From the Guidelines
The plan of care for this 47-year-old male patient should focus on addressing his low testosterone level of 162 ng/dL while managing his multiple comorbidities, and I recommend initiating testosterone replacement therapy, specifically intramuscular testosterone formulation, as it is more cost-effective and has similar clinical effectiveness and harms compared to transdermal formulations, as suggested by the American College of Physicians 1.
The patient's current medications, including Adderall, Rosuvastatin, Levothyroxine, Enalapril, Pantoprazole, Vitamin D3, Clomiphene, and Vitamin B12, should be continued, and the dose of Clomiphene could be adjusted or discontinued in favor of direct testosterone replacement.
The patient would benefit from lifestyle modifications, including:
- Weight loss
- Regular exercise
- Dietary changes to address his metabolic syndrome and binge eating disorder A referral to a nutritionist and possibly a behavioral health specialist for his binge eating disorder would be appropriate.
Testosterone replacement is justified because levels below 300 ng/dL are considered hypogonadal, and replacement can improve energy, mood, libido, and body composition, which may indirectly help with several of his other conditions, as supported by studies on the benefits of testosterone replacement therapy in men with hypogonadism and obesity 1.
Follow-up testosterone levels should be checked after 3 months of therapy, along with hematocrit, PSA, and liver function tests to monitor for potential side effects, and the patient should be reevaluated within 12 months and periodically thereafter to assess the effectiveness of testosterone treatment and discontinue it if there is no improvement in symptoms, as recommended by the American College of Physicians 1.
From the FDA Drug Label
Lithium carbonate – The stimulatory effects of amphetamines may be inhibited by lithium carbonate. Meperidine – Amphetamines potentiate the analgesic effect of meperidine. Methenamine therapy – Urinary excretion of amphetamines is increased, and efficacy is reduced, by acidifying agents used in methenamine therapy. Norepinephrine – Amphetamines enhance the adrenergic effect of norepinephrine Phenobarbital – Amphetamines may delay intestinal absorption of phenobarbital; co-administration of phenobarbital may produce a synergistic anticonvulsant action. Phenytoin – Amphetamines may delay intestinal absorption of phenytoin; co-administration of phenytoin may produce a synergistic anticonvulsant action Propoxyphene – In cases of propoxyphene overdosage, amphetamine CNS stimulation is potentiated and fatal convulsions can occur. Veratrum alkaloids – Amphetamines inhibit the hypotensive effect of veratrum alkaloids. Drug/Laboratory Test Interactions Amphetamines can cause a significant elevation in plasma corticosteroid levels. This increase is greatest in the evening Amphetamines may interfere with urinary steroid determinations.
The patient is taking Adderall 15mg BID, which contains amphetamines. The patient's lab results show low testosterone levels at 162 ng/dL.
- The FDA drug label for amphetamine does not provide information on the management of low testosterone levels.
- The label does discuss drug interactions and laboratory test interactions, but it does not address the patient's specific condition of low testosterone levels.
- There is no direct information in the label that supports a specific plan of care for this patient's low testosterone levels. The FDA drug label does not answer the question.
From the Research
Patient Profile
- 47-year-old male patient with a past medical history of ADHD, GERD, binge eating disorder, metabolic syndrome, hypertension with CKD Stage II, mixed hyperlipidemia, and hypothyroidism
- Current medications: Adderall 15mg BID, Rosuvastatin 40mg QHS, Levothyroxine 75mcg daily, Enalapril 10mg daily, Pantoprazole 40mg daily, Vitamin D3 5000 IU (2 capsules daily), Clomiphene 50mg 0.5 tab QOD at bedtime, and Vitamin B12 1000mcg daily
- Lab results show low testosterone levels at 162 ng/dL
Treatment Options for Low Testosterone
- Testosterone replacement therapy (TRT) is a common treatment for male hypogonadism, but it may not be suitable for all patients, especially those who desire fertility 2
- Alternative treatments such as clomiphene citrate (CC) and human chorionic gonadotropin (hCG) can stimulate endogenous testosterone production and may be considered for patients who want to preserve fertility 3, 4
- CC and hCG have been shown to be effective in restoring testosterone levels in hypogonadal men, with no significant difference in efficacy between the two treatments 4
Considerations for Fertility Preservation
- TRT can suppress the hypothalamic-pituitary-gonadal axis, leading to impaired spermatogenesis and potential infertility 3, 5
- Concomitant use of hCG with TRT may help preserve fertility by maintaining intratesticular testosterone levels and supporting spermatogenesis 5
- HCG-based combination therapy has been used to recover spermatogenesis after testosterone use, with a high success rate of 95.9% 6
Plan of Care
- Consider alternative treatments such as CC or hCG to stimulate endogenous testosterone production, especially if the patient desires fertility
- If TRT is still considered necessary, concomitant use of hCG may help preserve fertility
- Monitor testosterone levels and semen parameters regularly to assess the effectiveness of treatment and potential impact on fertility 2, 3, 5, 4, 6