What is the best approach to manage low testosterone levels in a 78-year-old man?

Management of Low Testosterone Levels in a 78-Year-Old Man

Testosterone treatment should not be initiated in a 78-year-old man with age-related low testosterone to improve energy, vitality, physical function, or cognition, but may be considered only for sexual dysfunction after careful discussion of benefits, risks, and costs. 1

Assessment and Diagnosis

• Age-related decline in testosterone is common, with approximately 50% of men older than 80 years having low testosterone levels 1
• No universally accepted threshold exists for defining testosterone deficiency in older men 1
• Diagnosis requires both:
  • Presence of specific symptoms (particularly sexual dysfunction)
  • Confirmed low testosterone levels measured in the morning on at least two occasions 1, 2

Treatment Decision Algorithm

When to Consider Treatment:

• Only consider testosterone treatment if ALL of the following are present:
  • Documented low morning testosterone levels (preferably <300 ng/dL or 10.41 nmol/L) 1
  • Presence of sexual dysfunction symptoms 1
  • Patient desires improvement in sexual function 1
  • No contraindications to therapy 3, 2

When NOT to Initiate Treatment:

• Do not initiate testosterone treatment for:
  • Improving energy or vitality 1
  • Enhancing physical function 1
  • Improving cognitive function 1
  • Asymptomatic low testosterone 2, 4

Contraindications to Testosterone Treatment

• Absolute contraindications include:
  • Prostate cancer or breast cancer 3, 5
  • Erythrocytosis or hyperviscosity 3, 2
  • Untreated obstructive sleep apnea 3, 2
  • Severe heart failure 3, 2

Treatment Approach if Indicated

• If treatment is initiated for sexual dysfunction:
  • Consider intramuscular rather than transdermal formulations (similar effectiveness but lower cost) 1
  • Target serum testosterone levels in the mid-normal range 2
  • Reevaluate symptoms within 12 months of starting treatment 1
  • Discontinue if no improvement in sexual function is observed 1

Monitoring and Safety

• If treatment is initiated, monitor:
  • Prostate health (PSA and digital rectal exam) before and during treatment 3, 5
  • Hematocrit/hemoglobin (risk of polycythemia) 3, 5
  • Cardiovascular risk factors 3
  • Sleep apnea symptoms 3

Important Considerations for Older Men

• The benefit-risk profile is less favorable in men ≥78 years compared to younger men 6
• Multiple comorbidities common in older men may increase risks of treatment 6, 5
• Evidence for long-term safety in men over 75 is limited 1
• The FDA requires labeling that testosterone products are approved only for low testosterone due to known medical causes, not age-related decline 1

Treatment Trial Approach

• If treatment is initiated for sexual dysfunction:
  • Consider a 3-month therapeutic trial 4
  • Establish clear, measurable goals for symptom improvement 2, 4
  • Discontinue if no benefit is observed 1
  • Annual reassessment is required if treatment continues 2