Should this influence our practice as emergency physicians given the low likelihood we will prescribe testosterone supplementation? It should give us pause when a patient comes through our doors with a history of testosterone supplementation. As of today, it is unclear if we should advocate for or against testosterone’s use, but it puts even greater emphasis on the shared decision-making process between patient and doctor.
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ACEP Now: Vol 34 – No 04 – April 2015As one ages, is it worth increasing the already-looming risk of a vascular event in exchange for the Fountain of Youth? Drinking from the Fountain is sweet, indeed, but the Fountain runs dry all too soon. It remains unclear whether testosterone ultimately influenced the outcome of my patient. He was a father and husband looking to regain his youth. Would he have changed his mind about testosterone if he knew there might be a possibility, however small, that it would result in death? Or, even worse, result in a severe and incapacitating disability? Patients often have a difficult time making the best choice for themselves, even when possessing adequate knowledge of the risks. In the postpaternalistic age, we must sometimes, unfortunately, stand aside and let patients make their own choices once they have been presented with the risks and benefits as best we know them.
As a cirrhotic patient with a large hydrothorax and uncomfortable scrotal edema said to me so aptly, “Stop talking about my lung. The lung can wait. Take care of my stuff down there first.”
Dr. Lim is a resident in the department of emergency medicine at The Brooklyn Hospital Center in New York. Dr. Hulbanni and Dr. Chew are emergency physicians at The Brooklyn Hospital Center.
References
- Drehle D. Manopause?! Aging, insecurity and the $2 billion testosterone industry. Time. July 31, 2014.
- Vigen R, O’Donnell CI, Baron AE, et al. Association of testosterone therapy with mortality, myocardial infarction, and stroke in men with low testosterone levels. JAMA. 2013;310:1829-1836.
- Finkle WD, Greenland S, Ridgeway GK, et al. Increased risk of non-fatal myocardial infarction following testosterone therapy prescription in men. PLoS ONE. 2014;9:e85805.
- Baillargeon J, Urban RJ, Kuo YF, et al. Risk of myocardial infarction in older men receiving testosterone therapy. Ann Pharmacother. 2014;48:1138-1144.
- Basaria S, Coviello AD, Travison TG, et al. Adverse events associated with testosterone administration. N Eng J Med. 2010;363:109-122.
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3 Responses to “Testosterone to Slow Aging in Men Could Pose Cardiovascular Risk”
May 3, 2015
DavidI think the article brings up some very appropriate questions but it also is a bit irresponsible. Clearly this patient suffered an PE and the cause of the PE would have needed to be investigated had he lived. The CVA that became hemorrhagic with the use of TPA is unfortunate. However, to put all this together in an article about aging and bioidentical hormone usage is a bit of a reach at this point without knowing a lot more about this patient.
While it is clear that we need a lot more research on most things we do in medicine, making the jump in this case, that PE and CVA were directly related to Testosterone or other supplements that this patient was taking is a bit of a jump. As long as this is an editorial article and not perceived as anything scientific it is up to the discretion of the editor to publish it. Aging and hormone supplements are a popular topic grabbing a lot of headlines and the center of much discussion and controversy, but the tone of the article intimates that there is a direct connect at this point. In my humble and pseudo scientific opinion, this is a bit sensationalistic and irresponsible.
May 4, 2015
Louise B Andrew MD JDThere were significant design flaws in the cited NEJM study not noted by the study authors. The test subjects were highly subject (by virtue of age, sex and inactivity) to having androgen deficiency, preexisting CV disease predisposing to subsequent events. The degree of preexisting testosterone deficiency was not assessed. The doses of exogenous testosterone greatly exceeded manufacturor’s safety recommendations. Increased activity levels following study initiation were not taken into consideration. Estradiol levels were not considered (aromatization of testosterone leads to estradiol, which predisposes to cardiovascular events in men, for example those placed on ADT).
So sweeping and unqualified generalizations could not legitimately have been arrived at by the study authors about supposed dangers of testosterone administration. The horrendous case study presented by the resident does serve to remind that a complete medication history should be elicited in any patient, and that many patients fail to mention supplements and therapies which they do not believe to be mainstream; but it does not mitigate against the use of testosterone supplementation in properly screened individuals with appropriate treatment dosage and adequate followup. Many studies have demonstrated a decrease in cardiovascular complications with testosterone supplementation, especially in diabetics. See e.g. a subsequent review article Diabetes Metab Res Rev 2012; 28(Suppl 2): 52–59.
May 6, 2015
D Johnson, MDI view this is another example of a bad outcome (ICH with 1/18 probability and a 45% mortality rate when it occurs) with the use tPA in ischemic stroke.