What are the options for testosterone replacement therapy in a 61-year-old male?

From the Guidelines

Testosterone replacement therapy (TRT) for a 61-year-old male should be initiated with intramuscular formulations, such as testosterone cypionate or testosterone enanthate, as they are more cost-effective and have similar clinical effectiveness and harms compared to transdermal formulations, as suggested by the American College of Physicians (1). The options for TRT include:

• Injectable testosterone: testosterone cypionate (100-200 mg every 1-2 weeks) or testosterone enanthate (100-200 mg every 1-2 weeks)
• Transdermal options: testosterone gel (AndroGel, Testim, 50-100 mg applied daily) and testosterone patches (Androderm, 2-6 mg applied nightly)
• Testosterone pellets (Testopel, 150-450 mg implanted subcutaneously every 3-6 months)
• Nasal testosterone (Natesto, 11 mg applied three times daily) and buccal testosterone (Striant, 30 mg applied to the gum twice daily) are less common alternatives. Before starting TRT, baseline PSA and hematocrit levels should be checked, with regular monitoring during treatment, as recommended by the American College of Physicians (1). TRT is appropriate for men with documented low testosterone levels and symptoms such as fatigue, decreased libido, and reduced muscle mass, as stated in the guidelines (1). The therapy works by restoring testosterone to physiological levels, which helps maintain secondary sexual characteristics, bone density, muscle mass, and overall energy levels, as described in the studies (1). Potential side effects include acne, fluid retention, increased red blood cell production, and possible effects on prostate health, which necessitates regular monitoring, as reported in the literature (1).

From the FDA Drug Label

INDICATIONS AND USAGE Testosterone Cypionate Injection is indicated for replacement therapy in the male in conditions associated with symptoms of deficiency or absence of endogenous testosterone. INDICATIONS AND USAGE Testosterone gel 1.62% is indicated for replacement therapy in males for conditions associated with a deficiency or absence of endogenous testosterone: Testosterone enanthate is also used for replacement therapy in males for conditions associated with symptoms of deficiency or absence of endogenous testosterone.

The options for testosterone replacement therapy in a 61-year-old male are:

• Testosterone Gel 1.62%: a topical gel formulation for daily application.
• Testosterone Cypionate Injection: an intramuscular injection formulation.
• Testosterone Enanthate: an intramuscular injection formulation. It is essential to consult a healthcare provider to determine the best course of treatment and to discuss the potential benefits and risks of testosterone replacement therapy 2, 3, 4.

From the Research

Testosterone Replacement Therapy Options

The options for testosterone replacement therapy in a 61-year-old male include:

• Transdermal testosterone delivery through patches or gels, which deliver testosterone at a controlled rate into the systemic circulation, avoiding hepatic first pass and reproducing the diurnal rhythm of testosterone secretion 5
• Intramuscular injections, which are a traditional long-acting option but may have peak and trough levels 5
• Buccal, nasal, and subdermal routes of delivery, which are also approved for use in the Western world 6
• Oral formulations, such as JATENZO and TLANDO, which are new options that address some of the limitations of other dosing routes and provide a safe option without evidence of liver dysfunction 7

Considerations for Older Men

When considering testosterone replacement therapy for a 61-year-old male, it is essential to take into account the potential risks and benefits, particularly in older men with a history of heart failure 6

• Shorter-acting testosterone preparations may be an advantage in older men, as they allow for a fast reduction of circulating testosterone levels if necessary 5
• The treatment of androgen deficiency syndrome or male hypogonadism may be complex, and there is no consensus on when to start treating or the best treatment option for an individual patient 8

Available Formulations

The available formulations for testosterone replacement therapy include:

• Testosterone patches, which are a transdermal option that delivers testosterone at a controlled rate 5
• Testosterone gels, which are a transdermal option that reaches a steady-state in the first 24 hours of application and remains in the normal range for the duration of the application 9
• Injectable testosterone esters, which are associated with peaks and troughs with each dose 9
• Oral formulations, such as JATENZO and TLANDO, which are new options that provide a safe and convenient alternative to traditional dosing routes 7