Case Studies

CASE 1

CC, a 27-year-old man, comes to the pharmacy counter carrying a number of boxes containing various minoxidil products, including different strengths (2% and 5%) and preparations (solutions and foams). Upon quick inspection, you see recession of CC’s frontal hairline, mainly in a triangular pattern. CC asks if you can recommend a product to treat his male pattern baldness. CC is otherwise healthy and takes no prescription or OTC medications. What advice should you give CC about which product to use and what to expect?

CASE 2

BB, a 67-year-old man, is at his dentist appointment. His dentist determines that BB needs to have a tooth extracted and should schedule an appointment. In BB’s chart, the dentist sees that BB has hypertension, type 2 diabetes mellitus, and atrial fibrillation, and that BB is being treated with apixaban 5 mg twice daily for stroke prevention, lisinopril 20 mg once daily, metformin 1000 mg twice daily, and glipizide XL 10 mg once daily. The dentist calls you (BB’s pharmacist) to ask how long BB’s anticoagulation treatment needs to be stopped before a tooth extraction can be performed.

How should you respond to the dentist?

ANSWERS

Case 1: Topical minoxidil 2% to 5% (1 mL twice daily for the solution, or a half capful twice daily for the foam) is recommended to improve or prevent progression of hair loss in male patients older than 18 years with mild to moderate androgenetic alopecia. The 5% minoxidil products have been shown to have greater efficacy than the 2% products; however, the 5% solutions tend to cause more scalp irritation than the foams because of their higher propylene glycol content. For this reason, you might recommend a 5% minoxidil foam product in order for CC to obtain optimal results with the least irritation. CC should continue the treatment for 6 months to assess whether he responds to it. If improvement is seen, the therapy needs to be continued to maintain efficacy.

CC should be counseled that the most common side effect of all minoxidil products is hypertrichosis (an abnormal amount of hair growth), which is often due to incorrect application. To decrease the risk of hypertrichosis, CC should be advised to apply the drug at least 2 hours before going to bed to avoid contamination of his pillow and subsequent contact with his face.

CC should be warned that he may observe increased hair loss (“hair shedding”) in the first few months of treatment. This is a transitory effect that does not suggest a lack of efficacy, and minoxidil should be continued during this time.

Case 2: You can inform the dentist that when performing a procedure carrying no clinically important bleeding risk (such as a tooth extraction) in a patient receiving one of the newer oral anticoagulants (apixaban, rivaroxaban, or dabigatran), the anticoagulant does not need to be stopped prior to the procedure. However, the procedure should be performed when the anticoagulant concentration is at its trough level (ie, 12 to 24 hours after the last dose, depending on whether a once- or twice-daily anticoagulant is being administered). Apixaban, which is administered twice daily, will be at trough levels ~12 hours after BB takes his last dose.

For the sake of convenient timing, it may make sense to schedule BB’s tooth extraction 18 to 24 hours after his last dose, and then restart his apixaban about 6 hours after the procedure has been completed. BB should be monitored in the dentist’s office until all bleeding has stopped. If the dentist has concerns regarding bleeding after the procedure, the pharmacist could recommend that the dentist prescribe aminocaproic acid 5% solution, with directions to hold 10 mL in the mouth for 1 to 2 minutes, and then spit, and to repeat this 4 times a day for 5 days.

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Dr. Coleman is professor of pharmacy practice, as well as codirector and methods chief at Hartford Hospital Evidence-Based Practice Center, at the University of Connecticut School of Pharmacy.