How to manage a patient on testosterone cypionate (testosterone cypionate) 80mg weekly with Human Chorionic Gonadotropin (HCG) who has elevated testosterone levels but also elevated hematocrit (polycythemia)?

From the Guidelines

For a patient on testosterone cypionate 80mg weekly with HCG who has elevated testosterone and hematocrit levels, the primary management approach should be to reduce the testosterone dose to 50-60mg weekly while monitoring levels every 6-8 weeks until stabilized. This approach is based on the most recent and highest quality study, which recommends intervention when hematocrit exceeds 54% while on testosterone therapy, such as dose reduction or temporary discontinuation 1. The patient's current hematocrit level of 54.5% warrants immediate attention to prevent potential complications associated with polycythemia. Key considerations in managing this patient include:

• Reducing the testosterone dose to mitigate the risk of further increasing hematocrit levels
• Implementing therapeutic phlebotomy if hematocrit exceeds 54%, typically removing 450-500mL of blood every 2-3 months until hematocrit normalizes below 50%
• Adjusting the HCG dose as necessary to maintain testicular function while minimizing the risk of exacerbating polycythemia
• Encouraging lifestyle modifications, such as proper hydration, avoiding smoking, limiting alcohol, and regular aerobic exercise, to help manage polycythemia and overall health Regular monitoring, including complete blood count, comprehensive metabolic panel, lipid profile, and PSA testing every 3-6 months, is crucial to ensure the patient's safety and adjust the treatment plan as needed 1. If polycythemia persists despite these measures, consulting with a hematologist for further evaluation and management may be necessary, taking into account the potential risks and benefits of therapeutic phlebotomy, as outlined in guidelines for managing hematologic problems 1.

From the FDA Drug Label

Laboratory Tests Hemoglobin and hematocrit levels (to detect polycythemia) should be checked periodically in patients receiving long-term androgen administration. The patient has a hematocrit of 54.5, which is elevated, indicating polycythemia.

• The management of this patient should include reducing the dose of testosterone cypionate or stopping it temporarily to decrease the hematocrit level.
• Monitoring of hematocrit levels should be continued to assess the response to the dose adjustment.
• No conclusion can be drawn on the exact dose adjustment, as it depends on the individual patient's response and the appearance of adverse reactions 2.

From the Research

Management of Testosterone Replacement Therapy (TRT) in Patients with Elevated Hematocrit

• The patient in question is on testosterone cypionate 80mg weekly with Human Chorionic Gonadotropin (HCG) and has a testosterone level of 684, but also an elevated hematocrit of 54.5, indicating polycythemia.
• According to 3, elevated hematocrit is a common determinant of thrombotic risk in polycythemia and erythrocytosis, but the occurrence of thrombosis is independent of hematocrit in some cases.
• The study 4 suggests that therapeutic phlebotomy or venesection may be used to reduce hematocrit in patients with testosterone therapy-induced erythrocytosis, but the evidence supporting its efficacy and safety is lacking.

Considerations for Therapeutic Phlebotomy

• The review 5 notes that men undergoing TRT have a greater risk for developing erythrocytosis, and mechanisms involving iron bioavailability, erythropoietin production, and bone marrow stimulation may explain the erythrogenic effect of TRT.
• However, as mentioned in 4, phlebotomy may lower tissue oxygen partial pressure and deplete iron stores, potentially increasing thrombotic risk.
• The study 6 found an increase in therapeutic phlebotomy requests for patients on TRT, but highlights the need for careful consideration of the impact on blood centers and services.

Risks Associated with Elevated Hematocrit

• Elevated hematocrit is associated with reduced bleeding and increased thrombosis risk in humans, as noted in 7.
• The study 7 also found that elevated hematocrit enhances platelet accumulation following vascular injury, suggesting that red blood cells contribute to thrombus formation.
• Therefore, managing the patient's elevated hematocrit is crucial to reduce the risk of thrombotic events, and alternative strategies to phlebotomy, such as adjusting the testosterone dosage or using other formulations, may be considered 5.