A Review of Testosterone Replacement Therapy Materials

A REVIEW OF TESTOSTERONE REPLACEMENT THERAPY FOR THE HEALTHCARE TEAM

L. Austin Fredrickson, MD, FACP

L. Austin Fredrickson, MD, FACP, is an Associate Professor of Internal Medicine at Northeast Ohio Medical University, where he serves as core faculty and teaches diagnostics, therapeutics, clinical skills, and health humanities. He is board-certified in general internal medicine and practices rural primary care.

Liz Fredrickson, PharmD, BCPS

Liz Fredrickson is an Associate Professor of Pharmacy Practice and Pharmaceutical Sciences at the Northeast Ohio Medical University (NEOMED) College of Pharmacy.

Topic Overview:

One issue many men face is hypogonadism. Hypogonadism in men refers to a person with low testosterone levels. This androgen deficiency can cause a decrease in the quality and/or quantity of sperm. Testosterone levels naturally decline as men age, but some experience a more pronounced deficiency that can negatively affect their quality of life. Testosterone replacement therapy (TRT) may be used to correct the symptoms of testosterone deficiency as well as maintain secondary sex characteristics. Healthcare team members, including pharmacists and physicians, may overcome uncertainties and variations in diagnosis and management by being more knowledgeable about TRT. Team members must be able to identify candidates for therapy, educate patients on proper use and risks, monitor adverse effects, and optimize therapeutic outcomes. This continuing education activity will explore the clinical applications of TRT, including its benefits, risks, and considerations for safe and effective use, focusing on the roles of care team members.

Accreditation Statement

RxCe.com LLC is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education.

Universal Activity Number (UAN): The ACPE Universal Activity Number assigned to this activity is 

Pharmacist  0669-0000-24-169-H01-P

Pharmacy Technician  0669-0000-24-170-H01-T

Credits: 2 contact hour(s) (0.2 CEU(s)) of continuing education credit

Type of Activity: Knowledge

Media: Internet/Home study Fee Information: $6.99

Estimated time to complete activity: 2 contact hour(s) (0.2 CEU(s)), including Course Test and course evaluation

Release Date: November 30, 2024 Expiration Date: November 30, 2027

Target Audience: This educational activity is for pharmacists and pharmacy technicians.

How to Earn Credit: From November 30, 2024, through November 30, 2027, participants must:

Read the “learning objectives” and “author and planning team disclosures;”

Study the section entitled “Educational Activity;” and

Complete the Course Test and Evaluation form. The Course Test will be graded automatically. Following successful completion of the Course Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)

Credit for this course will be uploaded to CPE Monitor®.

Learning Objectives: Upon completion of this educational activity, participants should be able to:

Describe testosterone replacement therapy (TRT) formulations, including administration methods

Evaluate the benefits and risks of TRT

Counsel patients on administration, storage, and side effects of TRT

Disclosures

The following individuals were involved in developing this activity: Austin Fredrickson, MD, Liz Fredrickson, PharmD, BCPS, and Pamela Sardo, PharmD, BS. Pamela Sardo, Liz Fredrickson, PharmD, BCPS, and Austin Fredrickson, MD, have no conflicts of interest or financial relationships regarding the subject matter. There are no financial relationships or commercial or financial support relevant to this activity to report or disclose by RxCe.com or any of the individuals involved in the development of this activity.

© RxCe.com LLC 2024: All rights reserved. No reproduction of all or part of any content herein is allowed without the prior, written permission of RxCe.com LLC.

Educational Activity

A Review of Testosterone Replacement Therapy for the Healthcare Team

Introduction

Men can experience low testosterone levels for many reasons, including a natural decline occurring as they age. In this context, “men” refers to individuals assigned male at birth (AMAB), though TRT is also used within the transgender and gender-diverse communities among those seeking masculinization. Some patients experience a more pronounced deficiency that can negatively affect their quality of life. Testosterone replacement therapy may be used to correct the symptoms of testosterone deficiency as well as maintain secondary sex characteristics. Testosterone replacement therapy is also a fundamental component of medical care for transgender men, and other nonbinary individuals seeking masculinization, helping them achieve serum testosterone levels within the typical male reference range. There are benefits to testosterone replacement therapy, but these therapies are not without risk. Healthcare team members, including pharmacists and physicians, may overcome uncertainties and variations in diagnosis and management by being more knowledgeable about testosterone replacement therapy. Team members must be able to identify candidates for therapy, educate patients on proper use and risks, monitor adverse effects, and optimize therapeutic outcomes. This continuing education activity will explore the clinical applications of testosterone replacement therapy, including its benefits, risks, and considerations for safe and effective use, focusing on the roles of care team members.

