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Lee H, Hwang EC, Oh CK, Lee S, Yu HS, Lim JS, Kim HW, Walsh T, Kim MH, Jung JH, Dahm P. Testosterone replacement in men with sexual dysfunction. Cochrane Database Syst Rev 2024; 1:CD013071. [PMID: 38224135 PMCID: PMC10788910 DOI: 10.1002/14651858.cd013071.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
BACKGROUND Clinical practice guidelines recommend testosterone replacement therapy (TRT) for men with sexual dysfunction and testosterone deficiency. However, TRT is commonly promoted in men without testosterone deficiency and existing trials often do not clearly report participants' testosterone levels or testosterone-related symptoms. This review assesses the potential benefits and harms of TRT in men presenting with complaints of sexual dysfunction. OBJECTIVES To assess the effects of testosterone replacement therapy compared to placebo or other medical treatments in men with sexual dysfunction. SEARCH METHODS We performed a comprehensive search of CENTRAL (the Cochrane Library), MEDLINE, EMBASE, and the trials registries ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform, with no restrictions on language of publication or publication status, up to 29 August 2023. SELECTION CRITERIA We included randomized controlled trials (RCTs) in men (40 years or over) with sexual dysfunction. We excluded men with primary or secondary hypogonadism. We compared testosterone or testosterone with phosphodiesterase-5 inhibitors (PDEI5I) to placebo or PDE5I alone. DATA COLLECTION AND ANALYSIS Two review authors independently screened the literature, assessed the risk of bias, extracted data, and rated the certainty of evidence (CoE) according to GRADE using a minimally contextualized approach. We performed statistical analyses using a random-effects model and interpreted them according to standard Cochrane methodology. Predefined primary outcomes were self-reported erectile dysfunction assessed by a validated instrument, sexual quality of life assessed by a validated instrument, and cardiovascular mortality. Secondary outcomes were treatment withdrawal due to adverse events, prostate-related events, and lower urinary tract symptoms (LUTS). We distinguished between short-term (up to 12 months) and long-term (> 12 months) outcomes. MAIN RESULTS We identified 43 studies with 11,419 randomized participants across three comparisons: testosterone versus placebo, testosterone versus PDE5I, and testosterone with PDE5I versus PDE5I alone. This abstract focuses on the most relevant comparison of testosterone versus placebo. Testosterone versus placebo (up to 12 months) Based on a predefined sensitivity analysis of studies at low risk of bias, and an analysis combing data from the similar International Index of Erectile Function (IIEF-EF) and IIEF-5 instruments, TRT likely results in little to no difference in erectile function assessed with the IIEF-EF (mean difference (MD) 2.37, 95% confidence interval (CI) 1.67 to 3.08; I² = 0%; 6 RCTs, 2016 participants; moderate CoE) on a scale from 6 to 30 with larger values reflecting better erectile function. We assumed a minimal clinically important difference (MCID) of greater than or equal to 4. TRT likely results in little to no change in sexual quality of life assessed with the Aging Males' Symptoms scale (MD -2.31, 95% CI -3.63 to -1.00; I² = 0%; 5 RCTs, 1030 participants; moderate CoE) on a scale from 17 to 85 with larger values reflecting worse sexual quality of life. We assumed a MCID of greater than or equal to 10. TRT also likely results in little to no difference in cardiovascular mortality (risk ratio (RR) 0.83, 95% CI 0.21 to 3.26; I² = 0%; 10 RCTs, 3525 participants; moderate CoE). Based on two cardiovascular deaths in the placebo group and an assumed MCID of 3%, this would correspond to no additional deaths per 1000 men (95% CI 1 fewer to 4 more). TRT also likely results in little to no difference in treatment withdrawal due to adverse events, prostate-related events, or LUTS. Testosterone versus placebo (later than 12 months) We are very uncertain about the longer-term effects of TRT on erectile dysfunction assessed with the IIEF-EF (MD 4.20, 95% CI -2.03 to 10.43; 1 study, 42 participants; very low CoE). We did not find studies reporting on sexual quality of life or cardiovascular mortality. We are very uncertain about the effect of testosterone on treatment withdrawal due to adverse events. We found no studies reporting on prostate-related events or LUTS. AUTHORS' CONCLUSIONS In the short term, TRT probably has little to no effect on erectile function, sexual quality of life, or cardiovascular mortality compared to a placebo. It likely results in little to no difference in treatment withdrawals due to adverse events, prostate-related events, or LUTS. In the long term, we are very uncertain about the effects of TRT on erectile function when compared to placebo; we did not find data on its effects on sexual quality of life or cardiovascular mortality. The certainty of evidence ranged from moderate (signaling that we are confident that the reported effect size is likely to be close to the true effect) to very low (indicating that the true effect is likely to be substantially different). The findings of this review should help to inform future guidelines and clinical decision-making at the point of care.
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Affiliation(s)
- Hunju Lee
- Department of Preventive Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea, South
| | - Eu Chang Hwang
- Department of Urology, Chonnam National University Medical School, Chonnam National University Hwasun Hospital, Hwasun, Korea, South
- Center of Evidence-Based Medicine, Institute of Convergence Science, Yonsei University, Seoul, Korea, South
| | - Cheol Kyu Oh
- Department of Urology, Heaundae Paik Hospital, Inje University, Busan, Korea, South
| | - Solam Lee
- Department of Dermatology, Yonsei University Wonju College of Medicine, Wonju, Korea, South
| | - Ho Song Yu
- Department of Urology, Chonnam National University, Gwangju, Korea, South
| | - Jung Soo Lim
- Division of Endocrinology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea, South
| | - Hong Wook Kim
- Department of Urology, Konyang University College of Medicine, Daejeon, Korea, South
| | - Thomas Walsh
- Immunocompromised Host Section, Pediatric Oncology Branch, National Cancer Institute, Bethesda, MD, USA
| | - Myung Ha Kim
- Yonsei Wonju Medical Library, Yonsei University Wonju College of Medicine, Wonju, Korea, South
| | - Jae Hung Jung
- Center of Evidence-Based Medicine, Institute of Convergence Science, Yonsei University, Seoul, Korea, South
- Department of Urology, Yonsei University Wonju College of Medicine, Wonju, Korea, South
- Department of Precision Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea, South
| | - Philipp Dahm
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
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Livingston M, Heald AH. Adult Male Hypogonadism: A Laboratory Medicine Perspective on Its Diagnosis and Management. Diagnostics (Basel) 2023; 13:3650. [PMID: 38132234 PMCID: PMC10743125 DOI: 10.3390/diagnostics13243650] [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: 08/16/2023] [Revised: 11/13/2023] [Accepted: 11/16/2023] [Indexed: 12/23/2023] Open
Abstract
Testosterone (T), the principal androgen secreted by the testes, plays an essential role in male health. Male hypogonadism is diagnosed based on a combination of associated clinical signs and symptoms and laboratory confirmation of low circulating T levels. In this review, we have highlighted factors, both biological and analytical, that introduce variation into the measurement of serum T concentrations in men; these need to be considered when requesting T levels and interpreting results. There is an ongoing need for analytical standardisation of T assays and harmonisation of pre- and post-analytical laboratory practices, particularly in relation to the laboratory reference intervals provided to clinicians. Further, there is a need to share with service users the most up-to-date and evidence-based action thresholds for serum T as recommended in the literature. Estimation of free testosterone may be helpful. Causes of secondary hypogonadism should be considered. A comprehensive approach is required in the management of male hypogonadism, including lifestyle modification as well as medication where appropriate. The goal of treatment is the resolution of symptoms as well as the optimisation of metabolic, cardiovascular, and bone health. The advice of an endocrinologist should be sought when there is doubt about the cause and appropriate management of the hypogonadism.
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Affiliation(s)
- Mark Livingston
- Department of Clinical Biochemistry, Black Country Pathology Services, The Royal Wolverhampton NHS Trust, Wolverhampton WV10 0QP, UK
- School of Medicine and Clinical Practice, The University of Wolverhampton, Wolverhampton WV1 1LY, UK
| | - Adrian H. Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, Manchester University, Manchester M13 9PL, UK;
- Department of Endocrinology and Diabetes, Salford Royal Hospital, Salford M6 8HD, UK
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Kanakis GA, Pofi R, Goulis DG, Isidori AM, Armeni E, Erel CT, Fistonić I, Hillard T, Hirschberg AL, Meczekalski B, Mendoza N, Mueck AO, Simoncini T, Stute P, van Dijken D, Rees M, Lambrinoudaki I. EMAS position statement: Testosterone replacement therapy in older men. Maturitas 2023; 178:107854. [PMID: 37845136 DOI: 10.1016/j.maturitas.2023.107854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
INTRODUCTION Late-onset hypogonadism is the clinical entity characterised by low testosterone concentrations associated with clinical symptoms in the absence of organic disease in ageing men. It has been associated with metabolic syndrome, reduced bone mineral density, and increased cardiovascular morbidity and mortality risk. Although testosterone replacement therapy (TRT) reverses most of these conditions in young hypogonadal men, the risk/benefit ratio of TRT in older men is debatable. AIM To update the 2015 EMAS statement on TRT in older men with new research on late-onset hypogonadism and TRT. MATERIALS AND METHODS Literature review and consensus of expert opinion. SUMMARY RECOMMENDATIONS TRT should be offered only to symptomatic older men with confirmed low testosterone concentrations after explaining the uncertainties regarding the long-term safety of this treatment. TRT may be offered to men with severe hypogonadism and erectile dysfunction to improve sexual desire, erectile, and orgasmic function. It should also be considered in hypogonadal men with severe insulin resistance or pre-diabetes mellitus. TRT may also be considered, in combination with proven treatment strategies, for osteoporosis, or for selected patients with persistent mild depressive symptoms and/or low self-perceived quality of life, combined with standard medical care for each condition. TRT is contraindicated in hypogonadal men actively seeking fertility treatment. Due to a lack of data, TRT should not be routinely used in older men to improve exercise capacity/physical function, improve cognitive function, or prevent cognitive decline. TRT must be avoided in older, frail men with known breast cancer or untreated prostate cancer and all men who have had myocardial infarction or stroke within the last four months, and those with severe or decompensated heart failure. The quality of evidence regarding patients with previous prostate cancer or cardiovascular disease is too low to draw definitive conclusions. Any limits on duration of use are arbitrary, and treatment should continue for as long as the man feels the benefits outweigh the risks for him, and decisions must be made on an individual basis. Withdrawal should be considered when hypogonadism is reversed after the resolution of underlying disorder. Short-acting transdermal preparations should be preferred for TRT initiation in older men, but injectable forms may be considered subsequently. Older men on TRT should be monitored at 3, 6, and 12 months after initiation and at least yearly thereafter, or earlier and more frequently if indicated. Evaluation should include assessment of the clinical response, and measurement of total testosterone, haematocrit, and prostate-specific antigen (PSA) concentrations. Bone density and/or quality should also be assessed. Obese and overweight patients should be encouraged to undergo lifestyle modifications, including exercise and weight loss, to increase endogenous testosterone.
