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Transcript of Update on Hypogonadism and - Grant/Downing€¦ · Update on Hypogonadism and Testosterone...
Update on Hypogonadism and Testosterone Replacement Therapy
The Primary Care Perspective
Update on Hypogonadism and Testosterone Replacement Therapy
The Primary Care Perspective
Martin Miner MD
Clinical Associate Professor of Family Medicine
Warren Alpert School of Medicine
Brown University
Co-Director Men’s Health Center
Miriam Hospital
Providence, RI
Martin Miner MD
Clinical Associate Professor of Family Medicine
Warren Alpert School of Medicine
Brown University
Co-Director Men’s Health Center
Miriam Hospital
Providence, RI
3
DisclosuresDisclosures
Dr Miner: consultant: Auxilium Pharmaceuticals, Inc., Bayer Schering Pharma, BoehringerIngelheim, Endo Pharmaceuticals
Research support: GSK
Dr Miner: consultant: Auxilium Pharmaceuticals, Inc., Bayer Schering Pharma, BoehringerIngelheim, Endo Pharmaceuticals
Research support: GSK
4
Learning ObjectivesLearning Objectives
Explain the role of testosterone in overall health and the burden of testosterone deficiency
Recognize the role of hypogonadism in obesity, metabolic syndrome, diabetes, cardiovascular disease, and erectile dysfunction (ED)
Identify the signs and symptoms of hypogonadism and their complex clinical presentation
List the options available to treat hypogonadism
Monitor potential adverse effects of treatment
Explain the role of testosterone in overall health and the burden of testosterone deficiency
Recognize the role of hypogonadism in obesity, metabolic syndrome, diabetes, cardiovascular disease, and erectile dysfunction (ED)
Identify the signs and symptoms of hypogonadism and their complex clinical presentation
List the options available to treat hypogonadism
Monitor potential adverse effects of treatment
5
How Is HypogonadismDefined?
How Is HypogonadismDefined?
● “Hypogonadism is a clinical condition characterized by low serum testosterone levels occurring in association specific signs and symptoms.”
●Other terminologies for hypogonadism
Decline of testosterone and male androgens in men of any age
Andropause: hypogonadism in older men or androgen deficiency in aging men (ADAM)
Late-onset hypogonadism (LOH)
Partial androgen deficiency in aging men (PADAM)
● “Hypogonadism is a clinical condition characterized by low serum testosterone levels occurring in association specific signs and symptoms.”
●Other terminologies for hypogonadism
Decline of testosterone and male androgens in men of any age
Andropause: hypogonadism in older men or androgen deficiency in aging men (ADAM)
Late-onset hypogonadism (LOH)
Partial androgen deficiency in aging men (PADAM)Rhoden EL, Morgentaler A. N Engl J Med. 2004;350:482-492.
6
How Is HypogonadismDefined?
How Is HypogonadismDefined?
A symptom complex in the presence of low levels of testosterone1,2
Age-related changes in physiologic function affected by testosterone levels2
Increased BMILow bone mineral densityReduced cognition and memory Depressed moodDecreased sexual desire and functionReduced strength and energy
A symptom complex in the presence of low levels of testosterone1,2
Age-related changes in physiologic function affected by testosterone levels2
Increased BMILow bone mineral densityReduced cognition and memory Depressed moodDecreased sexual desire and functionReduced strength and energy
BMI = body mass index.1. Morley JE et al. Metabolism. 2000;49:1239-1242. 2. Bhasin S et al. J Clin Endocrinol Metab.
2006;91:1995-2010.
71. AACE Hypogonadism Task Force. Endocr Pract. 2002;8:439-456. 2. Bhasin S et al. J Clin Endocrinol Metab.
2006;91:1995-2010. 3. Mulligan T et al. Int J Clin Pract. 2006;60:762-769.
