9-Month Efficacy and Safety Study of Testosterone Solution 2% for Sex Drive and Energy in Hypogonadal Men

Testosterone replacement therapy and vascular thromboembolic events: a systematic review and meta-analysis

ABSTRACT

To evaluate the relationship between testosterone replacement therapy (TRT) and arterial and/or venous thrombosis in patients with pre-treatment total testosterone (TT) <12 nmol l-1, we performed a meta-analysis following the Population Intervention Comparison Outcome model. Population: men with TT <12 nmol l-1 or clear mention of hypogonadism in the inclusion criteria of patients; intervention: TRT; comparison: placebo or no therapy; outcomes: arterial thrombotic events (stroke, myocardial infarction [MI], upper limbs, and lower limbs), VTE (deep vein thrombosis [DVT], portal vein thrombosis, splenic thrombosis, and pulmonary embolism), and mortality. A total of 2423 abstracts were assessed for eligibility. Twenty-four studies, including 14 randomized controlled trials (RCTs), were finally included, with a total of 4027 and 310 288 hypotestosteronemic male patients, from RCTs and from observational studies, respectively. Based on RCT-derived data, TRT did not influence the risk of arterial thrombosis (odds ratio [OR] = 1.27, 95% confidence interval [CI]: 0.47-3.43, P = 0.64), stroke (OR = 1.34, 95% CI: 0.09-18.97, P = 0.83), MI (OR = 0.51, 95% CI: 0.11-2.31, P = 0.39), VTE (OR = 1.42, 95% CI: 0.22-9.03, P = 0.71), pulmonary embolism (OR = 1.38, 95% CI: 0.27-7.04, P = 0.70), and mortality (OR = 0.70, 95% CI: 0.20-2.38, P = 0.56). Meanwhile, when only observational studies are considered, a significant reduction in the risk of developing arterial thrombotic events, MI, venous thromboembolism, and mortality was observed. The risk for DVT remains uncertain, due to the paucity of RCT-based data. TRT in men with TT <12 nmol l-1 is safe from the risk of adverse cardiovascular events. Further studies specifically assessing the risk of DVT in men on TRT are needed.

Androgens and male sexual function

Sexual symptoms are the most specific determinants of low testosterone (T) observed during adulthood. In this narrative review, we summarize the most important evidence supporting the positive relationships between endogenous T levels and sexual activity in the adult male, by using preclinical and clinical observations. In addition, we also report an update of our previous meta-analysis evaluating the effects of T treatment (TRT) on sexual functioning in subjects with T deficiency. Available data indicate that TRT of symptomatic hypogonadal men can improve several aspects of sexual life, including erection. However, the effect is rather modest and lower in subjects with associated metabolic conditions. The specific observed effects are similar to those derived from lifestyle intervention. Since TRT might result in body composition improvement, it is reasonable to suppose that an initial treatment with T can improve the willingness of hypogonadal subjects to perform physical exercise and to adhere to a healthier behavior. Similar data were derived from animal models. However, it should be important to recognize that lifestyle modifications should be the first step to promote weigh reduction. TRT can be combined with lifestyle interventions only in symptomatic hypogonadal subjects especially in the presence of comorbid metabolic conditions.

The Role of Testosterone in the Elderly: What Do We Know?

Testosterone is the most important hormone in male health. Aging is characterized by testosterone deficiency due to decreasing testosterone levels associated with low testicular production, genetic factors, adiposity, and illness. Low testosterone levels in men are associated with sexual dysfunction (low sexual desire, erectile dysfunction), reduced skeletal muscle mass and strength, decreased bone mineral density, increased cardiovascular risk and alterations of the glycometabolic profile. Testosterone replacement therapy (TRT) shows several therapeutic effects while maintaining a good safety profile in hypogonadal men. TRT restores normal levels of serum testosterone in men, increasing libido and energy level and producing beneficial effects on bone density, strength and muscle as well as yielding cardioprotective effects. Nevertheless, TRT could be contraindicated in men with untreated prostate cancer, although poor findings are reported in the literature. In addition, different potential side effects, such as polycythemia, cardiac events and obstructive sleep apnea, should be monitored. The aim of our review is to provide an updated background regarding the pros and cons of TRT, evaluating its role and its clinical applicability in different domains.

