What is the recommended adjustment to the patient's transdermal testosterone (testosterone) replacement therapy dose of 40.5 milligrams (mg) per day, given total testosterone levels of 282, free testosterone levels of 31, and bioavailable testosterone levels of 63.7?

From the Guidelines

I recommend increasing the transdermal testosterone dose to 60 mg daily. The current laboratory values show that the patient's testosterone levels are below the normal adult male range despite daily use of 40.5 mg transdermal testosterone. Total testosterone should ideally be between 350-1000 ng/dL, but the patient's level is only 282 ng/dL, which is below the normal range as indicated by 1. Free and bioavailable testosterone are also on the lower end. A 50% dose increase is appropriate in this situation, as it allows for meaningful adjustment while minimizing the risk of overshooting into supraphysiologic levels.

The patient should apply the increased dose at the same time each day to maintain consistent blood levels, and follow up with repeat testosterone testing in 4-6 weeks to assess the response to the dose adjustment, as suggested by 1. If the patient experiences any adverse effects such as acne, mood changes, or breast tenderness, they should contact their healthcare provider. Transdermal testosterone has a relatively short half-life, so dose adjustments can be made safely with appropriate monitoring. It is also important to monitor the patient's prostate-specific antigen (PSA) levels and perform digital rectal examinations regularly, as recommended by 1, to minimize the risks associated with testosterone replacement therapy.

Some key points to consider when adjusting the testosterone dose include:

• Monitoring the patient's symptoms and adjusting the dose accordingly, as suggested by 1
• Considering the potential benefits and risks of testosterone replacement therapy, as discussed in 1
• Regularly monitoring the patient's testosterone levels, PSA levels, and performing digital rectal examinations, as recommended by 1
• Adjusting the dose based on the patient's response to treatment and minimizing the risk of adverse effects, as suggested by 1.

From the FDA Drug Label

The dose can be adjusted between a minimum of 20. 25 mg of testosterone (1 pump actuation) and a maximum of 81 mg of testosterone (4 pump actuations). To ensure proper dosing, the dose should be titrated based on the pre-dose morning serum testosterone concentration from a single blood draw at approximately 14 days and 28 days after starting treatment or following dose adjustment Table 1: Dose Adjustment Criteria Pre-Dose Morning Total Serum Testosterone Concentration Dose Titration Greater than 750 ng/dL Decrease daily dose by 20. 25 mg (1 pump actuation) Equal to or greater than 350 and equal to or less than 750 ng/dL No change: continue on current dose Less than 350 ng/dL Increase daily dose by 20.25 mg (1 pump actuation)

The patient's total testosterone level is 282 ng/dL, which is less than 350 ng/dL.

• The current dose is 40.5 mg daily.
• According to the dose adjustment criteria, since the total serum testosterone concentration is less than 350 ng/dL, the daily dose should be increased by 20.25 mg (1 pump actuation).
• The new dose would be 40.5 mg + 20.25 mg = 60.75 mg daily 2.

From the Research

Testosterone Levels and Dose Adjustment

• The patient's current testosterone levels are: total testosterone 282, free testosterone 31, and bioavailable testosterone 63.7.
• The patient is using transdermal testosterone replacement at a dose of 40.5 mg daily.

Considerations for Dose Adjustment

• According to 3, dose adjustment with transdermal testosterone preparations should recognize the variability of serum total testosterone levels between applications and over the course of 24 hours.
• The study also suggests that free or bioavailable testosterone may be a better choice for monitoring the progress and dosing of testosterone-treated men with adult onset hypogonadism.
• 4 recommends aiming at achieving T concentrations in the mid-normal range during treatment with any of the approved formulations, taking into consideration patient preference, pharmacokinetics, formulation-specific adverse effects, treatment burden, and cost.

Monitoring and Adjustment

• The patient's testosterone levels and symptoms should be monitored regularly to determine if the current dose is effective and if adjustments are needed.
• As stated in 4, clinicians should monitor men receiving T therapy using a standardized plan that includes: evaluating symptoms, adverse effects, and compliance; measuring serum T and hematocrit concentrations; and evaluating prostate cancer risk during the first year after initiating T therapy.
• Based on the patient's current testosterone levels and the fact that they are using transdermal testosterone replacement at a dose of 40.5 mg daily, it may be necessary to adjust the dose to achieve optimal testosterone levels.
• However, without more specific guidance on the optimal testosterone levels for this patient, it is difficult to determine the exact dose adjustment needed.
• It is recommended to consult the studies 5, 6, and 7 for more information on testosterone replacement therapy and its effects on the body.