Clinical Manifestations of Hypogonadism
Clinical Manifestations of Hypogonadism
Physical/Metabolic Psychological1,2 Sexual1,2
• Decreased bonemineral density1,2
• Decreased musclemass and strength1,2
• Gynecomastia1,2
• Anemia1,2
• Frailty3
• Increased body fat or BMI1,2
• Fatigue1,2
• Insulin resistance
• Depressed mood• Diminished energy,
sense of vitality, orwell-being
• Impaired cognitionand memory
• Diminished libido• Erectile dysfunction• Difficulty
achieving orgasm• Decreased spontaneous
erections
Production and Regulation of TestosteroneProduction and Regulation of Testosterone
HypothalamusGnRH
Pituitary
Testes
FSHandLH
(Leydig cells) (Sertoli cells)
Testosterone Spermatogenesis
Testes++
+ -
- -
+- S. Urquhart 2007
9
Classification of Hypogonadism
Classification of Hypogonadism
Primary1,2 Secondary1,2 Mixed2
Dual HPGAxis Defects
• Hemochromatosis
• Sickle cell disease
• Thalassemia
• Glucocorticoidtreatment
• Alcoholism
PituitaryCauses
• Hypopituitarism
• Pituitary tumors:
• Ischemia
• Space Occupying Lesions
• Granulomatousdisease
HypothalamicCauses
• Kallmann syndrome
• Constitutional delay in growth and development
• Chronic illnesses
TesticularDisorders
• Klinefelter syndrome
• Orchitis
• Congenital or acquired anorchia
• Testicular tumors
• Testicular Torsion
HPG = hypothalamic-pituitary-gonadal.1. AACE Hypogonadism Task Force. Endocr Pract. 2002;8:439-456. 2. Bhasin S et al. J Clin Endocrinol Metab.
2006;91:1995-2010.
Epidemiology and Prevalence of Hypogonadism: The Baltimore Aging Study
Epidemiology and Prevalence of Hypogonadism: The Baltimore Aging Study
Harman SM, et al. J Clin Endocrinol Metab. 2001;86:724-731.
Perc
enta
ge
60 - 69
12%12%19%19%
28%28%
49%49%
50 - 59 70 - 79 80+
Age in Years
Percentage of men, by decade, with a testosterone valuein the hypogonadal range—total T <11.3 nmol/L (325 ng/dL)
Prevalence of Symptomatic Androgen Deficiency in Men
Prevalence of Symptomatic Androgen Deficiency in Men
Boston Area Community Health
N=1,475 men, aged 39-79 (better ethnic mix)
24% of the men had TT <300 ng/dL
11% of the men had free T <5 ng/mL
Crude prevalence of symptomatic hypogonadismwas 5.6%
Increases substantially with age
Better overall estimate is that 4-5 million men in the US have hypogonadism
Boston Area Community Health
N=1,475 men, aged 39-79 (better ethnic mix)
24% of the men had TT <300 ng/dL
11% of the men had free T <5 ng/mL
Crude prevalence of symptomatic hypogonadismwas 5.6%
Increases substantially with age
Better overall estimate is that 4-5 million men in the US have hypogonadism
Araujo et al (NERI) J Clin Endo Metab 2007; 92: 4241-4247
12
Prevalence and Under-treatmentin the United States
Prevalence and Under-treatmentin the United States
BACH, Boston Area Community Health Survey.1. Araujo AB et al. J Clin Endocrinol Metab. 2007;92:4241-4247. 2. Reproduced with permission from Hall SA et al.
Arch Intern Med. 2008;168:1070-1076. 3. IMS Health analyzes testosterone use in U.S. IMS Health Web site. http://www.imshealth.com/portal/site/imshealth/menuitem.a46c6d4df3db4b3d88f611019418c22a/?vgnextoid=
77d68ede1ca19110VgnVCM10000071812ca2RCRD&vgnextfmt=default. Accessed September 18, 2009.