Hypogonadism in Men

Men’s Health Month is celebrated in the United States in June each year to spread awareness and educate people on men’s health issues.1 One issue many men face is hypogonadism, i.e., low testosterone levels. Low

testosterone levels cause a decrease in the quality and/or quantity of sperm as well as androgen deficiency.2

As men age, testosterone levels naturally decline, but some experience a more pronounced deficiency that can negatively affect their quality of life. Studies, including the notable Baltimore Longitudinal Study of Aging, have found that declines in testosterone often begin around the third decade of life and progress slowly over time.3 The prevalence of hypogonadism was estimated at approximately 5% in the US in 2017, increasing from 0.8% in 2008.2,4 Table 1 provides useful abbreviations for testosterone replacement therapy (TRT).

Table 1

TRT Abbreviations

Testing Testosterone Levels

Initial testing begins with measuring total serum testosterone levels in the morning when testosterone levels peak. A single low measurement should be confirmed with a second test on a different day, as testosterone levels can vary due to factors like stress, sleep, and illness. If low testosterone levels are confirmed, further evaluation should be done, including assessing luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels to determine if the hypogonadism is primary (a testicular issue) or secondary (a hypothalamic/pituitary issue). High LH and FSH indicate primary hypogonadism, while low or normal LH and FSH suggest secondary hypogonadism.5

For patients with secondary hypogonadism, additional tests may be necessary to identify the underlying etiology. Prolactin levels, thyroid function (T4), morning cortisol, and iron studies (ferritin) can provide insights into other potential causes, such as pituitary tumors, hypothyroidism, or hemochromatosis. If secondary hypogonadism is suspected, imaging studies, such as a brain MRI, may be warranted to rule out pituitary or hypothalamic lesions. For primary hypogonadism, karyotype analysis may be indicated, especially in younger males, to screen for genetic disorders such as Klinefelter syndrome. Often, in aging males without other clinical concerns but labs consistent with primary hypogonadism, no further testing is indicated.

Recognizing these testing strategies is crucial for guiding appropriate management and potential testosterone replacement therapy if clinically indicated.5

Free testosterone should be checked when total testosterone levels are borderline low or inconsistent with clinical symptoms, as free testosterone represents the biologically active portion of testosterone not bound to proteins. This test is particularly useful in older men or those with conditions affecting sex hormone-binding globulin (SHBG) levels, such as obesity, liver disease, or thyroid disorders, where total testosterone may not accurately reflect bioavailable testosterone.5

Testosterone Replacement Therapy

Testosterone is the primary male hormone responsible for regulating sex differentiation, developing male characteristics, spermatogenesis, and fertility.2,6 It plays a crucial role in forming male sex organs and promoting testicular descent during fetal development. Additionally, testosterone influences secondary male characteristics such as hair patterns, deepening voice, muscle growth support, bone density, and spermatogenesis throughout life.2,5,6

The purpose of TRT is to correct the symptoms of testosterone deficiency as well as maintain secondary sex characteristics.6 Before initiating TRT, physicians should first work with patients to address any underlying or related causes, which may include obesity, type 2 diabetes mellitus, and metabolic syndrome.6 Weight loss and increased exercise have been shown to increase total testosterone levels. Testosterone levels should be tested before starting therapy, but unfortunately, studies have shown many men do not receive this testing.3,6 The American College of Physicians (ACP) has provided four key recommendations pertaining to testosterone treatment. These have also been endorsed by the American Academy of Family Physicians.7

For individuals with age-related low testosterone and sexual dysfunction who want to improve sexual function, the decision to initiate testosterone therapy should occur with shared decision- making of a discussion of the potential benefits, harms, costs, and patient preferences.

For individuals with age-related low testosterone and sexual dysfunction who decide to initiate testosterone therapy, symptoms should be reevaluated within 12 months, and treatment should be discontinued when there is no improvement in sexual function.

For individuals with age-related low testosterone and sexual dysfunction who decide to initiate testosterone therapy, intramuscular and transdermal formulations have similar clinical effectiveness and harms. However, intramuscular formulations are preferred as the costs are considerably lower.

