Endo 2012

[Michael Scally MD]

Welcome to ENDO 2012: The 94th Annual Meeting & Expo
Welcome to ENDO 2012: The 94th Annual Meeting & Expo

Register [Free] To Access Abstracts
http://www.abstracts2view.com/endo/

 

[zkt]

Is Lustig, Taubes or the like going to speak. The childhood obesity seemed interesting. registered

 

[Michael Scally MD]

Elevated Serum Testosterone and Sex Hormone Binding Globulin Associated with Sexual Dysfunction

[SUN-79] Elevated Serum Testosterone and Sex Hormone Binding Globulin Associated with Sexual Dysfunction: A Familial Disorder?
http://www.abstracts2view.com/endo/view.php?nu=ENDO12L_SUN-79

Thanh Duc Hoang, Vinh Q Mai, Patrick W Clyde, KM Mohamed Shakir. Walter Reed National Military Medical Center, Bethesda, MD.

Background: Elevated sex hormone binding globulin (SHBG) levels have been reported to be associated with increased insulin sensitivity, hyperthyroidism, reduced risk of type 2 diabetes mellitus (1,2) and sexual dysfunction in men with chronic hepatitis C infection (3). We report a familial case of hypertestosteronemia and elevated SHBG associated with decreased libido and erectile dysfunction.

Clinical case: A 37 y/o male with a 2-year history of gradually decreased libido and erectile dysfunction was found to have repeated elevation of serum testosterone and SHBG levels. He shaves daily and denies any headaches, vision changes, breast enlargement, chest pain, shortness of breath, or weight changes. Past medical history was significant for shingles and seasonal allergy. He was taking a multivitamin daily. He never smoked and drank 2 beers weekly. He has 2 healthy children. He reports a family history of hypertension and diabetes mellitus.

Vital signs: BP 122/71, HR 60 bpm, weight 176 lbs, height 72 in, and BMI 24 kg/m2.

Physical examination: normal thyroid, no gynecomastia, no galactorrhea, normal phallus, testicles 25 cc bilaterally without palpable mass. Heart, lungs and neurological examination was normal.

Lab results: 8 A.M serum total testosterone 1186-1448 ng/dL (nl 250-1100), free testosterone 141-169 pg/mL (nl 35-155), SHBG 86-98 nmol/L (nl 10-50), LH 8.8 mIU/mL (nl 1.5-9.3), FSH 6.0 mIU/mL (nl 1.4-18.1), estradiol 58.8 pg/mL (nl 7.6-42.6), and TSH 1.09 mcIU/mL (nl 0.27-4.20).
Fasting glucose, prolactin, HCG, CBG, liver associated enzymes, hepatitis and congenital adrenal hyperplasia panels were normal. Clomiphene challenge test was normal.
Abdominal CT scan showed normal liver and adrenal glands.
Pituitary MRI, testicular ultrasound, baseline DXA scan, and EKG were all normal.

Testing of his 11 y/o daughter and 8 y/o son revealed SHBG values of 158 nmol/L (nl 24-120) and 120 nmol/L (nl 32-158) with total testosterone levels of 13 ng/dL and 5ng/dL (nl <25), respectively. Estradiol and TSH levels are normal for both children.

Conclusions: The patient most likely has familial elevated SHBG leading to hypertestosteronemia, given the fact that his daughter also has elevated SHBG and his son with high-normal SHBG. To our knowledge, hypertestosteronemia due to familial elevated SHBG has not been reported previously. Patients with hypertestosteronemia and elevated SHBG need further investigations, including possible genetic studies.

(1) Lakshman KM et al., J Gerontol A Biol Sci Med Sci 2010; 65:503-9.
(2) Perry JR et al., Human Molecular Genetics 2010; 19: 535–544.
(3) Rao J et al., J Clin Gastroenterology 2009; 43:94-95.

 

[Michael Scally MD]

Side-Effect Profile of Long-Term Treatment of Elderly Hypogonadal Men with Testosterone Undecanoate

[MON-50] Side-Effect Profile of Long-Term Treatment of Elderly Hypogonadal Men with Testosterone Undecanoate
http://www.abstracts2view.com/endo/view.php?nu=ENDO12L_MON-50

Farid Saad, Ahmad Haider, Gheorghe Doros, Louis Gooren. Bayer Pharma AG, Berlin, Germany; Gulf Medical University School of Medicine, Ajman, United Arab Emirates; Private Practice, Bremerhaven, Germany; Public School of Health, Boston University, Boston, MA; VUMC Amsterdam, Amsterdam, Netherlands.

Introduction: Testosterone therapy for hypogonadal men has been used for decades. However, there are still concerns regarding the safety of this treatment, particularly in elderly men.

Methods: Prospective registry study of 255 men (mean age 60.6 ± 8.0 years), with testosterone levels between ? 3.5 ng/ml. They received parenteral testosterone undecanoate 1000 mg at day 1, week 6 and every 12 weeks thereafter for up to 66 months.

Results: After 60 months the following changes were observed:

Erythropoiesis: haemoglobin increased from14.44 ± 0.72 to 14.99 ± 0.45 g/dl (p<0.0001 vs baseline). Haematocrit increased from 43.22 ± 2.84 to 48.78 ± 1.7% (p<0.0001 vs baseline). Four patients had haematocrit levels > 52% which resolved without intervention.

Prostate: PSA increased from 1.77 ± 0.96 to 1.82 ± 0.96 ng/ml (p<0.0001 vs baseline) with a plateau after 24 months. Prostate volume increased from 28.51 ± 11.2 to 30.23 ± 12.4 ml (p<0.0001 vs baseline). 3/255 patients were diagnosed with prostate cancer following elevated PSA (< 4 ng/mL) at 18 weeks of treatment. Tumour grade was T2 in all three and Gleason score 3+3 in two and 3+2 in one patient, resp. They all underwent radical prostatectomy. The proportion was 1.18% with an incidence of 30.334 per 10.000 patient years. For comparison: in the PLCO trial with a 7-year follow-up, the proportion of prostate cancer was 7.35% with an incidence of 116 per 10.000 patient years [1]. – The International Prostate Symptom score (IPSS) improved from 6.73 ± 4.21 to 2.83 ± 1.25 (p<0.0001).

