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Houghton DE, Alsawas M, Barrioneuvo P, Tello M, Farah W, Beuschel B, Prokop LJ, Layton JB, Murad MH, Moll S. Testosterone therapy and venous thromboembolism: A systematic review and meta-analysis. Thromb Res 2018; 172:94-103. [PMID: 30396049 PMCID: PMC10601700 DOI: 10.1016/j.thromres.2018.10.023] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 10/17/2018] [Accepted: 10/24/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Testosterone prescribing for men has dramatically increased, and there have been concerns about inappropriate use and adverse events. While regulatory bodies have warned about increased risk of venous thromboembolism (VTE), published clinical data supporting an increased risk for VTE are limited. OBJECTIVE To conduct a systematic review of studies examining the association between testosterone therapy in men and VTE. METHODS Comprehensive searches of multiple databases were performed from inception through October 3rd, 2018. Randomized control trials (RCTs) and observational studies examining the association between exogenous testosterone (any route) and VTE. Study selection and data extraction were performed by two independent investigators. Random-effect model meta-analyses were used to estimate pooled odds ratios (OR) and 95% confidence intervals (CIs). Heterogeneity among studies was evaluated using the I2 statistic. Risk of bias was assessed using the Cochrane and Newcastle-Ottawa tools. RESULTS Six RCTs (n = 2236) and 5 observational studies (n = 1,249,640) were included. Five RCTs were performed in men with documented hypogonadism. The observational studies included: 2 case-control studies, 2 retrospective cohorts, and 1 retrospective cohort with a nested case-control study. There was no evidence of a statistically significant association between VTE and testosterone (OR 1.41, 95%CI 0.96-2.07). Heterogeneity was high (I-squared = 84.4%). The association remained nonsignificant when the analysis was stratified by study design: RCTs (2.05, 95% CI 0.78-5.39); cohort (1.06, 95% CI 0.85-1.33); and case-control (1.34, 95% CI 0.78-2.28). The overall risk of bias was moderate. CONCLUSIONS The current evidence is of low certainty but does not support an association between testosterone use and VTE in men.
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Affiliation(s)
- Damon E Houghton
- Mayo Clinic, Department of Cardiovascular Diseases, Division of Vascular Medicine & Department of Internal Medicine, Division of Hematology/Oncology, 200 1st St SW, Rochester, MN 55905, USA.
| | - Mouaz Alsawas
- Mayo Clinic, Evidence-based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 1st St SW, Rochester, MN 55901, USA
| | - Patricia Barrioneuvo
- Mayo Clinic, Evidence-based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 1st St SW, Rochester, MN 55901, USA
| | - Mouaffaa Tello
- Mayo Clinic, Evidence-based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 1st St SW, Rochester, MN 55901, USA
| | - Wigdan Farah
- Mayo Clinic, Evidence-based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 1st St SW, Rochester, MN 55901, USA
| | - Brad Beuschel
- Mayo Clinic, Evidence-based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 1st St SW, Rochester, MN 55901, USA
| | - Larry J Prokop
- Mayo Clinic Libraries, 200 1st St SW, Rochester, MN 55901, USA
| | - J Bradley Layton
- RTI Health Solutions, Research Triangle Park, NC 27709-2194, USA
| | - M Hassan Murad
- Mayo Clinic, Evidence-based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 1st St SW, Rochester, MN 55901, USA
| | - Stephan Moll
- University of North Carolina School of Medicine, Department of Medicine, Division of Hematology/Oncology, Chapel Hill, NC, USA
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Deprescribing in Geriatric Medicine: Challenges and Opportunities. J Am Med Dir Assoc 2018; 19:919-922. [DOI: 10.1016/j.jamda.2018.09.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 09/20/2018] [Indexed: 11/18/2022]
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Masterson T, Molina M, Ibrahim E, Ramasamy R. Natesto Effects on Reproductive Hormones and Semen Parameters: Results from an Ongoing Single-center, Investigator-initiated Phase IV Clinical Trial. Eur Urol Focus 2018; 4:333-335. [PMID: 30177402 DOI: 10.1016/j.euf.2018.08.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/11/2018] [Accepted: 08/15/2018] [Indexed: 11/20/2022]
Abstract
Promising initial data from our perspective clinical trial demonstrates that Natesto can not only increase serum testosterone but also maintain follicle-stimulating hormone, luteinizing hormone, and importantly, semen parameters.
