Finasteride for androgenetic alopecia is not associated with sexual dysfunction: a survey-based, single-centre, controlled study

Multidimensional assessment of adverse events of finasteride：a real-world pharmacovigilance analysis based on FDA Adverse Event Reporting System (FAERS) from 2004 to April 2024

BACKGROUND

Finasteride is commonly utilized in clinical practice for treating androgenetic alopecia, but real-world data regarding the long-term safety of its 0adverse events(AEs) remains incomplete, necessitating ongoing supplementation. This study aims to evaluate the AEs associated with finasteride use, based on data from the US Food and Drug Administration Adverse Event Reporting System (FAERS), to contribute to its safety assessment.

METHODS

We reviewed AE reports associated with finasteride from the US Food and Drug Administration Adverse Event Reporting System database, covering the period from the first quarter of 2004 to the first quarter of 2024. We assessed the safety of finasteride medication and AEs using four proportional disproportionality analyses: reported odds ratio (ROR), proportionate reporting ratio (PRR), Bayesian Confidence Propagation Neural Network (BCPN), and Multi-Item Gamma Poisson Shrinkage (MGPS). These methods were used to evaluate whether there is a significant association between finasteride drug use and AEs. To investigate potential safety issues related to drug use, we further analyzed the similarities and differences in the onset time and AEs by sex, as well as the similarities and differences in AEs by age.

RESULTS

A total of 11,557 AE reports in which finasteride was the primary suspected drug were analysed. The majority of patients were male (86.04%) and a significant proportion were young adults aged 18-45 years (27.22%). A total of 73 different AEs were categorised into 7 system organ classes (SOCs), with common AEs including erectile dysfunction and sexual dysfunction. In addition, we identified previously unlisted AEs, including Peyronie's disease and post-5α reductase inhibitor syndrome. Of the reported AEs, 102 occurred in men and 7 in women, with depression and anxiety being significant AEs observed in both sexes. When analysed by age group, there were 17 AEs in patients aged ≤ 18 years, 157 in patients aged 18-65 years and 133 in patients aged ≥ 65 years. Common AEs in all age groups included erectile dysfunction, decreased libido, depression, suicidal ideation, psychotic disturbances and attention disorders. The median time to onset of all AEs was 61 days, with the majority occurring within the first month of treatment. Notably, a significant number of AEs persisted beyond one year of treatment.

CONCLUSION

The results of our study uncovered both known and novel AEs associated with finasteride medication. Some of these AEs were identical to the specification, and some of them signaled AEs that were not demonstrated in the specification. In addition, some AEs showed variations based on sex and age in our study. Consequently, our findings offer valuable insights for future research on the safety of finasteride medication and are anticipated to enhance its safe use in clinical practice.

Maternal androgen excess significantly impairs sexual behavior in male and female mouse offspring: Perspective for a biological origin of sexual dysfunction in PCOS

INTRODUCTION

Polycystic ovary syndrome (PCOS) is the most common infertility disorder worldwide, typically characterised by high circulating androgen levels, oligo- or anovulation, and polycystic ovarian morphology. Sexual dysfunction, including decreased sexual desire and increased sexual dissatisfaction, is also reported by women with PCOS. The origins of these sexual difficulties remain largely unidentified. To investigate potential biological origins of sexual dysfunction in PCOS patients, we asked whether the well-characterized, prenatally androgenized (PNA) mouse model of PCOS exhibits modified sex behaviours and whether central brain circuits associated with female sex behaviour are differentially regulated. As a male equivalent of PCOS is reported in the brothers of women with PCOS, we also investigated the impact of maternal androgen excess on the sex behaviour of male siblings.

METHODS

Adult male and female offspring of dams exposed to dihydrotestosterone (PNAM/PNAF) or an oil vehicle (VEH) from gestational days 16 to 18 were tested for a suite of sex-specific behaviours.

RESULTS

PNAM showed a reduction in their mounting capabilities, however, most of PNAM where able to reach ejaculation by the end of the test similar to the VEH control males. In contrast, PNAF exhibited a significant impairment in the female-typical sexual behaviour, lordosis. Interestingly, while neuronal activation was largely similar between PNAF and VEH females, impaired lordosis behaviour in PNAF was unexpectedly associated with decreased neuronal activation in the dorsomedial hypothalamic nucleus (DMH).

CONCLUSION

Taken together, these data link prenatal androgen exposure that drives a PCOS-like phenotype with altered sexual behaviours in both sexes.

Pharmacological Management of Pattern Hair Loss

Pattern hair loss (PHL) is a condition that worsens with time and the only way it can be slowed down is with pharmacological intervention. Pharmacological treatments for PHL, from an evidenced-based perspective with respect to safety and efficacy, are limited to only two drugs, minoxidil and finasteride. However, there are a host of drugs being used, off-label with limited evidence. This article attempts to review the literature on this topic, and the authors add to this, with their experience of over two decades on incorporating pharmacologic treatments along with hair transplantation in their management of PHL.

Efficacy and safety of topical finasteride spray solution for male androgenetic alopecia: a phase III, randomized, controlled clinical trial

Background

Oral finasteride is a well‐established treatment for men with androgenetic alopecia (AGA), but long‐term therapy is not always acceptable to patients. A topical finasteride formulation has been developed to minimize systemic exposure by acting specifically on hair follicles.

