Post-finasteride syndrome: An emerging clinical problem

Abstract

The presence of side effects during pharmacological treatment is unfortunately a quite common problem. In this review, we focused our attention on adverse events related to 5 alpha-reductase (5?-R) inhibitors (i.e., finasteride and dutasteride), approved for the treatment of benign prostatic hyperplasia and androgenetic alopecia (AGA).

Although these drugs are generally well tolerated, many reports described adverse effects in men during treatment, such as sexual dysfunction and mood alteration. In addition, it has been also reported that persistent side effects may occur in some AGA patients. This condition, termed post-finasteride syndrome (PFS) is characterized by sexual side effects (i.e., low libido, erectile dysfunction, decreased arousal and difficulty in achieving orgasm), depression, anxiety and cognitive complaints that are still present despite drug withdrawal. Indeed, some national agencies (e.g., Swedish Medical Products Agency, the Medicines and Healthcare Products Regulatory Agency of UK and the U.S. Food and Drug Administration) required to include multiple persistent side effects within the finasteride labels.

As here reported, these observations are mainly based on self-reporting of the symptomatology by the patients and few clinical studies have been performed so far. In addition, molecular mechanisms and/or genetic determinants behind such adverse effects have been poorly explored both in patients and animal models. Therefore, results here discussed indicate that PFS is an emerging clinical problem that needs to be further elucidated.

This article in full can be found here:  https://www.sciencedirect.com/science/article/pii/S235228951930061X?via%3Dihub#bib122https://www.sciencedirect.com/science/article/pii/S235228951930061X?via%3Dihub#bib122

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http://tau.amegroups.com/article/view/39898/html

Original Article

Penile vascular abnormalities in young men with persistent side effects after finasteride use for the treatment of androgenic alopecia

Mohit Khera¹, Jeffrey K. Than², James Anaissie¹, Ali Antar¹, Weitao Song¹, Boriss Losso¹, Alexander Pastuszak³, Taylor Kohn⁴, Jorge Rivera Mirabal¹

¹Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA; ²Baylor College of Medicine, Houston, TX, USA; ³Division of Urology, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA; ⁴The James Buchanan Brady Urological Institute at Johns Hopkins School of Medicine, Baltimore, MD, USA

Contributions: (I) Conception and design: All Authors; (II) Administrative support: All authors; (III) Provision of study materials or patients: M Khera; (I) Collection and assembly of data: All authors; (I) Data analysis and interpretation: All authors; (I) Manuscript writing: All authors; (I) Final approval of manuscript: All authors.

Correspondence to: Mohit Khera, MD. Professor, Scott Department of Urology, Baylor College of Medicine, 7200 Cambridge St, Suite 10B, Houston, Texas 77030, USA. Email: mkhera@bcm.edu.

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Background: The constellation of persistent sexual, neurological, and physical adverse effects in patients who discontinue 5?-reductase inhibitors (5ARIs) has garnered recent concern. The objective of this study was to evaluate potential penile vascular changes and persistent adverse effects of 5ARIs in men treated for androgenic alopecia (AGA).

Methods: This was a prospective case-control study with 25 subjects with a history of 5ARI use for AGA and 28 controls. Patient self-reported questionnaires including the International Index of Erectile Function (IIEF), International Prostate Symptom Score (IPSS), Patient Health Questionnaire-9 (PHQ-9), the Epworth Sleepiness Scale (ESS) and the Androgen Deficiency in the Aging Male (ADAM) were used. Penile duplex Doppler ultrasound (PDDU) results were evaluated in men with a history of 5ARI use.

Results: A significant difference in total IIEF score between the 5ARI (median: 35; IQR: 29–43) and control group (median: 29; IQR: 27–32) (P=0.035) was observed. Seventeen 5ARI subjects (68%) had a vascular abnormality on PDDU. The median (IQR) for total IPSS score for the 5ARI group was 10 [5–16] compared to 3 [2–8] for the controls (P<0.01). The 5ARI group had a higher median total PHQ-9 score than controls [10 (6.5–16) vs. 1 (0–2) (P<0.001)]. Two subjects (8%) committed suicide during or after the study.

Conclusions: While the sexual side effects of 5ARIs are well known, there may be persistent genitourinary, physical, psycho-cognitive, anti-androgenic and penile vascular changes after 5ARI discontinuation. Use of 5ARIs for treatment of AGA may lead to persistent sexual, genitourinary, physical, psycho-cognitive, and anti-androgenic sequelae even after cessation of 5ARI therapy.

Keywords: Finasteride; penile duplex Doppler; major depressive disorder; hypogonadism; erectile dysfunction (ED)

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https://wjmh.org/search.php?where=aview&id=10.5534/wjmh.200012&code=2074WJMH&vmode=FULL

Health Risks Associated with Long-Term Finasteride and Dutasteride Use: It’s Time to Sound the Alarm

Abdulmaged M. Traish

Department of Urology, Boston University School of Medicine, Boston, MA, USA.

