201
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Liu H, Lyu Y, Li D, Cui Y, Huang Y, Dai W, Li Y. Potential relation between soluble growth differentiation factor-15 and testosterone deficiency in male patients with coronary artery disease. Cardiovasc Diabetol 2019; 18:21. [PMID: 30819257 PMCID: PMC6394066 DOI: 10.1186/s12933-019-0823-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 02/05/2019] [Indexed: 02/08/2023] Open
Abstract
Background There is a mutual interaction between inflammation and endocrine disorders in the development of coronary artery disease (CAD). Growth differentiation factor-15 (GDF-15) is associated with CAD, and the effects of testosterone on CAD as reported in literature have been considered as anti-atherosclerotic. The present study aimed to examine the possible association between serum GDF-15 and testosterone in male CAD patients. Methods GDF-15 and testosterone concentrations were determined in blood samples of 426 male patients with CAD and 220 male controls. Serum concentrations of hs-CRP, and other baseline characteristics were also measured. Results Serum levels of GDF-15 were higher in CAD patients when compared to controls, and testosterone concentrations were lower (p < 0.001). Patients with low testosterone levels had higher concentrations of GDF-15 (p < 0.001). In stratified analyses, inverse relations between GDF-15 levels and testosterone were noted for almost all strata, stratified by categories of hs-CRP, leukocytes, neutrophils, neutrophil to lymphocyte ratio, glucose, HDL-c, and LDL-c, and whether had hypertension, diabetes, and underwent percutaneous coronary intervention (PCI). Furthermore, in the linear regression models with bootstrap resampling with 1000 replications, high GDF-15 levels were independently associated with testosterone deficiency in male patients with CAD. Conclusions In male patients with CAD, high GDF-15 levels were associated with testosterone deficiency. These results support that upregulation of GDF-15 in the presence of low testosterone levels during CAD progression is a potential mechanism by which GDF-15 affects CAD. Electronic supplementary material The online version of this article (10.1186/s12933-019-0823-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Huan Liu
- Dept of Clinical Laboratory, Wuhan Univ, Renmin Hospital, Jiefang Road 238, Wuhan, 430060, Hubei, China
| | - Yongnan Lyu
- Dept of Cardiology, Wuhan Univ, Renmin Hospital, Jiefang Road 238, Wuhan, 430060, Hubei, China
| | - Di Li
- Dept of Clinical Laboratory, Wuhan Univ, Renmin Hospital, Jiefang Road 238, Wuhan, 430060, Hubei, China
| | - Yan Cui
- Dept of Clinical Laboratory, Wuhan Univ, Renmin Hospital, Jiefang Road 238, Wuhan, 430060, Hubei, China
| | - Yun Huang
- Dept of Clinical Laboratory, Wuhan Univ, Renmin Hospital, Jiefang Road 238, Wuhan, 430060, Hubei, China
| | - Wen Dai
- Dept of Clinical Laboratory, Wuhan Univ, Renmin Hospital, Jiefang Road 238, Wuhan, 430060, Hubei, China
| | - Yan Li
- Dept of Clinical Laboratory, Wuhan Univ, Renmin Hospital, Jiefang Road 238, Wuhan, 430060, Hubei, China.
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202
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Hackett G. Metabolic Effects of Testosterone Therapy in Men with Type 2 Diabetes and Metabolic Syndrome. Sex Med Rev 2019; 7:476-490. [PMID: 30803918 DOI: 10.1016/j.sxmr.2018.12.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 12/10/2018] [Accepted: 12/13/2018] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Up to 40% of men with type 2 diabetes (T2DM) and metabolic syndrome (MetS) have hypogonadotrophic hypogonadism (HH). Men with HH are at increased risk of cardiovascular (CV) and all-cause mortality, as well as of the development of incident T2DM. AIM To review the current literature on the metabolic effects of testosterone therapy (TTh) in men with T2DM and MetS. METHODS We searched MEDLINE, Embase, and Cochrane Reviews for articles on T2DM, HH, testosterone deficiency, and CV and all-cause mortality published between May 2005 and July 2018, yielding 1817 articles, including 54 clinical trials and 32 randomized controlled trials (RCTs). MAIN OUTCOME MEASURES The main outcomes were glycemic control, insulin resistance, lipid profile, and metabolic markers associated with increased CV risk. RESULTS RCTs of TTh suggest significant benefits for sexual function, quality of life, glycemic control, insulin sensitivity, anemia, bone density, and fat and lean muscle mass that might be expected to translate into reduced long-term morbidity and mortality. Several longitudinal and observational studies suggest long-term sustained improvements in metabolic parameters and a trend toward reduced CV and all-cause mortality, especially in men at increased CV risk, such as those with T2DM and MetS. The greatest benefit is seen in those men treated with TTh to target levels and for longer durations. CONCLUSION Meta-analyses of RCTs, rather than providing clarification, may have further confused the issue by including underpowered studies of inadequate duration, multiple therapy regimens, some obsolete or withdrawn, and built-in bias in terms of studies included or excluded from analysis. Hackett G. Metabolic Effects of Testosterone Therapy in Men with Type 2 Diabetes and Metabolic Syndrome. Sex Med Rev 2019;7:476-490.
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Affiliation(s)
- Geoffrey Hackett
- Department of Urology, University Hospitals Birmingham NHS Foundation Trust and University of Aston, Birmingham, United Kingdom.
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203
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Brown TT. Hypogonadism in Men With Hepatitis C: What Is a Clinician to Do? Clin Infect Dis 2019; 69:577-579. [DOI: 10.1093/cid/ciy968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Todd T Brown
- Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University, Baltimore, Maryland
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204
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Abstract
Adult-onset hypogonadism is used to define androgen deficiency and its associated symptoms commonly occurring in middle-aged and elderly men, who are unable to mount an adequate compensatory gonadotropin response but may also have an element of testicular failure. It often occurs in relation with chronic metabolic conditions such as diabetes and the metabolic syndrome. There is a growing demand from elderly men for testosterone therapy. The physician should therefore be well-informed so as the patient can make an informed decision. Indeed, testosterone therapy in older men has been a matter of debate, especially with regard to its impact on cardiovascular events and mortality. Not all studies have reported consistent results regarding its effect on diabetes, obesity and the metabolic syndrome. In contrast, it appears to improve sexual, physical function and bone density and it does not appear to increase the risk of prostate cancer; however, it increases hematocrit and hemoglobin levels. Therefore, testosterone therapy might provide significant beneficial effects in older symptomatic hypogonadal men; treatment should be individualized, and comorbidities addressed. Further research is required into its long-term effects.
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Affiliation(s)
- Carol Cardona Attard
- Diabetes and Endocrine Center, Mater Dei Hospital, Msida, Malta.,Department of Medicine, University of Malta Medical School, Msida, Malta
| | - Stephen Fava
- Diabetes and Endocrine Center, Mater Dei Hospital, Msida, Malta - .,Department of Medicine, University of Malta Medical School, Msida, Malta
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205
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Chasland LC, Knuiman MW, Divitini ML, Murray K, Handelsman DJ, Flicker L, Hankey GJ, Almeida OP, Golledge J, Ridgers ND, Naylor LH, Green DJ, Yeap BB. Higher circulating androgens and higher physical activity levels are associated with less central adiposity and lower risk of cardiovascular death in older men. Clin Endocrinol (Oxf) 2019; 90:375-383. [PMID: 30478933 DOI: 10.1111/cen.13905] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 11/06/2018] [Accepted: 11/21/2018] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Low endogenous sex hormones and low physical activity (PA) levels have been associated with CVD risk. Whether these interact to influence CVD outcomes remains unclear. We assessed whether sex hormone concentrations and PA were additively associated with lower central adiposity and CVD risk. PATIENTS 3351 community-dwelling men, mean age 77 years. MEASUREMENTS Baseline testosterone (T), dihydrotestosterone (DHT) and oestradiol (E2) were assayed. Levels of PA were ascertained by questionnaire. Men were stratified using median splits into high hormone + high PA (H/H), high hormone + low PA (H/L); low hormone + high PA (L/H) and low hormone + low PA (L/L) groups. RESULTS A total of 865 CVD events and 499 CVD deaths occurred during 10-year mean follow-up. Men with higher T, DHT or SHBG and higher PA had the lowest BMI, waist circumference and risk of metabolic syndrome. Men with higher T had the lowest risk of incident CVD events, irrespective of PA level. Men with higher T or DHT and higher PA had the lowest risk of dying from CVD (eg, hazard ratios for T/PA H/H 0.76 P = 0.031; H/L 0.85 P = 0.222; L/H 0.80 P = 0.075; L/L 1.00). CONCLUSION Higher circulating androgens and higher PA were associated with less central adiposity at baseline and fewer CVD deaths during follow-up. These findings are consistent with a potential additive effect of androgens and PA on cardiometabolic outcomes in older men.
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Affiliation(s)
- Lauren C Chasland
- School of Human Sciences (Exercise and Sport Science), University of Western Australia, Perth, Western Australia, Australia
| | - Matthew W Knuiman
- School of Population and Global Health, University of Western Australia, Perth, Western Australia, Australia
| | - Mark L Divitini
- School of Population and Global Health, University of Western Australia, Perth, Western Australia, Australia
| | - Kevin Murray
- School of Population and Global Health, University of Western Australia, Perth, Western Australia, Australia
| | | | - Leon Flicker
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- WA Centre for Health & Ageing, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
- Department of Geriatric Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Graeme J Hankey
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Department of Neurology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Osvaldo P Almeida
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- WA Centre for Health & Ageing, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
- Department of Psychiatry, Royal Perth Hospital and Bentley Hospital, Perth, Western Australia, Australia
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia
| | - Nicola D Ridgers
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition, Deakin University, Geelong, Victoria, Australia
| | - Louise H Naylor
- School of Human Sciences (Exercise and Sport Science), University of Western Australia, Perth, Western Australia, Australia
| | - Daniel J Green
- School of Human Sciences (Exercise and Sport Science), University of Western Australia, Perth, Western Australia, Australia
| | - Bu B Yeap
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, Western Australia, Australia
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206
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Abstract
In this issue of Asian Journal of Andrology (AJA), several experts have reviewed the latest data on the potential and known effects of endogenous and exogenous testosterone (T) on cardiovascular risk. In the review by Meyer and Wittert, low endogenous serum T appears to be associated with higher risk of cardiovascular disease and overall mortality in certain populations such as Klinefelter syndrome and older men, but not in men with congenital hypogonadotropic hypogonadism.1 Whether this association is causal or whether low serum testosterone is a marker of other risk factors for cardiovascular disease such as obesity, diabetes mellitus, or other systemic disease is unknown. In Yeap's review of the relationship between circulating endogenous testosterone and its major metabolites, dihydrotestosterone, and estradiol, he raises the provocative hypotheses that there might be differential effects on cardiovascular and cerebrovascular risk related to endogenous testosterone and dihydrotestosterone concentrations.2 Based on the same epidemiological studies, Yeap postulates that there might be a U-shaped curve for circulating endogenous androgen concentrations such that lower and higher concentrations might confer greater risk of cardiovascular events and all-cause mortality than midrange concentrations. Shores demonstrates in a carefully done review of studies of large prescription databases (including >200 000 men) that testosterone therapy is not associated with overall mortality, myocardial infarction, stroke, or deep venous thrombosis events.3
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Affiliation(s)
- Bradley D Anawalt
- Division of Medicine, University of Washington School of Medicine, Seattle, Washington 98195, United States
| | - Bu B Yeap
- School of Medicine, University of Western Australia, Perth, Western Australia 6009, Australia.,Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, Western Australia 6150, Australia
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207
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Grant PM, Li X, Jacobson LP, Palella FJ, Kingsley LA, Margolick JB, Dobs AS, Lake JE, Althoff KN, Brown TT. Effect of Testosterone Use on Bone Mineral Density in HIV-Infected Men. AIDS Res Hum Retroviruses 2019; 35:75-80. [PMID: 30280921 DOI: 10.1089/aid.2018.0150] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
HIV-infected men have increased rates of osteoporosis and fracture compared to HIV-uninfected men. Testosterone use among HIV-infected men is common. In HIV-uninfected men, testosterone increases bone mineral density (BMD), but its effects have not been evaluated in HIV-infected men. In a substudy of Multicenter AIDS Cohort Study (MACS), the Bone Strength Substudy (BOSS) enrolled 202 HIV-infected and 201 HIV-uninfected men aged between 50 and 69 years. Study participants underwent dual-energy X-ray absorptiometry (DXA) at the lumbar spine (LS), total hip (TH), and femoral neck (FN) and detailed assessment of osteoporosis risk factors. We used multivariable linear regression to determine associations and 95% confidence intervals (CIs) between self-reported testosterone use and T-scores at the LS, TH, and FN after adjustment for demographics, behavioral covariates, comorbidities, and other traditional osteoporosis risk factors. HIV-infected men reported more frequent testosterone use (22% vs. 4%; p < .001) and had lower median BMD T-score at TH than HIV-uninfected men (0.0 vs. 0.3; p = .045) but similar T-scores at LS and FN. In the overall study population, testosterone use was associated with significantly greater BMD T-score at LS (0.68; 95% CI: 0.22-1.13). In HIV-infected men with virologic suppression, testosterone was significantly associated with higher BMD T-score at LS (0.95; 95% CI: 0.36-1.54) and TH (0.45; 95% CI: 0.04-0.86). Current testosterone use is common in HIV-infected men and was associated with higher BMD, compared to those not taking testosterone. Testosterone's role in reducing fracture risk in HIV-infected men should be investigated.
