decreased libido, and ejaculation disorder.

The purpose of this study is to review the existing medical literature with regard to the sexual side effects of 5-alpha-reductase inhibitor therapy.

This review is an extensive look at the sexual effects of 5-alpha-reductase inhibitors and compares outcomes for finasteride versus dutasteride in addition to comparing sexualside effects for each of the different dosages prescribed of finasteride and dutasteride.

Fertig RM, Gamret AC, Darwin E, Gaudi S. Sexual side effects of 5-alpha-reductase inhibitors finasteride and dutasteride: A comprehensive review. Dermatology online journal 2017;23. Sexual side effects of 5-α-reductase inhibitors finasteride and dutasteride: A comprehensive review

 

[Michael Scally MD]

Mosher LJ, Godar SC, Morissette M, et al. Steroid 5alpha-reductase 2 deficiency leads to reduced dominance-related and impulse-control behaviors. Psychoneuroendocrinology 2018;91:95-104. http://www.psyneuen-journal.com/article/S0306-4530(17)31394-X/abstract

Highlights
· 5α-reductase 2 (5αR2) catalyzes the conversion of testosterone into DHT.
· We found that 5αR2 knockout (KO) mice have reduced dominance-related behaviors.
· These deficits are accompanied by lower novelty-seeking and risk-taking.
· 5αR2 KO mice exhibit reduced D2-like receptor binding in the nucleus accumbens.

The enzyme steroid 5alpha-reductase 2 (5alphaR2) catalyzes the conversion of testosterone into the potent androgen 5alpha-dihydrotestosterone. Previous investigations showed that 5alphaR2 is expressed in key brain areas for emotional and socio-affective reactivity, yet the role of this enzyme in behavioral regulation remains mostly unknown. Here, we profiled the behavioral characteristics of 5alphaR2 heterozygous (HZ) and knockout (KO) mice, as compared with their wild-type (WT) littermates.

While male 5alphaR2 KO mice displayed no overt alterations in motoric, sensory, information-processing and anxiety-related behaviors, they exhibited deficits in neurobehavioral correlates of dominance (including aggression against intruders, mating, and tube dominance) as well as novelty-seeking and risk-taking responses. Furthermore, male 5alphaR2 KO mice exhibited reduced D2-like dopamine receptor binding in the shell of the nucleus accumbens - a well-recognized molecular signature of social dominance.

Collectively, these results suggest that 5alphaR2 is involved in the establishment of social dominance and its behavioral manifestations. Further studies are warranted to understand how the metabolic actions of 5alphaR2 on steroid profile may be implicated in social ranking, impulse control, and the modulation of dopamine receptor expression in the nucleus accumbens.

 

[Old]

Mosher LJ, Godar SC, Morissette M, et al. Steroid 5alpha-reductase 2 deficiency leads to reduced dominance-related and impulse-control behaviors. Psychoneuroendocrinology 2018;91:95-104. http://www.psyneuen-journal.com/article/S0306-4530(17)31394-X/abstract

Highlights
· 5α-reductase 2 (5αR2) catalyzes the conversion of testosterone into DHT.
· We found that 5αR2 knockout (KO) mice have reduced dominance-related behaviors.
· These deficits are accompanied by lower novelty-seeking and risk-taking.
· 5αR2 KO mice exhibit reduced D2-like receptor binding in the nucleus accumbens.

The enzyme steroid 5alpha-reductase 2 (5alphaR2) catalyzes the conversion of testosterone into the potent androgen 5alpha-dihydrotestosterone. Previous investigations showed that 5alphaR2 is expressed in key brain areas for emotional and socio-affective reactivity, yet the role of this enzyme in behavioral regulation remains mostly unknown. Here, we profiled the behavioral characteristics of 5alphaR2 heterozygous (HZ) and knockout (KO) mice, as compared with their wild-type (WT) littermates.

While male 5alphaR2 KO mice displayed no overt alterations in motoric, sensory, information-processing and anxiety-related behaviors, they exhibited deficits in neurobehavioral correlates of dominance (including aggression against intruders, mating, and tube dominance) as well as novelty-seeking and risk-taking responses. Furthermore, male 5alphaR2 KO mice exhibited reduced D2-like dopamine receptor binding in the shell of the nucleus accumbens - a well-recognized molecular signature of social dominance.

Collectively, these results suggest that 5alphaR2 is involved in the establishment of social dominance and its behavioral manifestations. Further studies are warranted to understand how the metabolic actions of 5alphaR2 on steroid profile may be implicated in social ranking, impulse control, and the modulation of dopamine receptor expression in the nucleus accumbens.

Do you have a copy of the complete article? Am particularly interested in CNS effects/functions of DHT ... this article suggesting DHT influences D2 binding. Thanks

 

[Michael Scally MD]

5alpha-Reductase Inhibitors (5ARIs) and Male Reproduction

The 5ARIs, finasteride and dutasteride, are used to treat benign prostate hyperplasia and lower urinary tract symptoms. At much lower doses, 5ARI treatment reduces male hair loss. These drugs inhibit the conversion of testosterone to the more active dihydrotestosterone (DHT).

In men taking these medications, DHT levels are reduced by some 90% while testosterone levels remain relatively stable. Well known for their negative effects on libido and erectile function, 5ARIs also cause ejaculatory dysfunction in some men, having the potential to decrease semen quality.

In fact, some studies of men treated with these drugs have reported lower total sperm count, along with lower sperm motility, although the changes are probably insufficient to reduce fertility in men with normal semen before treatment. There is a population of men with more severely decreased sperm numbers; as low as 10% of pretreatment values.

Fewer studies have looked at the lower doses used for male alopecia, indicating little affect in men with normal semen quality, but a negative effect on sperm numbers in men with oligozoospermia. There have been no studies looking at fertility endpoints for these medications.

Drobnis EZ, Nangia AK. 5alpha-Reductase Inhibitors (5ARIs) and Male Reproduction. Advances in experimental medicine and biology 2017;1034:59-61. 5α-Reductase Inhibitors (5ARIs) and Male Reproduction

 

[Michael Scally MD]

Baas WR, Butcher MJ, Lwin A, et al. A Review of the FAERS Data on 5-Alpha Reductase Inhibitors: Implications for Post-Finasteride Syndrome. Urology 2018. https://www.goldjournal.net/article/S0090-4295(18)30590-9/abstract

OBJECTIVE: To quantify reports made to the Food and Drug Administration Adverse Event Reporting System (FAERS), create a demographic of patient reports, and examine the cluster of symptoms to correlate consistency of post-finasteride syndrome (PFS) complaints. PFS is a provisional diagnosis encompassing a cluster of sexual, physical, and psychological/neurologic symptoms associated with 5-alpha reductase inhibitor (5ARI) use that emerge or continue after discontinuation of medication.

MATERIALS AND METHODS: FAERS dataset of 5ARI's from April 2011 to October 2014 was obtained. Each FAERS report had 16 categories for completion, but not every report was fully completed. Statistical analysis compared variables of interest between the two doses of finasteride (1mg vs 5mg).

RESULTS: From FAERS, 2,048 monotherapy cases were identified: 1581 of finasteride 1mg, 240 of finasteride 5mg, and 226 of unreported doses. Possibly related to labeling changes, from 2011 to 2014, there was a significant increase in adverse events (AEs) reported involving 1mg dosing. Finasteride use was reported with many sexual AEs including diminished libido, erectile dysfunction and ejaculatory complaints. Other common AEs included dermatologic, metabolic and psychological/neurological complaints. There were more AE reports with the 1mg dose than the 5mg dose. One case of dutasteride reported back pain, not generally attributed to PFS.

CONCLUSIONS: FAERS data suggests that finasteride exposure is reported with a diverse collection of symptoms, particularly in younger men on 1 mg dosage compared to older men on 5mg. Many of these complaints fall well out of the realm of previously established AEs from long-term controlled studies.

 

[Michael Scally MD]

Maksym RB, Kajdy A, Rabijewski M. Post-finasteride syndrome - does it really exist? The aging male: the official journal of the International Society for the Study of the Aging Male 2019:1-10. https://www.tandfonline.com/doi/full/10.1080/13685538.2018.1548589

Inhibitors of 5alpha-steroid reductase are drugs used to treat androgen-dependent conditions including prostate diseases and androgenic alopecia. Finasteride was the first on the market and is currently the most widely used inhibitor. Dutasteride was the second inhibitor to be approved and has a similar safety profile.

Common adverse events of treatment consist of sexual disorders and a negative affect balance. It was described that the prolonged use of 5alpha-steroid reductase inhibitors in patients with alopecia can cause persistent side effects called a post-finasteride syndrome (PFS), that is not just a simple coexistence of events, but rather a definite syndrome with an iatrogenic background.

