MEDICATION QUESTIONS

There’s nothing wrong with starting 2.5 mg or 5 mg. 5 mg is the best studied dose but really we don’t have good studies directly comparing 2.5 mg and 5 mg. So there is a bit of guess work here. We need those studies.

I often start finasteride 2.5 mg 3-7 times per week (depending on the patient) and other treatments used at the same time and risk factors the patient might have. If the patient is tolerating it well, I often increase to 2.5 mg daily 7 days per week or to 5 mg daily, 7 days per week. I might increase after 6 months.

But I take everything on a case by case basis. A patient who is using minoxidil and laser and doing really well but needs a bit more help might be prescribed 2.5 mg of finasteride 4 to 5 times per week. A patient who failed most treatments might be put on 5 mg. It just depends on the situation. There is nothing wrong with just starting 5 mg of finasteride from the start but my feeling is that if I can achieve a similar outcome for the patient on a lower dose, I might go for that option.

While 5 mg could be better than 2.5 mg, we don’t have amazing data to really support that. We have data to suggest that 5 mg is better than topical 5% minoxidil or oral minoxidil at 1 mg but we don’t have data comparing 5 mg to 2.5 mg. They likely are pretty similar.

We need these studies!

Some women are not candidates for finasteride at all. Finasteride is contraindicated in women of child bearing age. Finasteride is relatively contraindicated in women with a history of breast cancer although we are seeing a bit of a shift away from that in a few recent studies. We don’t have any evidence whatsoever that finasteride causes breast cancer in women but there have been rare studies linking breast cancer and finasteride in males and so this is how the concern came about. Most studies in males don’t show a risk of breast cancer at all. I’m careful about using finasteride in women with sexual dysfunction, severe poorly controlled depression and those with concerns about weight gain.

Most dermatologists view it as fairly safe to use these agents long term. Provided the doses are 0,5% to 5% we don’t have good evidence these cause cancer.

I am okay is patients use these 1-2 times per week if they need to but generally I hope that they can reduce use over time. These agents can irritate the scalps of some patients so not all can tolerate use.

Coal tar should not be used during pregnancy. I do not use in children under age 12.

For healthy women under 40-45 who do not take any medications and not not have any medical issues, we probably don’t need to routinely monitor potassium. This was certainly done in the past. Studies have shown that women under 40 who use spironolactone are not at risk for hyperkalemia (high potassium). For women over 40-45, we need to measure potassium levels at least once within the first 6-8 weeks. If levels are normal and there are no risk factors for hyperkalemia, it’s probably reasonable to measure every 12-18 months. There are not alot of great evidence based guidelines in women using sprionolactone for AGA to guide us. If potassium is 4.9-5.1, I may repeat again in 6 months, but that’s really a clinical judgement. Women with cardiovascular disease, kidney disease, diabetes and women taking certain medications that affect potassium levels (ie potassium sparing diuretics) may or may not be deemed good candidates for spironolactone in the first place but if they are they will certainly require periodic potassium measurements. It’s not impossible to use spironolactone with various blood pressure drugs (even diuretics) provided one is willing to monitor electrolytes more frequently. For women who have some sort of a risk factor for hyperkalemia, I might measure potassium 6-8 weeks after starting and then again at the 4 months mark and then yearly if everything is stable and health and medications are unchanged.

To read more see LINK

If someone has a true allergic contact dermatitis, then one might consider other treatments. If minoxidil is really felt to be necessarily, then oral minoxidil can be tried. Small studies have suggested that oral minoxidil seems safe in patients with ACD to topical. Studies are small. Read more here

There are several options here.

First, many males use 5 mg and simple cut into 4 pieces to get 1.25 mg. This can be used daily. So it’s possible for the pharmacy to dispense 5 mg pills to the male patient and the male can cut it at home. Extremely large numbers of males are doing this around the world.