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Affiliation(s)
- Philip M. Grant
- Division of Infectious Diseases, Department of Medicine, Stanford University, Palo Alto, California
| | - Xiuhong Li
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Lisa P. Jacobson
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Frank J. Palella
- Division of Infectious Diseases, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Lawrence A. Kingsley
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joseph B. Margolick
- Department of Molecular Microbiology and Immunology, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Adrian S. Dobs
- Division of Endocrinology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jordan E. Lake
- Division of Infectious Diseases, Department of Medicine, University of Texas Health Science Center at Houston, Houston, Texas
| | - Keri N. Althoff
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Todd T. Brown
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
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208
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Swee DS, Gan EH. Late-Onset Hypogonadism as Primary Testicular Failure. Front Endocrinol (Lausanne) 2019; 10:372. [PMID: 31244778 PMCID: PMC6581721 DOI: 10.3389/fendo.2019.00372] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 05/24/2019] [Indexed: 12/21/2022] Open
Affiliation(s)
- Du Soon Swee
- Endocrine Unit, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Earn H. Gan
- Institute of Genetic Medicine, International Centre for Life, Newcastle University, Newcastle upon Tyne, United Kingdom
- South Tyneside and Sunderland NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- *Correspondence: Earn H. Gan
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209
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Zhang B, Miller VM, Miller JD. Influences of Sex and Estrogen in Arterial and Valvular Calcification. Front Endocrinol (Lausanne) 2019; 10:622. [PMID: 31620082 PMCID: PMC6763561 DOI: 10.3389/fendo.2019.00622] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 08/27/2019] [Indexed: 01/14/2023] Open
Abstract
Vascular and cardiac valvular calcification was once considered to be a degenerative and end stage product in aging cardiovascular tissues. Over the past two decades, however, a critical mass of data has shown that cardiovascular calcification can be an active and highly regulated process. While the incidence of calcification in the coronary arteries and cardiac valves is higher in men than in age-matched women, a high index of calcification associates with increased morbidity, and mortality in both sexes. Despite the ubiquitous portending of poor outcomes in both sexes, our understanding of mechanisms of calcification under the dramatically different biological contexts of sex and hormonal milieu remains rudimentary. Understanding how the critical context of these variables inform our understanding of mechanisms of calcification-as well as innovative strategies to target it therapeutically-is essential to advancing the fields of both cardiovascular disease and fundamental mechanisms of aging. This review will explore potential sex and sex-steroid differences in the basic biological pathways associated with vascular and cardiac valvular tissue calcification, and potential strategies of pharmacological therapy to reduce or slow these processes.
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Affiliation(s)
- Bin Zhang
- Department of Surgery, Mayo Clinic, Rochester, MN, United States
- Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, MN, United States
| | - Virginia M. Miller
- Department of Surgery, Mayo Clinic, Rochester, MN, United States
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, United States
| | - Jordan D. Miller
- Department of Surgery, Mayo Clinic, Rochester, MN, United States
- Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, MN, United States
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, United States
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, United States
- *Correspondence: Jordan D. Miller
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210
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Testosterone Therapy, Thrombophilia, Venous Thromboembolism, and Thrombotic Events. J Clin Med 2018; 8:jcm8010011. [PMID: 30577621 PMCID: PMC6352146 DOI: 10.3390/jcm8010011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 12/11/2018] [Accepted: 12/18/2018] [Indexed: 01/24/2023] Open
Abstract
In our sequential studies of 67 and 21 patients, testosterone therapy (TT) interacted with thrombophilia⁻hypofibrinolysis, leading to venous thromboembolism (VTE). Compared to 111 VTE controls not taking TT (VTE-no TT), the 67 and 21 cases were more likely (p < 0.05 for all) to have Factor V Leiden (FVL) heterogeneity (24% and 33% vs. 12%), the lupus anticoagulant (14% and 33% vs. 4%), and high lipoprotein(a) (33% vs. 13%, n = 21). After a first VTE and continuing TT, 11 thrombophilic cases had a second VTE despite adequate anticoagulation, 6 of whom, still anticoagulated, had a third VTE. The greatest density of thrombotic events was at three months after starting TT, with a rapid decline by 10 months. From <1 to 8 months after starting TT, 65% of VTE occurred, which may reflect TT-induced depletion of susceptible thrombophilic patients, leaving a winnowed residual group with fewer VTE events despite the continuation of TT. Before starting TT, we suggest screening for FVL, lipoprotein(a), and the lupus anticoagulant to identify patients at increased VTE risk, with an adverse risk-to-benefit ratio for TT. We suggest that TT should not be started in patients with known thrombophilia⁻hypofibrinolysis, and should not be continued after a first VTE. When TT is given to patients with thrombophilia⁻hypofibrinolysis, VTE may occur and then recur despite adequate anticoagulation.
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211
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Nightingale TE, Moore P, Harman J, Khalil R, Gill RS, Castillo T, Adler RA, Gorgey AS. Body composition changes with testosterone replacement therapy following spinal cord injury and aging: A mini review. J Spinal Cord Med 2018; 41:624-636. [PMID: 28770686 PMCID: PMC6217462 DOI: 10.1080/10790268.2017.1357917] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Context Hypogonadism is a male clinical condition in which the body does not produce enough testosterone. Testosterone plays a key role in maintaining body composition, bone mineral density, sexual function, mood, erythropoiesis, cognition and quality of life. Hypogonadism can occur due to several underlying pathologies during aging and in men with physical disabilities, such as spinal cord injury (SCI). This condition is often under diagnosed and as a result, symptoms undertreated. Methods In this mini-review, we propose that testosterone replacement therapy (TRT) may be a viable strategy to improve lean body mass (LBM) and fat mass (FM) in men with SCI. Evidence Synthesis Supplementing the limited data from SCI cohorts with consistent findings from studies in non-disabled aging men, we present evidence that, relative to placebo, transdermal TRT can increase LBM and reduce FM over 3-36 months. The impact of TRT on bone mineral density and metabolism is also discussed, with particular relevance for persons with SCI. Moreover, the risks of TRT remain controversial and pertinent safety considerations related to transdermal administration are outlined. Conclusion Further research is necessary to help develop clinical guidelines for the specific dose and duration of TRT in persons with SCI. Therefore, we call for more high-quality randomized controlled trials to examine the efficacy and safety of TRT in this population, which experiences an increased risk of cardiometabolic diseases as a result of deleterious body composition changes after injury.
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Affiliation(s)
- Tom E. Nightingale
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA,Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Pamela Moore
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Joshua Harman
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Refka Khalil
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Ranjodh S. Gill
- Endocrinology Service, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA,Endocrine Division, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Teodoro Castillo
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA,Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Robert A. Adler
- Endocrinology Service, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA,Endocrine Division, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Ashraf S. Gorgey
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA,Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia, USA,Correspondence to: Ashraf S. Gorgey, Department of Veterans Affairs, Hunter Holmes McGuire Medical Center, Spinal Cord Injury & Disorders Service, 1201 Broad Rock Boulevard, Richmond, VA 23249, USA.
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212
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Anawalt BD, Page ST. Testosterone therapy and physical function. Lancet Diabetes Endocrinol 2018; 6:839-840. [PMID: 30366565 DOI: 10.1016/s2213-8587(18)30202-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 06/21/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Bradley D Anawalt
- Department of Medicine, University of Washington, Seattle, WA 98119, USA
| | - Stephanie T Page
- Department of Medicine, University of Washington, Seattle, WA 98119, USA.
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213
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Kim JH, Baek MJ, Sun HY, Lee B, Li S, Khandwala Y, Del Giudice F, Chung BI. Efficacy and safety of 5 alpha-reductase inhibitor monotherapy in patients with benign prostatic hyperplasia: A meta-analysis. PLoS One 2018; 13:e0203479. [PMID: 30281615 PMCID: PMC6169865 DOI: 10.1371/journal.pone.0203479] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 08/21/2018] [Indexed: 12/11/2022] Open
Abstract
Background Although combination therapy with 5 alpha-reductase inhibitor (5ARI) and alpha-blocker is one of the standard interventions in symptomatic benign prostatic hyperplasia (BPH), 5ARI monotherapy is seldom the focus of attention. Adverse events associated with 5ARI include depression and suicidal attempts in addition to persistent erectile dysfunction. The aim of this study is to update our knowledge of clinical efficacy and incidence of adverse events associated with 5ARI treatment in symptomatic BPH. Methods and findings A meta-analysis of randomized controlled clinical trials (RCTs) from 1966 until March, 2017 was performed using database from PubMed, Cochrane Collaboration and Embase. A total of 23395 patients were included in this study and the inclusion criteria were: RCTs with 5ARI and placebo in symptomatic BPH patients. Parameters included prostate specific antigen (PSA), prostate volume (PV), International Prostate Symptom Score (IPPS), post-void residual urine (PVR), voiding symptoms of IPSS (voiding IPSS), maximum urinary flow rate (Qmax), and adverse events (AEs). A meta-analysis with meta-regression was performed for each effect size and adverse events, sensitivity analysis, cumulative analysis along with the analysis of ratio of means (ROM) in the placebo group. A total of 42 studies were included in this study for review, and a total of 37 studies were included in the meta-analysis, including a total of 23395 patients (treatment group: 11392, placebo group: 12003). The effect size of all variables except PVR showed a significant improvement following 5ARI treatment compared with placebo. However, the effect size of differences showed declining trend in PV, IPSS and Qmax according to recent years of publication. In ROM analysis, PV showed no significant increase in the placebo group, with a ROM of 1.00 (95% CI, 0.88, 1.14). The 5ARI treatment resulted in a significantly higher incidence of decreased libido (OR = 1.7; 95% CI, 1.36, 2.13), ejaculatory disorder (OR = 2.94; 95% CI, 2.15, 4.03), gynecomastia (OR = 2.32; 95% CI, 1.41, 3.83), and impotence (OR = 1.74; 95% CI, 1.32, 2.29). Our study has the following limitations: included studies were heterogeneous and direct comparison of efficacy between alpha blocker and 5ARI was not performed. Adverse events including depression or suicidal attempt could not be analyzed in this meta-analysis setting. Conclusions Although there was a significant clinical benefit of 5ARI monotherapy compared with placebo, the effective size was small. Moreover, the risk of adverse events including sexually related complications were high. Additional head-to-head studies are needed to re-evaluate the clinical efficacy of 5ARI compared with alpha-adrenergic receptor blockers.