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Affiliation(s)
- George A Kanakis
- Department of Endocrinology & IVF Unit, Athens Naval and Veteran Affairs Hospital, Athens, Greece.
| | - Riccardo Pofi
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Greece
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, 00161 Rome, Italy
| | - Eleni Armeni
- Second Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Greece; Royal Free Hospital, London, UK
| | - C Tamer Erel
- İstanbul-Cerrahpaşa University, Cerrahpaşa School of Medicine, Department of Obstetrics and Gynecology, İstanbul, Turkey
| | - Ivan Fistonić
- Faculty for Health Studies, University of Rijeka, Rijeka, Croatia
| | - Timothy Hillard
- Department of Obstetrics & Gynaecology, University Hospitals Dorset, Poole, UK
| | - Angelica-Lindén Hirschberg
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Blazej Meczekalski
- Department of Gynecological Endocrinology, Poznan University of Medical Sciences, Poznan, Poland
| | - Nicolás Mendoza
- Department of Obstetrics and Gynecology, University of Granada, Spain
| | - Alfred O Mueck
- Department of Women's Health, University Hospital Tuebingen, Germany; Beijing OB/GYN Hospital, Capital Medical University, China
| | - Tommaso Simoncini
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56100 Pisa, Italy
| | - Petra Stute
- Department of Obstetrics and Gynecology, University Clinic Inselspital, Bern, Switzerland
| | - Dorenda van Dijken
- Department of Obstetrics and Gynecology, OLVG Hospital, Amsterdam, the Netherlands
| | - Margaret Rees
- Women's Centre, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Irene Lambrinoudaki
- Second Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Greece
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Loeffler I, Ziller N. Sex-Related Aspects in Diabetic Kidney Disease-An Update. J Clin Med 2023; 12:jcm12082834. [PMID: 37109170 PMCID: PMC10145498 DOI: 10.3390/jcm12082834] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/05/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
Differences between the sexes exist in many diseases, and in most cases, being a specific sex is considered a risk factor in the development and/or progression. This is not quite so clear in diabetic kidney disease (DKD), the development and severity of which depends on many general factors, such as the duration of diabetes mellitus, glycemic control, and biological risk factors. Similarly, sex-specific factors, such as puberty or andro-/menopause, also determine the microvascular complications in both the male and female sex. In particular, the fact that diabetes mellitus itself influences sex hormone levels, which in turn seem to be involved in renal pathophysiology, highlights the complexity of the question of sex differences in DKD. The major objective of this review is to summarize and simplify the current knowledge on biological sex-related aspects in the development/progression but also treatment strategies of human DKD. It also highlights findings from basic preclinical research that may provide explanations for these differences.
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Affiliation(s)
- Ivonne Loeffler
- Department of Internal Medicine III, Jena University Hospital, Friedrich Schiller University, 07747 Jena, Germany
| | - Nadja Ziller
- Department of Internal Medicine III, Jena University Hospital, Friedrich Schiller University, 07747 Jena, Germany
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Kumari K, Kumar R, Memon A, Kumari B, Tehrim M, Kumari P, Shehryar M, Islam H, Islam R, Khatri M, Kumar S, Kumar A. Treatment with Testosterone Therapy in Type 2 Diabetic Hypogonadal Adult Males: A Systematic Review and Meta-Analysis. Clin Pract 2023; 13:454-469. [PMID: 36961066 PMCID: PMC10037582 DOI: 10.3390/clinpract13020041] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 03/14/2023] [Accepted: 03/16/2023] [Indexed: 03/25/2023] Open
Abstract
Testosterone replacement therapy (TRT) has been used to treat hypogonadal males with type 2 diabetes mellitus (T2DM) for a long time, despite variable results. This meta-analysis examines TRT's role in hypogonadal males with T2DM. The databases PubMed, Embase, and Google Scholar were searched for relevant RCTs and observational studies. Estimated pooled mean differences (MDs) and relative risks with 95% confidence intervals were used to measure the effects of TRT (CIs). When compared to the placebo, TRT improves glycemic management by significantly reducing glycated hemoglobin (HBA1c) levels (WMD = -0.29 [-0.57, -0.02] p = 0.04; I2 = 89.8%). Additionally, it reduces the homeostatic model assessment levels of insulin resistance (WMD = -1.47 [-3.14, 0.19]; p = 0.08; I2 = 56.3%), fasting glucose (WMD = -0.30 [-0.75, 0.15]; p = 0.19; I2 = 84.4%), and fasting insulin (WMD = -2.95 [-8.64, 2.74]; however, these results are non-significant. On the other hand, HBA1c levels are significantly reduced with TRT; in addition, total testosterone levels significantly increase with testosterone replacement therapy (WMD = 4.51 [2.40, 6.61] p = 0.0001; I2 = 96.3%). Based on our results, we hypothesize that TRT can improve glycemic control and hormone levels, as well as lower total cholesterol, triglyceride, and LDL cholesterol levels while raising HDL cholesterol in hypogonadal type 2 diabetes patients. To this end, we recommend TRT for these patients in addition to standard diabetes care.
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Affiliation(s)
- Kajol Kumari
- Medicine Department, Ghulam Muhammad Mahar Medical College, Sukkur 65200, Pakistan
| | - Rohan Kumar
- Medicine Department, Jinnah Sindh Medical University, Karachi 75510, Pakistan
| | - Areeba Memon
- Medicine Department, Dow University of Health Sciences, Karachi 74200, Pakistan
| | - Beena Kumari
- Medicine Department, Dow University of Health Sciences, Karachi 74200, Pakistan
| | - Moniba Tehrim
- Medicine Department, Karachi Medical and Dental College, Karachi 74700, Pakistan
| | - Pooja Kumari
- Medicine Department, Dow University of Health Sciences, Karachi 74200, Pakistan
| | - Muhammad Shehryar
- Medicine Department, King Edward Medical University, Lahore 54000, Pakistan
| | - Hamza Islam
- Medicine Department, Punjab Medical College, Faisalabad 38000, Pakistan
| | - Rabia Islam
- Medicine Department, Punjab Medical College, Faisalabad 38000, Pakistan
| | - Mahima Khatri
- Medicine Department, Dow University of Health Sciences, Karachi 74200, Pakistan
| | - Satesh Kumar
- Shaheed Mohtarma Benazir Bhutto Medical College, Lyari General Hospital, Karachi 74200, Pakistan
| | - Ajay Kumar
- Medicine Department, MedStar Union Memorial Hospital, Baltimore, MD 21218, USA
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Interaction between gut microbiota and sex hormones and their relation to sexual dimorphism in metabolic diseases. Biol Sex Differ 2023; 14:4. [PMID: 36750874 PMCID: PMC9903633 DOI: 10.1186/s13293-023-00490-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 01/30/2023] [Indexed: 02/09/2023] Open
Abstract
Metabolic diseases, such as obesity, metabolic syndrome (MetS) and type 2 diabetes (T2D), are now a widespread pandemic in the developed world. These pathologies show sex differences in their development and prevalence, and sex steroids, mainly estrogen and testosterone, are thought to play a prominent role in this sexual dimorphism. The influence of sex hormones on these pathologies is not only reflected in differences between men and women, but also between women themselves, depending on the hormonal changes associated with the menopause. The observed sex differences in gut microbiota composition have led to multiple studies highlighting the interaction between steroid hormones and the gut microbiota and its influence on metabolic diseases, ultimately pointing to a new therapy for these diseases based on the manipulation of the gut microbiota. This review aims to shed light on the role of sexual hormones in sex differences in the development and prevalence of metabolic diseases, focusing on obesity, MetS and T2D. We focus also the interaction between sex hormones and the gut microbiota, and in particular the role of microbiota in aspects such as gut barrier integrity, inflammatory status, and the gut-brain axis, given the relevance of these factors in the development of metabolic diseases.