819,000 men receive testosterone therapy3
(breakdown by age)BACH Survey estimated crude
prevalence of symptomatic androgen deficiency is 5.6%1
2
Wei
ghte
d P
reva
lenc
e (%
)
Treated12.2%
Symptomaticuntreated
87.8%
1%>65 y
46-65 y
18-45 y
<18 y
Hypogonadism in MalesHIM Study
Hypogonadism in MalesHIM Study
An Epidemiological Study to Estimate the Population Prevalence of Hypogonadism
in the US
Mulligan T, et al. Prevalence of hypogonadism in males aged at least 45 years: the HIM Study. Int J Clin Pract 2006; 60:762-9
An Epidemiological Study to Estimate the Population Prevalence of Hypogonadism
in the US
Mulligan T, et al. Prevalence of hypogonadism in males aged at least 45 years: the HIM Study. Int J Clin Pract 2006; 60:762-9
Hypogonadism in MalesHIM Study
An Epidemiological Study to Estimate the Population Prevalence of Hypogonadism in the US
Hypogonadism in MalesHIM Study
An Epidemiological Study to Estimate the Population Prevalence of Hypogonadism in the US
2650 sites contacted
95 sites enrolled patients in 25 states47 Family Practice, 44 Internal Medicine, 3 Endocrinology, 1 Urology
2,165 patients enrolled
Prevalence of hypogonadism: 38.7%Hypogonadism: TT < 10.4 nmol/L
2650 sites contacted
95 sites enrolled patients in 25 states47 Family Practice, 44 Internal Medicine, 3 Endocrinology, 1 Urology
2,165 patients enrolled
Prevalence of hypogonadism: 38.7%Hypogonadism: TT < 10.4 nmol/L
Mulligan, Mulligan, IntInt J J ClinClin PractPract 2006; 60: 7622006; 60: 762--99
The Prevalence of Low Testosterone Increases with Age (<300 ng/dL)
The Prevalence of Low Testosterone Increases with Age (<300 ng/dL)
45 to 54 55 to 64 65 to 74 75 to 84 85+ Total0
10
20
30
40
50
60
70
38.7(36.6–40.7)
50.0(32.7–67.3)
45.5 (39.0–52.1)39.9
(35.4–44.4)40.2
36.6–43.8)34.0
(30.6–37.4)
Patient Age Range
Pre
vale
nce
of L
ow T
in A
ll E
nrol
led
Pat
ient
s (%
, 95%
CI)
Mulligan, et al. Int J Clin Pract. 2006 Jul;60(7):762–769.
Over 1/3 of men over 45 years of age have a low testosterone level
Co-Morbidities in Hypogonadal MenMulligan, Int J Clin Pract 2006; 60: 762-9
Co-Morbidities in Hypogonadal MenMulligan, Int J Clin Pract 2006; 60: 762-9
* P = <0.001
Odds Ratio of Selected Co-Existing Diseases
Mulligan, Int J Clin Pract 2006; 60: 762-9
Odds Ratio of Selected Co-Existing Diseases
Mulligan, Int J Clin Pract 2006; 60: 762-9
Medical ConditionsMedical Conditions Odds Ratio (95% C.I.)Odds Ratio (95% C.I.)
ObesityObesity 2.33 (1.90, 2.85)2.33 (1.90, 2.85)
DiabetesDiabetes 2.04 (1.67, 2.50)2.04 (1.67, 2.50)
HypertensionHypertension 1.80 (1.50, 2.14)1.80 (1.50, 2.14)
OsteoporosisOsteoporosis 1.59 (0.77, 3.30)1.59 (0.77, 3.30)
Rheumatoid ArthritisRheumatoid Arthritis 1.55 (0.91, 2.62)1.55 (0.91, 2.62)
HyperlipidemiaHyperlipidemia 1.49 (1.25, 1.78)1.49 (1.25, 1.78)
Asthma/COPDAsthma/COPD 1.42 (1.07, 1.88)1.42 (1.07, 1.88)
Chronic PainChronic Pain 1.20 (0.95, 1.50)1.20 (0.95, 1.50)
Prostate DiseaseProstate Disease 1.19 (0.95, 1.49)1.19 (0.95, 1.49)
18
Case Study: AdamCase Study: AdamA 48-year-old man presents with ED, fatigue,
depressed mood, and distress in the marital relationship. Low libido. Medical history otherwise unremarkable
Weight 220 lb BMI 35.5
Height 5’ 6’’
Waist circumference 44”
BP 140/90
Genital exam normal
DRE normal
A 48-year-old man presents with ED, fatigue, depressed mood, and distress in the marital relationship. Low libido. Medical history otherwise unremarkable
Weight 220 lb BMI 35.5
Height 5’ 6’’
Waist circumference 44”
BP 140/90
Genital exam normal
DRE normalDRE = digital rectal exam.
19
What would be your next step?What would be your next step?