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Affiliation(s)
| | - Manuel Molina
- Department of Urology, University of Miami, Miami, FL, USA
| | - Emad Ibrahim
- Department of Urology, University of Miami, Miami, FL, USA
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Abstract
Overdiagnosis, is defined as the diagnosis of a condition that, if unrecognized, would not cause symptoms or harm a patient during his or her lifetime, and it is increasingly acknowledged as a consequence of screening for cancer and other conditions. Because preventive care is a crucial component of primary care, which is delivered to the broad population, overdiagnosis in primary care is an important problem from a public health perspective and has far reaching implications. The scope of overdiagnosis as a result of services delivered in primary care is unclear, though overdiagnosis of indolent breast, prostate, thyroid, and lung cancers is well described and overdiagnosis of chronic kidney disease, depression, and attention-deficit/hyperactivity disorder is also recognized. However, overdiagnosis is a known consequence of all screening and can be assumed to occur in many more clinical contexts. Overdiagnosis can harm patients by leading to overtreatment (with associated potential toxicities), diagnosis related anxiety or depression, and labeling, or through financial burden. Many entrenched factors facilitate overdiagnosis, including the growing use of advanced diagnostic technology, financial incentives, a medical culture that encourages greater use of tests and treatments, limitations in the evidence that obscure the understanding of diagnostic utility, use of non-beneficial screening tests, and the broadening of disease definitions. Efforts to reduce overdiagnosis are hindered by physicians' and patients' lack of awareness of the problem and by confusion about terminology, with overdiagnosis often conflated with related concepts. Clarity of terminology would facilitate physicians' understanding of the problem and the growth in evidence regarding its prevalence and downstream consequences in primary care. It is hoped that international coordination regarding diagnostic standards for disease definitions will also help minimize overdiagnosis in the future.
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Affiliation(s)
- Minal S Kale
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Deborah Korenstein
- Department of Medicine and Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY 10017, USA
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Yeap BB, Page ST, Grossmann M. Testosterone treatment in older men: clinical implications and unresolved questions from the Testosterone Trials. Lancet Diabetes Endocrinol 2018; 6:659-672. [PMID: 30017800 DOI: 10.1016/s2213-8587(17)30416-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 11/02/2017] [Accepted: 11/06/2017] [Indexed: 10/28/2022]
Abstract
A decrease in the concentration of circulating testosterone in many older men is a biomarker and possibly a rectifiable contributing factor to ill health. Low circulating testosterone concentration has been associated with cardiovascular disease, reduced cognition, fracture risk, and anaemia. However, randomised placebo-controlled trials are essential to clarify the benefits and possible risks of testosterone treatment in men without hypothalamic, pituitary, or testicular disease. The Testosterone Trials (T-Trials) were a coordinated set of trials that, following a screening-to-enrolment ratio of 65:1, randomly assigned 790 men aged 65 years or older who had a baseline testosterone concentration of less than 9·54 nmol/L and symptoms consistent with hypogonadism, but no recognisable hypothalamic-pituitary-testicular axis pathology, to daily transdermal testosterone or placebo for 12 months. In the main trial, testosterone treatment resulted in a modest benefit for sexual function, whereas the other primary outcomes of vitality and physical function were not met. Data from concomitant substudies raised a possible concern over changes in coronary plaque volume, showed a neutral effect on memory and other cognitive functions, and revealed improvements in volumetric bone mineral density and anaemia. Although insufficient to alter the existing clinical equipoise, the T-Trials provided substantial new data on organ-specific outcomes for testosterone treatment in older men. Further clinical trials are necessary to determine whether testosterone treatment will translate into patient-valued health outcomes and to clarify effects on the cardiovascular system.
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Affiliation(s)
- Bu B Yeap
- School of Medicine, University of Western Australia, Perth, WA, Australia; Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, WA, Australia
| | - Stephanie T Page
- Division of Metabolism and Endocrinology, University of Washington, Seattle, WA, USA.
| | - Mathis Grossmann
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; Department of Endocrinology, Austin Health, Melbourne, VIC, Australia
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Haberlen SA, Jacobson LP, Palella FJ, Dobs A, Plankey M, Lake JE, Kingsley LA, Stall R, Post WS, Brown TT. To T or not to T: Differences in Testosterone Use and Discontinuation by HIV Serostatus among Men who Have Sex with Men. HIV Med 2018; 19:634-644. [PMID: 29989322 DOI: 10.1111/hiv.12644] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The aim of the study was to characterize contemporary patterns and correlates of testosterone therapy (TTh) use and discontinuation by HIV serostatus among men in the Multicenter AIDS Cohort Study (MACS). METHODS Self-reported testosterone use data were collected semiannually from 2400 (1286 HIV-infected and 1114 HIV-uninfected) men who have sex with men. Multivariable Poisson regression was used to estimate prevalence ratios for TTh use and predictors of TTh discontinuation (2012-2015). RESULTS Use was higher among HIV-infected compared with HIV-uninfected men in all age strata, with an age-adjusted prevalence of 17% vs. 5%, respectively (adjusted prevalence ratio 3.7; P < 0.001). Correlates of use in the multivariable model were similar by HIV serostatus: white race, the Los Angeles (LA) site, more than one recent sexual partner, non-smoking status, and higher American Heart Association/American College of Cardiology (AHA/ACC) cardiovascular disease (CVD) risk score category (approximately 70% of testosterone users were in the high-risk category). Compared with HIV-uninfected men, HIV-infected men more frequently reported building muscle mass as a motivation for testosterone use. The TTh discontinuation rate was 20.9/100 person-years [95% confidence interval (CI) 17.3, 25.0/100 person-years]. Relative to HIV-uninfected men, HIV-infected men were half as likely to discontinue (adjusted incidence rate ratio 0.4; P < 0.001). Discontinuation was 40% higher in the period after the US Food and Drug Administration (FDA) safety communication for testosterone in 2014, independent of co-factors (P = 0.06). CONCLUSIONS Given the high prevalence of both TTh use and CVD risk among HIV-infected men, the benefits and risks of TTh should be examined in future studies of aging HIV-infected men and monitored routinely in clinical practice.
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Affiliation(s)
- S A Haberlen
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - L P Jacobson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - F J Palella
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - A Dobs
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - M Plankey
- Department of Medicine, Division of Infectious Diseases, Georgetown University Medical Center, Washington, DC, USA
| | - J E Lake
- Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - L A Kingsley
- Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - R Stall
- Department of Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - W S Post
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - T T Brown
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Hara K, Tomio J, Svensson T, Ohkuma R, Svensson AK, Yamazaki T. Association measures of claims-based algorithms for common chronic conditions were assessed using regularly collected data in Japan. J Clin Epidemiol 2018; 99:84-95. [DOI: 10.1016/j.jclinepi.2018.03.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 02/23/2018] [Accepted: 03/07/2018] [Indexed: 10/17/2022]
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Mintzes B. The marketing of testosterone treatments for age-related low testosterone or 'Low T'. Curr Opin Endocrinol Diabetes Obes 2018; 25:224-230. [PMID: 29570470 DOI: 10.1097/med.0000000000000412] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To summarize the research evidence on promotion of testosterone for 'Low T', or age-related hypogonadism. RECENT FINDINGS Marketing of testosterone for 'Low T' has relied on strategies that are inadequately regulated to prevent off-label promotion, such as unbranded 'disease-awareness' advertising campaigns targeting the general public, sponsored continuing medical education (CME) and ghostwriting. A recent US analysis of television advertising exposure levels versus insurance claims found that both unbranded 'disease-awareness' advertising and branded ads were associated with increased rates of testosterone testing, treatment initiation, and treatment without prior testing. Exposés of sponsored CME and ghostwriting indicate misrepresentation of the research evidence on the sequelae of untreated low testosterone and on treatment efficacy. In the United States, advertising to the general public ceased in 2014 after the Food and Drug Administration changed product labeling to clarify that testosterone is only indicated for pathological hypogonadism. Unbranded 'disease-awareness' advertising to the general public and 'Low T' messages for health professionals have continued elsewhere. SUMMARY The review of the experience of promotion of testosterone for 'Low T' and research evidence on effects of advertising targeting the public highlights the need for improved regulation of unbranded 'disease awareness' advertising to ensure adequate protection of public.
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Affiliation(s)
- Barbara Mintzes
- Charles Perkins Centre and Faculty of Pharmacy, University of Sydney, Sydney, New South Wales, Australia
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Debate position: cognition and mood are not improved in men administered exogenous testosterone therapy. Curr Opin Urol 2018; 27:525-531. [PMID: 28863017 DOI: 10.1097/mou.0000000000000435] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this article is to provide an overview of the increasing evidence suggesting that exogenous testosterone therapy is not associated with improvements in cognition or mood. This article is part of a series, in this issue, in which authors are assigned opinion pieces on controversial topics pertaining to testosterone replacement. RECENT FINDINGS Testosterone is increasingly being prescribed. Particularly in the setting of recent data suggestive of possible cardiovascular risk associated with its use; a clear understanding of the domains of health that improve with exogenous testosterone use is important. Data on endogenous and exogenous testosterone with cognition and mood are mixed, likely partly related to methodological differences of type of testosterone, patient population, and dosing. SUMMARY Overall, available data are not suggestive of a clear benefit of testosterone supplementation in multiple domains of cognition and in mood. Supraphysiologic testosterone has been associated with adverse psychological outcomes, albeit not uniformly in studies.