But as far as your question goes, yes, broken finasteride pills should not be touched by females who wish to become pregnant within the next 1 month or who are pregnant now. Finasteride has a half life of 6 hours in serum but may stay in tissues longer than this. In general, finasteride is largely out of a person’s system in 2 weeks but we say one month to be sure. In other words, there would be no reason to believe that a woman who accidently touched finasteride would have any negative reproductive effects provided she did not become pregnant sooner than 1 months. But wearing gloves, cleaning surfaces where pills are handled and washing ones hands can largely prevent any problems.

I think in case like this I would get the opinion of the endocrinologist if it’s easy to do. The patient has been on multiple treatments - and has an unusual case of early onset osteoporosis/osteopenia. I prefer shared decision making in a case like this. However, the literature does not really support a strong association and for the most part studies suggest not much of a link. You are correct that studies are conflicting. I’m not of the opinion that current evidence points to much of a risk. But so much has gone into the evaluation and work up of this patient’s osteoporosis, that it’s reasonable to have an endocrinologist weigh in on the subject and give his or her opinion. You can save that documentation in the patient’s chart. Clearly the patient is at risk for fractures. I think in a grey area like this, having a second opinion is reasonable. The worse case scenario is the patient has a fracture and develops significant disability and a medical legal issues ensues. It's one thing for you to say that you did a Pubmed search on everything you can find and another to say that you reached out to the endocrinologist. There have been hours and hours of discussion between the endocrinologist and this patient so I think it's valuable to help make this connection again. I would want to know if the endocrinologist sees any value in repeating a BMD in 2 years or not. It's a great question and the short answer is that evidence does not support a link. The reality is that this is a situation where sufficient complexity exists in a young patient that getting a bone mineralization expert to offer his or her opinion is reasonable.

Thanks for the question.

There are a few options in a situation like this.

a) Reduce the dose and accept the fact that there could be a reversal of the nice effects

b) Continue the dose and bring onboard strategies to fight the swelling.

Reducing the dose will likely cause some hair loss. It could be a lot, or it could be a little. It’s hard to say. That’s just the reality.

The second option is to try to reduce the effects of the oral minoxidil on swelling.

a) A dramatic reduction in salt intake helps a lot. So if patients normally salt their food, it’s worth advising them not to salt quite so much. Sometimes, this helps a lot.

b) The second option is to add an oral diuretic. I’m not a great fan of this plan in males as, generally speaking, I don’t like addressing side effects with more and more drugs. However, for women, spironolactone is a treatment for AGA anyway, and sometimes 25-50 mg helps the swelling and perhaps helps the AGA a bit. If well tolerated, then patients can increase to 50-100 mg. The maximum dose is 200 mg (taken as 100 mg twice daily).

c) Some patients can use diuretic teas as well. I don’t think they do all that much for most people but I have been surprised in some. Examples include Milk Thistle Tea, Green Tea, Peppermint, Nettle and Dandelion Root. They are not without possible side effects, but fortunately, the side effects are low. Practitioners should review side effects before recommending anything.

d) Switching to topical minoxidil. We are in a bit of an oral minoxidil frenzy right now. 1 mg is fairly equivalent to 5 % minoxidil in women. So yes, the patient could improve with a switch to topical. Oral minoxidil is not necessarily better than topical minoxidil. At very low doses of oral minoxidil, it’s fairly equivalent.

I have had patients raise this concern but it seems very rare. I’m not clear if it truly was related but yes, I have had patients. I’m guessing it’s well under 0.5% of users.

Oral minoxidil at higher doses (from the hypertensive era of the use of oral minoxidil) rarely caused blood sugars to increase and rarely caused follicular acneiform issues (pseudofolliculitis barbae). So it’s not impossible.

It’s difficult to prove without a bit of a challenge. If the acne disappears when going off and reappears when going back on, that’s a bit of a suggestion. If there is more acne with 1 mg than 0.5 mg that’s also a suggestion.

Yes, I don’t think it’s impossible. I can’t say whether it is a cause in your patient though.

FFA can itself cause all sorts of acneiform eruptions and the follicular papules in FFA look like acne. FFA is a hormonal condition! Acneiform changes due to FFA need to be strongly considered.

We’ll speak about the Naranjo scale in the future but here’s a nice link. It’s a helpful way of thinking about these issues.

https://www.evidencio.com/models/show/661