Liver enzymes: aspartate transaminase (AST) decreased from 43.05 ± 17.29 to 20.16 ± 3.21 U/L (p<0.0001 vs baseline) reaching a plateau after 24 months, alanine transaminase (ALT) from 43.89 ± 18.11 to 20.54 ± 3.92 U/L (p<0.0001 vs baseline) with a plateau after 36 months.

Conclusions: The incidence of 3/255 patients with prostate cancer does not suggest an increased risk of prostate cancer in elderly men on long-term testosterone treatment. Long-term treatment with testosterone undecanoate with monitoring according to the guidelines is acceptably safe.

(1) Andriole G et al., New Engl J Med 2009; 360(13): 1310-1319.

 

[Michael Scally MD]

Vitamin D3 and Androgen Status in Men

[MON-357] Vitamin D3 and Androgen Status in Men
http://www.abstracts2view.com/endo/view.php?nu=ENDO12L_MON-357

Juraj Payer, Adriana Banarova, Peter Jackuliak, Tomas Koller. University Hospital and Medical Faculty of Comenius University, Bratislava, Slovakia (Slovak Republic).

Objective: 25-OH vitamin D3 (D3) possibly affects testosterone production in Leydig cells. Although pathogenesis of this relationship is not well understood, in some cross sectional studies the level of D3 correlates positively with total testosterone (TT) and free androgen index (FAI). In the European Male Ageing Study positive association of D3 with secondary and compensated hypogonadism was confirmed. In other study supplementation of D3 led to increase of testosterone levels in men.

Aim of the study: was to determine the relationship between D3 levels and levels of TT, luteninizing hormone (LH), follicle-stimulating hormone (FSH) and FAI in men with acute coronary syndrome. Secondary aim was to divide measured values into quartiles of physiological range.

Methods: In 38 men with average age 72 years admitted to 5th Department of Internal Medicine with acute coronary syndrome we determined levels of D3 by chromatograhy, TT, LH and FSH by electrochemiluminescence and calculated FAI (TT/SHBG x100). Patients with severe liver disease and malignancy were excluded. Patients did not receive antiandrogen therapy and vitamin D3 supplements. The correlation statistic was done by MedCalc system.

Results: The average level of TT was 12.93 nmol/l (interval 3.22-24.15 nmol/l), FAI 32.33% (14- 47.26%), FSH 9.03 IU/l (2.12-45.14), LH 7.92 IU/l (2.26-34.26) and D3 21 ug/l (4 – 52.7 ug/l). We did not confirmed correlation of D3 with neither TT (r: -0.03; p: 0.86), nor FAI (r: -0.13; p: 0.43) by statistical methods. We also did not confirm correlation of D3 with FSH or LH. By dividing measured values into quartiles of physiological range we figured out that 100% of patients had levels of D3 vitamin in 2 lowest quartiles, 84% of patients had TT in 2 lowest quartiles and 97% of patients had FAI in 2 lowest quartiles of physiological range.

Conclusion: In our study we did not confirme correlation of D3 with TT, FAI, FSH and LH by statistical methods. Limitations of our study were small and specific sample (patients with acute coronary syndrome) and high average age. By dividing patients into quartiles of physiological range we can conclude that most patients with low levels of TT and FAI had also low levels of D3. More investigation is necessary to explain the relationship between D3 and androgen status in men.

 

[Michael Scally MD]

A Rare Case of Pubertal Gynecomastia Due to Male Androgen Insensitivity Syndrome

[MON-616] A Rare Case of Pubertal Gynecomastia Due to Male Androgen Insensitivity Syndrome: A Novel Mutation and Clinical and Hormonal Findings
http://www.abstracts2view.com/endo/view.php?nu=ENDO12L_MON-616

Priya Vaidyanathan. Children's National Medical Center, Washington, DC.

Introduction: Gynceomastia is common in pubertal boys. It is considered to be physiological affecting 2/3rd of pubertal boys and resolves spontaneously most of the time. Pathological causes of gynecomastia in this age group are rare. We report a case of a healthy 17 y/o male whose clinical exam and hormonal evaluation led to the suspicion of MAIS (male androgen insensitivity syndrome) as the cause of his gynecomastia and the resultant novel molecular finding.

Clinical Case: A 17 year old African American male was evaluated for gynecomastia of 3 yrs duration. Height was 178.5 cm, weight is 63 Kg. He was not obese and did not take any medications. He had a normal physical and systemic exam. Distinct features were a lack of facial hair, sparse axillary hair, mid pubertal penile length, tanner 3 pubic hair, testicular volume of 15 cc with bilateral breast development tanner 3. Pertinent labs were a LH of 14 mu/ml (n; <3.7) FSH 7.7 mu/ml (n <5.6), Testosterone total of 1660 ng/dl (n<1000), Estradiol of 64 pg/ml(n;0-53), Karyotype 46, XY. Partial Androgen Insensitivity Syndrome (PAIS) was suspected and molecular analysis of the Androgen Receptor (AR) gene was done at GeneDX. A novel A721C missense mutation was detected in the AR gene.

While this mutation has not been previously identified as a cause of PAIS or MAIS, Shi X et al (2002) have studied 44 mutant androgen receptors from human prostate cancer and reported that this particular mutation is associated with reduced androgen activity. The patient has no family history of gynecomastia or infertility and therefore one could speculate that this is a new mutation. Patient was referred to the plastic surgeon and successfully underwent bilateral mastectomy.

CONCLUSION: This case highlights a rare cause of pubertal gynecomastia, the importance of good physical exam and the utility of checking FSH, LH, Testosterone and Estradiol in boys with atypical gynecomastia. The very high testosterone level, lack of adequate body and facial hair and a smaller testicular volume for the testosterone level were clues to the diagnosis. To our knowledge, the mutation described in this young man is a novel one and fits the phenotype of MAIS.

1. Functional analysis of 44 mutant androgen receptors from human prostate cancer. Shi XB, Ma AH, Xia L, Kung HJ, de Vere White RW; Cancer Res. 2002 Mar 1;62(5):1496-502.

