From the Guidelines
The recommended protocol for Testosterone Replacement Therapy (TRT) in patients with hypogonadism typically involves either injectable testosterone cypionate or enanthate at 50-100mg weekly or 100-200mg every two weeks, transdermal testosterone gel (AndroGel, Testim) at 50-100mg applied daily, or testosterone pellets implanted subcutaneously every 3-6 months. Treatment should begin after confirming hypogonadism through at least two morning total testosterone measurements below 300 ng/dL along with clinical symptoms, as suggested by the American College of Physicians 1. Before initiating therapy, patients should undergo baseline assessments including prostate-specific antigen (PSA), hematocrit, and lipid profile. Monitoring should occur at 3,6, and 12 months after starting treatment, then annually, checking testosterone levels, hematocrit, PSA, and symptom improvement, as recommended by the clinical guideline from the American College of Physicians 1. Dose adjustments aim to maintain testosterone levels in the mid-normal range (500-700 ng/dL). TRT is contraindicated in men with breast or prostate cancer, untreated severe sleep apnea, severe lower urinary tract symptoms, or hematocrit above 54%, as stated in the evidence report for a clinical practice guideline by the American College of Physicians 1. The therapy works by replacing deficient testosterone, which helps restore sexual function, increase energy, improve mood, increase muscle mass, and maintain bone density in hypogonadal men. It is essential to consider patient preferences and values when deciding on a treatment option, as some patients may prefer injectable testosterone over gel-based regimens due to lower cost, while others may prefer a topical gel for convenience and ease of use 1. Additionally, the relative importance of outcomes, such as lack of energy, decreased strength and endurance, and deterioration in work performance, should be taken into account when evaluating the effectiveness of TRT 1. The annual cost of TRT can vary significantly, with transdermal formulations costing $2135.32 per beneficiary and intramuscular formulations costing $156.24 per beneficiary, according to the 2016 Medicare Part D Drug Claims data 1. Overall, the goal of TRT is to improve the quality of life for hypogonadal men, and the recommended protocol should be tailored to individual patient needs and preferences. Key points to consider when implementing TRT include:
- Confirming hypogonadism through laboratory tests and clinical symptoms
- Conducting baseline assessments and regular monitoring
- Adjusting doses to maintain testosterone levels in the mid-normal range
- Considering patient preferences and values
- Evaluating the effectiveness of TRT based on individual patient outcomes.
From the FDA Drug Label
2 DOSAGE AND ADMINISTRATION
Prior to initiating AVEED, confirm the diagnosis of hypogonadism by ensuring that serum testosterone concentrations have been measured in the morning on at least 2 separate days and that these serum testosterone concentrations are below the normal range. The recommended dose of AVEED is 3 mL (750 mg) injected intramuscularly, followed by 3 mL (750 mg) injected after 4 weeks, then 3 mL (750 mg) injected every 10 weeks thereafter.
The recommended protocol for Testosterone Replacement Therapy (TRT) in patients with hypogonadism is to administer 750 mg of testosterone undecanoate intramuscularly, with the following schedule:
- Initial dose: 750 mg
- Second dose: 750 mg after 4 weeks
- Subsequent doses: 750 mg every 10 weeks thereafter It is essential to confirm the diagnosis of hypogonadism by measuring serum testosterone concentrations on at least 2 separate days before initiating treatment 2.
From the Research
Protocol for Testosterone Replacement Therapy (TRT)
The recommended protocol for TRT in patients with hypogonadism involves various forms of testosterone administration, including:
- Transdermal application of testosterone gels, which are the most commonly used route of administration 3
- Intramuscular injections of testosterone undecanoate, which have a favorable pharmacokinetic profile and can maintain serum testosterone levels within the normal range for up to 3 months 4
- Long-acting injectable formulations, such as testosterone undecanoate, which can improve patient compliance and provide stable serum testosterone levels 5
- Oral testosterone formulations, such as oral testosterone undecanoate, which can be used but may have limitations due to variable absorption and bioavailability 4, 3
Key Considerations
When initiating TRT, it is essential to:
- Monitor patients carefully for changes in hematocrit, liver function, lipid parameters, and prostate-specific antigen (PSA) 6
- Individualize the dose and administration regimen based on patient response and tolerance 7
- Consider the patient's preferences and lifestyle when selecting a formulation, such as the convenience of transdermal gels or the stability of long-acting injectable formulations 4, 5
Formulations and Administration
The choice of formulation and administration regimen depends on various factors, including: