@anabolic Steroids - Pharmacology of Testosterone PDF
@anabolic Steroids - Pharmacology of Testosterone PDF
@anabolic Steroids - Pharmacology of Testosterone PDF
Contents
14.1
14.2
General considerations
14.3
14.3.1
14.3.1.1
14.3.1.2
14.3.1.3
14.3.1.4
14.3.1.5
14.3.2
14.3.3
14.3.4
14.3.5
14.3.6
14.3.6.1
14.3.6.2
14.3.6.3
14.3.6.4
14.3.6.5
14.3.6.6
14.3.6.7
14.3.6.8
14.3.7
14.3.7.1
14.3.7.2
14.3.8
14.4
Key messages
14.5
References
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the abdomen of capons and recognized that the animals with the transplanted
testes behaved like normal roosters: They crowed quite considerably, often fought
among themselves and with other young roosters and showed a normal inclination
toward hens. Berthold concluded that the virilizing effects were exerted by testicular
secretions reaching the target organs via the bloodstream. Bertholds investigation
is generally considered the origin of experimental endocrinology (Simmer and
Simmer 1961). Following his observation various attempts were made to use testicular preparations for therapeutic purposes. The best known experiments are those
by Brown-Sequard (1889), who tried testis extracts on himself which can at best
have had placebo effects (Cussons et al. 2002). In the 1920s Voronoff transplanted
testes from animals to humans for the purpose of rejuvenation (Voronoff 1920), but
the effectiveness of his methods was disproven by a committee of the Royal Society
London. The rst testicular extracts with demonstrable biological activity were prepared by Loewe and Voss (1930) using the seminal vesicle as a test organ. Finally, the
groundstone for modern androgen therapy was laid when steroidal androgens were
rst isolated from urine by Butenandt (1931), testosterone was obtained in crystalline form from bull testes by David et al. (1935) and testosterone was chemically
synthesized by Butenandt and Hanisch (1935) and Ruzicka and Wettstein (1935).
Immediately after its chemical isolation and synthesis, testosterone was introduced into clinical medicine (unthinkable had it happened today) and used for the
treatment of hypogonadism. Since testosterone was ineffective orally it was either
compressed into pellets and applied subcutaneously or was used in the form of
17-methyltestosterone. In the 1950s longer-acting injectable testosterone esters
(Junkmann 1957) became the preferred therapeutic modality. In the 1950s and
1960s chemists and pharmacologists concentrated on the chemical modication
of androgens in order to emphasize their erythropoetic (Gardner and Besa 1983)
or anabolic effects (Kopera 1985). These preparations never played an important
role in the treatment of hypogonadism and were abandoned for purposes of clinical medicine. In the late 1970s the orally effective testosterone undecanoate was
added to the spectrum of testosterone preparations used clinically (Coert et al.
1975; Nieschlag et al. 1975). In the mid 1990s, transdermal testosterone patches
applied either to scrotal skin (Bals-Pratsch et al. 1986) or non-scrotal skin (Mazer
et al. 1992) were introduced into clinical practice. In 2000, a transdermal testosterone gel became available for treatment of male hypogonadism, rst in the US
and subsequently in other countries as well (Wang et al. 2000).
14.2 General considerations
Although testosterone has been in clinical use for almost 70 years, it has only
slowly attracted interest from clinical researchers. This is partly due to the fact that
hypogondal men requiring testosterone treatment constitute only a minority of all
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Fig. 14.1
Molecular structure of testosterone and clinically used testosterone esters and derivatives.
However, new insights into the molecular mechanisms of androgen action may
lead to the development of steroids suited for specic purposes (see Chapter 20).
7-methyl-19-nortestosterone serves as an example, as it is experiencing a renaissance due to its high androgenicity combined with low prostatotropic effects shown
in hypogonadal patients (Anderson et al. 2003). Whether such steroids may become
useful and safe for clinical use remains to be seen.
This chapter provides an overview of the various conventional and new testosterone preparations used in clinical medicine.
