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Fayzullin A, Bakulina A, Mikaelyan K, Shekhter A, Guller A. Implantable Drug Delivery Systems and Foreign Body Reaction: Traversing the Current Clinical Landscape. Bioengineering (Basel) 2021; 8:bioengineering8120205. [PMID: 34940358 PMCID: PMC8698517 DOI: 10.3390/bioengineering8120205] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/03/2021] [Accepted: 12/06/2021] [Indexed: 01/02/2023] Open
Abstract
Precise delivery of therapeutics to the target structures is essential for treatment efficiency and safety. Drug administration via conventional routes requires overcoming multiple transport barriers to achieve and maintain the local drug concentration and commonly results in unwanted off-target effects. Patients’ compliance with the treatment schedule remains another challenge. Implantable drug delivery systems (IDDSs) provide a way to solve these problems. IDDSs are bioengineering devices surgically placed inside the patient’s tissues to avoid first-pass metabolism and reduce the systemic toxicity of the drug by eluting the therapeutic payload in the vicinity of the target tissues. IDDSs present an impressive example of successful translation of the research and engineering findings to the patient’s bedside. It is envisaged that the IDDS technologies will grow exponentially in the coming years. However, to pave the way for this progress, it is essential to learn lessons from the past and present of IDDSs clinical applications. The efficiency and safety of the drug-eluting implants depend on the interactions between the device and the hosting tissues. In this review, we address this need and analyze the clinical landscape of the FDA-approved IDDSs applications in the context of the foreign body reaction, a key aspect of implant–tissue integration.
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Affiliation(s)
- Alexey Fayzullin
- Department of Experimental Morphology and Biobanking, Institute for Regenerative Medicine, Sechenov First Moscow State Medical University (Sechenov University), 119991 Moscow, Russia; (A.F.); (A.B.); (K.M.); (A.S.)
- World-Class Research Center “Digital Biodesign and Personalized Healthcare”, Sechenov First Moscow State Medical University (Sechenov University), 119991 Moscow, Russia
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW 2109, Australia
| | - Alesia Bakulina
- Department of Experimental Morphology and Biobanking, Institute for Regenerative Medicine, Sechenov First Moscow State Medical University (Sechenov University), 119991 Moscow, Russia; (A.F.); (A.B.); (K.M.); (A.S.)
| | - Karen Mikaelyan
- Department of Experimental Morphology and Biobanking, Institute for Regenerative Medicine, Sechenov First Moscow State Medical University (Sechenov University), 119991 Moscow, Russia; (A.F.); (A.B.); (K.M.); (A.S.)
- World-Class Research Center “Digital Biodesign and Personalized Healthcare”, Sechenov First Moscow State Medical University (Sechenov University), 119991 Moscow, Russia
| | - Anatoly Shekhter
- Department of Experimental Morphology and Biobanking, Institute for Regenerative Medicine, Sechenov First Moscow State Medical University (Sechenov University), 119991 Moscow, Russia; (A.F.); (A.B.); (K.M.); (A.S.)
| | - Anna Guller
- Department of Experimental Morphology and Biobanking, Institute for Regenerative Medicine, Sechenov First Moscow State Medical University (Sechenov University), 119991 Moscow, Russia; (A.F.); (A.B.); (K.M.); (A.S.)
