What are alternative testosterone replacement options for a patient who refuses intramuscular (IM) injections?

Testosterone Replacement Options for Patients Who Refuse Injections

For patients who refuse intramuscular testosterone injections, transdermal testosterone preparations (gels, patches) are the recommended first-line alternative due to their ease of application, good skin tolerability, and ability to maintain stable testosterone levels. 1

Transdermal Testosterone Options

Testosterone Gels

• Provide stable serum testosterone levels with once-daily application to the upper arms and shoulders 1
• Available in various formulations including:
  • AndroGel 1% (50-100 mg/day) and 1.62% (20.25-81 mg/day) 1, 2
  • Testim 1% gel (50-100 mg/day) 1
  • Fortesta 2% gel (10-70 mg/day) 1
  • Axiron 2% solution (30-120 mg/day) for axillary application 1
• Advantages:
  • Easy application with good skin tolerability 1, 3
  • Convenient once-daily dosing 3
  • Flexible dosing options 1
  • Rapid normalization of testosterone levels within 24 hours 3, 4
• Disadvantages:
  • Potential for transfer to partners or children through skin contact 1, 2
  • Higher cost compared to injectable options 1
  • Variable absorption in some patients 1

Testosterone Patches

• Androderm (2-6 mg/day) applied to dry, intact skin of back, abdomen, upper thighs, or upper arms 1
• Advantages:
  • Easy application 1
  • No risk of secondary transfer to others 1
  • Stable day-to-day testosterone levels 1
• Disadvantages:
  • Skin rash/irritation at application site 1, 5
  • Poor adhesion issues 1
  • Higher discontinuation rates due to skin reactions compared to gels 3, 5

Other Non-Injectable Options

Subcutaneous Implants (Pellets)

• Testopel (150-450 mg) implanted subcutaneously every 3-6 months 1
• Advantages:
  • Long-lasting therapy (3-6 months) 1, 5
  • Stable testosterone levels 1
  • No risk of transfer to others 1
  • Infrequent administration 1
• Disadvantages:
  • Requires minor surgical procedure for insertion 1
  • Risk of pellet extrusion or infection at insertion site 1
  • Less flexibility in dosing adjustments 5

Buccal Testosterone

• Striant (30 mg twice daily) applied to the gum above the incisor tooth 1
• Advantages:
  • No risk of skin-to-skin transfer 1
  • Bypasses first-pass liver metabolism 6
• Disadvantages:
  • Poor adherence 1
  • Gum irritation 1
  • Changes in taste of food 1
  • Requires twice-daily administration 1

Monitoring and Safety Considerations

• Testosterone levels should be tested 2-3 months after treatment initiation and after any dose change 1
• For transdermal preparations, levels can be measured at any time, understanding that peak values occur 6-8 hours after patch application 1
• Once stable levels are confirmed, monitoring every 6-12 months is typically sufficient 1
• Target mid-normal testosterone values (500-600 ng/dL) 1
• Monitor for potential adverse effects:
  • Cardiovascular events (FDA required labeling change in 2015 regarding possible increased risk) 1
  • Prostate health (PSA monitoring) 2, 7
  • Polycythemia (less common with transdermal forms compared to injections) 3

Patient Preference Considerations

• In one study, 71% of patients preferred topical gel over injections or patches due to convenience, ease of use, and non-staining of clothes 1
• Cost considerations: Annual cost in 2016 per Medicare beneficiary was $2,135.32 for transdermal formulations versus $156.24 for intramuscular formulations 1
• The method of testosterone replacement should be individualized based on patient preference, cost considerations, and clinical factors 1

Clinical Pitfalls to Avoid

• Failing to properly educate patients about the risk of secondary exposure with gel formulations 2
• Not instructing patients to wash hands thoroughly after gel application 2
• Neglecting to cover application sites with clothing after the gel has dried 2
• Applying gels to areas other than recommended sites (upper arms and shoulders) 2
• Not waiting at least 2 hours after application before swimming or showering 2