What are the recommendations for a patient with hypertension and erectile dysfunction who is on testosterone therapy?

Management of Hypertension and Erectile Dysfunction in Patients on Testosterone Therapy

For a patient with hypertension and erectile dysfunction on testosterone therapy, continue the testosterone replacement therapy while optimizing blood pressure control with angiotensin receptor blockers or nebivolol (rather than thiazides or traditional beta-blockers), add a PDE5 inhibitor for erectile dysfunction treatment, and conduct comprehensive cardiovascular risk assessment. 1, 2

Cardiovascular Risk Assessment Priority

• All men with erectile dysfunction should undergo comprehensive cardiovascular risk assessment regardless of testosterone therapy status, as ED itself is an independent marker of increased cardiovascular disease risk, particularly in men aged 30-60 years. 1

• Required baseline assessments include: blood pressure measurement, waist circumference, body mass index, fasting glucose, HbA1c, lipid profile, and resting electrocardiogram. 1, 2

• The presence of both hypertension and erectile dysfunction significantly elevates cardiovascular risk and warrants consideration for noninvasive cardiac testing (exercise stress testing, carotid intima-media thickness, or ankle-brachial index). 1

Testosterone Therapy Continuation and Monitoring

Continue testosterone replacement therapy with appropriate monitoring, as recent evidence demonstrates testosterone therapy actually reduces blood pressure rather than increasing it. 3

• Testosterone undecanoate therapy is associated with significant reductions in systolic blood pressure (median reduction of 12.5 mmHg), diastolic blood pressure (8.0 mmHg reduction), and pulse pressure (6.0 mmHg reduction) in men not on antihypertensive agents. 3

• In men with preexisting cardiovascular disease and hypogonadism, long-term testosterone therapy (up to 8 years) improves erectile function while concurrently improving cardiometabolic risk factors including blood pressure, with systolic blood pressure decreasing from 164±14 to 133±9 mmHg. 4

• Despite FDA labeling warnings about potential hypertension with testosterone products, prospective registry data of 737 men showed testosterone undecanoate lowered blood pressure regardless of antihypertensive therapy use, with greater reductions in men with higher baseline blood pressure. 5, 3

• For patients with congestive heart failure history, use caution with testosterone therapy due to fluid retention risk; target mid-range testosterone levels (350-600 ng/dL) and use easily titratable formulations (gel, spray, or patch) rather than long-acting injectables. 1

• Mandatory monitoring includes baseline and 6-month assessments of hematocrit and prostate-specific antigen. 1

Antihypertensive Medication Selection

Optimize blood pressure control by preferentially using angiotensin receptor blockers or the beta-blocker nebivolol, as these agents are less likely to cause or worsen erectile dysfunction compared to thiazide diuretics or traditional beta-blockers. 1

• Angiotensin receptor blockers are significantly less likely to cause erectile dysfunction than diuretics or other antihypertensive classes. 1

• Nebivolol, which has direct vasodilating properties, is less likely to cause erectile dysfunction than other beta-blockers. 1

• Thiazide diuretics are particularly problematic as they contribute to erectile dysfunction and should be avoided or replaced when possible. 6

• In the testosterone therapy cohort, only 1 of 152 men (0.7%) not on antihypertensives at baseline required initiation of antihypertensive therapy during follow-up, while 33 of 202 men (16.3%) on antihypertensives had their medications discontinued due to blood pressure improvements. 3

Erectile Dysfunction Treatment

Initiate PDE5 inhibitor therapy (sildenafil 50-100mg, tadalafil 10-20mg, or vardenafil 10-20mg) as first-line treatment for erectile dysfunction, regardless of testosterone level, with effectiveness demonstrated in up to 65% of men. 2

• PDE5 inhibitors are safe in patients with hypertension and those on antihypertensive medications, causing only small decreases in systolic and diastolic blood pressure without increased adverse events. 6

• PDE5 inhibitors are absolutely contraindicated with concurrent organic nitrate use due to risk of severe hypotension. 6

• Testosterone replacement therapy enhances PDE5 inhibitor response, as hypogonadism is a documented cause of PDE5 inhibitor failure; a minimal testosterone level is required for complete PDE5 inhibitor effect. 1

• In men with confirmed low testosterone (<230 ng/dL) or borderline levels (230-350 ng/dL) with symptoms, adding testosterone replacement therapy to PDE5 inhibitor therapy is recommended after PDE5 inhibitor failure. 1, 2

• No major adverse cardiovascular events occurred in 111 erectile dysfunction patients receiving testosterone replacement therapy during 2-year follow-up, compared to 3 events in 110 patients with normal testosterone levels (p=0.314). 7

Mandatory Lifestyle Modifications

Implement aggressive lifestyle modifications immediately, as these interventions reduce both cardiovascular risk and improve erectile function with mortality benefits. 1

• Smoking cessation reduces total mortality by 36% in patients with coronary heart disease. 1

• Regular dynamic exercise accounts for 30-50% reductions in incident type 2 diabetes and coronary heart disease, with pleiotropic effects on blood pressure, glucose-insulin homeostasis, and endothelial function. 1

• Mediterranean diet (emphasizing fruits, vegetables, beans, legumes, whole grains, nuts, fish, poultry, lean red meat, cheese, and yogurt) reduces death from coronary heart disease by up to 36%. 1

• Weight loss if BMI >25, with target waist circumference reduction. 2

• Moderate alcohol consumption limited to <21 units per week for men. 1

Critical Safety Considerations

• Testosterone gel is flammable until dry; patients must allow gel to dry completely before smoking or approaching open flames. 5

• Patients must wash hands with soap and water immediately after applying testosterone gel and cover application sites with clothing after drying to prevent secondary exposure to women and children. 5

• Wash application sites thoroughly with soap and water before any anticipated skin-to-skin contact with others. 5

• Management of erectile dysfunction should always be considered secondary to maintaining cardiovascular function; treatment for erectile dysfunction should not negatively affect cardiovascular health. 1

• In high-risk cardiac patients, sexual activity should be deferred until cardiac condition stabilization, with cardiology referral for collaborative management. 1