Dutasteride, one of the most widely used 5α-reductase inhibitors.
|Synonyms||Dihydrotestosterone antagonists; Dihydrotestosterone blockers|
|Use||Benign prostatic hyperplasia, androgenic alopecia, hirsutism, transgender women|
5α-Reductase inhibitors (5-ARIs) are a class of drugs with anti-androgen effects, used primarily in the treatment of benign prostatic hyperplasia (BPH, enlarged prostate) and androgenic alopecia (pattern hair loss). They are also used less commonly to treat hirsutism (excessive hair growth) in women. These are two types of 5-ARIs, categorized as steroidal and non-steroidal 5α-recuctase inhibitors.
These agents inhibit the enzyme 5α-reductase, which is involved in the metabolic transformations of a variety of endogenous steroids. 5α-reductase inhibition is most known for preventing conversion of testosterone, the major androgen sex hormone, to the more potent dihydrotestosterone (DHT), in androgen-associated disorders.
- 1 Medical uses
- 2 Adverse effects
- 3 Mechanism of action
- 4 Drug discovery and design
- 5 Natural products
- 6 See also
- 7 References
5-ARIs are clinically used in the treatment of conditions that are exacerbated by DHT:
- Mild-to-moderate benign prostatic hyperplasia and lower urinary tract symptoms
- Androgenic alopecia in both men and women
They have also been explored in the treatment and prevention of prostate cancer. While the 5-ARI finasteride reduces the cancer risk by about a third, it also increases the fraction of aggressive forms of prostate cancer. Overall, there does not seem to be a survival benefit for prostate cancer patients under finasteride.
5-ARIs can be used in the treatment of hirsutism in women.
In general, adverse drug reactions (ADRs) experienced with 5-ARIs are dose-dependent. Common ADRs include impotence, decreased libido and decreased ejaculate volume. Rare ADRs include breast tenderness and enlargement (gynecomastia), and allergic reaction. Other symptoms such as depression, and anxiety have been claimed with the use of 5-ARIs such as finasteride, however no significant difference in depression scores and loss of libido, compared to unaffected individuals, has been confirmed in a study that was conducted in 1992. Finasteride has also been associated with intraoperative floppy iris syndrome and cataract formation.
The FDA has notified healthcare professionals that the Warnings and Precautions section of the labels for the 5-ARI class of drugs has been revised to include new safety information about the increased risk of being diagnosed with a more serious form of prostate cancer (high-grade prostate cancer).
Sexual dysfunction, including erectile dysfunction, loss of libido, and reduced ejaculate, may occur in 3.4 to 15.8% of men treated with finasteride or dutasteride. This is linked to lower quality of life and can cause stress in relationships. There is also an association with lowered sexual desire. It has been reported that in a subset of men, these adverse sexual side effects may persist even after discontinuation of finasteride or dutasteride.
Depression and self-harm
In May 2017, a very large, population-based, matched-cohort study of 93,197 men aged 66 years and older found that finasteride and dutasteride were associated with a significantly increased risk of depression (HR, 1.94; 95% CI, 1.73–2.16) and self-harm (HR, 1.88; 95% CI, 1.34–2.64) during the first 18 months of treatment, but were not associated with an increased risk of suicide (HR, 0.88; 95% CI, 0.53–1.45). After the initial 18 months of therapy, the risk of self-harm was no longer heightened, whereas the elevation in risk of depression lessened but remained marginally increased (HR, 1.22; 95% CI, 1.08–1.37). The absolute increase in the rate of depression was 247 per 100,000 patient-years and of self-harm was 17 per 100,000 patient-years. As such, on the basis of these statistics, it has been stated that cases of depression in patients that are attributable to 5α-reductase inhibitors will be encountered on occasion, while cases of self-harm attributable to 5α-reductase inhibitors will be encountered very rarely. There were no significant differences in the rates of depression, self-harm, and suicide between finasteride and dutasteride, indicating that type of 5α-reductase inhibitor does not appear to influence the risks.
