Should topical testosterone be continued in hospitalized elderly patients or those with complex medical conditions?

Topical Testosterone Should Generally Be Discontinued During Hospitalization

In hospitalized elderly patients or those with complex medical conditions, topical testosterone should be discontinued unless the patient has organic hypogonadism from documented pituitary or testicular disease. 1

Rationale for Discontinuation

Cardiovascular Risk Considerations

• Testosterone therapy should not be commenced for 3-6 months following cardiovascular events, and hospitalized patients often have acute or unstable cardiovascular conditions that warrant cessation. 1
• The available literature does not provide sufficient evidence for safe continuation in patients with existing cardiovascular disease or recent cardiac events. 1
• While pooled mortality data from trials showed fewer deaths with testosterone (Peto odds ratio 0.47), these trials specifically excluded high-risk hospitalized patients, making this data inapplicable to the inpatient setting. 1

Limited Acute Benefit

• Testosterone replacement produces only modest improvements in vitality (SMD 0.17) and depressive symptoms (SMD 0.19), which are not clinically meaningful in the acute hospital setting. 1, 2
• The primary benefits of testosterone—improved sexual function, muscle mass, and bone density—require months of therapy and are irrelevant to acute hospitalization outcomes. 1, 2
• No evidence demonstrates that continuing testosterone during hospitalization improves morbidity, mortality, or quality of life in acutely ill patients. 1

Potential Harms in Hospitalized Patients

• Testosterone can cause polycythemia and hypertension, both of which complicate management of acutely ill hospitalized patients. 1, 3
• Hospitalized patients frequently have conditions that represent relative contraindications, including acute thrombotic events, malignancy concerns, or severe illness. 1

Specific Exceptions Where Continuation May Be Considered

Organic Hypogonadism

• Men with documented pituitary disease, testicular failure, or other organic causes of hypogonadism may benefit from continuation, as abrupt cessation could worsen their underlying endocrine disorder. 1
• Even in these cases, temporary discontinuation during acute illness is reasonable given the lack of acute benefits. 1

Cirrhosis Patients

• In select men with cirrhosis and documented low testosterone, continuation may be considered as testosterone replacement may improve muscle mass in this specific population. 1
• However, relative contraindications include history of hepatocellular carcinoma, other malignancy, or thrombosis—all common in hospitalized cirrhotic patients. 1

Practical Management Algorithm

For most hospitalized patients:

1. Discontinue topical testosterone on admission unless organic hypogonadism is documented. 1
2. Reassess need for testosterone at hospital discharge or 3-6 months post-cardiovascular event. 1
3. Address reversible causes of low testosterone during hospitalization (weight loss, optimization of comorbidities, medication review). 4

For patients with documented organic hypogonadism:

1. Consider temporary discontinuation during acute illness. 1
2. If continuation is deemed necessary, monitor hematocrit and blood pressure closely. 1, 3
3. Avoid continuation in patients with recent cardiovascular events, active malignancy, or thrombotic complications. 1

Key Pitfalls to Avoid

• Do not assume all men on testosterone have organic hypogonadism—most older men on testosterone have functional gonadal suppression from obesity, comorbidities, or medications rather than true hypogonadism. 4
• Do not restart testosterone before addressing the 3-6 month waiting period post-cardiovascular event, as this is an expert opinion safety recommendation. 1
• Recognize that discontinuation rates for testosterone are high (only 15.4% of patients continue at 12 months), suggesting many patients do not derive sufficient benefit to warrant continuation even in outpatient settings. 5