Identifying the outcomes important to men with hypogonadism: A qualitative evidence synthesis

Symptomatic benefits of testosterone treatment in patient subgroups: a systematic review, individual participant data meta-analysis, and aggregate data meta-analysis

BACKGROUND

Testosterone replacement therapy is known to improve sexual function in men younger than 40 years with pathological hypogonadism. However, the extent to which testosterone alleviates sexual dysfunction in older men and men with obesity is unclear, despite the fact that testosterone is being increasingly prescribed to these patient populations. We aimed to evaluate whether subgroups of men with low testosterone derive any symptomatic benefit from testosterone treatment.

METHODS

We did a systematic review and meta-analysis to evaluate characteristics associated with symptomatic benefit of testosterone treatment versus placebo in men aged 18 years and older with a baseline serum total testosterone concentration of less than 12 nmol/L. We searched major electronic databases (MEDLINE, Embase, Science Citation Index, and the Cochrane Central Register of Controlled Trials) and clinical trial registries for reports published in English between Jan 1, 1992, and Aug 27, 2018. Anonymised individual participant data were requested from the investigators of all identified trials. Primary (cardiovascular) outcomes from this analysis have been published previously. In this report, we present the secondary outcomes of sexual function, quality of life, and psychological outcomes at 12 months. We did a one-stage individual participant data meta-analysis with a random-effects linear regression model, and a two-stage meta-analysis integrating individual participant data with aggregated data from studies that did not provide individual participant data. This study is registered with PROSPERO, CRD42018111005.

FINDINGS

9871 citations were identified through database searches. After exclusion of duplicates and publications not meeting inclusion criteria, 225 full texts were assessed for inclusion, of which 109 publications reporting 35 primary studies (with a total 5601 participants) were included. Of these, 17 trials provided individual participant data (3431 participants; median age 67 years [IQR 60-72]; 3281 [97%] of 3380 aged ≥40 years) Compared with placebo, testosterone treatment increased 15-item International Index of Erectile Function (IIEF-15) total score (mean difference 5·52 [95% CI 3·95-7·10]; τ2=1·17; n=1412) and IIEF-15 erectile function subscore (2·14 [1·40-2·89]; τ2=0·64; n=1436), reaching the minimal clinically important difference for mild erectile dysfunction. These effects were not found to be dependent on participant age, obesity, presence of diabetes, or baseline serum total testosterone. However, absolute IIEF-15 scores reached during testosterone treatment were subject to thresholds in patient age and baseline serum total testosterone. Testosterone significantly improved Aging Males' Symptoms score, and some 12-item or 36-item Short Form Survey quality of life subscores compared with placebo, but it did not significantly improve psychological symptoms (measured by Beck Depression Inventory).

INTERPRETATION

In men aged 40 years or older with baseline serum testosterone of less than 12 nmol/L, short-to-medium-term testosterone treatment could provide clinically meaningful treatment for mild erectile dysfunction, irrespective of patient age, obesity, or degree of low testosterone. However, due to more severe baseline symptoms, the absolute level of sexual function reached during testosterone treatment might be lower in older men and men with obesity.

FUNDING

National Institute for Health and Care Research Health Technology Assessment Programme.

Weight strategy in older adults with obesity: calorie restriction or not?

PURPOSE OF REVIEW

Along with the marked increase in the population of older adults with obesity is the need for effective strategies to treat aging- and obesity-related complications. This review highlights recent progress in obesity management in older adults.

RECENT FINDINGS

Although calorie restriction is needed to significantly reduce fat mass, an exercise protocol is crucial to ameliorate functional outcomes. The addition of a resistance exercise protocol improves the response of muscle protein synthesis to anabolic stimuli, preventing the calorie restriction-induced reduction in muscle and bone mass. The addition of an aerobic exercise protocol improves cardiorespiratory fitness and cognitive function. However, the addition of both aerobic and resistance exercise protocols to calorie restriction provides the greatest improvements in myocellular quality, frailty, and cardiometabolic and cognitive outcomes, translating into the greatest improvement in quality of life. Such comprehensive lifestyle intervention effectively improves glucometabolic control and age-relevant outcomes in older adults with diabetes. When combined with testosterone therapy, such lifestyle intervention also preserves muscle and bone mass in older, men with obesity and hypogonadism.

SUMMARY

We conclude that calorie restriction among older adults with obesity should be prescribed in combination with both aerobic and resistance exercise to maximize benefits on overall health.

Association between snoring frequency and male serum testosterone: Findings from the 2015-2016 National Health and Nutrition Examination Survey

BACKGROUND

This study aimed to assess the association between snoring frequency and male serum testosterone levels.

METHODS

We analyzed data from the 2015 to 2016 National Health and Nutrition Examination Survey. Snoring frequency was relied on self-report, and was divided into never, rarely (1-2 nights a week), occasionally (3-4 nights a week), or frequently (5 or more nights a week) groups. Multivariable analysis controlling for age, race, waist circumference, total cholesterol, diabetes, and hypertension was used to evaluate the association between snoring frequency and male serum testosterone. Furthermore, we performed the subgroup analyses stratified by age and waist circumference.

RESULTS

Our analysis included 1900 participants. In the fully adjusted model, only frequent snoring was inversely associated with male serum testosterone (β -0.053, 95% CI -0.101 to -0.006, P = 0.028); According to the subgroup analysis stratified by age, only in 40-59 years group, frequent snoring was inversely associated with male serum testosterone in the fully adjusted model (β -0.113, 95% CI -0.196 to -0.031, P = 0.007). As for the subgroup analysis stratified by waist circumference, our results showed only in the waist circumference ≥102 cm group (abdominal obesity), frequent snoring was inversely associated with male serum testosterone (β -0.133, 95% CI -0.216 to -0.05, P = 0.002).

CONCLUSIONS

Frequent snoring (5 or more nights a week) is inversely associated with male serum testosterone levels, especially in those aged 40-59 years and those with abdominal obesity.