Testosterone therapy is not recommended in men with age-related low testosterone to improve energy, vitality, physical function, or cognition.

Clinical Pearl: TRT in the Transgender Community

Testosterone replacement therapy is a fundamental component of medical care for transgender men and other gender-diverse individuals who aim to masculinize, with the aim of achieving serum testosterone levels within the typical biological male reference range and phenotypical masculinization.8 This therapy produces desired changes such as increased facial and body hair, enhanced lean muscle mass and strength, reduced fat mass, voice deepening, heightened sexual desire, menstrual cessation, clitoral growth, and alleviation of gender dysphoria, stress, anxiety, and depression.8 However, along with these benefits come notable side effects and risks, including acne, hair loss, lowered high-density lipoprotein (HDL) cholesterol, elevated triglycerides, and a potential rise in systolic blood pressure.

A significant challenge in TRT research for transgender men is the limited availability of high-quality data.9 This is due to a scarcity of randomized controlled trials, many of which are constrained by ethical considerations. One open-label randomized clinical trial conducted in Melbourne, Australia, involved 64 transgender and gender-diverse adults ages 18-70 seeking testosterone therapy for masculinization.9 Participants were divided into two groups. One received immediate testosterone therapy, and the other followed a 3-month waiting period (standard care). Key outcomes measured included gender dysphoria (using the Gender Preoccupation and Stability Questionnaire), depression (PHQ-9), and suicidality (SIDAS), assessed at baseline and 3 months.

The study found that the testosterone group experienced more significant reductions in the following:9

Gender dysphoria (mean difference of −7.2 points, P < .001)

Depression (mean difference of −5.6 points, P < .001)

Suicidality (mean difference of −6.5 points, P < .001)

Additionally, 52% of participants in the testosterone group reported resolution of suicidality compared to only 5% in the standard care group (p = 0.002).9 Minor side effects included injection site discomfort and transient headache, with no cases of polycythemia reported. The authors concluded this study provides evidence supporting the mental health benefits of immediate testosterone therapy for transgender and gender-diverse individuals, and the findings highlight the importance of timely access to gender-affirming care.

The complexity of care for transgender men and others undergoing TRT also underscores the need for robust interprofessional collaboration.10 Here, healthcare team members engage in comprehensive discussions regarding patient needs, monitor for adverse effects, evaluate outcomes, and support shared decision-making processes. One study examined the impact of an interprofessional team, which included a clinical pharmacist, psychiatrist, nurse practitioner, endocrinologist, diabetes educator, massage therapist,

nurse, nutritionist, and medical assistants working together to support transgender and gender-nonconforming (TGNC) patients.10

The clinical pharmacist fulfilled multiple roles to enhance patient care, such as assessing health literacy and tailoring the consent process to each patient’s understanding, engaging in detailed discussions about the medical risks, benefits, and alternatives to cross-sex hormone therapy (HT), and providing information on the expected timelines for HT effects. Additionally, the pharmacist helped patients align their treatment goals with realistic outcomes, assisted in selecting the most suitable HT formulation, facilitated the clinic team’s efforts to obtain prior authorizations, and contributed to risk management strategies, such as promoting smoking cessation and weight loss. The pharmacist's involvement improved the accessibility and quality of care for patients.

Testosterone Replacement Therapy Formulations

When TRT is started, providers have numerous therapies from which to choose. Thoughtful consideration should be taken, which should also involve the patient, to select the most appropriate therapy. Per the World Health Organization (WHO), the ideal androgen for replacement therapy should meet several key criteria, including safety, efficacy in addressing symptoms and consequences of testosterone deficiency, affordability, ease of administration, and flexible dosing.3 Each route of administration for TRT has unique considerations, and the choice of therapy should be based on patient preference, tolerability, and clinical goals. Pharmacists play a critical role in guiding patients through the selection process, ensuring the safe and effective use of testosterone replacement therapy. Pharmacy teams are also ideally positioned to communicate patient issues or concerns to the prescriber. Available formulations are summarized in Table 2, and these are discussed in more detail below.