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Kang WH, Mohamad Sithik MN, Khoo JK, Ooi YG, Lim QH, Lim LL. Gaps in the management of diabetes in Asia: A need for improved awareness and strategies in men's sexual health. J Diabetes Investig 2022; 13:1945-1957. [PMID: 36151988 DOI: 10.1111/jdi.13903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/22/2022] [Accepted: 08/17/2022] [Indexed: 11/28/2022] Open
Abstract
Sexual dysfunction, which is defined as 'difficulty during any stage of the sexual encounter that prevents or impairs the individual or couple from enjoying sexual activity', is globally prevalent in males with prediabetes and diabetes. It is an early harbinger of cardiovascular diseases and has a profound impact on one's physical, mental, and social health. Among patients with either prediabetes or diabetes, the most common male sexual dysfunctions are hypogonadism, erectile dysfunction, and premature ejaculation. In Asia, although sexual health is an important factor of men's health, it is rarely discussed freely in real-life practice. Addressing sexual health in Asian males has always been challenging with multiple barriers at the levels of patients and health care providers. Therefore, the assessment and management of sexual dysfunction in routine clinical practice should involve a holistic approach with effective patient-provider communication. In this review, we discuss the epidemiology, pathophysiology, and the management of hypogonadism, erectile dysfunction, and premature ejaculation among males with either prediabetes or diabetes (type 1 and type 2), as well as the evidence gaps across Asia.
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Affiliation(s)
- Waye-Hann Kang
- Department of Medicine, Faculty of Medicine and Health Sciences, University Tunku Abdul Rahman, Selangor, Malaysia
| | | | - Jun-Kit Khoo
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Ying-Guat Ooi
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Quan-Hziung Lim
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Lee-Ling Lim
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China.,Asia Diabetes Foundation, Hong Kong SAR, China
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Kumar S, Khatri M, Memon RA, Velastegui JL, Podaneva KZ, Gutierrez DB, Nadeem B, Anumolu AR, Azhar M, Zain A. Effects of testosterone therapy in adult males with hypogonadism and T2DM: A meta-analysis and systematic review. Diabetes Metab Syndr 2022; 16:102588. [PMID: 35952509 DOI: 10.1016/j.dsx.2022.102588] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 07/21/2022] [Accepted: 07/23/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND AIMS Testosterone supplementation therapy (TST) is a longstanding treatment for hypogonadal men with type 2 diabetes mellitus (T2DM), even though the benefits of TST are variable among trials. This meta-analysis was done to determine the specific role of TST in hypogonadal men with T2DM. METHODS PubMed, Embase, and Google Scholar were queried to discover eligible randomized controlled trials (RCTs) and observational studies. To quantify the specific effects of TST, we estimated pooled mean differences (MDs) and relative risks with 95% confidence intervals (CIs). RESULTS Our meta-analysis included 1596 hypogonadal T2DM subjects from 12 randomized controlled trials and one observational study. TST can significantly enhance glycemic control compared to placebo by decreasing homeostatic model assessment of insulin resistance (WMD = -1.55 [-2.65, -0.45]; p = 0.26; I2 = 20.2%), fasting glucose (WMD = -0.35 [-0.79, 0.10]; p = 0.07; I2 = 69.7%), fasting insulin (WMD = -2.88 [-6.12, 0.36]; p = In addition, TST can decrease cholesterol (WMD = -0.28 [-0.47, -0.09] p = 0.0008; I2 = 91%) and triglyceride (WMD = -0.23 [-0.43, -0.03] p = 0.03; I2 = 79.2%). Furthermore, Testosterone therapy is related to a significant rise in total testosterone levels (WMD = 5.08 [2.90, 7.26] p = 0.0002; I2 = 92.9%). Pooling of free testosterone levels indicated a larger increase in the patients who got TST than placebo (WMD = 81.21 [23.87, 138.54] p = 0.07; I2 = 70%). CONCLUSION Our findings suggested that TST can enhance glycemic control and hormone levels and reduce total cholesterol, triglyceride, LDL cholesterol whereas increase HDL cholesterol in hypogonadal T2DM patients. Therefore, in these patients, we propose TST alongside anti-diabetic treatment.
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Affiliation(s)
- Satesh Kumar
- Medicine, Shaheed Mohtarma Benazir Bhutto Medical College, Lyari, Parsa Citi Block E Flat 501 Near Police Headquarter, Garden East, Karachi, Pakistan.
| | - Mahima Khatri
- Medicine, Dow University of Health Sciences, Karachi, Karachi, Pakistan.
| | - Rahat Ahmed Memon
- Cardiology, Abington Jefferson Hospital, Pennsylvania, Pennsylvania, United States.
| | | | | | | | - Bilawal Nadeem
- Medicine, Kind Edward Medical University, Lahore, Lahore, Pakistan.
| | - Akhil Raj Anumolu
- Medicine, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India.
| | - Masood Azhar
- Medicine, King Edward Medical University, Lahore, Lahore, Pakistan.
| | - Ahmad Zain
- Medicine, Services Institute of Medical Sciences, Lahore, Lahore, Pakistan.
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Adverse cardiovascular events and mortality in men during testosterone treatment: an individual patient and aggregate data meta-analysis. THE LANCET. HEALTHY LONGEVITY 2022; 3:e381-e393. [PMID: 35711614 PMCID: PMC9184259 DOI: 10.1016/s2666-7568(22)00096-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Background Testosterone is the standard treatment for male hypogonadism, but there is uncertainty about its cardiovascular safety due to inconsistent findings. We aimed to provide the most extensive individual participant dataset (IPD) of testosterone trials available, to analyse subtypes of all cardiovascular events observed during treatment, and to investigate the effect of incorporating data from trials that did not provide IPD. Methods We did a systematic review and meta-analysis of randomised controlled trials including IPD. We searched MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, MEDLINE Epub Ahead of Print, Embase, Science Citation Index, the Cochrane Controlled Trials Register, Cochrane Database of Systematic Reviews, and Database of Abstracts of Review of Effects for literature from 1992 onwards (date of search, Aug 27, 2018). The following inclusion criteria were applied: (1) men aged 18 years and older with a screening testosterone concentration of 12 nmol/L (350 ng/dL) or less; (2) the intervention of interest was treatment with any testosterone formulation, dose frequency, and route of administration, for a minimum duration of 3 months; (3) a comparator of placebo treatment; and (4) studies assessing the pre-specified primary or secondary outcomes of interest. Details of study design, interventions, participants, and outcome measures were extracted from published articles and anonymised IPD was requested from investigators of all identified trials. Primary outcomes were mortality, cardiovascular, and cerebrovascular events at any time during follow-up. The risk of bias was assessed using the Cochrane Risk of Bias tool. We did a one-stage meta-analysis using IPD, and a two-stage meta-analysis integrating IPD with data from studies not providing IPD. The study is registered with PROSPERO, CRD42018111005. Findings 9871 citations were identified through database searches and after exclusion of duplicates and of irrelevant citations, 225 study reports were retrieved for full-text screening. 116 studies were subsequently excluded for not meeting the inclusion criteria in terms of study design and characteristics of intervention, and 35 primary studies (5601 participants, mean age 65 years, [SD 11]) reported in 109 peer-reviewed publications were deemed suitable for inclusion. Of these, 17 studies (49%) provided IPD (3431 participants, mean duration 9·5 months) from nine different countries while 18 did not provide IPD data. Risk of bias was judged to be low in most IPD studies (71%). Fewer deaths occurred with testosterone treatment (six [0·4%] of 1621) than placebo (12 [0·8%] of 1537) without significant differences between groups (odds ratio [OR] 0·46 [95% CI 0·17-1·24]; p=0·13). Cardiovascular risk was similar during testosterone treatment (120 [7·5%] of 1601 events) and placebo treatment (110 [7·2%] of 1519 events; OR 1·07 [95% CI 0·81-1·42]; p=0·62). Frequently occurring cardiovascular events included arrhythmia (52 of 166 vs 47 of 176), coronary heart disease (33 of 166 vs 33 of 176), heart failure (22 of 166 vs 28 of 176), and myocardial infarction (10 of 166 vs 16 of 176). Overall, patient age (interaction 0·97 [99% CI 0·92-1·03]; p=0·17), baseline testosterone (interaction 0·97 [0·82-1·15]; p=0·69), smoking status (interaction 1·68 [0·41-6·88]; p=0.35), or diabetes status (interaction 2·08 [0·89-4·82; p=0·025) were not associated with cardiovascular risk. Interpretation We found no evidence that testosterone increased short-term to medium-term cardiovascular risks in men with hypogonadism, but there is a paucity of data evaluating its long-term safety. Long-term data are needed to fully evaluate the safety of testosterone. Funding National Institute for Health Research Health Technology Assessment Programme.
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Singh P, Covassin N, Marlatt K, Gadde KM, Heymsfield SB. Obesity, Body Composition, and Sex Hormones: Implications for Cardiovascular Risk. Compr Physiol 2021; 12:2949-2993. [PMID: 34964120 PMCID: PMC10068688 DOI: 10.1002/cphy.c210014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Cardiovascular disease (CVD) continues to be the leading cause of death in adults, highlighting the need to develop novel strategies to mitigate cardiovascular risk. The advancing obesity epidemic is now threatening the gains in CVD risk reduction brought about by contemporary pharmaceutical and surgical interventions. There are sex differences in the development and outcomes of CVD; premenopausal women have significantly lower CVD risk than men of the same age, but women lose this advantage as they transition to menopause, an observation suggesting potential role of sex hormones in determining CVD risk. Clear differences in obesity and regional fat distribution among men and women also exist. While men have relatively high fat in the abdominal area, women tend to distribute a larger proportion of their fat in the lower body. Considering that regional body fat distribution is an important CVD risk factor, differences in how men and women store their body fat may partly contribute to sex-based alterations in CVD risk as well. This article presents findings related to the role of obesity and sex hormones in determining CVD risk. Evidence for the role of sex hormones in determining body composition in men and women is also presented. Lastly, the clinical potential for using sex hormones to alter body composition and reduce CVD risk is outlined. © 2022 American Physiological Society. Compr Physiol 12:1-45, 2022.