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Layton JB, Li D, Meier CR, Sharpless JL, Stürmer T, Brookhart MA. Injection testosterone and adverse cardiovascular events: A case-crossover analysis. Clin Endocrinol (Oxf) 2018; 88:719-727. [PMID: 29446829 PMCID: PMC5903996 DOI: 10.1111/cen.13574] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 02/05/2018] [Accepted: 02/06/2018] [Indexed: 12/16/2022]
Abstract
CONTEXT Exogenous testosterone administration may affect blood clotting, polycythaemia, and may increase atherosclerosis, though any association with cardiovascular events is unclear. While the literature is inconclusive, some studies have suggested testosterone use may increase short-term risk of cardiovascular events and stroke, and injection testosterone may convey higher risks than other dosage forms. OBJECTIVE We sought to evaluate the short-term cardiovascular risk of receiving injection testosterone. DESIGN We conducted a case-crossover analysis comparing injection testosterone exposure in the 7 days prior to an outcome event to referent windows in the past to estimate the acute association of cardiovascular outcomes with the receipt of testosterone injections. PATIENTS We identified adult male testosterone users hospitalized with myocardial infarction (MI), stroke or a composite of MI, stroke or unstable angina in US commercial claims (2000-2013) or Medicare (2007-2010) databases. MEASUREMENTS We identified testosterone use for the patients from pharmacy dispensing claims or in-office procedure codes in the insurance billing data. RESULTS We identified 2898 commercially insured men with events and recent testosterone use, and 339 from Medicare. Injected testosterone was associated with an increased risk of adverse events (composite outcome of myocardial infarction, stroke or unstable angina) in the immediate postinjection period for the older, Medicare population only: commercial insurance, odds ratios (OR) = 0.98 (95% confidence intervals [CI]: 0.86-1.12); Medicare, OR = 1.45 (1.07, 1.98). This association was either greatly attenuated or not present when evaluating receipt of any testosterone dosage forms (injection, gel, patch, implant): commercial insurance, OR = 1.01 (0.92, 1.11); Medicare, OR = 1.26 (95% CI: 0.98-1.63). CONCLUSIONS Testosterone injections were uniquely associated with short-term risk of acute cardio- and cerebrovascular events in older adult men following injection receipt.
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Affiliation(s)
- J Bradley Layton
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- RTI Health Solutions, Research Triangle Park, NC, USA
| | - Dongmei Li
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Christoph R Meier
- Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Julie L Sharpless
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Til Stürmer
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - M Alan Brookhart
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Klara K, Kim J, Ross JS. Direct-to-Consumer Broadcast Advertisements for Pharmaceuticals: Off-Label Promotion and Adherence to FDA Guidelines. J Gen Intern Med 2018; 33:651-658. [PMID: 29484575 PMCID: PMC5910340 DOI: 10.1007/s11606-017-4274-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/28/2017] [Accepted: 12/06/2017] [Indexed: 10/17/2022]
Abstract
BACKGROUND Direct-to-consumer (DTC) advertisements for prescription drugs in the United States are regulated by the Food and Drug Administration (FDA). Off-label promotion, or the advertisement of a drug for an indication not approved by the FDA, is prohibited. Our objective was to examine the presence of off-label promotion in broadcast DTC ads and to assess their adherence to FDA guidelines mandating fair balance in presentation of risks and benefits and prohibiting misleading advertisement claims. METHODS All English-language broadcast DTC ads for prescription drugs that aired in the United States from January 2015 to July 2016 were obtained from AdPharm, an online collection of healthcare advertisements. Ad length was measured and adherence to FDA guidelines was assessed for several categories: key regulatory items, indicators of false or misleading ads, and indicators of fair balance in presentation of risks and benefits. RESULTS Our sample included 97 unique DTC ads, representing 60 unique drugs and 67 unique drug-indication combinations. No ads described drug risks quantitatively, whereas drug efficacy was presented quantitatively in 25 (26%) ads. Thirteen (13%) ads, all for diabetes medications, suggested off-label uses for weight loss and blood pressure reduction. The most commonly advertised drugs were indicated for the treatment of inflammatory conditions (n = 12; 18%), diabetes or diabetic neuropathy (n = 11; 16%), bowel or bladder dysfunction (n = 6; 9%), and infections or allergic reaction (n = 6; 9%). More than three-quarters (n = 51; 76%) advertised drugs to treat chronic conditions. CONCLUSIONS Few broadcast DTC ads were fully compliant with FDA guidelines. The overall quality of information provided in ads was low, and suggestions of off-label promotion were common for diabetes medications. The impact of current DTC ads and off-label marketing on patient and prescriber decisions merits further scrutiny.
