Presentation Authors: Jethro C.C. Kwong*, Yonah Krakowsky, Ethan Grober, Toronto, Canada
Introduction: Testosterone deficiency (TD) is characterized by low levels of testosterone (T) with associated signs and symptoms. Several controversies related to approach to TD have been identified. We compare current guidelines for the diagnosis and management of TD, as well as special considerations for specific patient populations.
Methods: The following guidelines were included for analysis: American Urological Association (AUA, 2018), European Association of Urology (EAU, 2018), Endocrine Society (ES, 2018), and Canadian Medical Association (CMAJ, 2015). The comparison focused on the biochemical definition (cut-off) for low T, principles of management of TD, and recommendations for patients with low-to-normal total testosterone, prostate cancer, or cardiovascular disease.
Results: Recommendations are generally consistent across guidelines, however there are notable differences (Table 1). For biochemical cut-off, most guidelines require 2 lab measurements of total T ranging between 8 to 10.4 nmol/L, however the CMAJ requires only one measurement and has no specific cut-off. In patients with low-to-normal total T, additional hormonal evaluation is recommended, however only the CMAJ suggests a 3-month trial of TTh in symptomatic patients. The ES has the strictest recommendations for patients with TD and prostate cancer. Other guidelines generally recommend against TTh in patients with metastatic prostate cancer. Although there is limited evidence linking TTh and risk of cardiovascular events (MI, stroke, sudden CV death), the AUA and EAU impose more restrictions in offering TTh to patients with cardiovascular disease. Notably, the AUA recommends against TTh if patients experienced a cardiovascular event within the past 3-6 months, while the EAU states that TTh is contraindicated in patients with NYHA Class IV heart failure. In contrast, the CMAJ recommends TTh in patients with stable cardiovascular disease.
Conclusions: While there is consensus among current guidelines on TD, notable differences may impact diagnosis and eligibility for TTh. Additional work is needed to consolidate recommendations across guidelines, especially for specific patient populations. We highlight the limitations of relying exclusively on guidelines in managing patients with TD.