Testosterone 1000 mg Every 3 Months is NOT Appropriate for a 70-Year-Old Man with Erectile Dysfunction
For a 70-year-old man with ED, long-acting injectable testosterone formulations like 1000 mg every 3 months should be avoided; instead, use easily titratable formulations (gel, spray, or patch) if testosterone replacement is indicated at all. 1
Critical Age-Specific Contraindication
The Princeton III Consensus explicitly recommends against intermediate and long-acting injectable testosterone formulations in patients older than 70 years. 1 The consensus panel specifically states that in patients older than 70 years and those with chronic illness, easily titratable testosterone formulations (gel, spray, or patch) should be used rather than intermediate and long-acting injectable formulations. 1
Prerequisites Before ANY Testosterone Therapy
Before considering testosterone therapy in this patient, you must:
- Measure morning total testosterone levels on at least two separate occasions to confirm true deficiency 2
- Only proceed if testosterone is below 230 ng/dL (clear benefit) or 231-346 ng/dL (trial basis with careful discussion) 1
- Do NOT initiate testosterone if levels are above 350 ng/dL 1
- Understand that testosterone is NOT an effective monotherapy for ED - it requires combination with PDE5 inhibitors 1
Baseline Testing Required
Before initiating any testosterone therapy, perform: 1
- Prostate-specific antigen (PSA) measurement
- Digital rectal examination
- Hematocrit or hemoglobin level
- Assessment of voiding symptoms
- Screen for sleep apnea history
- Cardiovascular risk assessment (all men with ED over age 30 are considered at increased CVD risk) 1
If Testosterone Therapy is Appropriate, Use Short-Acting Formulations
If testosterone replacement is indicated after proper evaluation, intramuscular formulations should be considered over transdermal due to lower cost, but the dosing must be appropriate. 1 However, for men over 70, transdermal preparations are preferred for safety and titratability. 1, 3
The FDA-approved dosing for intramuscular testosterone cypionate is 50-400 mg every 2-4 weeks, NOT 1000 mg every 3 months. 4
Target Testosterone Levels
- Aim for mid-normal range (350-600 ng/dL), especially in older men and those with heart failure risk 1
- Avoid supraphysiologic levels 1
- In men over 70, use the lowest effective dose 1
Mandatory Monitoring Protocol
After initiating testosterone therapy: 1
- First follow-up at 1-2 months to assess efficacy and consider dose adjustment
- Subsequent visits at 3-6 month intervals for the first year
- Yearly visits thereafter
- At each visit: measure serum testosterone, PSA, hematocrit/hemoglobin, perform digital rectal examination, assess symptomatic response and voiding symptoms 1
Discontinuation Criteria
Discontinue testosterone if no improvement in sexual function within 12 months. 1, 2 Testosterone should be continued beyond 6 months only in cases of clear clinical benefit. 1
Critical Safety Concerns in Older Men
- Fluid retention risk - use cautiously in men with congestive heart failure 1
- Polycythemia risk - if hematocrit rises above reference range, temporarily withhold therapy, reduce dose, or perform phlebotomy 1
- Cardiovascular risk - evidence for long-term safety in men over 75 is limited 2
- Prostate cancer monitoring is mandatory given widespread concerns about stimulating occult cancer 1
The Correct Treatment Approach for ED in This Patient
- First-line therapy should be PDE5 inhibitors, not testosterone 1
- Measure testosterone levels - if confirmed low on two morning measurements 2
- If testosterone is low AND patient has sexual dysfunction symptoms, consider combination therapy with PDE5 inhibitor plus testosterone 1
- If testosterone therapy is warranted, use transdermal formulations (gel, spray, patch) in this 70-year-old, NOT long-acting injectables 1
- Emphasize lifestyle modifications: smoking cessation, regular exercise, weight loss, Mediterranean diet, moderate alcohol consumption 1