Mechanism of action
When uninhibited, the 5α-reductase reduces the steroid Δ4,5 double-bond in testosterone to its more active form dihydrotestosterone (DHT). Thus, the inhibition results in decreased amounts of DHT. Because of this, slight elevations in testosterone levels occur.  The 5α-reductase reaction is a rate-limiting step in the testosterone reduction and involves the binding of NADPH to the enzyme followed by the substrate. 
- Substrate + NADPH + H+ → 5α-substrate + NADP+
In addition to reducing testosterone 5α-reductases substrates include progesterone, androstenedione, epitestosterone, cortisol, aldosterone, and deoxycorticosterone. The entire physiologic effect of their reduction is unknown, but likely related to their excretion or is itself physiologic. Other enzymes compensate to a degree for the absent conversion, specifically with local expression at the skin of reductive 17β-hydroxysteroid dehydrogenase, and oxidative 3α-hydroxysteroid dehydrogenase and 3β-hydroxysteroid dehydrogenase enzymes.
Drug discovery and design
Steroidal 5α-reductase inhibitors
Steroid 5α-reductase is a membrane-associated enzyme in an oxidoreductase family and has an important role in biological actions towards steroid metabolism. If the steroid 5α-reductase is overexpressed it causes overproduction of DHT that can lead to androgenic disorders in humans.
The 5α-reductase isozymes possess a similar steroidal catalytic site. The only available information about the 5α-reductase isozymes is their primary sequence estimated from c-DNAs and that affects the design of the novel inhibitors. The crystal structure of the 5α-reductase isozymes is not known because the nature of the 5α-reductase enzyme is so unstable during purification. The first 5α-reductase inhibitors were designed by modifying the structure of natural substrates, including the substitution of one carbon atom of the rings of the steroids by a heteroatom such as nitrogen thereby forming azasteroids. The receptor is known to consist of two hydrogen bond donors, where the C3 and 17β-side chain of the ligands connect, as well as three hydrophobic groups distributed over the steroidal structure. The best receptor inhibitors comply with these factors. Azasteroids are a type of steroid derivatives which have nitrogen atoms replaced at various positions for one of the carbon atoms in the steroid ring system. Two 4-azasteroids, finasteride and dutasteride are marketed as 5α-reductase inhibitors. Finasteride (Proscar or Propecia) was the first steroidal 5α-reductase inhibitor approved by the U.S. Food and Drug Administration (USFDA). It inhibits the function of two of the isoenzymes (type II and III). In human it decreases the prostatic DHT level by 70–90% and reduces the prostatic size.
Dutasteride (Avodart) was the second steroidal 5α-reductase approved after finasteride. It is a competitive inhibitor of all three 5α-reductase isoenzymes and it inhibits types 1 and 2 better than finasteride, leading to it causing further reduction in DHT, with >90% recuded DHT levels following 1 year of oral administration.
Epristeride is the third marketed steroidal 5α-reductase inhibitor. It is a noncompetitive, specific inhibitor. It potency is not as significant as finasteride or dutasteride and thus it is only marketed in China.
Nonsteroidal 5α-reductase inhibitors
Various pharmaceutical and academic groups have conducted the synthesis of nonsteroidal compounds that inhibit human 5α-reductases due to the unwanted hormonal side effects of steroidal compounds. Non-steroidal inhibitors can be categorized due to their structure. Many have been obtained from azasteroid inhibitors by taking away one or more rings from the steroid structure.
Four main categories of non-steroidal 5α-reductase inhibitors have been described.
- Carboxylic acids
Nonsteroidal inhibitors are thought to act as competitive inhibitors on the 5α-reductase isozymes, except for epristeride analogues (carboxylic acids), which are noncompetitive inhibitors.
Bexlosteride falls into the category of benzo(f)quinolonones, and is probably the derivative that has come closest to being marketed. It functions as a 5-ARI1 inhibitor which inhibits testosterone stimulated LNCaP cell growth but without testosterone the compound shows no effect and was therefore never marketed.