 

[Michael Scally MD]

[MON-34] Longitudinal Changes in Testosterone over 5 Years in Community-Dwelling Men
http://www.abstracts2view.com/endo/view.php?nu=ENDO12L_MON-34

Andre B Araujo, Zumin Shi, Sean A Martin, Gary A Wittert. New England Research Institutes, Inc, Watertown, MA; University of Adelaide, Adelaide, Australia.

There are few population-based studies reporting longitudinal changes in testosterone (T) levels, and limited information on risk factors for longitudinal change in T. We examined changes in serum T levels assessed by liquid chromatography mass spectrometry (LC-MS/MS) among a cohort of 1,588 men aged 35-80y at baseline with available data at 2 clinic visits separated by 5 years. Excluded from analyses were men on medications (N=102) or with medical conditions (N=45) known to affect hormones, and men with pathological laboratory values (N=59), leaving 1,382 for analysis. Multivariate linear regression was used to assess the association between baseline predictors as well as change in predictors and annualized change in T. All models were minimally adjusted for baseline age.

At baseline, mean age was 54±11y, 21% were unmarried, 19% were current smokers, 30% had BMI ? 30 kg/m2, 48% had waist ? 100 cm, and 8% were depressed. Mean baseline T was 16.2±1.4 nmol/L, with 3%<8 nmol/L, 36% 8-15 nmol/L, and 61%>15 nmol/L. Mean T at follow-up was 15.6±1.4 nmol/L, representing a non-significant T change of -0.13 nmol/L/y (95% CI: -0.62, 0.41) or an approximate decline of -0.80%/y.

Baseline variables significantly associated with annualized T changes were: being unmarried (-0.18 nmol/L/y vs. married, p<.01), central obesity (+0.13 nmol/L/y vs. non-central obesity, p<.01), BMI ? 30 kg/m2(+0.22 nmol/L vs. <25 kg/m2, p<.01), and current smoking (-0.17 nmol/L/y vs. non-smoker, p<.01).

The effects of smoking status was driven by decreasing T in men who quit smoking (-0.17 nmol/L/y vs. non-smoker at both time points, p<.01). The effects of central obesity and high BMI were driven by changes in status between baseline and follow-up, with for instance, a T change of -0.25 nmol/L/y in men who became centrally obese (waist ? 100cm) and a T change of +0.20 nmol/L/y in men who became non-centrally obese, both compared to men who were not centrally obese at both time points (both p<.01). In addition, men who were depressed at both time points had a significantly greater T decline (-0.28 nmol/L/y vs. men without depression at both time points, p<.01).

In conclusion, this study strongly suggests that
(i) T decline is not an inevitable part of aging and
(ii) variability in T changes are largely explained by smoking behavior and intercurrent changes in health status, particularly obesity and depression.

Sources of Research Support: This study was supported by the National Health and Medical Research Council of Australia (NHMRC grant 627227).


Declining Testosterone Levels in Men Not Part of Normal Aging
Declining testosterone levels in men not part of normal aging

 

[Michael Scally MD]

[OR28-6] Obstructive Sleep Apnea Is Not an Independent Determinant of Plasma Testosterone
http://www.abstracts2view.com/endo/view.php?nu=ENDO12L_OR28-6

Gary Wittert, Sean Martin, Robert Adams, Amy Reynolds, Zumin Shi, Anne Taylor, Andre Araujo, Andrew Vakulin. University of Adelaide, Adelaide, Australia; University of South Australia, Adelaide, Australia; New England Research Institutes, Watertown, MA; Repatriation General Hospital, Adelaide, Australia.

It is generally considered that obstructive sleep apnoea (OSA) lowers testosterone in men, although the data supporting this are relatively limited. We determined the relationship between the presence and severity of sleep disordered breathing and plasma testosterone in a comprehensively characterized community based cohort of men aged over 40 yrs (MAILES) from whom fasting morning plasma samples were drawn in 2009-2010 (n=1869). Plasma total testosterone (T) was measured by liquid chromatography mass spectrometry (LC-MS/MS).

In 2011, home polysomnography was done in 810 randomly selected men from the cohort using an 8 channel Embletta X100 device. The Apnoea Hypopnea Index (AHI), and absence or presence and severity (mild: AHI 10-20; moderate AHI 21-30; severe: AHI ? 30) of OSA were classified according to the International Classification of Sleep Disorders (ICDS-2) from the American Academy of Sleep. After excluding men with pathological conditions or taking medications affecting testosterone, with missing values or using CPAP, 654 men aged 41-85 remained.

The effect of OSA severity, or AHI, on T were analysed using generalized linear models controlling for potential confounders (age, BMI, smoking, marital status, presence of depression (self-report), HbA1c and SHBG).

The mean (±SD) characteristics of the men were: age 59 (10) yrs, T 16.5 (5.4) nmol/L, SHBG 33.1 (13.4) nmol/L, BMI 28.4 (4.2) kg/m2, AHI 14.1 (14). OSA was present in 53.7%, (mild 28.6%, moderate 13.6, and severe 11.5%). A significant inverse relationship between AHI and T (Beta -.118, P=0.002), remained after adjustment for age, smoking, marital status, presence of depression, and HbA1c (Beta-.109, P=0.007), and SHBG (Beta -0.077, P=0.017), but not after additional adjustment for BMI (Beta -0.022, P=0.504). The results using OSA category rather than AHI were similar.

These data suggest that obesity, or sleep related factors rather than OSA per se, determine T. This accords with the graded effect of weight loss, but limited effect of CPAP to increase T and highlights the importance of managing obesity effectively, particularly in the context of OSA.

Sources of Research Support: This study was supported by the National Health and Medical Research Council of Australia (NH&MRC grant 627227).

Disclosures: RA: Speaker, GlaxoSmithKline.
Nothing to Disclose: GW, SM, AR, ZS, AT, AA, AV

 

[Michael Scally MD]

[SUN-693] Continuous Kisspeptin Infusion Restores Pulsatile LH Secretion in Patients with Neurokinin B Signaling Deficiencies
http://www.abstracts2view.com/endo/view.php?nu=ENDO12L_SUN-693

Jacques Young, Jyothis T George, Javier A Tello, Bruno Francou, Jerome Bouligand, Anne Guiochon-Mantel, Sylvie Brailly-Tabard, Richard A Anderson, Robert P Millar. Université Paris-Sud, Paris, France; (INSERM U693) Institut National de la Santé et de la Recherche Médicale, Paris, France; Hôpital Bicêtre, Paris, France; University of Edinburgh, Edinburgh, UK; University of Edinburgh, Edinburgh, UK; Hôpital Bicêtre, Paris, France; University of Pretoria, Pretoria, South Africa; Medical Research Council/University of Cape Town, Cape Town, South Africa.

