American College of Physicians: Limit testosterone supplementation in older men to the treatment of sexual function issues

Reference

Qaseem A, Horwitch CA, Vijan S, Etxeandia-Ikobaltzeta I, Kansagara D; Clinical Guidelines Committee of the American College of Physicians. Testosterone treatment in adult men with age-related low testosterone: A clinical guideline from the American College of Physicians. Ann Intern Med 2020;172(2):126-133.

Synopsis

These guidelines were produced following a systematic review of the evidence and were based on the effect of testosterone treatment in men with identified age-related low testosterone levels; in other words, not based on changes in testosterone levels. None of the authors had financial conflicts of interest and one working group member did not vote because of an intellectual conflict of interest. The development group included a patient representative and a methodologist. The guidelines do not suggest when to test for low testosterone levels, but a recommendation can be inferred by working backward from the treatment recommendations, which are: (1) Based on low-quality evidence and some likelihood that benefits outweigh risks, men with age-related low testosterone and with a desire to improve sexual function can be engaged in a conversation to consider the benefits, risks, and burden of using testosterone (low evidence certainty; conditional recommendation). The average benefit is low for improved global sexual function and improvement in erectile function. (2) Based primarily on an almost 10-fold cost difference in the United States, intramuscular injection should be offered to men over transdermal treatment after a discussion of their preferences (low evidence certainty; conditional recommendation). (3) If started, treatment effectiveness should be evaluated after 12 months and discontinued if there is no perceived difference in sexual function. (4) Most men will not benefit from testosterone treatment to improve energy, vitality, physical function, or cognition, and treatment should be restricted to sexual function issues (low evidence certainty; conditional recommendation).