Is testosterone therapy safe in individuals with alcohol use disorder?

Testosterone Therapy in Individuals with Alcohol Use Disorder

Testosterone therapy is generally not recommended for individuals with active alcohol use disorder due to potential liver toxicity, cardiovascular risks, and altered hormone metabolism, though it may be considered with caution after 3-6 months of abstinence and with close monitoring. 1, 2

Risks and Concerns

Liver Considerations

• Alcoholic liver disease is a significant concern when considering testosterone therapy:
  • Alkylated oral testosterone is contraindicated due to increased risk of liver toxicity 1
  • Alcohol itself affects androgen balance and metabolism 3, 4
  • While one older study found no adverse effects of oral testosterone on liver morphology in men with alcoholic cirrhosis 5, current guidelines recommend avoiding alkylated oral testosterone due to liver toxicity concerns 1

Cardiovascular Considerations

• The AUA guidelines recommend a 3-6 month waiting period after cardiovascular events before initiating testosterone therapy 1
• Alcohol use disorder can exacerbate cardiovascular risks:
  • Testosterone therapy may cause fluid retention which could worsen cardiovascular status 2
  • Erythrocytosis is a dose-dependent risk of testosterone therapy that could potentially aggravate vascular disease 2

Hormone Interactions

• Alcohol consumption affects testosterone levels in complex ways:
  • Acute low-dose alcohol intake may temporarily increase testosterone levels 3
  • Chronic alcohol use combined with smoking can lead to abnormal testosterone levels 4
  • After 6 weeks of sobriety, testosterone levels may be significantly higher than in healthy controls 4

Recommendations for Clinical Practice

Pre-Treatment Assessment

• Before considering testosterone therapy in patients with alcohol use disorder:
  • Assess liver function thoroughly (liver enzymes, bilirubin, albumin)
  • Screen for cardiovascular disease
  • Evaluate for existing complications of alcoholism
  • Determine alcohol consumption patterns and potential for abstinence

Treatment Considerations

1. Prioritize alcohol abstinence first:

   • Consider medications for alcohol dependence that are safer in liver disease, such as baclofen 1
   • Implement brief interventions and motivational interviewing 1

2. If testosterone therapy is considered:

   • Wait for a period of abstinence (at least 3-6 months) 1
   • Avoid alkylated oral testosterone preparations 1
   • Use commercially manufactured testosterone products rather than compounded formulations 1
   • Target testosterone levels in the mid-normal range (450-600 ng/dL) 1, 2

3. Monitoring requirements:

   • More frequent monitoring than standard patients:
     • Liver function tests before treatment and regularly during therapy
     • Hematocrit/hemoglobin (risk of erythrocytosis)
     • Cardiovascular parameters
     • Testosterone levels 4-6 weeks after initiation and every 3 months thereafter 2

Special Considerations

• For patients with established alcoholic liver disease: The benefit-risk profile is unfavorable; a study of testosterone in men with alcoholic cirrhosis showed no beneficial effect on survival or liver biochemistry 6, 7

• For patients in recovery: Consider testosterone therapy only after sustained abstinence and with normal or stabilized liver function

• Alternative treatments: For patients with hypogonadism who cannot safely use testosterone, consider non-testosterone approaches to symptom management and lifestyle modifications 2

Common Pitfalls to Avoid

• Initiating testosterone without confirming sustained alcohol abstinence
• Failing to monitor liver function regularly
• Using oral alkylated testosterone preparations
• Not educating patients about potential interactions between alcohol and testosterone
• Overlooking cardiovascular risk factors that may be exacerbated by both alcohol and testosterone