If you look at the article … the urologists think this is a pretty good model for humans. Anyway, if there is a reason to be on ezetimibe, potentially, it might also stop the prostate from being hypertrophied.
Might be a good thing to include in the lipid management for men as they get 45+ years old … note to self.
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Would be interesting to know if ezetimibe provided a similar protection from prostate cancer. If yes, that would be a potent combination to avoid it altogether.
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The thought by this group was probably so on the cancer. They had a follow up article - including pictures of the prostate cells treated with ezetimibe (Zetia) vs. Finasteride in Figure 1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4051281/
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Thank you for follow-up, @DrFraser
Although we were not the first to use this hamster strain in preclinical experiments on BPH, the last published studies using this model in this context were reported in the early 1980s106. Our results suggest that ezetimibe might be effective as an alternative to standard medical BPH therapy and, further, that dysregulation of cholesterol metabolism may be an important, and neglected, component of disease etiology113. These results also strongly suggest that the original findings described above with polyene macrolides, published over 30 years ago, were likely correct and that reducing intestinal cholesterol absorption is a viable approach to controlling LUTS in men. Our preclinical data provide support for prospective studies on ezetimibe in men as a novel approach to treating BPH.
Interesting findings/hypotheses. I am still a bit concerned about the possible side effects of finasteride. Therefore, it is good to know that there is some likelihood that a medication with a “low-risk profile”, such as ezetimibe, could have this beneficial secondary effect 
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I have been taking ezetimibe for 1.5 years with no benefit to BPH so far. It can’t be a huge effect. Or “everybody is different”… again. (Or a man is not a hampster). I’ll keep taking ezetimibe for the apoB benefits and hope for more.
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I guess the issue is … for a condition that is generally progressive … if just staying the same, that is a win … if getting worse despite being on ezetimibe … then I’d agree would be a fail.
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Ezetimibe may be a good secondary treatment when combined with alpha blockers and 5ar inhibitors.
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What about start it earlier as part of lipid treatment before there is disease and hope nothing becomes symptomatic. I have older men come in several times per month in urinary retention from their prostates - having to leave with a catheter in place. I’d rather avoid that situation myself … and a preventive drug (which this might be) that has another reason I could be on it … might not be a bad choice.
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I’d not go with finasteride unless there was evidence of some BPH … but then I’d be favoring Dutasteride. I appreciate many feel that PFS is garbage … I’ve also had some reasoned comments from those seeing modest number of men who their assessment is that finasteride was the cause. Given that there is another option with similar efficacy, I’d go with that if there was a need. But as a preventive … ezetimibe seems like a nice dual use medication, if I was dealing with someone with hyperlipidemia … where I could escalate the statin or keep the statin at lower dose and add ezetimibe … might go with the latter.
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AnUser
#31
So how would you possibly prevent hair loss?
I looked up PFS anecdotes, like this one randomly.
Sounds to me he had a manic episode around the same time starting/stopping finasteride. Later in the video he said he went to the doctor who wanted to prescribe anti-psychotics but he wouldn’t take them. Basically sounds to me this PFS thing is very harmful if it makes people not take their medications. The host say it’s androgens and the guest says “you can’t do anything to fix it”, etc, etc.
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As men age, ED rates automatically go up with or without finasteride. Without a placebo-controlled study, it’s impossible to figure out whether finasteride was the cause. Mechanistically it doesn’t make sense as finasteride leaves the tissue within weeks.
It’s also interesting that you would rather prescribe dutasteride over finasteride as dutasteride blocks both types of 5ar, unlike finasteride which only blocks the type 2. This indicates that the issue your patients have is not primarily the 5ar inhibition but rather how villified finasteride is on the internet.
As for ezetimibe, we need further human clinical trials showing that it does decrease BPH rates if given early enough as clearly it doesn’t help with existing issues, unlike finasteride and alpha blockers.
@AnUser If you check out reddit, you will find many people who got similar issues from even placebo supplements. PFS/PSSD/Post-Accutane and every other term that hypochondric people come up with. Doctors should screen patients for anxiety and gullibility before prescribing drugs to them as otherwise they will fall for the nocebo effect.
Well same answer … dutasteride does that. But I have great options topically that mix a whole bunch of things including topical 5-alpha-reductase inhibitor, ketoconazole, minoxidil, Azelaic acid … we don’t see much systemic absorption - so topical finasteride seems fine. You can look at Empower Pharmacy Hair Restore Ultra Scalp Solution … that’s a common option for that problem.
@Virilius Yes I’m satisfied that Dutasteride is a reasonable option for someone who has BPH … probably not going to give a systemic agent for hair loss very often.
My point on Ezetimibe is not to Rx it for that diagnosis primarily - but consider that it may well be quite helpful … and when I have someone who needs lipid treatment who is a mid aged male - considering this as part of therapy, given that it may well be dual use seems sensible. The data will follow at some point, but I already have a reason to Rx it.
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It doesn’t sound like you should prescribe dutasteride either. At least not to anxious and easily suggestable men.
