Ho RS. Ongoing Concerns Regarding Finasteride for the Treatment of Male-Pattern Androgenetic Alopecia. JAMA Dermatol. 2020 Nov 11. doi: 10.1001/jamadermatol.2020.3384. Epub ahead of print. PMID: 33175098. Ongoing Concerns Regarding Finasteride for the Treatment of Male-Pattern Androgenetic Alopecia
Since its approval for the treatment of male-pattern androgenetic alopecia by the United States Food and Drug Administration in 1997, finasteride has continued to be at the center of many controversies regarding its adverse events.
Although sexual adverse events were included in the original label of finasteride, little attention was initially paid to the 2002 elimination of the word “all” in the drug monograph1 regarding sexual adverse events, changing the language from “resolution occurred in all men who discontinued therapy” to “resolution occurred in men who discontinued therapy.”
However, mounting evidence, such as case reports and small surveys, prompted the addition of the adverse reaction “sexual dysfunction that continued after discontinuation of treatment, including erectile dysfunction, libido disorders, ejaculation disorders, and orgasm disorders” in 2012 under the postmarketing experience section of the drug monograph.
Although a definitive causal relationship had yet to be established, the labeling change captured immediate media attention. Shortly thereafter, many pharmacovigilance databases saw an uptick in adverse event reports for finasteride, including controversial adverse events such as suicidality and mental health concerns.
These subsequent reports of suicidality and psychological adverse events, together with the well-publicized sexual adverse events, resulted in the coining of the term “post-finasteride syndrome” and the establishment of the Post-Finasteride Syndrome Foundation in 2012.
Nguyen DD, Marchese M, Cone EB, Paciotti M, Basaria S, Bhojani N, Trinh QD. Investigation of Suicidality and Psychological Adverse Events in Patients Treated With Finasteride. JAMA Dermatol. 2020 Nov 11. doi: 10.1001/jamadermatol.2020.3385. Epub ahead of print. PMID: 33175100. Suicidality and Psychological Adverse Events in Patients Treated With Finasteride
Importance: There is ongoing controversy about the adverse events of finasteride, a drug used in the management of alopecia and benign prostatic hyperplasia (BPH). In 2012, reports started emerging on men who had used finasteride and either attempted or completed suicide.
Objective: To investigate the association of suicidality (ideation, attempt, and completed suicide) and psychological adverse events (depression and anxiety) with finasteride use.
Design, setting, and participants: This pharmacovigilance case-noncase study used disproportionality analysis (case-noncase design) to detect signals of adverse reaction of interest reported with finasteride in VigiBase, the World Health Organization's global database of individual case safety reports. To explore the strength of association, the reporting odds ratio (ROR), a surrogate measure of association used in disproportionality analysis, was used.
Extensive sensitivity analyses included stratifying by indication (BPH and alopecia) and age (≤45 and >45 years); comparing finasteride signals with those of drugs with different mechanisms but used for similar indications (minoxidil for alopecia and tamsulosin hydrochloride for BPH); comparing finasteride with a drug with a similar mechanism of action and adverse event profile (dutasteride); and comparing reports of suicidality before and after 2012. Data were obtained in June 2019 and analyzed from January 25 to February 28, 2020.
Exposures: Reported finasteride use.
Main outcomes and measures: Suicidality and psychological adverse events.
Results: VigiBase contained 356 reports of suicidality and 2926 reports of psychological adverse events (total of 3282 adverse events of interest) in finasteride users (3206 male [98.9%]; 615 of 868 [70.9%] with data available aged 18-44 years). A significant disproportionality signal for suicidality (ROR, 1.63; 95% CI, 1.47-1.81) and psychological adverse events (ROR, 4.33; 95% CI, 4.17-4.49) in finasteride was identified.
In sensitivity analyses, younger patients (ROR, 3.47; 95% CI, 2.90-4.15) and those with alopecia (ROR, 2.06; 95% CI, 1.81-2.34) had significant disproportionality signals for increased suicidality; such signals were not detected in older patients with BPH. Sensitivity analyses also showed that the reports of these adverse events significantly increased after 2012 (ROR, 2.13; 95% CI, 1.91-2.39).
Conclusions and relevance: In this pharmacovigilance case-noncase study, significant RORs of suicidality and psychological adverse events were associated with finasteride use in patients younger than 45 years who used finasteride for alopecia. The sensitivity analyses suggest that these disproportional signals of adverse events may be due to stimulated reporting and/or younger patients being more vulnerable to finasteride's adverse effects.
