Ask Dr. Stephan Moll

These questions have been submitted by folks on the mailing list and answered by Dr. Moll, Director of the Thrombophilia Program at the Carolina Cardiovascular Biology Center, Department of Medicine, Division of Hematology-Oncology, UNC Chapel Hill (North Carolina, USA). Why am I doing this?

22. Hair loss and coumadin^®

Q1: “In the past couple of months I have noticed that my hair is coming out. It never happened until I started taking coumadin®?. Another friend of mine with APS [= antiphospholipid antibody syndrome] had the same problem and ended up bald and had to buy a wig. She was on coumadin®? about a year or so when she noticed her hair was falling out. Is this a side effect that nobody bothered telling me about? If so, I am going to quit taking coumadin? and see if it continues. To me...it's not worth losing my hair over. My looks have gone to hell as it is and the last thing I need now is to go bald. I'm willing to take risks without the coumadin®? to try to hold on to what little looks I have left.”
A1: Hair loss can be due to coumadin®? (= warfarin). It can also be due to the underlying disorder, particularly autoimmune disorders, such as lupus erythematosus and antiphospholipid antibody syndrome. If it is bothersome enough one should discuss the use of long-term low-molecular-weight-heparin (Lovenox?, Fragmin?, etc.) instead.

Q2: “Since I have increased my coumadin®? to 12.5 mg per day, my hair has started coming out by the handfuls each time that I wash it. Is it possible that this is a side effect of coumadin®?, and what can I do for it if it is indeed a side effect?”
A2: Hair loss can be due to coumadin®? (= warfarin). Coenzyme Q10 (= ubidecarenone), 30 mg per day, may help, but has not been studied well. There are no other therapies that have been studied.

Q3:"My mother is having hair loss from her coumadin® treatment. Is there any information beyond Coenzyme Q-10 which has not worked for her? Is switching to low molecular weight heparin (Fragmin®, Innohep®, or Lovenox®) an option? She is afraid that the hair loss will occur with that drug as well, since it is reported as a side effect. She is also concerned that there is not a lot of data on the efficacy of long-term use of low molecular weight heparin in treating deep vein thrombosis."
A3: In patients who have significant side effect from warfarin (such as significant hairloss, uncontrollable INR fluctuations, severe fatigue) it may be reasonable to switch to long-term treatment with a low molecular weight heparin (Fragmin®, Innohep®, or Lovenox®). Treatment with long-term low-molecular-weight heparin appears to be a safe and effective alternative to warfarin [reference 2]. However, low molecular weight heparins have also been reported to occasionally cause hairloss [references 3-5]. The traditional unfractionated heparin can also do that [reference 6]).

Hair loss (= alopecia) is a known side effect of coumadin®(= warfarin) therapy, but has hardly been studied. Solid data on how frequently it occurs, on its time-course, and on treatment are therefore not available. Mild hair loss may be common, severe hair loss appears to be uncommon, complete hair loss has not been reported. In some patients hair loss occurs because of the patient’s acute illness, i.e. the clotting event itself (and not because of initiation of coumadin® therapy) and appears to start weeks to months after the acute event, and then slowly resolve. The coumadin®-associated hair loss may occur within weeks to months of starting coumadin®, but has also been reported to occur after several years of therapy. In some patients the hair loss slows down in spite of continuation of coumadin®. The hair loss has been found to be reversible, once coumadin® is stopped.

Little is know as to what to do to prevent the hair loss. There is a report in the medical literature that Coenzyme-Q10 (= ubidecarenone), 30 mg per day, slowed and reversed the hair loss in 2 patients, in spite of continuation of coumadin® therapy [reference 1]. If a patient starts Coenzyme Q10, he/she should get an INR checked 3-4 days later and again approximately 10 days later to make sure that Coenzyme Q10 does not influence the INR (an increase in INR was observed in one of the 2 patients reported). Other treatment interventions, such as Biotin or Zinc tablets, have not been studied. I am not aware of any data on whether the drug Minoxidil helps with warfarin-associated hairloss.

Additional comment:
Eleven of the over 700 subscribers on the FV Leiden LIST-SERVE responded positive (in November 2001) to my question whether anybody had experienced hair loss on coumadin® (= warfarin): 3 reported mild, 6 moderate, and 2 severe hair loss. Nobody reported that he/she lost all hair or started wearing a wig. In several individuals the hair loss resolved or slowed down in spite of continuation of coumadin®.

Reference:

1. Nagao T, Ibayashi S, Fujii K, Sugimori H, Sadoshima S and Fujishima M: Treatment of warfarin-induced hair loss with ubidecarenone. Lancet 1995;346:1104-1105.
2. van der Heijden JF, Hutten BA, Büller HR, Prins MH: Vitamin K antagonists or low-molecular-weight heparin for the long term treatment of symptomatic venous thromboembolism. Cochrane Database Syst Rev 2002;(1):CD002001. Review.
3. Apsner R, Horl WH, Sunder-Plassmann G Dalteparin-induced alopecia in hemodialysis patients: reversal by regional citrate anticoagulation. Blood 2001 May 1;97(9):2914-5.
4. Sarris E, Tsele E, Bagiatoudi G, Salpigidis K, Stavrianaki D, Kaklamanis L, Siakotos M: Diffuse alopecia in a hemodialysis patient caused by a low-molecular-weight heparin, tinzaparin. Am J Kidney Dis. 2003 May;41(5):E15.
5. Barnes C, Deidun D, Hynes K, Monagle P.Alopecia and dalteparin: a previously unreported association. Blood 2000 Aug 15;96(4):1618-9.
6. Hirschboeck JS, Madison FW, Pisciotta AV: Alopecia and other toxic effects of heparin and synthetic heparinoids. Am J Med Sci. 1954 Mar;227(3):279-82

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