PFS occurs in susceptible individuals even after small doses of the drug and can last for a long time after the discontinuation of treatment. A deterioration in the quality of life in affected individuals does not justify use of the drug.

Wider recognition of PFS symptoms, its incidence, course, prevention, and treatment possibilities will allow the indications for drug use to be reconsidered and treatment to be more personalized. Knowledge about PFS will also help to provide the best treatment for affected individuals and to properly educate patients before obtaining an informed consent for therapy with 5alpha-steroid reductase inhibitors.

 

[Michael Scally MD]

[OA] A Comment on the Post-Finasteride Syndrome

The post-Finasteride syndrome (PFS) has been claimed to occur in men who have taken oral finasteride to treat hair loss or benign prostatic hyperplasia. While the incidence of persistent sexual, mental, and physical side effects despite quitting finasteride is unknown, and the condition is not recognized by the scientific community, individuals who suffer from PFS do present with very distinctive and homogenous symptoms.

The concept has emerged from reports of nondermatologists, neuroendocrinological research, case reports, and uncontrolled studies. These have been scrutinized by hair experts who found that persistent sexual side effects were only documented in low-quality studies with a strong bias selection and a significant nocebo effect. Others totally dispute the credibility of the PFS.

In any case, the PFS is a problem that has to be dealt with. Low-quality studies neither confirm nor refute the condition as a valid nosologic entity. Therefore, it is as inappropriate to dismiss the condition, as it would be to demonize finasteride for the treatment of male pattern hair loss. Whether the PFS represents a nocebo reaction or a real drug adverse event is irrelevant, while the best way to alleviate the emotional distress related to hair loss is to effectively treat the condition causing the problem. It is not sufficient to only discuss the plausibility of the PFS.

There is a need for practical recommendations to include such important issues as patient selection and risk assessment, appropriate patient information, how to react in case of drug-related adverse events, issues of fertility and malignancy, management of the PFS, and alternatives, specifically the use of topical finasteride. It is the aim of this commentary to provide the respective information.

Rezende HD, Dias M, Trueb RM. A Comment on the Post-Finasteride Syndrome. International journal of trichology 2018;10:255-61. A comment on the post-finasteride syndrome Rezende HD, Dias MF, Trueb RM - Int J Trichol

 

[Michael Scally MD]

Haber RS, Gupta AK, Epstein E, Carviel JL, Foley KA. Finasteride for androgenetic alopecia is not associated with sexual dysfunction: A survey-based, single-center, controlled study. Journal of the European Academy of Dermatology and Venereology : JEADV 2019. https://onlinelibrary.wiley.com/doi/abs/10.1111/jdv.15548

BACKGROUND: The occurrence of sexual dysfunction side effects associated with finasteride use in men with androgenetic alopecia (AGA) is thought to be less prevalent than is publicized. There is a need to investigate sexual dysfunction among finasteride users with population-based controls.

OBJECTIVE: To evaluate presence of sexual dysfunction in men using finasteride or not using finasteride.

METHOD: Adult men visiting a dermatologist's office for any reason were asked to complete a survey including a modified version of the Arizona Sexual Experience Scale (ASEX) to assess presence of sexual dysfunction with and without finasteride use.

RESULTS: Data from 762 men aged 18 to 82 was collected; 663 finasteride users and 99 non-finasteride users. There were no significant differences between finasteride users and non-user controls in reporting sexual dysfunction using the ASEX scale. Regression analysis indicated that self-reporting libido loss and reduced sexual performance, not finasteride use, predicts a higher ASEX score.

CONCLUSION: Use of finasteride does not result in sexual dysfunction in men with AGA. This data is consistent with other large survey-based controlled studies.

 

[Michael Scally MD]

Zakhem GA, Goldberg JE, Motosko CC, Cohen BE, Ho RS. Sexual Dysfunction in Men Taking Systemic Dermatologic Medication: A Systematic Review. Journal of the American Academy of Dermatology 2019. https://www.jaad.org/article/S0190-9622(19)30459-1/pdf

BACKGROUND: Prescription medications are among the most common causes of sexual dysfunction, and patients are often hesitant to seek help when experiencing these symptoms.

OBJECTIVE: In this review, we identified the available evidence of sexual side effects in men using systemic dermatologic medications and suggest screening protocols and actions that may improve a patient's symptom where possible.