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Affiliation(s)
- Jae Heon Kim
- Department of Urology, Stanford University Medical Center, Stanford, CA, United States of America
- Department of Urology, Soonchunhyang University Hospital, Soonchuhyang University Medical College, Seoul, Korea
- * E-mail: , (JHK); (BL)
| | - Min Jung Baek
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, Seongnam, Korea
| | - Hwa Yeon Sun
- Department of Urology, Soonchunhyang University Hospital, Soonchuhyang University Medical College, Seoul, Korea
| | - Bora Lee
- Department of Statistics, Graduate School of Chung-Ang University, Seoul, Korea
- * E-mail: , (JHK); (BL)
| | - Shufeng Li
- Department of Urology and Dermatology, Stanford University Medical Center, Stanford, CA, United States of America
| | - Yash Khandwala
- Department of Urology, Stanford University Medical Center, Stanford, CA, United States of America
- University of California, San Diego School of Medicine, San Diego, CA, United States of America
| | | | - Benjamin I. Chung
- Department of Urology, Stanford University Medical Center, Stanford, CA, United States of America
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214
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Abstract
The finding of low circulating testosterone level in men is relatively frequent. The symptoms of hypogonadism are very frequent in the aging men. However, the diagnosis of hypogonadism is often neglected and the opportunity to replace low testosterone in older men is highly debated. The aim of this narrative review is to summarize the steps necessary to formulate a proper diagnosis and to guide toward an individualized treatment. While universally recognized the need to treat the young adults with known causes of pituitary or testicular failure, there are controversies on the cost-benefit of treating testosterone deficiency in older men. Discrepancies among the several available guidelines do not help to clarify the scenario, however, the recent larger clinical trials have shed some light on the fact that testosterone treatment carries some benefit, that is not free from risks. We provide an updated review of the diagnostic hallmarks, the several treatment modalities, with their advantages and disadvantages, and how to individualize and monitor treatment in order to maximize the benefits and minimize the risks. The treatment of male hypogonadism can no longer be downgraded and must become part of the cultural baggage of the endocrinologist.
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Affiliation(s)
- Christos P Tsametis
- Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
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215
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Rezanezhad B, Borgquist R, Willenheimer R, Elzanaty S. Association between serum levels of testosterone and biomarkers of subclinical atherosclerosis. Aging Male 2018; 21:182-186. [PMID: 29272977 DOI: 10.1080/13685538.2017.1412422] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To investigate the association between serum levels of testosterone and biomarkers of subclinical atherosclerosis based on data from 119 middle-aged men of the general population. METHODS Testosterone, Apolipoprotein A-1 (ApoA-1), Apolipoprotein B (ApoB), Apolipoprotein B-to-Apolipoprotein A-1 ratio (ApoB-to-ApoA-1), high-sensitive C-reactive protein (hsCRP), and fibrinogen levels were measured. Data were also gathered based on age, BMI, waist circumference, smoking, alcohol consumption, and family history of cardiovascular diseases. Men were classified into two groups based on testosterone levels: hypogonadal (testosterone ≤12 nmol/L) and eugonadal men (testosterone >12 nmol/L). RESULTS When compared to eugonadal, the hypogonadal men were significantly older (56 years vs. 55 years, p = .03), had greater BMI (28 kg/cm2 vs. 26 kg/cm2, p = .01), and higher waist circumference (104 cm vs. 100 cm, p = .01). Moreover, ApoB, ApoB-to-ApoA-1 ratio, and hsCRP were significantly higher in hypogonadal men compared to eugonadal men (1.1 g/L vs. 1.0 g/L, p = .03), (0.8 vs. 0.7, p = .03), (3.3 mg/L vs. 2.0 mg/L, p = .01), respectively. On the other hand, ApoA-1 and fibrinogen levels did not differ significantly between groups (p > .05). In an adjusted multivariate regression analysis model, only ApoB showed a significant negative association with testosterone levels (β = -0.01; 95% CI = -0.02, -1.50; p = .04). CONCLUSION Testosterone levels showed an inverse relation to ApoB, a biomarker implicated in subclinical atherosclerosis. These findings support the hypothesis that low testosterone levels play a role in atherosclerosis.
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Affiliation(s)
- Babak Rezanezhad
- a Department of Internal Medicine , Skåne University Hospital, Lund University , Lund , Sweden
| | - Rasmus Borgquist
- b Department of Arrhythmia , Skåne University Hospital, Lund University , Lund , Sweden
| | | | - Saad Elzanaty
- d Department of Translational Medicine , Skåne University Hospital, Lund University , Malmö , Sweden
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216
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Clegg A, Hassan-Smith Z. Frailty and the endocrine system. Lancet Diabetes Endocrinol 2018; 6:743-752. [PMID: 30017798 DOI: 10.1016/s2213-8587(18)30110-4] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 03/28/2018] [Accepted: 04/03/2018] [Indexed: 12/14/2022]
Abstract
Frailty is a condition characterised by loss of biological reserves, failure of homoeostatic mechanisms, and vulnerability to adverse outcomes. The endocrine system is considered particularly important in frailty, because of its complex inter-relationships with the brain, immune system, and skeletal muscle. This Review summarises evidence indicating a key role for the hypothalamic-pituitary axis in the pathogenesis of frailty through aberrant regulation of glucocorticoid secretion, insulin-like growth factor signalling, and androgen production. Evidence also indicates a potential role for vitamin D and insulin resistance in the pathogenesis of frailty. The role of thyroid hormones in the pathogenesis of frailty remains uncertain. Key convergent pathological effects of frailty include loss of muscle mass and strength, with consequent impact on mobility and activities of daily living. Future translational research should focus on the understanding of endocrine mechanisms, to identify potential biomarkers of the condition, modifiable targets for treatment, and novel pharmacological drugs targeted at the endocrine components of frailty.
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Affiliation(s)
- Andrew Clegg
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK.
| | - Zaki Hassan-Smith
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Faculty of Health and Life Sciences, University of Coventry, Coventry, UK
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217
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Rastrelli G, Dicuio M, Reismann Y, Sforza A, Maggi M, Corona G. Cardiovascular impact of testosterone therapy for hypogonadism. Expert Rev Cardiovasc Ther 2018; 16:617-625. [DOI: 10.1080/14779072.2018.1510314] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Giulia Rastrelli
- Sexual Medicine and Andrology Unit Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Florence, Italy
| | - Mauro Dicuio
- Urology Unit,Surgical Department, Azienda Usl, Maggiore-Bellaria Hospital, Bologna, Italy
- Department of Urology, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Yacov Reismann
- Department of Urology, Amstelland Hospital, Amsterdam, The Netherlands
| | - Alessandra Sforza
- Endocrinology Unit, Medical Department, Azienda Usl, Maggiore-Bellaria Hospital, Bologna, Italy
| | - Mario Maggi
- Sexual Medicine and Andrology Unit Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Florence, Italy
| | - Giovanni Corona
- Endocrinology Unit, Medical Department, Azienda Usl, Maggiore-Bellaria Hospital, Bologna, Italy
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218
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Gravholt CH, Chang S, Wallentin M, Fedder J, Moore P, Skakkebæk A. Klinefelter Syndrome: Integrating Genetics, Neuropsychology, and Endocrinology. Endocr Rev 2018; 39:389-423. [PMID: 29438472 DOI: 10.1210/er.2017-00212] [Citation(s) in RCA: 131] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 02/05/2018] [Indexed: 01/15/2023]
Abstract
Although first identified over 70 years ago, Klinefelter syndrome (KS) continues to pose substantial diagnostic challenges, as many patients are still misdiagnosed, or remain undiagnosed. In fact, as few as 25% of patients with KS are accurately diagnosed and most of these diagnoses are not made until adulthood. Classic characteristics of KS include small testes, infertility, hypergonadothropic hypogonadism, and cognitive impairment. However, the pathophysiology behind KS is not well understood, although genetic effects are also thought to play a role. For example, recent developments in genetics and genomics point to a fundamental change in our understanding of KS, with global epigenetic and RNA expression changes playing a central role for the phenotype. KS is also associated with more general health markers, including higher morbidity and mortality rates and lower socioeconomic status (which likely affect both morbidity and mortality). In addition, hypogonadism is associated with greater risk of metabolic syndrome, type 2 diabetes, cardiovascular disease, breast cancer, and extragonadal germ cell tumors. Medical treatment typically focuses on testosterone replacement therapy (TRT), although the effects of this therapy have not been studied rigorously, and future studies need to evaluate the effects of TRT on metabolic risk and neurocognitive outcomes. This review presents a comprehensive interdisciplinary examination of recent developments in genetic, endocrine, and neurocognitive science, including the study of animal models. It provides a number of recommendations for improving the effectiveness of research and clinical practice, including neonatal KS screening programs, and a multidisciplinary approach to KS treatment from childhood until senescence.
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Affiliation(s)
- Claus H Gravholt
- Department of Endocrinology and Internal Medicine (MEA), Aarhus University Hospital, Aarhus C, Denmark.,Department of Molecular Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Simon Chang
- Department of Endocrinology and Internal Medicine (MEA), Aarhus University Hospital, Aarhus C, Denmark.,Department of Clinical Biochemistry, Esbjerg Sygehus, Esbjerg, Denmark
| | - Mikkel Wallentin
- Department of Linguistics, Cognitive Science, and Semiotics, Aarhus University, Aarhus C, Denmark.,Center of Functionally Integrative Neuroscience, Aarhus University Hospital, Aarhus C, Denmark
| | - Jens Fedder
- Centre of Andrology and Fertility Clinic, Department of Gynaecology and Obstetrics, Odense University Hospital, Odense C, Denmark
| | - Philip Moore
- Department of Psychology, The George Washington University, Washington DC
| | - Anne Skakkebæk
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus N, Denmark.,Department of Clinical Genetics, Aarhus University Hospital, Aarhus N, Denmark
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219
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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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220
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Multicenter AIDS Cohort Study Quantitative Coronary Plaque Progression Study: rationale and design. Coron Artery Dis 2018; 29:23-29. [PMID: 28777120 DOI: 10.1097/mca.0000000000000546] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND AND AIM The association of HIV with coronary atherosclerosis has been established; however, the progression of coronary atherosclerosis over time among participants with HIV is not well known. The Multicenter AIDS Cohort Study Quantitative Coronary Plaque Progression Study is a large prospective multicenter study quantifying progression of coronary plaque assessed by serial coronary computed tomography angiography (CTA). PATIENTS AND METHODS HIV-infected and uninfected men who were enrolled in the Multicenter AIDS Cohort Study Cardiovascular Substudy were eligible to complete a follow-up contrast coronary CTA 3-6 years after baseline. We measured coronary plaque volume and characteristics (calcified and noncalcified plaque including fibrous, fibrous-fatty, and low attenuation) and vulnerable plaque among HIV-infected and uninfected men using semiautomated plaque software to investigate the progression of coronary atherosclerosis over time. CONCLUSION We describe a novel, large prospective multicenter study investigating incidence, transition of characteristics, and progression in coronary atherosclerosis quantitatively assessed by serial coronary CTAs among HIV-infected and uninfected men.