- World-Class Research Center “Digital Biodesign and Personalized Healthcare”, Sechenov First Moscow State Medical University (Sechenov University), 119991 Moscow, Russia
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW 2109, Australia
- Biomolecular Discovery Research Centre, Macquarie University, Sydney, NSW 2109, Australia
- Correspondence:
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Pastuszak AW, Gittelman M, Tursi JP, Jaffe JS, Schofield D, Miner MM. Pharmacokinetics of testosterone therapies in relation to diurnal variation of serum testosterone levels as men age. Andrology 2021; 10:209-222. [PMID: 34510812 PMCID: PMC9293229 DOI: 10.1111/andr.13108] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 08/09/2021] [Accepted: 08/24/2021] [Indexed: 12/18/2022]
Abstract
Background To improve symptoms associated with testosterone deficiency, many testosterone therapies are available that aim to restore serum testosterone (T) levels to the normal physiologic range. The magnitude, frequency, and duration between peak and trough T concentrations vary with route of administration, and none reflect normal endogenous daily diurnal T variations. Objective To compare pharmacokinetic profiles of serum T from approved T formulations with endogenous diurnal T variations in young and older men, and to consider whether there may be value in mimicking the diurnal T rhythmicity with exogenous testosterone therapies as men age. Materials and methods A literature search of studies examining the diurnal variation of endogenous T in healthy men and men with testosterone deficiency was performed using PubMed in January 2020. Additional searches for serum T pharmacokinetic profiles of various testosterone therapy formulations were also conducted. Prescribing information for various T formulations was also reviewed. Discussion and conclusion Endogenous diurnal T variation is well described and appears to be blunted naturally as men age. Men with testosterone deficiency lack diurnal T variation and exhibit a flatter T profile compared with eugonadal men. Some T replacement options provide intraday T level variations similar to normal circadian secretion, and others provide a flatter exposure profile reflective of depot release. Others provide profiles that exceed the frequency and physiologic range of the natural diurnal variation of T. All exogenous T replacement dosing targets an increase in average T levels to within the normal physiologic range and improves symptoms associated with low T, but no single testosterone therapy can exactly mimic the normal diurnal T patterns seen in younger men and the blunted circadian T secretion of older men.
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Affiliation(s)
| | - Marc Gittelman
- 21st Century Oncology, Uro-Medix/GenesisCare, Aventura, Florida, USA
| | | | | | | | - Martin M Miner
- Men's Health Center, Miriam Hospital, Providence, Rhode Island, USA
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3
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Griggs J, Almohanna H, Ahmed A, Tosti A. New-Onset Androgenic Alopecia following Human Chorionic Gonadotropic Diet and Testosterone Pellet Implantation. Int J Trichology 2019; 10:284-285. [PMID: 30783337 PMCID: PMC6369644 DOI: 10.4103/ijt.ijt_75_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A diet involving human chorionic gonadotropic (hCG) injections combined with extreme caloric restriction is sometimes undertaken by people desiring rapid weight loss. We report a patient with new-onset androgenic alopecia following hCG diet combined with the implantation of testosterone pellets.
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Affiliation(s)
- Jacob Griggs
- Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Hind Almohanna
- Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Azhar Ahmed
- Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Antonella Tosti
- Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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McFarland J, Craig W, Clarke NJ, Spratt DI. Serum Testosterone Concentrations Remain Stable Between Injections in Patients Receiving Subcutaneous Testosterone. J Endocr Soc 2017; 1:1095-1103. [PMID: 29264562 PMCID: PMC5686655 DOI: 10.1210/js.2017-00148] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 07/18/2017] [Indexed: 01/05/2023] Open
Abstract
Purpose: Intramuscular (IM) testosterone is the most common modality for testosterone therapy of both male hypogonadism and female-to-male (FTM) gender transition. However, IM injections can be painful and often are not self-administered by the patient. The objective of this study was to further characterize subcutaneous (SC) administration of testosterone as an effective and safe alternative to IM injections by evaluating the pharmacodynamics of serum total and free testosterone concentrations between weekly testosterone injections. Methods: Eleven FTM transgender patients already receiving weekly SC testosterone cypionate with documented therapeutic levels prior to enrollment had free and total serum testosterone levels measured at eight different time points during a 1-week dosing interval. Results: Mean levels of total and free testosterone were stable and remained well within the normal range between injections. Overall mean ± standard deviation levels for the seven samples taken between injections were 627 ± 206 ng/dL (range, 205 to 1410) for total testosterone and 146 ± 51 pg/mL (range, 38 to 348) for free testosterone. No adverse effects were encountered. Conclusions: The results of this study support use of SC testosterone to achieve therapeutic and stable serum testosterone levels for the purpose of gender transition. It is anticipated that these results can be extended to hypogonadal men. This route may be preferred over IM testosterone because it is relatively painless and easy to self-inject thus allowing for the convenience and economy of patient self-administration.