PDE5 = phosphodiesterase type 5.
1. Refer to marital counseling
2. Refer to psychiatrist
3. Order labs including testosterone
4. Prescribe PDE5 inhibitor and check testostoerone
5. Prescribe testosterone
1. Refer to marital counseling
2. Refer to psychiatrist
3. Order labs including testosterone
4. Prescribe PDE5 inhibitor and check testostoerone
5. Prescribe testosterone
20
Low Testosterone Also PredictsAll-Cause Mortality in Older MenLow Testosterone Also PredictsAll-Cause Mortality in Older Men
Laughlin G, et al. J Clin Endocrinol Metab. 2008;93:68-75.
PopulationPopulation--based Studybased Study——1212--Year FollowYear Follow--upup
Testosterone Testosterone ((ng/dLng/dL))
Median Hormone Median Hormone Level (Level (ng/dLng/dL))
Adjusted HR (95% CI)*Adjusted HR (95% CI)*
>370>370 436436 1.001.00
300300--370370 331331 0.93 (0.73, 1.19)0.93 (0.73, 1.19)
241241--299299 273273 1.15 (0.90, 1.47)1.15 (0.90, 1.47)
<241<241 204204 1.44 (1.12, 1.84)1.44 (1.12, 1.84)
PP for trend = 0.002for trend = 0.002
*Adjusted for age, BMI, waist-hip ratio, alcohol use, current smoking, exercise
Men with low and equivocal serum T levels had increased all-cause mortality and shorter survival times.
•VA Puget Sound study of 858 men•8 year follow-up
•Low T <250 ng/dLor a free T <0.75
ng/dL•All-cause mortality was 34.9% in men
with low T and 20.1% in men with normal T.
Low Testosterone Levels are Associated with an Increased Mortality Rate
Low Testosterone Levels are Associated with an Increased Mortality Rate
Shores MM. Arch Intern Med. 2006;166(15):1660-1665
EPICEPIC--Norfolk Study: Testosterone Levels are Norfolk Study: Testosterone Levels are Related to AllRelated to All--Cause and CVD MortalityCause and CVD Mortality
Increasing endogenous Testosterone levels are inversely related to mortality due to all causes, CV causes, and cancer.
N-2314 men aged 42-78 y.Khaw KT et al. Circulation 2007;116(23):2694-2701
23
In spite of differences among various labs, total testosterone level is commonly
considered hypogonadal when it is below:
In spite of differences among various labs, total testosterone level is commonly
considered hypogonadal when it is below:
1. 400 ng/dL
2. 300 ng/dL
3. 200 ng/dL
4. 100 ng/dL
5. 50 ng/dL
1. 400 ng/dL
2. 300 ng/dL
3. 200 ng/dL
4. 100 ng/dL
5. 50 ng/dL
International Society for the Study of the Aging Male (ISSAM) and European Academy of
Andrology (EAU) Guidelines 2008
International Society for the Study of the Aging Male (ISSAM) and European Academy of
Andrology (EAU) Guidelines 2008
●Total T: drawn between 7:00 am -11am
●No lower limit for normal
●Total T > 12 nmoL/l (350 ng/dL) do not generally require repletion
●Patients with Total T < 8 nmoL/l (230 ng/dL) will usually benefit from T Rx
●Total T: drawn between 7:00 am -11am
●No lower limit for normal
●Total T > 12 nmoL/l (350 ng/dL) do not generally require repletion
●Patients with Total T < 8 nmoL/l (230 ng/dL) will usually benefit from T Rx
24
Androgen Deficiency in Hypogonadal MenLaboratory Diagnosis
Androgen Deficiency in Hypogonadal MenLaboratory Diagnosis
If repeat serum total T between 250 and 350 ng/dL
Measure serum free T level by equilibrium dialysis
or Measure serum SHBG
and calculate free T or bioavailable T (bT)
If repeat serum total T between 250 and 350 ng/dL
Measure serum free T level by equilibrium dialysis
or Measure serum SHBG
and calculate free T or bioavailable T (bT)
SHBG
ALB
FreeEquilibrium
dialysis or
calc free TDirect
measurement of non-SHBG-
bound T or calculate
bioavailable T
26
What Level of Serum Testosterone Is Diagnostic for Hypogonadism?