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Affiliation(s)
- Prachi Singh
- Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, Louisiana, USA
| | | | - Kara Marlatt
- Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, Louisiana, USA
| | - Kishore M Gadde
- Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, Louisiana, USA
| | - Steven B Heymsfield
- Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, Louisiana, USA
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11
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Kim SH, Park JJ, Kim KH, Yang HJ, Kim DS, Lee CH, Jeon YS, Shim SR, Kim JH. Efficacy of testosterone replacement therapy for treating metabolic disturbances in late-onset hypogonadism: a systematic review and meta-analysis. Int Urol Nephrol 2021; 53:1733-1746. [PMID: 34089171 DOI: 10.1007/s11255-021-02876-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 04/22/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE Late onset hypogonadism (LOH) is an age-dependent reduction of testosterone associated with alterations of metabolic profile, including glucose control, insulin sensitivity, and lipid profile. The purpose of this study was to investigate the efficacy of testosterone replacement therapy (TRT) for treating metabolic disturbances through a meta-analysis of randomized clinical trials (RCTs). METHODS A systematic review of literature published from 1964 to November, 2019 was performed using the PubMed/Medline, Embase, and Cochrane databases. Among the 1562 articles screened, 17 articles were selected for qualitative analysis and 16 articles (n = 1373) were included for data synthesis following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). Criteria for final inclusion were RCTs. RESULTS Sixteen studies were finally included (TRT group, n = 709; placebo group, n = 664). Among the metabolic markers, HbA1C [Mean difference (MD) = - 0.172, 95% CI - 0.329, - 0.015], HOMA IR (MD = - 0.514, 95% CI - 0.863, - 0.165), serum insulin (MD = - 12.622, 95% CI - 19.660, - 5.585), and leptin (MD = - 2.381, 95% CI - 2.952, - 1.810) showed significant improvement after TRT versus placebo. Among the lipid profiles, total cholesterol showed significant improvement (MD = - 0.433, 95% CI - 0.761, - 0.105) after TRT. However, HDL showed a decrease (MD = - 0.069, 95% CI - 0.121, - 0.018) after TRT. Among anthropometric markers, waist circumference showed significant improvement (MD = - 0.1640, 95% CI - 2.857, - 0.423). CONCLUSION This study demonstrated greater improvement in metabolic profiles for patients given TRT versus placebo. Further well-designed trials are needed to verify our findings and further elucidate effects of TRT on lipid profiles. This systematic review demonstrates that TRT can exert a net beneficial effect on metabolic profiles.
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Affiliation(s)
- Si Hyun Kim
- Department of Urology, Soonchunhyang University Cheonan Hospital, Soonchunhyang University Medical College, Cheonan, Korea
| | - Jae Joon Park
- Department of Urology, Soonchunhyang University Seoul Hospital, Soonchunhyang University Medical College, 59 Daesagwan-ro, Yongsan-gu, Seoul, 04401, Korea
| | - Ki Hong Kim
- Department of Urology, Soonchunhyang University Cheonan Hospital, Soonchunhyang University Medical College, Cheonan, Korea
| | - Hee Jo Yang
- Department of Urology, Soonchunhyang University Cheonan Hospital, Soonchunhyang University Medical College, Cheonan, Korea
| | - Doo Sang Kim
- Department of Urology, Soonchunhyang University Cheonan Hospital, Soonchunhyang University Medical College, Cheonan, Korea
| | - Chang Ho Lee
- Department of Urology, Soonchunhyang University Cheonan Hospital, Soonchunhyang University Medical College, Cheonan, Korea
| | - Youn Soo Jeon
- Department of Urology, Soonchunhyang University Cheonan Hospital, Soonchunhyang University Medical College, Cheonan, Korea
| | - Sung Ryul Shim
- Department of Preventive Medicine, Korea University College of Medicine, Anamdong 5Ga, Seongbuk-gu, Seoul, 136-701, Korea.
| | - Jae Heon Kim
- Department of Urology, Soonchunhyang University Seoul Hospital, Soonchunhyang University Medical College, 59 Daesagwan-ro, Yongsan-gu, Seoul, 04401, Korea.
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Dayton KA, Bril F, Barb D, Lai J, Kalavalapalli S, Cusi K. Severity of non-alcoholic steatohepatitis is not linked to testosterone concentration in patients with type 2 diabetes. PLoS One 2021; 16:e0251449. [PMID: 34077443 PMCID: PMC8172043 DOI: 10.1371/journal.pone.0251449] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/27/2021] [Indexed: 02/05/2023] Open
Abstract
Background Hypogonadism is reported to occur in non-alcoholic fatty liver disease (NAFLD), but earlier studies used low-sensitivity diagnostic techniques (CT, ultrasound), for NAFLD diagnosis. We hypothesized that if hypogonadism was due to NAFLD, and not solely attributable to underlying obesity/diabetes, it would be more severe in the presence of steatohepatitis (NASH). To examine the influence of liver disease on testosterone in males with type 2 diabetes mellitus (T2DM), we used gold-standard liver imaging with MR-spectroscopy (1H-MRS), and performed liver biopsies to grade/stage the NAFLD. Methods In this cross-sectional study, we measured in 175 males with T2DM total and free testosterone, markers of insulin resistance, and intrahepatic triglyceride content (IHTG) by 1H-MRS. Those with NAFLD on imaging underwent a liver biopsy. Results Total testosterone was higher in the group without NAFLD (“No-NAFLD”; n = 48) compared to isolated steatosis (IS; n = 62) or NASH (n = 65) (385 ± 116 vs. 339 ± 143 vs. 335 ± 127 ng/ml, ptrend 0.03). Testosterone was also lower in obese vs. non-obese subjects in both the No-NAFLD and IS groups (p = 0.06 and p = 0.11, respectively), but not in obese vs. non-obese patients with NASH (p = 0.81). IHTG was independently associated with total testosterone (ß = -4.8, p = 0.004). None of the liver histology characteristics were associated with lower testosterone. Conclusions NAFLD is linked to lower total testosterone in patients with T2DM, but likely given a common soil of insulin resistance/obesity and not from the severity of liver necroinflammation or fibrosis. Nevertheless, clinicians should consider screening patients with T2DM and NAFLD for hypogonadism.
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Affiliation(s)
- Kristin Alexandra Dayton
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Florida, Gainesville, Florida, United States of America
| | - Fernando Bril
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Florida, Gainesville, Florida, United States of America
- Malcom Randall Veterans Administration Medical Center, Gainesville, Florida, United States of America
| | - Diana Barb
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Florida, Gainesville, Florida, United States of America
| | - Jinping Lai
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Srilaxmi Kalavalapalli
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Florida, Gainesville, Florida, United States of America
| | - Kenneth Cusi
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Florida, Gainesville, Florida, United States of America
- Malcom Randall Veterans Administration Medical Center, Gainesville, Florida, United States of America
- * E-mail:
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Barnouin Y, Armamento-Villareal R, Celli A, Jiang B, Paudyal A, Nambi V, Bryant MS, Marcelli M, Garcia JM, Qualls C, Villareal DT. Testosterone Replacement Therapy Added to Intensive Lifestyle Intervention in Older Men With Obesity and Hypogonadism. J Clin Endocrinol Metab 2021; 106:e1096-e1110. [PMID: 33351921 DOI: 10.1210/clinem/dgaa917] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Obesity and hypogonadism additively contribute to frailty in older men; however, appropriate treatment remains controversial. OBJECTIVE Determine whether testosterone replacement augments the effect of lifestyle therapy on physical function in older men with obesity and hypogonadism. DESIGN Randomized, double-blind, placebo-controlled trial. SETTING VA Medical Center. PARTICIPANTS 83 older (age ≥65 years) men with obesity (body mass index ≥30 kg/m2) and persistently low am testosterone (<10.4 nmol/L) associated with frailty. INTERVENTIONS Participants were randomized to lifestyle therapy (weight management and exercise training) plus either testosterone (LT+Test) or placebo (LT+Pbo) for 6 months. OUTCOME MEASURES Primary outcome was change in Physical Performance Test (PPT) score. Secondary outcomes included other frailty measures, body composition, hip bone mineral density (BMD), physical functions, hematocrit, prostate specific antigen (PSA), and sex hormones. RESULTS PPT score increased similarly in LT+Test and LT+Pbo group (17% vs. 16%; P = 0.58). VO2peak increased more in LT+Test than LT+Pbo (23% vs. 16%; P = 0.03). Despite similar -9% weight loss, lean body mass and thigh muscle volume decreased less in LT+Test than LT+Pbo (-2% vs. -3%; P = 0.01 and -2% vs -4%; P = 0.04). Hip BMD was preserved in LT+Test compared with LT+Pbo (0.5% vs -1.1%; P = 0.003). Strength increased similarly in LT+Test and LT+Pbo (23% vs 22%; P = 0.94). Hematocrit but not PSA increased more in LT+Test than LT+Pbo (5% vs 1%; P < 0.001). Testosterone levels increased more in LT+Test than LT+Pbo (167% vs 27%; P < 0.001). CONCLUSION In older, obese hypogonadal men, adding testosterone for 6 months to lifestyle therapy does not further improve overall physical function. However, our findings suggest that testosterone may attenuate the weight loss-induced reduction in muscle mass and hip BMD and may further improve aerobic capacity.