Structure-activity relationship (SAR)
Many steroidal 5α-reductase inhibitors have been researched but only 3 are marketed. Two of them are 4-azasteroids and will be covered here. As mentioned above, the third one, epristeride is only marketed in China and will not be covered here. The basic SAR of 4-azasteroids is shown below. For competitive inhibiting functions there are two functions considered crucial, 4-en-3-one function and a lipophilic 17β-side chain with one or more oxygen atoms. The main problems for 4-azasteroids is the rapid conversion into inactive 4,5-dihydro form, which is done by the enzyme.
Finasteride is considered similar to the transition state of reduced testosterone and is thus a slow-offset, irreversible inhibitor. The similarity to the transition state is a formation of an enzyme-NADP-dihydrofinasteride adduct by rearrangement on the A-ring of the compound.
Finasteride mainly inhibits the 5α-R2 (IC50=69 nM) and 5α-R3 (IC50=17.4 nM) with little inhibition of 5α-R1 (IC50=360 nM). As mentioned above, finasteride reduces prostatic DHT levels on a 70-90% range but the detailed reduction of DHT is 70.8% and 85% of intraprostatic DHT.
Dutasteride, however, is a so-called dual inhibitor with both 5α-R1 and 5α-R2 inhibition. IC50 for 5α-R1 is 7 nM but 6 nM for 5α-R2. As mentioned above, it reduces DHT > 90% overall, or precisely 94.7% and for intraprostatic DHT the reduction is 97-99%. Dutasteride has also been found to inhibit 5α-R3, in vitro, with IC50=0.33 nM.  The 2,5-difluorophenyl side chain on the D-ring of the compound shows significant lipophilic features and as increased lipophilicity enhances the potency of the compounds binding at pocket site, its potency is much greater than of finasteride.
Finasteride is an unsaturated analogue of another 4-azasteroid, or 4-MA. 4-MA is known to have dual inhibiting features with good inhibition on 5α-R1 (IC50=1.7 nM) and 5α-R2 (IC50=1.9 nM). However, 4-MA was never marketed as it showed hepatotoxicity. There is no detailed data about the cause of hepatotoxicity in 4-MA regarding SAR, but a conclusion may be drawn that the R2 group is the cause as there are other 4-azasteroid compounds containing the same R1 group as 4-MA, or CH3, without showing hepatotoxicity.
The common factor in non-steroidal 5-ARI discovery is that the first compounds were all selective inhibitors to 5α-reductase type 1 only, but were then developed in order to get dual inhibition on both type 1 and 2, since inhibition of the type 2 isozyme is a more important factor in treating the disease of BPH.
Benzo(c)quinolizinones are tricyclic derivatives of 10-azasteroids. The D-ring has been removed and the C-ring substituted for an aromatic one. The first compounds developed were selective 5-alpha reductase type 1 inhibitors, but the most potent one inhibits both type 1 and 2. The fluorine atom is an important part of the structure.
Benzo(f)quinolonone are also tricyclic compounds, but derivatives of the 4-azasteroid structure. The compounds that have been designed can be divided into two categories, hexahydro derivatives and octahydro derivatives. The octahydro derivatives have been proven to be more potent. Compound LY 191704, later named bexlosteride, is the most potent octahydro derivative designed. It is a selective inhibitor to the type 1 isozyme, especially because of the chlorine atom and the amino-methyl group.
Piperidones are also 4-azasteroid derivatives but both B- and D-ring have been removed. The original compounds designed were type 1 selective, especially the ones containing a chlorine atom connected to the aromatic ring. By inserting a styryl group to the piperidones type 2 inhibitory activity increased. 
Non-steroidal carboxylic acids are tricyclic compounds designed to resemble steroidal carboxylic acids such as episteride. As with the other non-steroidal inhibitors, they have been designed by removing steroid ring systems. As with the piperidones, addition of a styryl group provides good dual inhibition on isozyme 1 and 2, but the non-steroidal carboxylic acids are mostly type 1 selective.
