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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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Khodamoradi K, Khosravizadeh Z, Parmar M, Kuchakulla M, Ramasamy R, Arora H. Exogenous testosterone replacement therapy versus raising endogenous testosterone levels: current and future prospects. ACTA ACUST UNITED AC 2021; 2:32-42. [PMID: 33615283 DOI: 10.1016/j.xfnr.2020.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Testosterone replacement therapy is an important treatment option for men with low testosterone and symptomatic hypogonadism. Various formulations of exogenous testosterone replacement therapy exist, including oral, buccal, intramuscular, transdermal, subdermal, and nasal preparations. However, exogenous testosterone replacement therapy is a double-edged sword, posing risks to fertility due to negative feedback mechanisms on the hypothalamic-pituitary-gonadal (HPG) axis, which is the main regulator of testosterone production and spermatogenesis in males. Alternative pharmacologic therapies are being used to increase endogenous testosterone levels while attempting to preserve fertility and function of the HPG axis. These include selective estrogen receptor modulators, gonadotropins, and aromatase inhibitors. This review focuses on overviewing and comparing the currently available methods of exogenous testosterone replacement therapy, alternative treatments to increasing endogenous testosterone, and novel treatments that are currently under investigation to normalize testosterone levels while preserving the function of the HPG axis. In conclusion, reports suggest that, though Testosterone replacement therapy is an important way to restore testosterone levels and reduce symptoms associated with low testosterone, it is often difficult to decide which treatment to select for patients with testosterone deficiency. Several factors need to be considered to decide on optimal therapy option for the patient which include but are not limited to safety, efficacy, cost-effectiveness, dosing flexibility, and side effects. Alternative approaches which aim to improve endogenous testosterone production and preserve fertility are promising but still are at their initial stages of development. Ultimately, patient-centered decision making is paramount to appropriate treatment selection.
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Affiliation(s)
- Kajal Khodamoradi
- Department of Urology, Miller School of Medicine, University of Miami, 1600 NW 10th Ave #1140, Miami, FL 33136, USA
| | - Zahra Khosravizadeh
- Department of Urology, Miller School of Medicine, University of Miami, 1600 NW 10th Ave #1140, Miami, FL 33136, USA
| | - Madhu Parmar
- Department of Urology, Miller School of Medicine, University of Miami, 1600 NW 10th Ave #1140, Miami, FL 33136, USA
| | - Manish Kuchakulla
- Department of Urology, Miller School of Medicine, University of Miami, 1600 NW 10th Ave #1140, Miami, FL 33136, USA
| | - Ranjith Ramasamy
- Department of Urology, Miller School of Medicine, University of Miami, 1600 NW 10th Ave #1140, Miami, FL 33136, USA
| | - Himanshu Arora
- Department of Urology, Miller School of Medicine, University of Miami, 1600 NW 10th Ave #1140, Miami, FL 33136, USA.,The Interdisciplinary Stem Cell Institute, University of Miami, Miller School of Medicine, 1501 NW 10th Avenue, Suite 909, Miami, FL 33136, USA
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Barbonetti A, D’Andrea S, Francavilla S. Testosterone replacement therapy. Andrology 2020; 8:1551-1566. [DOI: 10.1111/andr.12774] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 02/11/2020] [Accepted: 02/14/2020] [Indexed: 12/25/2022]
Affiliation(s)
- Arcangelo Barbonetti
- Andrology Unit Department of Life, Health and Environmental Sciences University of L’Aquila L’Aquila Italy
| | - Settimio D’Andrea
- Andrology Unit Department of Life, Health and Environmental Sciences University of L’Aquila L’Aquila Italy
| | - Sandro Francavilla
- Andrology Unit Department of Life, Health and Environmental Sciences University of L’Aquila L’Aquila Italy