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221
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Erdogan T, Bahat G. Some aspects need to be considered in assessment and treatment of sarcopenia. Clin Interv Aging 2018; 13:1231-1232. [PMID: 30022815 PMCID: PMC6044338 DOI: 10.2147/cia.s176216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Tugba Erdogan
- Department of Internal Medicine, Division of Geriatrics, Istanbul University, Istanbul Medical School, Istanbul, Turkey,
| | - Gulistan Bahat
- Department of Internal Medicine, Division of Geriatrics, Istanbul University, Istanbul Medical School, Istanbul, Turkey,
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222
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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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223
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Miner M, Morgentaler A, Khera M, Traish AM. The state of testosterone therapy since the FDA's 2015 labelling changes: Indications and cardiovascular risk. Clin Endocrinol (Oxf) 2018; 89:3-10. [PMID: 29486065 DOI: 10.1111/cen.13589] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 02/17/2018] [Accepted: 02/22/2018] [Indexed: 01/23/2023]
Abstract
OBJECTIVE A label change in testosterone (T) products in March 2015 followed a highly publicized FDA advisory committee meeting in September 2014. Changes included a warning of possible increased cardiovascular (CV) risks and restriction of indicated populations to younger men with a limited set of known aetiologies of testosterone deficiency (TD). These changes greatly impacted clinical practice and public perception of T therapy (TTh). Our aim was to review these changes in the light of subsequently published studies. DESIGN We identified 23 studies through June 2017, including 12 clinical trials and 11 observational studies. The Testosterone Trials included 790 men aged 65 years and older with TD without known aetiology, assigned to 1-year T gel or placebo. RESULTS Demonstrated benefits of T included sexual activity and desire, physical activity and mood. There were 9 major adverse CV events (MACE) in the T arm and 16 in the placebo arm. No study reported increased MACE with TTh. A 3-year RCT showed no difference in carotid atherosclerosis. Several large observational studies reported reduced CV events with TTh, including one showing progressively reduced CV and mortality risk with greater duration of TTh. Men whose serum T normalized with TTh had reduced risk of MI and death compared with men whose T levels failed to normalize. CONCLUSION We conclude that existing evidence fails to support increased CV risk with TTh; on the contrary, there is evidence suggestive of real-world CV benefits. Finally, existing evidence provides benefits of TTh in older men without known aetiology for T deficiency.
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Affiliation(s)
- Martin Miner
- Men's Health Center, Miriam Hospital, Providence, RI, USA
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Abraham Morgentaler
- Men's Health Boston, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mohit Khera
- Department of Urology, Baylor School of Medicine, Houston, TX, USA
| | - Abdulmaged M Traish
- Department of Urology, Boston University School of Medicine, Boston, MA, USA
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224
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Abstract
OBJECTIVE The decrease in testosterone levels that occurs with aging has become an important clinical issue both due to the growth of the geriatric population and patient interest in testosterone therapy. The decision to assess for testosterone deficiency and the ability to determine whether the benefits exceed the risks require a comprehensive evaluation of the aging patient. This article is part of a series of papers focused on the endocrinology of aging. This review addresses common issues needed for clinical decision making, including how to interpret test results, differential diagnosis, potential impact of testosterone treatment on insulin resistance and cardiovascular disease, and options for therapy. METHODS Papers reviewed were identified through literature searches conducted on PubMed. RESULTS Assessment of testosterone levels in the geriatric male requires an understanding of the limitations of the assay that is used, the symptoms associated with low testosterone, the impact of comorbid conditions on levels, and risks of therapy. Successful treatment requires setting realistic expectations of the benefits of replacement therapy. CONCLUSION While the prevalence of low testosterone concentrations is increased with aging, the common comorbidities such as obesity and diabetes may contribute to changes in testosterone levels. Clinical trial evidence shows modest benefit for treatment of low testosterone in the presence of symptoms. Assessment of the geriatric male should include evaluation of their testosterone level in the context of their functional status and comorbidities. ABBREVIATIONS CDC = Centers for Disease Control and Prevention; CI = confidence interval; CVD = cardiovascular disease; DXA = dual-energy X-ray absorptiometry; EMAS = European Male Aging Study; FDA = U.S. Food and Drug Administration; FHS = Framingham Heart Study; HDL = high-density lipoprotein; HOMA-IR = homeostasis model assessment of insulin resistance; LH = luteinizing hormone; OR = odds ratio; PSA = prostate-specific antigen; SHBG = sex hormone-binding globulin; T2DM = type 2 diabetes mellitus; vBMD = volumetric bone mineral density.
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225
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Rosenberg MA, Shores MM, Matsumoto AM, Bůžková P, Lange LA, Kronmal RA, Heckbert SR, Mukamal KJ. Serum androgens and risk of atrial fibrillation in older men: The Cardiovascular Health Study. Clin Cardiol 2018; 41:830-836. [PMID: 29671886 DOI: 10.1002/clc.22965] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 04/16/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Decline in serum androgens is common among older men and has been associated with cardiovascular disease, although its role in risk of atrial fibrillation (AF) has not been well defined. HYPOTHESIS Low serum androgens are associated with an increased risk of AF. METHODS We examined the prospective associations between testosterone, its more active metabolite dihydrotestosterone (DHT), and sex hormone-binding globulin (SHBG) with risk of AF among 1019 otherwise healthy men with average age 76.3 ±4.9 years in the Cardiovascular Health Study. RESULTS After median follow-up of 9.5 years, 304 (30%) men developed AF. We detected a nonlinear association with risk of incident AF in both free and total DHT, in which subjects with the lowest levels had a higher risk of incident AF. After adjustment for demographics, clinical risk factors, left atrial diameter, and serum NT-proBNP levels, men with free DHT <0.16 ng/dL were at increased risk compared with men with higher levels (hazard ratio: 1.48, 95% confidence interval: 1.01-2.17, P <0.05). Sensitivity analyses confirmed that the increased risk was not cutpoint-specific, with a significant association noted up to cutpoints <~0.2 ng/dL. We also detected a complex nonlinear association between SHBG and incident AF, in which subjects in the middle quintile (52.9-65.3 nmol/L) had increased risk. CONCLUSIONS Among older men, low free DHT is associated with an increased risk of incident AF. Further studies are needed to explore mechanisms for this association.
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Affiliation(s)
- Michael A Rosenberg
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado.,Division of Biomedical Informatics and Personalized Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Molly M Shores
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, VA Puget Sound Health Care System, Washington
| | - Alvin M Matsumoto
- Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Puget Sound Health Care System, Washington.,Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Petra Bůžková
- Department of Biostatistics, University of Washington, Seattle
| | - Leslie A Lange
- Division of Biomedical Informatics and Personalized Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | | | | | - Kenneth J Mukamal
- Department of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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226
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Snyder PJ, Bhasin S, Cunningham GR, Matsumoto AM, Stephens-Shields AJ, Cauley JA, Gill TM, Barrett-Connor E, Swerdloff RS, Wang C, Ensrud KE, Lewis CE, Farrar JT, Cella D, Rosen RC, Pahor M, Crandall JP, Molitch ME, Resnick SM, Budoff M, Mohler ER, Wenger NK, Cohen HJ, Schrier S, Keaveny TM, Kopperdahl D, Lee D, Cifelli D, Ellenberg SS. Lessons From the Testosterone Trials. Endocr Rev 2018; 39:369-386. [PMID: 29522088 PMCID: PMC6287281 DOI: 10.1210/er.2017-00234] [Citation(s) in RCA: 132] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 03/02/2018] [Indexed: 12/11/2022]
Abstract
The Testosterone Trials (TTrials) were a coordinated set of seven placebo-controlled, double-blind trials in 788 men with a mean age of 72 years to determine the efficacy of increasing the testosterone levels of older men with low testosterone. Testosterone treatment increased the median testosterone level from unequivocally low at baseline to midnormal for young men after 3 months and maintained that level until month 12. In the Sexual Function Trial, testosterone increased sexual activity, sexual desire, and erectile function. In the Physical Function Trial, testosterone did not increase the distance walked in 6 minutes in men whose walk speed was slow; however, in all TTrial participants, testosterone did increase the distance walked. In the Vitality Trial, testosterone did not increase energy but slightly improved mood and depressive symptoms. In the Cognitive Function Trial, testosterone did not improve cognitive function. In the Anemia Trial, testosterone increased hemoglobin in both men who had anemia of a known cause and in men with unexplained anemia. In the Bone Trial, testosterone increased volumetric bone mineral density and the estimated strength of the spine and hip. In the Cardiovascular Trial, testosterone increased the coronary artery noncalcified plaque volume as assessed using computed tomographic angiography. Although testosterone was not associated with more cardiovascular or prostate adverse events than placebo, a trial of a much larger number of men for a much longer period would be necessary to determine whether testosterone increases cardiovascular or prostate risk.
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Affiliation(s)
- Peter J Snyder
- Division of Endocrinology, Diabetes, and Metabolism, Perelman School of
Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shalender Bhasin
- Research Program in Men’s Health: Aging and Metabolism, Brigham and Women’s
Hospital, Harvard Medical School, Boston, Massachusetts
| | - Glenn R Cunningham
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine
and Baylor St. Luke's Medical Center, Houston, Texas
| | - Alvin M Matsumoto
- Geriatric Research, Education, and Clinical Center, Department of Veterans
Affairs Puget Sound Health Care System, and Division of Gerontology and Geriatric Medicine,
Department of Medicine, University of Washington School of Medicine, Seattle,
Washington
| | - Alisa J Stephens-Shields
- Department of Biostatistics, Epidemiology and Bioinformatics, Perelman School
of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jane A Cauley
- Department of Epidemiology, University of Pittsburgh, Graduate School of Public
Health, Pittsburgh, Pennsylvania
| | - Thomas M Gill
- Division of Geriatric Medicine, Yale School of Medicine, New Haven,
Connecticut
| | - Elizabeth Barrett-Connor
- Division of Epidemiology, Department of Family Medicine and Public Health,
University of California, San Diego, School of Medicine, La Jolla, California
| | - Ronald S Swerdloff
- Division of Endocrinology, Harbor-University of California at Los Angeles
Medical Center and Los Angeles Biomedical Research Institute, Torrance, California
| | - Christina Wang
- Division of Endocrinology, Harbor-University of California at Los Angeles
Medical Center and Los Angeles Biomedical Research Institute, Torrance, California
| | - Kristine E Ensrud
- Division of Epidemiology and Community Health, Department of Medicine,
University of Minnesota, Minneapolis, Minnesota
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Cora E Lewis
- Division of Preventive Medicine, University of Alabama at Birmingham,
Birmingham, Alabama
| | - John T Farrar
- Department of Biostatistics, Epidemiology and Bioinformatics, Perelman School
of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Cella
- Department of Medical Social Sciences, Northwestern University Feinberg School
of Medicine, Chicago, Illinois
| | - Raymond C Rosen
- New England Research Institutes, Inc., Watertown, Massachusetts
| | - Marco Pahor
- Department of Aging and Geriatric Research, University of Florida,
Gainesville, Florida
| | - Jill P Crandall
- Divisions of Endocrinology and Geriatrics, Albert Einstein College of
Medicine, Bronx, New York
| | - Mark E Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern
University, Feinberg School of Medicine, Chicago, Illinois
| | - Susan M Resnick
- Laboratory of Behavioral Neuroscience, National Institute on Aging, National
Institutes of Health, Baltimore, Maryland
| | - Matthew Budoff
- Division of Cardiology, Harbor-University of California at Los Angeles Medical
Center and Los Angeles Biomedical Research Institute, Torrance, California
| | - Emile R Mohler
- Division of Cardiovascular Disease, Section of Vascular Medicine, Department
of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia,
Pennsylvania
| | - Nanette K Wenger
- Division of Cardiology, Emory University School of Medicine, Emory Heart and
Vascular Center, and Emory Women’s Heart Center, Atlanta, Georgia
| | - Harvey Jay Cohen
- Center for the Study of Aging, Duke University Medical Center, Durham, North
Carolina
| | - Stanley Schrier
- Department of Medicine, Stanford University, Stanford, California
| | | | | | - David Lee
- O.N. Diagnostics, LLC, Berkeley, California
| | - Denise Cifelli
- Department of Biostatistics, Epidemiology and Bioinformatics, Perelman School
of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology and Bioinformatics, Perelman School
of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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227
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Sadaie MR, Farhoudi M, Zamanlu M, Aghamohammadzadeh N, Amouzegar A, Rosenbaum RE, Thomas GA. What does the research say about androgen use and cerebrovascular events? Ther Adv Drug Saf 2018; 9:439-455. [PMID: 30364888 DOI: 10.1177/2042098618773318] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 03/29/2018] [Indexed: 12/21/2022] Open
Abstract
Many studies have investigated the benefits of androgen therapy and neurosteroids in aging men, while concerns remain about the potential associations of exogenous steroids and incidents of cerebrovascular events and ischemic stroke (IS). Testosterone is neuroprotective, neurotrophic and a potent stimulator of neuroplasticity. These benefits are mediated primarily through conversion of a small amount of testosterone to estradiol by the catalytic activity of estrogen synthetase (aromatase cytochrome P450 enzyme). New studies suggest that abnormal serum levels of the nonaromatized potent metabolite of testosterone, either high or low dihydrotestosterone (DHT), is a risk factor for stroke. Associations between pharmacologic androgen use and the incidence of IS are questionable, because a significant portion of testosterone is converted to DHT. There is also insufficient evidence to reject a causal relationship between the pro-testosterone adrenal androgens and incidence of IS. Moreover, vascular intima-media thickness, which is a predictor of stroke and myocardial symptoms, has correlations with sex hormones. Current diagnostic and treatment criteria for androgen therapy for cerebrovascular complications are unclear. Confounding variables, including genetic and metabolic alterations of the key enzymes of steroidogenesis, ought to be considered. Information extracted from pharmacogenetic testing may aid in expounding the protective-destructive properties of neurosteroids, as well as the prognosis of androgen therapy, in particular their cerebrovascular outcomes. This investigative review article addresses relevant findings of the clinical and experimental investigations of androgen therapy, emphasizes the significance of genetic testing of androgen responsiveness towards individualized therapy in post-IS injuries as well as identifying pertinent questions.
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Affiliation(s)
| | - Mehdi Farhoudi
- Neurosciences Research Center (NSRC), Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Masumeh Zamanlu
- Neurosciences Research Center (NSRC), Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Nasser Aghamohammadzadeh
- Department of Endocrinology, Endocrine Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Atieh Amouzegar
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Gary A Thomas
- Penn State Hershey Neurology, Penn State University, PA, USA
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228
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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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229
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Bhasin S, Brito JP, Cunningham GR, Hayes FJ, Hodis HN, Matsumoto AM, Snyder PJ, Swerdloff RS, Wu FC, Yialamas MA. Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2018; 103:1715-1744. [PMID: 29562364 DOI: 10.1210/jc.2018-00229] [Citation(s) in RCA: 856] [Impact Index Per Article: 142.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 01/26/2018] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To update the "Testosterone Therapy in Men With Androgen Deficiency Syndromes" guideline published in 2010. PARTICIPANTS The participants include an Endocrine Society-appointed task force of 10 medical content experts and a clinical practice guideline methodologist. EVIDENCE This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies. CONSENSUS PROCESS One group meeting, several conference calls, and e-mail communications facilitated consensus development. Endocrine Society committees and members and the cosponsoring organization were invited to review and comment on preliminary drafts of the guideline. CONCLUSIONS We recommend making a diagnosis of hypogonadism only in men with symptoms and signs consistent with testosterone (T) deficiency and unequivocally and consistently low serum T concentrations. We recommend measuring fasting morning total T concentrations using an accurate and reliable assay as the initial diagnostic test. We recommend confirming the diagnosis by repeating the measurement of morning fasting total T concentrations. In men whose total T is near the lower limit of normal or who have a condition that alters sex hormone-binding globulin, we recommend obtaining a free T concentration using either equilibrium dialysis or estimating it using an accurate formula. In men determined to have androgen deficiency, we recommend additional diagnostic evaluation to ascertain the cause of androgen deficiency. We recommend T therapy for men with symptomatic T deficiency to induce and maintain secondary sex characteristics and correct symptoms of hypogonadism after discussing the potential benefits and risks of therapy and of monitoring therapy and involving the patient in decision making. We recommend against starting T therapy in patients who are planning fertility in the near term or have any of the following conditions: breast or prostate cancer, a palpable prostate nodule or induration, prostate-specific antigen level > 4 ng/mL, prostate-specific antigen > 3 ng/mL in men at increased risk of prostate cancer (e.g., African Americans and men with a first-degree relative with diagnosed prostate cancer) without further urological evaluation, elevated hematocrit, untreated severe obstructive sleep apnea, severe lower urinary tract symptoms, uncontrolled heart failure, myocardial infarction or stroke within the last 6 months, or thrombophilia. We suggest that when clinicians institute T therapy, they aim at achieving T concentrations in the mid-normal range during treatment with any of the approved formulations, taking into consideration patient preference, pharmacokinetics, formulation-specific adverse effects, treatment burden, and cost. Clinicians should monitor men receiving T therapy using a standardized plan that includes: evaluating symptoms, adverse effects, and compliance; measuring serum T and hematocrit concentrations; and evaluating prostate cancer risk during the first year after initiating T therapy.
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Affiliation(s)
| | | | | | | | - Howard N Hodis
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Alvin M Matsumoto
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Peter J Snyder
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Clavell-Hernández J, Wang R. Emerging Evidences in the Long Standing Controversy Regarding Testosterone Replacement Therapy and Cardiovascular Events. World J Mens Health 2018; 36:92-102. [PMID: 29706034 PMCID: PMC5924961 DOI: 10.5534/wjmh.17050] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 10/19/2017] [Indexed: 02/02/2023] Open
Abstract
The increasing rate of late-onset hypogonadism has led to an exceptional growth in the use of testosterone therapy (TTh). Even though TTh has been used for more than 70 years, there has been an emerging controversy in the past several years regarding its safety due to a suggested increased risk of cardiovascular (CV) disease among its users. Given the growing prevalence of testosterone deficiency in our population and the increased use of TTh, the goal of this review is to present the history and emerging evidence in regards to this controversy. CV safety concerns are mostly based on a few studies and trials that have been noted to have multiple flaws and limitations. However, the most recent data has found no association between TTh and the development of CV disease. Nevertheless, until this controversy is clarified with larger clinical trials, health-care professionals should continue to inform their patients about the possible CV risk when prescribing TTh products to patients.
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Affiliation(s)
- Jonathan Clavell-Hernández
- Division of Urology, University of Texas Health Science Center, McGovern Medical School at Houston, Houston, TX, USA
- Department of Surgery, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Run Wang
- Division of Urology, University of Texas Health Science Center, McGovern Medical School at Houston, Houston, TX, USA
- Department of Surgery, University of Texas, MD Anderson Cancer Center, Houston, TX, USA.
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231
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Abstract
Most current treatments for osteoporosis inhibit bone resorption and reduce total fracture numbers by about one-quarter. The identification of the osteocytic protein sclerostin as a potent regulator of bone turnover and bone density has led to the development of a new therapeutic class-agents that inhibit sclerostin activity, resulting in increased bone formation and reduced bone resorption. Romosozumab and blosozumab are monoclonal antibodies that bind to sclerostin, reducing its inhibition of Wnt signaling. They have comparable activities in phase I and II studies, doubling formation markers, halving resorption indices, and increasing spine bone density by >10% over 12 months. Only romosozumab has progressed to phase III, where the first study showed a 73% reduction in vertebral fracture risk and a 36% reduction in clinical fractures at 1 year. It was well-tolerated. A further phase III study will conclude in 2017. Romosozumab is a very promising medication in the management of established osteoporosis, but much remains to be done to determine its optimal duration and sequence of administration.
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232
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Takov K, Wu J, Denvir MA, Smith LB, Hadoke PWF. The role of androgen receptors in atherosclerosis. Mol Cell Endocrinol 2018; 465:82-91. [PMID: 29024781 DOI: 10.1016/j.mce.2017.10.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 10/02/2017] [Accepted: 10/07/2017] [Indexed: 12/19/2022]
Abstract
Male disadvantage in cardiovascular health is well recognised. However, the influence of androgens on atherosclerosis, one of the major causes of many life-threatening cardiovascular events, is not well understood. With the dramatic increase in clinical prescription of testosterone in the past decade, concerns about the cardiovascular side-effects of androgen supplementation or androgen deprivation therapy are increasing. Potential atheroprotective effects of testosterone could be secondary to (aromatase-mediated) conversion into oestradiol or, alternatively, to direct activation of androgen receptors (AR). Recent development of animal models with cell-specific AR knockout has indicated a complex role for androgen action in atherosclerosis. Most studies suggest androgens are atheroprotective but the precise role of AR remains unclear. Increased use of AR knockout models should clarify the role of AR in atherogenesis and, thus, lead to exploitation of this pathway as a therapeutic target.
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Affiliation(s)
- Kaloyan Takov
- University/ BHF Centre for Cardiovascular Science, University of Edinburgh, The Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK
| | - Junxi Wu
- MRC Centre for Reproductive Health, University of Edinburgh, The Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK; University/ BHF Centre for Cardiovascular Science, University of Edinburgh, The Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK
| | - Martin A Denvir
- University/ BHF Centre for Cardiovascular Science, University of Edinburgh, The Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK
| | - Lee B Smith
- MRC Centre for Reproductive Health, University of Edinburgh, The Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK; School of Environmental and Life Sciences, University of Newcastle, Callaghan, NSW, 2308, Australia
| | - Patrick W F Hadoke
- University/ BHF Centre for Cardiovascular Science, University of Edinburgh, The Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK.