Pulsatile gonadotropin releasing hormone (GnRH) is a requirement for normal reproductive function. Abnormalities in pulse frequency result in reproductive dysfunction. Kisspeptin and neurokinin B (NKB) are neuropeptides secreted by the same neuronal population in the ventral hypothalamus, which are crucial central regulators of GnRH and thus gonadotropin secretion. Patients with mutations resulting in loss of signaling by either of these neuroendocrine peptides fail to advance through puberty but the mechanisms mediating this remain unresolved. We show that continuous kisspeptin infusion restores gonadotropin and pulse frequency and amplitude in patients with loss-of-function mutations in neurokinin B (TAC3) or its receptor, (TAC3R). Thus indicates that kisspeptin on its own is sufficient to stimulate pulsatile GnRH secretion. Moreover, our findings suggest that NKB action is proximal to kisspeptin in the reproductive neuroendocrine cascade regulating GnRH secretion, and may act as an autocrine modulator of kisspeptin secretion. The ability of continuous kisspeptin infusion to induce pulsatile gonadotropin secretion further indicates that GnRH neurons are able to set up pulsatile secretion in the absence of pulsatile exogenous kisspeptin.

Sources of Research Support: Medical Research Council(UK) _ Experimental Medicine Grant.

Nothing to Disclose: JY, JTG, JAT, BF, JB, AG-M, SB-T, RAA, RPM

 

[Michael Scally MD]

[OR12-2] Disruption of Glucocorticoid Receptor Signaling in Kisspeptin Neurons Accelerates the Recovery of Reproductive Function in the Post-Traumatic Stress Period
http://www.abstracts2view.com/endo/view.php?nu=ENDO12L_OR12-2

Oulu Wang, Anne Lanjuin, Caroline Ho, Juliana Basko, Catherine Dulac, Joseph Majzoub. Children's Hospital Boston, Boston, MA; Harvard Medical School, Boston, MA; Harvard University, Howard Hughes Medical Institute, Cambridge, MA.

Stressors can generate adaptive stress responses that prepare for the return to homeostasis, but also maladaptive responses, including the inhibition of reproductive function even after cessation of the stressor. How acute stress causes these maladaptive, post-traumatic effects is not well understood.

Kisspeptin (KISS1) is required for the activation of the hypothalamic-pituitary-gonadal (HPG) reproductive axis in humans and mice (1-3). We hypothesized that acute stress in adult mice transiently inhibits kisspeptin neurons and the downstream HPG axis, and that restoration of kisspeptin signaling is necessary to reactivate the axis, similar to its role during puberty. This inhibition of kisspeptin expression could be caused by the concomitant stress-induced elevation of glucocorticoids, with the subsequent fall in glucocorticoids allowing the restoration of kisspeptin expression required for the recovery of the reproductive axis after stress.

To test this hypothesis, we first examined the response of hypothalamic Kiss1 mRNA expression to different stressors in male mice. After restraint, plasma corticosterone was increased, testosterone was decreased, and Kiss1 expression was decreased. After food deprivation, corticosterone was increased, testosterone was decreased, and Kiss1 expression was decreased. After cold exposure, corticosterone was unchanged, and Kiss1 expression was unchanged, even though testosterone was decreased. All changes were significant.

The consistent relationship between a rise in corticosterone and fall in Kiss1 expression suggested that elevated corticosterone caused stress-induced inhibition of Kiss1 expression. To test this directly, we injected mice with a stress dose of corticosterone and observed that testosterone and Kiss1 expression were decreased.

To evaluate the role of glucocorticoid signaling in kisspeptin neurons, we generated mice lacking glucocorticoid receptors specifically in kisspeptin-containing neurons. In these animals, Kiss1 expression was no longer inhibited during restraint stress, even though corticosterone was increased. Both testosterone and copulatory behaviors showed significantly accelerated recovery in the post-traumatic stress period. Blockade of glucocorticoid receptor signaling in kisspeptin neurons during stress accelerates the recovery of reproductive function during the post-traumatic stress period, and this finding may have therapeutic implications in humans with post-traumatic stress disorders.

(1) Seminara et al., 2003.
(2) De Roux et al., 2003.
(3) Lapatto et al., 2007.

 

[Michael Scally MD]

[SAT-39] Testosterone Measurement by Mass Spectrometry — A Tale of Three Internal Standards
http://www.abstracts2view.com/endo/view.php?nu=ENDO12L_SAT-39

Laura Jane Owen, Brian George Keevil. UHSM, Manchester, UK.

Introduction - Testosterone measurement by liquid chromatography tandem mass spectrometry (LC-MS/MS) is well accepted as the preferred technique for the analysis of serum testosterone in both males and particularly females. However variation is seen between LC-MS/MS assays and is most likely to be due to method differences between laboratories. One area of inconsistency amongst routine LC-MS/MS assays is the choice of internal standard. We investigated the effects of three internal standards on the results obtained.

Methods - Stable isotopes of testosterone were prepared in methanol. Testosterone with two deuterium (D2), five deuterium (D5) and three carbon thirteen enrichment (C13) were separately assessed. Sera, calibrators and quality controls (100 µL) were extracted using 0.5 mL of ether following the addition of 10 µL of internal standard. All aliquots were prepared in triplicate, one for each type of internal standard. After mixing the ether was transferred to the wells of a 96-deep well block then evaporated to dryness. Extracts were reconstituted with 100 µL of 50% mobile phases and analysed using a Waters Acquity LC and Quattro Premier tandem mass spectrometer. This method had previously shown to have excellent agreement with a reference method using the D2 internal standard.

Results - Lower results were obtained when using D5 testosterone when compared to D2 testosterone. The Passing-Bablock regression equation was; testosterone (D5) nmol/L = 0.86 x testosterone (D2) + 0.04. The C13 internal standard also gave lower results but was closer than the D2 target than the D5 internal standard. The Passing-Bablock regression analysis was; testosterone (C13) nmol/L = 0.90 x testosterone (D2) + 0.02.