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Affiliation(s)
| | - Jeanie Kim
- Yale Law School, New Haven, CT, USA
- Collaboration for Research Integrity and Transparency (CRIT) at Yale University, New Haven, CT, USA
| | - Joseph S Ross
- Collaboration for Research Integrity and Transparency (CRIT) at Yale University, New Haven, CT, USA.
- Section of General Internal Medicine and the National Clinician Scholars Program, Yale School of Medicine, New Haven, CT, USA.
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA.
- Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, New Haven, CT, USA.
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Sullivan HW, O'Donoghue AC, Gard Read J, Amoozegar JB, Aikin KJ, Rupert DJ. Testimonials and Informational Videos on Branded Prescription Drug Websites: Experimental Study to Assess Influence on Consumer Knowledge and Perceptions. J Med Internet Res 2018; 20:e13. [PMID: 29362205 PMCID: PMC5801518 DOI: 10.2196/jmir.7959] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 10/10/2017] [Accepted: 11/16/2017] [Indexed: 02/07/2023] Open
Abstract
Background Direct-to-consumer (DTC) promotion of prescription drugs can affect consumer behaviors and health outcomes, and Internet drug promotion is growing rapidly. Branded drug websites often capitalize on the multimedia capabilities of the Internet by using videos to emphasize drug benefits and characteristics. However, it is unknown how such videos affect consumer processing of drug information. Objective This study aimed to examine how videos on prescription drug websites, and the inclusion of risk information in those videos, influence consumer knowledge and perceptions. Methods We conducted an experimental study in which online panel participants with acid reflux (n=1070) or high blood pressure (n=1055) were randomly assigned to view 1 of the 10 fictitious prescription drug websites and complete a short questionnaire. On each website, we manipulated the type of video (patient testimonial, mechanism of action animation, or none) and whether the video mentioned drug risks. Results Participants who viewed any video were less likely to recognize drug risks presented only in the website text (P≤.01). Including risk information in videos increased participants’ recognition of the risks presented in the videos (P≤.01). However, in some cases, including risk information in videos decreased participants’ recognition of the risks not presented in the videos (ie, risks presented in text only; P≤.04). Participants who viewed a video without drug risk information thought that the website placed more emphasis on benefits, compared with participants who viewed the video with drug risk information (P≤.01). Compared with participants who viewed a video without drug risk information, participants who viewed a video with drug risk information thought that the drug was less effective in the high blood pressure sample (P=.03) and thought that risks were more serious in the acid reflux sample (P=.01). There were no significant differences between risk and nonrisk video conditions on other perception measures (P>.05). In addition, we noted a few differences among the types of videos. Conclusions Including risks in branded drug website videos may increase in-video risk retention at the expense of text-only risk retention.
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Affiliation(s)
- Helen W Sullivan
- US Food and Drug Administration, Silver Spring, MD, United States
| | | | | | | | - Kathryn J Aikin
- US Food and Drug Administration, Silver Spring, MD, United States
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Corona G, Rastrelli G, Reisman Y, Sforza A, Maggi M. The safety of available treatments of male hypogonadism in organic and functional hypogonadism. Expert Opin Drug Saf 2018; 17:277-292. [PMID: 29334271 DOI: 10.1080/14740338.2018.1424831] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION In the case of primary male hypogonadism (HG), only testosterone (T) replacement therapy (TRT) is possible whereas when the problem is secondary to a pituitary or hypothalamus alteration both T production and fertility can be, theoretically, restored. We here systematically reviewed and discussed the advantages and limits of medications formally approved for the treatment of HG. AREAS COVERED Data derived from available meta-analyses of placebo controlled randomized trials (RCTs) were considered and analyzed. Gonadotropins are well-toleratedand their use is mainly limited by higher costs and a more cumbersome treatment schedule than TRT. Available RCTs on TRT suggest that cardiovascular (CV) and venous thromboembolism risk is not a major issue and that prostate safety is guaranteed. The risk of increased hematocrit is mainly limited to the use of short terminjectable preparations. EXPERT OPINION In the last few years the concept of 'organic' irreversible HG and 'functional' or age- and comorbidity-related HG has been introduced. This definition is not evidence-based. The majority of RCTs enrolled patients with 'functional' HG. Considering the significant improvement in body composition, glucose metabolism and sexual activity, TRT should not be limited to 'organic' HG, but also offered for 'functional'.