METHODS: A systematic review was conducted of all articles in the PubMed database published from the time of inception to May 2018 to identify studies evaluating use of systemic dermatologic medications in men with evidence of sexual side effects. Subsequently, a secondary in-depth literature review was performed for each individual medication.

RESULTS: 5497 articles were reviewed in the primary systematic review. A total of 59 articles covering 11 systemic dermatologic medications met inclusion criteria. We identified level 1 evidence for sexual side effects as a primary outcome in patients taking finasteride.

LIMITATIONS: Many included studies were limited by sample size and methodology.

CONCLUSION: The information in this review may serve as a reference of side effects when deciding on a therapeutic agent and a guide to identify patients to screen for sexual dysfunction.

 

[Michael Scally MD]

[OA] Incidence of Type 2 Diabetes Mellitus in Men Receiving Steroid 5α-Reductase Inhibitors

Objective To investigate the incidence of new onset type 2 diabetes mellitus in men receiving steroid 5α-reductase inhibitors (dutasteride or finasteride) for long term treatment of benign prostatic hyperplasia.

Design Population based cohort study.

Setting UK Clinical Practice Research Datalink (CPRD; 2003-14) and Taiwanese National Health Insurance Research Database (NHIRD; 2002-12).Participants Men in the CPRD who received dutasteride (n=8231), finasteride (n=30 774), or tamsulosin (n=16 270) were evaluated.

Propensity score matching (2:1; dutasteride to finasteride or tamsulosin) produced cohorts of 2090, 3445, and 4018, respectively. In the NHIRD, initial numbers were 1251 (dutasteride), 4194 (finasteride), and 86 263 (tamsulosin), reducing to 1251, 2445, and 2502, respectively, after propensity score matching.

Main outcomes measure Incident type 2 diabetes using a Cox proportional hazard model.

Results In the CPRD, 2081 new onset type 2 diabetes events (368 dutasteride, 1207 finasteride, and 506 tamsulosin) were recorded during a mean follow-up time of 5.2 years (SD 3.1 years). The event rate per 10 000 person years was 76.2 (95% confidence interval 68.4 to 84.0) for dutasteride, 76.6 (72.3 to 80.9) for finasteride, and 60.3 (55.1 to 65.5) for tamsulosin.

There was a modest increased risk of type 2 diabetes for dutasteride (adjusted hazard ratio 1.32, 95% confidence interval 1.08 to 1.61) and finasteride (1.26, 1.10 to 1.45) compared with tamsulosin. Results for the NHIRD were consistent with the findings for the CPRD (adjusted hazard ratio 1.34, 95% confidence interval 1.17 to 1.54 for dutasteride, and 1.49, 1.38 to 1.61 for finasteride compared with tamsulosin). Propensity score matched analyses showed similar results.

Conclusions The risk of developing new onset type 2 diabetes appears to be higher in men with benign prostatic hyperplasia exposed to 5α-reductase inhibitors than in men receiving tamsulosin, but did not differ between men receiving dutasteride and those receiving finasteride. Additional monitoring might be required for men starting these drugs, particularly in those with other risk factors for type 2 diabetes.

Wei L, Lai EC-C, Kao-Yang Y-H, Walker BR, MacDonald TM, Andrew R. Incidence of type 2 diabetes mellitus in men receiving steroid 5α-reductase inhibitors: population based cohort study. BMJ (Clinical research ed) 2019;365:l1204. Incidence of type 2 diabetes mellitus in men receiving steroid 5α-reductase inhibitors: population based cohort study

 

[Michael Scally MD]

[OA] Incidence of Type 2 Diabetes Mellitus in Men Receiving Steroid 5α-Reductase Inhibitors

Objective To investigate the incidence of new onset type 2 diabetes mellitus in men receiving steroid 5α-reductase inhibitors (dutasteride or finasteride) for long term treatment of benign prostatic hyperplasia.

Design Population based cohort study.

Setting UK Clinical Practice Research Datalink (CPRD; 2003-14) and Taiwanese National Health Insurance Research Database (NHIRD; 2002-12).Participants Men in the CPRD who received dutasteride (n=8231), finasteride (n=30 774), or tamsulosin (n=16 270) were evaluated.

Propensity score matching (2:1; dutasteride to finasteride or tamsulosin) produced cohorts of 2090, 3445, and 4018, respectively. In the NHIRD, initial numbers were 1251 (dutasteride), 4194 (finasteride), and 86 263 (tamsulosin), reducing to 1251, 2445, and 2502, respectively, after propensity score matching.