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233
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[Androgens and cardiovascular risk: A series of case report in the French and Canadian pharmacovigilance databases]. Prog Urol 2018; 28:315-321. [PMID: 29650456 DOI: 10.1016/j.purol.2018.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Revised: 11/12/2017] [Accepted: 03/16/2018] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Age-related androgenic deficiency (DALA) is a pathology that is increasingly cited in recent publications. The cardiovascular risk of testosterone is debated: present for the FDA, absent for the European Medicines Agency in 2015. Our objective was to analyze the association between androgens and vascular pathologies in adverse reactions reported in pharmacovigilance databases. MATERIAL AND METHOD We conducted a retrospective case series study of the French and Canadian pharmacovigilance databases for the period 2005-2015. Cases were defined as the association of the occurrence of a cardiovascular event (myocardial infarction or stroke) and the presence of testosterone in the treatment of patients. RESULTS Of the 10 years analyzed, 12 French cases and 6 Canadian cases (representing 13 MIs and 5 strokes) were recorded in men aged 55 years on average. All were doubtful: differential diagnoses were possible (2.4 confounding conditions on average per patient) and overall cardiovascular risk was high for the majority of cases. CONCLUSION Our study shows a very low report of cardiovascular effects under testosterone, all doubtful. Pending further studies, it seems reasonable to consider the cardiovascular risk of patients who are candidates for hormone therapy for age-related androgen deficiency. LEVEL OF EVIDENCE 3.
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234
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Chrysant SG, Chrysant GS. Cardiovascular benefits and risks of testosterone replacement therapy in older men with low testosterone. Hosp Pract (1995) 2018; 46:47-55. [PMID: 29478348 DOI: 10.1080/21548331.2018.1445405] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Many studies have shown that low testosterone (T) levels have been associated with increased risk for cardiovascular (CV) events, type 2 diabetes mellitus (T2DM), and strokes. In contrast, many other studies have demonstrated that normal T levels or the normalization of low T levels with testosterone replacement therapy (TRT) is associated with decreased incidence of CV events, T2DM, and strokes, besides improving sexual function and the quality of life. However, recent studies have indicated that TRT could lead to increased incidence of CV events and strokes. These latter studies have created a great controversy among physicians regarding these findings, who question the validity of their results. In order to get a better perspective on the current status of TRT in hypogonadal men, a focused Medline and EMBASE search of the English language literature was conducted between 2010 and 2017 using the terms hypogonadism, low Testosterone, cardiovascular disease, testosterone replacement therapy, benefits, risks, older men, mechanism of action, and 58 papers with pertinent information were selected and 48 papers were rejected. The selected papers will be discussed in this review. In conclusion, based on the current status of TRT, the majority of studies indicate that TRT is safe and is associated with prevention of CVD and strokes in hypogonadal men. However, the evidence is not uniform and the therefore, decision to administer TRT should be discussed with the patient till more definitive information becomes available.
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Affiliation(s)
- Steven G Chrysant
- a Department of Cardiology , University of Oklahoma Health Sciences Center , Oklahoma City , OK , USA
| | - George S Chrysant
- b Department of Cardiology , INTEGRIS Baptist Medical Center , Oklahoma City , OK , USA
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235
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Jasuja GK, Bhasin S, Rose AJ, Reisman JI, Skolnik A, Berlowitz DR, Gifford AL. Use of testosterone in men infected with human immunodeficiency virus in the veterans healthcare system. AIDS Care 2018; 30:1207-1214. [PMID: 29557189 DOI: 10.1080/09540121.2018.1447080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Testosterone supplementation has been widely used in those infected with human immunodeficiency virus (HIV) for hypogonadism, and wasting. But with effective antiretroviral therapy and increasing recognition of atherosclerotic disease and adults infected with HIV, the risks of inappropriate testosterone use in HIV-infected patients are far better recognized than previously. Testosterone use has expanded among U.S. males, but few studies have examined prescribing in those infected with HIV. In a national cohort of males with at least one outpatient prescription in the Veterans Health Administration (VHA), we examined 9475 HIV-infected males, including 2484 who had received testosterone and a randomly selected 6991 who had not. For comparison, we identified 1,387,241 uninfected males (189,369 had received testosterone and a randomly selected 1,197,872 had not). We determined rates of new and prevalent testosterone use, and also examined the adequacy of the diagnostic evaluation that had preceded testosterone initiation among our HIV-infected and uninfected testosterone groups. Our main results were as follows. HIV-infected men had higher rates of initiation (0.8% vs. 0.4% in FY09; p < 0.001) and prevalence of testosterone use (2.2% vs. 0.8% in FY08; p < 0.001) compared to the uninfected men across the entire period. Trends of prescribing for both groups followed a similar pattern, rising from FY08, reaching a peak in FY13, and then dipping in FY 14. Only 1.1% of HIV-infected patients had a fully guideline-concordant workup before starting testosterone therapy, compared to 3.5% of uninfected patients (p < 0.001). In conclusion, testosterone use among HIV-infected patients in the VHA system rose to a peak in FY13 and has decreased somewhat since. Only a small minority of HIV-infected patients who receive testosterone therapy from VHA have undergone an appropriate workup before starting therapy, suggesting an opportunity for improvement.
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Affiliation(s)
- Guneet K Jasuja
- a Center for Healthcare Organization and Implementation Research (CHOIR) , ENRM VAMC , Bedford , MA , USA.,c Department of Health Law, Policy and Management , Boston University School of Public Health , Boston , MA , USA
| | - Shalender Bhasin
- d 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 , MA , USA
| | - Adam J Rose
- a Center for Healthcare Organization and Implementation Research (CHOIR) , ENRM VAMC , Bedford , MA , USA.,e Department of Medicine , Section of General Internal Medicine, Boston University School of Medicine , Boston , MA , USA
| | - Joel I Reisman
- a Center for Healthcare Organization and Implementation Research (CHOIR) , ENRM VAMC , Bedford , MA , USA
| | - Avy Skolnik
- a Center for Healthcare Organization and Implementation Research (CHOIR) , ENRM VAMC , Bedford , MA , USA.,c Department of Health Law, Policy and Management , Boston University School of Public Health , Boston , MA , USA
| | - Dan R Berlowitz
- a Center for Healthcare Organization and Implementation Research (CHOIR) , ENRM VAMC , Bedford , MA , USA.,c Department of Health Law, Policy and Management , Boston University School of Public Health , Boston , MA , USA
| | - Allen L Gifford
- a Center for Healthcare Organization and Implementation Research (CHOIR) , ENRM VAMC , Bedford , MA , USA.,b VA Boston Healthcare System , Boston , MA , USA.,c Department of Health Law, Policy and Management , Boston University School of Public Health , Boston , MA , USA.,e Department of Medicine , Section of General Internal Medicine, Boston University School of Medicine , Boston , MA , USA
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Abstract
Hypogonadism is a common condition defined by the presence of low serum testosterone levels and hypogonadal symptoms, and most commonly treated using testosterone therapy (TTh). The accuracy of diagnosis and appropriateness of treatment, along with proper follow-up, are increasingly important given the large increase in testosterone prescriptions and the recent concern for cardiovascular (CV) risk associated with TTh. In March of 2015, the US Food and Drug Administration required that testosterone product labels disclose a potential CV risk, despite the evidence base for this association being weak and inconclusive. However, TTh may improve CV outcomes rather than increase risks.
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Affiliation(s)
- John T Sigalos
- Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA
| | - Alexander W Pastuszak
- Center for Reproductive Medicine, Baylor College of Medicine, 1 Baylor Plaza, Room N730 Houston, TX 77030, USA; Scott Department of Urology, Baylor College of Medicine, 7200 Cambridge Street, Houston, TX 77030, USA
| | - Mohit Khera
- Scott Department of Urology, Baylor College of Medicine, 7200 Cambridge Street, Houston, TX 77030, USA.
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237
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Yeap BB, Anawalt BD. Why is understanding the relationship of testosterone to cardiovascular risk so important? Asian J Androl 2018; 20:107-108. [PMID: 29405170 PMCID: PMC5858091 DOI: 10.4103/aja.aja_71_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Affiliation(s)
- Bu B Yeap
- School of Medicine, University of Western Australia, Perth, Western Australia 6009, Australia.,Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, Western Australia 6150, Australia
| | - Bradley D Anawalt
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington 98195, United States
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238
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Miner MM, Heidelbaugh J, Paulos M, Seftel AD, Jameson J, Kaplan SA. The Intersection of Medicine and Urology: An Emerging Paradigm of Sexual Function, Cardiometabolic Risk, Bone Health, and Men's Health Centers. Med Clin North Am 2018; 102:399-415. [PMID: 29406067 DOI: 10.1016/j.mcna.2017.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Men's mental health and how they think about their health are critical to the future of men's health. Poor health choice patterns are established under age 50, when men are twice as likely to die than women. As the future of medicine focuses on quality and value, a better understanding of the social determinants of men's health will identify areas for improvement. The presentation of a man to a clinician's office with a sexual health complaint presents an opportunity for more complete evaluation. The future of men's health will be well served by integrated men's health centers that focus on the entire man.
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Affiliation(s)
- Martin M Miner
- Department of Family Medicine and Urology, The Men's Health Center, The Miriam Hospital, The Warren Alpert Medical School of Brown University, 164 Summitt Avenue, Providence, RI 02906, USA.
| | - Joel Heidelbaugh
- Departments of Family Medicine and Urology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Mark Paulos
- Departments of Internal Medicine and Urology, Men's Health Center, The Miriam Hospital, The Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Allen D Seftel
- Division of Urology, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Jason Jameson
- Division of Urology, Mayo Clinic, Scottsdale, AZ, USA
| | - Steven A Kaplan
- Benign Urologic Diseases and The Men's Health Program, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA
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239
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Gagliano-Jucá T, Basaria S. Trials of testosterone replacement reporting cardiovascular adverse events. Asian J Androl 2018; 20:131-137. [PMID: 28782738 PMCID: PMC5858095 DOI: 10.4103/aja.aja_28_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 06/12/2017] [Indexed: 12/18/2022] Open
Abstract
The numbers of testosterone prescriptions written have increased several-fold worldwide, but the incidence of pathological hypogonadism due to hypothalamic, pituitary, and testicular disease has remained unchanged. Most of these prescriptions are being dispensed to middle-aged and older men who have experienced age-related decline in serum testosterone levels; a subset of the population in which benefits of testosterone replacement is at best, modest. Recently, some randomized controlled trials have reported increased cardiovascular events in men (mainly older men and those with prevalent cardiovascular disease) with testosterone use, and a few recent meta-analyses have confirmed these findings. In this review, we discuss trials of testosterone therapy that have reported higher cardiovascular events, relevant trials that have not reported increased cardiovascular events and large trials that have focused on cardiovascular risk (mainly atherosclerosis progression) as their main outcome. We also review findings from meta-analyses that have evaluated cardiovascular events in various testosterone trials. Finally, we discuss some potential mechanisms by which testosterone use might result in an increased cardiovascular risk. As none of the trials conducted to date were adequately powered to evaluate cardiovascular events, no firm conclusions can be drawn regarding the cardiovascular safety of testosterone therapy at this time. In the interim, we hope that this review will help practitioners make informed decisions regarding the care of their patients.
