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 injections, which can cost around $30-60 per month when self-administered, as recommended by the American College of Physicians 1.

Key Considerations

• A standard regimen involves 100-200mg injected intramuscularly every 1-2 weeks.
• To minimize costs, patients can ask their doctor for a prescription for multi-dose vials rather than pre-filled syringes, purchase syringes and needles in bulk online, and learn to self-inject rather than paying for clinic visits.
• Some patients may qualify for manufacturer assistance programs or GoodRx discounts.
• Compounded testosterone creams from specialized pharmacies can also be cost-effective alternatives to brand-name gels.
• Insurance coverage varies significantly, so checking with your provider about coverage is essential.

Evidence-Based Recommendations

• The American College of Physicians suggests that clinicians consider 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.
• The annual cost of TRT was $2135.32 for the transdermal and $156.24 for the intramuscular formulation, according to paid pharmaceutical claims provided in the 2016 Medicare Part D Drug Claims data 1.

Patient Preferences and Values

• Fifty-three percent of patients receiving testosterone treatment chose injectable testosterone over gel-based pellet regimens, mostly because of lower cost 1.
• Patients should discuss the potential benefits, harms, costs, and their preferences with their clinicians before initiating testosterone treatment 1.

Monitoring and Safety

• Testosterone therapy requires regular blood tests to monitor hormone levels and potential side effects, which should be factored into the overall cost.
• This therapy should only be pursued under medical supervision, as improper use can lead to serious health complications including cardiovascular issues and infertility.

From the Research

Cost-Effectiveness of Testosterone Replacement Therapy (TRT)

The cost-effectiveness of TRT can be evaluated based on the available forms of treatment and their respective administration frequencies.

• Intramuscular injections of testosterone esters, such as testosterone enanthate, are commonly prescribed and have been shown to be efficacious in improving bone and muscle mass 2.
• However, these esters have unfavorable pharmacokinetics, resulting in fluctuations in mood, energy, and sexual function, and require frequent injections every 2-4 weeks 2.
• Long-acting injectable testosterone undecanoate (Nebido) has been developed to address these issues, with a more favorable pharmacokinetic profile and less frequent administration (every 3 months) 2, 3.
• Hydroalcoholic gel containing 1% testosterone has also been shown to be effective and has a higher grade of patient satisfaction, with daily application delivering sufficient amounts of testosterone to restore normal hormonal values 3.
• Subcutaneous administration of testosterone esters has gained popularity due to its ease of self-administration and potential for improved patient adherence 4.
• A study comparing the safety of subcutaneous vs intramuscular administration of testosterone esters is desirable, but available evidence suggests that subcutaneous testosterone therapy results in comparable pharmacokinetics and mean serum testosterone levels 4.

Comparison of TRT Forms

The following forms of TRT have been compared in terms of their cost-effectiveness:

• Intramuscular injections of testosterone esters (e.g., testosterone enanthate)
• Long-acting injectable testosterone undecanoate (Nebido)
• Hydroalcoholic gel containing 1% testosterone
• Subcutaneous administration of testosterone esters
• Oral testosterone formulations (e.g., oral undecanoate T) have been shown to have variable absorption and poor bioavailability due to the first-pass effect of the liver 3, 5.

Most Cost-Effective Form of TRT

Based on the available evidence, intramuscular injections with testosterone esters are the most inexpensive modality, but they are difficult to self-administer and associated with some discomfort 4.

• Subcutaneous administration of testosterone esters may be a more practical and reasonable option, with easier self-administration and less discomfort compared to the intramuscular route 4.
• Long-acting injectable testosterone undecanoate (Nebido) has a favorable pharmacokinetic profile and less frequent administration, which may improve patient compliance 2, 3.