Main outcomes measure Incident type 2 diabetes using a Cox proportional hazard model.

Results In the CPRD, 2081 new onset type 2 diabetes events (368 dutasteride, 1207 finasteride, and 506 tamsulosin) were recorded during a mean follow-up time of 5.2 years (SD 3.1 years). The event rate per 10 000 person years was 76.2 (95% confidence interval 68.4 to 84.0) for dutasteride, 76.6 (72.3 to 80.9) for finasteride, and 60.3 (55.1 to 65.5) for tamsulosin.

There was a modest increased risk of type 2 diabetes for dutasteride (adjusted hazard ratio 1.32, 95% confidence interval 1.08 to 1.61) and finasteride (1.26, 1.10 to 1.45) compared with tamsulosin. Results for the NHIRD were consistent with the findings for the CPRD (adjusted hazard ratio 1.34, 95% confidence interval 1.17 to 1.54 for dutasteride, and 1.49, 1.38 to 1.61 for finasteride compared with tamsulosin). Propensity score matched analyses showed similar results.

Conclusions The risk of developing new onset type 2 diabetes appears to be higher in men with benign prostatic hyperplasia exposed to 5α-reductase inhibitors than in men receiving tamsulosin, but did not differ between men receiving dutasteride and those receiving finasteride. Additional monitoring might be required for men starting these drugs, particularly in those with other risk factors for type 2 diabetes.

Wei L, Lai EC-C, Kao-Yang Y-H, Walker BR, MacDonald TM, Andrew R. Incidence of type 2 diabetes mellitus in men receiving steroid 5α-reductase inhibitors: population based cohort study. BMJ (Clinical research ed) 2019;365:l1204. Incidence of type 2 diabetes mellitus in men receiving steroid 5α-reductase inhibitors: population based cohort study

Reducing the risk of type 2 diabetes in men with benign prostatic hyperplasia—old steroids, new tricks
Reducing the risk of type 2 diabetes in men with benign prostatic hyperplasia—old steroids, new tricks - The BMJ

Troublesome symptoms from benign prostatic hypertrophy (BPH) are common. 5α-Reductase inhibitors (5αRI) are increasingly prescribed to alleviate these problems. Unfortunately, like many other treatments, 5αRI medicines have adverse effects that may modify clinicians enthusiasm to prescribe these medicines.

Clinicians aspire to do no harm and alleviating one condition while causing another important morbidity requires a careful evaluation of the benefits and risks. We now have to add increasing the risk of diabetes to the list of adverse effects caused by 5αRIs.

…

 

[Michael Scally MD]

[OA] [5ARi] Infertility and Teratogenicity After Paternal Exposure to Systemic Dermatologic Medications

BACKGROUND: This systematic review assesses effects of paternal exposure to dermatologic medications by using the former US Food and Drug Administration (FDA) pregnancy categories as a benchmark.

OBJECTIVE: To assess whether systemic dermatologic medications can cause infertility and teratogenicity when taken by men.

METHODS: Categories D and X dermatologic medications were identified; a systematic review of the literature and reviews of the FDA Adverse Events Reporting System and prescribing information were performed to identify the effects of these medications on male fertility and teratogenicity. A secondary search was performed to assess for other systemic dermatologic medications causing teratogenicity or infertility following paternal exposure.

RESULTS: A total of 13 medications met the inclusion criteria. Of 1,032 studies identified, 19 were included after a systematic review of the literature. Studies evaluating medication effects with paternal exposure were identified for 10 of the 13 evaluated medications, and evidence of a negative effect was identified for 6 medications.

LIMITATIONS: We did not encounter any studies for 3 medications that met the inclusion criteria. Information submitted to the FDA Adverse Events Reporting System may not reflect the incidence of side effects.

CONCLUSIONS: Many former pregnancy category D and X systemic dermatologic medications also have effects on male fertility. More research and better-quality studies are required in this area, particularly studies assessing potential teratogenicity.

Zakhem GA, Motosko CC, Mu EW, Ho RS. Infertility and teratogenicity after paternal exposure to systemic dermatologic medications: A systematic review. Journal of the American Academy of Dermatology 2019;80:957-69. https://www.jaad.org/article/S0190-9622(18)32641-0/fulltext

 

[Michael Scally MD]

Special Report: Court let Merck hide secrets about baldness drug's risks
Special Report: Court let Merck hide secrets about baldness drug's risks - Reuters

It had started with dark, sulking moods. Then he lost interest in sex. His wife asked him if he was having an affair. “No … Something’s just not right down there,” Kelly said her husband told her. Panic attacks set in.

