Tuesday, January 31, 2012

New Androderm Strength - It's Lower! Part 2

I was going through my mail earlier today when I stumbled upon a letter from Watson Pharmaceuticals, the manufacturer of Androderm.  If you'll remember my post from this past fall, Androderm was being manufactured & promoted in a smaller dose/strength, 2mg & 4mg patches vs 2.5mg & 5mg.  

I wasn't sure of their plans but wondered how they would market both 2mg & 2.5mg as well as 4mg & 5mg patches.  Well, wonder no more.  It's official.  Watson has "discontinued the manufacture and sale of Androderm 2.5mg and 5mg" and is now solely focused on promoting its smaller sized 2mg and 4mg patches.  Of course, this is the company that claims that 97% of hypogonadal users (34 out of 35) had total testosterone levels between 300ng/dL and 1,030ng/dL after using Androderm for a month.

That's like me claiming that 34 out of 35 failing students passed with a grade between D- and A after I tutored them.  But shouldn't my goal be to tutor all of them to complete understanding of the subject material?  So rather than focus on a grade or testosterone level, I like to focus on my patients' clinical well-being.  Can they tell a difference now compared to prior to supplementing their testosterone?  That's the goal (well that and no side effects from excessive levels, too).  Just a thought the next time your doc tells you that your labs are normal.  And how normal is normal?  

By the way, remember than 1 out of 35?  He failed (despite my best attempts).  Nice, huh?



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Dead Fax Leads to Communications Withdrawal!

What a nightmare!  First, my cell phone.  Now my fax (again!).  2nd time in less than 2wks in which my fax went down.  Can't send out.  Can't receive.  Spent over an hour on the phone trying to get working again.  Running my solo private practice isn't anywhere near as easy & fun as on ABC's Private Practice.



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Dutasteride vs Low Grade Prostate Cancer

Low grade cancer is a very difficult concept for most people to consider.  To the average layperson, cancer is binary and digital.  It's either present or not.  However, to the clinician, especially the oncologist, cancer is really analog; in other words, there are lesser evils.  For instance, if I had to have a cancer but was also given the opportunity to choose which kind of cancer, I'd pick a simple basal cell carcinoma since they're easy to eradicate and very rarely metastasize (spread) rather than melanoma which has the opposite characteristics.

For most men, when we hear about prostate cancer, all we can think of is dying a slow & painful death from bone metastases & bladder obstruction, or something like that.  However, as my colleagues know, there are various grades of prostate cancer as denoted by Gleason score.  And in fact, localized (not yet having spread) prostate cancer with a low Gleason score can often be actively monitored (otherwise known as watchful waiting) without any loss of continence, erectile function, or quality-adjusted life years.

Which brings me to a randomized, double-blind, placebo-controlled study published last week in Lancet which concluded that dutasteride taken daily for 3 years compared to placebo could decrease the risk of low grade prostate cancer from progressing onward to high grade disease.  Specifically, the authors noted that only 38% of those randomized to the 5 alpha reductase inhibitor progressed while 48% randomized to placebo had biopsy proven progression.  As expected, those randomized to dutasteride (24%) complained more of side effects such as decrease in libido, breast enlargement, and/or nipple sensitivity than those randomized to placebo (15%).  

While the above study might make the use of dutasteride as chemoprophlaxis against prostate cancer, let's not forget another study published almost 2 years ago in NEJM in which it appears that dutasteride might increase the risk for high grade cancer, even while lowering one's risk for low grade disease.  Of course, the editorial for this latest study brought up the question of why even screen if there is no benefit to be gained.  After all, the recent analysis of the ongoing PLCO trial demonstrated no mortality benefit after 13 years of annual screening for prostate cancer.

Clearly, there is no easy answer.  Each man will need to assess his risk aversion vs tolerance in order to make an informed decision with the assistance of his family physician.