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Affiliation(s)
- Thiago Gagliano-Jucá
- Research Program in Men's Health: Aging and Metabolism, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Shehzad Basaria
- Research Program in Men's Health: Aging and Metabolism, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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240
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Zhao JV, Schooling CM. Letter by Zhao and Schooling Regarding Article, “Thyroid Function and the Risk of Atherosclerotic Cardiovascular Morbidity and Mortality: The Rotterdam Study”. Circ Res 2018; 122:e17. [DOI: 10.1161/circresaha.117.312491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jie V. Zhao
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - C. Mary Schooling
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
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241
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Hackett G, Kirby M. Erectile dysfunction and testosterone deficiency as cardiovascular risk factors? Int J Clin Pract 2018; 72. [PMID: 29381240 DOI: 10.1111/ijcp.13054] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 12/14/2017] [Indexed: 12/18/2022] Open
Abstract
Graham Jackson introduced the concept that erectile dysfunction was a marker for undiagnosed cardiovascular disease and future events. Unfortunately this had had modest impact on CVD management as ED is not incorporated into current risk calculators. In this paper, we examine recent evidence as to whether ED should be upgraded to a risk factor, especially with the high predictive value in younger men. In the Princeton 3 guidelines, he recognised the important impact of testosterone deficiency (TD) on all-cause and cardiovascular mortality. Recent evidence suggests that testosterone therapy to target levels and for sufficient duration, reduces cardiovascular events. In this paper, we also produce a case for testosterone deficiency to be considered as an independent risk factor. The evidence for inclusion of both ED and TD may now be stronger than accepted risk factors and have the advantages of being easily assessed, being quantitative, symptomatic and clinically relevant, especially in younger men.
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Affiliation(s)
| | - Michael Kirby
- The Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
- The Prostate Centre, London, UK
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Mohler ER, Ellenberg SS, Lewis CE, Wenger NK, Budoff MJ, Lewis MR, Barrett-Connor E, Swerdloff RS, Stephens-Shields A, Bhasin S, Cauley JA, Crandall JP, Cunningham GR, Ensrud KE, Gill TM, Matsumoto AM, Molitch ME, Pahor M, Preston PE, Hou X, Cifelli D, Snyder PJ. The Effect of Testosterone on Cardiovascular Biomarkers in the Testosterone Trials. J Clin Endocrinol Metab 2018; 103:681-688. [PMID: 29253154 PMCID: PMC5800829 DOI: 10.1210/jc.2017-02243] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 12/11/2017] [Indexed: 11/19/2022]
Abstract
CONTEXT Studies of the possible cardiovascular risk of testosterone treatment are inconclusive. OBJECTIVE To determine the effect of testosterone treatment on cardiovascular biomarkers in older men with low testosterone. DESIGN Double-blind, placebo-controlled trial. SETTING Twelve academic medical centers in the United States. PARTICIPANTS In all, 788 men ≥65 years old with an average of two serum testosterone levels <275 ng/dL who were enrolled in The Testosterone Trials. INTERVENTION Testosterone gel, the dose adjusted to maintain the testosterone level in the normal range for young men, or placebo gel for 12 months. MAIN OUTCOME MEASURES Serum markers of cardiovascular risk, including lipids and markers of glucose metabolism, fibrinolysis, inflammation, and myocardial damage. RESULTS Compared with placebo, testosterone treatment significantly decreased total cholesterol (adjusted mean difference, -6.1 mg/dL; P < 0.001), high-density lipoprotein cholesterol (adjusted mean difference, -2.0 mg/dL; P < 0.001), and low-density lipoprotein cholesterol (adjusted mean difference, -2.3 mg/dL; P = 0.051) from baseline to month 12. Testosterone also slightly but significantly decreased fasting insulin (adjusted mean difference, -1.7 µIU/mL; P = 0.02) and homeostatic model assessment‒insulin resistance (adjusted mean difference, -0.6; P = 0.03). Testosterone did not change triglycerides, d-dimer, C-reactive protein, interleukin 6, troponin, glucose, or hemoglobin A1c levels more than placebo. CONCLUSIONS AND RELEVANCE Testosterone treatment of 1 year in older men with low testosterone was associated with small reductions in cholesterol and insulin but not with other glucose markers, markers of inflammation or fibrinolysis, or troponin. The clinical importance of these findings is unclear and requires a larger trial of clinical outcomes.
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Affiliation(s)
- Emile R. Mohler
- Section of Vascular Medicine, Division of Cardiovascular Disease, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Susan S. Ellenberg
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Cora E. Lewis
- Division of Preventive Medicine, The University of Alabama at Birmingham, Birmingham, Alabama 32594
| | - Nanette K. Wenger
- Department of Medicine, Division of Cardiology, Emory Heart and Vascular Center, Emory University School of Medicine, Atlanta, Georgia 30322
| | - Matthew J. Budoff
- Los Angeles Biomedical Research Institute, Division of Cardiology, Harbor‒University of California at Los Angeles Medical Center, Torrance, California 90509
| | - Michael R. Lewis
- Department of Pathology and Laboratory Medicine, University of Vermont, Burlington, Vermont 05401
| | - Elizabeth Barrett-Connor
- Department of Family and Preventive Medicine, Division of Epidemiology, University of California, San Diego School of Medicine, La Jolla, California 92103
| | - Ronald S. Swerdloff
- Los Angeles Biomedical Research Institute, Division of Endocrinology, Harbor‒University of California at Los Angeles Medical Center, Torrance, California 90509
| | - Alisa Stephens-Shields
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Shalender Bhasin
- Research Program in Men’s Health: Aging and Metabolism, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115
| | - Jane A. Cauley
- Department of Epidemiology, University of Pittsburgh, Graduate School of Public Health, Pittsburgh, Pennsylvania 15261
| | - Jill P. Crandall
- Divisions of Endocrinology and Geriatrics, Albert Einstein College of Medicine, Bronx, New York 10461
| | - Glenn R. Cunningham
- Departments of Medicine and Molecular & Cellular Biology, Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine and Baylor St. Luke’s Medical Center, Houston, Texas 77030
| | - Kristine E. Ensrud
- Department of Medicine, Division of Epidemiology & Community Health, University of Minnesota, Minneapolis, Minnesota 55417
- Minneapolis VA Health Care System, Minneapolis, Minnesota 55417
| | - Thomas M. Gill
- Section of Geriatric Medicine, Yale School of Medicine, New Haven, Connecticut 06510
| | - Alvin M. Matsumoto
- Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs, Puget Sound Health System, and Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington 98108
| | - Mark E. Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60610
| | - Marco Pahor
- Department of Aging and Geriatric Research, University of Florida, Gainesville, Florida 32610
| | - Peter E. Preston
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Xiaoling Hou
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Denise Cifelli
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Peter J. Snyder
- Division of Endocrinology, Diabetes, and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104
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Budoff M, Brent Muhlestein J, Le VT, May HT, Roy S, Nelson JR. Effect of Vascepa (icosapent ethyl) on progression of coronary atherosclerosis in patients with elevated triglycerides (200-499 mg/dL) on statin therapy: Rationale and design of the EVAPORATE study. Clin Cardiol 2018; 41:13-19. [PMID: 29365351 PMCID: PMC5838559 DOI: 10.1002/clc.22856] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 11/17/2017] [Accepted: 11/21/2017] [Indexed: 02/02/2023] Open
Abstract
Despite reducing progression and promoting regression of coronary atherosclerosis, statin therapy does not fully address residual cardiovascular (CV) risk. High‐purity eicosapentaenoic acid (EPA) added to a statin has been shown to reduce CV events and induce regression of coronary atherosclerosis in imaging studies; however, data are from Japanese populations without high triglyceride (TG) levels and baseline EPA serum levels greater than those in North American populations. Icosapent ethyl is a high‐purity prescription EPA ethyl ester approved at 4 g/d as an adjunct to diet to reduce TG levels in adults with TG levels >499 mg/dL. The objective of the randomized, double‐blind, placebo‐controlled EVAPORATE study is to evaluate the effects of icosapent ethyl 4 g/d on atherosclerotic plaque in a North American population of statin‐treated patients with coronary atherosclerosis, TG levels of 200 to 499 mg/dL, and low‐density lipoprotein cholesterol levels of 40 to 115 mg/dL. The primary endpoint is change in low‐attenuation plaque volume measured by multidetector computed tomography angiography. Secondary endpoints include incident plaque rates; quantitative changes in different plaque types and morphology; changes in markers of inflammation, lipids, and lipoproteins; and the relationship between these changes and plaque burden and/or plaque vulnerability. Approximately 80 patients will be followed for 9 to 18 months. The clinical implications of icosapent ethyl 4 g/d treatment added to statin therapy on CV endpoints are being evaluated in the large CV outcomes study REDUCE‐IT. EVAPORATE will provide important imaging‐derived data that may add relevance to the clinically derived outcomes from REDUCE‐IT.
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Affiliation(s)
- Matthew Budoff
- Department of Internal Medicine, Los Angeles Biomedical Research Institute, Torrance, California
| | - J Brent Muhlestein
- Department of Internal Medicine, Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah.,Department of Internal Medicine, University of Utah, Salt Lake City
| | - Viet T Le
- Department of Internal Medicine, Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah
| | - Heidi T May
- Department of Internal Medicine, Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah
| | - Sion Roy
- Department of Internal Medicine, Los Angeles Biomedical Research Institute, Torrance, California
| | - John R Nelson
- Department of Cardiology, California Cardiovascular Institute, Fresno, California
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244
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Popa MA, Mihai MC, Constantin A, Şuică V, Ţucureanu C, Costache R, Antohe F, Dubey RK, Simionescu M. Dihydrotestosterone induces pro-angiogenic factors and assists homing of MSC into the cardiac tissue. J Mol Endocrinol 2018; 60:1-15. [PMID: 29247133 DOI: 10.1530/jme-17-0185] [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] [Received: 10/10/2017] [Accepted: 10/12/2017] [Indexed: 01/01/2023]
Abstract
The use of mesenchymal stem cells (MSC) as a therapeutic tool in cardiovascular diseases is promising. Since androgens exert some beneficial actions on the cardiovascular system, we tested our hypothesis that this hormone could promote MSC-mediated repair processes, also. Cultured MSCs isolated from Wharton's jelly were exposed to 30 nM dihydrotestosterone (DHT) for 1 or 4 days and the effects of the hormone on their growth/migration/adhesion and the underlying mechanisms were assessed. Results were obtained by real-time cell impedance measurements, and DNA quantification showed that DHT increased MSC proliferation by ~30%. As determined by xCELLigence system, DHT augmented (~2 folds) the migration of MSC toward cardiac tissue slices (at 12 h), and this effect was blocked by flutamide, an androgen receptor (AR) antagonist. Exposure of cells to DHT, upregulated the gene and protein expression of AR, EMMPRIN and MMP-9 and downregulated the expression of MMP-2 DHT significantly induced the release of nitric oxide by MSC (≥2-fold) and flutamide blocked this effect. When MSCs were co-cultured with cardiac slices, immunohistochemical analysis and qRT-PCR showed that the integration of DHT-stimulated MSC was significantly higher than that of in controls. In conclusion, our findings provide the first evidence that DHT promotes MSC growth, migration and integration into the cardiac slices. The modulating effects of DHT were associated with upregulation of ARs and of key molecules known to promote tissue remodeling and angiogenesis. Our findings suggest that priming of MSC with DHT may potentially increase their capability to regenerate cardiac tissue; in vivo studies are needed to confirm our in vitro findings.