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Khera M, Adaikan G, Buvat J, Carrier S, El-Meliegy A, Hatzimouratidis K, McCullough A, Morgentaler A, Torres LO, Salonia A. Diagnosis and Treatment of Testosterone Deficiency: Recommendations From the Fourth International Consultation for Sexual Medicine (ICSM 2015). J Sex Med 2017; 13:1787-1804. [PMID: 27914560 DOI: 10.1016/j.jsxm.2016.10.009] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 10/19/2016] [Accepted: 10/21/2016] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Testosterone deficiency (TD), also known as hypogonadism, is a condition affecting a substantial proportion of men as they age. The diagnosis and management of TD can be challenging and clinicians should be aware of the current literature on this condition. AIM To review the available literature concerning the diagnosis and management of TD and to provide clinically relevant recommendations from the Fourth International Consultation for Sexual Medicine (ICSM) meeting. METHODS A literature search was performed using the PubMed database for English-language original and review articles published or e-published up to January 2016. MAIN OUTCOME MEASURES Levels of evidence (LoEs) and grades of recommendations are provided based on a thorough analysis of the literature and committee consensus. RESULTS Recommendations were given for 12 categories of TD: definition, clinical diagnosis, routine measurement, screening questionnaires, laboratory diagnosis, threshold levels for the biochemical diagnosis of TD, prostate cancer, cardiovascular disease, fertility, testosterone (T) formulations, alternatives to T therapy, and adverse events and monitoring. A total of 42 recommendations were made: of these, 16 were unchanged from the Third ICSM and 26 new recommendations were made during this Fourth ICSM. Most of these recommendations were supported by LoEs 2 and 3. Several key new recommendations include the following: (i) the clinical manifestations of TD occur as a result of decreased serum androgen concentrations or activity, regardless of whether there is an identified underlying etiology [LoE = 1, Grade = A]; (ii) symptomatic men with total T levels lower than 12 nmol/L or 350 ng/dL should be treated with T therapy [LoE = 1, Grade = C]; (iii) a trial of T therapy in symptomatic men with total T levels higher than 12 nmol/L or 350 ng/dL can be considered based on clinical presentation [LoE = 3, Grade = C]; (iv) there is no compelling evidence that T treatment increases the risk of developing prostate cancer or that its use is associated with prostate cancer progression [LoE = 1, Grade = C]; and (v) the weight of evidence indicates that T therapy is not associated with increased cardiovascular risk [LoE = 2, Grade = B]. CONCLUSION TD is an important condition that can profoundly affect the sexual health of men. We provide guidance regarding its diagnosis and management. Men with TD who receive treatment often experience resolution or improvement in their sexual symptoms and non-sexual health benefits.
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Affiliation(s)
- Mohit Khera
- Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA.
| | - Ganesh Adaikan
- Section of Sexual Medicine, Obstetrics and Gynaecology, National University Hospital, National University of Singapore, Singapore
| | - Jacques Buvat
- CETPARP (Centre d'études et de traitement de la pathologie de l'appareil reproducteur), Lille, France
| | - Serge Carrier
- Department of Urology, McGill University, Montreal, QC, Canada
| | - Amr El-Meliegy
- Department of Andrology, Dr Soliman Fakeeh Hospital, Jeddah, Saudi Arabia
| | - Kostas Hatzimouratidis
- Second Department of Urology, Aristotle University of Thessaloniki, Pefka Thessaloniki, Greece
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Davidiuk AJ, Broderick GA. Adult-onset hypogonadism: evaluation and role of testosterone replacement therapy. Transl Androl Urol 2016; 5:824-833. [PMID: 28078213 PMCID: PMC5182238 DOI: 10.21037/tau.2016.09.02] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Testosterone deficiency (TD) has become a growing concern in the field of men’s sexual health, with an increasing number of men presenting for evaluation of this condition. Given the increasing demand for testosterone replacement therapy (TRT), a panel of experts met in August of 2015 to discuss the treatment of men who present for evaluation in the setting of low or normal gonadotropin levels and the associated signs and symptoms of hypogonadism. This constellation of factors can be associated with elements of both primary and secondary hypogonadism. Because this syndrome commonly occurs in men who are middle-aged and older, it was termed adult-onset hypogonadism (AOH). AOH can be defined by the following elements: low levels of testosterone, associated signs and symptoms of hypogonadism, and low or normal gonadotropin levels. Although there are significant benefits of TRT for patients with AOH, candidates also need to understand the potential risks. Patients undergoing TRT will need to be monitored regularly because there are potential complications that can develop with long-term use. This review is aimed at providing a deeper understanding of AOH, discussing the benefits and risks of TRT, and outlining each modality of TRT in use for AOH.