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Affiliation(s)
- G Corona
- a Endocrinology Unit, Medical Department , Maggiore-Bellaria Hospital, Azienda-Usl Bologna , Bologna , Italy
| | - G Rastrelli
- b Sexual Medicine and Andrology Unit, Department of Experimental, Clinical and Biomedical Sciences , University of Florence , Florence , Italy
| | - Y Reisman
- c Department of Urology , Amstelland Hospital , Amsterdam , The Netherlands
| | - A Sforza
- a Endocrinology Unit, Medical Department , Maggiore-Bellaria Hospital, Azienda-Usl Bologna , Bologna , Italy
| | - M Maggi
- b Sexual Medicine and Andrology Unit, Department of Experimental, Clinical and Biomedical Sciences , University of Florence , Florence , Italy
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Re: Association Between Direct-to-consumer Advertising and Testosterone Testing and Initiation in the United States, 2009–2013. Eur Urol 2017; 72:853. [DOI: 10.1016/j.eururo.2017.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 08/29/2017] [Indexed: 11/17/2022]
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Wallach JD, Gonsalves GS, Ross JS. Research, regulatory, and clinical decision-making: the importance of scientific integrity. J Clin Epidemiol 2017; 93:88-93. [PMID: 29042327 DOI: 10.1016/j.jclinepi.2017.08.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 08/10/2017] [Accepted: 08/17/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Joshua D Wallach
- Collaboration for Research Integrity and Transparency (CRIT), Yale Law School, 157 Church Street, 17th Floor, Suite 1, New Haven, CT 06510-2100, USA; Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, 1 Church Street # 200, New Haven, CT 06510-2100, USA.
| | - Gregg S Gonsalves
- Collaboration for Research Integrity and Transparency (CRIT), Yale Law School, 157 Church Street, 17th Floor, Suite 1, New Haven, CT 06510-2100, USA; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, 60 College Street, P.O. Box 208034, New Haven, CT 06520-8034, USA; Yale Law School, Yale University, 127 Wall Street, New Haven, CT 06511, USA
| | - Joseph S Ross
- Collaboration for Research Integrity and Transparency (CRIT), Yale Law School, 157 Church Street, 17th Floor, Suite 1, New Haven, CT 06510-2100, USA; Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, 1 Church Street # 200, New Haven, CT 06510-2100, USA; Section of General Medicine, Department of Internal Medicine, Yale School of Medicine, P.O. Box 208093, New Haven, CT 06520-8093, USA; Department of Health Policy and Management, Yale School of Public Health, 60 College Street, New Haven, CT 06510-2100, USA
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Bandari J, Ayyash OM, Emery SL, Wessel CB, Davies BJ. Marketing and Testosterone Treatment in the USA: A Systematic Review. Eur Urol Focus 2017; 3:395-402. [PMID: 29174614 DOI: 10.1016/j.euf.2017.10.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 10/21/2017] [Accepted: 10/24/2017] [Indexed: 10/18/2022]
Abstract
CONTEXT Testosterone replacement therapy (TRT) is currently approved by the Food and Drug Administration only for classic hypogonadism, although off-label indications have resulted in a dramatic expansion in prescriptions in the USA. Marketing may significantly affect prescriber behavior. OBJECTIVE To systematically review all available evidence on marketing and TRT in the USA. EVIDENCE ACQUISITION PubMed, Embase, and Scopus were searched up to July 2017 for all relevant publications reporting on assessments of the TRT market size, economic costs associated with hypogonadism, trends in TRT prescriptions, drug discontinuation rates, and advertising and sales efforts in the USA. EVIDENCE SYNTHESIS Twenty retrospective studies were included in the final analysis. The market size for hypogonadism constitutes 5.6-76.8% of men in the USA, with the lower end of the range representing the strictest criteria for diagnosis. Men with a diagnosis of hypogonadism consume $14 118 in direct and indirect costs to the payer. Over the last 2 decades, TRT prescriptions have increased between 1.8- and 4-fold. After 1 yr, 80-85% of men discontinue TRT. There is an association between direct-to-consumer advertising and testosterone testing, TRT prescriptions, and TRT without testosterone testing. There is a high prevalence of misinformation on Internet advertising. CONCLUSIONS Off-label indications have driven the dramatic expansion of TRT prescriptions over the last 2 decades. Direct-to-consumer advertising poses a unique challenge in the USA. Overtreatment can be avoided by applying strict diagnostic criteria for hypogonadism, which limits the addressable market for TRT. PATIENT SUMMARY In this report, we reviewed the relationship between marketing and testosterone therapy in the USA. We found that many patients are prescribed testosterone without an appropriate diagnosis of hypogonadism, which may be related to the marketing efforts for off-label prescribing.
