Androgens in Health and Disease.pdf - E Library

Chapter 18/Androgens in Older Men 359
Table 7
Testosterone Delivery Forms for Use in ART
Recommended
Preparation initial dose regimen Potential specific adverse effects
Injectable Esters
Testosterone enanthate 75 mg im/wk Pain at injection site
or cypionate or 150 mg im/2 wk Mood swings
Large increase in hemoglobin/hematocrit
Elevated serum estradiol
Pellets 224 mg/4–6 mo Local-site infection
Extravasations of pellet
Large increase in hemoglobin/hematocrit
Patches
Scrotal 40 cm 2 patch/d Shaving of scrotum necessary
Adhesion problems
Elevated DHT levels
Nonscrotal 5 mg/d Adhesion problems
Dermatitis at application site
Gel 5-g packet/d Mildly elevated DHT levels
The patch delivery forms of T provide physiologic levels of T throughout most of the
24-h dosing period and, if needed, allow for rapid discontinuation of therapy. The
transdermal patch also provides physiologic levels of estradiol and DHT, whereas
the scrotal patch yields supraphysiologic levels of serum DHT. If applied in the evening,
patch therapy can mirror the diurnal variation in blood levels of T, although the importance
of this has not been demonstrated. Hemoglobin and hematocrit changes with the
patch forms of therapy are usually quite small. Limitations of patch therapy include the
following: lack of flexibility in the dosing because only whole-patch adjustments can
be made; strong dependence of T levels obtained on patient compliance with skin preparation
and application instructions; lack of acceptance by some men because of cosmetic
reasons; and the incidence of skin reactions to the patch, which seems to occur more often
in older men than in younger men and more often with the first-generation transdermal
patch (Androderm) than with the other patch forms. Coapplication of 0.1% triamcinolone
cream may lessen or negate the skin reaction.
The gel form of T provides about 24 h of midrange physiologic levels of T and
estradiol while producing serum DHT levels that are mildly supraphysiologic. The application
of the gel requires a moderate amount of skin area, but the gel is colorless and
the skin surface area utilized has only a small influence on T levels achieved. The gel
comes in two different dose packets, and application of less than a full packet is possible,
allowing for some dosing flexibility. Skin reactions to the gel have not proven to be a
problem to date. At this time, the major drawback to the gel form of therapy is its cost.
Monitoring for appropriateness of serum level of T obtained, for efficacy of therapy,
and for possible adverse effects is an ongoing process. The initial monitoring should be
within about 3 mo after initiating therapy and should include an evaluation for weight
gain, peripheral edema, gynecomastia or breast tenderness, LUTS, problems with sleep,
bothersome changes in mood or libido, and a digital rectal examination of the prostate.