Guideline on Testosterone Treatment in Men With Age-Related Low Levels: Key Points

Authors:
Qaseem A, Horwitch CA, Vijan S, et al.
Citation:
Testosterone Treatment in Adult Men With Age-Related Low Testosterone: A Clinical Guideline From the American College of Physicians. Ann Intern Med 2020;172:126-133.

The following are key points to remember from the American College of Physicians (ACP) clinical guideline on testosterone treatment in adult men with age-related low testosterone:

  1. The safety and efficacy of testosterone replacement therapy in men with age-related low levels of testosterone is not clear. The ACP provided guidelines based on a systematic review.
  2. The incidence of age-related low testosterone in the United States ranges from 20% in men >60 years to 50% in those >80 years. The prevalence of symptomatic low testosterone (defined as ≥3 sexual symptoms with a total testosterone level <320 ng/dl) is lower.
  3. Energy and vitality, physical function, mood (depression), fracture reduction, libido and sexual function, and lower urinary tract symptoms were rated as important outcomes. Mean age was 66 years, and follow-up ranged from 6 to 36 months. Mean baseline total testosterone level was 300 ng/dl or lower. Outcomes did not vary substantially in studies that had different baseline testosterone levels or evaluated different testosterone formulations. There was no evidence for adverse cardiovascular (CV) or other serious events or mortality including those with recent CV disease. Testosterone improved vitality and fatigue by a “less-than-small amount” in three trials and in five trials, similar improvement.
  4. Twenty observational studies with a mean follow-up of 0.73-10.3 years showed no increase in risk for mortality, CV events, prostate cancer, or pulmonary embolism/deep vein thrombosis. But evidence for long-term safety was not adequate. Annual cost per patient use of testosterone was $2,125 for transdermal and $156 for intramuscular.
  5. Recommendations: In men with age-related low testosterone who want to improve sexual function, there is low certainty of evidence. If prescribed, it should be re-evaluated long-term and discontinued if there is no improvement. Testosterone should not be initiated to improve energy, vitality, physical function, or cognition.

Keywords: Depression, Fatigue, Fracture Fixation, Hormone Replacement Therapy, Libido, Lower Urinary Tract Symptoms, Physical Fitness, Prostatic Neoplasms, Pulmonary Embolism, Secondary Prevention, Testosterone, Treatment Outcome, Venous Thrombosis


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