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Discussion in 'Men's Health Forum' started by Michael Scally MD, Sep 30, 2010.
Thought so too.
So transdermal is better to help keep the blood levels more manageable then?
Is testosterone Replacement Therapy in Older Men Effective and Safe?
The number of older adults over 65 years of age is expected to increase to almost 100 million in the US by 2050, more than double the current figure of 46 million. Advanced age is associated with increased frailty among older Americans and often leads to increased disability, hospitalization, institutionalization, and, eventually, mortality.
In search of means to improve age-related risks for adverse health outcomes, the question of restoring diminishing sex hormones has gathered much interest and has led to the practice of sex hormone replacement therapies in older men.
Recent data suggest that androgen prescription rates in the US for men older than 60 years of age quadrupled from the years 2001 to 2011. While prescription sales of testosterone have increased from $150 million in 2000 to $1.8 billion in 2011, a significant portion of men prescribed testosterone replacement therapy did not meet the laboratory criteria for hypogonadism.
While some clinical trials reported an association between testosterone insufficiency in older men and increased risk of death, the exact effects and consequences of testosterone replacement therapy, specifically in older men, remain unclear. This review is aimed at discussing the possible benefits and complications of testosterone replacement therapy in older men over 60 years of age.
Yabluchanskiy A, Tsitouras PD. Is Testosterone Replacement Therapy in Older Men Effective and Safe? Drugs & Aging 2019. Is Testosterone Replacement Therapy in Older Men Effective and Safe?
[OA] Late-Onset Hypogonadism (LOH): A Concept Comes of Age
The term Late-onset hypogonadism (LOH) was coined in 2002 and defined as a disease entity in the ISA, ISSAM, EAU, EAA and ASA endorsed Recommendations for Investigation, Treatment and Monitoring of LOH (2005 and 2008) as "a clinical and biochemical syndrome associated with advancing age, characterized by symptoms and a deficiency in serum testosterone (T)".
LOH was classified as a combined primary and secondary hypogonadism since the endocrine capacity of the testes as well as the pituitary are impaired. Symptoms of LOH include loss of libido, erectile dysfunction, loss of muscle mass, increased body fat, anemia, osteoporosis, depressed mood, decreased vitality, sweating and hot flushes.
Since these symptoms may also have origins other than LOH, exclusion of other disease entities and subnormal serum T levels are considered prerequisites for the diagnosis and possible treatment of LOH. However, during following years these guidelines were often neglected and, especially in the USA, indiscriminate prescribing of T was widely practised so that the US FDA warned against such irresponsible behavior.
In Europe T prescribing remained largely restricted to LOH as defined above. Nevertheless, a discussion started whether LOH really exists or is only a consequence of age-related comorbidities. Numerous studies have helped to clarify the situation, in particular, the European Male Aging Study (EMAS) and the US-initiated 7 T trials.
Consequently the newest US Endocrine Society Practice Guideline on T treatment (2018) includes advanced age as a cause of organic hypogonadism and recommends that "in men >65 years who have symptoms or conditions suggestive of T deficiency ... and consistently and unequivocally low morning T concentrations we suggest that clinicians offer T therapy on an individualised basis after explicit discussion of the potential risks and benefits." Thus the concept of LOH as conceived two decades ago has weathered criticism and survived the times.
Nieschlag E. Late-onset hypogonadism (LOH): a concept comes of age. Andrology 2019. https://onlinelibrary.wiley.com/doi/abs/10.1111/andr.12719
[OA] Factors Associated with The Initiation of testosterone Replacement Therapy in Men From The 45 And Up Study
BACKGROUND AND OBJECTIVES: There have been large increases in testosterone prescribing since 2000. The aim of this study was to identify factors associated with testosterone replacement therapy (TRT) initiation in men.
METHODS: Data were from the 45 and Up Study, an ongoing cohort study involving 266,942 participants from New South Wales aged >/=45 years. Baseline data (2006-09) were linked to administrative data on government-subsidised prescriptions and medical services.
RESULTS: The study included 105,429 men. In two years following baseline, 2.9 per 1000 men (95% confidence interval: 2.6, 3.2) had initiated TRT. Men with self-rated poor health, those treated for osteoporosis; anxiety, depression or high blood cholesterol, and those who lived in major cities or were aged 55-74 years had greater odds of TRT initiation. In the six months before TRT initiation, 41% of men had a hormone test record.
DISCUSSION: The high rate of TRT initiation and low rate of recommended investigations suggest TRT may have been prescribed outside recommended indications.
Cheng Y, Bateson D, Concepcion K, et al. Factors associated with the initiation of testosterone replacement therapy in men from the 45 and Up Study. Australian journal of general practice 2018;47:698-704. RACGP - Initiation of testosterone replacement therapy
A Critique of the AUA Guidelines on testosterone Deficiency
The publication of the first American Urological Association (AUA) guidelines regarding the evaluation and management of testosterone deficiency (TD) in 2018 (“Guidelines”) was a landmark event, serving to recognize the importance of this condition for US urologists.
Urologists play an outsized role in the treatment of men with TD because presenting symptoms are usually sexual. Urologists also have nearly 80 years of experience observing the effects of androgen deprivation.
The creation of clinical guidelines is a rigorous process intended to distill the best available evidence into a set of recommendations to guide health care providers in management of a condition. We congratulate the AUA Guidelines Committee for producing an excellent, useful document for the evaluation and management of men with TD.
In particular, the Guidelines have advanced the field by acknowledging the utility of testosterone (T) therapy (TTh) in selected men with prostate cancer.
As experienced clinicians and investigators in the field, we welcomed the Journal’s invitation to provide a critique of the Guidelines. Below, we comment on a number of topics where our perspective differs from that of the Guideline authors.
These Guidelines, as do all others, emphasize reliance on evidence to support recommendations; yet, as Powers noted, “. guidelines are not just summaries of the evidence. They are also interpretations of that evidence by guideline authors who bring to the process their own conscious and unconscious biases.” Further, many aspects of clinical decision-making have never been tested experimentally.
Together, these limitations mean that many recommendations represent opinions rather than clear interpretations of high-quality data. This is a general feature of all guidelines. A study of cardiology guidelines found that of more than 7,000 recommendations a median of only 11% were based on data from randomized controlled trials, and 48% were based on expert opinion.
The challenge for new guidelines is to incorporate solid existing practices with the best research evidence. It is no wonder that numerous studies across many fields show poor compliance with guidelines.
Our greatest area of disagreement is with the overly conservative diagnostic threshold of 300 ng/dL. This threshold is not followed by most experienced clinicians, and its application will result in many men suffering from classic symptoms of TD being denied treatment. We hope this threshold value will be liberalized in future Guidelines. We also believe that free testosterone plays an important role in diagnosing TD, and we encourage ordering this test as well as SHBG to evaluate the man presenting with symptoms suggestive of TD.
Morgentaler A, Traish AM, Khera M. A Critique of the AUA Guidelines on Testosterone Deficiency. The Journal of Sexual Medicine. Redirecting