‘Lack of consensus evidence’ may drive variability in testosterone prescribing
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Nearly one-quarter of men reporting low libido and a total testosterone measurement indicating likely hypogonadism did not receive a prescription for testosterone replacement therapy, according to a U.K. database analysis.
In a study analyzing electronic health records for more than 2.5 million general practitioner-registered patients, researchers found men who did receive a testosterone prescription tended to be older and have a higher BMI and greater risk for comorbidities such as type 2 diabetes.
“We were surprised at how much variation there was in primary health care prescribing within the study population located in London,” Channa Jayasena MD PhD, a reproductive endocrinologist at Imperial College London, told Healio. “It is plausible that some prescribers may be either over- or undertreating men being assessed for hypogonadism.”
In a retrospective study, Jayasena and colleagues analyzed EHR data from 20,299 men without prior testosterone prescription records who had at least one total testosterone measurement between 2015 and 2019, using a U.K. primary health care database. Researchers assessed whether testosterone was prescribed and analyzed patient clinical characteristics related to hypogonadism.
The findings were published in Clinical Endocrinology.
Within the cohort, 19,583 men (96.4%) were not prescribed testosterone replacement therapy and 716 (3.5%) were prescribed testosterone. Men were more likely to be prescribed testosterone if they were older, had a higher BMI and were at greater risk for hypertension, depression, type 2 diabetes and ischemic heart disease. Men prescribed testosterone also had lower mean pretreatment total testosterone and were less likely to have prostate cancer. There were 436 men (24.3%) with a total testosterone measurement of less than 8 nmol/L and symptoms of low libido who were not prescribed testosterone therapy.
The researchers noted that clearer guidance for clinicians may help to improve the consistency of treatment of men with hypogonadism, adding that “it is plausible that lack of consensus evidence on testosterone replacement therapy safety, and multiple sources of clinical guidance contribute to variability in testosterone prescribing in primary care.”
“It would be helpful to understand more about what factors drive individual health care practitioners to prescribe or not prescribe testosterone,” Jayasena told Healio. “Identifying themes associated with either under- or overprescribing would help improve the consistency of treatment of hypogonadism.”
For more information:
Channa Jayasena, MD, PhD, can be reached at c.jayasena@imperial.ac.uk.
Perspective
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Abraham Morgentaler, MD, FACS
New research from the U.K. provides an interesting snapshot of current testosterone therapy prescribing by general practitioners in northwest London, at a time when evidence is accumulating that testosterone deficiency is associated with increased mortality, testosterone therapy may have general health benefits in testosterone-deficient men, and that concerns regarding prostate cancer and cardiovascular risks are abating.
The article by Sharma and colleagues investigated 20,299 men without a prior testosterone prescription who underwent at least one test for total testosterone between 2015 and 2019. Of these men, only 3.5% received a testosterone prescription. Among the subgroup of men with a documented symptom of low libido and unarguably low levels of testosterone, defined as less than 8 nmol/L (approximately 230 ng/dL), 75.7% received a prescription. Notably, 24.3% of these men did not.
It is somewhat reassuring, to my mind, that three-quarters of men with very low testosterone levels and low libido did receive a prescription, indicating a reasonable level of awareness and willingness to treat among general practitioners in northwest London. However, we must be cautious interpreting this result. This study provides information as to how often prescriptions were offered for men with a known testosterone value; however, it cannot tell us how many symptomatic men did not have a testosterone test at all. Since ordering a testosterone lab test is not (yet) part of any recommended routine for general practitioners, it must be assumed that there was a reason the test was ordered in these men — presumably for one or more symptoms. Further, the reality of electronic health data is that not all symptoms are adequately captured. In that regard, the 3.5% of men who received a prescription seems low.
My takeaway from this study is that we have come a long way in the education of general practitioners, at least in the U.K., with regard to testosterone deficiency and its treatment. When lecturing to health care providers who are uncertain about the value of testosterone therapy, I always recommend taking the first step of simply ordering testosterone studies in men at high-risk for testosterone deficiency, such as men with diabetes or obesity, or in men with sexual symptoms or unexplained fatigue. This may be what has been observed in this study by Sharma and colleagues.
The next step is to determine whether testosterone therapy makes a difference for our patients. This requires clinical experience gained over time. The larger issue will be whether such treatment improves major health outcomes. One day, an educated primary care health force may come to recognize that testosterone deficiency merits treatment for its general health benefits, and not only for treatment of symptoms.
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