testosterone and MI

there seems to be much more demand for testosterone (i assume promoted by advertising and men's magazines), even in inner city Boston.  there have been a couple of cautionary articles in the past year or so (small RCT in 2010 of testosterone gel in men with  decreased muscle function, stopped because of excess cardiovasc events; VA study of men>60yo most with CAD found increase in cardiovasc outcomes).  the open access journal PLOS ONE published an article today funded by the national cancer institute -- and not pharma (see testosterone and nonfatal MI pLos 2014, or DOI: 10.1371/journal.pone.0085805), a cohort study of 56K men prescribed testosterone therapy (TT) from a large health-care database (representing men from around the US) and looked at the incidence of MI in the 90 days following the initial prescription (earlier studies found excess cardiovasc risk occurred soon after starting TT). they compared this rate to 167K men men receiving phosphodiesterage-5 inhibitors (PDE5I, sildenafil/tadalafil), and compared MIs as a ratio of post-TT  to pre-TT, with MIs post-to-pre PDE5I). comparison to PDE5I was chosen since men with some similar issues are given TT or PDE5I, and PDE5I has no testosterone effects.  results:

    --MI ratio for men pos/pre TT: 1.36
    --MI ratio for men over age 65 was 2.19, but a non-significant 1.15 for PDE5I
    --MI ratio with TT varied with age, from .95 in those<55yo to 3.43 in those >75, with no trend with PDE5I
    --MI ratio for TT in men with prior history of heart disease was 2.9, but a nonsignificant 1.4 for PDE5I

so, this study adds to the concern about testosterone therapy.  there are important weaknesses, since they used a health care database (without knowledge of clinical indication for TT or data on testosterone levels), though a meta-analysis of small RCTs did not find an association with baseline testosterone levels. in addition, they chose a reasonable surrogate, by comparing TT with men on PDE5I, since there was at least a commonality between these groups around sexual function (though not around fatigue, muscle weakness, etc).  so, no firm conclusions, but a cautionary note....

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