Adherence to testosterone therapy

- short term treatment is not sufficient for achievement of maximal benefits

Adherence to testosterone therapy

Long-term treatment patterns of testosterone replacement medications.
Donatucci C, Cui Z, Fang Y, Muram D. The journal of sexual medicine. Aug 2014;11(8):2092-2099.

Medication adherence and treatment patterns for hypogonadal patients treated with topical testosterone therapy: a retrospective medical claims analysis.
Schoenfeld MJ, Shortridge E, Cui Z, Muram D. The journal of sexual medicine. May 2013;10(5):1401-1409.

Testosterone therapy confers a wide range of health benefits for hypogonadal men, including improvements in body composition (reduction in body fat, increase in muscle mass, weight loss), lipid profile, cardiovascular function, insulin sensitivity/glucose metabolism, bone mineral density, inflammatory parameters, quality of life and potentially longevity.1

Despite this, there is a high discontinuation rate with testosterone therapy.2,3 This editorial presents findings from two studies which have investigated adherence to testosterone therapy and treatment patterns.2,3

KEY POINTS

  • The rates of testosterone therapy treatment discontinuation are similar between men using topical testosterone formulations and short-acting testosterone injections.2
  • 66% of patients discontinued testosterone therapy with a topical gel after 2 months, and only 31% and 14% of patients remained on therapy for 6 months and 1 year, respectively.3
  • Of the patients who discontinued testosterone gel therapy, almost half reinitiated therapy, and the majority of these men restarted therapy using the same medication at the same dose. Only 5% of men restarted therapy by using a different testosterone product.3
  • A large proportion of patients stop and restart therapy every 2 to 3 months.2
  • Majority of patients who begin testosterone therapy discontinue its use within 3 years.2
  • Because continuous therapy over a longer period (years, if not indefinitely) is necessary to derive all the benefits of testosterone therapy4-7, these low adherence rates mean that the majority of men who start testosterone therapy will not achieve maximum benefits from it.

What is known

Severe hypogonadism (<8 nmol/L or <231 ng/dL), as well as mild hypogonadism (8 to 12 nmol/L or 231 to 346 ng/dL), are associated with several negative health effects, including insulin resistance, reduced muscle mass and bone mineral density, low hemoglobin, impaired physical function, increased fat mass, enlarged waist circumference, and poorer general health.8-10

The main symptoms and signs of hypogonadism are decreased frequency of morning erections, decreased frequency of sexual thoughts, and erectile dysfunction.11 These sexual symptoms are also among the first ones to improve with testosterone therapy.4,12 However, improvements in other parameters take longer time to manifest, and many of them (e.g. insulin resistance, HbA1c, blood lipids, bone mineral density) need to be objectively measured and monitored, as they are not related to perceptible, subjective signs or symptoms.

What these studies add

Hypogonadism is often irreversible. This means that once a man gets diagnosed with hypogonadism, in order to gain and maintain the full spectrum of health benefits, it is necessary to stay on testosterone therapy for life. However, it appears that most men who start testosterone therapy do not remain on treatment for a prolonged period.2

Only 14% of patients remain on testosterone therapy for 1 year, and the large majority of patients who begin testosterone therapy discontinue its use within 3 years.3 This is an important concern because continuous therapy over a longer period (years, if not indefinitely) is necessary to derive all the benefits of testosterone therapy.4-7

The low adherence rates reported by these studies are in line with previous other reports. For example, it has been found that patients who initiated treatment with testosterone therapy stayed on treatment for a median of 150 days during the 12 months following initiation of treatment, and almost 20% of all new users received treatment for only a maximum of 30 days.13

Most patients used testosterone therapy in a cyclic fashion; on treatment for a few months, stopped treatment for 2–3 months, and then restarted testosterone treatment with the same dose and medication.2 This cycle repeated, but with each successive cycle, the number of men who restarted testosterone therapy decreased. This cyclic pattern was observed with both topical testosterone gels and short-acting testosterone injections, indicating that treatment patterns are not related to a specific testosterone preparation or route of administration.

Reasons for poor adherence are not fully understood but possible explanations, as reported for other therapies, may be cost of therapy, preference for different preparations (e.g., topical, injectable) that they are not getting from their doctor, perceived low efficacy, concerns about therapy safety, inadequate patient education, and unrealistic patient expectations for alleviation of symptoms.14 After testosterone therapy initiation, patients may not have been informed about the time course of symptom improvement or may not have experienced rapid symptom improvement and so discontinued therapy. Alternatively, patients may have experienced symptom improvement but then questioned the need to remain on therapy.

The exclusive focus on symptom improvement neglects the wide range of health benefits with testosterone therapy. While symptomatic relief can be experienced as soon as after 3-4 weeks4,15, noticeable effects on body fat, muscle mass and bone mineral density may take at least 6 months to years to manifest.4 Importantly, these long-term improvements keep continuing with continuing testosterone therapy.16-22 Therefore, merely asking patients whether they "feel better" after 3-6 months might lead to these important health benefits being underestimated, and to discontinuation of testosterone therapy. It is equally important to measure and monitor long-term effects.

These results highlight the importance of both physician and patient education and communication between the physician and patient; for expression of all benefits with testosterone therapy it is critical to inform patients about what effects to expect and when, and encourage patients to remain on therapy even after sexually related symptoms have receded. This can be done by regular comprehensive blood testing, body weight and waist circumference assessments, which provide objective proof of treatment effects and health benefits.