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Affiliation(s)
- Yoann Barnouin
- Center for Translational Research on Inflammatory Diseases, Michael E DeBakey VA Medical Center, Houston TX, USA
- Division of Endocrinology, Diabetes, and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - Reina Armamento-Villareal
- Center for Translational Research on Inflammatory Diseases, Michael E DeBakey VA Medical Center, Houston TX, USA
- Division of Endocrinology, Diabetes, and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - Alessandra Celli
- Center for Translational Research on Inflammatory Diseases, Michael E DeBakey VA Medical Center, Houston TX, USA
- Division of Endocrinology, Diabetes, and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - Bryan Jiang
- Center for Translational Research on Inflammatory Diseases, Michael E DeBakey VA Medical Center, Houston TX, USA
- Division of Endocrinology, Diabetes, and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - Arjun Paudyal
- Center for Translational Research on Inflammatory Diseases, Michael E DeBakey VA Medical Center, Houston TX, USA
- Division of Endocrinology, Diabetes, and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - Vijay Nambi
- Center for Translational Research on Inflammatory Diseases, Michael E DeBakey VA Medical Center, Houston TX, USA
- Division of Atherosclerosis and Vascular Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Mon S Bryant
- Center for Translational Research on Inflammatory Diseases, Michael E DeBakey VA Medical Center, Houston TX, USA
- Pulmonary Section, Medical Care Line, Michael E DeBakey VA Medical Center
| | - Marco Marcelli
- Center for Translational Research on Inflammatory Diseases, Michael E DeBakey VA Medical Center, Houston TX, USA
- Division of Endocrinology, Diabetes, and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - Jose M Garcia
- Geriatrics Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA
- Division of Gerontology & Geriatric Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Clifford Qualls
- Department of Mathematics and Statistics, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Dennis T Villareal
- Center for Translational Research on Inflammatory Diseases, Michael E DeBakey VA Medical Center, Houston TX, USA
- Division of Endocrinology, Diabetes, and Metabolism, Baylor College of Medicine, Houston, TX, USA
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Sepu N, Adeleye JO, Kuti MO. Serum testosterone in Nigerian men with type 2 diabetes mellitus and its relationship with insulin sensitivity and glycemic control. J Natl Med Assoc 2021; 113:285-293. [PMID: 33353658 DOI: 10.1016/j.jnma.2020.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 11/10/2020] [Accepted: 11/29/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND There is increasing evidence that testosterone deficiency has key associations with insulin sensitivity and glycemic control. Its presence may therefore contribute to and/or exacerbate clinical disease in men with type 2 diabetes mellitus (T2DM). This study sought to determine the frequency of low free testosterone and explore its relationship with, insulin sensitivity and glycemic control among Nigerian men with T2DM. METHODS One hundred and four men with type 2 DM and one hundred and one apparently healthy non-diabetic men matched for age, were recruited into the study Socio-demographic data, anthropometric measurements and blood samples were obtained for measurement of serum total testosterone (TT), sex hormone binding globulin (SHBG), fasting plasma insulin, fasting plasma glucose (FPG), glycated hemoglobin (HbA1c) and fasting lipid profile in all the subjects. Insulin sensitivity (%IS) and free testosterone (CFT) were then calculated. RESULTS The median CFT for men with T2DM was significantly lower than that of non-diabetic controls (0.17 nmol/L vs 0.58 nmol/L respectively; P < 0.001). 52.9% of men with T2DM had low CFT, as compared with 21.4% amongst the non-diabetic controls; P < 0.001. Among men with T2DM, those with lower CFT had significantly lower median % S and higher mean HbA1c than those with normal CFT (37.0% versus 63.0%; P = 0.021 and 7.79 (2.03) % versus 7.02 (1.94) %; P = 0.038 respectively]. HbA1c had significant negative correlations with both CFT (correlation coefficient: -0.239 (P < 0.05) and TT (correlation coefficient: 0.354; P < 0.01. There was no significant difference in serum lipids when T2DM men with low serum CFT were compared with T2DM men with normal serum CFT levels. CONCLUSION We conclude that low serum testosterone is common among men with T2DM and has a significant association with glycemic control (HbA1c) and insulin sensitivity.
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Affiliation(s)
- Ngamariju Sepu
- Department of Medicine, University College Hospital, Ibadan, Oyo State, Nigeria
| | - Jokotade O Adeleye
- Department of Medicine, College of Medicine, University of Ibadan/University College Hospital, Ibadan, Oyo State, Nigeria.
| | - Modupe O Kuti
- Department of Chemical Pathology, College of Medicine, University of Ibadan/University College Hospital, Ibadan, Oyo State, Nigeria
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Wittert G, Bracken K, Robledo KP, Grossmann M, Yeap BB, Handelsman DJ, Stuckey B, Conway A, Inder W, McLachlan R, Allan C, Jesudason D, Fui MNT, Hague W, Jenkins A, Daniel M, Gebski V, Keech A. Testosterone treatment to prevent or revert type 2 diabetes in men enrolled in a lifestyle programme (T4DM): a randomised, double-blind, placebo-controlled, 2-year, phase 3b trial. Lancet Diabetes Endocrinol 2021; 9:32-45. [PMID: 33338415 DOI: 10.1016/s2213-8587(20)30367-3] [Citation(s) in RCA: 136] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 10/12/2020] [Accepted: 10/12/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Men who are overweight or obese frequently have low serum testosterone concentrations, which are associated with increased risk of type 2 diabetes. We aimed to determine whether testosterone treatment prevents progression to or reverses early type 2 diabetes, beyond the effects of a community-based lifestyle programme. METHODS T4DM was a randomised, double-blind, placebo-controlled, 2-year, phase 3b trial done at six Australian tertiary care centres. Men aged 50-74 years, with a waist circumference of 95 cm or higher, a serum testosterone concentration of 14·0 nmol/L or lower but without pathological hypogonadism, and impaired glucose tolerance (oral glucose tolerance test [OGTT] 2-h glucose 7·8-11·0 mmol/L) or newly diagnosed type 2 diabetes (provided OGTT 2-h glucose ≤15·0 mmol/L) were enrolled in a lifestyle programme and randomly assigned (1:1) to receive an intramuscular injection of testosterone undecanoate (1000 mg) or placebo at baseline, 6 weeks, and then every 3 months for 2 years. Randomisation was done centrally, including stratification by centre, age group, waist circumference, 2-h OGTT glucose, smoking, and first-degree family history of type 2 diabetes. The primary outcomes at 2 years were type 2 diabetes (2-h OGTT glucose ≥11·1 mmol/L) and mean change from baseline in 2-h OGTT glucose, assessed by intention to treat. For safety assessment, we did a masked monitoring of haematocrit and prostate-specific antigen, and analysed prespecified serious adverse events. This study is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12612000287831. FINDINGS Between Feb 5, 2013, and Feb 27, 2017, of 19 022 men who were pre-screened, 1007 (5%) were randomly assigned to the placebo (n=503) and testosterone (n=504) groups. At 2 years, 2-h glucose of 11·1 mmol/L or higher on OGTT was reported in 87 (21%) of 413 participants with available data in the placebo group and 55 (12%) of 443 participants in the testosterone group (relative risk 0·59, 95% CI 0·43 to 0·80; p=0·0007). The mean change from baseline 2-h glucose was -0·95 mmol/L (SD 2·78) in the placebo group and -1·70 mmol/L (SD 2·47) in the testosterone group (mean difference -0·75 mmol/L, -1·10 to -0·40; p<0·0001). The treatment effect was independent of baseline serum testosterone. A safety trigger for haematocrit greater than 54% occurred in six (1%) of 484 participants in the placebo group and 106 (22%) of 491 participants in the testosterone group, and a trigger for an increase of 0·75 μg/mL or more in prostate-specific antigen occurred in 87 (19%) of 468 participants in the placebo group and 109 (23%) of 480 participants in the testosterone group. Prespecified serious adverse events occurred in 37 (7·4%, 95% CI 5·4 to 10·0) of 503 patients in the placebo group and 55 (10·9%, 8·5 to 13·9) of 504 patients in the testosterone group. There were two deaths in each group. INTERPRETATION Testosterone treatment for 2 years reduced the proportion of participants with type 2 diabetes beyond the effects of a lifestyle programme. Increases in haematocrit might be treatment limiting. Longer-term durability, safety, and cardiovascular effects of the intervention remain to be further investigated. FUNDING Australian National Health and Medical Research Council, Bayer, Eli Lilly, University of Adelaide, and WW (formerly Weight Watchers).