He suspected the cause might have been Propecia, the popular Merck & Co drug he had been taking to treat hair loss since around the time his problems started. He quit the pills, but still he couldn’t sleep, and he flashed random anger at the children. He started talking about killing himself.

On the morning of March 5, 2013, about 45 minutes before his wife got home, John Pfaff stepped onto the railroad tracks a block away and into the path of a southbound Amtrak train. He was killed on impact.

Kelly Pfaff blames Merck for her husband’s death at age 40. In a lawsuit filed in 2015, she alleges that the pharmaceuticals company for years knew but concealed from the public that Propecia could cause the persistent sexual dysfunction and depression that led to her husband’s suicide about a year after he quit taking the drug.

John Pfaff wasn’t the only man who experienced sexual problems after taking Propecia. His widow’s lawsuit was one of more than 1,100 filed across the United States and consolidated in so-called multidistrict litigation (MDL) in federal court in Brooklyn, New York. They accuse Merck of not adequately warning patients of the drug’s possible side effects and their duration.

Merck has denied the allegations in court filings and declined to comment further on Pfaff’s case. In a statement to Reuters, Merck said it “stands behind the safety and efficacy of Propecia,” noting that the drug has been prescribed safely to millions of men since the late 1990s. While the drug’s label lists erectile dysfunction and other sexual problems as possible side effects among a small percentage of men, the company rejects allegations that Propecia causes those problems to persist after men stop taking it or that it can lead to mental health issues. Merck says the symptoms themselves could be caused by a variety of other factors.

However, confidential documents reviewed by Reuters accuse Merck of exaggerating the drug’s safety record.

Citing internal company communications, these legal briefs filed by plaintiffs’ lawyers allege that in revisions to the drug’s original 1997 label, Merck understated the number of men who experienced sexual symptoms in clinical trials, and how long those symptoms lasted. Other documents show that Merck knew roughly 20 years ago that sales of the drug would suffer if the public became aware of Propecia’s possible long- term effects on men’s sexual health.

 

[Michael Scally MD]

Post-Finasteride Syndrome: An Induced Delusional Disorder with the Potential of a Mass Psychogenic Illness?

Post-finasteride syndrome (PFS) has been claimed to occur in men who have taken oral finasteride to treat either hair loss or benign prostatic hyperplasia, independent of age, dosage, or indication. By definition, the condition is characterized by sexual dysfunction, somatic symptoms, and psychological disorders that persist after cessation of finasteride treatment. As yet, the condition is not recognized by the medical community, although individuals who suffer from PFS present with relatively homogenous symptoms.

The concept of PFS has emerged from reports of non-dermatologists, neuroendocrinological research and reflections, and uncontrolled studies of low quality and with a strong bias selection, while a significant nocebo effect among patients informed about possible side effects of finasteride is recognized. There are no predictive factors for the risk of development of PFS. Nevertheless, it has been suggested that a patient history of preexisting mental health disorder, particularly depression, may put patients at an increased risk.

We report the first case of PFS in a long-standing (over 20 years) dermatotrichological practice with frequent finasteride prescription observed in a 25-year-old male following dutasteride treatment for male androgenetic alopecia. There was circumstantial evidence that PFS may represent a delusional disorder of the somatic type, possibly on a background of a histrionic personality disorder, which would explain the refractoriness of the condition and a high degree of suggestibility.

Trueb RM, Regnier A, Dutra Rezende H, Gavazzoni Dias MFR. Post-Finasteride Syndrome: An Induced Delusional Disorder with the Potential of a Mass Psychogenic Illness? Skin appendage disorders 2019;5:320-6. https://www.karger.com/Article/Abstract/497362

 

[Michael Scally MD]

Finasteride and Suicide: A Postmarketing Case Series

Background: In 2011, depression was added to the product labeling of finasteride in the USA. The US Food and Drug Administration's Adverse Event Reporting System database contains at least 36 death cases for finasteride. The aim of this study is to characterize the clinical histories and symptoms reported by a series of 6 suicide victims who took finasteride for treatment of androgenic alopecia.

Methods: Medical records and autopsy reports were provided by family members of the cases. Relevant information was extracted according to guidelines for submitting adverse event reports.

