Can a patient with a recent Transient Ischemic Attack (TIA) safely use testosterone replacement therapy to increase testosterone levels?

From the Guidelines

Patients with a recent transient ischemic attack (TIA) should avoid testosterone supplementation due to the potential increased risk of cardiovascular events, including stroke. Testosterone therapy can increase the risk of cardiovascular events, including stroke, by potentially increasing blood viscosity, raising hematocrit levels, and promoting thrombosis 1. Since a TIA is a warning sign of stroke risk, adding testosterone could significantly increase the danger of a full stroke.

Key Considerations

• Before considering any hormone therapy, these patients should first focus on optimizing their cardiovascular health through appropriate antiplatelet therapy (such as aspirin 81-325mg daily or clopidogrel 75mg daily), blood pressure control, cholesterol management, and lifestyle modifications.
• If testosterone deficiency symptoms are severe, consultation with both a neurologist and endocrinologist is essential to weigh individual risks and benefits 1.
• Any consideration of testosterone therapy would require close monitoring of hematocrit levels, lipid profiles, and cardiovascular parameters.
• Alternative approaches to address symptoms like fatigue or decreased libido might be safer options for these high-risk patients.

Evidence Summary

The current evidence consistently shows that untreated low testosterone levels are associated with an increased risk of major adverse cardiovascular events (MACE); however, studies that measure cardiovascular benefit or harm in men on testosterone therapy have returned inconsistent and controversial results 1. The FDA has issued a Safety Announcement cautioning against the use of testosterone replacement therapy (TRT) for hypogonadism due to aging alone and recommended a labeling change to reflect an increased risk of heart attack and stroke 1.

From the FDA Drug Label

There have been postmarketing reports of venous thromboembolic events, including deep vein thrombosis (DVT) and pulmonary embolism (PE), in patients using testosterone products, such as testosterone enanthate injection. Long term clinical safety trials have not been conducted to assess the cardiovascular outcomes of testosterone replacement therapy in men To date, epidemiologic studies and randomized controlled trials have been inconclusive for determining the risk of major adverse cardiovascular events (MACE), such as non-fatal myocardial infarction, non-fatal stroke, and cardiovascular death, with the use of testosterone compared to non-use Some studies, but not all, have reported an increased risk of MACE in association with use of testosterone replacement therapy in men.

Testosterone therapy is not recommended for patients with a recent Transient Ischemic Attack (TIA) due to the potential increased risk of major adverse cardiovascular events (MACE) and venous thromboembolic events. The FDA drug label does not provide sufficient information to support the safe use of testosterone in this population 2.

From the Research

Testosterone Levels and TIA

• There is no direct evidence to suggest that a patient with a recent Transient Ischemic Attack (TIA) can safely increase testosterone levels using supplements like Dehydroepiandrosterone (DHEA) 3, 4.
• However, studies have shown that DHEA supplementation can increase testosterone levels in various populations, including healthy individuals and those with certain medical conditions 4.
• The effect of DHEA on testosterone levels may vary depending on factors such as dosage, duration of treatment, and individual characteristics 4.
• It is essential to note that patients with a recent TIA require urgent assessment and treatment to prevent recurrent stroke, and any decisions regarding testosterone replacement therapy should be made in consultation with a healthcare professional 5.

Cardiovascular Risks and Testosterone Replacement Therapy

• Testosterone replacement therapy has been associated with reduced mortality in men with type 2 diabetes, but its impact on cardiovascular risk is still being studied 6.
• One study found that testosterone undecanoate was associated with significant reductions in blood pressure in men with adult-onset testosterone deficiency, regardless of antihypertensive therapy 7.
• However, the relationship between testosterone replacement therapy and cardiovascular risk is complex, and more research is needed to fully understand its effects 6, 7.

Management of TIA

• TIA should be treated as a medical emergency, and patients require urgent assessment and treatment to prevent recurrent stroke 5.
• Management options include anticoagulation, carotid revascularization, antiplatelet therapy, and vascular risk factor reduction strategies 5.
• Imaging of the brain and blood vessels is an essential part of the diagnostic assessment, and treatment should be individualized based on the patient's specific needs and risk factors 5.