Pharmacology Watch

Does Finasteride Cause Permanent Sexual Side Effects?

In this issue: Side effects of finasteride; new ruling on pharmaceutical companies paying generic manufacturers; and FDA actions.

Sexual side effects of finasteride

Finasteride — the popular drug used to treat male pattern baldness and symptomatic benign prostatic hypertrophy — may cause long-term sexual dysfunction, according to a new study. Several recent studies have shown that the drug, which is marketed as 1 mg (Propecia) and 5 mg (Proscar), can cause sexual side effects that persist after stopping the drug in as many as 20% of men. In April, the FDA required new labeling for both strengths regarding libido, ejaculation, orgasm disorders, and even infertility that may persist after treatment ends. The new study looked at 54 men, with an average age of 31, who reported ≥ 3 months of sexual side effects after taking the 1 mg strength for male pattern baldness. All men were previously healthy without previous history of sexual dysfunction, medical conditions, psychiatric conditions, or prescription medication use. After 9-16 months of follow-up, 96% of subjects reported persistent sexual side effects (based on the Arizona Sexual Experience Scale). The duration of finasteride use did not correlate with changes in sexual dysfunction scores. The authors urge prescribers of finasteride to warn men of potential adverse effects (J Sex Med published online July 12, 2012).

Pharmaceutical company ruling

Is it legal for pharmaceutical companies to pay generic manufacturers to keep their products off the market? Until now it has been. Brand-name manufacturers have written enormous checks to keep their low-cost generic competitors off the market. That may change, however, after a federal appeals court in Philadelphia ruled that the practice is anticompetitive, a decision that is counter to three previous federal circuit courts rulings. The New York Times cites the example of Bayer Pharmaceuticals which paid generic drug maker Barr Laboratories and other generic houses $400 million to withhold their generic version of ciprofloxacin, their $1 billion a year blockbuster antibiotic. The case could eventually end up at the Supreme Court. At stake is billions of dollars in lost profits for pharmaceutical manufacturers, but an equal amount of savings for Medicare/Medicaid, health plans, and consumers.

FDA actions

The FDA has approved the second new weight-loss medication within a month. The new product combines phentermine along with topiramate in an extended-release product. Phentermine has been marketed since 1959 and was part of the infamous "fen-phen" combination that was popular in the 1990s (fenfluramine was eventually banned due to cardiac valvulopathy in 1997). Topiramate is currently marketed as an anticonvulsant and for migraine prophylaxis as Topamax. The combination was rejected by the FDA in 2010 due to safety concerns, but Vivus Pharmaceuticals submitted additional data to the agency and recently won approval in July. In the process, the company changed the brand name from Qnexa to Qsymia. Similar to the recently approved lorcaserin (Belviq), phentermine/topiramate is approved as an addition to a reduced-calorie diet and exercise for weight management in adults with a BMI of 30 or greater, or with a BMI of 27 or greater with at least one weight-related condition such as hypertension, type 2 diabetes, or dyslipidemia. In two placebo-controlled trials, 3700 obese and overweight patients lost an average of 6.7-8.9% of their body weight, depending on the recommended or higher dose therapy (slightly better results than those seen with lorcaserin). Patients who have not lost at least 3% of their body weight by week 12 should discontinue the drug. Because of continued safety concerns, the drug was approved with a Risk Evaluation and Mitigation Strategy (REMS), which consists of a medication guide, prescriber training, and pharmacy certification. The drug cannot be used during pregnancy or in patients with recent stroke or heart disease, and patients should have their heart rates monitored during therapy. Vivus will market Qsymia immediately, but will be required to conduct 10 postmarketing studies to assess safety.

The FDA has approved aclidinium bromide, a dry powder inhaler for long-term maintenance treatment of bronchospasm associated with chronic obstructive pulmonary disease (COPD). Aclidinium is a long-acting antimuscarinic agent that works primarily on the M3 receptor causing sustained bronchodilation. The approval was based on three studies of nearly 1300 patients with COPD. The drug may cause anticholinergic side effects, including worsening narrowing-angle glaucoma and urinary retention. It should not be used as a rescue inhaler and is not recommended for those 18 years of age or younger. It is dosed twice a day. Aclidinium inhaler is the second anticholinergic inhaler to be approved after tiotropium (Spiriva), which was approved in 2004. Aclidinium will be distributed by Forest Laboratories and will be marketed as Tudorza Pressair.

The FDA has approved mirabegron to treat adults with overactive bladder. The drug is a novel, once-daily beta-3 adrenergic agonist that works by enhancing storage function and relaxing the urinary bladder, a unique effect and distinct from currently marketed antimuscarinics that inhibit bladder contraction. The once-a-day medication will be available in 25 mg pills. The dose can be increased to 50 mg after 2 months if needed. The approval was based on three placebo-controlled trials that showed statistically significant improvement in incontinence episodes and number of urinations per 24 hours. The most common adverse effects were hypertension, nasopharyngitis, urinary tract infection, and headache. Mirabegron will be marketed by Astellas Pharma as Myrbetriq.

The FDA has approved a new colon cleansing agent for colonoscopy prep. The new prep is sodium picosulfate, magnesium oxide, and citric acid in powder form that is dissolved in water and taken in two doses the night before and the morning of the procedure. It may also be taken the afternoon and the evening before the procedure (Day-Before regimen). The safety and efficacy of the new agent was studied in two studies of about 1200 patients undergoing colonoscopy in which standard PEG plus electrolytes was used as a comparator, and the new prep was found to be at least as effective as the standard prep. Ferring Pharmaceuticals will market the new two-dose prep as Prepopik.

The FDA has approved icosapent ethyl, a new fish oil preparation for the treatment of hypertriglyceridemia. It is approved as an adjunct to diet to treat patients with triglyceride levels greater than 500 mg/dL. The drug contains ultra purified ethyl EPA, an omega-3 fatty acid. The new product follows GlaxoSmithKline's Lovaza, another fish oil that is currently marketed for the same indication and generates more than $1 billion in annual sales. The new product is manufactured by Amarin Corporation and will be marketed as Vascepa. Fish oils are effective at lowering triglycerides but evidence is lacking that they are effective for secondary prevention of cardiovascular disease (Arch Intern Med 2012;172:686-694).

An FDA advisory committee has recommended an new indication for Genentech's ranibizumab (Lucentis) for the treatment of diabetic macular edema, an indication for which there is currently no approved therapy. The drug is approved to treat neovascular age-related macular degeneration and macular edema following retinal vein occlusion. Diabetic macular edema is commonly treated with laser therapy, a procedure that has the potential side effect of some vision loss. The FDA generally follows its advisory committee's recommendations and should make a final recommendation later this year.

This supplement was written by William T. Elliott, MD, FACP, Chair, Formulary Committee, Kaiser Permanente, California Division; Assistant Clinical Professor of Medicine, University of California-San Francisco. In order to reveal any potential bias in this publication, we disclose that Dr. Elliott reports no consultant, stockholder, speaker's bureau, research, or other financial relationships with companies having ties to this field of study. Questions and comments, call: (404) 262-5404. E-mail: