What are the risks of initiating testosterone therapy in an 82-year-old man with hypertension?

Risks of Testosterone Therapy in an 82-Year-Old Man with Hypertension

Testosterone therapy should not be initiated in an 82-year-old man with hypertension due to significant cardiovascular risks, potential for worsening hypertension, and limited benefits that do not justify these risks. 1, 2

Cardiovascular Risks

• Increased cardiovascular events in older men: Testosterone therapy is associated with increased cardiovascular events, particularly during the first 12 months of treatment and especially in men ≥65 years of age 3
• Hypertension risk: Testosterone can cause or worsen hypertension, which is particularly concerning in a patient who already has hypertension 4
• Fluid retention: Androgens promote sodium and water retention, which can worsen existing hypertension and potentially lead to edema or congestive heart failure in patients with pre-existing cardiac conditions 2
• Venous thromboembolism: FDA labeling warns about increased risk of deep vein thrombosis and pulmonary embolism with testosterone products 2

Hematologic Risks

• Erythrocytosis: Testosterone therapy commonly causes increases in hematocrit (2.8-17.9% of patients), which may require dose reduction or discontinuation 1, 2
• Increased thrombotic risk: The increase in red blood cell mass associated with testosterone therapy may increase the risk of thromboembolic events 2

Prostate Risks

• Prostate concerns: While the risk of prostate cancer remains controversial, long-term monitoring is required, and evaluation for prostate cancer is necessary before initiating treatment 1, 2
• Worsening of benign prostatic hyperplasia: May occur, though clinical significance is reported as rare 1

Limited Benefits in Elderly Men

• Limited efficacy: The American College of Physicians (ACP) suggests not initiating testosterone treatment in men with age-related low testosterone to improve energy, vitality, physical function, or cognition due to low-certainty evidence 1
• Sexual function only: ACP only suggests considering testosterone for sexual dysfunction, and even then, only after thorough discussion of risks, benefits, costs, and patient preferences 1
• Discontinuation recommendation: Treatment should be discontinued if no improvement in sexual function occurs within 12 months 1

Special Considerations for Elderly Patients with Hypertension

• Age-related risk amplification: The risk of adverse cardiovascular events is particularly high in men ≥65 years during the first year of testosterone therapy 3
• Mobility-limited older men: Those experiencing cardiovascular events had greater increases in serum free testosterone levels than those who did not 5
• Post-cardiovascular event waiting period: Testosterone therapy should not be initiated for 3-6 months after cardiovascular events 6

Recent Evidence on Cardiovascular Safety

While the recent TRAVERSE trial (2023) suggested testosterone therapy may be noninferior to placebo regarding major adverse cardiac events in men with hypogonadism and cardiovascular disease 7, this study did note higher incidences of atrial fibrillation, acute kidney injury, and pulmonary embolism in the testosterone group. Additionally, this trial did not specifically focus on very elderly patients (82 years old) with hypertension.

Monitoring Requirements if Therapy is Initiated Despite Risks

If testosterone therapy is initiated despite these significant risks:

1. Baseline assessments:

   • Testosterone, LH, FSH levels
   • Hemoglobin and hematocrit
   • Cardiovascular risk factors
   • Prostate-specific antigen

2. Follow-up monitoring:

   • Check hematocrit 3-6 months after starting treatment, then annually
   • Monitor testosterone levels 2-3 months after treatment initiation
   • Regular assessment of cardiovascular status, particularly in elderly patients

3. Immediate discontinuation criteria:

   • Elevated hematocrit
   • Signs of venous thromboembolism
   • Worsening hypertension
   • Cardiovascular events

The risks of testosterone therapy in an 82-year-old man with hypertension significantly outweigh the potential benefits, and alternative approaches to address specific symptoms should be considered instead.