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Preparation
Route of application
oral
buccal
intramuscular injection
intramuscular injection
intramuscular injection
implantation under the
abdominal skin
scrotal skin
non-scrotal skin
non-scrotal skin
Under development
Testosterone cyclodextrin
Testosterone buciclate
Testosterone microcapsules
sublingual
intramuscular injection
subcutaneous injection
Obsolete
17-Methyltestosterone
Fluoxymesterone
oral
sublingual/oral
In clinical use
Testosterone undecanoate
Testosterone tablets
Testosterone enanthate
Testosterone cypionate
Testosterone undecanoate
Testosterone implants
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et al. 1978; Johnsen et al. 1974; Nieschlag et al. 1975; 1977). The testosteronemetabolizing capacity of the liver, however, is age- and sex-dependent. An oral
dose of 60 mg unmodied testosterone does not affect peripheral testosterone levels in normal adult men, but produces a signicant rise in prepubertal boys and
women (Nieschlag et al. 1977). This demonstrates that testosterone induces liver
enzymes responsible for its own metabolism (Johnsen et al. 1976). When the liver
is severely damaged its metabolizing capacity decreases. Thus, in patients with liver
cirrhosis a dose of 60 mg testosterone (ineffective in normal men) produces high
serum levels (Nieschlag et al. 1977).
In hypogonadal men with normal liver function, 400600 mg testosterone must
be administered daily if the patient is to be substituted by oral testosterone (Johnsen
1978; Johnsen et al. 1974), a dose exceeding the testosterone production of a normal man almost 100fold. Aside from being uneconomical, the possibility of adverse
effects of such huge testosterone doses cannot be excluded, especially when given
over long periods of time as required for substitution therapy. However, in a small
group of patients treated for as long as seven years with oral testosterone no serious
side-effects were observed (Johnson 1978). Nevertheless, oral administration of
unmodied testosterone has not become a generally accepted method for therapeutic purposes.
As a relict of experiments performed last century (see 14.1), preparations containing animal testis or plant extracts or dried organ powder are still being manufactured
and are available on the market. Although synthesized in the testis, the testosterone
content of these preparations is negligible since the testis, in contrast to other endocrine glands (such as the thyroid), does not store its hormonal products (Cussons
et al. 2002). Moreover, the testosterone in these orally consumed products cannot
become effective for the reasons described above. Such preparations may at best
exert placebo effects and do not belong to a rational therapeutic repertoire. Similarly,
there is no evidence that ingestion of animal testes as food has endocrine effects.
14.3.1.2 17-methyltestosterone
Several attempts have been made to modify the testosterone molecule by chemical
means in order to render it orally effective, i.e. to delay metabolism in the liver.
In this regard, the longest known testosterone derivative is 17-methyltestosterone
(Ruzicka et al. 1935) which is a fully effective oral androgen preparation. 17methyltestosterone is quickly absorbed and maximal blood levels are observed 90
to 120 minutes after ingestion. The half-life in blood amounts to approximately
150 minutes (Alkalay et al. 1973).
Ever since this steroid was introduced for clinical use, hepatotoxic side-effects
such as an increase in serum liver enzymes (Carbone et al. 1959), cholestasis of the
liver (de Lorimer et al. 1965; Werner et al. 1950), and peliosis of the liver (Westaby
et al. 1977) have been reported repeatedly. It is of interest that humans are more
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Mesterolone can be considered a derivative of the 5-reduced testosterone metabolite 5-dihydrotestosterone (DHT) which is protected from rapid metabolism in
the liver by a methyl group in position 1 (Gerhards et al. 1966) and thus becomes
orally active. It is free of liver toxicity. Unlike testosterone, mesterolone cannot
be metabolized to estrogens (Breuer and Gutgemann 1966) and at a molecular
level acts like DHT. Because of its limited effectiveness in suppressing pituitary
gonadotropin secretion (Aakvaag and Stromme 1974; Gordon et al. 1975) it can
only be considered an incomplete androgen. Altogether, mesterolone is not suited
for the substitution of hypogonadism. Nevertheless, in 2001 it still represented 12%
of all androgen sales in Germany.
14.3.1.5 Testosterone undecanoate
When testosterone is esteried in the 17-position with a long fatty acid side
chain such as undecanoic acid and given orally, its route of absorption from the
gastrointestinal tract is slightly shifted from the vena portae to the lymph and
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Fig. 14.2
reaches the circulation via the thoracic duct (Coert et al. 1975; Horst et al. 1976;
Shackleford et al. 2003). Absorption is improved if the ester is taken in arachis oil
(Nieschlag et al. 1975) and with a meal (Frey et al. 1979; Bagchus et al. 2003). After
oral ingestion of a 40 mg capsule, of which 63% i.e. 25 mg is testosterone, maximum
serum levels are reached two to six hours later (Nieschlag et al. 1975). Thus, with 2 to
4 capsules (80 to 160 mg) per day substitution of hypogonadism can be achieved.