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Affiliation(s)
- Gary Wittert
- Freemasons Centre for Male Health and Wellbeing, University of Adelaide, Adelaide, SA, Australia; South Australian Health and Medical Research Institute, Adelaide, SA, Australia.
| | - Karen Bracken
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
| | - Kristy P Robledo
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
| | - Mathis Grossmann
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; Department of Endocrinology, Austin Health, Melbourne, VIC, Australia
| | - Bu B Yeap
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, WA, Australia; Medical School, University of Western Australia, Perth, WA, Australia
| | - David J Handelsman
- ANZAC Research Institute, Concord Hospital, University of Sydney, Sydney, NSW, Australia
| | - Bronwyn Stuckey
- Medical School, University of Western Australia, Perth, WA, Australia; Keogh Institute for Medical Research, Perth, WA, Australia; Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Ann Conway
- ANZAC Research Institute, Concord Hospital, University of Sydney, Sydney, NSW, Australia
| | - Warrick Inder
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Brisbane, QLD, Australia; Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Robert McLachlan
- Hudson Institute of Medical Research and Monash University, Clayton, VIC, Australia
| | - Carolyn Allan
- Hudson Institute of Medical Research and Monash University, Clayton, VIC, Australia
| | - David Jesudason
- Department of Endocrinology, The Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Mark Ng Tang Fui
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; Department of Endocrinology, Austin Health, Melbourne, VIC, Australia
| | - Wendy Hague
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
| | - Alicia Jenkins
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
| | - Mark Daniel
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; Health Research Institute, University of Canberra, Canberra, ACT, Australia
| | - Val Gebski
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
| | - Anthony Keech
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
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Assyov Y, Gateva A, Karamfilova V, Gatev T, Nedeva I, Velikova T, Kamenov ZA. Impact of testosterone treatment on circulating irisin in men with late-onset hypogonadism and metabolic syndrome. Aging Male 2020; 23:1381-1387. [PMID: 32456511 DOI: 10.1080/13685538.2020.1770721] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVES The beneficial effects of testosterone replacement therapy (TRT) in men with late-onset hypogonadism (LOH) on the body composition and metabolic outcomes are well-established. A potential explanation might lie in the hormones, secreted from skeletal muscles, named "myokines". The aim of this study was to evaluate the effects of TRT on the levels of serum irisin in subjects with LOH. STUDY DESIGN A total 40 men with metabolic syndrome (MS) and LOH (measured serum testosterone concentration < 12 nmol/l). TRT with Testosterone Undecanoate (Nebido™) was performed at baseline and at week 6. Irisin serum concentration was determined at baseline and at week 18 by means of ELISA. RESULTS Circulating irisin was positively associated with serum testosterone (r = 0.283, p < 0.05). TRT has led to a statistically significant rise in circulating serum irisin levels (7.12 ± 0.76 mcg/ml versus 7.76 ± 0.75 mcg/ml; paired-samples t-test p < 0.001). ROC-analyses determined irisin to be predictive of treatment response (AUC = 0.741, p = 0.014). CONCLUSIONS Irisin is positively associated with serum testosterone in a population of men with MS and LOH. TRT in these subjects has led to a significant improvement in associated clinical symptoms as well as to a significant rise in serum irisin levels.
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Affiliation(s)
- Yavor Assyov
- Department of Internal Diseases, Medical University of Sofia, Sofia, Bulgaria
| | - Antoaneta Gateva
- Department of Internal Diseases, Medical University of Sofia, Sofia, Bulgaria
| | - Vera Karamfilova
- Department of Internal Diseases, Medical University of Sofia, Sofia, Bulgaria
| | - Tsvetan Gatev
- Department of Internal Diseases, Medical University of Sofia, Sofia, Bulgaria
| | - Iveta Nedeva
- Department of Internal Diseases, Medical University of Sofia, Sofia, Bulgaria
| | - Tsvetelina Velikova
- Department of Clinical Immunology, Lozenetz University Hospital, Sofia, Bulgaria
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Haider KS, Haider A, Saad F, Doros G, Hanefeld M, Dhindsa S, Dandona P, Traish A. Remission of type 2 diabetes following long-term treatment with injectable testosterone undecanoate in patients with hypogonadism and type 2 diabetes: 11-year data from a real-world registry study. Diabetes Obes Metab 2020; 22:2055-2068. [PMID: 32558149 PMCID: PMC7689919 DOI: 10.1111/dom.14122] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/16/2020] [Accepted: 06/16/2020] [Indexed: 12/13/2022]
Abstract
AIMS To investigate whether testosterone therapy (TTh) in men with hypogonadism and type 2 diabetes mellitus (T2DM) improves glycaemic control and insulin sensitivity, and results in remission of T2DM. MATERIAL AND METHODS A total of 356 men who had total testosterone levels ≤12.1 nmol/L (350 ng/dL) and symptoms of hypogonadism were included in the study and followed up for 11 years. All patients received standard diabetes treatment and 178 patients additionally received parenteral testosterone undecanoate 1000 mg every 12 weeks following an initial 6-week interval. A control group comprised 178 hypogonadal patients who opted not to receive TTh. RESULTS Patients with hypogonadism and T2DM treated with testosterone had significant progressive and sustained reductions in fasting glucose, glycated haemoglobin (HbA1c) and fasting insulin over the treatment period. In the control group, fasting glucose, HbA1c and fasting insulin increased. Among the patients treated with testosterone 34.3% achieved remission of their diabetes and 46.6% of patients achieved normal glucose regulation. Of the testosterone-treated group, 83.1% reached the HbA1c target of 47.5 mmol/mol (6.5%) and 90% achieved the HbA1c target of 53.0 mmol/mol (7%). In contrast, no remission of diabetes or reductions in glucose or HbA1c levels were noted in the control group. There were fewer deaths, myocardial infarctions, strokes and diabetic complications in the testosterone-treated group. CONCLUSIONS Long-term TTh in men with T2DM and hypogonadism improves glycaemic control and insulin resistance. Remission of diabetes occurred in one-third of the patients. TTh is potentially a novel additional therapy for men with T2DM and hypogonadism.
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Affiliation(s)
| | | | - Farid Saad
- Consultant to Medical Affairs Andrology, Bayer AGBerlinGermany
- Research DepartmentGulf Medical University School of MedicineAjmanUnited Arab Emirates
| | - Gheorghe Doros
- Department of Epidemiology and BiostatisticsBoston University School of Public HealthBostonMassachusettsUSA
| | - Markolf Hanefeld
- Zentrum für klinische StudienGWT‐TU Dresden GmbHDresdenGermany
- Medizinische Klinik 3Universitätsklinikum Carl Gustav CarusDresdenGermany
| | - Sandeep Dhindsa
- Division of Endocrinology, Diabetes and MetabolismSaint Louis UniversitySt. LouisMissouriUSA
| | - Paresh Dandona
- Division of Endocrinology, Diabetes and MetabolismState University of New York at BuffaloNew YorkUSA
- Internal Medicine ‐ EndocrinologyKaleida HealthBuffaloNew YorkUSA
| | - Abdulmaged Traish
- Department of UrologyBoston University School of MedicineBostonMassachusettsUSA
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Livingston M, Downie P, Hackett G, Marrington R, Heald A, Ramachandran S. An audit of the measurement and reporting of male testosterone levels in UK clinical biochemistry laboratories. Int J Clin Pract 2020; 74:e13607. [PMID: 32649008 DOI: 10.1111/ijcp.13607] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/06/2020] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION A number of guidance documents have been published in recent years for the diagnosis and management of hypogonadism (HG). Laboratory practice has a major role in supporting guidelines with accurate and precise serum total testosterone (TT) methods and standardised pre- and post-analytical protocols. Our study investigated whether laboratory practice currently supports the management guidelines for HG. METHODS An internet-based questionnaire survey of senior laboratory biochemists (UK/Republic of Ireland) was conducted (April-May 2018). Questions reflected sampling, laboratory practice, reference ranges and reporting of results. The results were analysed in conjunction with data obtained from the UK National External Quality Assurance Service (UK NEQAS) on testosterone assay performance. RESULTS Analyses of 96 laboratory surveys returned the following: 74 laboratories stated that the optimal sampling time was communicated to users; 81 laboratories used immunoassays; 76 laboratories included reference ranges for adult men (31 had dual/multiple age-related intervals). Wide variability in lower/upper limits was evident in the common immunoassays; the majority of reference ranges were from manufacturers (50.0%) or historical (18.8%). Action limits based on TT levels were used by 64 laboratories, but 63 did not report a borderline range as suggested by the guidelines. Protocols for cascading tests based on TT were evident in 58 laboratories, with 50 laboratories offering estimated free testosterone; interpretative comments were provided by 67 laboratories, but no references were made to the management guidelines. Data from UK NEQAS demonstrated considerable variation in testosterone assay performance. CONCLUSIONS Our survey has highlighted inconsistencies that could lead to HG (and other conditions requiring measurement of TT) not being managed appropriately. The results from this survey and from UK NEQAS reinforce the requirement for action to be considered regarding the standardisation of testosterone assays and harmonisation of laboratory practice.
