How should a 78-year-old male with chronic thromboembolic pulmonary hypertension (CTEPH) be managed while on testosterone replacement therapy (TRT)?

Management of a 78-Year-Old Male with CTEPH on Testosterone Replacement Therapy

Testosterone replacement therapy (TRT) should be used with caution in a 78-year-old male with chronic thromboembolic pulmonary hypertension (CTEPH), with careful monitoring of hematocrit and testosterone levels, while maintaining the primary focus on optimal CTEPH management through anticoagulation and referral to a specialized CTEPH center for treatment evaluation. 1

CTEPH Management Priorities

Diagnosis Confirmation

• Ensure diagnosis meets criteria: mean pulmonary arterial pressure ≥25 mmHg, pulmonary wedge pressure ≤15 mmHg, and evidence of chronic thromboembolic obstruction 1
• Ventilation/perfusion (V/Q) scan is essential - a normal scan rules out CTEPH 1
• Complete evaluation should include:
  • Right heart catheterization to confirm pulmonary hypertension
  • CT pulmonary angiography to visualize thromboembolic obstructions
  • Pulmonary angiography at specialized centers for surgical planning 1

Primary Treatment Approach

1. Lifelong anticoagulation - mandatory for all CTEPH patients 1

   • Vitamin K antagonists (target INR 2.0-3.0) are recommended
   • No data support NOACs in CTEPH 1

2. Referral to CTEPH expert center for multidisciplinary evaluation 1

   • Centers should perform at least 20 pulmonary endarterectomies per year with mortality <10% 1
   • Treatment decisions require interdisciplinary discussion among specialists

3. Treatment options assessment in order of preference:

   • Pulmonary endarterectomy (PEA) - potentially curative surgical option and treatment of choice 1
   • Balloon pulmonary angioplasty (BPA) - for technically inoperable cases 2
   • Medical therapy - for inoperable disease or persistent PH after surgery 1
     • Riociguat has the strongest evidence for CTEPH 3, 4
     • Other pulmonary vasodilators may be considered in selected cases

TRT Considerations in CTEPH

Risk Assessment

• TRT may increase risk of thrombotic events and could potentially worsen CTEPH 1
• Advanced age (78 years) and CTEPH represent significant risk factors

TRT Management Recommendations

1. Testosterone level monitoring:

   • Continue TRT only if testosterone levels are <230 ng/dL and patient is symptomatic 1
   • For levels 231-346 ng/dL, carefully weigh risks/benefits 1
   • Levels >350 ng/dL generally do not require TRT 1

2. TRT administration:

   • Use easily titratable formulations (gel, spray, patch) rather than long-acting injectables in patients >70 years 1
   • Target mid-range testosterone levels (350-600 ng/dL) 1
   • Limit treatment duration to 4-6 months initially, continuing only if clear clinical benefit 1

3. Monitoring during TRT:

   • Baseline and 6-month hematocrit and PSA testing 1
   • Regular cardiovascular assessment
   • Monitor for fluid retention, especially with history of heart failure 1

Integrated Management Approach

1. Optimize CTEPH treatment first:

   • Ensure proper anticoagulation
   • Complete evaluation at specialized CTEPH center
   • Implement appropriate treatment (PEA, BPA, or medical therapy)

2. Reassess TRT necessity:

   • Consider discontinuation if CTEPH is severe or poorly controlled
   • If continuing TRT, use lowest effective dose with careful monitoring

3. Regular follow-up:

   • Monitor pulmonary hemodynamics
   • Assess right ventricular function
   • Evaluate for signs of disease progression or thrombotic complications

Pitfalls and Caveats

• Avoid delaying referral to CTEPH expert center - this is a potentially curable condition if treated appropriately
• Don't overlook the importance of lifelong anticoagulation, which is mandatory regardless of other treatments
• Be cautious with TRT in this high-risk patient; the Princeton III consensus notes that caution is warranted with TRT in patients with heart failure due to risk of fluid retention 1
• Remember that CTEPH has high mortality if untreated - 70% at 3 years in non-operated patients versus 89% survival in operated patients 1