Results: An important pattern of symptoms was common among all cases who committed suicide in the setting of finasteride use - insomnia and persistent sexual dysfunction after medication discontinuation. Insomnia and fatigue/tiredness were some of the most debilitating symptoms.

Apart from 1 case who had hyperlipidemia, there was no documentation of concomitant medication use with finasteride or any baseline medical or psychiatric diagnoses prior to starting finasteride.

The findings of this postmarketing series may not be generalizable to the population of men who committed suicide in the setting of finasteride use due to small sample size and bias. Associations between medication use and symptoms cannot prove causality.

Conclusion: Men under the age of 40 who use finasteride for alopecia are at risk for suicide if they develop persistent sexual adverse effects and insomnia. Further research is needed to establish whether finasteride has a causal relationship to suicide.

Irwig MS. Finasteride and Suicide: A Postmarketing Case Series [published online ahead of print, 2020 Jan 14]. Dermatology. 2020;1–6. Finasteride and Suicide: A Postmarketing Case Series

 

[Michael Scally MD]

Post-Finasteride Syndrome: A Surmountable Challenge for Clinicians

Post-finasteride syndrome (PFS) is a constellation of serious adverse side effects manifested in clinical symptoms that develop and persist in patients during and/or after discontinuing finasteride treatment in men with pattern hair loss (androgenetic alopecia) or benign prostatic hyperplasia.

These serious adverse side effects include persistent or irreversible sexual, neurological, physical and mental side effects. To date, there are no evidence-based effective treatments for PFS. Although increasing number of men report persistent side effects, the medical community has yet to recognize this syndrome nor are there any specific measures to address this serious and debilitating symptoms.

Here we evaluate the scientific and clinical evidence in the contemporary medical literature to address the very fundamental question: Is PFS a real clinical condition caused by finasteride use or are the reported symptoms only incidentally associated with but not caused by finasteride use?

One key indisputable clinical evidence noted in all reported studies with finasteride and dutasteride was that use of these drugs is associated with development of sexual dysfunction, which may persist in a subset of men, irrespective of age, drug dose or duration of study. Also, increased depression, anxiety and suicidal ideation in a subset of men treated with these drugs were commonly reported in a number of studies. It is important to note that many clinical studies suffer from incomplete or inadequate assessment of adverse events and often limited or inaccurate data reporting regarding harm.

Based on the existing body of evidence in the contemporary clinical literature, the author believes that finasteride and dutasteride induce a constellation of persistent sexual, neurological and physical adverse side effects, in a subset of men. These constellations of symptoms constitute the basis for PFS in individuals predisposed to epigenetic susceptibility. Indeed, delineating the pathophysiological mechanisms underlying PFS will be of paramount importance to the understanding of this syndrome and to development of potential novel therapeutic modalities.

Traish AM. Post-finasteride syndrome: a surmountable challenge for clinicians. Fertil Steril. 2020;113(1):21–50. https://www.fertstert.org/article/S0015-0282(19)32599-3/abstract

 

[Old]

Indeed, delineating the pathophysiological mechanisms underlying PFS will be of paramount importance to the understanding of this syndrome and to development of potential novel therapeutic modalities.

Since these meds reduce Dihydrotestosterone, Dihydroprogesterone, Dihydrocortisol, and others, it would seem that supplying these might be a place to start. This was suggested in post #400 [ Finasteride [5ARI] Induced/Associated Effects] though I do not have a copy of this article, just that abstract.

Testing this treatment is complicated since DHT is generally not available in most countries, including USA. It is also complicated by the complexity of hormone effects, ratios, etc. and the brain's adaptation to changed hormone from taking finasteride. But again, it is a place to start.

 

[Michael Scally MD]

Androgenetic Alopecia: Effects of Oral Finasteride on Hormone Profile, Reproduction and Sexual Function

Purpose: Androgenetic Alopecia (AGA) is a common non-cicatricial alopecia. AGA treatment with finasteride was reported to have sexological side effects and its induced hormonal alterations could damage spermatogenesis. Thus, in patients affected by AGA undergoing oral therapy with Finasteride 1 mg/die, we aimed to evaluate the presence of modification in sperm parameters, hormone profile and sexual function.

Methods: We retrospectively evaluated 55 male subjects aged 18-45 years with AGA who underwent systemic therapy with Finasteride 1 mg/die. Each subject underwent semen and blood hormone analysis, IIEF15 questionnaire administration at baseline (T0) at 6 (T6) and 12 (T12) months after the beginning of therapy and 1 year after treatment discontinuation (TD).

