Clinical use of androgenic steroids at a major medical center: who prescribes androgens and how well do they do it?

Marketing and Testosterone Treatment in the USA: A Systematic Review

CONTEXT

Testosterone replacement therapy (TRT) is currently approved by the Food and Drug Administration only for classic hypogonadism, although off-label indications have resulted in a dramatic expansion in prescriptions in the USA. Marketing may significantly affect prescriber behavior.

OBJECTIVE

To systematically review all available evidence on marketing and TRT in the USA.

EVIDENCE ACQUISITION

PubMed, Embase, and Scopus were searched up to July 2017 for all relevant publications reporting on assessments of the TRT market size, economic costs associated with hypogonadism, trends in TRT prescriptions, drug discontinuation rates, and advertising and sales efforts in the USA.

EVIDENCE SYNTHESIS

Twenty retrospective studies were included in the final analysis. The market size for hypogonadism constitutes 5.6-76.8% of men in the USA, with the lower end of the range representing the strictest criteria for diagnosis. Men with a diagnosis of hypogonadism consume $14 118 in direct and indirect costs to the payer. Over the last 2 decades, TRT prescriptions have increased between 1.8- and 4-fold. After 1 yr, 80-85% of men discontinue TRT. There is an association between direct-to-consumer advertising and testosterone testing, TRT prescriptions, and TRT without testosterone testing. There is a high prevalence of misinformation on Internet advertising.

CONCLUSIONS

Off-label indications have driven the dramatic expansion of TRT prescriptions over the last 2 decades. Direct-to-consumer advertising poses a unique challenge in the USA. Overtreatment can be avoided by applying strict diagnostic criteria for hypogonadism, which limits the addressable market for TRT.

PATIENT SUMMARY

In this report, we reviewed the relationship between marketing and testosterone therapy in the USA. We found that many patients are prescribed testosterone without an appropriate diagnosis of hypogonadism, which may be related to the marketing efforts for off-label prescribing.

Population-based patterns of prescription androgen use, 1976-2008

PURPOSE

Prescription testosterone (T) has limited approved medical indications and is a controlled substance in Canada. Utilization studies in other Westernized countries have revealed sharp increases in T use in recent years. We examined medical use of androgens, including T, over a ≥30-year period among adult (18+) men in a population-based study set in a Canadian juridisdiction of universal health care.

METHODS

Analyses were based on data from electronic records of dispensed prescriptions during 1976-2008 in Saskatchewan, Canada. All formulations of androgens listed in the provincial formulary (oral and injectable) were included. We examined demographics of users, androgen types used, switching patterns, and trends in the annual rate of use over time.

RESULTS

There were 11 521 androgen users who were followed for an average of 11.8 years. Overall, 11 types of androgens were used, and there were 86 812 dispensing events. The mean age at first use was 56.4 years (median: 58). Men had 7.5 prescription dispensing events on average (median: 2). The most commonly used formulations were methyl-T (36.2% of users) followed by T-enanthate (32.5%), T-cypionate (22.3%), and T-undecanoate (20.0%). Most users (82%) did not switch among androgen types. The annual rate of use varied substantially over time, with a marked increase observed from 1994 to 1999 and a decrease from 2000 to 2008.

CONCLUSIONS

Androgen users were largely middle aged and had relatively few dispensings. We hypothesize that observed secular trends in androgen use may align with drug treatment pattern changes for erectile dysfunction, including the advent of phosphodiesterase type 5 inhibitors.

Temporal trends in testosterone levels and treatment in older men

PURPOSE OF REVIEW

Longitudinal studies of testosterone concentrations have yielded sharper estimates of age-related androgen declines than their cross-sectional counterparts. A potential explanation for this phenomenon is a secular (age independent) mechanism acting to accelerate within-individual testosterone decreases with time. This article reviews the evidence in favor of such secular trends and discusses potential causes and implications.

RECENT FINDINGS

The magnitude of the proposed secular trend may be as much as 1% per calendar year in excess of per year cross-sectional trends. Current evidence suggests that body composition changes as expressed by BMI can in part account for the trend in testosterone. More speculative recent findings suggest a potential contributory role for environmental endocrine disruptors, but to date no longitudinal studies have examined this question. Symptomatic androgen deficiency as currently defined is associated with diverse downstream morbidity, but may not constitute a robust designation over longer term periods of time. Information concerning treatment patterns in the general population is limited.

SUMMARY

Existing evidence, though limited, supports the hypothesis of secular declines in serum testosterone levels in adult men. It is conceivable that these trends may influence the health of the public. Studies confirming and accounting for these trends are needed.