How do you titrate the dose of AndroGel (testosterone gel)?

Titrating AndroGel (Testosterone Gel) Dose

The optimal approach to titrating AndroGel is to start with 40.5 mg (2 pump actuations) applied once daily in the morning, then adjust the dose based on serum testosterone levels measured at 14 days and 28 days after initiation, targeting a mid-normal range of 450-600 ng/dL. 1, 2

Initial Dosing and Application

• Start with 40.5 mg of testosterone (2 pump actuations of 1.62% gel) applied once daily in the morning
• Apply to clean, dry, intact skin of the shoulders and upper arms only
• Do not apply to abdomen, genitals, chest, armpits, or knees
• Wash hands immediately with soap and water after application
• Allow gel to dry completely before dressing

Monitoring and Dose Adjustment Protocol

1. Baseline measurements (before starting therapy):

   • Morning total testosterone (measured on at least two separate days)
   • PSA
   • Hematocrit/hemoglobin
   • Lipid profile

2. First follow-up (14 days after starting):

   • Measure morning serum testosterone level (pre-dose)
   • Adjust dose if outside target range of 450-600 ng/dL

3. Second follow-up (28 days after starting):

   • Measure morning serum testosterone level (pre-dose)
   • Further adjust dose if needed

4. Dose adjustment guidelines:

   • If testosterone < 450 ng/dL: Increase by 20.25 mg (1 pump actuation)
   • If testosterone > 600 ng/dL: Decrease by 20.25 mg (1 pump actuation)
   • Minimum dose: 20.25 mg (1 pump actuation)
   • Maximum dose: 81 mg (4 pump actuations)

5. Ongoing monitoring:

   • Testosterone levels: Annually after stabilization
   • PSA: Every 3-6 months for first year, then annually
   • Hematocrit: Every 3-6 months
   • Action threshold for hematocrit: Discontinue if >54%

Safety Considerations and Precautions

Transdermal gel formulations like AndroGel offer several advantages over injectable testosterone, including:

• More stable testosterone levels with fewer fluctuations 3, 4
• Lower risk of erythrocytosis compared to injections 3
• Improved quality of life and physical/emotional well-being 4

Important precautions:

1. Secondary exposure risk: Cover application site with clothing after gel dries to prevent transfer to women or children 2
2. Erythrocytosis monitoring: Gels have lower risk than injections but still require monitoring; discontinue if hematocrit exceeds 54% 3, 1
3. Prostate monitoring: Watch for PSA increases (>4.0 ng/mL or >1.0 ng/mL in any year) 1
4. Cardiovascular risk: Evidence is inconclusive but requires careful consideration 1

Common Pitfalls to Avoid

1. Incorrect application site: Using abdomen instead of shoulders/upper arms can alter absorption
2. Inadequate monitoring: Failing to check testosterone levels at appropriate intervals
3. Secondary transfer: Not washing hands or covering application sites
4. Overtreatment: Targeting supraphysiologic testosterone levels rather than mid-normal range
5. Ignoring hematocrit: Not monitoring for erythrocytosis, which is less common with gels but still possible

By following this structured approach to AndroGel titration, you can optimize testosterone replacement while minimizing risks and adverse effects, ultimately improving patient outcomes related to morbidity, mortality, and quality of life.