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Long-Term Surveillance of Growth Hormone

Growth hormone was first offered as a cadaveric derivative.  In other words, it was obtained from (dead) human brains in the 1960s.  After it was associated with Creuzfeldt-Jakob disease (think Mad Cow disease), cadaveric growth hormone was pulled off the market in the 1980s, just as recombinant human growth hormone (hGH) became available.  Since then, we've been monitoring patients closely in groups composed of children, cancer survivors, adults, and others.

The good news is that no concerns have been raised with regards to safety, especially in adult survivors of childhood cancers.  However, it should also be noted that these open-label studies have been supported by the pharmaceutical companies, which falls far short of gold-standard double-blind, placebo-controlled studies.  Still, we can only make decisions today based upon information that's currently available, not what we'd like to know in the future.  With that in mind, take some time to read a nice summary published this month in the Journal of Clinical Endocrinology & Metabolism.  As always, don't forget the editorial.



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Monday, January 30, 2012

Statin Options - Which is Best for You?

Have you ever wondered how the various statins are different from each other?  After all, what makes your doctor choose any given statin to lower your cholesterol?  I mean besides the obvious drug dinners and samples in our closet.  While I was attempting to answer a patient's question about this issue, I stumbled upon Consumer Reports' take in Best Buy Drugs.  It gives a nice explanation about lipophilicity (more could potentially increase side effect risk) and how to choose based upon potency (although I would suggest focus on lifestyle for LDL <30% above goal) as well as individual (medical) needs.  In fact, it offers a great summary of published data through its June 2010 publication date.  Best of all, you can find out how to get the best deal possible for your health care dollar.  Happy reading!



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Testosterone Options - Which is Best for You?

If you're curious about your (traditional, on-label) options to treat hypogonadism, check out Monthly Prescribing Reference which is used by many physicians to keep up-to-date regarding all the (new) medications available.  Personally, I've always stated that the best therapy for any given individual is the one that he can afford and is willing to self-administer.  More importantly, this method may change from time to time depending upon specific needs, eg international travel or backpacking/camping in the wild vs staying at home.  After all, you might not want to cross borders & check points and have to explain needles & a vial to some security guard.  Or you might feel a bit apprehensive about injecting under sterile conditions while deep inside a National Park.

While oral androgens do carry FDA approval, I would never prescribe them to any of my patients due to greater concern for liver issues, eg peliosis hepatis, compared to any other form of administration.  I can certainly understand why traditionally we've asked our patients to come into our offices for intramuscular (IM) shots of testosterone.  And I can certainly understand why some patients might not feel comfortable self-administering an IM shot into their gluteus maximus or vastus lateralis.  However, off-label subcutaneous injections (similar to injecting insulin) have been studied and are a consideration.

For hypogonadal men who are still interested in maintaining their fertility, I would avoid any of the above options as they tend to suppress pituitary function and thus testicular production of sperm.  Off-label options to consider are chorionic gonadotropin (for direct testicular stimulation by mimicking LH & FSH) and clomiphene (by inducing the pituitary to produce more LH & FSH).  These latter options might be beyond the comfort level of many primary care physicians but are certainly not without support in published literature.

The take home point?  Make sure you're aware of all your options and make sure your treatment is individualized to you.



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Sunday, January 29, 2012

Q&A Session at Avvo.com

MY QUESTION FOR A DOCTOR I am 57 years old, in excellent health, weigh 295lbs am 6’, and am a SCHOOL BUS DRIVER for 12 year




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How can i get a free penis stretching device




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I have a pain in my groin area. I am a woman, age 55. The pain is in my left leg. How can you help?




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I have a soreness on the right side of my groin and it feels swollen. I don't know what I should do?




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My penis, when erect, bends severely to the left an downward. there is also a hard lump at the left side of the base. Why?




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Ever since yesterday I have been peeing a lot but its very little amount almost a few drops and it stings a little in the end




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What is causing me to still have frequent urination urges?




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What are options for prostate enlargement?




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Testicular pain?




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I'm worried about herpes




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What does it mean if the bladder feels like it go ever 5 minutes and it hurts and blood is coming out of the same place?




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What kind of doctor do I need?




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