13 Thera VI Andropause/Testosterone Cosep Flashcards
What is Andropause?
Often referred to as “male menopause” or ADAM (Androgen deficiency in the aging male). Testosterone decreases as men age
What is the prevalence of Andropause?
20% of men 60-80 years of age have low testosterone
What are the physical symptoms of low testosterone?
Fatigue. Muscle weakness. Decreased bone mineral density. Decreased muscle mass. Increased fat. Impaired hematopoiesis
What are the sexual/emotional symptoms of low testosterone?
Decreased libido. ED. Oligospermia. Depression. Anxiety. Mood swings. Loss of memory. Cognitive dysfunction
What are the hormone levels like in Primary low testosterone?
Low testosterone levels, high gonadotropines/LH/FSH
What are the hormone levels like in Secondary low testosterone?
Low testosterone and low gonadotropine releasing hormone (GnRH)
What is testosterone production like with age?
Younger men have diurnal variation in serum testosterone concentrations. Older men lose this diurnal rhythm. Sex-hormone-binding globulin (SHBG) increases. Leydig cells decrease. Blood supply to gonads impaired
What is testosterone binding like?
60% of testosterone is bound to SHBG. 38% bound to Albumin. 2% Free T
What are the causes of primary (testicular failure) hypogonadism?
Klinefelter’s syndrome. Vanishing testes syndromes. Fetal testicular loss. Anorchia
What are the causes of secondary (pituitary failure) hypogonadism?
Kallman’s syndrome. Prader-Willi syndrome. Pituitary adenoma
What are some chronic diseases linked to hypogonadism?
Obesity. DM. CVD. Lung cancer. Prostate disease. Inflammatory diseases. Endocrine disorders
What are some medications associated with hypogonadism?
Alcohol. Opioids. Anabolic steroids. Ketoconazole. GLucocorticoids. Spironolactone. Cimetidine. Phenytoin. Flutamide
What are the normal Serum Total Testosterone levels?
300-1050 ng/dL
What are the normal Free Testosterone levels?
50-210 ng/L
What are some potential benefits of testosterone replacement?
Bone. Body composition. Cardiovascular. Sexual effects. Emotional effects
What are the ADRs associated with Testosterone Replacement?
Acne. Fluid retention. Edema. Polycythemia. Suppression of sperm production. Gynecomastia. Sleep apnea. Increase in lean body mass. Weight gain. Aggressive behavior. Hepatic dysfunction
What are the Safety issues in testosterone replacement?
Increase LDL and TGs, decrease HDL. Induce insulin resistance and carbohydrate intolerance. Increase risk for prostate and breast cancer
What are the pretreatment screenings that should be done?
Baseline hemoglobin/hematocrit. Prostate-specific antigen (PSA) level. Digital rectal exam (DRE). Liver function tests. Lipid profile
What are the oral testosterone replacement medications?
Methyltestosterone. Fluoxymesterone
What is the approximate oral medication dose?
10-40mg/day. Given in divided daily doses
What are the limitations of oral testosterone replacement?
Poor oral BA. Poor androgen effect. Adverse lipid changes. Priapism. Increase risk of hepatic side effects!!
What is the buccal preparation used?
Striant. 30mg applied BID. Avoid in soy allergies
What are the advantages of the buccal preparation?
Closely approximates physiological testosterone levels (higher in morning, lower in evening). BID dosing allows for normal testosterone levels throughout the day. Not affected by eating, tooth brushing, gum chewing, or alcoholic beverages
What are the disadvantages of the buccal preparation?
BID dosing required. Some initial gum irritation
What is the transdermal patch used?
Androderm. Applied every evening b/w 8pm to midnight. Never apply to genitals/damaged skin. If falls off, may press back on or replace before noon
What is the usual Androderm dose?
2.5mg/day to 7.5mg/day
What are the advantages of the transdermal patch?
Closely mimics normal diurnal changes in testosterone levels in men. Once daily dosing
What are the disadvantages of the transdermal patch?
Skin irritation. Problems with patch adhering properly
What are the topical gel preparations used?
Androgel. Testim
What is the usual dose of topical gel preparations?
5g/day (max 10g/day)
What type of allergy should topical gel preparations be avoided in?
Soy
Where should androgel/testim be applied?
Androgel: upper arms or stomach. Testim: upper arms
How should topical gel preparations be applied?
Same time each day (morning). Entire contents should be applied immediately to application sites. Do not swim/shower for 5-6 hours after application. Hands should be washed with soap and water after application. Never apply to genitals/damaged skin
What are the subcutaneous implants used?
Testopel (75mg). SQ implantation only
What is the usual subcutaneous implant dose?
150-450mg Q3-6 months
What are the advantages of subcutaneous implants?
Long-acting. Convenient delivery system (every 3-6 months)
What are the disadvantages of subcutaneous implants?
Potential fluctuations in testosterone levels. Inflammation and pain at pellet site. Difficulty adjusting dose. Pellet extrusion (8%-10% of patients). Invasive nature of administration
What are the intramuscular injections used?
Testosterone cypionate (Depo-Testosterone). Testosterone enanthate (Delatestryl)
What is the usual IM dose?
50-400mg IM every 2-4 weeks
What are the advantages of intramuscular injections?
Safe delivery system. Convenient schedule (every 2-4 weeks)
What are the disadvantages of intramuscular injections?
Potential for significant fluctuations. Longer intervals - may have greater fluctuations and lead to variations in effects
What are the general contraindications to testosterone replacement?
Males with carcinoma of the breast. Males with known or suspected carcinoma of the prostate gland. Women who are or who may become pregnant
When is systemic testosterone replacement use contraindicated?
Patients with serious cardiac, hepatic, or renal disease. BPH with obstruction. Undiagnosed genital bleeding. Hypercalcemia
Which medications should be avoided with soy allergies?
Androgel. Testim. Striant
What are the warnings/precautions with testosterone replacement?
Patients with other risk factors for prostate cancer. Cardiovascular disease/edematous conditions. Prolonged oral use –> serious hepatic effects. May potentiate sleep apnea. Transdermal patch may contain conducting metals
What is a DDI associated with testosterone replacement?
May increase the effects of warfarin
