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Staff Pharmacist Stop and Shop Pharmacy #473 Fall River, Massachusetts
Associate Professor of Pharmacy Practice Massachusetts College of Pharmacy and Health Sciences 179 Longwood Avenue Boston, Massachusetts 02115 fax 617/732-2244 jennifer.goldman-levine{at}mcphs.edu Clinical Faculty Tufts University Family Medicine Residency Program
Published Online, May 22, 2007. www.theannals.com, DOI 10.1345/aph.1G442
Case Report. A 25-year-old white woman being treated for depression presented to her community pharmacy in January 2005 complaining of hair loss. She denied any changes in her diet, shampoos, soaps, and any known medication allergies. As shown in her medication profile, the newest medications had been started in August 2004 and included venlafaxine ER and trazodone 100 mg at bedtime. Venlafaxine had been started at 75 mg daily and titrated to 150 mg twice a day over a 5 month period using a dose increase of 75 mg every 2 months. She had also been taking an oral contraceptive (drospirenone 3 mg plus ethinyl estradiol 30 µg daily) since September 2003. She denied using any herbal, homeopathic remedies or over-the-counter drug products. Her medical history included depression (sometimes with suicidal ideations), anxiety, and insomnia. She had no history or evidence of endocrine disorders. The patient denied tobacco, alcohol, or caffeine use.
Following 5 months of venlafaxine ER therapy, hair loss was noticed. The dose was then decreased to 225 mg each morning. At this time, a decrease in hair loss and an increase in her depressive symptoms occurred. Venlafaxine ER was then discontinued over a 6 week period while citalopram 20 mg daily was initiated.
During this time of venlafaxine ER discontinuation, trazodone 100 mg at bedtime, the oral contraceptive, and citalopram 20 mg were continued. Upon discontinuation of venlafaxine ER, the patient, at the suggestion of her pharmacist, began treatment with zinc gluconate 50 mg daily for 2 weeks because, in some cases of hair loss induced by antipsychotics, chelation of zinc may occur, leading to depletion of zinc levels.3,4 A zinc level was not determined in this patient. Zinc has been used in the treatment of alopecia, but efficacy has not been established. During the 2 week period, an increase in hair growth in previously affected areas was reported by the patient. It is unknown whether zinc gluconate contributed to regrowth of hair or whether it was a result of discontinuing the venlafaxine ER.
Discussion: We found no reports of hair loss associated with the other medications that the patient was taking. Trazodone therapy and the oral contraceptive have been continued and the patient has not experienced any further hair loss after the discontinuation of venlafaxine ER. No other adverse events have been reported.
In the 2 reported cases of venlafaxine-induced alopecia, the authors stated that alopecia ensued upon increasing the dosage, but each woman noticed hair loss at different times during the course of therapy.1,2 Upon discontinuation of venlafaxine therapy, both women reported hair regrowth within 2–4 weeks. Neither patient had a pertinent medical history to suggest that the hair loss was associated with another cause. Neither of these cases had been assessed using the Naranjo probability scale.5
Application of the Naranjo probability scale indicated a probable relationship between alopecia and venlafaxine ER therapy in our patient.5 Clinicians should be aware that selective serotonin-reuptake inducers, bupropion, and now a third case involving venlafaxine have been implicated in drug-induced alopecia.
Footnotes
Letters are subject to review prior to acceptance. They should address areas related to pharmacy practice, research, or education, or articles recently published. Corrections of previously published material also are accepted. Letters are limited to no more than five authors. In cases where adverse drug effects are described, the Naranjo ADR probability scale should be used to determine the likelihood that the adverse effect was drug-related (Clin Pharmacol Ther 1981;30:239-45). Text: limit 500 words. References: limit 5. Art: limit 1 table or figure.
References
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