What Level of Serum Testosterone Is Diagnostic for Hypogonadism?
●AACE GuidelinesTT* <200 ng/dL
Free T <50 pg/mL
Bioavailable T <70 ng/dL
●Endocrine Society GuidelinesTT <200 ng/dL = diagnostic
TT 200-320 ng/dL = equivocal range of hypogonadism
Free T <6.5 ng/dL or bioavailable T <15 ng/dL differentiates eugonadism from hypogonadism
● ISA, ISSAM, EAU: TT <346 ng/dL If TT < 150, order Proactin level
●AACE GuidelinesTT* <200 ng/dL
Free T <50 pg/mL
Bioavailable T <70 ng/dL
●Endocrine Society GuidelinesTT <200 ng/dL = diagnostic
TT 200-320 ng/dL = equivocal range of hypogonadism
Free T <6.5 ng/dL or bioavailable T <15 ng/dL differentiates eugonadism from hypogonadism
● ISA, ISSAM, EAU: TT <346 ng/dL If TT < 150, order Proactin level
*Most frequently used laboratory test for the diagnosis of hypogonadism.ISA = International Society of Andrology; ISSAM = International Society for the Study of the Aging Male; EAU = European Association of
Andrology
AACE Hypogonadism Task Force. Endocr Pract. 2002;8:440-456; Rosner W, et al. J Clin Endocrinol Metab. 2007; 92:405-413; Nieschlag E, et al. J Androl. 2006;27:135-137.
27
What Testosterone Level Warrants Treatment?
What Testosterone Level Warrants Treatment?
●Total testosterone <300 ng/dL
US Food and Drug Administration
American Society of Andrology
Endocrine Society 2006
●Total testosterone <300 ng/dL
US Food and Drug Administration
American Society of Andrology
Endocrine Society 2006
ASA Position Statement. J Androl. 2006; 27:133-134; Rosner W, et al. J ClinEndocrinol Metab. 2007; 92:405-413.
28
Laboratory Test ResultsLaboratory Test Results
Morning total testosterone: 160 ng/dLLH: lowProlactin: normalThyroid functions: normalLiver and kidney functions: normalLDL: 160Fasting glucose: 105CBC: normal
Morning total testosterone: 160 ng/dLLH: lowProlactin: normalThyroid functions: normalLiver and kidney functions: normalLDL: 160Fasting glucose: 105CBC: normalCBC = complete blood count; LDL = low-density lipoprotein.
29
What would be your next step?What would be your next step?
1. Prescribe testosterone
2. Prescribe PDE5 inhibitor
3. Prescribe testosterone + PDE5 inhibitor
4. Initiate weight loss program
5. Prescribe statin and oral hypoglycemic
1. Prescribe testosterone
2. Prescribe PDE5 inhibitor
3. Prescribe testosterone + PDE5 inhibitor
4. Initiate weight loss program
5. Prescribe statin and oral hypoglycemic
"Silent Killers" –Components of the metabolic syndrome
"Silent Killers" –Components of the metabolic syndrome
Dyslipidemia
Arterial Hypertension
Insulin Resistance /DM Type 2
+
Visceral fat tissue
BMI and BMI are not the same... Count on waist circumference
BMI and BMI are not the same... Count on waist circumference
189 cm, 93 kg = BMI 26 190 cm, 94 kg = BMI 26
Waist circumference Waist circumference>Testosterone Testosterone<
Guav AT J. Androl. 2009 Jul-Aug;30(4):370-6.Traish AM J. Androl. 2009b;302-23-32
There is an increased risk of hypogonadism in men with MS and its individual components, including insulin resistance.
Androgen Deficiency and Metabolic Androgen Deficiency and Metabolic Syndrome Share Many Common FactorsSyndrome Share Many Common Factors
Low Testosterone Levels are Associated with the Low Testosterone Levels are Associated with the Development of Metabolic SyndromeDevelopment of Metabolic Syndrome
In the MMAS, lower total T levels were predictive of metabolic syndrome, especially among those men with a body mass index below 25 kg/m2
Kupelian V et al. J Clin Endocrinol Metabl. 2006;91(3):843-850
Review of English-language literature re T and PCa
Number of articles in PSA era (1985-2004) regarding effect of TRT in men with PCa…
Review of English-language literature re T and PCa
Number of articles in PSA era (1985-2004) regarding effect of TRT in men with PCa…
Rhoden EL, Morgentaler R. N Engl J Med. 2004;350:482-492.