Discussion - The choice of internal standard alone can have a significant affect on the results obtained by LC-MS/MS assays for testosterone using this chromatography. The effects of the combination of chromatography and internal standard choice should be investigated during method development.

 

[Michael Scally MD]

[SUN-LB18] Short-Term Testosterone Treatment Suppresses Skeletal Muscle NIK Expression in Older Men
http://www.abstracts2view.com/endo/view.php?nu=ENDO12L_SUN-LB18

Astrid M Horstman, Sanjeev Choudhary, William J Durham, E Lichar Dillon, Ronald G Tilton, Randall J Urban, Melinda Sheffield-Moore. University of Texas Medical Branch, Galveston, TX.

A number of events are known to trigger muscle loss with aging including inflammation, inactivity, and loss of anabolic hormones such as testosterone. It is unclear, however, what role NF-?B inducing kinase (NIK), an upstream regulatory MAP kinase in the NF-?B activation pathway, plays in mediating age-related muscle loss. Our data show that a link exists between increased NIK and decreased Notch levels in aging skeletal muscle. Moreover, testosterone has been shown to exert anti-catabolic properties in the skeletal muscle of older men.

Thus, we hypothesized that testosterone may be involved in regulating NIK levels, as NIK has been shown to be significantly elevated in aging and diseases where chronic inflammation is present. We investigated whether short-term administration (7 days) of testosterone was capable of counteracting aberrantly regulated NIK signaling in older men with serum testosterone concentrations in the low normal range (?500 ng/dl), suggestive of a possible NIK-testosterone link in counteracting muscle loss with aging.

Blood was collected and biopsies were obtained from the mixed vastus lateralis muscle before and 7 days after either a single dose (intramuscular injection) of testosterone enanthate (100 mg on Day 1) or initiation of daily topical testosterone gel (two 5g packets of 1%AndroGel®/day). Muscle samples were homogenized and protein lysates were fractionated on 10% SDS-PAGE and immunoblotted for NIK using specific antibodies. GAPDH served as a loading control. Serum testosterone was measured on an Immulite 2000.

Skeletal muscle NIK levels significantly decreased following 7 days of testosterone treatment. Further, we found a significant negative association (r=-0.841, p<0.036) between baseline serum testosterone and skeletal muscle NIK protein levels. Moreover, a negative correlation was found between the change in serum testosterone levels and the change in NIK protein expression after one- week treatment (r=-0.412), although this correlation did not reach statistical significance due to the small sample size.

These data clearly demonstrate that as little as seven days of testosterone treatment can suppress skeletal muscle NIK levels in older men, suggesting that testosterone may exert its anti-catabolic properties in skeletal muscle via its regulation of NIK.

 

[Michael Scally MD]

[SUN-74] Effects of Baseline Testosterone Levels on Symptom Improvement in Hypogonadal Men Receiving Testosterone Replacement Therapy
http://www.abstracts2view.com/endo/view.php?nu=ENDO12L_SUN-74

Xiao Ni, David Muram. Eli Lilly and Company, Indianapolis, IN; Eli Lilly and Company, Indianapolis, IN.

It is possible that symptom improvement may be affected by baseline testosterone (T) level in men receiving testosterone replacement therapy (TRT). We performed a post-hoc analysis to evaluate the effects of baseline T level on changes in sexual function and mood in hypogonadal men receiving 2% testosterone in a topical solution applied daily to the axillae.

An open-label trial (1) was conducted in 155 androgen-deficient men started on daily 60 mg T. Dose was adjusted on days 45 and 90 based on average serum T on days 15 and 60, respectively, as necessary to maintain T in the physiologic range (300-1050ng/dL). Sexual desire, sexual activity, positive mood, negative mood, percent full erection and erection maintained were assessed by the Psychosexual Daily Questionnaire (PDQ) (2) for 7 days preceding visits at days 1, 15, 60 and 120. Subjects were divided into four subgroups depending on baseline (pre-day 1) total serum testosterone (TT)<100, 100<200, 200<300, and ?300 ng/dL. For each PDQ parameter, change from baseline to days 15, 60 and 120 was analyzed using repeated measures analysis of covariance (ANCOVA) adjusted for TT group, age, body mass index (BMI) and visit, with baseline TT subgroup effect assessed by the type III test of fixed effects.

All PDQ domains showed significant (p<0.05) improvement for subjects in all TT subgroups. In general, improvement was maintained or increased during the 120-day treatment. When subgroups were compared, T levels at baseline did not appear to affect the magnitude of improvement; p>0.05 for all PDQ domains. Subjects in the lowest TT group (TT<100ng/dL) seemed to have the greatest numerical improvement in sexual desire, sexual activity, percent full erection, and erection maintained after adjusting for baseline age, BMI and visit. For example, the least squares (LS) means of the TT groups (main effects, averaged across other factors) for sexual desire were 1.70, 1.15, 1.13 and 0.97 for the TT<100, <200, 200<300, and ?300ng/dL groups respectively. This trend was not observed in the positive and negative mood domains.

The study is limited by lack of a placebo control group and a relatively small number of patients with very low serum T levels at baseline. While adjustments were made for age and BMI, other confounders may have affected patients' response to therapy. Additional research is needed to better understand the effects of TRT on symptom improvement in men with hypogonadism.

(1) Wang C et al., J Clin Endocrinol Metab 1996;81:3578.
(2) Lee KK et al., J Androl 2003;24:688.

Sources of Research Support: Eli Lilly and Company.

Disclosures: XN: Researcher, Eli Lilly & Company. DM: Clinical Researcher, Eli Lilly & Company.

 

[Michael Scally MD]

[MON-41] Effect of Testosterone Replacement on Response to Sildenafil Citrate in Men with Erectile Dysfunction: A Randomized, Placebo-Controlled Trial
http://www.abstracts2view.com/endo/view.php?nu=ENDO12L_MON-41

Matthew Jonathan Spitzer, Shehzad Basaria, Maithili N Davda, Thomas G Travison, Amanda Paley, Beth Kaplan, Norman A Mazer, Philip E Knapp, Samson Hanka, Jagadish Ulloor, Anqi Zhang, Katie Orwoll, Richard Eder, Lauren Collins, Nurahmed Mohammed, Shalender Bhasin. Boston University School of Medicine and Boston Medical Center, Boston, MA; Boston University School of Public Health, Boston, MA; Hoffman LaRoche, Basel, Switzerland.