Table 2

Summary of TRT Formulations6

Oral Testosterone

Oral testosterone is typically ineffective due to rapid inactivation by first- pass metabolism in the liver.6 However, testosterone undecanoate, an esterified form, is absorbed through the lymphatic system and can provide native testosterone in the body.6 Despite this, its oral bioavailability is inconsistent, and patients must take multiple doses daily with meals. Side effects such as gastrointestinal and liver issues have prevented the approval of oral testosterone undecanoate in the US.6

Buccal Testosterone

Buccal testosterone involves applying mucoadhesive tablets to the gums, bypassing the liver, and steadily releasing testosterone.6 This method ensures peak testosterone levels within 10-12 hours, but levels drop soon after tablet removal.6 Buccal testosterone was generally well tolerated in clinical trials, though common side effects included gum irritation. Despite these advantages, the efficacy of buccal testosterone in alleviating symptoms of testosterone deficiency remains unclear.6 The buccal tablet (Striant®) is no longer available within the US.

Nasal Testosterone

Nasal gel formulations offer an alternative route for TRT, bypassing first- pass metabolism and achieving peak testosterone concentrations within 40 minutes.6 Administered via a metered-dose pump, nasal testosterone is well tolerated but can cause mild side effects like nosebleeds and upper respiratory infections.6 It maintains testosterone levels without significantly affecting luteinizing hormone (LH) or follicle-stimulating hormone (FSH) levels, preserving fertility.6

Subdermal Testosterone Implants

Subdermal implants are a long-lasting option for TRT, delivering consistent testosterone release for 3-6 months. Testosterone pellets, inserted under the skin, offer the benefit of infrequent dosing and high patient compliance.6 However, the invasive nature of the procedure, as well as potential complications like pellet extrusion and site infections, limits their use.6 Implants are typically reserved for specific cases where other forms of testosterone administration are not suitable.6

Transdermal Testosterone (Patches)

Testosterone patches offer patients a non-invasive way to administer TRT.6 They mimic the body's natural circadian rhythm of testosterone release when applied daily to the skin.6 However, skin reactions such as erythema and pruritus are common, and the patches may cause discomfort or poor adherence.6 Despite these limitations, transdermal patches allow for steady testosterone levels and avoid transference risks, making them a preferred option for some patients.6 The patch (Androderm®) has been discontinued in the US.

Testosterone Gels and Solutions

Gels and liquids are widely used for TRT because they provide consistent serum testosterone levels and are easy to apply.6 However, there is a risk of testosterone transfer to others, particularly women and children, leading to the inclusion of boxed warnings on these products.6 Patients are advised to wash their hands after application and cover the treated area to minimize transfer.6 The flexibility in dosing and consistent pharmacokinetics make gels and solutions popular options for managing testosterone deficiency.6

Intramuscular (IM) Testosterone Injections

Intramuscular injections of testosterone esters, such as testosterone cypionate and testosterone enanthate, are among the oldest and most commonly used TRT formulations.6 These injections provide prolonged testosterone release, but serum levels can fluctuate, leading to peaks and troughs that may affect mood and energy levels.6 Testosterone undecanoate is a longer-acting IM formulation that requires less frequent dosing, providing more stable testosterone levels over time.6 However, rare complications such as pulmonary oil microembolism (POME) and the need for regular monitoring make IM injections less convenient for some patients.6

Benefits and Risks of TRT

Testosterone replacement therapy can offer benefits to patients but it also comes with risks.

Benefits of TRT

Testosterone replacement therapy can offer benefits to patients, particularly older men. A review of 38 randomized control trials in the Annals of Internal Medicine found that TRT administered via intramuscular or transdermal routes was shown to provide small improvements in sexual function and self-reported quality of life in men with low testosterone levels not caused by primary or secondary hypogonadism.3 Quality of life improvements were mostly associated with improvements in sexual function, as measured by the AMS scale.3 The evidence for these benefits was of low to moderate certainty, with most trials including men over 60 years old and without severe comorbid conditions.3

Testosterone replacement therapy has also been shown to significantly increase bone mineral density, particularly in the vertebral and femoral regions, and improve estimated bone strength compared to placebo, making it valuable in supporting bone health.5 Testosterone replacement therapy also

increases hemoglobin levels, effectively correcting anemia in a higher proportion of men with unexplained anemia of aging.5 Additionally, therapy is associated with improvements in lean body mass, grip strength, and self- reported physical function, offering some physical benefits, particularly in maintaining muscle mass and strength.5