Number of Articles in PSA Era (1985-2004) Demonstrating TRT Causes PCa Progression…
Number of Articles in PSA Era (1985-2004) Demonstrating TRT Causes PCa Progression…
Testosterone and Prostate Cancer Prevalence
Prostate cancer risk doubled for men with the lowest testosterone values.
N=345aP=.04
Morgentaler A, Rhoden EL. Urology 2006;68(6):1263-1267
Is High T a Problem for PCa?Is High T a Problem for PCa?
Collaborative pooled worldwide analysis of 18 longitudinal studies
3886 men with PCa, 6438 controls
No association of PCa with serum androgensMen with PCa have similar T concentrations as men without PCa
Men with highest T at no greater risk of PCathan men with lowest T
Collaborative pooled worldwide analysis of 18 longitudinal studies
3886 men with PCa, 6438 controls
No association of PCa with serum androgensMen with PCa have similar T concentrations as men without PCa
Men with highest T at no greater risk of PCathan men with lowest T
RoddamRoddam AW, et al. AW, et al. J J NatlNatl Cancer InstCancer Inst. 2008;100:170. 2008;100:170--183.183.
38
Prostate Health AssessmentProstate Health AssessmentDRE
PSA
Consult with urologist
PSA >4.0 ng/mL
PSA velocity >0.4 ng/mL/y (using PSA level after 6 mo of therapy)
Detection of prostate abnormality on DRE
AUA prostate symptom score >19 with bother if PCP uncomfortable
DRE
PSA
Consult with urologist
PSA >4.0 ng/mL
PSA velocity >0.4 ng/mL/y (using PSA level after 6 mo of therapy)
Detection of prostate abnormality on DRE
AUA prostate symptom score >19 with bother if PCP uncomfortable
AUA = American Urological Association.Bhasin S et al. J Clin Endocrinol Metab. 2006;91:1995-2010.
39
Prostate Health Assessment Results
Prostate Health Assessment Results
IPSS: 11
DRE: normal
PSA: 0.7
IPSS: 11
DRE: normal
PSA: 0.7
IPSS = international prostate symptom score.
40
How would you counsel the patient?
How would you counsel the patient?
1. Testosterone therapy can be initiated safely
2. Referral to a urologist is necessary prior to testosterone therapy
3. Prostate biopsy will be necessary to rule out cancer
4. Consider alternatives to testosterone therapy
5. Not sure
1. Testosterone therapy can be initiated safely
2. Referral to a urologist is necessary prior to testosterone therapy
3. Prostate biopsy will be necessary to rule out cancer
4. Consider alternatives to testosterone therapy
5. Not sure
Effects of Testosterone Replacement in the Hypogonadal Man
Effects of Testosterone Replacement in the Hypogonadal Man
↑ Muscle strength/mass↑ Exercise tolerance
↑ Bone mineral density
↑ Mood/well-being↑ Cognition↑ Libido
↑ Erectile function↑ Sexual function
Effects on semen parameters
↓ CV risk factors
Improved CV profile
↓ Abdominal fat
↑ Insulin sensitivity
↑ Quality of life
↑ Erythropoeisis
Hair and beard effects
Skin effects
TRT improves insulin resistance, glycaemiccontrol, visceral adiposity and hyperlipidemia
in hypogonadal men with diabetes II
TRT improves insulin resistance, glycaemiccontrol, visceral adiposity and hyperlipidemia
in hypogonadal men with diabetes II
Double-blind placebo-controlled crossover study in 24 hypogonadal men over the age of 30 y with diabetes II.
Methods: IM testosterone 200 mg or placebo every 2 weeks for 3 months in random order, followed by a washout period of 1 month before the alternate treatment phase.
Double-blind placebo-controlled crossover study in 24 hypogonadal men over the age of 30 y with diabetes II.
Methods: IM testosterone 200 mg or placebo every 2 weeks for 3 months in random order, followed by a washout period of 1 month before the alternate treatment phase.