The Role of Testosterone in the Elderly: What Do We Know?

Testosterone is the most important hormone in male health. Aging is characterized by testosterone deficiency due to decreasing testosterone levels associated with low testicular production, genetic factors, adiposity, and illness. Low testosterone levels in men are associated with sexual dysfunction (low sexual desire, erectile dysfunction), reduced skeletal muscle mass and strength, decreased bone mineral density, increased cardiovascular risk and alterations of the glycometabolic profile. Testosterone replacement therapy (TRT) shows several therapeutic effects while maintaining a good safety profile in hypogonadal men. TRT restores normal levels of serum testosterone in men, increasing libido and energy level and producing beneficial effects on bone density, strength and muscle as well as yielding cardioprotective effects. Nevertheless, TRT could be contraindicated in men with untreated prostate cancer, although poor findings are reported in the literature. In addition, different potential side effects, such as polycythemia, cardiac events and obstructive sleep apnea, should be monitored. The aim of our review is to provide an updated background regarding the pros and cons of TRT, evaluating its role and its clinical applicability in different domains.

Testosterone therapy and venous thromboembolism: A systematic review and meta-analysis

BACKGROUND

Testosterone prescribing for men has dramatically increased, and there have been concerns about inappropriate use and adverse events. While regulatory bodies have warned about increased risk of venous thromboembolism (VTE), published clinical data supporting an increased risk for VTE are limited.

OBJECTIVE

To conduct a systematic review of studies examining the association between testosterone therapy in men and VTE.

METHODS

Comprehensive searches of multiple databases were performed from inception through October 3rd, 2018. Randomized control trials (RCTs) and observational studies examining the association between exogenous testosterone (any route) and VTE. Study selection and data extraction were performed by two independent investigators. Random-effect model meta-analyses were used to estimate pooled odds ratios (OR) and 95% confidence intervals (CIs). Heterogeneity among studies was evaluated using the I2 statistic. Risk of bias was assessed using the Cochrane and Newcastle-Ottawa tools.

RESULTS

Six RCTs (n = 2236) and 5 observational studies (n = 1,249,640) were included. Five RCTs were performed in men with documented hypogonadism. The observational studies included: 2 case-control studies, 2 retrospective cohorts, and 1 retrospective cohort with a nested case-control study. There was no evidence of a statistically significant association between VTE and testosterone (OR 1.41, 95%CI 0.96-2.07). Heterogeneity was high (I-squared = 84.4%). The association remained nonsignificant when the analysis was stratified by study design: RCTs (2.05, 95% CI 0.78-5.39); cohort (1.06, 95% CI 0.85-1.33); and case-control (1.34, 95% CI 0.78-2.28). The overall risk of bias was moderate.

CONCLUSIONS

The current evidence is of low certainty but does not support an association between testosterone use and VTE in men.

Testosterone therapy improves erectile function and libido in hypogonadal men

PURPOSE OF REVIEW

Erectile dysfunction and decreased libido are common complaints in the older male population. Recent studies have elucidated the role testosterone therapy (TTh) can play in men with low testosterone levels. The aim of this review is to provide an overview of these findings and the utility of TTh. We specifically examine the role of TTh on erectile function, coadministration with phosphodiesterase type 5 inhibitors, and libido.

RECENT FINDINGS

Recent publications suggest that TTh improves mild erectile dysfunction, though may be less useful in men with more severe erectile dysfunction. In men unresponsive to phosphodiesterase type 5 inhibitors and with mild erectile dysfunction, TTh can further improve erectile function. TTh has also shown consistent benefit in improving libido in men with low testosterone levels at baseline, with no additional improvements once testosterone levels are normalized.

SUMMARY

The available literature supports a role for TTh in men with low testosterone levels, erectile dysfunction, and low libido, with symptomatic improvement in these men.