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Affiliation(s)
- Julie McFarland
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Maine Medical Center, Portland, Maine 04102
| | - Wendy Craig
- Maine Medical Center Research Institute, Scarborough, Maine 04074
| | | | - Daniel I Spratt
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Maine Medical Center, Portland, Maine 04102
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Spratt DI, Stewart II, Savage C, Craig W, Spack NP, Chandler DW, Spratt LV, Eimicke T, Olshan JS. Subcutaneous Injection of Testosterone Is an Effective and Preferred Alternative to Intramuscular Injection: Demonstration in Female-to-Male Transgender Patients. J Clin Endocrinol Metab 2017; 102:2349-2355. [PMID: 28379417 DOI: 10.1210/jc.2017-00359] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 03/29/2017] [Indexed: 02/04/2023]
Abstract
CONTEXT Testosterone (T) is commonly administered intramuscularly to treat hypogonadal males and female-to-male (FTM) transgender patients. However, these injections can involve significant discomfort and may require arrangements for administration by others. OBJECTIVE We assessed whether T could be administered effectively and safely subcutaneously as an alternative to intramuscular (IM) injections. DESIGN Retrospective cohort study. SETTING Outpatient reproductive endocrinology clinic at an academic medical center. PATIENTS Sixty-three FTM transgender patients aged >18 years electing to receive subcutaneous (SC) T therapy for sex transition were included. Fifty-three patients were premenopausal. INTERVENTION Patients were administered T cypionate or enanthate weekly at an initial dose of 50 mg. Dose was adjusted if needed to achieve serum total T levels within the normal male range. MAIN OUTCOME MEASUREMENTS Serum concentrations of free and total T and total estradiol (E2), masculinization, and surveillance for reactions at injection sites. RESULTS Serum T levels within the normal male range were achieved in all 63 patients with doses of 50 to 150 mg (median, 75/80 mg). Therapy was effective across a wide range of body mass index (19.0 to 49.9 kg/m2). Minor and transient local reactions were reported in 9 out of 63 patients. Among 53 premenopausal patients, 51 achieved amenorrhea and 35 achieved serum E2 concentrations <50 pg/mL. Twenty-two patients were originally receiving IM and switched to SC therapy. All 22 had a mild (n = 2) or marked (n = 20) preference for SC injections; none preferred IM injections. CONCLUSIONS Our observations indicate that SC T injections are an effective, safe, and well-accepted alternative to IM T injections.
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Affiliation(s)
- Daniel I Spratt
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Maine Medical Center, Portland, Maine 04102
| | - India I Stewart
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Maine Medical Center, Portland, Maine 04102
| | - Clara Savage
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Maine Medical Center, Portland, Maine 04102
| | - Wendy Craig
- Maine Medical Center Research Institute, Scarborough, Maine 04704
| | - Norman P Spack
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts 02115
| | | | - Lindsey V Spratt
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Maine Medical Center, Portland, Maine 04102
| | - Toni Eimicke
- Department of Pediatrics, Division of Pediatric Endocrinology, Maine Medical Center, Portland, Maine 04102
| | - Jerrold S Olshan
- Department of Pediatrics, Division of Pediatric Endocrinology, Maine Medical Center, Portland, Maine 04102
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Abstract
The treatment of hypogonadism in men is of great interest to both patients and providers. There are a number of testosterone formulations currently available and several additional formulations under development. In addition, there are some lesser-used alternative therapies for the management of male hypogonadism, which may have advantages for certain patient groups. The future of hypogonadism therapy may lie in the development of selective androgen receptor modulators that allow the benefits of androgens whilst minimizing unwanted side effects.