Kapoor D, Goodwin E, Channer KS & Jones TH: Euro J Endocrin 2006
3 mo Testosterone Treatment in 24 3 mo Testosterone Treatment in 24 HypogonadalHypogonadal Men Men (mean age: 64 yrs.) with Type 2 Diabetes Reduces HbA(mean age: 64 yrs.) with Type 2 Diabetes Reduces HbA1c1c ––
5 out of 10 Insulin5 out of 10 Insulin--Dependent Patients Reduced their Insulin Dependent Patients Reduced their Insulin Dosages Dosages
by a mean of 7 Unitsby a mean of 7 Units
Kapoor D et al. Eur J Endocrinol 154: 899-906 (2006)
p=0.03
3 mo Testosterone Treatment in 24 3 mo Testosterone Treatment in 24 HypogonadalHypogonadal Men (mean age: Men (mean age: 64 yrs.) with Type 2 Diabetes Reduces Waist Circumference and WH64 yrs.) with Type 2 Diabetes Reduces Waist Circumference and WHRR
a doublea double--blind, placeboblind, placebo--controlled, crossover studycontrolled, crossover study
Kapoor D et al. Eur J Endocrinol 154: 899-906 (2006)
p=0.03
p=0.01
WC WHR
45
Goals and Potential Benefits of Testosterone Replacement
Therapy
Goals and Potential Benefits of Testosterone Replacement
Therapy
Goals
●Treat signs and symptoms of hypogonadism
●Achieve and maintain eugonadalserum testosterone levels
●Individualize therapy to specific patient needs
Goals
●Treat signs and symptoms of hypogonadism
●Achieve and maintain eugonadalserum testosterone levels
●Individualize therapy to specific patient needs
Potential Benefits
●Restore libido and erectile function
●Increase energy and improve mood
●Improve body composition
↓ Fat mass
↑ Lean body mass
Possibly ↑ muscle strength
●Stabilize or increase BMD; perhaps reduce fractures
Potential Benefits
●Restore libido and erectile function
●Increase energy and improve mood
●Improve body composition
↓ Fat mass
↑ Lean body mass
Possibly ↑ muscle strength
●Stabilize or increase BMD; perhaps reduce fractures
Steidle CP. Rev Urol. 5(suppl 1):S34-S40; Nieschlag E, et al. Hum Reprod Update. 2004;10:409-419.
46
Options in Testosterone Replacement Therapy
Options in Testosterone Replacement Therapy
●IM: testosterone propionate, enanthate, or cypionate; testosterone undecanoate in development
●Buccal testosterone
●Transdermal patches
●Transdermal gel
●Oral: not approved in US
●Subcutaneous pellets
●IM: testosterone propionate, enanthate, or cypionate; testosterone undecanoate in development
●Buccal testosterone
●Transdermal patches
●Transdermal gel
●Oral: not approved in US
●Subcutaneous pellets Edelstein D, et al. Expert Opin Emerg Drugs. 2006;11:685-707.
48
Risks Associated With Testosterone Replacement Therapy
Risks Associated With Testosterone Replacement Therapy
COPD = chronic obstructive pulmonary disease
Wald M, et al. J Androl. 2006;27:126-132.
RISK COMMENT
• Oily skin, acne, skin reactions
Skin irritation more common with nonscrotal patches
• Breast enlargement or tenderness
Often transient and abates with continued treatment
• Sleep apnea?? Not reported as a consequence of treatment, but consider COPD in heavy smokers or overweight persons a relative contraindication
• Polycythemia Uncommon, but associated with age, sleep apnea, smoking history, and COPD
• Liver function abnormalities or tumors
Rare with injectable esters and transdermal formulations
• Lower extremity edema
May occur in first few months of treatment
• Symptomatic BPH and prostate cancer
Modest and inconsistent increases in prostate volume
Monitoring of Men Receiving TRT Monitoring of Men Receiving TRT Baseline
Determine voiding symptoms via history or IPSS
Determine history of sleep apnea
Digital rectal exam (DRE)
T levels, PSA, Hct, Hgb
Assess treatment efficacy at 1-2 mo; adjust dosage for suboptimal response
Evaluate patient at 3 mo and annually thereafter to assess symptom response and any adverse events
Baseline
Determine voiding symptoms via history or IPSS
Determine history of sleep apnea
Digital rectal exam (DRE)
T levels, PSA, Hct, Hgb
Assess treatment efficacy at 1-2 mo; adjust dosage for suboptimal response
Evaluate patient at 3 mo and annually thereafter to assess symptom response and any adverse events IPSS = International Prostate Symptom Score
Rhoden EL, Morgentaler A. N Engl J Med. 2004;350:482-492; Bhasin S, et al. J Clin Endocrinol Metab. 2006;91:1995-2010.