Results: At T6 we detected a statistically significant worsening of total sperm number (232.4 ± 160.3 vs. 133.2 ± 82.0; p = 0.01 vs. T0) and abnormal forms (79.8 ± 6.0 vs. 82.7 ± 5.7; p < 0.05 vs. T0). No difference was found for all sperm parameters at T12 and T24, except for the percentage of abnormal forms (79.8 ± 6.0 vs. 82.6 ± 4.8; p < 0.05 T24 vs. T0). Testosterone levels were increased at T0 vs. T6 (22.1 ± 7.1 vs. 28.0 ± 8.0 ng/mL; p < 0.05). No significant differences of IIEF15 questionnaire were detected across the study.

Conclusions: Finasteride is associated with significant seminological and testosterone alterations, but no sexual dysfunctions were reported during treatment of these andrologically healthy subjects. Although, sperm parameters seem to return comparable to baseline after treatment discontinuation, it is advisable to perform a careful andrological evaluation before treatment.

Pallotti F, Senofonte G, Pelloni M, et al. Androgenetic alopecia: effects of oral finasteride on hormone profile, reproduction and sexual function [published online ahead of print, 2020 Feb 12]. Endocrine. 2020;10.1007/s12020-020-02219-2. Androgenetic alopecia: effects of oral finasteride on hormone profile, reproduction and sexual function

 

[Michael Scally MD]

[OA] Long-term Consequences of Medical Therapy for Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH) is a common disease in men. Although transurethral resection of the prostate (TURP) is the gold standard therapy for treatment of BPH and associated lower urinary tract symptoms (LUTS), many patients choose to avoid surgery and instead choose medical therapy. Until recently, medical therapy for BPH has been thought to be both safe and effective.

However, new studies have shown that some of these medications can have significant neurocognitive, psychiatric, and sexual side effects, including dementia and depression. As most patients taking these medications will continue them for the long term, it is vital for physicians to explain these potential risks to the patient prior to prescribing them for a quality-of-life condition.

Bortnick EM, Simma-Chiang V, Kaplan SA. Long-term Consequences of Medical Therapy for Benign Prostatic Hyperplasia. Rev Urol. 2019;21(4):154–157. Long-term Consequences of Medical Therapy for Benign Prostatic Hyperplasia

 

[Michael Scally MD]

Lack of Association Between 5α-Reductase Inhibitors and Depression

Purpose: Depressed mood and suicidality reported with 5α-reductase inhibitors (5-ARIs; finasteride and dutasteride) during post-marketing surveillance resulted in the addition of depression risk to finasteride labeling. As peer-reviewed studies are limited and have reported mixed findings, we aimed to further evaluate 5-ARI exposure and depression risk using sequence symmetry analysis.

Materials and methods: National Veterans Health Administration administrative data were used to identify 53,848 male patients initiating 5-ARI therapy during fiscal year 2014. Incident depression events were assessed separately using two measures: antidepressant prescription and depression diagnosis. Symmetry ratios (SR) were calculated as the ratio of patients with an incident depression event in the year following 5-ARI initiation to the year preceding initiation. An identical exposure counterfactual analysis was conducted among veterans initiating α-1-adrenergic receptor antagonists (α1-ARAs).

Results: Incident antidepressant prescribing was observed in 2,563 patients following 5-ARI initiation and 3,051 patients preceding 5-ARI initiation (SR: 0.84; 95% CI: 0.80-0.89). Similar findings were observed for incident depression diagnosis (SR: 0.83; 95% CI: 0.79-0.86). Stratification by age group, 5-ARI agent, antidepressant class, prior α1-ARA exposure, and depression diagnosis type failed to demonstrate any positive association between 5-ARI and depression. Nearly identical results were observed in the α1-ARA analysis (SR: 0.87; 95% CI: 0.84-0.90).

Conclusions: Initiation of a 5-ARI was not associated with increased risk of depression. Our findings support the hypothesis that depression is more likely attributable to underlying benign prostatic hyperplasia and associated lower urinary tract symptoms than 5-ARI exposure.

Dyson TE, Cantrell MA, Lund BC. Lack of Association Between 5α-Reductase Inhibitors and Depression [published online ahead of print, 2020 Apr 14]. J Urol. 2020;101097JU0000000000001079. doi:10.1097/JU.0000000000001079 American Urological Association