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Affiliation(s)
- Arthi Thirumalai
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Kathryn E Berkseth
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, WA, USA
| | - John K Amory
- Center for Research in Reproduction and Contraception, Department of Medicine, University of Washington, Seattle, WA, USA
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Hayden RP, Bennett NE, Tanrikut C. Hematocrit Response and Risk Factors for Significant Hematocrit Elevation with Implantable Testosterone Pellets. J Urol 2016; 196:1715-1720. [DOI: 10.1016/j.juro.2016.05.110] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2016] [Indexed: 12/23/2022]
Affiliation(s)
- Russell P. Hayden
- Department of Urology, Massachusetts General Hospital, Boston, Massachusetts
| | - Nelson E. Bennett
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Cigdem Tanrikut
- Department of Urology, Massachusetts General Hospital, Boston, Massachusetts
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Berkseth KE, Thirumalai A, Amory JK. Pharmacologic Therapy in Men's Health: Hypogonadism, Erectile Dysfunction, and Benign Prostatic Hyperplasia. Med Clin North Am 2016; 100:791-805. [PMID: 27235615 PMCID: PMC5639879 DOI: 10.1016/j.mcna.2016.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
This article reviews current pharmacologic treatment options for 3 common men's health concerns: hypogonadism, erectile dysfunction (ED), and benign prostatic hyperplasia (BPH). Specific topics addressed include: management of male hypogonadism using testosterone replacement therapy, use of oral phosphodiesterase inhibitors as first-line therapy for men with ED and the utility of intraurethral and intrapenile alprostadil injections for patients who do not respond to oral medications, and the role of alpha1-adrenergic antagonists, 5-alpha-reductase inhibitors, anticholinergic agents, and herbal therapies in the management of BPH.
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Affiliation(s)
- Kathryn E Berkseth
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, 1959 Northeast Pacific Street, Box 356426, Seattle, WA 98195, USA.
| | - Arthi Thirumalai
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, 1959 Northeast Pacific Street, HSB C-209, UW Box# 357138, Seattle, WA 98195, USA
| | - John K Amory
- Department of Medicine, University of Washington, 4245 Roosevelt Way Northeast, Box #354760, Seattle, WA 98105, USA
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10
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Abstract
Testosterone supplementation therapy (TST) use has dramatically increased over the past decade, due to the availability of newer agents, aggressive marketing, and an increasing incidence of testosterone deficiency (TD). Despite the increase in TST, a degree of ambiguity remains as to the exact diagnostic criteria of TD, and administration and monitoring of TST. One explanation for this phenomenon is the complex role testosterone plays in multiple physiologic pathways. Numerous medical co-morbidities and medications can alter testosterone levels resulting in a wide range of nonspecific clinical signs and symptoms of TD. The diagnosis is also challenging due to the lack of a definitive serum total testosterone level that reliably correlates with symptoms. This observation is particularly true in the aging male and is exacerbated by inconsistencies between different laboratory assays. Several prominent medical societies have developed guideline statements to clarify the diagnosis, but they differ from each other and with expert opinion in several ways. Aside from diagnostic dilemmas, there are numerous subtle advantages and disadvantages of the various testosterone agents to appreciate. The available TST agents have changed significantly over the past decade similar to the trends in the diagnosis of TD. Therefore, as the usage of TST increases, clinicians will be challenged to maintain an up-to-date understanding of TD and TST. The purpose of this review is to provide a clear description of the current strategies for diagnosis and management of TD.
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Affiliation(s)
| | | | - Robert M Coward
- Department of Urology, University of North Carolina School of Medicine, NC, USA
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Ferrati S, Nicolov E, Zabre E, Geninatti T, Shirkey BA, Hudson L, Hosali S, Crawley M, Khera M, Palapattu G, Grattoni A. The Nanochannel Delivery System for Constant Testosterone Replacement Therapy. J Sex Med 2015; 12:1375-80. [DOI: 10.1111/jsm.12897] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Morgentaler A, Feibus A, Baum N. Testosterone and cardiovascular disease – the controversy and the facts. Postgrad Med 2015; 127:159-65. [DOI: 10.1080/00325481.2015.996111] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Ferrati S, Nicolov E, Bansal S, Zabre E, Geninatti T, Ziemys A, Hudson L, Ferrari M, Goodall R, Khera M, Palapattu G, Grattoni A. Delivering enhanced testosterone replacement therapy through nanochannels. Adv Healthc Mater 2015; 4:446-51. [PMID: 25274059 DOI: 10.1002/adhm.201400348] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 07/21/2014] [Indexed: 11/08/2022]
Abstract
Primary or secondary hypogonadism results in a range of signs and symptoms that compromise quality of life and requires life-long testosterone replacement therapy. In this study, an implantable nanochannel system is investigated as an alternative delivery strategy for the long-term sustained and constant release of testosterone. In vitro release tests are performed using a dissolution set up, with testosterone and testosterone:2-hydroxypropyl-β-cyclodextrin (TES:HPCD) 1:1 and 1:2 molar ratio complexes release from the implantable nanochannel system and quantify by HPLC. 1:2 TES:HPCD complex stably achieve 10-15 times higher testosterone solubility with 25-30 times higher in vitro release. Bioactivity of delivered testosterone is verified by LNCaP/LUC cell luminescence. In vivo evaluation of testosterone, luteinizing hormone (LH), and follicle stimulating hormone (FSH) levels by liquid chromatography mass spectrometry (LC/MS) and multiplex assay is performed in castrated Sprague-Dawley rats over 30 d. Animals are treated with the nanochannel implants or degradable testosterone pellets. The 1:2 TES:HPCD nanochannel implant exhibits sustained and clinically relevant in vivo release kinetics and attains physiologically stable plasma levels of testosterone, LH, and FSH. In conclusion, it is demonstrated that by providing long-term steady release 1:2 TES:HPCD nanochannel implants may represent a major breakthrough for the treatment of male hypogonadism.