Monitoring of Men Receiving TRT(cont’d )
Monitoring of Men Receiving TRT(cont’d )
Check Hct and Hgb at 3 mo, then annually; if Hct>54%, stop therapy
Perform DRE and check PSA at 3-6 mo, then follow guidelines for screening (Q6month level, PSA, Hct, and DRE)
Measure BMD after 1-2 yr of therapy in men with osteoporosis
Evaluate formulation-specific adverse events at each visit
Check Hct and Hgb at 3 mo, then annually; if Hct>54%, stop therapy
Perform DRE and check PSA at 3-6 mo, then follow guidelines for screening (Q6month level, PSA, Hct, and DRE)
Measure BMD after 1-2 yr of therapy in men with osteoporosis
Evaluate formulation-specific adverse events at each visit IPSS = International Prostate Symptom Score
Rhoden EL, Morgentaler A. N Engl J Med. 2004;350:482-492; Bhasin S, et al. J Clin Endocrinol Metab.2006;91:1995-2010.
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Testosterone FormulationsTestosterone Formulations
Formulation DosageInjectable
Testosterone cypionate/enanthate1,2
Testosterone undecanoate (TU)(in development in the United States)
50-400 mg every 2 wk750 mg at baseline, 4 wk, and every 10 wk thereafter
ImplantsTestosterone pellets4 150-450 mg (2-6 pellets) every 3-6 mo
TopicalTopical gel5,6
Transdermal patch system7
5-10 g daily5 mg daily
BuccalBuccal system8 30 mg every 12 h
1. Delatestryl [package insert]. Lexington, MA: Indevus Pharmaceuticals Inc; 2005. 2. Depo-Testosterone [package insert]. Kalamazoo, MI: Pharmacia Corporation; 2002. 3. Morgentaler A et al. J Urol. 2008;180:2307-
2313. 4. Testopel [package insert]. Rye, NY: Bartor Pharmacal Co Inc; 2007. 5. AndroGel [package insert]. Marietta, GA: Solvay Pharmaceuticals Inc; 2007. 6. Testim [package insert]. Norristown, PA: Auxilium
Pharmaceuticals Inc; 2003. 7. Androderm [package insert]. Corona, CA: Watson Pharma Inc; 2005. 8. Striant[package insert]. Livingston, NJ: Columbia Laboratories Inc; 2003.
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Formulation-Specific Adverse EffectsFormulation-Specific Adverse Effects
Bhasin S et al. J Clin Endocrinol Metab. 2006;91:1995-2010.
Formulation Adverse EffectInjectable
Testosterone cypionate/enanthate Mood fluctuations or changes in libidoPain at injection siteErythrocytosis
TU (in development in the United States) Pain at injection site
ImplantsTestosterone pellets Potential infections or expulsion
TopicalTopical gel Skin-to-skin transferencePatch system Skin irritation
BuccalBuccal system Alterations in taste and irritation of gums and oral
mucosa
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ConclusionsConclusionsHypogonadism and TRT
A symptom complex in the presence of low levels of testosterone
Age-related changes in physiologic function affected by testosterone levels
Hypogonadism is associated with significant reduction of quality of life, important comorbidities and maybe increased mortality
TRT in carefully selected patients provides satisfactory results
Expanding options for TRT
Hypogonadism and TRT
A symptom complex in the presence of low levels of testosterone
Age-related changes in physiologic function affected by testosterone levels
Hypogonadism is associated with significant reduction of quality of life, important comorbidities and maybe increased mortality
TRT in carefully selected patients provides satisfactory results
Expanding options for TRT
TRT = testosterone replacement therapy.