Who Gets Testosterone? Patient Characteristics Associated with Testosterone Prescribing in the Veteran Affairs System: a Cross-Sectional Study

Abstract

BACKGROUND: There has been concern about the growing off-label use of testosterone. Understanding the context within which testosterone is prescribed may contribute to interventions to improve prescribing. OBJECTIVE: To evaluate patient characteristics associated with receipt of testosterone. DESIGN: Cross-sectional. SETTING: A national cohort of male patients, who had received at least one outpatient prescription within the Veterans Affairs (VA) system during Fiscal Year 2008-Fiscal Year 2012. PARTICIPANTS: The study sample consisted of 682,915 non-HIV male patients, of whom 132,764 had received testosterone and a random 10% sample, 550,151, had not. MAIN MEASURES: Conditions and medications associated with testosterone prescription. KEY RESULTS: Only 6.3% of men who received testosterone from the VA during the study period had a disorder of the testis, pituitary or hypothalamus associated with male hypogonadism. Among patients without a diagnosed disorder of hypogonadism, the use of opioids and obesity were the strongest predictors of testosterone prescription. Patients receiving >100 mg/equivalents of oral morphine daily (adjusted odds ratio = 5.75, p < 0.001) and those with body mass index (BMI) >40 kg/m 2 (adjusted odds ratio = 3.01, p < 0.001) were more likely to receive testosterone than non-opioid users and men with BMI <25 kg/m 2 . Certain demographics (age 40-54, White race), comorbid conditions (sleep apnea, depression, and diabetes), and medications (antidepressants, systemic corticosteroids) also predicted a higher likelihood of testosterone receipt, all with an adjusted odds ratio less than 2 (p < 0.001). CONCLUSIONS: In the VA, 93.7% of men receiving testosterone did not have a diagnosed condition of the testes, pituitary, or hypothalamus. The strongest predictors of testosterone receipt (e.g., obesity, receipt of opioids), which though are associated with unapproved, off-label use, may be valid reasons for therapy. Interventions should aim to increase the proportion of testosterone recipients who have a valid indication.

Pharmacoepidemiology of testosterone: Curbing off-label prescribing

“…Beyond the unverified verbal approval to prescribe testosterone within the PBS scheme, compliance with the PBS criteria is not audited so the extent of compliance is not known. In the VA analysis, the vast majority (93.7%) of 132 764 men treated with testosterone did not have pathological hypogonadism . Characteristically, they were aged 40‐55 years old, white nonhispanics suffering from a wide variety of medical comorbidities of ageing including obesity, metabolic disorders (hyperlipidemia, diabetes), hypertension, chronic pulmonary disease, sleep disorders, psychiatric conditions (anxiety, bipolar disorder, depression, post‐traumatic stress disorder), or were taking specific medications (anti‐depressants, glucocorticoids, opiates).…”

Hypogonadism and male obesity: Focus on unresolved questions

“…Obesity was not considered to be an aetiological factor in male hypogonadism in authoritative reviews published in the 1980s . However, today, obesity has emerged as one of the strongest predictors of receiving testosterone treatment in middle‐aged US American men . Global increases in testosterone prescribing and a marked increase in the prevalence of obesity, which has doubled since the 1980s in many countries in conjunction with secular trends of reductions in circulating testosterone likely contribute to an increasing number of obese men receiving testosterone treatment.…”

Health Outcomes Among Long-term Opioid Users With Testosterone Prescription in the Veterans Health Administration

“…4,5 Prescription opioid use has been shown to have an association with testosterone deficiency; nearly 20% of testosterone prescriptions written in the Veterans Health Administration (VHA) system were for men who were opioid users. 6 Testosterone deficiency among opioid users is associated with increased risk of sexual dysfunction, osteoporosis, and bone fractures. 7 However, to our knowledge, no data exist on major health outcomes in opioid users who are hypogonadal and either receive or do not receive testosterone treatment.…”