How to manage a patient with leukocytosis and neutrophilia on AndroGel (testosterone) and GLP-1 agonist, with finasteride and losartan?

Management of Leukocytosis in a Patient on AndroGel, GLP-1 Agonist, Finasteride, and Losartan

The elevated white blood cell count (15.2 × 10^9/L) with neutrophilia (10.49 × 10^9/L) in this patient is most likely a medication-induced effect, particularly from testosterone (AndroGel) therapy, and requires monitoring but not immediate discontinuation of medication unless other concerning symptoms develop.

Assessment of Current Laboratory Findings

• The patient presents with leukocytosis (WBC 15.2 × 10^9/L) and neutrophilia (neutrophil count 10.49 × 10^9/L) 1
• Monocytosis is also present (1.19 × 10^9/L) 1
• Other cell lines appear normal, including red blood cells, hemoglobin, hematocrit, and platelets 1
• The absence of immature granulocytes (0.10 × 10^9/L) suggests a non-malignant process 1

Likely Etiology of Leukocytosis

• Testosterone replacement therapy (AndroGel) is the most probable cause of the leukocytosis in this patient 2, 3
• Glucocorticoid-like effects of testosterone can induce neutrophilia through several mechanisms:
  • Demargination of neutrophils from the vascular endothelium 3
  • Delayed apoptosis of neutrophils 3
  • Increased release of neutrophils from bone marrow 3
• Studies have shown that steroid-induced leukocytosis can increase WBC counts by approximately 5 × 10^9/L on average in patients 2
• Finasteride, losartan, and GLP-1 agonists are not typically associated with significant leukocytosis 4

Recommended Management Approach

1. Continue current medications with monitoring

   • The degree of leukocytosis is mild to moderate and likely medication-related 2
   • In the absence of symptoms or other concerning features, immediate discontinuation of medications is not necessary 1

2. Additional laboratory evaluation

   • Repeat CBC with differential in 4-8 weeks to monitor trend 1
   • If WBC continues to rise or exceeds 20 × 10^9/L, consider additional workup 1
   • Examination of peripheral blood smear to confirm absence of blasts or dysplastic changes 1

3. Clinical monitoring

   • Monitor for signs of infection (fever, chills, localized symptoms) 1
   • Assess for symptoms of hematologic malignancy (night sweats, weight loss, fatigue, lymphadenopathy) 1

4. Indications for medication adjustment

   • If WBC count exceeds 20 × 10^9/L 1
   • If neutrophil count exceeds 15 × 10^9/L 1
   • If patient develops symptoms concerning for infection or malignancy 1
   • Consider temporary dose reduction of AndroGel rather than complete discontinuation if adjustment needed 2

Special Considerations

• Distinguish between reactive leukocytosis and potential myeloproliferative disorders:

  • Reactive leukocytosis typically shows normal cell morphology 1
  • Absence of basophilia and eosinophilia makes chronic myeloid leukemia less likely 5
  • Normal platelet count and hemoglobin make polycythemia vera unlikely 1

• Medication interactions:

  • Monitor for potential interactions between AndroGel and other medications 5
  • GLP-1 agonists are not known to significantly affect white blood cell counts 1

• Common pitfalls to avoid:

  • Don't attribute leukocytosis to infection without evidence 2
  • Don't unnecessarily discontinue beneficial medications when leukocytosis is mild and asymptomatic 1
  • Don't overlook potential underlying conditions that could be masked by medication effects 1

If leukocytosis persists or worsens despite monitoring, consider hematology consultation for further evaluation, including bone marrow examination if clinically indicated 1.