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Affiliation(s)
- Jathin Bandari
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Omar M Ayyash
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Charles B Wessel
- University of Pittsburgh Health Sciences Library System, Pittsburgh, PA, USA
| | - Benjamin J Davies
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Jasuja GK, Bhasin S, Rose AJ, Reisman JI, Hanlon JT, Miller DR, Morreale AP, Pogach LM, Cunningham FE, Park A, Wiener RS, Gifford AL, Berlowitz DR. Provider and Site-Level Determinants of Testosterone Prescribing in the Veterans Healthcare System. J Clin Endocrinol Metab 2017; 102:3226-3233. [PMID: 28911150 PMCID: PMC5587071 DOI: 10.1210/jc.2017-00468] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 05/26/2017] [Indexed: 01/05/2023]
Abstract
CONTEXT Testosterone prescribing rates have increased substantially in the past decade. However, little is known about the context within which such prescriptions occur. OBJECTIVE We evaluated provider- and site-level determinants of receipt of testosterone and of guideline-concordant testosterone prescribing. DESIGN This study was cross-sectional in design. SETTING This study was conducted at the Veterans Health Administration (VA). PARTICIPANTS Study participants were a national cohort of male patients who had received at least one outpatient prescription within the VA during fiscal year (FY) 2008 to FY 2012. A total of 38,648 providers and 130 stations were associated with these patients. MAIN OUTCOME MEASURE This study measured receipt of testosterone and guideline-concordant testosterone prescribing. RESULTS Providers ranging in age from 31 to 60 years, with less experience in the VA [all adjusted odds ratio (AOR), <2; P < 0.01] and credentialed as medical doctors in endocrinology (AOR, 3.88; P < 0.01) and urology (AOR, 1.48; P < 0.01) were more likely to prescribe testosterone compared with older providers, providers of longer VA tenure, and primary care providers, respectively. Sites located in the West compared with the Northeast [AOR, 1.75; 95% confidence interval (CI), 1.45-2.11] and care received at a community-based outpatient clinic compared with a medical center (AOR, 1.22; 95% CI, 1.20-1.24) also predicted testosterone use. Although they were more likely to prescribe testosterone, endocrinologists were also more likely to obtain an appropriate workup before prescribing compared with primary care providers (AOR, 2.14; 95% CI, 1.54-2.97). CONCLUSIONS Our results highlight the opportunity to intervene at both the provider and the site levels to improve testosterone prescribing. This study also provides a useful example of how to examine contributions to prescribing variation at different levels of the health care system.