Testosterone undecanoate pharmacokinetics after single-dose administration
were tested in eight hypogonadal patients and twelve normal men (Schurmeyer
et al. 1983). Directly before and at hourly intervals after oral application of three
times 40 mg of testosterone undecanoate in arachis oil taken together with a standardized breakfast, matched saliva samples, as a parameter for free testosterone at
the tissue level, and blood samples were collected hourly for up to 8 h. After administration of testosterone undecanoate, serum and saliva testosterone always showed
a parallel rise and fall, as demonstrated by a constant saliva/serum testosterone
ratio. On average maximum levels could be observed ve hours after testosterone
undecanoate administration. However, the serum testosterone prole showed high
interindividual variability of the time when maximum concentrations were reached,
as well as of the maximum levels themselves that ranged from 17 to 96 nmol/l. When
the individual serum concentration versus time curves were centralized about the
time of maximal serum concentrations, serum concentrations signicantly different from basal values were seen only two hours before and one hour after the time
of maximal serum concentrations in hypogonadal patients (Fig. 14.2) (Schurmeyer
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et al. 1983). Based on this observation it can be deduced that even with administration of testosterone undecanoate 3 times daily, only short-lived testosterone peaks
resulting in high uctuations can be obtained.
This judgment is in agreement with the data of a two-month multiple-dose
study with testosterone undecanoate for replacement therapy in hypogonadal men
(Skakkebaek et al. 1981). Applying a double blind cross-over design, serum testosterone levels were studied in 12 hypogonadal patients to whom 80 mg of testosterone undecanoate had been administered twice per day 12 hours apart. Whereas
four hours after administration of testosterone undecanoate a signicant increase
of testosterone serum levels was observed compared to the placebo group, twelve
hours after administration no signicant difference in testosterone serum levels
between treatment and placebo control group was seen. Even four hours after
administration, in four of twelve patients testosterone levels were still below the
lower level of the normal range after both one month and two months of treatment.
A signicant marked variability between subjects as well as within the same subjects
has also been observed in other clinical studies (Cantrill et al. 1984; Conway et al.
1988).
The original preparation of oral testosterone undecanoate had to be refrigerated
(28 C) in the pharmacy for reasons of stability, whereas patients must store it at
room temperature to ensure optimal absorption. The shelf-life at room temperature
is only three months. Therefore, a new, more stable pharmaceutical formulation of
testosterone undecanoate was developed in which the oleic acid solvent was replaced
by castor oil and propylene glycol laurate. This new formulation can be stored at
room temperature (1530 C) for three years (Bagchus et al. 2003). According to an
unpublished randomized multicenter study in 49 hypogonadal men, oral administration of 2 80 mg or 3 80 mg of the reformulated testosterone undecanoate
might result in more physiological and stable serum testosterone levels.
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Testosterone (nmol/l)
50.0
40.0
30.0
20.0
10.0
0.0
0
12
16
20
24
Time (hours)
Fig. 14.3
be achieved this therapy would require repeated daily applications and would have
the same disadvantages as conventional oral testosterone undecanoate therapy.
14.3.3 Buccal application
Administration of testosterone via the buccal mucosa bypasses the liver and avoids
rst-pass clearance by delivering the drug directly into systemic circulation. Compared to sublingual administration, buccal mucosa is less permeable and potentially
better suited for sustained delivery systems. An initial randomized, double-blind,
placebo-controlled study in hypogonadal patients receiving 10 mg testosterone or
placebo buccal tablets showed unfavourable pharmacokinetics with serum levels of
testosterone far above the upper normal range and returning to baseline as soon as
four to six hours after administration (Dobs et al. 1998).
Signicantly improved pharmacokinetics were obtained with newly formulated
buccal tablets. In a randomized, double-blind, crossover design 24 healthy men
received a GnRH agonist for suppression of endogenous testosterone (Baisley et al.
2002). Buccal tablets containing 10, 20 or 30 mg testosterone were taken daily at
8.00 h for 10 days. Steady state was reached by day 5. Peak total and free testosterone
were reached eight to nine hours after tablet application (Fig. 14.3). Hormone concentrations increased with the testosterone dose of the tablets, but this increase was
less than dose-proportional. Whereas the average concentration of testosterone did
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not exceed the normal range, some individual blood samples still showed supraphysiological testosterone concentrations. About half of the volunteers reported
local discomfort at the buccal application site, in most subjects during the rst treatment period. The advantage of this buccal testosterone preparation seems to be the
mimicking of the physiological circadian testosterone rhythm, however, long-term
studies in hypogonadal patients including evaluation of acceptability are awaited.