A new 2% testosterone gel formulation: a comparison with currently available topical preparations

Testosterone gel formulations have become a popular testosterone replacement therapy in patients with hypogonadism since their advent in the year 2000. The gel formulations restore testosterone levels to mid-normal physiological levels (14-17.5 nmol/L) as early as within 24 h, and help alleviate the signs and symptoms of testosterone deficiency, thereby leading to an improved quality of life. Although testosterone gels have a favourable efficacy and safety profile as compared to injectable and patch formulations, risk of secondary exposure poses a challenge. Approved testosterone topical formulations include Tostrex^® (Tostran^® , Fortesta^® ), Androgel^® (Testogel^® ), Testim^® and Axiron^® (solution), which have a favourable efficacy profile and positively impacted patient-reported outcome(s). Besides, Testavan, which is a 2% testosterone gel, is under registration in Europe and already approved in Australia in May 2017. Testavan uses a novel hydroalcoholic and highly viscous topical formulation. This product comes with a metered dose dispenser and a cap applicator that allows a hands-free application for precise dispensing and application. The present article provides a comprehensive review of pharmacokinetic, tolerability and safety profile of the testosterone gels available in the market along with the new 2% testosterone gel, Testavan.

Testosterone replacement therapy and the risk of stroke in men: A systematic review

In recent years, questions have been raised regarding the cardiovascular safety of testosterone replacement therapy (TRT). The objective of this study was to systematically review the available evidence on TRT safety in men, specifically with respect to the risk of stroke. We identified publications from MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials up to May 2017. Articles eligible for review included observational studies evaluating TRT and the risk of stroke among men aged 18 or older. Randomized controlled trials (RCTs) comparing testosterone to placebo in men were also eligible, provided stroke was identified as an adverse event. Among seven cohort studies of hypogonadal men, one study reported that TRT was associated with a significant decrease in the risk of ischemic stroke (hazard ratio (HR) 0.64; 95% confidence interval (CI) 0.52-0.80). Another reported a similar decrease in risk (HR 0.64; 95% CI 0.43-0.96) among treated men who achieved normalized levels of testosterone. Limitations in study design, including immortal time bias and residual confounding, may have influenced both of these results. The remaining observational studies did not report measures of association to estimate the independent risk of stroke associated with TRT. Among eight RCTs, a low frequency of stroke events (<5) was observed across both testosterone and control groups, thus precluding any definitive conclusions. Based on these findings, the association between TRT and the risk of stroke in men remains unclear, and further large and methodologically robust studies are needed to establish this relationship.

Practice Patterns in the Diagnosis and Management of Hypogonadism: A Survey of Sexual Medicine Society of North America Members

OBJECTIVE

To describe practice patterns in the diagnosis and treatment of hypogonadism, as the optimal approaches are controversial. Multiple therapeutic options are currently available for hypogonadal men and treatment patterns vary considerably. The safety of testosterone therapy (TTh) remains understudied.

MATERIALS AND METHODS

A 23-question survey regarding diagnosis and treatment of hypogonadism was sent to all members of the Sexual Medicine Society of North America. Subgroup analyses compared responses between sexual medicine fellows and non-fellows, as well as between academic and nonacademic physicians, using a chi-squared analysis.

RESULTS

A total of 101 responses were included for analysis. The most common cutoff value used to diagnose hypogonadism was 300 ng/dL (55%, range = 200-400 ng/dL), and 31% felt comfortable giving TTh to a symptomatic patient with normal serum testosterone levels. No respondents felt that TTh increased a cardiovascular event risk. Of those surveyed, 68% would prescribe TTh to a hypogonadal man with severe lower urinary tract symptoms, and 64% would offer TTh to a man with low-risk prostate cancer on active surveillance. Fellowship-trained physicians were more likely to prescribe TTh to a man with hypogonadism but normal serum testosterone (P = .038), but they differed in the types of therapy they would use for men with hypogonadism who wish to preserve or regain fertility.

CONCLUSION

Significant variety exists in the diagnosis and treatment of hypogonadism. The majority of physicians will only prescribe TTh in the setting of subnormal serum testosterone levels, despite the presence of symptoms. None of the surveyed physicians reported concern over the risk of cardiovascular events.