Feb 24, 2017

Old men roar

The story

Sex sells, and testosterone purchases have skyrocketed in the past 15 years. But can the king of male hormones really help Mufasa get his growl back? Look to new research for clues.

The background

Back in 2004, Justin Timberlake dated Cameron Diaz and JLo left Ben Affleck for Marc Anthony. But also that year the US Institute of Medicine concluded that we knew way less about testosterone than estrogen. The NIH began the TTrials to determine the short-term efficacy of testosterone in older men with low T, for which the primary results, published last year, showed a transient increase in sexual function for men on testosterone supplementation. More outcomes arrived this week. 

The pits

Twelve months of testosterone use increased coronary plaque volume in a study of 140 elderly men with low T and high atherosclerotic risk. CT imaging detected an increase in non-calcified plaque relative to placebo, though there was no difference in calcified plaque or cardiovascular event rates. Nonetheless, the extent of plaque expansion is unprecedented for a drug effect in a short time period, and has some wondering if the surge of testosterone during teenage years is responsible for the head start men have on women when it comes to cardiovascular disease.

The perks

Testosterone treatment increased bone mineral density and estimated bone strength in 200 men with low circulating testosterone levels, though the study was not designed to assess for fracture risk. Testosterone treatment also increased hemoglobin levels in older men with unexplained anemia. 

The wash

Those hoping that supplemental testosterone could keep the brain sharp are likely to be disappointed with the Cognitive Function Trial. Testosterone did not enhance recall or executive function at 6 or 12 months relative to placebo in an RCT of 500 men with low T and memory impairment.

The takeaway

The one unequivocal indication for testosterone remains pathologic hypogonadism. Patients are still going to want to get their hands on testosterone with or without your help, so make sure to warn them about potential risks. 

Say it on rounds

When your stethoscope doubles as a reflex hammer

You need tools that multitask as much as you do. Liraglutide (brand name Victoza) is already approved for use in type 2 diabetes and weight loss. The injectable GLP-1 agonist reduced the risk of progression from prediabetes to diabetes by 80% compared to placebo in an RCT of 2,200 obese patients. Three years of daily liraglutide also resulted in sustained weight loss of about 6% of body weight. Since about 5 - 10% of prediabetics will progress to diabetes each year, preventive therapy may catch on quickly. 

When your patient has more bells and whistles than your car

Everyone has seen a pacemaker or ICD make a patient ineligible for MRI, even though recent models are designed to reduce potential risks. A prospective trial of 1,500 patients with 'non-MRI conditional' (read: old) devices found no episodes of device failure following non-thoracic MRI scans. Minor changes in device settings were common, but none were clinically meaningful.

When you want eyes in the back of your head

Settle instead for eyes on the sides of your endoscope. A small study from Australia found that full spectrum (FUSE) colonoscopy, which incorporates lateral cameras to provide panoramic views of the colon, increased the number of dysplastic lesions detected when compared to standard colonoscopy in patients with inflammatory bowel disease. Total colonoscopy times were similar, but withdrawal time was longer with FUSE cases.

Brush up


Regularly up there with the scariest things that happen to young, healthy patients, myocarditis is implicated in almost 10% of sudden death in adults younger than age 35. Coxsackievirus B, adenovirus, parvovirus B19, and human herpes virus 6 are common viral pathogens, but parasites, fungi, bacteria, and drug hypersensitivity reactions can also be responsible. Twenty percent of affected patients will develop chronic dilated cardiomyopathy. 

What's the evidence

For improvement in cardiac function in myocarditis-driven cardiomyopathy? The best data comes from kids, so take it with a grain of salt. An Australian outcomes study found that 96% of patients with biopsy proven lymphocytic myocarditis were free of cardiac symptoms 15 years after diagnosis, and 80% were no longer on meds. In a second study of children, those with myocarditis had more favorable outcomes than those with idiopathic cardiomyopathy. 

What your public health friends are talking about

Can expensive sugar reduce obesity or diabetes? Mexico, known for its love of Coca-Cola, has found a sustained reduction in purchases of sugary beverages in year two of a national sugar tax.

Spread the word

People feel all kinds of hormonal about The Scope. Share with your friends and see for yourself.


Sign up at

Copyright © 2017 Medicine Scope. All rights reserved.