Wat betreft

Liu et al. conducted a double-blind, placebo controlled, randomized trial assessing response to hCG therapy in older men (mean age 67 years) with androgen deficiency.399 The authors found a 150% increase in total testosterone level, which they concluded demonstrates that older males retain "testicular responsiveness" to gonadotropin therapy. One study of 60 patients undergoing long-term therapy of 50 mg methyltestosterone three times a day found that nearly one-third of patients, none of whom had a history of liver disease, returned abnormal liver function tests and/or liver scans.387 Testosterone undecanoate is an oral testosterone analogue that is absorbed via the intestinal lymphatics allowing it to avoid the first pass liver effect. Clinicians should counsel patients on the association between low testosterone and the increased risk of cardiovascular events, as well as the ill-defined cardiovascular risks and benefits of testosterone therapy in the testosterone deficient patient.
As such, low testosterone is likely better considered as a covariate with these comorbid conditions rather than as an independent observation. Specifically, the AUA does not recommend routine PSA testing in men years of age unless they are at higher risk (e.g., positive family history, African American race), at which point decisions regarding PSA testing should be individualized. For patients who have an elevated PSA at baseline, a second PSA test is recommended to rule out a spurious elevation. Finally, a randomized trial of 76 men (mean age 50.6 years), who had at least 1 ejaculatory dysfunction symptom and at least 2 testosterone tests 182 In the IM testosterone group, there were no new cases of gynecomastia, and one patient with pre-existing gynecomastia had gynecomastia resolution.181 An evaluation for a prolactinoma in such patients is imperative because these benign tumors can be effectively managed using medications, such as bromocriptine or carbergoline. Hypogonadotropic hypogonadism can result from a number of conditions, including congenital abnormalities (e.g., Kallman syndrome), as well as pituitary or suprasellar tumors, pituitary infiltrative disorders (e.g., hemochromatosis, tuberculosis, sarcoidosis, histiocytosis), medications (i.e., chronic narcotic exposure), hyperprolactinemia, prior head trauma, pituitary apoplexy, and severe chronic illness.
One RCT by Maggi et al. followed 715 testosterone deficient men for 12 weeks to evaluate the effects of a 2% transdermal testosterone agent on sex drive and energy. A discussion regarding the benefit of stopping testosterone therapy should include the possibility of a decline in PSA. PSA recurrence in men on testosterone therapy should be evaluated in the same fashion as untreated men. There are limited data in men on active surveillance who are candidates for testosterone therapy.
Furthermore, the identification of other pituitary tumors or processes may have important clinical implications for the patient beyond testosterone deficiency.178 Hyperprolactinemia is an uncommon condition172, 173 but it is a well-established cause of secondary (central) testosterone deficiency and can lead to infertility, decreased libido, sexual dysfunction, and gynecomastia. However, the literature at this time fails to define the LH level below which such adjunctive testing is warranted. LH, which is routinely measured by immunoassay, may help to establish the etiology of testosterone deficiency and can be an important factor in determining if adjunctive tests should be ordered (Appendix C - refer to the Appendix C section in the left menu). Their role in diagnosing testosterone deficiency is unclear, and they should not be used at the expense of a full patient evaluation, including laboratory testosterone measurement. Screening questionnaires are not an appropriate tool to identify candidates for testosterone therapy. With worsening Leydig cell function, there is a reduction in the feedback mechanism resulting in elevation of LH levels (hypergonadotropic hypogonadism).
Another meta-analysis of 37 studies138 found that diabetic men had significantly lower testosterone values than those who did not have diabetes; individual studies with adjusted point estimates also support this outcome.97, 133, 139 A multivariate logistic regression model from one study of 1,089 men who had total testosterone 94 Corona et al. likewise found that the prevalence of low testosterone levels (defined as total testosterone of 107 Although confounders were accounted for in the analysis, concurrent medications that may have reduced the risk for myocardial infarction or other testosterone therapies used outside of the study protocol were not controlled for or assessed.Since the FDA warning in 2015, other studies have failed to demonstrate a risk of cardiovascular events in patients on testosterone therapy. Men with total testosterone level 315 ng/dL declined from 100% at 4 weeks to 86%, 75%, and 14% by 12, 20, and 24 weeks, respectively.Mean peak total testosterone levels are dose-dependent, with a mean of 746, 866, and 913 ng/dL noted with 8, 10, and 12 pellets administered (not BMI adjusted).446 The duration of effect is similar, however, and is relatively independent of dosing. In a 12-week study in 82 men, 72.6% of patients achieved a total testosterone concentration within the physiological range at steady state.434 Men treated with the agent were compared to a group of patients given 5 mg of a testosterone gel formulation, and no differences in mean testosterone serum levels were observed between the two groups.435 The study showed 92% of buccal versus 83% of gel patients achieved testosterone levels in the physiologic range. If patients achieve target testosterone levels, but do not feel that they have sufficient improvement in their symptoms, clinicians should question whether testosterone deficiency is the etiology of their symptoms.