What is the most cost-effective form of testosterone replacement therapy (TRT)?

From the Guidelines

The most cost-effective form of testosterone replacement therapy (TRT) is intramuscular testosterone, which is significantly cheaper than transdermal formulations, with an annual cost of $156.24 compared to $2135.32 for transdermal formulations, according to the American College of Physicians guideline 1. When considering the cost-effectiveness of TRT, it's essential to weigh the benefits and harms of different formulations. The American College of Physicians recommends considering intramuscular rather than transdermal formulations when initiating testosterone treatment to improve sexual function in men with age-related low testosterone, as costs are considerably lower for the intramuscular formulation and clinical effectiveness and harms are similar 1. Some key points to consider when evaluating the cost-effectiveness of TRT include:

• The annual cost of TRT can vary significantly depending on the formulation, with intramuscular testosterone being the most cost-effective option 1.
• Patient preferences may also play a role in the choice of formulation, with some patients preferring injectable testosterone due to its lower cost, while others may prefer topical gels or patches for convenience and ease of use 1.
• Clinicians should discuss the potential benefits, harms, costs, and patient preferences when deciding whether to initiate testosterone treatment, and reevaluate symptoms within 12 months and periodically thereafter to determine the effectiveness of treatment 1.
• The American College of Physicians guideline recommends against initiating testosterone treatment in men with age-related low testosterone to improve energy, vitality, physical function, or cognition, due to low-certainty evidence and potential harms 1.

From the Research

Cost-Effectiveness of Testosterone Replacement Therapy (TRT)

The cost-effectiveness of TRT can be evaluated based on various factors, including the type of treatment, frequency of administration, and patient adherence.

• Intramuscular injections of testosterone esters, such as testosterone enanthate, are considered a cost-effective option 2, 3, 4.
• However, these injections have unfavourable pharmacokinetics, resulting in fluctuations in mood, energy, and sexual function, and require frequent administration every 2-4 weeks 2.
• Testosterone patches and gels are also available, but may have limitations, such as skin reactions and variable absorption 3, 5.
• A new 2% testosterone gel formulation, Testavan, has been developed, which has a favourable efficacy and safety profile, but its cost-effectiveness compared to other options is not well established 5.
• Subcutaneous administration of testosterone esters is a relatively new approach that has gained popularity due to its ease of self-administration and potential for improved patient adherence 6.
• Intramuscular injection of testosterone undecanoate is another option that can be administered quarterly, which may be more cost-effective than weekly-to-biweekly injections of testosterone cypionate or enanthate 3, 4.

Comparison of TRT Options

A comparison of the different TRT options is necessary to determine the most cost-effective form of treatment.

• Weekly-to-biweekly injections of testosterone cypionate or enanthate are widely used and generally well tolerated, but may not be the most cost-effective option in the long run 4.
• Once-daily transdermal therapies, such as patches and gels, have become increasingly popular, but their cost-effectiveness compared to injectable options is not well established 3, 5.
• Subcutaneous administration of testosterone esters and intramuscular injection of testosterone undecanoate are relatively new approaches that may offer improved cost-effectiveness due to their ease of administration and potential for improved patient adherence 3, 6, 4.

Factors Influencing Cost-Effectiveness

Several factors can influence the cost-effectiveness of TRT, including:

• Frequency of administration: Treatments that require less frequent administration, such as intramuscular injection of testosterone undecanoate, may be more cost-effective in the long run 3, 4.
• Patient adherence: Treatments that are easier to administer, such as subcutaneous injections, may improve patient adherence and reduce costs associated with non-adherence 6.
• Side effects: Treatments with fewer side effects, such as testosterone gels, may reduce costs associated with managing side effects 5.