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Abstract
Age-related hormonal decline is gradual and less recognized in men than in women. Symptoms are oftentimes ignored and non-specific. Fatigue, lack of concentration, mood swings, decreased sexual desire, erectile dysfunction, infertility, hair loss, reduced muscle and bone mass, and weight gain are a few of the symptoms of male hypogonadism. This disorder is linked to reduction in quality of life, and poorer health outcomes as it may increase the risk for cardiovascular disease, diabetes mellitus, metabolic syndrome, Alzheimer's disease and premature death. Different modalities of testosterone replacement therapy have evolved over 70 years, and sales continue to grow. Each preparation is differentiated by route of delivery, ease of use, cost and pharmacokinetics. Topical/transdermal testosterone replacement therapy, including patches and gels, are the most modern formulations on the market. These are more expensive treatments, but yield more physiological concentrations of testosterone. Restoration of testosterone levels to the eugonadal range reverses signs and symptoms of hypogonadism, except for infertility, and may alleviate co-morbidities associated with hypogonadism. Patient understanding of and compliance with both treatment and monitoring are of utmost importance to achieve clinical success with maximum benefit and minimum risk. The aim of our review is to summarize the indications, contraindications, benefits and risks of testosterone replacement therapy as they relate to transdermal administration. Further, we compare the various testosterone preparations, focusing on the newest topical/transdermal routes of administration that are currently available.
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Affiliation(s)
- Katrina A Abadilla
- Johns Hopkins UniversitySinai Hospital Program in Internal Medicine, Baltimore, MD, USA
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8
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Modeling the oral cavity: In vitro and in vivo evaluations of buccal drug delivery systems. J Control Release 2012; 161:746-56. [DOI: 10.1016/j.jconrel.2012.05.026] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Revised: 05/10/2012] [Accepted: 05/14/2012] [Indexed: 11/22/2022]
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9
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Dinsmore WW, Wyllie MG. The long-term efficacy and safety of a testosterone mucoadhesive buccal tablet in testosterone-deficient men. BJU Int 2012; 110:162-9. [DOI: 10.1111/j.1464-410x.2011.10837.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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10
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Belchetz PE, Barth JH, Kaufman JM. Biochemical endocrinology of the hypogonadal male. Ann Clin Biochem 2010; 47:503-15. [DOI: 10.1258/acb.2010.010150] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Hypogonadism in the male results from inadequate testicular function, especially defects in androgen synthesis and secretion, or action. Androgen action is important throughout normal male development: in the fetus, puberty, adult life and old age. Regulation is by variable activity of the hypothalamo-pituitary axis at different phases of the life span. Clinical aspects include: genetic aspects presenting at birth and pubertal failure/arrest. Aspects in adult life embrace sexuality, somatic symptoms and osteoporosis. Acquired causes of hypogonadism may arise from various forms of testicular damage (primary hypogonadism), pituitary and hypothalamic disorders, as well as aetiologies acting at several sites. Measurement of testosterone (T) is crucial to the diagnosis of hypogonadism and the technologies continue to develop, with recent major advances. A growing problem relates to the diagnosis and treatment of hypogonadism in the ageing male. T therapy is available in several forms, with major improvements in more newly available modalities.
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Affiliation(s)
| | - Julian H Barth
- Clinical Biochemistry, Leeds General Infirmary, Great George Street, Leeds, UK
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11
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Gooren LJ, Saad F, Haide A, Yassin A. Decline of plasma 5alpha-dihydrotestosterone (DHT) levels upon testosterone administration to elderly men with subnormal plasma testosterone and high DHT levels. Andrologia 2008; 40:298-302. [PMID: 18811920 DOI: 10.1111/j.1439-0272.2008.00857.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The study was performed to measure the impact of testosterone (T) administration on circulating levels of 5alpha-dihydrotestosterone (DHT). Group 1 (32 men; mean age 61 years; mean T 6.9 +/- 1.9 nmol l(-1)) were treated for 15 months with long-acting T undecanoate. Group 2 (23 men, mean age 60 years, mean T 7.6 +/- 2.0 nmol l(-1)) were treated for 9 months with T gel. Plasma T and DHT were measured before and after 9 months T administration. In the men treated with T undecanoate plasma T and DHT were also measured after 12 and 15 months. Before T administration, plasma DHT ranged from 0.39 to 1.76 nmol l(-1) (0.30-1.90 nmol l(-1)). Mean DHT declined upon T administration from 0.95 +/- 0.50 to 0.55 +/- 0.30 nmol l(-1) (P < 0.05). With an arbitrary cut-off at 0.60 nmol l(-1), all 21 values of DHT > 0.60 nmol l(-1) had fallen from 1.29 +/- 0.50 to 0.70 +/- 0.60 nmol l(-1) (P < 0.01). Below this cut-off point 13 values rose and 21 fell upon T administration. Below this cut-off point values on average declined from 0.39 +/- 0.12 to 0.30 +/- 0.14 nmol l(-1) (P < 0.05). The study revealed that in a cohort of elderly men with subnormal plasma T levels plasma DHT levels declined upon T administration when they were in the higher range of normal (>0.6 nmol l(-1)), with a profound shift of DHT/T ratios presumed to be an indicator of a reduced 5alpha-reductase activity. Below plasma DHT levels of 0.6 nmol l(-1), responses of plasma DHT to T administration varied.