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Affiliation(s)
- Mark Livingston
- Department of Clinical Biochemistry, Black Country Pathology Services, Walsall Manor Hospital, Walsall, UK
- The School of Medicine and Clinical Practice & Department of Biomedical Science and Physiology, The University of Wolverhampton, Wolverhampton, UK
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Paul Downie
- Department of Clinical Biochemistry, Bristol Royal Infirmary, Bristol, UK
| | - Geoff Hackett
- School of Health and Life Sciences, Aston University, Birmingham, UK
| | - Rachel Marrington
- Birmingham Quality (UK NEQAS) University Hospitals NHS Foundation Trust, Birmingham, UK
| | - Adrian Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
- Department of Endocrinology and Diabetes, Salford Royal Hospital, Manchester, UK
| | - Sudarshan Ramachandran
- Department of Clinical Biochemistry, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Clinical Biochemistry, University Hospitals of North Midlands, Stoke-on-Trent, UK
- Institute of Science and Technology, Keele University, Keele, UK
- Faculty of Health Sciences, Staffordshire University, Staffordshire, UK
- College of Engineering, Design and Physical Sciences, Brunel University London, London, UK
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19
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Kirlangic OF, Yilmaz-Oral D, Kaya-Sezginer E, Toktanis G, Tezgelen AS, Sen E, Khanam A, Oztekin CV, Gur S. The Effects of Androgens on Cardiometabolic Syndrome: Current Therapeutic Concepts. Sex Med 2020; 8:132-155. [PMID: 32201216 PMCID: PMC7261691 DOI: 10.1016/j.esxm.2020.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 01/31/2020] [Accepted: 02/11/2020] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Cardiometabolic syndrome (CMS), as a bunch of metabolic disorders mainly characterized by type 2 diabetes mellitus (T2DM), hypertension, atherosclerosis, central adiposity, and abdominal obesity triggering androgen deficiency, is one of the most critical threats to men. Although many significant preclinical and clinical findings explain CMS, new approaches toward common pathophysiological mechanisms and reasonable therapeutic targets are lacking. AIM To gain a further understanding of the role of androgen levels in various facets of CMS such as the constellation of cardiometabolic risk factors including central adiposity, dyslipidemia, insulin resistance, diabetes, and arterial hypertension and to define future directions for development of effective therapeutic modalities. METHODS Clinical and experimental data were searched through scientific literature databases (PubMed) from 2009 to October 2019. MAIN OUTCOME MEASURE Evidence from basic and clinical research was gathered with regard to the causal impact and therapeutic roles of androgens on CMS. RESULTS There are important mechanisms implicated in androgen levels and the risk of CMS. Low testosterone levels have many signs and symptoms on cardiometabolic and glycometabolic risks as well as abdominal obesity in men. CLINICAL IMPLICATIONS The implications of the findings can shed light on future improvements in androgen levels and add potentially predictive risk for CMS, as well as T2DM, abdominal obesity to guide clinical management in the early stage. STRENGTHS & LIMITATIONS This comprehensive review refers to the association between androgens and cardiovascular health. A limitation of this study is the lack of large, prospective population-based studies that analyze the effects of testosterone treatment on CMS or mortality. CONCLUSION Low testosterone levels have several common features with metabolic syndrome. Thus, testosterone may have preventive role in the progress of metabolic syndrome and subsequent T2DM, abdominal obesity, and cardiovascular disease and likely affect aging men's health mainly through endocrine and vascular mechanisms. Further studies are necessary to evaluate the therapeutic interventions directed at preventing CMS in men. Kirlangic OF, Yilmaz-Oral D, Kaya-Sezginer E, et al. The Effects of Androgens on Cardiometabolic Syndrome: Current Therapeutic Concepts. Sex Med 2020;8:132-155.
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Affiliation(s)
- Omer Faruk Kirlangic
- University of Health Sciences, Gulhane Faculty of Medicine, Department of Medical Biochemistry, Ankara, Turkey
| | - Didem Yilmaz-Oral
- Cukurova University, Faculty of Pharmacy, Department of Pharmacology, Adana, Turkey
| | - Ecem Kaya-Sezginer
- Ankara University, Faculty of Pharmacy, Department of Biochemistry, Ankara, Turkey
| | - Gamze Toktanis
- Ankara University, Faculty of Pharmacy, Department of Pharmacology, Ankara, Turkey
| | | | - Ekrem Sen
- Ankara University, Faculty of Pharmacy, Department of Pharmacology, Ankara, Turkey
| | - Armagan Khanam
- Ankara University, Faculty of Pharmacy, Department of Pharmacology, Ankara, Turkey
| | - Cetin Volkan Oztekin
- Department of Urology, Faculty of Medicine, University of Kyrenia, Girne, Turkish Republic of North Cyprus, Mersin 10, Turkey
| | - Serap Gur
- Ankara University, Faculty of Pharmacy, Department of Pharmacology, Ankara, Turkey.
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Tatem AJ, Holland LC, Kovac J, Beilan JA, Lipshultz LI. Nandrolone decanoate relieves joint pain in hypogonadal men: a novel prospective pilot study and review of the literature. Transl Androl Urol 2020; 9:S186-S194. [PMID: 32257859 PMCID: PMC7108994 DOI: 10.21037/tau.2019.11.03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Testosterone is an archetypal androgenic-anabolic steroid (AAS), while its exogenous administration is considered to be the gold standard for the treatment of male hypogonadism. The benefits are not due to its intrinsic nature alone but are due to the result of its interactions with the androgen receptor (AR). As the management of hypogonadism continues to advance into the modern era, it would be preferable for modern andrologists to have multiple tools at their disposal to influence AR activity. Nandrolone, or 19-nortestosterone, is one such compound. In the following review of the literature, we examine the history, pharmacology, and clinical applications of this medication. We also present the results of our novel pilot study examining the favorable effects of nandrolone on joint pain for hypogonadal men.
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Affiliation(s)
| | - Levi C Holland
- McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - Jason Kovac
- Men's Health Center, Urology of Indiana, Greenwood, IN, USA
| | | | - Larry I Lipshultz
- Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
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21
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Differential effects of 11 years of long-term injectable testosterone undecanoate therapy on anthropometric and metabolic parameters in hypogonadal men with normal weight, overweight and obesity in comparison with untreated controls: real-world data from a controlled registry study. Int J Obes (Lond) 2020; 44:1264-1278. [PMID: 32060355 PMCID: PMC7260126 DOI: 10.1038/s41366-019-0517-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 11/18/2019] [Accepted: 12/11/2019] [Indexed: 01/08/2023]
Abstract
Background and significance Obesity is a chronic disease, warranting long-term medical intervention. We evaluated effects of testosterone (T) therapy (Th) in men with T deficiency with normal weight, overweight and obesity on anthropometric and metabolic parameters, compared with untreated men. Methods Hypogonadal men (n = 823) with total T ≤ 12.1 nmol/L (age: 60.6 ± 7.0 years) participated in an ongoing registry study. Among these men 474 (57.6%) were obese, 286 (34.8%) overweight and 63 (7.7%) had normal weight. T undecanoate injections were administered to 428 men and 395 remained untreated. Anthropometric and metabolic parameters were measured at least twice a year and changes adjusted for confounding factors to account for baseline differences between groups. Results Long-term TTh in hypogonadal men, irrespective of weight at baseline, produced improvements in body weight, waist circumference (WC) and body mass index (BMI). Furthermore, TTh decreased fasting blood glucose and HbA1c and improved lipid profiles. Gradual decreases in blood pressure (systolic and diastolic) and pulse pressure occurred in men treated with T in each group. Marked reductions in mortality and major cardiovascular events were recorded in men receiving TTh. Conclusions Our findings demonstrate that TTh produces reductions in weight, WC, and BMI. There were 77 (19.5%) deaths in the untreated groups and 23 (5.4%) in the T-groups. Based on these findings we suggest that long-term TTh in overweight and obese hypogonadal men produces progressive and sustained clinically meaningful weight loss and that TTh may contribute to reductions in mortality and incident major adverse cardiovascular events.
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22
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Diem SJ, Greer NL, MacDonald R, McKenzie LG, Dahm P, Ercan-Fang N, Estrada A, Hemmy LS, Rosebush CE, Fink HA, Wilt TJ. Efficacy and Safety of Testosterone Treatment in Men: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians. Ann Intern Med 2020; 172:105-118. [PMID: 31905375 DOI: 10.7326/m19-0830] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Testosterone treatment rates in adult men have increased in the United States over the past 2 decades. PURPOSE To assess the benefits and harms of testosterone treatment for men without underlying organic causes of hypogonadism. DATA SOURCES English-language searches of multiple electronic databases (January 1980 to May 2019) and reference lists from systematic reviews. STUDY SELECTION 38 randomized controlled trials (RCTs) of at least 6 months' duration that evaluated transdermal or intramuscular testosterone therapies versus placebo or no treatment and reported prespecified patient-centered outcomes, as well as 20 long-term observational studies, U.S. Food and Drug Administration review data, and product labels that reported harms information. DATA EXTRACTION Data extraction by a single investigator was confirmed by a second, 2 investigators assessed risk of bias, and evidence certainty was determined by consensus. DATA SYNTHESIS Studies enrolled mostly older men who varied in age, symptoms, and testosterone eligibility criteria. Testosterone therapy improved sexual functioning and quality of life in men with low testosterone levels, although effect sizes were small (low- to moderate-certainty evidence). Testosterone therapy had little to no effect on physical functioning, depressive symptoms, energy and vitality, or cognition. Harms evidence reported in trials was judged to be insufficient or of low certainty for most harm outcomes. No trials were powered to assess cardiovascular events or prostate cancer, and trials often excluded men at increased risk for these conditions. Observational studies were limited by confounding by indication and contraindication. LIMITATION Few trials exceeded a 1-year duration, minimum important outcome differences were often not established or reported, RCTs were not powered to assess important harms, few data were available in men aged 18 to 50 years, definitions of low testosterone varied, and study entry criteria varied. CONCLUSION In older men with low testosterone levels without well-established medical conditions known to cause hypogonadism, testosterone therapy may provide small improvements in sexual functioning and quality of life but little to no benefit for other common symptoms of aging. Long-term efficacy and safety are unknown. PRIMARY FUNDING SOURCE American College of Physicians. (PROSPERO: CRD42018096585).