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Affiliation(s)
- Silvia Ferrati
- The Department of Nanomedicine; Houston Methodist Research Institute; 6670 Bertner Avenue Houston TX 77030 USA
| | - Eugenia Nicolov
- The Department of Nanomedicine; Houston Methodist Research Institute; 6670 Bertner Avenue Houston TX 77030 USA
| | - Shyam Bansal
- The Department of Nanomedicine; Houston Methodist Research Institute; 6670 Bertner Avenue Houston TX 77030 USA
- Division of Cardiovascular Diseases The University of Alabama at Birmingham; 1530 3 Avenue South Birmingham AL 35294 USA
| | - Erika Zabre
- The Department of Nanomedicine; Houston Methodist Research Institute; 6670 Bertner Avenue Houston TX 77030 USA
| | - Thomas Geninatti
- The Department of Nanomedicine; Houston Methodist Research Institute; 6670 Bertner Avenue Houston TX 77030 USA
| | - Arturas Ziemys
- The Department of Nanomedicine; Houston Methodist Research Institute; 6670 Bertner Avenue Houston TX 77030 USA
| | - Lee Hudson
- NanoMedical Systems Inc.; Austin, TX, 4401 Freidrich Ln 307 Austin TX 78744 USA
| | - Mauro Ferrari
- The Department of Nanomedicine; Houston Methodist Research Institute; 6670 Bertner Avenue Houston TX 77030 USA
| | - Randal Goodall
- NanoMedical Systems Inc.; Austin, TX, 4401 Freidrich Ln 307 Austin TX 78744 USA
| | - Mohit Khera
- Department of Urology; Baylor College of Medicine; 7200 Cambridge Street Houston TX 77030 USA
| | - Ganesh Palapattu
- Department of Urology; University of Michigan; 1500 E Medical Center Drive SPC 5913 Ann Arbor MI 48109 USA
| | - Alessandro Grattoni
- The Department of Nanomedicine; Houston Methodist Research Institute; 6670 Bertner Avenue Houston TX 77030 USA
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Carruthers M, Cathcart P, Feneley MR. Evolution of testosterone treatment over 25 years: symptom responses, endocrine profiles and cardiovascular changes. Aging Male 2015. [PMID: 26218766 PMCID: PMC4732450 DOI: 10.3109/13685538.2015.1048218] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Testosterone treatment has evolved rapidly over the past 25 years as new, more effective and convenient methods have become available. This study reports experience with seven different methods, introduced on the market in the UK. AIM To establish the symptom response when testosterone treatment was initiated on the basis of clinical features and symptoms of androgen deficiency, and the resulting endocrine, biochemical and physiological responses. METHODS Of 2693 patients attending the 3 Men's Health Centers - The UK Androgen Study (UKAS), 2247 were treated. Treatments included pellet implants, oral testosterone undecanoate (Testocaps), mesterolone (Proviron), testosterone gel (Testogel), testosterone scrotal cream (Andromen) and scrotal gel (Tostran). RESULTS There was no correlation between initial testosterone level, initial symptom score or the success of treatment as defined by adequate resolution of symptoms. Despite the diverse endocrine patterns produced, the testosterone preparations appear equally safe over prolonged periods, with either no change or improvement of cardiovascular risk factors, especially in lowering cholesterol and diastolic blood pressure. CONCLUSIONS It is suggested that because of excessive reliance on laboratory measures of androgens and undue safety concerns, many men who could benefit from symptom relief, improvement in related clinical conditions and given preventive medical benefits remain untreated.