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Affiliation(s)
- L J Gooren
- Vrije Universiteit Medical Center, Amsterdam, The Netherlands.
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12
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Pfeil E, Dobs AS. Current and future testosterone delivery systems for treatment of the hypogonadal male. Expert Opin Drug Deliv 2008; 5:471-81. [PMID: 18426387 DOI: 10.1517/17425247.5.4.471] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Emily Pfeil
- Johns Hopkins University, School of Medicine, Department of Medicine, Division of Endocrinology and Metabolism, 1830 E. Monument Street, Suite 328, Baltimore, MD 21205, USA
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13
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Edelstein D, Sivanandy M, Shahani S, Basaria S. The latest options and future agents for treating male hypogonadism. Expert Opin Pharmacother 2007; 8:2991-3008. [DOI: 10.1517/14656566.8.17.2991] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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14
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The role for intramuscular testosterone injection in the gel era. CURRENT SEXUAL HEALTH REPORTS 2007. [DOI: 10.1007/s11930-007-0014-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Fabbri A, Giannetta E, Lenzi A, Isidori AM. Testosterone treatment to mimic hormone physiology in androgen replacement therapy. A view on testosterone gel and other preparations available. Expert Opin Biol Ther 2007; 7:1093-106. [PMID: 17665996 DOI: 10.1517/14712598.7.7.1093] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
There is still considerable controversy concerning the issue of testosterone replacement therapy. This is because testosterone replacement therapy is not a 'risk-free' treatment and a randomized controlled trial to evaluate safety of prolonged testosterone replacement therapy is not available, nor is it likely to be in the near future. However, recent testosterone delivery systems, such as the 1% gel (Testogel, Androgel and Testim), have proven to have a good physiologic profile, allowing constant monitoring of the possible complications and prompt discontinuation in the event of adverse effects. The aim of this paper is to provide a comprehensive review of the available testosterone preparations to treat male hypogonadism, with special interest in the treatment of ageing men and late-onset hypogonadism. In addition, the experimental and clinical data on the effect of testosterone on sexual function domains is reviewed along with the indication for the combination therapy of androgens with pro-erectile drugs, for example, type 5 phosphodiesterase inhibitors.
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Affiliation(s)
- Andrea Fabbri
- Università Tor Vergata, Cattedra di Endocrinologia, UOC Endocrinologia, Ospedale S. Eugenio, Rome, Italy.
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16
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Hughes SM, Harrison MA, Gallup GG. Sex Differences in Romantic Kissing among College Students: An Evolutionary Perspective. EVOLUTIONARY PSYCHOLOGY 2007. [DOI: 10.1177/147470490700500310] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This study provides a descriptive account of kissing behavior in a large sample of undergraduate college students and considers kissing in the context of both short-term and long-term mating relationships. Kissing was examined as a mate assessment device, a means of promoting pair bonds, and a means of inducing sexual arousal and receptivity. A total 1,041 college students completed one of three questionnaires measuring kissing preferences, attitudes, styles, and behaviors. Results showed that females place more importance on kissing as a mate assessment device and as a means of initiating, maintaining, and monitoring the current status of their relationship with a long-term partner. In contrast, males place less importance on kissing, especially with short-term partners, and appear to use kissing to increase the likelihood of having sex. The results suggest that kissing may play an important role as an adaptive courtship/mating ritual.
