What is the recommended usage of Androgel (testosterone) for testosterone replacement therapy in Singapore?

Recommended Usage of AndroGel for Testosterone Replacement Therapy in Singapore

For testosterone replacement therapy in Singapore, AndroGel 1% should be applied at a dose of 50-100 mg daily or AndroGel 1.62% at 20.25-81 mg daily to clean, dry skin of the upper arms and shoulders only, with monitoring of testosterone levels, hematocrit, and PSA at regular intervals. 1, 2

Dosing and Application

AndroGel Formulations and Dosing

• AndroGel 1%: 50-100 mg daily (5-10 g of gel)
• AndroGel 1.62%: 20.25-81 mg daily (1.25-5 g of gel)

Proper Application Technique

• Apply only to clean, dry, intact skin of the upper arms and shoulders 2
• Do not apply to abdomen, genitals, chest, armpits, or knees
• Application area should be limited to what can be covered by a short-sleeve t-shirt
• Use palm of hand to spread gel across maximum surface area
• Allow application site to dry before covering with clothing
• Wash hands thoroughly with soap and water after application

Important Precautions

• Avoid swimming or showering for at least 2 hours after application 2
• Avoid fire, flames, or smoking until gel has dried (product is flammable)
• Children and women should avoid contact with unwashed application sites
• Cover application site with clothing after gel has dried
• Wash application site thoroughly before skin-to-skin contact with others

Monitoring Protocol

Initial Assessment

• Baseline blood tests: PSA, hematocrit/hemoglobin 1
• Digital rectal examination
• Assessment of voiding symptoms and sleep apnea history

Follow-up Schedule

• First follow-up: 1-2 months after initiation to assess efficacy
• Subsequent monitoring: Every 3-6 months for the first year, then yearly
• At each visit:
  • Assess symptomatic response to treatment
  • Check for voiding symptoms and sleep apnea
  • Perform digital rectal examination
  • Measure serum testosterone, PSA, and hematocrit/hemoglobin levels

Target Testosterone Levels

• Aim for mid- to upper-normal range of testosterone levels 1
• If clinical response is adequate, no dose adjustment needed even with low-normal levels
• If response is suboptimal and levels are low-normal, increase dosage

Clinical Benefits and Risks

Expected Benefits

• Improved sexual function and mood 3, 4
• Increased lean body mass
• Decreased fat mass
• Improved bone mineral density (particularly in spine)

Potential Side Effects

• Skin reactions (erythema, pruritus) - less common with gels (5%) than patches (66%) 1
• Fluid retention (uncommon and generally mild)
• Breast tenderness and swelling (in small number of users)
• Decreased testicular size and compromised fertility 1
• Hematocrit/hemoglobin increases

Safety Considerations

• Cardiovascular risk: FDA required labeling change in 2015 regarding possible increased risk of heart attack and stroke 1
• Prostate monitoring: Mandatory due to concerns about potential stimulation of occult cancer 1
• Use with caution in men with congestive heart failure or renal insufficiency

Special Considerations

Combination Therapy

• For men with both ED and testosterone deficiency, combining testosterone therapy with PDE5 inhibitors may be more effective than PDE5 inhibitors alone 1, 5

Alternative Formulations

• If gel application is problematic, consider other options:
  • Injectable testosterone (less expensive but causes fluctuating levels) 1, 6
  • Transdermal patches (stable levels but higher skin irritation) 1
  • Testosterone pellets (long-lasting but risk of extrusion) 6

Common Pitfalls to Avoid

• Applying gel to incorrect body areas (reduces absorption efficacy) 7
• Showering too soon after application (reduces absorption)
• Not allowing for sufficient trials before determining efficacy
• Failing to monitor for potential adverse effects (particularly hematocrit and PSA)
• Transferring testosterone to women or children through skin contact

By following these guidelines, testosterone replacement therapy with AndroGel can effectively address symptoms of hypogonadism while minimizing potential risks and complications.