Testosterone replacement therapy should be considered in hypogonadal men with liver cirrhosis, a leading hepatologist says.
Associate Professor Paul Gow, from the Victorian Liver Transplant Unit, told AGW 2019 that there was a big overlap between symptoms in cirrhosis and those in hypogonadism.
And, in particular, sarcopenia was strongly linked with outcomes in both patient groups.
Sarcopenia was associated with rates of sepsis in both transplant and non-transplant populations, contributes to insulin resistance which accelerates progression of liver disease and was also associated with mortality.
Therefore a treatment which could help restore muscle mass was likely to have additional benefits.
“It’s easy for us to look at this group of patients and say they’re complaining because they’ve got liver failure but actually they might be complaining because they’ve got hypogonadism which is somewhat fixable.”
Associate Professor Gow reported the results of a randomised placebo-controlled trial of intramuscular testosterone replacement therapy in 100 men with cirrhosis of any aetiology and total testosterone levels less than 12 nmol/L.
The study found the primary endpoint of muscle mass measured with DEXA improved by 1.13 kg at six months and 1.69 kg at 12 months compared to baseline. There was no improvement in the control group.
As well there were other significant non-muscle improvements including reductions in fat and HbA1c and improved bone density and haemoglobin. There was also a trend to improved grip strength.
There were no differences in quality of life or mental health between the groups and no adverse events.
Due to the severity of liver disease, the mortality rate during the study was 20%.
Associate Professor Gow said testosterone replacement therapy was available on the PBS for men with hypogonadism – requiring two testosterone levels <6.0.
However a prescription also required discussion and approval from an endocrinologist.
“Endocrinologists are split between believers and non-believers with testosterone replacement therapy generally, so some will say no men need it, others will say a lot of men need it. So you need to find one on the believing side.”
He said IM testosterone was preferable due to concerns about absorption in men with fluid overload.
Associate Professor Gow said despite the demonstrated benefits of treatment, the trial was underpowered to assess for an effect on mortality.
“To do the study that shows they live longer, you’d probably need 1,000 patients and that needs big pharmaceutical company money, not one hospital doing a tiny study. It would probably need multiple sites internationally to get enough patients.”