Some of you have been asking about this article from yesterday’s New York Times. The study they refer to, which can be seen in its entirety here, was not an interventional study, but rather one where they retrospectively sifted through hospital and pharmacy data to look for associations. They looked at men who were given testosterone prescriptions:
- What kind of testosterone? We don’t know.
- What dose? We don’t know.
- If injectable, were they injecting large doses once a week (which is what is typically prescribed by doctors unfamiliar with testosterone therapy– and is not advisable for many reasons), or were they injecting small (physiologic) doses two or three times a week? We don’t know.
- What did their follow-up bloodwork show? We don’t know.
Then they looked at how many of those men had heart attacks in the year prior to getting the testosterone prescription– and how many of them had a heart attack in the three months after getting a prescription. What did they find?
- In men under age 65, with no history of heart disease, there was no increased rate of heart attack. (In fact, there was technically
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a 10% DECREASE in heart attack rate in that group, but that did not reach statistical significance.)
- In men under age 65 who also had a history of heart disease, there was a significant increase in the rate of heart attacks after getting testosterone.
- And men over age 65 did have an increase in the rate of heart attacks– though, interestingly, it was the same whether they had heart disease or not.
They also looked at whether giving the men prescriptions for Viagra was associated with an increase heart attacks, presumably to see if increased sexual activity alone was the cause of the heart attacks. They found that the Viagra prescriptions did not correlate with heart attacks. (No word on whether the Viagra worked as hoped– which isn’t meant to be funny; we don’t know if the men actually had increased sexual activity or not, because there’s no follow up on any of these patients.) So, what can we learn from this? Two months ago I wrote a longer blog post on this same topic, and I ask you to please take a look at that, as it has a much more in-depth review of the studies on testosterone and cardiovascular disease. I have the same thoughts now that I had then.
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This study doesn’t provide nearly enough information to add much to the conversation, but it does highlight some possible areas of concern: We need to be wary of prescribing testosterone willy-nilly to anyone who walks in the door. In this study, men under age 65 with no history of heart disease had no issue: there is nothing in this study to suggest danger in that group (which describes about 95% of my male patients). My practice is made up primarily of pro-active patients who exercise, eat well, and have very few co-morbidities. In other words, I have very few patients with heart disease, and the ones who do have heart disease are quite meticulous about their diet, exercise regimen, and follow-up. All of our patients get two hour evaluations when they first come in. All of them get follow-up bloodwork done 4 weeks after their initial prescription is written. That does not appear to be the case for the patients in this study. In the NY Times article, one professor of public health pointed out,
Testosterone increases the production of red blood cells, which can clump together or coagulate, essentially making blood thicker. That may be especially hazardous in men who have narrowed arteries because of aging and disease.
Agreed– which is why we track hematocrit levels in our patients (and our patients donate blood if their hematocrit gets too high). We don’t have any hematocrit numbers for the patients in this study, so we are only guessing as to whether it had any effect. (Usually, it takes at least a couple of months for hematocrit to rise, so I would be surprised if that were the primary issue.) What’s most interesting to me about this New York Times article are the final few paragraphs, which I copied here:
Dr. Peter J. Snyder of the University of Pennsylvania School of Medicine, who is leading a $50 million series of trials looking at testosterone treatment in men 65 and older with documented low levels, cautioned against drawing conclusions based on the new study.
“We don’t know if these findings apply to men who have low testosterone and meet the criteria for a prescription, or if it applies only to men who have normal levels and then take testosterone in addition,” he said.
Dr. Snyder said he and his colleagues found it plausible that testosterone might actually protect against heart disease, in part by reducing body fat and improving blood sugar metabolism. (emphasis added)
But, he added, the sharp rise in such prescriptions in the last decade was evidence that many men without testosterone deficiencies were receiving them. “In those cases, there is no medical reason for it,” he said, “and that runs counter to all guidelines for physicians.”
And that last part fascinates me: As Dr Snyder acknowledges, we have plenty of data showing that testosterone helps reduce body fat and improve metabolism– everything you could want to PREVENT the development of heart disease! So why would we want to wait until these men are clinically below the low end of normal range to supplement their levels? The normal range covers men from age 18
to age 80! Why would you want to let a 50 year old sit with the average testosterone level of a 75 year old for years, accumulating body fat and vascular risk, until he finally becomes “below normal range”? If this study shows us anything (and I’m not sure it does), it’s that once you have let the patient deteriorate that far, testosterone may very well be too much of a shock to the system. Preventive medicine is the name of the game. It is true that not every 40 year old with “low energy” needs testosterone. But when you have a 50 year old flirting with metabolic syndrome, hypertension or Type 2 diabetes, and you have a tool at your disposal that can bring him back from the edge of that cliff– a tool that even this study says is safe– why wouldn’t you use it?
I just became aware that another review of testosterone and cardiovascular disease was published in JAMA only two months ago (December 2013). Not surprisingly, the authors gave a much more positive commentary on testosterone therapy than we have seen in the popular press. They summarized,
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men with hypogonadism improves obesity, Type 2 Diabetes, myocardial ischemia [angina], exercise capacity, and [improves abnormal QT intervals on EKG].
There was no mention of this review in the NY Times article, which chose instead to focus on a weak observational study. For those of us who have studied and written about the uneven reporting on women’s HRT studies,
it feels a bit like deja vu.
ADDENDUM #2 (2/16/14)
A number of comments were posted below questioning the association of elevated hematocrit with cardiovascular events. So, I elaborated on that issue further in a separate post which you can find here.