6.4.2 Male sex hormones and antagonists

Androgen replacement has been indicated in patients with symptomatic hypogonadism having confirmed two low early morning testosterone and considering the underlying cause.

Oral replacement is not generally recommended due to very poor absorption. Standard therapy is IM injection of testosterone.

Monitoring

  • Prostate-specific antigen (PSA): PSA should be measured at the start of therapy and annually thereafter. If PSA is increasing over time then a referral to urology and stopping testosterone supplementation should be considered.
  • Full blood count: FBC should be performed and treatment reduced or stopped if polycythaemia or haematocrit is greater than 50%.

Testosterone and esters

Testosterone IM injection
  • Sustanon® 250 injection (£2.45 = 1ml amp)

Dose

  • Usual therapy is 250mg IM injection every 3-4 weeks. For patients who report large swings in their symptomatic response, an alternative dosing schedule of a lower dose more frequently.

Notes

  1. Contains peanut oil

The following 2nd line treatment options cost considerably more and should be reserved for those patients with very fluctuant symptoms on Sustanon® or those unable to attend frequent injection appointments. Transdermal preparations may be useful for patients with needle phobia.

Testosterone long-acting IM injection
  • Nebido® injection (oily), testosterone undecanoate 250mg/mL (£21.78 = 4ml amp or vial)

Dose

  • 1g every 10-14 weeks. A loading dose may be given at 6 weeks to achieve rapid steady state plasma levels
Testosterone transdermal
  • Testogel® gel 50mg/5g sachet (£31.11 = 30 sachets
  • Tostran® gel 2% (10mg / metered application) (£28.67 = 60g)

Dose

  • Testogel®: 50mg daily. Apply thin layer of gel to a covered area of nongenital skin. Allow to dry for 3-5 minutes before covering and wash hands after use
  • Tostran®: initially 60mg testosterone (3g gel) applied once daily. Subsequent applications adjusted according to response

Anti-androgens

Cyproterone acetate
  • Tablets 50mg, 100mg (£55.19 = 300mg daily)

Notes

  1. Hepatotoxicity: Direct hepatic toxicity including jaundice, hepatitis and hepatic failure has been reported (usually after several months) in patients treated with cyproterone acetate 200-300 mg daily. Liver function tests should be performed before treatment and whenever symptoms suggestive of hepatotoxicity occur-if confirmed cyproterone should normally be withdrawn. Cyproterone is no longer recommended for long term use.
  2. Prevention of tumour flare in patients starting treatment with gonadorelin analogues should be achieved by the use of cyproterone 300mg daily in 2 or 3 divided doses starting at least 3 days before the gonadorelin analogue and continuing for 3 weeks.
  3. Megestrol acetate 160mg daily (see 8.3.2) or cyproterone acetate 50-150mg daily may be used in low doses to control unacceptable symptomatic flushes associated with LHRH analogues.

5 alpha-reductase inhibitors

Finasteride
  • Tablets 5mg (£1.12)

Indications

Notes

  1. Finasteride is an alternative to alpha blockers in older men, particularly if the prostate is larger than 40mL. There is evidence that finasteride reduces the risk of symptomatic progression due to prostatic enlargement. The urologists are happy to advise on management.
  2. Combination therapy with alpha blockers is appropriate for men with bothersome moderate to severe LUTS and prostates estimated greater than 30g or a PSA greater than 1.4ng/mL. An attempt to withdraw the alpha blocker may be made at 9-12 months and finasteride continued as monotherapy. If symptoms recur the alpha blocker can be restarted. One further attempt to withdraw the alpha blocker 6 months later would be appropriate.
  3. Relief of symptoms may take several months.
  4. Urologists use finasteride off-licence in patients who have prostatic bleeds.
  5. Patients should stop finasteride immediately if they develop depression and inform a healthcare professional.

 

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