Saw palmetto extract
The European Medicines Agency (EMA) has concluded that the extract of the natural product Saw palmetto can be used to treat symptoms of benign prostatic hyperplasia (BPH) as research has shown its 5-ARI effects. An extract of Serenoa repens, also known as saw palmetto extract, is a 5-ARI that is sold as an over-the-counter dietary supplement. It is also used under the brand name Permixon in Europe as a pharmaceutical drug for the treatment of benign prostatic hyperplasia.
- Ulrike Blume-Peytavi; David A. Whiting; Ralph M. Trüeb (26 June 2008). Hair Growth and Disorders. Springer Science & Business Media. pp. 368–370. ISBN 978-3-540-46911-7.
- Aggarwal, Saurabh; Thareja, Suresh; Verma, Abhilasha; Bhardwaj, Tilak Raj; Kumar, Manoj. "An overview on 5α-reductase inhibitors". Steroids. 75 (2): 109–153. doi:10.1016/j.steroids.2009.10.005.
- Rossi S (Ed.) (2004). Australian Medicines Handbook 2004. Adelaide: Australian Medicines Handbook. ISBN 0-9578521-4-2
- Thompson, Ian M. Jr.; Goodman, Phyllis J.; Tangen, Catherine M.; Parnes, Howard L.; Minasian, Lori M.; Godley, Paul A.; Lucia, M. Scott; Ford, Leslie G. (2013-08-15). "Long-Term Survival of Participants in the Prostate Cancer Prevention Trial". New England Journal of Medicine. 369 (7): 603–610. ISSN 0028-4793. PMC . PMID 23944298. doi:10.1056/NEJMoa1215932.
- Rahimi-Ardabili B, Pourandarjani R, Habibollahi P, Mualeki A (2006). "Finasteride induced depression: a prospective study". BMC Clinical Pharmacology. 6: 7. PMC . PMID 17026771. doi:10.1186/1472-6904-6-7.
- Singh, M. K.; Avram, M. (2014). "Persistent sexual dysfunction and depression in finasteride users for male pattern hair loss: a serious concern or red herring?". The Journal of clinical and aesthetic dermatology. 7 (12): 51–5. PMC . PMID 25584139.
- Wong, A. C. M.; Mak, S. T. (2011). "Finasteride-associated cataract and intraoperative floppy-iris syndrome". Journal of Cataract & Refractive Surgery. 37 (7): 1351–1354. PMID 21555201. doi:10.1016/j.jcrs.2011.04.013.
- Issa, S. A.; Dagres, E. (2007). "Intraoperative floppy-iris syndrome and finasteride intake". Journal of Cataract & Refractive Surgery. 33 (12): 2142–2143. PMID 18053919. doi:10.1016/j.jcrs.2007.07.025.
- "FDA Alert: 5-alpha reductase inhibitors (5-ARIs): Label Change – Increased Risk of Prostate Cancer". Drugs.com. Retrieved 2014-06-08.
- Hirshburg JM, Kelsey PA, Therrien CA, Gavino AC, Reichenberg JS (2016). "Adverse Effects and Safety of 5-alpha Reductase Inhibitors (Finasteride, Dutasteride): A Systematic Review". J Clin Aesthet Dermatol. 9 (7): 56–62. PMC . PMID 27672412.
- Liu, L; Zhao, S; Li, F; Li, E; Kang, R; Luo, L; Luo, J; Wan, S; Zhao, Z (September 2016). "Effect of 5α-Reductase Inhibitors on Sexual Function: A Meta-Analysis and Systematic Review of Randomized Controlled Trials.". The journal of sexual medicine. 13 (9): 1297–310. PMID 27475241. doi:10.1016/j.jsxm.2016.07.006.
- Gur, S; Kadowitz, PJ; Hellstrom, WJ (January 2013). "Effects of 5-alpha reductase inhibitors on erectile function, sexual desire and ejaculation.". Expert opinion on drug safety. 12 (1): 81–90. PMID 23173718. doi:10.1517/14740338.2013.742885.
