Screening, Diagnostic, and Treatment Patterns for Testosterone Deficiency in an Academic Medical Center

Program: Abstracts - Orals, Poster Previews, and Posters
Session: SUN 176-202-Male Reproductive Endocrinology and Male Reproductive Tract (posters)
Bench to Bedside
Sunday, April 3, 2016: 1:15 PM-3:15 PM
Exhibit/Poster Hall (BCEC)

Poster Board SUN 190
Syed Rifat Ahmed*1, Sarah Elizabeth Smith2, Alex K Bonnecaze3, Kristen T Hairston4 and Cynthia Anne Burns5
1Wake Forest School of Medicine, Winston salem, NC, 2Wake Forest University School of Medicine, Winston Salem, NC, 3Wake Forest Baptist Medical Center, Winston-Salem, NC, 4Wake Forest University School of Medicine, Winston-Salem, NC, 5Wake Forest School of Medicine, Winston Salem, NC
While there are some clear indications for testosterone replacement in children, the role of testosterone therapy in most adult men is not as clearly defined.  This has implications as testosterone therapy is associated with numerous risks, including worsening sleep apnea, erythrocytosis, and prostate enlargement. There are three sexual symptoms (erectile dysfunction, low libido, and decreased frequency of morning erections) that have high specificity for testosterone deficiency (TD).  There is also a myriad of non-specific symptoms associated with TD (e.g., fatigue, dysthymia, poor concentration) that can be seen in patients with innumerable other medical conditions, but may prompt screening for TD. Since testosterone secretion is diurnal, Endocrine Society guidelines state that the most accurate total testosterone levels (TTL) are drawn in the morning.  If this initial TTL is low, a second AM TTL should be drawn to confirm the diagnosis of TD.  Screening inappropriately based on non-specific symptoms and diagnosing TD without appropriate workup leads to costly and unnecessary therapy initiation, with the potential to harm the patient.  The purpose of this study was to characterize screening, diagnosis, and treatment patterns for TD in an academic center across various specialties. 

We queried our electronic medical record from September 2012 to January 2015 for men with a TTL drawn and/or a new testosterone prescription. 206 patients were randomly selected from this pool.  Data points collected were: age at screening, symptoms which prompted screening (specific sexual symptoms and non-specific symptoms), time of day / number of TTLs collected prior to testosterone therapy initiation, and whether or not testosterone was prescribed.  The actual TTL values were not taken into account in this study.  The average age was 54 years old (SD 11.7 years) with all having at least one TTL drawn.  61 patients (30%) received screening but had no specific symptoms of testosterone deficiency.  132 patients (64%) had their initial TTL drawn after morning hours.  59 (29%) of patients got a second confirmatory TTL; of these, 28/59 (47%) were drawn after morning hours.  Ultimately, 203 (99%) of those screened were prescribed testosterone, but only 12 (7%) of these patients had an appropriate evaluation (defined here as two TTLs drawn during morning hours).

Our data suggest that just being screened for TD is associated with receiving a prescription for testosterone almost 100% of the time in our center.  The risk for misdiagnosis was high given that 30% of patients were screened for inappropriate reasons, and 93% of patients were prescribed testosterone after inappropriate evaluation.  These data suggest that current patterns of screening and prescribing for TD are not optimal and may contribute to increased healthcare costs and potential harm to patients.

(1) Bhasin S., Cunningham G. R., Hayes F. J., et al. Testosterone therapy in men with androgen deficiency syndromes: an endocrine society clinical practice guideline. Journal of Clinical Endocrinology and Metabolism. 2010;95(6):2536–2559. doi: 10.1210/jc.2009-2354. (2) Wu F.C., Tajar A., Beynon J.M., Pye S.R., Silman A.J., Finn J.D. Identification of late-onset hypogonadism in middle-aged and elderly men. N Engl J Med. (3) Bremner WJ, Vitiello MV, Prinz PN. Loss of circadian rhythmicity in blood testosterone levels with aging in normal men. J Clin Endocrinol Metab. 1983. (4) Schwartz LM, Woloshin S (2013) Low “T” as in “Template”: How to Sell Disease: Comment on “Promoting ‘Low T’”. JAMA Intern Med:1–3. (5) Snyder, PJ. Clinical features and diagnosis of male hypogonadism. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on October 26, 2015).

Nothing to Disclose: SRA, SES, AKB, KTH, CAB

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