Management of a Patient on Testosterone with Elevated Hematocrit Before Surgery
For a patient on testosterone therapy with elevated hematocrit before surgery, phlebotomy should be performed to reduce hematocrit to <45% prior to the surgical procedure, and testosterone therapy should be temporarily discontinued. 1, 2
Assessment of Hematocrit and Surgical Risk
- Elevated hematocrit (erythrocytosis) is the most common side effect of testosterone therapy, occurring in up to 11% of patients with levels >0.50 L/L 3
- Increased hematocrit raises the risk of thromboembolic events during surgery, which can significantly impact morbidity and mortality 2, 4
- The FDA label for testosterone specifically warns about polycythemia and recommends checking hematocrit prior to initiating treatment, 3-6 months after starting, and then annually 2
Pre-Surgical Management Protocol
- Hematocrit should be controlled for at least 3 months before elective surgery, with a goal of normalization or near-normalization of complete blood count 1
- Additional phlebotomy should be performed to maintain hematocrit <45% prior to elective surgery 1
- Therapeutic phlebotomy is an effective immediate intervention to reduce hematocrit, though evidence for long-term efficacy is limited 4, 5
- Temporarily discontinue testosterone therapy until hematocrit normalizes, as continuing therapy may counteract efforts to reduce hematocrit 2, 6
Timing Considerations
- Schedule the phlebotomy at least 1-2 weeks before surgery to allow for volume equilibration 1
- Verify hematocrit levels 24-48 hours before surgery to ensure they remain below the target threshold of 45% 1, 7
- If hematocrit remains elevated despite initial phlebotomy, consider a second phlebotomy session at least 48-72 hours before surgery 1
Additional Perioperative Management
- Cytoreductive therapy (if being used) can be continued throughout the perioperative period unless contraindicated by the surgical team 1
- Ensure adequate hydration before and after surgery to prevent hemoconcentration 7
- Monitor for signs of anemia after phlebotomy, especially if multiple sessions are required 1, 7
- Resume testosterone therapy only after surgical recovery is complete and hematocrit has stabilized at an acceptable level 2, 6
Post-Surgical Considerations
- Consider switching to transdermal testosterone formulations after recovery, as they are associated with lower rates of erythrocytosis compared to injectable forms 3
- Advise smoking cessation, as tobacco use is associated with higher risk of erythrocytosis (OR 2.2) in patients on testosterone therapy 3
- Implement regular hematocrit monitoring after resuming testosterone therapy (every 3 months initially, then annually if stable) 2
Common Pitfalls to Avoid
- Relying solely on blood donation as a management strategy is insufficient to maintain hematocrit below 54% in patients on testosterone therapy 5
- Failing to address modifiable risk factors for erythrocytosis, such as smoking and obesity, which can exacerbate the condition 3
- Neglecting to consider the patient's cardiovascular risk profile, as those with existing cardiovascular disease are at higher risk for complications from elevated hematocrit 1, 2