- Traish, AM; Hassani, J; Guay, AT; Zitzmann, M; Hansen, ML (March 2011). "Adverse side effects of 5α-reductase inhibitors therapy: persistent diminished libido and erectile dysfunction and depression in a subset of patients.". The journal of sexual medicine. 8 (3): 872–84. PMID 21176115. doi:10.1111/j.1743-6109.2010.02157.x.
- Welk B, McArthur E, Ordon M, Anderson KK, Hayward J, Dixon S (2017). "Association of Suicidality and Depression With 5α-Reductase Inhibitors". JAMA Intern Med. 177 (5): 683–691. PMID 28319231. doi:10.1001/jamainternmed.2017.0089.
- Thielke S (2017). "The Risk of Suicidality and Depression From 5-α Reductase Inhibitors". JAMA Intern Med. 177 (5): 691–692. PMID 28319227. doi:10.1001/jamainternmed.2017.0096.
- Locci A, Pinna G (2017). "Neurosteroid biosynthesis downregulation and changes in GABAA receptor subunit composition: A biomarker axis in stress-induced cognitive and emotional impairment". Br. J. Pharmacol. PMID 28456011. doi:10.1111/bph.13843.
- Andersson, S. (July 2001). "Steroidogenic enzymes in skin". European journal of dermatology: EJD. 11 (4): 293–295. ISSN 1167-1122. PMID 11399532.
- Azzouni F, Godoy A, Li Y, Mohler J, et al. (2012). "The 5 alpha-reductase isozyme family: a review of basic biology and their role in human diseases". Adv Urol. 2012: 530121. PMC . PMID 22235201. doi:10.1155/2012/530121.
- Finn, Deborah A.; Beadles-Bohling, Amy S.; Beckley, Ethan H.; Ford, Matthew M.; Gililland, Katherine R.; Gorin-Meyer, Rebecca E.; Wiren, Kristine M. (2006). "A new look at the 5alpha-reductase inhibitor finasteride". CNS drug reviews. 12 (1): 53–76. ISSN 1080-563X. PMID 16834758. doi:10.1111/j.1527-3458.2006.00053.x.
- Karnsomwan, Wiranpat; Rungrotmongkol, Thanyada; De-Eknamkul, Wanchai; Chamni, Supakarn (2016-06-01). "In silico structural prediction of human steroid 5α-reductase type II". Medicinal Chemistry Research. 25 (6): 1049–1056. ISSN 1054-2523. doi:10.1007/s00044-016-1541-y.
- Chen, Grace Shiahuy; Chang, Chih-Shiang; Kan, Wai Ming; Chang, Chih-Long; Wang, K. C.; Chern, Ji-Wang (2001-11-01). "Novel Lead Generation through Hypothetical Pharmacophore Three-Dimensional Database Searching: Discovery of Isoflavonoids as Nonsteroidal Inhibitors of Rat 5α-Reductase". Journal of Medicinal Chemistry. 44 (23): 3759–3763. ISSN 0022-2623. doi:10.1021/jm010433s.
- Yamana, Kazutoshi; Labrie, Fernand; Luu-The, Van (2010-08-01). "Human type 3 5α-reductase is expressed in peripheral tissues at higher levels than types 1 and 2 and its activity is potently inhibited by finasteride and dutasteride". Hormone Molecular Biology and Clinical Investigation. 2 (3). ISSN 1868-1891. doi:10.1515/hmbci.2010.035.
- Borchardt, Ronald T.; et al. (2006). Integration of Pharmaceutical Discovery and Development. Google Books: Kluwer Academic Publishers. p. 398. ISBN 0-306-47384-4.
- Chang, Chawnshang (2005). Prostate Cancer: Basic Mechanisms and Therapeutic Approaches. Singapore: World Scientific Publishing. p. 250. ISBN 981-256-067-X.
- Kulig, Katarzyna., Malawska, Barbara (2006). "Trends in the Development of New Drugs for Treatment of Benign Hyperplasia". Current Medicinal Chemistry. 13: 3395–2416.
- "Herbal medicine: Summary for the Public. Saw Palmetto Fruit." (PDF). www.ema.europa.eu. 5 April 2016. Retrieved 28 September 2017.