Risks of TRT

Side effects associated with TRT include acne, oily skin, erythrocytosis (high concentration of red blood cells), breast tenderness, breast enlargement, and leg edema (swelling).5 Use also places patients at an increased risk of prostate events.5 Transdermal patch use may result in skin irritation, and buccal formulations can cause gum problems and ulceration in patients.5 Injectable preparations have been associated with mood fluctuations and pain at the injection site, and nasal formulations can cause issues such as irritation, epistaxis (nose bleeds), and nasal scabs.5

In the Annals article, the studies reviewed were not large or long enough to definitively assess the risk of major adverse cardiovascular events, prostate cancer, or other serious harms.3 While some studies showed an increase in coronary artery noncalcified plaque, no significant differences in cardiovascular outcomes, such as coronary artery calcium scores or carotid intima-media thickness, were found.3 Other potential risks, like polycythemia, elevated PSA levels, and increased blood pressure, were not within the scope of this review but are recognized as concerns with TRT.3

The long-term risks of TRT are still unclear, especially in relation to prostate cancer and cardiovascular disease.5 While no clear evidence links testosterone to prostate cancer, there are concerns it could promote the growth of subclinical cancers.5 The relationship between testosterone and cardiovascular events remains inconsistent, with some studies suggesting an increased risk of mortality, especially in men with comorbidities.5 Meta- analyses have not established a significant association between testosterone and major cardiovascular events. Screening for low testosterone is not

recommended for all men, but therapy may be considered for symptomatic men with clear testosterone deficiency, following a careful discussion of risks and benefits.5 Ongoing trials, such as the TRAVERSE study, will provide more data on the long-term cardiovascular and prostate safety of testosterone therapy.

Contraindications to TRT

Clinicians should know the contraindications when using TRT and ensure patients can safely utilize these therapies. Numerous organizations, including the Endocrine Society, BSSM, and EMAS, have identified contraindications to therapy and provided recommendations.5 Testosterone administration is associated with a very high risk of serious adverse outcomes when used in patients with certain conditions, including metastatic prostate cancer and breast cancer.5,6 Additionally, there are conditions where testosterone use poses a moderate to high risk of adverse outcomes, including the presence of an undiagnosed prostate nodule or induration, a prostate-specific antigen (PSA) level greater than 3, and erythrocytosis, where the hematocrit level exceeds 50%.5,6 Severe lower urinary tract symptoms associated with benign prostatic hypertrophy, as indicated by an AUA/International Prostate Symptom Score greater than 19, also fall into this risk category.5,6 Additionally, patients with uncontrolled or poorly controlled congestive heart failure, as well as those who have experienced a myocardial infarction, stroke, or acute coronary syndrome within the preceding three months, are at elevated risk when receiving testosterone therapy.5,6 In general, patients who are trying to conceive, wish to have a child or wish to maintain their fertility should avoid TRT.6 A full review of contraindications is presented in Table 4.

Table 4 Contraindications to TRT Therapy6

TRT Monitoring

Once patients have been initiated on TRT, they will require regular follow-up and monitoring to assess the improvement of symptoms and the development of any side effects. It is recommended that patients are assessed within 1-3 months and then annually.5

Laboratory monitoring includes serum testosterone concentrations, hematocrit values, and PSA levels.5 Additionally, it is recommended that patients with baseline abnormal bone mineral density have this monitored 1- 2 years after starting TRT.6 Monitoring recommendations by various guidelines are summarized in Table 5.6

Table 5

Recommendations for Monitoring Patients on TRT6

Pharmacists can assist the team in assessing patients for adherence to therapy and providing recommendations when nonadherence is present. Ensuring patients understand the timeline of expected changes and improvements can help improve adherence to therapy. In general, patients may expect to see improvements in sexual desire within 3-6 weeks, while improved ejaculation requires upwards of six months of treatment.6 If improvements have not been seen within six months, patients should be reevaluated to continue therapy, with clinicians considering the risks and benefits.6

Pharmacists should carefully review other medications the patient may be taking, as TRT can interact with drugs such as insulin, anticoagulants, and corticosteroids.11 Because they are often the last healthcare professional a patient sees before starting their TRT, pharmacists and the pharmacy team play critical roles in ensuring the safety and efficacy of these therapies.6

Patient Counseling and Education

Patient education is critical before and during the use of TRT. Pharmacists play key roles in educating patients on the proper use, benefits, and risks of TRT and should stress several key counseling points when discussing TRT with patients. First, it is crucial to keep the medication away from women and children.11 Notably, in 2009, the FDA added a boxed warning to transdermal gel products describing the risk of transference to children and women.11 Additionally, if a patient is using a gel or solution, they should be instructed to wash their hands before and after application and cover the application area with a T-shirt to prevent accidental contact.11 Patients should also be advised to contact their physician immediately if they experience any severe reactions to testosterone therapy.11 The care team should caution patients that the use of testosterone injection products can result in supraphysiological (higher than normal) serum levels of testosterone produced during the dosing interval, and such increases have been linked to changes in mood. If a patient misses a transdermal gel dose, it should be applied when the patient remembers it. When the patient remembers, if it is

close to the next application, the patient should skip the missed dose and apply the transdermal gel at the next scheduled time. Patients should be counseled not to double the dosing.