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Affiliation(s)
- Guneet K. Jasuja
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts 02118
| | - Shalender Bhasin
- Research Program in Men’s Health, Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women’s Hospital, Harvard Medical School Boston, Boston, Massachusetts 02115
| | - Adam J. Rose
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts 02118
| | - Joel I. Reisman
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
| | - Joseph T. Hanlon
- Division of Geriatrics, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
- Center for Health Equity Research and Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania 15213
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
| | - Donald R. Miller
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
| | - Anthony P. Morreale
- Clinical Pharmacy Services and Healthcare Services Research, VA Pharmacy Benefits Management Services VACO, San Diego, California 92161
| | - Leonard M. Pogach
- Department of Veterans Affairs, New Jersey Healthcare System, East Orange, New Jersey 07018
| | | | - Angela Park
- New England Veterans Engineering Resource Center, Boston, Massachusetts 02130
| | - Renda S. Wiener
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
- Department of Medicine, The Pulmonary Center, Boston University, Boston, Massachusetts 02118
| | - Allen L. Gifford
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts 02118
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts 02118
| | - Dan R. Berlowitz
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts 02118
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Handelsman DJ. Pharmacoepidemiology of testosterone: Curbing off-label prescribing. Pharmacoepidemiol Drug Saf 2017; 26:1248-1255. [DOI: 10.1002/pds.4284] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/12/2017] [Accepted: 07/12/2017] [Indexed: 11/10/2022]
Affiliation(s)
- David J. Handelsman
- ANZAC Research Institute; University of Sydney; Sydney New South Wales Australia
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Abstract
PURPOSE OF REVIEW Testosterone therapy has been advocated in the treatment of symptoms that may represent normal aging. We briefly review randomized clinical trials on the effects of testosterone therapy on sexual function. RECENT FINDINGS About half of clinical trials showed no benefit of testosterone therapy on any aspect of sexual function. In those studies showing a benefit on some aspect of sexual function, most sexual function domains were not improved. Testosterone therapy has been disappointing in the treatment of erectile dysfunction. Potential risks of therapy include an increase in thromboembolic and other cardiovascular diseases. SUMMARY The limited and inconsistent benefits of testosterone therapy for sexual function argue against use of this therapy in aging men, including those with 'low testosterone'.
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Mailankody S, Prasad V. Pharmaceutical Marketing for Rare Diseases: Regulating Drug Company Promotion in an Era of Unprecedented Advertisement. JAMA 2017; 317:2479-2480. [PMID: 28520871 DOI: 10.1001/jama.2017.5784] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Sham Mailankody
- Myeloma Service, Division of Hematologic Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Vinay Prasad
- Knight Cancer Institute, Division of Hematology Oncology, Oregon Health & Science University, Portland3Department of Public Health and Preventive Medicine and Center for Health Care Ethics, Oregon Health & Science University, Portland
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Yi YA, Dupree JM. Science and Society: Testosterone replacement therapy and the knowledge gap. Nat Rev Urol 2017; 14:332-333. [PMID: 28485412 DOI: 10.1038/nrurol.2017.63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yooni A Yi
- Department of Urology, Michigan Medicine Department of Urology, 1500 E Medical Center Drive, 3875 Taubman Center/SPC 5330, Ann Arbor, Michigan 48109-5330, USA
| | - James M Dupree
- Department of Urology, Divisions of Andrology and Health Services Research, and Department of Obstetrics and Gynecology, University of Michigan, 1500 E Medical Center Drive, 3875 Taubman Center/SPC 5330, Ann Arbor, Michigan 48109-5330, USA
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Holzgreve H. [Not Available]. MMW Fortschr Med 2017; 159:42. [PMID: 28466321 DOI: 10.1007/s15006-017-9573-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Drobnis EZ, Nangia AK. Exogenous Androgens and Male Reproduction. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 1034:25-28. [PMID: 29256124 DOI: 10.1007/978-3-319-69535-8_4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Due in part to aggressive marketing, the prevalence of exogenous androgen use has increased to disturbing levels. Prescribing practitioners are often unaware of the severity of the anti-fertility effects. Exogenous androgens should only be prescribed if hypogonadism has been established by appropriate investigation, and preferably the patient does not intend to father a child. There are alternative medications, or combinations of medications, that can be used if hypogonadism is present and fertility is desired.It is somewhat counterintuitive that testosterone treatment will decrease or abolish fertility. Exogenous testosterone inhibits spermatogenesis by removing the feedback response to low testosterone at the hypothalamus and pituitary. This results in reduced synthesis and secretion of gonadotropins required to stimulate endogenous testosterone production and to support spermatogenesis. It is important to realize that the normal testicular levels of testosterone are approximately 100 times the concentration in circulation. These high levels are required locally to support spermatogenesis. So even with circulating androgen levels within the normal range, spermatogenesis fails due to insufficient gonadotropin and local testosterone support. Androgenic herbal supplements and illicit use of anabolic steroids have contributed to this serious challenge in the treatment of infertile men. Most men will recover normal spermatogenesis after cessation of exogenous testosterone treatment, but this requires 6 months or more in most men. In rare cases fertility is permanently impaired.
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Affiliation(s)
- Erma Z Drobnis
- Obstetrics, Gynecology and Women's Health, University of Missouri School of Medicine, Columbia, MO, USA
| | - Ajay K Nangia
- Department of Urology, University of Kansas Medical Center, Kansas City, KS, USA
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