Objectives

To evaluate the efficacy and safety of topical finasteride compared with placebo, and to analyse systemic exposure and overall benefit compared with oral finasteride.

Methods

This randomized, double‐blind, double dummy, parallel‐group, 24‐week study was conducted in adult male outpatients with AGA at 45 sites in Europe. Efficacy and safety were evaluated. Finasteride, testosterone and dihydrotestosterone (DHT) concentrations were measured.

Results

Of 458 randomized patients, 323 completed the study and 446 were evaluated for safety. Change from baseline in target area hair count (TAHC) at week 24 (primary efficacy endpoint) was significantly greater with topical finasteride than placebo (adjusted mean change 20.2 vs. 6.7 hairs; P < 0.001), and numerically similar between topical and oral finasteride. Statistically significant differences favouring topical finasteride over placebo were observed for change from baseline in TAHC at week 12 and investigator‐assessed change from baseline in patient hair growth/loss at week 24. Incidence and type of adverse events, and cause of discontinuation, did not differ meaningfully between topical finasteride and placebo. No serious adverse events were treatment related. As maximum plasma finasteride concentrations were >100 times lower, and reduction from baseline in mean serum DHT concentration was lower (34.5 vs. 55.6%), with topical vs. oral finasteride, there is less likelihood of systemic adverse reactions of a sexual nature related to a decrease in DHT with topical finasteride.

Conclusion

Topical finasteride significantly improves hair count compared to placebo and is well tolerated. Its effect is similar to that of oral finasteride, but with markedly lower systemic exposure and less impact on serum DHT concentrations.

Finasteride for hair loss: a review

BACKGROUND AND OBJECTIVES

Finasteride 1 mg/day is indicated for androgen-dependent conditions such as male androgenetic alopecia (AGA).

METHODS

The literature is comprehensively summarized on the pharmacodynamics, pharmacokinetics, mechanism of action, and metabolism of finasteride. Pairwise and network meta-analyses were performed to assess the efficacy of finasteride reported in clinical trials. The adverse events profile is described along with the post-marketing reports.

RESULTS AND CONCLUSION

Finasteride 1 mg/day significantly increased total hair count compared to placebo after 24 weeks (mean difference = 12.4 hairs/cm², p < .05), and 48 weeks (mean difference = 16.4 hairs/cm², p < .05). The efficacy of the two doses of finasteride (5 mg/day and 1 mg/day) and topical finasteride (1% solution) were not significantly different. The most commonly reported sexual events include erectile dysfunction and decreased libido. Increasing patient complaints and analysis of the FAERS database led to the inclusion of depression in the FDA label in 2011, as men were found to be at a risk of suicide due to the persistent sexual side effects, commonly termed as post-finasteride syndrome. Finasteride is shown to be reasonably tolerated in both men and women; however, patients need to be educated about the possible short- and long-term side-effects.

Combination Approaches for Combatting Hair Loss

Significant androgenetic hair loss occurs in men older than 50 years, and in women it occurs in many who are perimenopausal, menopausal, and postmenopausal. By age 60 years, it is estimated that 80% of women experience hair loss. Other nonandrogenetic forms of hair loss occur due to various dermatologic disorders as well as systemic disorders. Children may also experience significant hair loss, often due to genetic abnormalities and incidences of trauma. In this article the author discusses a combination approach to hair loss for men, women, and children.

Hair Transplantation: Basic Overview

Modern hair restoration surgery is based on a technique known as follicular unit transplantation in which follicular units (FUs) are the exclusive structures used as hair grafts. In Part 1 of this two-part review, we describe how the techniques employed in hair transplantation have evolved into their present forms. Anatomic concepts of specific relevance for dermatologists are discussed, including the distribution and ex-vivo morphology of scalp FUs. Male androgenetic alopecia and female pattern hair loss are the most common reasons for hair loss consultations with dermatologists and will be the primary focus of this review. However, as not all hair disorders are suitable for transplantation, this review will also describe which scalp conditions are amenable to surgery and which are not. In addition, guidelines are provided to help dermatologists better define good or bad candidates for hair transplantation. Finally, other conditions for which hair transplantation surgery is indicated are reviewed.

Shedding light on therapeutics in alopecia and their relevance to COVID-19

As of July 9, 2020, there were more than 12 million confirmed cases of coronavirus disease 2019 (COVID-19) across the globe, with more than 550,000 deaths. Many European countries, including Belgium, the United Kingdom, Italy, and Spain, have had the highest numbers of fatalities per capita. This indicates the potential for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus to overwhelm even the most advanced health care systems despite extreme societal interventions. Since its emergence, SARS-CoV-2 has disseminated across the globe, affecting the structure of global societies, infrastructure, and economies. Patients with alopecia are a diverse group who, for various indications, are prescribed a number of antimicrobials and antiandrogen treatments in addition to immunomodulatory therapies such as hydroxychloroquine, oral corticosteroids, and a range of broad immunosuppressants. These drugs are being scrutinized for their capacity to potentially affect SARS-CoV-2 outcomes. We examine these treatments and highlight the critical role that patient registries will play in generating real-world evidence to assess their impact on COVID-19 outcomes.

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.

Post-finasteride syndrome: An emerging clinical problem

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 (5α-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.