Additional counseling points are summarized in Table 6.11

Table 6

Counseling Points for Patients on TRT11

Roles of Care Team Members

Physicians

Physicians managing testosterone therapy should understand the benefits and drawbacks of different testosterone preparations and involve their patients in shared decision-making to select the best option. These providers should be familiar with the most current guidelines on the use and management of TRT and be aware of product-specific monitoring.

Pharmacists

Pharmacists can be essential in assisting the care team in managing TRT. In collaboration with physicians, pharmacists can screen for the condition, address risk factors, and manage treatment, including initiating and counseling on lab testing where permitted. A prospective cohort study comparing pharmacist management of testosterone therapy (TT) to PCP management showed that pharmacists significantly improved monitoring of baseline parameters (54% vs. 20%), documented more remarkable symptom improvement (96% vs. 26%), and more frequently monitored complete blood counts (100% vs. 83%) and testosterone levels (96% vs. 61%).12

Pharmacy Technicians

Pharmacy technicians are important in supporting patients on TRT and can assist pharmacists in several key areas. Testosterone replacement therapy formulations may be prepared when commercially available products are unsuitable for a specific patient and technicians are vital to the compounding process. Pharmacy technicians may be responsible for measuring ingredients accurately, following compounding protocols, and adhering to safety standards, such as USP <795> guidelines for non-sterile compounding. They ensure that the compounded TRT formulations are prepared in a safe environment, avoiding contamination and ensuring consistency in the final preparation. Additionally, they assist with labeling,

packaging, and providing instructions for compounded TRT formulations to ensure proper use and storage.

Additional Resources

More information on organization-specific guidelines for TRT is provided in Table 7. Clinicians should read and review organization-specific guidelines to better understand this topic.

Table 7

Guidelines Pertaining to the Use of TRT

Summary

Hypogonadism is characterized by low testosterone levels in men. It is associated with symptoms such as fatigue, reduced libido, mood disturbances, and muscle loss and is a condition affecting a growing number of men, particularly as they age. Testosterone replacement therapy has emerged as a widely used treatment to address these symptoms and improve a patient's quality of life. While TRT offers notable benefits, particularly in sexual function and bone density, it also carries risks, such as cardiovascular concerns, prostate health complications, and other potential side effects. Physicians and pharmacists are vital in identifying appropriate candidates for TRT, counseling patients on proper administration and storage, and monitoring for adverse effects to optimize therapy.

Course Test

Which of the following testosterone replacement formulations is known for its rapid absorption and ability to maintain testosterone levels without affecting fertility?

Oral testosterone

Buccal testosterone

Nasal testosterone

Injectable testosterone

Which formulation of TRT involves a minor surgical procedure and provides consistent testosterone release for 3-6 months?

Transdermal patches

Injectable testosterone

Subdermal implants

Buccal testosterone

Which of the following is a key counseling point for patients using testosterone gels?

Apply the gel to the scrotum for best absorption

Avoid contact with others until the gel has dried

Rotate injection sites to avoid irritation

Buccal administration is recommended with meals

Which of the following is a well-documented benefit of TRT in older men with low testosterone levels?

Increased bone mineral density and bone strength

Improvement in cognitive function

Significant improvement in mood and depressive symptoms

Decreased risk of prostate cancer

Which of the following is a recognized risk of testosterone replacement therapy?

A decrease in lean body mass

Erythrocytosis

Decreased sexual function

Reduced grip strength

Which choice below is an opportunity for interprofessional team communication regarding patients utilizing testosterone?

The patient states they will visit the dentist three hours after applying testosterone gel formulation for a routine dental cleaning appointment.

The patient brings a prescription refill request and asks for some names of eardrops, telling the pharmacy technician an earache developed the day after the testosterone injection.

