Finasteride to treat aggression in adolescent males with Autism

[DD214_DOC]

Has anyone ever heard of this being done before? I inherited a patient who recently moved to my area who was on this medication. It actually worked really, really well, and when another psychiatrist d/c it, symptoms returned. when it was restarted, symptoms resolved. I have never heard of it before, but it has piqued my curiosity. I have not been able to find too many articles about it, either.

Conceptually, it makes a bit of sense given the developmental age and problems that come along with ASD.

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[hamstergang]

How does this impact on the development of the kid? I'd imagine this would screw with normal adolescence so much as to be bordering on unethical, so I hope there's something I'm not considering/don't know.

 

[birchswing]

Wonder what the baseline testosterone is and after treatment. Could increased serum testosterone lead to better mood?

On the other hand the metabolites of endogenous testosterone are known to have beneficial psychological effects at GABA-A receptors (and the absence of them negative effects like anxiety/depression)--so the effect of blocking the metabolites of testosterone may have some paradoxical effect.

 

[DD214_DOC]

I was thinking more along the lines of increased testosterone in puberty leads to more aggressive behaviors in someone who already cannot tolerate frustrations and modulate their own emotional responses to things.

Regarding development, the patient is severely autistic and moderate ID, so....parents are ok with effects. I'm not the one who started the med, though, and I wasn't touching anything until I understood the case better and looked into the choice of medication.

 

[birchswing]

Doesn't finasteride increase serum testosterone by blocking its breakdown?

 

[DD214_DOC]

Doesn't finasteride increase serum testosterone by blocking its breakdown?

Yep, it sure does. I had it mixed up. Well, so much for my hypothesis, but this also just got a lot more interesting.

 

[Nymphicus]

Not exactly the same, but similar use of sex hormone inhibition for behavioral and developmental reasons in children.

https://en.wikipedia.org/wiki/Ashley_Treatment

 

[birchswing]

I only know because I have low testosterone (secondary) and looked into various alternative therapies besides exogenous testosterone. Finasteride is not really a legitimate one. Clomid on the other hand is a legitimate option.

 

[DD214_DOC]

Actually, if you block the conversion of testosterone to DHT, wouldn't the increased levels of testosterone suppress FSH/LH and further production/release of it?

 

[birchswing]

I just Googled this because I wasn't sure if I trusted my memory.

It looks like this is more complicated than I understood.

Also, a good reminder: I am not a doctor. I am not even studied in any sciences.

What I just Googled showed that what finasteride blocks testosterone from turning into (DHT) is actually a very potent androgen that is involved not just in hair loss but the other things you normally associate testosterone with.

I had seen some study that it increased overall serum testosterone, but that may not be relevant to the actual effects of it--which is bared out by a lot of articles I just saw from Googling that says it lowers labido and causes erectile problems etc.

I probably should not have commented.

<--NOT A DOCTOR

 

[nitemagi]

Sounds comparable to chemical castration used with sex offenders.

 

[birchswing]

Sounds comparable to chemical castration used with sex offenders.

A lot of balding men being treated like sex offenders if that's the case.

 

[Monocles]

Maybe I'm tired, but for some reason when I read the title, for a second I interpreted it as "finaseride treats aggression in adolescent males, by causing autism".

 

[nitemagi]

A lot of balding men being treated like sex offenders if that's the case.

In the mildest way, kinda. Hormonal, with eventually driving down testosterone levels. Lupron it isn't, don't get me wrong.

But... http://www.ncbi.nlm.nih.gov/pubmed/26053014

 

[smalltownpsych]

In the mildest way, kinda. Hormonal, with eventually driving down testosterone levels. Lupron it isn't, don't get me wrong.

But... http://www.ncbi.nlm.nih.gov/pubmed/26053014

Well if I ever get prostate problems, I know which drug not to take.

It does raise some interesting ethical questions though since aggression is linked to testosterone. I have also seen effects on mood for females with estrogen (a number of patients, including one just yesterday have switched to different forms of progesterone because of this) and have also seen girls with emotional regulation difficulties treated with hormones. I don't know if it is preferable to treat emotional difficulties with medications that are more specific to the neurotransmitters as opposed to the hormones, but clearly that is the direction that we are in currently with medications.

