Pharmacokinetics of a single dose of buccal testosterone

Current and future testosterone delivery systems for treatment of the hypogonadal male

BACKGROUND

Hypogonadism is manifest in all age groups, and a growing elderly population is requiring treatment for testosterone deficiency, presenting new safety challenges, as many of these individuals present with comorbidities and significant risk profiles.

OBJECTIVE

To discuss testosterone replacement modalities, their advantages and disadvantages, and provide a discussion of safety issues.

METHODS

We reviewed the literature regarding testosterone replacement therapy and have provided a summary of our most outstanding findings.

CONCLUSION

Potential benefits of testosterone replacement therapy include increased lean body mass, heightened libido, increased bone density and elevation of mood. Some disadvantages are clearly defined, while others require further investigation. Patient and physician must cooperate to agree on an individual patient's most appropriate and tolerable route of administration.

Rise of testosterone, nortestosterone, and 17ß-estradiol concentrations in peripheral blood plasma of pigs after sublingual application in vivo

Application of endogenous anabolic steroids to meat producing animals is not allowed in the EU. In other countries application is practised due to a low oral activity based on an efficient first liver passage. This contrasts with pharmacological investigations where steroids were readily absorbed by the buccal and sublingual mucosa using absorption enhancers. An in vivo study was performed to clarify possible absorption after sublingual applications of one milligram portions of either testosterone (T), 17beta-estradiol (E), or nortestosterone (NT) in sesame oil to castrated male pigs (n=5) without specific delivery systems during anaesthesia. Blood samples were drawn using jugular vein catheters for 15 min before and 3h after application. Hormone concentrations were determined by Radioimmunoassay for T and E or Enzymeimmunoassay for NT. For all steroids a slight increase was measurable one minute after application. Maximal values for T, E, and NT were 2.5 ng/ml, 1.5 ng/ml and 4.2 ng/ml, respectively, and were observed after 10 min. The concentrations of the three steroids decreased slowly thereafter but were still significantly elevated 1-3h after application. Oral absorption of steroids without enhancers should be considered in risk analysis.

Emerging drugs for hypogonadism

Male hypogonadism is a common endocrine problem that affects men of all ages. Recently, there has been a surge in testosterone use among middle-aged and older men who in the past may have been considered to have borderline or even normal testosterone levels. This increasing use of testosterone therapy among men has paralleled the increasing improvements in the development of treatments for male hypogonadism that have been made over the past few decades. Current therapies using transdermal formulations and long-acting injectables such as testosterone undecanoate are quickly replacing the old injectable testosterone esters. In recent years, pharmaceutical sales and prescription data have readily shown a shift in the testosterone marketplace towards greater use of slightly more expensive treatments such as transdermal therapies, which are easier to administer and yield more physiological levels of testosterone. On the horizon are several new compounds in development, such as selective androgen receptor modulators (SARMS), 7alpha-methyl-19-nortestosterone, aromatase inhibitors, clomifene, dihydrotestosterone and human chorionic gonadotropin. Compounds such as SARMs are designed to selectively target androgen receptors in specific tissues (such as bone and muscles), in the hope of dispersing some of the side effects experienced on the prostate, which are presently associated with therapy of exogenous testosterone.