Background: Erectile dysfunction (ED) and low testosterone levels frequently co-occur in men. It is unclear whether the addition of testosterone to a phosphodiesterase-5-inhibitor improves erectile response.

Methods: In this randomized, double-blind, placebo-controlled trial, men age 40 to 70 years old with Erectile Function Domain (EFD) scores of ?25 on the International Index of Erectile Function (IIEF), total testosterone <330 ng/dL (measured by LC-MS/MS) and/or free testosterone <50 pg/mL, were randomized to either 10-g testosterone or placebo gel for 14-weeks after they had received sildenafil for a period of 3-7 weeks. The primary outcome was change in EFD score. Secondary outcomes included changes in other domains of the IIEF and Male Sexual Health Questionnaire (MSHQ), frequency of total and successful sexual encounters, ED-Quality-of-Life (ED-QOL), marital-intimacy, vitality, and affectivity-balance. Sample mean changes and 95% confidence intervals (CI) were computed, and a Student's T-test was used to assess for differences by treatment arm.

Results: Testosterone and placebo groups were similar at baseline. Mean serum total testosterone at screening was 248 ng/dL and 254 ng/dL, which increased to 649 ng/dL and 338 ng/dL on sildenafil plus testosterone and sildenafil plus placebo, respectively. Administration of sildenafil alone was associated with substantial increases in EFD score (mean change for both arms 7.7; 95%CI 6.5 to 8.8) as well as in other domains of IIEF, MSHQ, frequency of total and successful sexual encounters, and ED-QOL. However, after randomization, the change in EFD score did not differ significantly between testosterone plus sildenafil (mean change 1.7) and placebo plus sildenafil (mean change 0.4; difference 1.3; 95%CI -0.8 to 3.5; P=0.23) arms. Similarly, changes with testosterone vs. placebo gel in other domains of the IIEF, frequency of total and successful sexual encounters, ED-QOL, marital-intimacy, vitality, and affectivity-balance did not differ between the two groups. Sensitivity analyses of men with baseline testosterone <250ng/dL did not reveal significant differences in EFD scores between arms.

Conclusions: Combined administration of testosterone plus sildenafil was not superior to sildenafil plus placebo in improving erectile function in men with ED and low testosterone levels.

 

[Michael Scally MD]

[MON-42] Cardiovascular Safety and Testosterone Replacement Therapy in Male Hypogonadism Including Men with Type 2 Diabetes and Cardiovascular Disease
http://www.abstracts2view.com/endo/view.php?nu=ENDO12L_MON-42

Jonathan Charles Brooke, David Stuart McLaren, Deborah J Walter, Vakkat Muraleedharan, Thomas Hugh Jones. Barnsley Hopsital, NHSFT, Barnsley, UK; University of Sheffield, Sheffield, UK.

Testosterone replacement therapy (TRT) has recently been shown to have beneficial effects on CVD risk factors including insulin resistance, dyslipidaemia, obesity, hypertension and pro-atherogenic states. Nevertheless, the use of TRT remains controversial in men with cardiovascular disease.

A long-term retrospective audit of 401 (47.4% Type 2 diabetes (T2D), 34.0% CVD) hypogonadal men (age 58.7±14.3 years; mean baseline testosterone 7.16±2.59 nmol/l) receiving physiological TRT (84% testosterone gels) for up to 27 years (mean 5.41 years) in normal clinical practice was carried out to evaluate TRT's safety. BMI, waist circumference, blood pressure (BP), hemoglobin (Hb), hematocrit (HCT), lipid profile, liver function, testosterone, estradiol and PSA levels were monitored at 3, 6 and 12 months and yearly thereafter. Data from the most recent visits represent the primary endpoint. Hospital admissions, major adverse cardiovascular events (MACEs), mortalities and prostate-related outcomes were recorded.

TRT was associated with a reduction in total cholesterol (-0.28 mmol/l, p=0.004), non- fasting triglycerides (-0.244 mmol/l, p=0.04) and liver transaminases (ALT and AST) at the primary endpoint. HDL cholesterol fell by 0. /l (p=0.044). Hb increased by 0.72g/dl (p=0.002), HCT by 0.035 (p=0.011), PSA by 0.26g/l (p=0.008) and estradiol 128.45±44.58 at baseline vs 157±66.89 pmol/l. At the end of the study PSA levels were comparable to those of eugonadal males and were not grossly elevated. No significant changes in BMI, waist circumference or BP were observed. Safety outcomes: Polycythaemia (HCT >0.52) developed in 22 patients. 3 new cases of BPH and 2 prostate carcinomas were diagnosed, but this is no more than expected in this population which included aging males. 4 patients were diagnosed with T2D during the study, and 24 MACEs (4 MI, 8 angina, 5 TIAs, 2 CVAs, 4 CABG, 1 CCF) were identified. Over the course of the study there were 54 hospital admissions and 2 deaths which are no higher than expected in this morbid population.

This audit confirms the cardioprotective role of physiological doses of testosterone and demonstrates that in clinical practice TRT has beneficial effects on cardiovascular risk factors including circulating lipid and cholesterol levels. This is the largest and most comprehensive study of TRT safety to date, representing over 1642 patient years of TRT. TRT was not associated with an increase in prostate carcinoma, MACEs or mortality.

 

[Michael Scally MD]

[OR28-1] Association between Serum Testosterone Levels and Vascular Calcification in Community-Dwelling Men: The Framingham Heart Study
http://www.abstracts2view.com/endo/view.php?nu=ENDO12L_OR28-1

Thomas G Travison, Shehzad Basaria, Shalender Bhasin, Anh-Hoa Nguyen, Joseph Massaro, Warren J Manning, Ramachandran S Vasan, Christopher J O'Donnell. Boston University School of Medicine, Boston, MA; Boston University School of Public Health, Boston, MA; Harvard Medical School, Boston, MA; National Heart, Lung and Blood Institute, Framingham, MA.