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Affiliation(s)
- Malcolm Carruthers
- Centre for Men’s HealthLondon,
UK
- Alzheimer's and Ageing Department, Edith Cowan University,
Perth,
WA,
Australia
- Address for correspondence: Malcolm Carruthers,
Centre for Men's Health, 96 Harley Street,
London, W1G 7HY,
UK. E-mail:
| | - Paul Cathcart
- Department of Urology, University College Hospital,
London,
UK
| | - Mark R. Feneley
- Department of Urology, University College Hospital,
London,
UK
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15
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Abstract
Currently, the most popular form of testosterone replacement is the topical gels that require daily applications and incur a risk of transfer of testosterone to partners and family. One of the problems with testosterone replacement is the short half-life of testosterone. A long-acting formulation is appealing to patients and physicians. In 1972, fused crystalline testosterone pellets were approved in the USA by the FDA but they were not marketed until 2008. Pharmacokinetics studies were available on a different formulation from which much can be learned and applied to the current formulation, Testopel®. The decay kinetics, pituitary suppression, and effect on other sex steroids are reviewed as well as the short-term complication rates. This review should provide the testosterone pellet implanter a better understanding of the physiology of testosterone pellet supplementation for hypogonadism.
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Udedibia E, Kaminetsky J. Phase II drugs currently being investigated for the treatment of hypogonadism. Expert Opin Investig Drugs 2014; 23:1605-18. [DOI: 10.1517/13543784.2014.948151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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17
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Abstract
INTRODUCTION Men who have symptoms associated with persistently low serum total testosterone level should be assessed for testosterone replacement therapy. AREAS COVERED Acute and chronic illnesses are associated with low serum testosterone and these should be recognized and treated. Once the diagnosis of male hypogonadism is made, the benefits of testosterone treatment usually outweigh the risks. Without contraindications, the patient should be offered testosterone replacement therapy. The options of testosterone delivery systems (injections, transdermal patches/gels, buccal tablets, capsules and implants) have increased in the last decade. Testosterone improves symptoms and signs of hypogonadism such as sexual function and energy, increases bone density and lean mass and decreases visceral adiposity. In men who desire fertility and who have secondary hypogonadism, testosterone can be withdrawn and the patients can be placed on gonadotropins. New modified designer androgens and selective androgen receptor modulators have been in preclinical and clinical trials for some time. None of these have been assessed for the treatment of male hypogonadism. EXPERT OPINION Despite the lack of prospective long-term data from randomized, controlled clinical trials of testosterone treatment on prostate health and cardiovascular disease risk, the available evidence suggests that testosterone therapy should be offered to symptomatic hypogonadal men.