The concept of PFS has emerged from reports of non-dermatologists, neuroendocrinological research and reflections, and uncontrolled studies of low quality and with a strong bias selection, while a significant nocebo effect among patients informed about possible side effects of finasteride is recognized. There are no predictive factors for the risk of development of PFS. Nevertheless, it has been suggested that a patient history of preexisting mental health disorder, particularly depression, may put patients at an increased risk. We report the first case of PFS in a long-standing (over 20 years) dermatotrichological practice with frequent finasteride prescription observed in a 25-year-old male following dutasteride treatment for male androgenetic alopecia. There was circumstantial evidence that PFS may represent a delusional disorder of the somatic type, possibly on a background of a histrionic personality disorder, which would explain the refractoriness of the condition and a high degree of suggestibility.
Post-Finasteride Syndrome: An Induced Delusional Disorder with the Potential of a Mass Psychogenic Illness? - PubMed (nih.gov)
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AnUser
#35
In this case I think he had a predisposition for mental illness and it basically got triggered by being hyped or not so hyped anymore about finasteride. Might as well have been anything else that was stressful for him which would trigger it in the first place. I’m sure avoiding the medications prescribed and following the PFS community doesn’t help him either. Probably is causing a lot of suffering. I would eat those anti-psychotics like a madman and ask the doctors to save me.
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Given that I’ve never started anyone on either one of these medications orally in 30 years of practice, it’s probably not a huge issue for me lose sleep on.
It’s a bit presumptive to think what a physician should or shouldn’t Rx, as there typically cannot be a full contemplation from those who haven’t gone to medical school and residency to entirely appreciate the decision making process. In my population, between longevity medicine and Emergency Medicine, I sometimes get patients already on these agents.
I understand the studies and the biases … I worked as medical statistician previous … but I also appreciate the opinions and experiences of seasoned colleagues who have a lot of experience in this area.
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Only a minority of dermatologists believe that PFS is even a thing. Though they prescribe finasteride primarily for hairloss, not for BPH.
The aim of this study was to evaluate the beliefs and counseling practices among dermatologists regarding adverse effects of finasteride. Anonymous paper surveys were personally distributed to 122 attendees at two annual major dermatology meetings. The participation rate was 82% with 47% women and 77% residents of the United States. 51% of respondents believed that finasteride could cause sexual side effects and 18% believed that it could cause persistent sexual side effects. Fewer than a quarter believed that finasteride could cause depression or lower sperm counts.
Beliefs and counseling practices among dermatologists regarding sexual and other adverse effects of finasteride | International Journal of Impotence Research (nature.com)
The FDA also shares this sentiment.
The US Food and Drug Administration (FDA) had advised that the PFS petition “does not provide reasonable evidence” of a link to suicide, but in August 2022 added suicidal ideation (SI) and behaviour to the adverse reactions listed for finasteride. According to the FDA statement, the PFS petition “does not provide reasonable evidence” of a causal link between finasteride and persistent SD, depression, or suicide. However, on the basis of reports from patients using the 1-mg dose for AGA, the FDA is “requiring the addition of SI and behaviour” to the listed AEs.
US Food and Drug Administration Warning Regarding Finasteride and Suicidal Ideation: What Should Urologists Know? - ScienceDirect
Given those information, I remain highly sceptical of such claims, especially given the mechanism of action finasteride has in the body.
Incidentally, I’m not at all referring to the mental health issues - I’m more concerned about the rare man that seems to have very persistent and difficult to treat sexual dysfunction.
What the dermatologists think isn’t hugely relevant as they only see a segment of their complications … for example if they have someone on an immunosuppressant for psoriasis … they show up in the ER septic … not something derm will be taking care of … it’ll be me. Same thing with difficult to treat sexual dysfunction.
I don’t know if it is causative … but I’ve got colleagues who primarily work in this space and they have groups of patients who have this … and don’t quite have patients with the same resistance to treatment, often long term that haven’t had finasteride. Yes —- isn’t evidence - is anecdote - but if I have another option … why take the one that might cause a problem?
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Same thing with difficult to treat sexual dysfunction.
I’m assuming patients would consult their dermatologist regarding side effects first.
Incidentally, I’m not at all referring to the mental health issues - I’m more concerned about the rare man that seems to have very persistent and difficult to treat sexual dysfunction.
In many cases, ED and psychological issues are deeply related, particularily in younger men. Next to lifestyle choices, depression, stress and anxiety are the highest risk factors for ED.
Prevalence, Comorbidities, and Risk Factors of Erectile Dysfunction: Results from a Prospective Real-World Study in the United Kingdom - PMC (nih.gov)
The Psychology of Erectile Dysfunction - Mark S. Allen, Alex M. Wood, David Sheffield, 2023 (sagepub.com)
Because oral finasteride works and is easy to use. It’s just another pill in the daily. supplement stack. Additionally, oral finasteride has potential benefits for prostate cancer prevention and lowering risk for cardiovascular disease.
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I have gotten mild depression from taking Finasteride. It’s manageable if I take it once a week, (I’ll be mildly down the next day) but any more than that it really makes me feel more and more depressed. I only take 1.25 mg and that’s enough to trigger depression for me. I have no other psychological issues.
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