Finasteride, fruit, and the matter of prostate health

by Arnon Krongrad, MD

The noose was loose on its neck. At first I worried, but then I relaxed. This was a bottle of pomegranate juice, the antioxidant superpower. As the billboard implied, it could cheat death. Perhaps if I consumed pomegranate juice, I could cheat death.

Last week, the Federal Trade Commission charged POM Wonderful, LLC, makers of pomegranate products, with deceptive advertising. What took so long is anyone’s guess. Of all the health implications floating in our ether – Ben and Jerry’s Chubby Hubby ice cream is all natural; mouthwash reduces plaque above the gum line –pomegranate promotions have seemed the most aggressive. And no pomegranate promotion has seemed to me the most insistent than the one for prostate health.

Do pomegranates promote prostate health? Assuming that “prostate health” means primary prevention of such illness as prostate cancer, then the answer is no: The scientific literature is without support for this idea. Yes, there are laboratory studies showing that pomegranate can effect biological changes in prostate cells and prostate grown in vitro. Yes, clinical trials are ongoing, but they have not yet matured. So while pomegranate may taste good and hold mystical meaning for some, it is for now an unproven clinical tool.

So how do consumers behave when scientific data actually support claims of prostate health?

Consider 5-alpha reductase, an enzyme that converts the androgen testosterone to the androgen dihydro-testosterone. The enzyme’s dysfunction as a consequence of genetic mutation manifests clinically with a failure of phenotypic virilization. Because of its relevance to androgen action, this enzyme has been a pharmaceutical target for conditions hypothesized to result from too much androgen action, especially in older men and ranging from urinary retention to chronic prostatitis to male pattern baldness.

The PCPT Trial showed that the 5-alpha reductase inhibitor finasteride (Proscar; Propecia) lowers the risk of prostate cancer, a disease whose development appears to rely upon the presence of androgens; likewise, the REDUCE Trial showed that dutasteride (Avodart), another 5-alpha reductase inhibitor, lowers the risk of prostate cancer. The data in support of finasteride are solid, the result of well done, randomized, placebo controlled clinical trials.

Has this mattered? Apparently not. A study published last month shows that in fact the publication of the finasteride data has seemed to make no significant difference in the prescription of finasteride.

Why do men interested in prostate health drink pomegranate juice but not take finasteride?

First of all, pomegranate is all natural; finasteride is all synthetic. People seem to love what is natural. However, this love is not uniform. Many people know that animal fat, another natural product, is generally bad. This is not about what is natural, but what people perceive to be good. And when it comes to pomegranates, perceptions have in recent years been altered by smoke and mirrors, not science. Perceptions can be altered through education, including by doctors, that sometimes science is better than nature.

Secondly, pomegranate is not regulated by the Food and Drug Administration; finasteride is. This means that we know little about the safety of large quantities of pomegranate; we know that finasteride is associated with the risk of gynecomastia, loss of libido, and reduced ejaculate volume. So pomegranates appear safe and they probably are in normal doses. But as with aspirin-containing willow bark, pomegranate toxicity may be dose dependent. Maybe at high doses, pomegranate is really not so safe.

You can get pomegranates from the tree in the yard; you can only get finasteride by prescription from your doctor. And if you see your doctor maybe you have to have a serious discussion about side effects and how finasteride will lower your serum PSA and perhaps mask a prostate cancer so maybe before you start it you should go see a urologist and have your prostate checked which means a blood test and a finger up your rear end. Finasteride is inconvenient compared with casually picking up a bottle of juice at your market.

Maybe the POM Wonderful, LLC people will be convicted of deceptive advertising. Maybe as a penalty they will do community service. If so, maybe they can teach Merck, makers of finasteride, how to market. Maybe if finasteride had a noose on its neck, we’ll behave in a way that makes sense.

Arnon Krongrad is Medical Director of the Krongrad Institute for Minimally Invasive Prostate Surgery and the not-for-profit Prostate Cancer International. He blogs at Prostatitis Blog and Scrub, Rinse, Repeat.

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