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Affiliation(s)
- Susan M. Hughes
- Department of Psychology, Albright College, Reading, PA 19612, USA
| | - Marissa A. Harrison
- Department of Social Sciences and Human Services, Borough of Manhattan Community College, The City University of New York, New York, NY, 10007, USA
| | - Gordon G. Gallup
- Department of Psychology, University at Albany, State University of New York, Albany, NY 12222, USA
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17
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Srinivas-Shankar U, Wu FCW. Drug insight: testosterone preparations. ACTA ACUST UNITED AC 2007; 3:653-65. [PMID: 17149382 DOI: 10.1038/ncpuro0650] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2006] [Accepted: 10/06/2006] [Indexed: 11/09/2022]
Abstract
Testosterone has been used for substitution therapy in testicular and hypothalamopituitary diseases for almost six decades, with injectable testosterone esters and implanted testosterone pellets being the mainstay of treatment. Growing interest in the possible use of testosterone in nonclassical situations such as male contraception, aging (late-onset hypogonadism), muscle-wasting conditions like HIV, erectile dysfunction, and female hypoactive sexual disorder has stimulated research, leading to the development of several new modes of administration of testosterone. Transdermal patches, gels, mucoadhesive sustained-release buccal tablets and long-acting testosterone esters are designed to provide testosterone levels that approximate normal physiologic levels, to improve patient acceptability, and to further increase the number of treatment options available. In this Review, we briefly describe the chemistry, mechanism of action, and metabolism of testosterone. We then discuss the pharmacokinetics, advantages, and disadvantages of various formulations and summarize the various preparations currently available.
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Affiliation(s)
- Upendram Srinivas-Shankar
- Andrology Research Unit, Department of Endocrinology, Central Manchester University and Manchester Children's Hospital, Manchester M13 OJH, UK.
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18
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Abstract
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.
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Affiliation(s)
- Daniel Edelstein
- Johns Hopkins University School of Medicine, Division of Endocrinology and Metabolism, Baltimore, MD, USA
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19
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Yassin AA, Saad F. Treatment of sexual dysfunction of hypogonadal patients with long-acting testosterone undecanoate (Nebido®). World J Urol 2006; 24:639-44. [PMID: 17048032 DOI: 10.1007/s00345-006-0120-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Recently, testosterone undecanoate (TU), a new parenteral testosterone (T) preparation has been introduced. Two of its distinctive features are (a) its prolonged action: after two initial loading injections 6 weeks apart, usually only one injection every 12 weeks is needed (b) over the full interval between two injections, plasma T levels are in the physiological range. New research presents convincing evidence that T has profound effects on tissues of the penis involved in the mechanism of erection and that testosterone deficiency impairs the anatomical and physiological substrate of erectile capacity, which is, at least, in part reversible upon androgen therapy. Our studies with TU demonstrated that venous leakage could be corrected with T treatment in a number of patients. We further could show that sexual functions, in a substantial number of elderly men, can be restored with treatment with T only. So, these results argue for determination of T levels in elderly men with sexual problems. If the levels are subnormal, T treatment is warranted.
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Affiliation(s)
- Aksam A Yassin
- Clinic of Urology/Andrology, Segeberger Kliniken, Norderstedt-Hamburg, Germany.
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20
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Abstract
Hypogonadism is a common problem in men. It affects 2% to 30% of men aged 40 to 59 years, 20% to 45% aged 60 to 69 years, 34% to 70% aged 70 to 79 years, and most men aged >80 years. Hypogonadism is also highly prevalent in men with chronic illnesses, such as HIV infection. The low testosterone (T) levels associated with hypogonadism impair sexual function and many other aspects of health and well-being. In aging men and in those who are chronically ill, impaired gonadal function is characterized by subtle changes at many stages of T regulation. T therapy reverses the effects of hypogonadism, improving sexual function, body composition, mood, and well-being. Although many forms of T therapy are available, some therapies have limitations that render them ineffective or inconvenient. A new type of T gel has improved pharmacokinetic and clinical profiles compared with other forms of T therapy. This T gel has been shown to be effective in older men and in men with HIV infection, despite unsatisfactory response to earlier T-gel therapy.
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Affiliation(s)
- Jed C Kaminetsky
- Department of Urology NewYork University Medical Center, New York, New York 10016, USA.