The patient receiving injected testosterone formulation asks for the shelf location of the decongestants because he developed a cold.

The patient states the testosterone laboratory appointment occurred last week, but the patient no longer has insurance and needs a low-cost option, or they will stop using it.

What is a common adverse effect associated with the use of testosterone gels?

Gum irritation

Skin reactions

Mood fluctuations and injection site pain

Increased sperm production

Which of the following is a key counseling point for patients using injectable testosterone?

Rotate injection sites to avoid irritation

Apply testosterone gel immediately after a shower

Store injections in the freezer for better efficacy

Take with food to improve absorption

What is the recommended storage method for testosterone gel formulations?

Refrigerate to prevent degradation

Store at room temperature, away from children

Keep it in the freezer to maintain potency

Store in a humid environment for better absorption

Which TRT formulation has the potential risk of accidental transference to women or children?

Injectable testosterone

Buccal testosterone

Nasal testosterone

Testosterone gel

References

Men’s Health Month. https://menshealthmonth.org/. Accessed November 25, 2024.

Thirumalai A, Anawalt BD. Epidemiology of Male Hypogonadism. Endocrinol Metab Clin North Am. 2022;51(1):1-27. doi:10.1016/j.ecl.2021.11.016

Diem SJ, Greer NL, MacDonald R, et al. Efficacy and Safety of Testosterone Treatment in Men: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians. Ann Intern Med. 2020;172(2):105-118. doi:10.7326/M19-0830

Auerbach JM, Moghalu OI, Das R, et al. Evaluating incidence, prevalence, and treatment trends in adult men with hypogonadism in the United States. Int J Impot Res. 2022;34(8):762-768. doi:10.1038/s41443-021-00471-2

Bhasin S, Jameson J. Disorders of the Testes and Male Reproductive System. In: Loscalzo J, Fauci A, Kasper D, Hauser S, Longo D, Jameson

J. eds. Harrison's Principles of Internal Medicine, 21e. McGraw-Hill Education; 2022.

Barbonetti A, D'Andrea S, Francavilla S. Testosterone replacement therapy. Andrology. 2020;8(6):1551-1566. doi:10.1111/andr.12774

American Academy of Family Physicians. Testosterone Treatment. AAFP. 2019. https://www.aafp.org/family-physician/patient-care/clinical- recommendations/all-clinical-recommendations/testosterone- treatment.html. Accessed November 25, 2024.

Irwig MS. Testosterone therapy for transgender men [published correction appears in Lancet Diabetes Endocrinol. 2017 Apr;5(4):e2. doi: 10.1016/S2213-8587(16)30143-7]. Lancet Diabetes Endocrinol. 2017;5(4):301-311. doi:10.1016/S2213-8587(16)00036-X

Nolan BJ, Zwickl S, Locke P, Zajac JD, Cheung AS. Early Access to Testosterone Therapy in Transgender and Gender-Diverse Adults Seeking Masculinization: A Randomized Clinical Trial. JAMA Netw Open. 2023;6(9):e2331919. Published 2023 Sep 5.

doi:10.1001/jamanetworkopen.2023.31919

Newsome C, Colip L, Sharon N, Conklin J. Incorporating a pharmacist into an interprofessional team providing transgender care under a medical home model. Am J Health Syst Pharm. 2017;74(3):135-139. doi:10.2146/ajhp1603221

Douglas AG, Speaks J, Elliott J, Fanning DB. Counseling male patients on testosterone replacement therapy with efficacy and safety in mind.

U.S. Pharmacist. 2015;40(8):25-9.

Matai A, Abdullahi M, Beahm NP, Sadowski CA. Practice guideline for pharmacists: The management of late-onset hypogonadism. Can Pharm J (Ott). 2021;155(1):26-38. Published 2021 Oct 11. doi:10.1177/17151635211047468

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The information provided in this course is general in nature, and it is solely designed to provide participants with continuing education credit(s). This course and materials are not meant to substitute for the independent, professional judgment of any participant regarding that participant’s professional practice, including but not limited to patient assessment, diagnosis, treatment, and/or health management. Medical and pharmacy practices, rules, and laws vary from state to state, and this course does not cover the laws of each state; therefore, participants must consult the laws of their state as they relate to their professional practice.

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© RxCe.com LLC 2024: All rights reserved. No reproduction of all or part of any content herein is allowed without the prior, written permission of RxCe.com LLC.