 

[DD214_DOC]

I've searched far and wide on pubmed and psychonline this morning, but alas -- still have not found this mythical study about using finasteride to treat aggression in an adolescent male with ASD. Perhaps I can write one...

 

[birchswing]

I've searched far and wide on pubmed and psychonline this morning, but alas -- still have not found this mythical study about using finasteride to treat aggression in an adolescent male with ASD. Perhaps I can write one...

I did find one mention of a connection, but you're not going to like the source. But you're already in new territory.

http://www.momsagainstmercury.org/Research/Mercury and Testosterone Medical Hypothesis1[1].pdf

 

[Shikima]

Aww but mercury is such a playful little pet.. you can keep it in your pocket when you're bored.

 

[DD214_DOC]

I did find one mention of a connection, but you're not going to like the source. But you're already in new territory.

http://www.momsagainstmercury.org/Research/Mercury and Testosterone Medical Hypothesis1[1].pdf

Ack, it's like kryptonite.

The parent said the doc who started it to begin with handed them an article about it, but I sure can't find one. I really, really want to find one because I'm not sure how else to justify continuing the medication, other than, "Well, it works even though there's nothing empirical to support it". Not sure that would pass our monthly peer review if that chart was randomly selected.

 

[birchswing]

Ack, it's like kryptonite.

The parent said the doc who started it to begin with handed them an article about it, but I sure can't find one. I really, really want to find one because I'm not sure how else to justify continuing the medication, other than, "Well, it works even though there's nothing empirical to support it". Not sure that would pass our monthly peer review if that chart was randomly selected.

I'm not a doctor, but it sounds like an interesting case study. If you have evidence that it works that seems like it should suffice. How often does one find something that helps? God, when you think of the alternatives for people with autism like the barbaric Judge Rotenberg Center.

If I were a doctor, however, I could be curious to do more endocrinological testing.

 

[DD214_DOC]

So, I had another thought last night but haven't had a chance to search for any studies yet.

The finasteride clearly works for this kid. I get why, ultimately lowers circulating testosterone levels. Makes sense.

The typical go-to for aggression in ASD is the SGA. It's usually trial and error to find one that works well. Some won't do anything long-term, although short-term they may help due to the sedating side effects. I realized a connection last night while not being able to fall asleep. The kids I've had in the past, the most effective SGA for them also significantly increased prolactin levels. (back when I checked it routinely). I would end up switching to another SGA, which usually helped for a couple weeks (sedation) then stopped working. It wouldn't do squat long-term, but their prolactin levels were normal. I switch them back to the original medication, anger/aggression goes away short-term and long-term, but prolactin goes up again. (I d/w a peds endo guy who recc not routinely testing prolactin unless symptomatic for hyperprolatinemia).

So, prolactin also suppresses testorone. Perhaps this is the mechanism behind the long-term efficacy of the SGA when used for this purpose? If so, then maybe finasteride could be a better alternative since it, you know, doesn't have all the metabolic and EPS to go with it.

This is off the cutt and I'm still deprived of sleep, so it may be nonsense too.

 

[nitemagi]

So, I had another thought last night but haven't had a chance to search for any studies yet.

The finasteride clearly works for this kid. I get why, ultimately lowers circulating testosterone levels. Makes sense.

The typical go-to for aggression in ASD is the SGA. It's usually trial and error to find one that works well. Some won't do anything long-term, although short-term they may help due to the sedating side effects. I realized a connection last night while not being able to fall asleep. The kids I've had in the past, the most effective SGA for them also significantly increased prolactin levels. (back when I checked it routinely). I would end up switching to another SGA, which usually helped for a couple weeks (sedation) then stopped working. It wouldn't do squat long-term, but their prolactin levels were normal. I switch them back to the original medication, anger/aggression goes away short-term and long-term, but prolactin goes up again. (I d/w a peds endo guy who recc not routinely testing prolactin unless symptomatic for hyperprolatinemia).

So, prolactin also suppresses testorone. Perhaps this is the mechanism behind the long-term efficacy of the SGA when used for this purpose? If so, then maybe finasteride could be a better alternative since it, you know, doesn't have all the metabolic and EPS to go with it.

This is off the cutt and I'm still deprived of sleep, so it may be nonsense too.

Interesting hypothesis.