References

1. Traish AM. Outcomes of testosterone therapy in men with testosterone deficiency (TD): Part II. Steroids. 2014;88C:117-126.
2. Donatucci C, Cui Z, Fang Y, Muram D. Long-term treatment patterns of testosterone replacement medications. The journal of sexual medicine. 2014;11(8):2092-2099.
3. Schoenfeld MJ, Shortridge E, Cui Z, Muram D. Medication adherence and treatment patterns for hypogonadal patients treated with topical testosterone therapy: a retrospective medical claims analysis. The journal of sexual medicine. 2013;10(5):1401-1409.
4. Saad F, Aversa A, Isidori AM, Zafalon L, Zitzmann M, Gooren L. Onset of effects of testosterone treatment and time span until maximum effects are achieved. Eur. J. Endocrinol. 2011;165(5):675-685.
5. Hackett G, Cole N, Bhartia M, et al. The response to testosterone undecanoate in men with type 2 diabetes is dependent on achieving threshold serum levels (the BLAST study). Int. J. Clin. Pract. 2014;68(2):203-215.
6. Hackett G, Cole N, Bhartia M, Kennedy D, Raju J, Wilkinson P. Testosterone replacement therapy improves metabolic parameters in hypogonadal men with type 2 diabetes but not in men with coexisting depression: the BLAST study. The journal of sexual medicine. 2014;11(3):840-856.
7. Rhoden EL, Morgentaler A. Symptomatic response rates to testosterone therapy and the likelihood of completing 12 months of therapy in clinical practice. The journal of sexual medicine. 2010;7(1 Pt 1):277-283.
8. Tajar A, Huhtaniemi IT, O'Neill TW, et al. Characteristics of androgen deficiency in late-onset hypogonadism: results from the European Male Aging Study (EMAS). J. Clin. Endocrinol. Metab. 2012;97(5):1508-1516.
9. Wang C, Nieschlag E, Swerdloff R, et al. Investigation, treatment, and monitoring of late-onset hypogonadism in males: ISA, ISSAM, EAU, EAA, and ASA recommendations. J. Androl. 2009;30(1):1-9.
10. Bhasin S, Pencina M, Jasuja GK, et al. Reference ranges for testosterone in men generated using liquid chromatography tandem mass spectrometry in a community-based sample of healthy nonobese young men in the Framingham Heart Study and applied to three geographically distinct cohorts. J. Clin. Endocrinol. Metab. 2011;96(8):2430-2439.
11. Wu FC, Tajar A, Beynon JM, et al. Identification of late-onset hypogonadism in middle-aged and elderly men. N. Engl. J. Med. 2010;363(2):123-135.
12. Hackett G, Cole N, Bhartia M, Kennedy D, Raju J, Wilkinson P. Testosterone replacement therapy with long-acting testosterone undecanoate improves sexual function and quality-of-life parameters vs. placebo in a population of men with type 2 diabetes. The journal of sexual medicine. 2013;10(6):1612-1627.
13. Baillargeon J, Urban RJ, Ottenbacher KJ, Pierson KS, Goodwin JS. Trends in androgen prescribing in the United States, 2001 to 2011. JAMA internal medicine. 2013;173(15):1465-1466.
14. Jin J, Sklar GE, Min Sen Oh V, Chuen Li S. Factors affecting therapeutic compliance: A review from the patient's perspective. Therapeutics and clinical risk management. 2008;4(1):269-286.
15. Jockenhovel F, Minnemann T, Schubert M, et al. Timetable of effects of testosterone administration to hypogonadal men on variables of sex and mood. The aging male : the official journal of the International Society for the Study of the Aging Male. 2009;12(4):113-118.
16. Francomano D, Ilacqua A, Bruzziches R, Lenzi A, Aversa A. Effects of 5-year treatment with testosterone undecanoate on lower urinary tract symptoms in obese men with hypogonadism and metabolic syndrome. Urology. 2014;83(1):167-173.
17. Haider A, Meergans U, Traish A, et al. Progressive Improvement of T-Scores in Men with Osteoporosis and Subnormal Serum Testosterone Levels upon Treatment with Testosterone over Six Years. International journal of endocrinology. 2014;2014:496948.
18. Haider A, Saad F, Doros G, Gooren L. Hypogonadal obese men with and without diabetes mellitus type 2 lose weight and show improvement in cardiovascular risk factors when treated with testosterone: An observational study. Obes Res Clin Pract. 2014;8(4):e339-349.
19. Haider A, Yassin A, Doros G, Saad F. Effects of long-term testosterone therapy on patients with "diabesity": results of observational studies of pooled analyses in obese hypogonadal men with type 2 diabetes. International journal of endocrinology. 2014;2014:683515.
20. Saad F, Haider A, Doros G, Traish A. Long-term treatment of hypogonadal men with testosterone produces substantial and sustained weight loss. Obesity (Silver Spring). 2013;21(10):1975-1981.
21. Traish AM, Haider A, Doros G, Saad F. Long-term testosterone therapy in hypogonadal men ameliorates elements of the metabolic syndrome: an observational, long-term registry study. Int. J. Clin. Pract. 2014;68(3):314-329.
22. Yassin A, Doros G. Testosterone therapy in hypogonadal men results in sustained and clinically meaningful weight loss. Clinical obesity. 2013;3(3-4):73-83.
Last updated: 2017
G.GM.MH.04.2015.0334