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Affiliation(s)
- Susan J Diem
- Minneapolis VA Health Care System and University of Minnesota School of Medicine, Minneapolis, Minnesota (S.J.D., P.D., N.E., A.E., L.S.H., H.A.F., T.J.W.)
| | - Nancy L Greer
- Minneapolis VA Health Care System, Minneapolis, Minnesota (N.L.G., R.M., L.G.M.)
| | - Roderick MacDonald
- Minneapolis VA Health Care System, Minneapolis, Minnesota (N.L.G., R.M., L.G.M.)
| | - Lauren G McKenzie
- Minneapolis VA Health Care System, Minneapolis, Minnesota (N.L.G., R.M., L.G.M.)
| | - Philipp Dahm
- Minneapolis VA Health Care System and University of Minnesota School of Medicine, Minneapolis, Minnesota (S.J.D., P.D., N.E., A.E., L.S.H., H.A.F., T.J.W.)
| | - Nacide Ercan-Fang
- Minneapolis VA Health Care System and University of Minnesota School of Medicine, Minneapolis, Minnesota (S.J.D., P.D., N.E., A.E., L.S.H., H.A.F., T.J.W.)
| | - Allison Estrada
- Minneapolis VA Health Care System and University of Minnesota School of Medicine, Minneapolis, Minnesota (S.J.D., P.D., N.E., A.E., L.S.H., H.A.F., T.J.W.)
| | - Laura S Hemmy
- Minneapolis VA Health Care System and University of Minnesota School of Medicine, Minneapolis, Minnesota (S.J.D., P.D., N.E., A.E., L.S.H., H.A.F., T.J.W.)
| | - Christina E Rosebush
- Minneapolis VA Health Care System and University of Minnesota School of Public Health, Minneapolis, Minnesota (C.E.R.)
| | - Howard A Fink
- Minneapolis VA Health Care System and University of Minnesota School of Medicine, Minneapolis, Minnesota (S.J.D., P.D., N.E., A.E., L.S.H., H.A.F., T.J.W.)
| | - Timothy J Wilt
- Minneapolis VA Health Care System and University of Minnesota School of Medicine, Minneapolis, Minnesota (S.J.D., P.D., N.E., A.E., L.S.H., H.A.F., T.J.W.)
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23
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The Complex Relationship Between Erectile Dysfunction and Hypogonadism in Diabetes Mellitus. CURRENT SEXUAL HEALTH REPORTS 2019. [DOI: 10.1007/s11930-019-00216-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Ramachandran S, Hackett GI, Strange RC. Sex Hormone Binding Globulin: A Review of its Interactions With Testosterone and Age, and its Impact on Mortality in Men With Type 2 Diabetes. Sex Med Rev 2019; 7:669-678. [DOI: 10.1016/j.sxmr.2019.06.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 06/04/2019] [Accepted: 06/11/2019] [Indexed: 12/12/2022]
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Yassin A, Haider A, Haider KS, Caliber M, Doros G, Saad F, Garvey WT. Testosterone Therapy in Men With Hypogonadism Prevents Progression From Prediabetes to Type 2 Diabetes: Eight-Year Data From a Registry Study. Diabetes Care 2019; 42:1104-1111. [PMID: 30862651 DOI: 10.2337/dc18-2388] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 02/18/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Type 2 diabetes (T2D) is a public health threat. Prediabetes represents a window of opportunity for intervention to prevent T2D. Men with T2D and prediabetes often have low testosterone. Since testosterone improves glycemic control in T2D, we investigated whether testosterone therapy (TTh) in men with hypogonadism and prediabetes prevents progression to T2D. RESEARCH DESIGN AND METHODS Three hundred and sixteen men with prediabetes (defined as HbA1c 5.7-6.4%) and total testosterone levels ≤12.1 nmol/L combined with symptoms of hypogonadism were analyzed. Two hundred and twenty-nine men received parenteral testosterone undecanoate (T-group), and 87 men with hypogonadism served as untreated control subjects. Metabolic and anthropometric parameters were measured twice yearly for 8 years. RESULTS HbA1c decreased by 0.39 ± 0.03% (P < 0.0001) in the T-group and increased by 0.63 ± 0.1% (P < 0.0001) in the untreated group. In the T-group, 90% achieved normal glucose regulation (HbA1c <5.7%). In the untreated group, 40.2% progressed to T2D (HbA1c >6.5%). TTh was also associated with significant improvements in fasting glucose, triglyceride:HDL ratio, triglyceride-glucose index, lipid accumulation product, total cholesterol, LDL, HDL, non-HDL, triglycerides, and Aging Males' Symptoms (AMS) scale. Significant deterioration in all these parameters was seen in the untreated group. Mortality was 7.4% in the T-group and 16.1% in the untreated group (P < 0.05). The incidence of nonfatal myocardial infarction was 0.4% in the T-group and 5.7% in the untreated group (P < 0.005). CONCLUSIONS Long-term TTh completely prevents prediabetes progression to T2D in men with hypogonadism and improves glycemia, lipids, and AMS score. TTh holds tremendous potential for the large and growing population of men with prediabetes and hypogonadism.
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Affiliation(s)
- Aksam Yassin
- Institute for Urology and Andrology, Norderstedt, Germany.,Dresden International University, Dresden, Germany.,Division of Urology/Andrology, Department of Surgery, Hamad Medical Corporation, Doha, Qatar
| | | | | | - Monica Caliber
- American Medical Writers Association, Fort Lauderdale, FL
| | - Gheorghe Doros
- Department of Epidemiology and Statistics, Boston University School of Public Health, Boston, MA
| | - Farid Saad
- Medical Affairs Andrology, Bayer AG, Berlin, Germany .,Gulf Medical University School of Medicine, Ajman, United Arab Emirates
| | - W Timothy Garvey
- Department of Nutrition Sciences, University of Alabama at Birmingham and the Birmingham VA Medical Center, Birmingham, AL
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König CS, Balabani S, Hackett GI, Strange RC, Ramachandran S. Testosterone Therapy: An Assessment of the Clinical Consequences of Changes in Hematocrit and Blood Flow Characteristics. Sex Med Rev 2019; 7:650-660. [PMID: 30926458 DOI: 10.1016/j.sxmr.2019.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/19/2019] [Accepted: 01/23/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Clinical guidelines indicate that hematocrit should be monitored during testosterone replacement therapy (TTh), with action taken if a level of 0.54 is exceeded. AIM To consider the extent of changes in hematocrit and putative effects on viscosity, blood flow, and mortality rates after TTh. METHODS We focused on literature describing benefits and possible pitfalls of TTh, including increased hematocrit. We used data from the BLAST RCT to determine change in hematocrit after 30 weeks of TTh and describe a clinical case showing the need for monitoring. We consider the validity of the current hematocrit cutoff value at which TTh may be modified. Ways in which hematocrit alters blood flow in the micro- and macro-vasculature are also considered. MAIN OUTCOME MEASURES The following measures were assessed: (i) change in hematocrit, (ii) corresponding actions taken in clinical practice, and (iii) possible blood flow changes following change in hematocrit. RESULTS Analysis of data from the BLAST RCT showed a significant increase in mean hematocrit of 0.01, the increase greater in men with lower baseline values. Although 0 of 61 men given TTh breached the suggested cutoff of 0.54 after 30 weeks, a clinical case demonstrates the need to monitor hematocrit. An association between hematocrit and morbidity and mortality appears likely but not proven and may be evident only in patient subgroups. The consequences of an increased hematocrit may be mediated by alterations in blood viscosity, oxygen delivery, and flow. Their relative impact may vary in different vascular beds. CONCLUSIONS TTh can effect an increased hematocrit via poorly understood mechanisms and may have harmful effects on blood flow that differ in patient subgroups. At present, there appears no scientific basis for using a hematocrit of 0.54 to modify TTh; other values may be more appropriate in particular patient groups. König CS, Balabani S, Hackett GI, et al. Testosterone Therapy: An Assessment of the Clinical Consequences of Changes in Hematocrit and Blood Flow Characteristics. Sex Med Rev 2019;7:650-660.
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Affiliation(s)
- Carola S König
- College of Engineering, Design & Physical Sciences, Brunel University, London, England, United Kingdom
| | - Stavroula Balabani
- Faculty of Engineering Sciences, University College London, London, United Kingdom
| | - Geoffrey I Hackett
- Department of Urology, University Hospitals Birmingham NHS Foundation Trust, West Midlands, England, United Kingdom
| | - Richard C Strange
- Institute for Science and Technology in Medicine, Keele University, Staffordshire, England, United Kingdom
| | - Sudarshan Ramachandran
- College of Engineering, Design & Physical Sciences, Brunel University, London, England, United Kingdom; Department of Clinical Biochemistry, University Hospitals Birmingham NHS Foundation Trust, West Midlands, England, United Kingdom; Department of Clinical Biochemistry, University Hospitals of North Midlands / Faculty of Health Sciences, Staffordshire University, Staffordshire, England, United Kingdom.
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Do Androgens Modulate the Pathophysiological Pathways of Inflammation? Appraising the Contemporary Evidence. J Clin Med 2018; 7:jcm7120549. [PMID: 30558178 PMCID: PMC6306858 DOI: 10.3390/jcm7120549] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 12/09/2018] [Accepted: 12/11/2018] [Indexed: 12/20/2022] Open
Abstract
The role of testosterone in the pathophysiology of inflammation is of critical clinical importance; however, no universal mechanism(s) has been advanced to explain the complex and interwoven pathways of androgens in the attenuation of the inflammatory processes. PubMed and EMBASE searches were performed, including the following key words: "testosterone", "androgens", "inflammatory cytokines", "inflammatory biomarkers" with focus on clinical studies as well as basic scientific studies in human and animal models. Significant benefits of testosterone therapy in ameliorating or attenuating the symptoms of several chronic inflammatory diseases were reported. Because anti⁻tumor necrosis factor therapy is the mainstay for the treatment of moderate-to-severe inflammatory bowel disease; including Crohn's disease and ulcerative colitis, and because testosterone therapy in hypogonadal men with chronic inflammatory conditions reduce tumor necrosis factor-alpha (TNF-α), IL-1β, and IL-6, we suggest that testosterone therapy attenuates the inflammatory process and reduces the burden of disease by mechanisms inhibiting inflammatory cytokine expression and function. Mechanistically, androgens regulate the expression and function of inflammatory cytokines, including TNF-α, IL-1β, IL-6, and CRP (C-reactive protein). Here, we suggest that testosterone regulates multiple and overlapping cellular and molecular pathways involving a host of immune cells and biochemical factors that converge to contribute to attenuation of the inflammatory process.
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