Background: Observational associations between male circulating testosterone (T) levels and cardiovascular disease and mortality have been widely reported, but the relationship between T and atherosclerosis is poorly understood. Here we report an analysis of association between serum testosterone and vascular calcification in adult men.

Methods: Data were available on 1678 participants belonging to Generation 2 (examination 7) and Generation 3 (examination 1) of the Framingham Heart Study cohort, and were obtained in clinical study visits conducted between 1998 and 2008. Early-morning serum total testosterone (TT) was measured by liquid chromatography-tandem mass spectrometry, and free testosterone was calculated (cFT) using mass action equations. Sex hormone-binding globulin (SHBG) was measured using immunofluorometric assay. Thoracic aortic calcification (TAC), abdominal aortic calcification (AAC), and coronary artery calcification (CAC) were measured by computed tomography scan. Covariables considered included age, body mass index (BMI), smoking, fasting lipids, and comorbid conditions. Estimates of association were obtained by Tobit regression, which acknowledges the influence of floor effects on outcomes.

Results: Subjects had mean (SD) age 49 (10) y with range 31-80 y; mean (SD) BMI was 28 (5) kg/m2. Mean (SD) TT, cFT, and SHBG were 616 (224) ng/dl, 111 (45) pg/ml, and 46 (23) nmol/l, respectively. TT and cFT exhibited highly significant positive, and SHBG negative, association with vascular calcification at all sites (p<0.001). After adjusting for age, SHBG displayed no association with vascular calcification. Scaled to the mean sample CAC, a 100-ng/dl between-subject increase in TT was associated with a mean (SE) age-adjusted decrease in CAC of -8.6% (4.5%), p=0.04. Similarly, a 10 pg/ml positive difference in cFT was associated with a mean (SE) CAC decrease of -5.1% (2.5%), p=0.04. Trends of similar magnitude were observed for AAC and TAC. However, multivariable model adjustment for other cardiovascular risk factors (BMI, history of smoking, lipids and comorbidities) reduced estimated associations between testosterone and vascular calcification scores at all sites to statistical nonsignificance.

Conclusion: Low circulating testosterone levels in men exhibit an association with increased vascular calcification that is not explained by age alone, but which may be accounted for by their co-occurrence with established cardiovascular risk factors.

 

[Michael Scally MD]

[SUN-575] The Role of Testosterone in the Control of Muscle Protein Balance
http://www.abstracts2view.com/endo/view.php?nu=ENDO12L_SUN-575

Lucian Nicolae Sandor, Daniel Lee, Gianluca Toraldo, Anqi Zhang, Ravi Jasuja, Shalender Bhasin, Carlo Serra. Boston Medical Center, Boston, MA.

Background: Skeletal muscle is the main protein and energy storage of the body. Aging and pathological conditions perturb protein turnover and the muscle response to anabolic stimuli. Gains in muscle mass occur through either increases in muscle protein synthesis or declines in muscle protein breakdown. Several lines of evidence indicate that testosterone increases muscle mass by stimulating either protein synthesis and reducing protein degradation. In addition, androgens prevent muscle atrophy and weakness caused by glucocorticoids in humans and rodents. These data suggest that androgens inhibit proteolysis, and enhance specific steps of protein synthesis and/or protect from degradation key factors of the translational machinery.

Methods: To assess the effect of testosterone on muscle protein synthesis and degradation we used the Hershberger assay in rodents. 2-month old male mice were castrated and treated with vehicle or testosterone propionate. Mice were killed after 4 and 7 days of testosterone treatment. Sham-operated, untreated mice and 7-day castrated mice served as control.

Results: The androgen-dependent levator ani muscle underwent rapid atrophy after castration, showed reduced level of androgen receptor and FoxOs phosphorylation, as well as increased MAFbx and MuRF1 gene expression. Testosterone administration rescued these changes. Castration induced the expression of key autophagy genes, such as Bnip3, LC3B, p62 and Cathepsin-L, indicating an active recruitment of autophagy components during levator ani muscle atrophy. Castrated mice showed also the increased gene expression of Fis1, a component of the mitochondrial fission machinery activated during autophagy. Castration was associated to reduced activation and activity of mTOR, as indicated by the level of its phosphorylation and by that of 4E-BP1. Testosterone rescued these effects and enhanced the phosphorylation of eIF4G and of the ribosomal protein S6rp, a target of activated p70S6k1. Castrated mice showed reduced protein level of eIF3f, of eIF2B?, the enzymatic subunit of the eIF2B complex, and of the elongation factor eEF2. Testosterone rescued all these changes.

Conclusion: Testosterone supplementation re-establishes an optimal protein balance in atrophic muscle, and regulates the protein degradation pathways as well as the early steps of mRNA translation. These data indicate potential new therapeutic targets in androgen-based therapies for muscle wasting.

 

[Michael Scally MD]

[SUN-577] Identification of Four New Sex Hormone-Binding Globulin Variants with Abnormal Production or Function
http://www.abstracts2view.com/endo/view.php?nu=ENDO12L_SUN-577

Tsung-Sheng Wu, Caroline Underhill, Geoffrey Lewis Hammond. Child & Family Research Institute, Vancouver, Canada.

Background: Sex hormone-binding globulin (SHBG) binds sex steroids with high affinity and specificity. The levels of SHBG in blood determine the non-protein bound “free” fractions of sex steroids that are able to access target tissues and cells. Genetic polymorphisms of SHBG have been associated with altered SHBG levels or functions and linked to the risk of several diseases, including reproductive tissue cancers and type 2 diabetes. Recently, large scale genome and exome sequencing projects have revealed numerous single nucleotide polymorphisms (SNP) within the SHBG gene. Based on our knowledge of SHBG tertiary and quaternary structure, we selected nine new SNPs, which result in amino acid substitutions in the SHBG amino-terminal LG domain that mediates steroid-binding and dimerization, and examined their impact on SHBG production and/or function.

Methods: SHBG variants were expressed in Chinese hamster ovary cells for characterization by steroid-binding capacity and time-resolved immunofluorometric assays, which allow the steroid binding and dimerization properties of SHBG to be assessed.