Abstract

5?-dihydrotestosterone (5?-DHT) is the most potent natural androgen. 5?-DHT elicits a multitude of physiological actions, in a host of tissues, including prostate, seminal vesicles, hair follicles, skin, kidney, and lacrimal and meibomian glands. However, the physiological role of 5?-DHT in human physiology, remains questionable and, at best, poorly appreciated. Recent emerging literature supports a role for 5?-DHT in the physiological function of liver, pancreatic ?-cell function and survival, ocular function and prevention of dry eye disease and kidney physiological function. Thus, inhibition of 5?-reductases with finasteride or dutasteride to reduce 5?-DHT biosynthesis in the course of treatment of benign prostatic hyperplasia (BPH) or male pattern hair loss, known as androgenetic alopecia (AGA) my induces a novel form of tissue specific androgen deficiency and contributes to a host of pathophysiological conditions, that are yet to be fully recognized. Here, we advance the concept that blockade of 5?-reductases by finasteride or dutasteride in a mechanism-based, irreversible, inhabitation of 5?-DHT biosynthesis results in a novel state of androgen deficiency, independent of circulating testosterone levels. Finasteride and dutasteride are frequently prescribed for long-term treatment of lower urinary tract symptoms in men with BPH and in men with AGA. This treatment may result in development of non-alcoholic fatty liver diseases (NAFLD), insulin resistance (IR), type 2 diabetes (T2DM), dry eye disease, potential kidney dysfunction, among other metabolic dysfunctions. We suggest that long-term use of finasteride and dutasteride may be associated with health risks including NAFLD, IR, T2DM, dry eye disease and potential kidney disease.

I will use hair fibers when I go out, and if I take a quick shower before going to bed, there would still be some fiber that I didn’t get out. I wake up and notice black fibers under my nails which means I’m actively scratching my head during sleep. I am planning on doing my surgery in a few months and I’m worried about scratching while I’m sleeping. What can be done to stop this? Other than tying up my hands I can’t think of anything else

Discipline! Realize that if you scratch your grafts out, you will lose a lot of money and possibly introduce infection. I have seen this just twice in 16000 surgeries.  Both men were told to wear mittens.

Hello Doc hope you are well. Just wanted to get your take on something. I’ve been taking finasteride for about 2 years with decent results , mostly maintenance. However I’ve seen considerable progress microneedling my scalp. I’ve been doing it for a over a year and it is still yielding positive results. I would attribute most of my regrowth to microneedling in fact. Since this is a natural treatment I was wondering what your thoughts were in regards to the possible longevity of this treatment. If I’m happy with where I’m at , could say a microneedling routine once a month maintain these results? Love to get your thoughts on this. Take care.

I know a little bit about the research done when injuries like microneedling induces hair growth. These hairs may need to be ‘kicked’ with another short course of microneedling, possibly every 6 months. We are not clear what will happen to the hair follicle when it goes into telogen (rest) cycle and then must come out of it into Anagen (growth) for the new hair to develop. I believe some ‘kick’ should occur periodically and I am guessing about every 6 months or so. We are learning more as we go forward.

hey dr. wrassman, i know there’s probably no chance you respond, but i wanted to just look for advice.

i’m 19 years old, about to turn 20 in january. my hair has been thinning and i’ve been a diffuse thinner for years, so the thinning is making it slightly worse as time goes on. i want to take finasteride so badly but the side effects scare me. i know they’re present in about 4% of men, but the recent reveal about merck lying about their side effects claim freaked me out as well. would you mind helping me calm down and explaining everything to me?

Most of the guys who take finasteride think that they are just taking their daily vitamins. That is my experience as I take it now and my son’s experience as well. This is completely your decision. If you don’t talk yourself into side effects, then if you get them you can just stop taking it. I don’t believe that PFS ever appeared in a normal person taking finasteride for a short time and then stopping it.

So I went to a GP as I wanted to get a prescription for Finasteride. Of course the doctor had never heard of the drug and apparently he had never had anyone come to him about hair loss. He started reading about the drug online and asked if I had tried minoxidil. I told him that I have been on minoxidil for two weeks but I wanted to use both treatments together. He responded to this by telling me that I should only use one treatment at a time and that I would have to choose which one I wanted to use. I told him I’d choose Finasteride and he wrote me script for it. I’m still considering using the two treatments together as I can’t find anywhere that says there’s something wrong with using these two treatments together. Has anyone else heard of this before and do you think that I should still use Minoxidil and Finasteride together anyways?

Brief History: I’m a 21 year old male, started noticing my hairline receding 2 years ago, it has been receding very slowly ever since but my hair loss has progressed to the point where I need to stop it before it becomes too noticeable. No hair loss on the crown and all my hair is still very thick.

If you have a balding or thinning area already, using minoxidil on it in addition to finastetide is something I often recommend. I like to get a HAIRCHECK test on all of my patients to be able to measure the progression or the reversal of hair loss while you are under treatment.

 I understand thank you once again. I was simply asking if oral min was generally considered safer in the long term then fin?

The answer for the drug finasteride and oral minoxidil is that if you don’t develop complications from the drugs, then they are safe for you. For example, oral minoxidil has a very rare cardiac side effect that is dangerous and must be picked up early (fainting, heart palpitations, allergy).

these are known complication of this drug so should you eliminate taking it because of this potential, even if it is rare? If you get sexual or other side effects from finasteride, then speak with your doctor and see if you should still take it. A few people believe that if you get sexual side effects and you stay on the drug, these side effects will continue (Post Finasteride Syndrome)

The doctor recommended 10 sessions of PRP at $500/session.   I would guess you might purchase a good used car for that $$ amount. So if you were shopping for a car, you would research it, right? Doubt that you will stop your hair loss with PRP and reversing it is another story! Some doctors are just not honorable. I can tell you that I would doubt that you would get much value from this PRP package.