I can add this.

http://www.ncbi.nlm.nih.gov/m/pubmed/18354385/
http://www.ncbi.nlm.nih.gov/m/pubmed/22877998/

 

[Mad Jack]

Doesn't finasteride increase serum testosterone by blocking its breakdown?

But the intended purpose is to decrease DHT, which is like testosterone on crack, with nearly three times the binding potency. So the upside is you probably won't hamper sexual development (not that it is a big concern, but it reduces the fear of ethical issues), as DHT isn't critical for development of secondary male sexual characteristics at puberty, but you will diminish the potent affects of DHT on the body.

 

[Information Underload]

Finasteride increases serum testosterone but there is no change in free testosterone, typically, because SHBG levels will increase. Thus, there would be no overall change in available testosterone that might lead to heightened aggression.

Here is an article linking DHT to level of aggression:

http://www.ncbi.nlm.nih.gov/pubmed/3610056

I didn't see the correlate to that in that reducing DHT (as would be the case with finasteride) would decrease aggression.

 

[Mad Jack]

Finasteride increases serum testosterone but there is no change in free testosterone, typically, because SHBG levels will increase. Thus, there would be no overall change in available testosterone that might lead to heightened aggression.

Here is an article linking DHT to level of aggression:

http://www.ncbi.nlm.nih.gov/pubmed/3610056

I didn't see the correlate to that in that reducing DHT (as would be the case with finasteride) would decrease aggression.

Sounds like someone might have a research study on their hands...

I've heard of guys taking Avodart and Propecia that felt like they became really placid after starting therapy- maybe DHT has more potent effects on the CNS than we currently appreciate.

 

[DD214_DOC]

Interesting.......

 

[smalltownpsych]

So, I had another thought last night but haven't had a chance to search for any studies yet.

The finasteride clearly works for this kid. I get why, ultimately lowers circulating testosterone levels. Makes sense.

The typical go-to for aggression in ASD is the SGA. It's usually trial and error to find one that works well. Some won't do anything long-term, although short-term they may help due to the sedating side effects. I realized a connection last night while not being able to fall asleep. The kids I've had in the past, the most effective SGA for them also significantly increased prolactin levels. (back when I checked it routinely). I would end up switching to another SGA, which usually helped for a couple weeks (sedation) then stopped working. It wouldn't do squat long-term, but their prolactin levels were normal. I switch them back to the original medication, anger/aggression goes away short-term and long-term, but prolactin goes up again. (I d/w a peds endo guy who recc not routinely testing prolactin unless symptomatic for hyperprolatinemia).

So, prolactin also suppresses testorone. Perhaps this is the mechanism behind the long-term efficacy of the SGA when used for this purpose? If so, then maybe finasteride could be a better alternative since it, you know, doesn't have all the metabolic and EPS to go with it.

This is off the cutt and I'm still deprived of sleep, so it may be nonsense too.

It took me a bit to figure out what SGA meant, but I was also wondering the same thing about effects of prolactin increase from certain medications after reading this yesterday. There are also the sedating effects of some of these which can decrease energy for the aggression. Quetiapine seems to be popular for this one. Still wondering what you guys think about medications that imfluence hormones to regulate mood verses medications that affect neurotransmitters. Either way, we are trying to regulate a pretty complex internal system that responds to an even more complex external system with some pretty blunt tools.

 

[kaige333]

Ditto. Not just during therapy, I have come across stories of guys becoming impotent, depressed, emotionally flat, and chronically fatigued after coming off Finasteride.

I suspect long term use of finasteride then cessation leads to what amounts to testosterone withdrawal for some people. The first possible reason is, like someone on here suggested already, as 5 alpha reductase is inhibited serum level of testosterone accumulates. The second possibility is that by virtue of its MOA as an antagonist of 5 alpha reductase, I wonder if the structural similarity between finasteride and testosterone is sufficient for it to act as an exogenous steroid. It is known that long term steroid use suppresses the hypothalamus anterior pituitary axis. When the treatment is stopped, it is not inconceivable that someone can come down with withdrawal symptoms due to the lack of or much lower level of endogenous testosterone subsequent to a prolonged period of excess. So maybe should take long term potential harm into consideration here as well.

Now when the patient is on finasteride, the calming effect could be due to the excess steroid, the accumulated endogenous testosterone, the lack of certain neuropeptides due to 5 alpha reductase inhibition, or a combination of all of the above.