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Affiliation(s)
- Prasanth Surampudi
- Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Division of Endocrinology, Department of Medicine , Torrance, CA, 90509 , USA
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18
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Testosterone supplementation versus clomiphene citrate for hypogonadism: an age matched comparison of satisfaction and efficacy. J Urol 2014; 192:875-9. [PMID: 24657837 DOI: 10.1016/j.juro.2014.03.089] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2014] [Indexed: 12/23/2022]
Abstract
PURPOSE We compared satisfaction and treatment efficacy in men with symptomatic hypogonadism who received clomiphene citrate or testosterone supplementation therapy. MATERIALS AND METHODS Men treated with clomiphene citrate, or testosterone injections or gels for symptomatic hypogonadism (total testosterone less than 300 ng/dl) reported satisfaction with the current treatment regimen using the qADAM questionnaire. RESULTS A total of 93 men on testosterone injections (31) or gels (31), or clomiphene citrate (31) were age matched from a retrospective cohort of 1,150 on testosterone supplementation therapy. We compared men who received testosterone supplementation therapy to 31 not on such therapy, who served as controls. Median serum testosterone increased from pretreatment levels in all men regardless of therapy with clomiphene citrate, and testosterone injections and gels (from 247 to 504, 224 to 1,104 and 230 to 412 ng/dl, respectively, p <0.05). Final median serum total testosterone in men on clomiphene citrate (504 ng/dl) was lower than in men receiving testosterone injections (1,014 ng/dl, p <0.01) but similar to that in men on testosterone gels (412 ng/dl, p = 0.31). Despite different serum testosterone levels men on all 3 therapies reported similar satisfaction on qADAM, including a score of 35 for clomiphene citrate, 39 for testosterone injections, 36 for testosterone gels and 34 for control treatment (p >0.05). Men receiving testosterone injections reported greater libido than men on clomiphene citrate (4 vs 3, p = 0.04) or testosterone gels (4 vs 3, p = 0.04), or controls (4 vs 3, p <0.01). CONCLUSIONS Testosterone supplementation regimens and clomiphene citrate are efficacious for improving serum total testosterone. No difference in overall hypogonadal symptoms was noted among men on any testosterone supplementation therapy. Despite lower serum total testosterone, men on clomiphene citrate and testosterone gels reported satisfaction similar to that of men treated with testosterone injections.
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Kovac JR, Rajanahally S, Smith RP, Coward RM, Lamb DJ, Lipshultz LI. Patient satisfaction with testosterone replacement therapies: the reasons behind the choices. J Sex Med 2014; 11:553-62. [PMID: 24344902 PMCID: PMC3946859 DOI: 10.1111/jsm.12369] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Testosterone replacement therapy (TRT) for male hypogonadism is rapidly gaining popularity and acceptance. Options include gels, injections, and implantable subcutaneous pellets. AIMS The aim of this study was to determine rates of patient satisfaction and reasons for patient preferences in hypogonadal men on TRT. METHODS An anonymous, prospective survey was distributed to men presenting for TRT at an academic urology clinic. The survey was organized into multiple domains including patient satisfaction and treatment motivation. MAIN OUTCOME MEASURES Patient satisfaction responses obtained via anonymous survey. RESULTS Average patient age was 49 ± 0.7 years (n = 382). Injectable testosterone was chosen by 53%, gel-based regimens by 31%, and pellets by 17%. Overall, 70% of patients were satisfied with their TRT and 14% reported dissatisfaction. Satisfaction rates were similar between gels (68%), injections (73%), and implantable pellets (70%). Doctor recommendation was the sole significant reason for patients preferring gel-based TRT (66% vs. 37% injection users vs. 31% pellet users). Injectable TRT was favored because of lower cost (35% vs. 21% gel users vs. 19% pellet users). Pellets were favored for ease of use (64% vs. 44% injection users vs. 43% gel users) and convenience (58% vs. 26% injection users vs. 19% gel users). Pellets had increased rates of satisfaction within the first 12 months. Improvements in concentration and mood occurred at higher percentages in satisfied patients. CONCLUSIONS Patients are satisfied with TRT. Lower costs are important to patients on injections. Convenience and ease of use are central in choosing pellet therapy. Men on TRT should be questioned about mood and concentration because these factors exhibited the greatest improvements in satisfied patients.