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Affiliation(s)
- Mirel-Adrian Popa
- Institute of Cellular Biology and Pathology 'Nicolae Simionescu' of the Romanian Academy, Bucharest, Romania
| | - Maria-Cristina Mihai
- Institute of Cellular Biology and Pathology 'Nicolae Simionescu' of the Romanian Academy, Bucharest, Romania
| | - Alina Constantin
- Institute of Cellular Biology and Pathology 'Nicolae Simionescu' of the Romanian Academy, Bucharest, Romania
| | - Viorel Şuică
- Institute of Cellular Biology and Pathology 'Nicolae Simionescu' of the Romanian Academy, Bucharest, Romania
| | - Cătălin Ţucureanu
- Infection and Immunity Laboratory, National Institute for Research and Development in Microbiology and Immunology 'I. Cantacuzino', Bucharest, Romania
| | - Raluca Costache
- Department of Obstetrics and Gynecology, Clinical Hospital 'Dr. Ioan Cantacuzino', Bucharest, Romania
| | - Felicia Antohe
- Institute of Cellular Biology and Pathology 'Nicolae Simionescu' of the Romanian Academy, Bucharest, Romania
| | - Raghvendra K Dubey
- Department for Reproductive Endocrinology, University Hospital Zurich, Schlieren, Switzerland
- Zurich Center for Integrative Human Physiology (ZIHP), University of Zurich, Zurich, Switzerland
| | - Maya Simionescu
- Institute of Cellular Biology and Pathology 'Nicolae Simionescu' of the Romanian Academy, Bucharest, Romania
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245
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Elagizi A, Köhler TS, Lavie CJ. Testosterone and Cardiovascular Health. Mayo Clin Proc 2018; 93:83-100. [PMID: 29275030 DOI: 10.1016/j.mayocp.2017.11.006] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 11/07/2017] [Accepted: 11/13/2017] [Indexed: 12/29/2022]
Abstract
There is an ongoing debate in the medical community regarding the effects of testosterone on cardiovascular (CV) health. For decades, there has been conflicting evidence regarding the association of endogenous testosterone levels and CV disease (CVD) events that has resulted in much debate and confusion among health care providers and patients alike. Testosterone therapy has become increasingly widespread, and after the emergence of studies that reported increased CVD events in patients receiving testosterone therapy, the US Food and Drug Administration (FDA) released a warning statement about testosterone and its potential risk regarding CV health. Some of these studies were later found to be critically flawed, and some experts, including the American Association of Clinical Endocrinologists and an expert panel regarding testosterone deficiency and its treatment, reported that some of the FDA statements regarding testosterone therapy were lacking scientific evidence. This article summarizes the current evidence regarding the relationship between testosterone (endogenous and supplemental) and CV health. A literature review was conducted via search using PubMed and specific journal databases, including the New England Journal of Medicine and the Journal of the American College of Cardiology. Key search terms included testosterone and cardiovascular health, coronary artery disease, heart failure, androgen deprivation therapy, intima-media thickness, and adrenal androgens. Initial study selection was limited to publications within the past 10 years (January 1, 2007, through December 31, 2016); however, key publications outside of this time frame were selected if they provided important quantitative data or historical perspectives for the review of this topic. The search was further supplemented by reviewing references in selected articles.
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Affiliation(s)
- Andrew Elagizi
- Department of Internal Medicine, Leonard J. Chabert Medical Center, Houma, LA
| | - Tobias S Köhler
- Department of Urology, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN
| | - Carl J Lavie
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, LA.
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246
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Glueck CJ, Goldenberg N, Wang P. Thromboembolism peaking 3 months after starting testosterone therapy: testosterone–thrombophilia interactions. J Investig Med 2017; 66:733-738. [DOI: 10.1136/jim-2017-000637] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2017] [Indexed: 11/03/2022]
Abstract
We assessed time of thrombotic events (venous thromboembolism (VTE)) after starting testosterone therapy (TT) in 21 men who sustained 23 VTE. The density of thrombotic events was greatest at 3 months after starting TT, with a rapid decline in events by 10 months. The 21 cases with VTE on TT differed from 110 patient controls with unprovoked VTE, not taking TT (VTE-no TT) for Factor V Leiden heterozygosity (FVL) (33 per cent vs 13 per cent, P=0.037), for high lipoprotein (a) (Lp(a)) (55 per cent vs 17 per cent, P=0.012), and for the lupus anticoagulant (33 per cent vs 4 per cent, P=0.003). These differences between cases and VTE-no TT controls were independent of age and gender. TT can interact with underlying thrombophilia–hypofibrinolysis promoting VTE. We suggest that TT should not be started in subjects with known thrombophilia. Coagulation screening, particularly for the FVL , Lp(a), and the lupus anticoagulant should be considered before starting TT, to identify men at high VTE risk who have an adverse risk/benefit ratio for TT.
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247
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Salem JE, Nguyen LS, Hammoudi N, Preud'homme G, Hulot JS, Leban M, Funck-Brentano C, Touraine P, Isnard R, Bachelot A. Complex Association of Sex Hormones on Left Ventricular Systolic Function: Insight into Sexual Dimorphism. J Am Soc Echocardiogr 2017; 31:231-240.e1. [PMID: 29246515 DOI: 10.1016/j.echo.2017.10.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Normal values of left ventricular ejection fraction (LVEF) and absolute values of global longitudinal strain (GLS) are lower in men than in women. Data concerning the association of sex hormone levels on these left ventricular systolic function surrogates are scarce. The aim of this study was to determine the association of sex hormones with systolic left ventricular function in healthy subjects and patients with congenital adrenal hyperplasia (CAH) as a model of testosterone dysregulation. METHODS Eighty-four adult patients with CAH (58 women; median age, 27 years; interquartile range, 23-36 years) and 84 healthy subjects matched for sex and age were prospectively included. Circulating concentrations of sex hormones were measured within 48 hours of echocardiography with assessment of LVEF and left ventricular longitudinal, radial, and circumferential strain. RESULTS LVEF and GLS were higher in healthy women than in healthy men (63.9 ± 4.2% vs 60.9 ± 5.1% [P < .05] and 20.0 ± 1.9% vs 17.9 ± 2.4% [P < .001], respectively), while there was no difference in LVEF or GLS between women and men with CAH (63.9 ± 4.5% vs 63.0 ± 4.6% [P = NS] and 19.4 ± 2.2% vs 18.3 ± 1.8% [P = NS], respectively). Bioavailable testosterone levels were higher in women with CAH than in female control subjects (0.08 ng/mL [interquartile range, 0.04-0.14 ng/mL] vs 0.16 ng/mL [interquartile range, 0.04-0.3 ng/mL], P < .001) and lower in men with CAH than in male control subjects (2.3 ng/mL [interquartile range, 1.3-3 ng/mL] vs 2.9 ng/mL [interquartile range, 2.5-3.4 ng/mL], P < .05). In men, LVEF and GLS were negatively correlated with bioavailable testosterone levels (r = -0.3, P ≤ .05, and r = -0.45, P < .01, respectively), while midventricular radial strain was positively correlated with bioavailable testosterone level (r = 0.38, P < .05). The absolute value of circumferential strain was positively correlated with follicle-stimulating hormone (r = 0.65, P < .0001). CONCLUSIONS These data support that the existence of sex dimorphism concerning left ventricular systolic cardiac function is significantly associated with testosterone levels.
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Affiliation(s)
- Joe-Elie Salem
- AP-HP, Pitié-Salpêtrière Hospital, Department of Pharmacology and CIC-1421; INSERM, CIC-1421 and UMR ICAN 1166; Sorbonne Universités, Paris, France; UPMC Univ Paris 06, Faculty of Medicine; Sorbonne Universités, UPMC Univ Paris 06, AP-HP, Pitié-Salpêtrière Hospital, Department of Cardiology, Echocardiography Unit, Paris, France; UMR ICAN 1166, Paris, France.
| | - Lee S Nguyen
- AP-HP, Pitié-Salpêtrière Hospital, Department of Pharmacology and CIC-1421; INSERM, CIC-1421 and UMR ICAN 1166; Sorbonne Universités, Paris, France; UPMC Univ Paris 06, Faculty of Medicine; Sorbonne Universités, UPMC Univ Paris 06, AP-HP, Pitié-Salpêtrière Hospital, Department of Cardiology, Echocardiography Unit, Paris, France; UMR ICAN 1166, Paris, France
| | - Nadjib Hammoudi
- Sorbonne Universités, UPMC Univ Paris 06, AP-HP, Pitié-Salpêtrière Hospital, Department of Cardiology, Echocardiography Unit, Paris, France; UMR ICAN 1166, Paris, France
| | - Gisèle Preud'homme
- Sorbonne Universités, UPMC Univ Paris 06, AP-HP, Pitié-Salpêtrière Hospital, Department of Cardiology, Echocardiography Unit, Paris, France; UMR ICAN 1166, Paris, France
| | - Jean-Sebastien Hulot
- AP-HP, Pitié-Salpêtrière Hospital, Department of Pharmacology and CIC-1421; INSERM, CIC-1421 and UMR ICAN 1166; Sorbonne Universités, Paris, France; UPMC Univ Paris 06, Faculty of Medicine; Sorbonne Universités, UPMC Univ Paris 06, AP-HP, Pitié-Salpêtrière Hospital, Department of Cardiology, Echocardiography Unit, Paris, France; UMR ICAN 1166, Paris, France
| | - Monique Leban
- AP-HP, Pitié-Salpêtrière Hospital, IE3M, Department of Endocrinology and Reproductive Medecine, and Centre de Référence des Maladies Endocriniennes Rares de la Croissance et Centre des Pathologies Gynécologiques Rares, and CIC-1421, Paris, France
| | - Christian Funck-Brentano
- AP-HP, Pitié-Salpêtrière Hospital, Department of Pharmacology and CIC-1421; INSERM, CIC-1421 and UMR ICAN 1166; Sorbonne Universités, Paris, France; UPMC Univ Paris 06, Faculty of Medicine
| | - Philippe Touraine
- AP-HP, Pitié-Salpêtrière Hospital, IE3M, Department of Endocrinology and Reproductive Medecine, and Centre de Référence des Maladies Endocriniennes Rares de la Croissance et Centre des Pathologies Gynécologiques Rares, and CIC-1421, Paris, France
| | - Richard Isnard
- Sorbonne Universités, UPMC Univ Paris 06, AP-HP, Pitié-Salpêtrière Hospital, Department of Cardiology, Echocardiography Unit, Paris, France; UMR ICAN 1166, Paris, France
| | - Anne Bachelot
- Sorbonne Universités, UPMC Univ Paris 06, AP-HP, Pitié-Salpêtrière Hospital, Department of Cardiology, Echocardiography Unit, Paris, France; UMR ICAN 1166, Paris, France
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Elkhoury FF, Rambhatla A, Mills JN, Rajfer J. Cardiovascular Health, Erectile Dysfunction, and Testosterone Replacement: Controversies and Correlations. Urology 2017; 110:1-8. [DOI: 10.1016/j.urology.2017.07.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 07/15/2017] [Accepted: 07/20/2017] [Indexed: 10/19/2022]
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249
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The Testosterone Trials: What the Results Mean for Healthcare Providers and for Science. CURRENT SEXUAL HEALTH REPORTS 2017. [DOI: 10.1007/s11930-017-0135-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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250
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Testosterone and Cardiovascular Diseases: Causes or Consequences: The Lesson from the Last 5 Years. CURRENT SEXUAL HEALTH REPORTS 2017. [DOI: 10.1007/s11930-017-0132-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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