Androgen Replacement Therapy

The major goal of androgen substitution is to replace testosterone at levels as close to physiological levels as is possible. For some androgen-dependent functions testosterone is a pro-hormone, peripherally converted to 5alpha-dihydrotestosterone (DHT) and 17beta-estradiol (E2), of which the levels preferably should be within normal physiological ranges. Furthermore, androgens should have a good safety profile without adverse effects on the prostate, serum lipids, liver or respiratory function, and they must be convenient to use and patient-friendly, with a relative independence from medical services. Natural testosterone is viewed as the best androgen for substitution in hypogonadal men. The reason behind the selection is that testosterone can be converted to DHT and E2, thus developing the full spectrum of testosterone activities in long-term substitution. The mainstays of testosterone substitution are parenteral testosterone esters (testosterone enantate and testosterone cipionate) administered every 2-3 weeks. A major disadvantage is the strongly fluctuating levels of plasma testosterone, which are not in the physiological range at least 50% of the time. Also, the generated plasma E2 is usually supraphysiological. A major improvement is parenteral testosterone undecanoate producing normal plasma levels of testosterone for 12 weeks, with normal plasma levels of DHT and E2 also. Subcutaneous testosterone implants provide the patient, depending on the dose of implants, with normal plasma testosterone for 3-6 months. However, their use is not widespread. Oral testosterone undecanoate dissolved in castor oil bypasses the liver via its lymphatic absorption. At a dosage of 80 mg twice daily, plasma testosterone levels are largely in the normal range, but plasma DHT tends to be elevated. For two decades transdermal testosterone preparations have been available and have an attractive pharmacokinetic profile. Scrotal testosterone patches generate supraphysiological plasma DHT levels, which is not the case with the nonscrotal testosterone patches. Transdermal testosterone gel produces fewer skin irritations than the patches and offers greater flexibility in dosage. Oromucosal testosterone preparations have recently become available. Testosterone replacement is usually of long duration and so patient compliance is of utmost importance. Therefore, the patient must be involved in the selection of type of testosterone preparation. Administration of testosterone to young individuals has almost no adverse effects. With increasing age the risk of adverse effects on the prostate, the cardiovascular system and erythropoiesis increases. Consequently, short-acting testosterone preparations are better suited for aging androgen-deficient men.

Near-infrared spectroscopy for the determination of testosterone in thin-film composites

More rapid, reproducible, and cost-effective methods to control product quality in the pharmaceutical industry continue to be a major emphasis, particularly with the FDA through its recent process analytical technologies (PAT) initiative. Many different methods have been used to determine the stability and content uniformity of a drug in various dosage forms; however, most of these methods include the destruction of the sample. Therefore, the development of nondestructive methods that allow the analysis of each individual dosage form has become the basis of much research. A new assay for the nondestructive determination of testosterone content in mucoadhesive bi-layer thin-film composites (TFCs) using near-infrared spectroscopy (NIR) was developed. Five sets of the circular films (n=5) with theoretical testosterone content of 0, 1, 2, 3, and 4 mg per 3/8th in. diameter disks were scanned in the near-infrared region of 1100-2500 nm to determine testosterone content. The NIR results were directly compared with those obtained using a previously developed ultraviolet assay for testosterone at 240 nm. Principal component regression (PCR) was performed to calibrate the NIR assay. This correlation produced r2=0.99 with a standard error of estimate (SEE)=0.18 mg, and a standard error of performance (SEP)=0.18 on cross validation with an equal number of samples (F test passed at P=0.05). Though the UV assay showed a slightly better r2 value, the NIR assay was much quicker, easier, and nondestructive. Therefore, the NIR assay may have significant potential for use in the quality control of pharmaceutical films containing drugs.

Oral mucosal drug delivery: clinical pharmacokinetics and therapeutic applications

Oral mucosal drug delivery is an alternative method of systemic drug delivery that offers several advantages over both injectable and enteral methods. Because the oral mucosa is highly vascularised, drugs that are absorbed through the oral mucosa directly enter the systemic circulation, bypassing the gastrointestinal tract and first-pass metabolism in the liver. For some drugs, this results in rapid onset of action via a more comfortable and convenient delivery route than the intravenous route. Not all drugs, however, can be administered through the oral mucosa because of the characteristics of the oral mucosa and the physicochemical properties of the drug. Several cardiovascular drugs administered transmucosally have been studied extensively. Nitroglycerin is one of the most common drugs delivered through the oral mucosa. Research on other cardiovascular drugs, such as captopril, verapamil and propafenone, has proven promising. Oral transmucosal delivery of analgesics has received considerable attention. Oral transmucosal fentanyl is designed to deliver rapid analgesia for breakthrough pain, providing patients with a noninvasive, easy to use and nonintimidating option. For analgesics that are used to treat mild to moderate pain, rapid onset has relatively little benefit and oral mucosal delivery is a poor option. Oral mucosal delivery of sedatives such as midazolam, triazolam and etomidate has shown favourable results with clinical advantages over other routes of administration. Oral mucosal delivery of the antinausea drugs scopolamine and prochlorperazine has received some attention, as has oral mucosal delivery of drugs for erectile dysfunction. Oral transmucosal formulations of testosterone and estrogen have been developed. In clinical studies, sublingual testosterone has been shown to result in increases in lean muscle mass and muscle strength, improvement in positive mood parameters, and increases in genital responsiveness in women. Short-term administration of estrogen to menopausal women with cardiovascular disease has been shown to produce coronary and peripheral vasodilation, reduction of vascular resistance and improvement in endothelial function. Studies of sublingual administration of estrogen are needed to clarify the most beneficial regimen. Although many drugs have been evaluated for oral transmucosal delivery, few are commercially available. The clinical need for oral transmucosal delivery of a drug must be high enough to offset the high costs associated with developing this type of product. Drugs considered for oral transmucosal delivery are limited to existing products, and until there is a change in the selection and development process for new drugs, candidates for oral transmucosal delivery will be limited.