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21
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Abstract
Male hypogonadism is one of the most common endocrinologic syndromes. The diagnosis is based on clinical signs and symptoms plus laboratory confirmation via the measurement of low morning testosterone levels on two different occasions. Serum luteinizing hormone and follicle-stimulating hormone levels distinguish between primary (hypergonadotropic) and secondary (hypogonadotropic) hypogonadism. Hypogonadism associated with aging (andropause) may present a mixed picture, with low testosterone levels and low to low-normal gonadotropin levels. Androgen replacement therapy in hypogonadal men has many potential benefits: improved sexual function, an enhanced sense of well-being, increased lean body mass, decreased body fat, and increased bone density. However, it also carries potential risks, including the possibility of stimulating the growth of an occult prostate cancer. The benefits of androgen therapy outweigh the risks in men with classic hypogonadism. However, for men with mild hypogonadism or andropause, the balance between benefits and risks is not always clear. Unfortunately, studies to date have included too small a number of patients and have been too short in duration to provide meaningful data on the long-term risks versus the benefits of androgen replacement therapy in these populations. Several products are currently marketed for the treatment of male hypogonadism. Weekly-to-biweekly injections of testosterone cypionate (cipionate) or testosterone enanthate (enantate) are widely used, as they are economical and generally well tolerated. However, once-daily transdermal therapies have become increasingly popular and now include both patch and gel systems. Intramuscular injection of testosterone undecanoate is an attractive new therapy that can be administered quarterly. To confirm an adequate replacement dosage, assessment of clinical responses and measurement of serum testosterone levels generally suffice. For selected men, serial measurement of bone mineral density during androgen therapy might be helpful to confirm end-organ effects. For men aged >50 years, we advocate measurement of hematocrit for detection of polycythemia and a digital rectal examination with a serum prostate-specific antigen level measurement for prostate cancer screening during the first few months of androgen therapy. Subsequently, a hematocrit should be obtained yearly or after changes in therapy, and annual prostate cancer screening can be offered to the patient after a discussion of its risks and benefits.
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Affiliation(s)
- Emily Darby
- Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington 98108, USA.
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Seftel A. Testosterone replacement therapy for male hypogonadism: Part III. Pharmacologic and clinical profiles, monitoring, safety issues, and potential future agents. Int J Impot Res 2005; 19:2-24. [PMID: 16193074 DOI: 10.1038/sj.ijir.3901366] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Male hypogonadism is associated with potentially distressing adverse effects on diverse organs and tissues. These include sexual dysfunction, particularly diminished libido, as well as mood disturbances, reduced lean body mass, and increased adipose-tissue mass. A wide range of effective and well-tolerated options exists. These include relatively noninvasive therapies, such as testosterone (T) gels and T patches; slightly more invasive treatments, such as the T buccal system; and invasive therapies, such as intramuscular T injections and subcutaneous depot implants (T pellets). Testosterone replacement therapy (TRT) can be individualized to enhance patient health and well-being. Screening and ongoing monitoring are necessary to ensure both the efficacy and safety of TRT, particularly prostate safety. Investigational agents, including selective androgen receptor modulators, may offer new pharmacodynamic and/or pharmacokinetic properties that enhance outcomes of TRT.
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Affiliation(s)
- A Seftel
- Department of Urology, Case Western Reserve University, University Hospitals of Cleveland, Cleveland, OH 44106-5046, USA.
