Efficacy and Safety of Oral Minoxidil 5 mg in Hair Loss

oRAL MINOXIDIL IN HAIR LOSS AND HAIR TRANSPLANT

Introduction:
The first side effect one notes when a person is taking oral minoxidil is an increase in facial hair. However, at times when there is a lockdown like in present times, not like me can be said to be on minoxidil.

No, I am not taking oral Minoxidil, my beard is due to the lockdown!

Use of Oral Minoxidil has been very controversial since the last decade or so.

Whenever there is a controversial treatment, sure enough, there is always a plus side to its use.

The first time I got interested in this topic was when a patient said he has been drinking Rogaine in dosage 0.1 ml to maintain a dose equal to 5 mg oral tablet a day.

Of course, you cannot drink a topical formulation since they have additives. And Rogaine has propylene glycol which can cause intense worrisome GI problems. Also, I do not think topical Minoxidil would act as well orally since digestive enzymes will destroy the pure form immediately.

What will my patients not do for hair regrowth!

The next incident was news emanating from a Spanish Pediatric hospital just 6 months back in Aug 2019 about symptoms of the dreaded werewolf syndrome or hypertrichosis developing in children who were simultaneously and due to a huge error, administered oral minoxidil.

TABLETS:

People do not wish to use topical application for 2 reasons-

1. Headaches, dizziness, spells of fainting

2. Itching and flakiness

3. Styling reasons

4. Lack of response to topical Minoxidil

Minoxidil (Loniten, Loxidil) tablets for oral administration contain either 2.5 mg or 10 mg of minoxidil.

Even when used for hypertension, and due to likely serious side effects of Oral Minoxidil, it is indicated only in the treatment of subborn hypertension that cannot be managed by even a combination of antihypertensive drugs. For lesser degrees of hypertension it is not used due suboptimal risk/benefit assessment.

Oral minoxidil is mostly metabolized through the liver and the metabolites are excreted through the kidney. However, the vasodilation benefits are present till 72 hours.

The use of Oral Minoxidil is not an approved use of the drug. Nor is it FDA certified for hair loss. A prescription carried enormous litigation potential.

Those who do prescribe the drug for hair loss, should not do so wantonly, but only for those who have verifiable intolerance to Topical Minoxidil and Finasteride and hat too if they are willing to come for frequent cardiovascular follow up.

I base my impressions about Oral use of Minoxidil on 3 resources:

1. Dr. Rodney Sinclair’s study 2017

2. Dr. D Pathomvanich’s verbal advice

3. My own experience with patients who have been on oral minoxidil

Keeping with Dr. Sincair’s study which is the background study of use of oral minoxidil, I am open to using it in low dose but only in those who are disease-free, are young 25-35 years old, have low body fat and under strict supervision in the dose 1 mg a day.

I only know of one doctor who has the longest experience with Oral Minoxidil of over 25 years with his patients as he felt it was better than topical Minoxidil. In one of the ISHRS on enquiring, he told me he routinely prescribes 5 mg once a day. I did not get a clear answer though on why only once a day when the duration of action in just 4.5 hours! He does not prescribe any diuretic alongwith or any betablocker for that matter. In fact he had been taking it himself for over 25 years at that time.

However this said, I cannot a single prospective study that has assessed its dosage for hair loss. Before you take a drug one needs to know its therapeutic index to determine its safety.

Because when side effects happen, they can be severe and include one or more of the following :

1. Angina

2. Pericardial effusion

3. Pulmonary hypertension

4. Sodium and water retention can lead to Congestive hear failure

5. Hypertrichosis

6. Pulsating headaches

7. Itchy eyes

8. Severe skin rash

9. Polymenorhhoea

A patient once said to me after I enumerated these side effects to him- I do not care about side effects of Oral Minoxidil since the mirror alone gives me chest pain, palpitations and anxiety attacks many times every single day of the year! This is the enormity of the problem that patients can take huge risks in their battle with hair loss.

On the other side there is not sufficient experience to know if at 5 mg there are any side effects, and even if there are, how serious are they? Even Apsirin has side effects and can be fatal in one rare patient.

However, it makes one wonder why it is not yet FDA approved if it is such a great drug for hair loss. Since there is so much money being made in hair loss medications, why has it not struck researchers that this could be a gold mine of sorts?

But though patients have been taking this medication on their own, why is there no doctor who is willing to prescribe it under his signature? I feel it has to do with the litiginous environment we work in and we shirk taking on extra liabilities.

DOSAGE:

Patients I know have been taking 10-20 mg a day, but I feel such doses are crazy.

0.625 mg a day which is raised to twice a day (quarter tablet of the 2.5 mg tablet with a pill breaker) if the patient tolerates the drug.

It is however preferable not to cross this relatively risk-free dosage.

However, patients in consultations with their doctors are known to build up the dosage gradually until they find their own unique sweet spot at upto 5 mg twice a day.

Many women have been reporting results with a combination of low-dose Tab Minoxidil 2.5 mg and Tab. Spironolactone 25 mg a day.

It is to be noted that the dose for hypertension is 10-40 mg per day. It is stated that the maximum dose of 100 mg a day should not be exceeded for hypertension which is ludicrous.

RESTRICTIONS:

1. SALT INTAKE: less than 2g per day

2. Alcohol in excess when taken with oral minoxidil can cause sudden fall in BP.

3. Also, reduce caffeine products including cold tablets.

4. 80-160 mg of betabocker is usually required while giving minoxidil for blood pressure.

5. Diuretic may also need to be prescribed to prevent sodium and water retention.

6. In the first week, the patent has to be closely monitored and if you develop sudden increase of HR to more than 20 per minute over and above your usual HR, rapid weight gain and ankle swelling, chest pain, shortness of breath or dizziness with or without fainting, call the emergency department.