Transmucosal delivery of testosterone in rabbits using novel bi-layer mucoadhesive wax-film composite disks

Testosterone exhibits very low oral bioavailability because of its low aqueous solubility and extensive first-pass metabolism. The purpose of this study was to develop a novel bi-layer mucoadhesive wax-film composite (WFC), and to test the relative bioavailability of testosterone via the buccal route in rabbits. The release rate of testosterone from optimal WFCs (3/8-in. diameter) per unit surface area was 5.6 microg x cm(2) x mL(-1) x min(-1) and was zero-order. Bi-layer WFCs (average weight of 14 +/- 2.6 mg and thickness of 186 +/- 34 microns) containing 4 mg of testosterone were applied to the buccal pouch of anesthetized New Zealand white rabbits. Rabbits (n = 3) injected intravenously had C(max) and area under the curve values of 1200 +/- 46 ng/mL, and 48,227 +/- 12,995 ng x min/mL, respectively. Rabbits (n = 3) dosed via the buccal pouch had C(max), T(max), and area under the curve values of 127 +/- 13 ng/mL, 200 +/- 35 min, and 24,221 +/- 1543 ng x min/mL. The relative bioavailability for rabbits treated with the WFC was 50.2 +/- 3.2% with a coefficient of variation of 6.4%. It was concluded that these bi-layer mucoadhesive WFCs disks could deliver physiologically relevant amounts of insoluble drugs such as testosterone across the buccal mucosa.

Pharmacokinetics of testosterone after percutaneous gel or buccal administration

OBJECTIVE

To determine the pharmacokinetics of testosterone following its administration using transdermal gel or buccal lozenges.

DESIGN

Pilot study.

SETTING

University-based hospital.

PATIENT(S)

Ten bilaterally oophorectomized women.

INTERVENTION(S)

Daily micronized testosterone gel (1 mg) and testosterone propionate lozenge (1 mg).

MAIN OUTCOME MEASURE(S)

Total testosterone, androstenedione, dihydrotestosterone, 3alpha-androstanediol glucuronide, and sex hormone-binding globulin were measured in serum by specific radioimmunoassays; free testosterone levels were also calculated.

RESULT(S)

Before treatment, serum testosterone levels in the groups using the lozenge and gel were 16 +/- 4.0 and 20 +/- 6.0 ng/dL, respectively. Mean maximum testosterone levels obtained with the lozenge occurred 1 hour after administration on days 1 (692 +/- 236 ng/dL) and 14 (836 +/- 309 ng/dL) of treatment and fell precipitously thereafter. In contrast, testosterone levels obtained with the gel showed a prolonged rise reaching maximal levels of 97 +/- 78 and 100 +/- 60 ng/dL after 18 hours. The serum level patterns of free testosterone, dihydrotestosterone, and 3alpha-androstanediol glucuronide were similar to the corresponding total testosterone levels.

CONCLUSION(S)

Administration of testosterone lozenge by buccal absorption produced a rapid and brief elevation of testosterone levels, with levels reaching upper limits of the male range. In contrast, transdermal testosterone gel absorption resulted in a prolonged elevation of testosterone levels, which were in the hyperandrogenic female range but resembled steady state pharmacokinetics.