Results: Four out of the nine naturally occurring SHBG variants studied have specific abnormalities. SHBG T48I and SHBG R123H have reduced steroid-binding affinity; SHBG R154W is dimerization deficient and has a lower binding affinity for estrogens but a normal affinity for androgens; SHBG G195E is not produced or secreted efficiently, probably due to misfolding during synthesis.

Conclusions: A method for the screening and functional analysis of SHBG genetic variants has been implemented to assess the impact of newly discovered genetic variants of SHBG on its production and/or function. This information will need to be assessed in relation to a wide range of diseases that have already been associated with SHBG polymorphisms. In addition, algorithms designed to calculate free testosterone or estradiol levels will need to take into consideration the effects of these new SHBG variants.

 

[Michael Scally MD]

[MON-51] Long-Term Testosterone Treatment in Hypogonadal Men Improves All Components of the Metabolic Syndrome
http://www.abstracts2view.com/endo/view.php?nu=ENDO12L_MON-51

Aksam Yassin, Youssef El Douaihy, Ridwan Shabsigh, Aiman Yassin, Farid Saad. Segeberger Kliniken, Norderstedt, Germany; Dresden International University, Dresden, Germany; Gulf Medical University School of Medicine, Ajman, United Arab Emirates; Maimonides Medical Center, Brooklyn, NY; Klinikum Braunschweig, Braunschweig, Germany; Bayer Pharma AG, Berlin, Germany; Gulf Medical University School of Medicine, Ajman, United Arab Emirates.

Introduction: Metabolic syndrome as well as all its individual components are associated with testosterone deficiency. We hypothesize that long-term testosterone therapy improves the metabolic syndrome.

Materials and Methods: Since November 2004, 261 patients diagnosed with LOH in our center in Germany were entered into our registry study for long term testosterone replacement therapy. Men with a total testosterone of ?3.5 ng/mL and symptoms of erectile dysfunction (IIEF-5< 21) met the inclusion criteria. Long acting testosterone undecanoate 1000 mg injections were administered at day 1, after 6 weeks and every 3 months thereafter. The mean follow up time was 4.25 years. Demographic data were collected at the baseline. Hormones, lipids, glucose and blood pressure were measured at every visit or every other visit. We used the International Diabetes Federation definition to define whether patients had the metabolic syndrome (MetS). MetS was considered in patients with central obesity and any two of the following: raised triglycerides, reduced HDL cholesterol, raised blood pressure, and raised fasting plasma glucose. Mean fasting glucose, triglycerides, and HDL were calculated at every T and linear regression was used to study their variation over time. Total testosterone and prevalence (%) of the MetS were plotted against time.

Results: we noticed a significant drop in the prevalence of the MetS from 56% to 30% after 57 months. There was a statistically significant drop of triglycerides, glucose, and the mean arterial pressure (p=0.00; ?=-0.77, p=0.00; ?=-0.67, and p=0.00; ?=-0.78respectively) and an increase in HDL (p=0.05; ?=0.53). In addition, we noticed a significant drop of 11 cm in the mean waist circumference.
Conclusion: All components of the MetS improved significantly and over the full observation period upon normalization of testosterone levels.

Sources of Research Support: Data entry was supported by Bayer Pharma AG.

Disclosures: AY: Speaker, Bayer Schering Pharma. RS: Speaker, Lilly USA, LLC. FS: Employee, Bayer Schering Pharma. Nothing to Disclose: YED, AY

 

[Michael Scally MD]

[SAT-118] Restoring Testosterone to Normal Levels in Elderly Men Is Efficacious in Weight Reduction. A Follow-Up Study over 5 Years
http://www.abstracts2view.com/endo/view.php?nu=ENDO12L_SAT-118

Farid Saad, Ahmad Haider, Louis Gooren. Bayer Pharma AG, Berlin, Germany; Gulf Medical University School of Medicine, Ajman, United Arab Emirates; Private Practice, Bermerhaven, Germany; VUMC Amsterdam, Amsterdam, Netherlands.

Introduction: Obesity is associated with reduced testosterone, and low testosterone induces weight gain. This study analysed the effects of normalization of serum testosterone in mainly elderly, hypogonadal men.

Methods: Open-label, single-center, cumulative, prospective registry study of 255 men (aged 38 – 83 years, mean 60.6 ± 8.0 years), with testosterone levels between 1.7 –3.5 ng/mL (mean: 2.87 ± 0.4). Cut-off point for testosterone treatment was serum testosterone ? 3.5. ng/mL). 215 men were studied for at least 2 years, 182 for 3 years, 148 for 4 and 116 for at least 5 years. They received parenteral testosterone undecanoate 1000 mg/12 weeks after an initial interval of 6 weeks.

Results: After 5 years the following changes were observed: weight (kg) decreased from 106.22 ± 16.93 (minimum: 70, maximum: 139) to 90.07 ± 9.51 (min 74.00, max 115). The statistical significance was p<0.0001 vs baseline and vs the previous year over 5 years indicating a continuous weight loss over the full observation period. Waist circumference (cm) declined from 107.24 ± 9.14 (min 86, max 129) to 98.46 ± 7.39 (min 84, max 117) (p<0.0001 vs baseline and vs the previous year over 5 years). Body mass index (BMI, m/kg2) declined from 33.93 ± 5.54 (min 21.91, max 46.51) to 29.17 ± 3.09 (min 22.7; max 36.71) (p<0.0001 vs baseline and vs the previous year over 5 years). The mean per cent weight loss after 1 year was 4.12 ± 3.48%, after 2 years 7.47 ± 5.01%, after 3 years 9.01 ± 6.5%, after 4 years 11.26 ± 6.76% and after 5 years 13.21 ± 7.24%. At baseline, 96% of men had a waist circumference of ? 94 cm. This proportion decreased to 71% after 5 years.

Conclusions: Raising serum testosterone to normal produced loss of body weight, waist circumference and BMI. These improvements were progressive over the full 5 years of the study.

Sources of Research Support: Data entry and statistical analysis were supported by Bayer Pharma AG.

Disclosures: FS: Employee, Bayer Schering Pharma. AH: Principal Investigator, Bayer Schering Pharma. LG: Speaker, Bayer Schering Pharma.