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Ebert T, Jockenhövel F, Morales A, Shabsigh R. The current status of therapy for symptomatic late-onset hypogonadism with transdermal testosterone gel. Eur Urol 2005; 47:137-46. [PMID: 15661407 DOI: 10.1016/j.eururo.2004.09.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2004] [Indexed: 10/26/2022]
Abstract
For over 50 years, testosterone therapy has been used for the treatment of hypogonadism. In recent years, there has been an increase in the use of testosterone therapy for men with late-onset hypogonadism, as more convenient and effective modes of application are developed. Testosterone therapy in these men can significantly improve their sense of well-being, and lead to increases in muscle and bone mass, upper body strength, virility and libido [Gruenewald, Matsumoto. J Am Geriatr Soc 2003;51:101; Morales. Aging Male 2004; in press]. However, ensuring that optimal testosterone therapy is achieved in men with hypogonadism remains challenging. Oral delivery of unmodified testosterone is not possible, due to rapid first-pass metabolism and its short half-life. Therefore, different derivatives and formulations of testosterone have been developed to enhance potency, prolong duration of action or improve bioavailability. In addition, several different routes of administration have now been evaluated, including intramuscular injections, oral formulations, transdermal patches, transbuccal systems and transdermal testosterone gel. Despite the broad range of testosterone therapy on offer, each form has its benefits and limitations, and some will suit one patient more than another. An important concern among clinicians is that testosterone therapy may cause or promote prostate cancer. While current evidence supports the safety of testosterone therapy, androgens are growth factors for pre-existing prostate cancer. Therefore, before therapy is initiated, careful digital rectal examination and determination of prostate-specific antigen (PSA) in serum should be performed, in order to exclude evident or suspected prostate cancer. The first 3-6 months after initiating testosterone therapy is the most critical time for monitoring effects on the prostate. Therefore, it is important to monitor PSA levels every 3 months for the first year of treatment; thereafter, regular monitoring (mostly for prostate safety but also for cardiovascular and haematological safety) during therapy is mandatory.
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Affiliation(s)
- T Ebert
- Department of Urology, Euromed Clinic, Europa-Allee 1, D-90763 Fürth, Germany.
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Korbonits M, Kipnes M, Grossman AB. Striant SR: a novel, effective and convenient testosterone therapy for male hypogonadism. Int J Clin Pract 2004; 58:1073-80. [PMID: 15605676 DOI: 10.1111/j.1368-5031.2004.00383.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Striant SR (marketed as Striant in the US) is a novel sustained-release mucoadhesive buccal testosterone tablet for the treatment of male hypogonadism. Striant SR restores serum testosterone concentrations to the physiological range within 4 h of application, and steady-state concentrations are achieved within 24 h of twice-daily dosing. In phase III clinical trials, 87-97% of patients using Striant SR achieved 24-h-averaged serum testosterone concentrations within the normal range. In a comparative study, Striant SR was more likely to restore testosterone concentrations to the physiological range than Andropatch. In a small study, Striant SR produced steady-state testosterone concentrations comparable with those achieved with a testosterone gel (50mg testosterone). Striant SR was well tolerated, with a low incidence of adverse events and a low discontinuation rate (3.5%) due to adverse events in phase III studies. Striant SR is an effective, well-tolerated, convenient and discreet treatment for male hypogonadism.
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Affiliation(s)
- M Korbonits
- Department of Endocrinology, St Bartholomew's Hospital, London, UK
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Nieschlag E, Behre HM, Bouchard P, Corrales JJ, Jones TH, Stalla GK, Webb SM, Wu FCW. Testosterone replacement therapy: current trends and future directions. Hum Reprod Update 2004; 10:409-19. [PMID: 15297434 DOI: 10.1093/humupd/dmh035] [Citation(s) in RCA: 127] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Male hypogonadism is characterized by abnormally low serum testosterone levels associated with typical symptoms, including mood disturbance, sexual dysfunction, decreased muscle mass and strength, and decreased bone mineral density. By restoring serum testosterone levels to the normal range using testosterone replacement therapy, many of these symptoms can be relieved. For many years, injectable testosterone esters or surgically implanted testosterone pellets have been the preferred treatment for male hypogonadism. Recently, newer treatment modalities have been introduced, including transdermal patches and gels. The development of a mucoadhesive sustained-release buccal tablet is the latest innovation, which will provide patients with an additional option. The availability of new treatment modalities has helped to renew interest in the management of male hypogonadism, highlighting the need to address a number of important but previously neglected questions in testosterone replacement therapy. These include the risks and benefits of treatment in different patient populations (e.g. the elderly) and the need for evidence-based diagnosis and treatment monitoring guidelines. While some recommendations have been developed in individual countries, up-to-date, internationally accepted evidence-based guidelines that take into account national differences in clinical practice and healthcare delivery would optimize patient care universally.
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Affiliation(s)
- E Nieschlag
- Institute of Reproductive Medicine of the University Domagkstr 11, D-48129 Munster, Germany.
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Abstract
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.
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Affiliation(s)
- Louis J G Gooren
- Department of Endocrinology, Section of Andrology, VU University Medical Center, Amsterdam, The Netherlands.
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