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Affiliation(s)
- Jason R Kovac
- Scott Department of Urology and the Center for Reproductive Medicine, Baylor College of Medicine, Houston, TX, USA
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Mechlin CW, Frankel J, McCullough A. Coadministration of anastrozole sustains therapeutic testosterone levels in hypogonadal men undergoing testosterone pellet insertion. J Sex Med 2013; 11:254-61. [PMID: 24119010 DOI: 10.1111/jsm.12320] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Current U.S. Food and Drug Administration-approved therapies for hypogonadism involve testosterone (T) replacement. Testosterone pellets (TP) require a minor office procedure every 3 to 4 months. The need for repeated insertions increases the likelihood of a complication. Anastrozole (AZ) is an aromatase inhibitor that has been used off-label for the treatment of male hypogonadism. AZ increases T levels by lowering serum estradiol (E2) levels and increasing gonadotropin (GTP) levels. AIM We hypothesized that the concomitant use of AZ with TP insertions would sustain therapeutic T levels and increase the interval between TP insertions. METHODS Men treated with TP for hypogonadism at an academic center were offered AZ (1 mg/day) at the time of TP reinsertion as a way of potentially decreasing the frequency of TP insertions. Total T (TT), free T (FT), sex hormone binding globulin, E2, luteinizing hormone (LH), and follicle-stimulating hormone FSH levels were obtained prior to T replacement and at 6 and 15 weeks from TP insertion. Men were re-implanted at 16 weeks if their TT levels were less than 350 ng/dL and their symptoms recurred. We retrospectively reviewed our records of men who underwent TP, TP, and AZ from 2011 to 2012. Demographics, TT, FT, LH, FSH, and E2 levels were recorded. Data were analyzed with anova and a Tukey's test. MAIN OUTCOME MEASURE TT level at 6, 15, or >15 weeks from TP insertion. RESULTS Thirty-eight men with 65 insertions were analyzed. The TP AZ group had significantly higher TT and FT levels than the TP group at >120 days (P < 0.05). The TP group had significantly higher E2 levels at all time points (P < 0.01). GTP levels remained stable in the TP AZ group. Average time to reinsertion in TP AZ was 198 days vs. 128 days in the TP group. CONCLUSION Men on TP AZ maintain therapeutic T levels longer than men on TP alone and have significantly less GTP suppression.
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Affiliation(s)
- Clay W Mechlin
- Department of Surgery, Division of Urology, Albany Medical College, Albany, NY, USA
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The Evaluation and Management of Testosterone Deficiency: the New Frontier in Urology and Men’s Health. Curr Urol Rep 2013; 14:557-64. [DOI: 10.1007/s11934-013-0370-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Smith RP, Khanna A, Coward RM, Rajanahally S, Kovac JR, Gonzales MA, Lipshultz LI. Factors Influencing Patient Decisions to Initiate and Discontinue Subcutaneous Testosterone Pellets (Testopel) for Treatment of Hypogonadism. J Sex Med 2013; 10:2326-33. [DOI: 10.1111/jsm.12226] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Corona G, Rastrelli G, Maggi M. Diagnosis and treatment of late-onset hypogonadism: systematic review and meta-analysis of TRT outcomes. Best Pract Res Clin Endocrinol Metab 2013; 27:557-79. [PMID: 24054931 DOI: 10.1016/j.beem.2013.05.002] [Citation(s) in RCA: 130] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Late-onset hypogonadism (LOH) is a relatively common conditions affecting the aging male. The aim of this review is to summarize the available evidence regarding LOH and its interaction with general health. LOH is often comorbid to obesity and several chronic diseases. For this reason lifestyle modifications should be strongly encouraged in LOH subjects with obesity, type 2 diabetes mellitus (T2DM) and metabolic syndrome (MetS) and good treatment balance of chronic diseases. Medical therapy of LOH should be individualized depending on the etiology of the disease and the patient's expectations. Available evidence seems to suggest that testosterone replacement therapy is able to improve central obesity (subjects with MetS) and glycometabolic control (patients with MetS and T2DM), as well as to increase lean body mass (HIV, chronic obstructive pulmonary disease), along with insulin resistance (MetS) and peripheral oxygenation (chronic kidney diseases). However, it should be recognized that the number of studies on benefits of T supplementation is too limited to draw final conclusions. Longer and larger studies are needed to better clarify the role of TRT in such chronic conditions.
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Affiliation(s)
- G Corona
- Sexual Medicine and Andrology Unit Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Florence, Italy; Endocrinology Unit, Maggiore-Bellaria Hospital, Medical Department, Azienda-Usl Bologna, Bologna, Italy
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Pastuszak AW, Pearlman AM, Godoy G, Miles BJ, Lipshultz LI, Khera M. Testosterone replacement therapy in the setting of prostate cancer treated with radiation. Int J Impot Res 2012; 25:24-8. [DOI: 10.1038/ijir.2012.29] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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