What is the dose adjustment for a patient on intramuscular (IM) testosterone 50mg once a week with a testosterone level greater than 1000 nanograms per deciliter (ng/dL)?

Dose Adjustment for IM Testosterone 50mg Weekly with Level >1000 ng/dL

Reduce the testosterone dose to 25-37.5mg weekly (50% reduction) and recheck the testosterone level in 2-3 months, targeting a mid-normal range of 450-600 ng/dL. 1

Rationale for Dose Reduction

The current testosterone level exceeds the therapeutic target range significantly. The AUA guideline explicitly recommends adjusting testosterone therapy dosing to achieve a total testosterone level in the middle tertile of the normal reference range (450-600 ng/dL), using the minimal dosing necessary to drive testosterone levels to the normal physiologic range. 1

Specific Dose Adjustment Strategy

• Reduce the current dose by approximately 50% to 25mg weekly initially, as the patient's level is more than double the upper target range 1
• Alternatively, consider 37.5mg weekly if a more conservative reduction is preferred 2
• Weekly dosing should be maintained rather than switching to biweekly, as it provides more stable testosterone levels and reduces adverse effects including erythrocytosis and cardiovascular risk 2

Monitoring After Adjustment

• Measure testosterone levels 2-3 months after the dose change, checking midway between injections 2
• Target mid-normal values of 450-600 ng/dL 1
• Once stable therapeutic levels are achieved, monitor every 6-12 months 2

Important Safety Considerations

Supraphysiological testosterone levels (>1000 ng/dL) increase the risk of adverse effects, particularly:

• Erythrocytosis: Higher testosterone levels are associated with increased hematocrit and hemoglobin 1, 2
• Cardiovascular risk: Fluctuating and supraphysiological testosterone levels may carry greater cardiovascular risk 2
• Monitor hematocrit at the next visit, as erythrocytosis occurs more frequently with injectable formulations, especially at supraphysiological levels 2

Common Pitfalls to Avoid

• Do not continue the current dose even if the patient reports feeling well, as supraphysiological levels increase adverse event risk 1, 2
• Do not make multiple small adjustments - a 50% reduction is appropriate given the degree of elevation 1
• Do not switch to biweekly dosing as this creates greater fluctuation in testosterone levels and increases adverse effects 2
• Do not stop therapy abruptly if the patient was initially hypogonadal; dose reduction is the appropriate intervention 1