A new testosterone bioadhesive buccal system was designed to adhere rapidly to
the buccal mucosa and gellify for delivering testosterone steadily into the circulation.
The pharmacokinetics were evaluated in 82 hypogonadal men. The tablet (30 mg
testosterone) was applied twice daily to the upper gums for three months. 73%
of the patients reached an average testosterone concentration over 24 hours within
the physiological range. Local problems associated with tablet use were transient
and minimal. This bioadhesive buccal system is approved for use in hypogonadal
men in the U.S.A. and approval in Europe is expected.
14.3.4 Nasal application
The rst-pass effect of the liver can also be avoided by applying testosterone to the
nasal mucosa (Danner and Frick 1980). However, unreliable absorption patterns
and short-lived serum peaks prevent this form of application from becoming a
desirable option for long-term substitution therapy and it has never passed the
experimental state.
14.3.5 Rectal application
In order to avoid the rst-pass effect of the liver, testosterone can be applied rectally
in suppositories (Hamburger 1958). Administration of a suppository containing
40 mg testosterone results in an immediate and steep rise of serum testosterone
lasting for about four hours. Effective serum levels can be achieved by repeated
applications (Nieschlag et al. 1976). This therapy, however, never gained much
popularity probably because the patients nd it unacceptable to use suppositories
three times daily on a long-term routine basis.
14.3.6 Intramuscular application
The most widely-used testosterone substitution therapy is the intramuscular injection of testosterone esters. Unmodied testosterone has a half-life of only ten minutes and would have to be injected very frequently. Esterication of the testosterone
molecule at position 17, e.g., with propionic or enanthic acid, prolongs the activity of testosterone in proportion to the length of the side chain when administered intramuscularly (Junkmann 1952; 1957). The deep intramuscular injection
of testosterone esters in oily vehicle is generally safe and well tolerated, but can
cause minor side-effects such as local pain (Mackey et al. 1995).
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Studies applying gas chromatography-mass spectrometry that allow discrimination between endogenous testosterone and exogenously administered deuteriumlabelled testosterone propionate-19,19,19-d3 and its metabolite testosterone19,19,19-d3 were able to show that after intramuscular administration, the
testosterone ester is slowly absorbed into the general circulation and then rapidly
converted to the active unesteried metabolite (Fujioka et al. 1986). The observation that the duration at the injection site is the major factor determining the
residence time of the drug in the body agrees with pharmacokinetic studies in
rats showing that the androgen ester 19-nortestosterone decanoate, when injected
into the musculus gastrocnemius of the rat in vivo, is absorbed unchanged from
the injection depot in the muscle into the general circulation according to rstorder kinetics with a long half-life of 130 h (van der Vies 1965). Comparisons
of the absorption kinetics of different testosterone esters clearly show that the
half-lives of the absorption of the esters increase when the esteried fatty acids
have a longer chain (van der Vies 1985). In addition, pharmacokinetics are inuenced by the oily vehicle, the injection site and the injection volume (Minto et al.
1997).
After absorption from the intramuscular depot, the testosterone ester is rapidly
hydrolysed in plasma, as could be shown by in vitro rat studies (van der Vies 1970)
and in vivo human studies (Fujioka et al. 1986). The rate of hydrolysis again depends
on the structure of the acid chain, but this process is much faster than release from
the injection depot (van der Vies 1985). The metabolism of the testosterone ester to
the unesteried testosterone occurs rapidly so that testosterone enanthate or testosterone have nearly identical intravenous pharmacokinetics (Sokol and Swerdloff
1986). Similarly, the duration of action of the orally effective ester testosterone
undecanoate seems to be dependent on the duration of absorption of the uncleaved
lipophilic testosterone undecanoate via the ductus thoracicus from the gut (Maisey
et al. 1981; Schurmeyer et al. 1983).
In men treated with testosterone, the testosterone concentration measurable
in the serum is the sum of endogenous testosterone and exogenous testosterone
hydrolysed from the injected ester. Hypogonadal patients are characterized by
impaired or absent endogenous testosterone secretion; exogenous testosterone
administration can further suppress endogenous testosterone secretion only to
a limited degree, if at all. Accordingly, in hypogonadal patients the serum concentration versus time prole is mainly a reection of the pharmacokinetics of
exogenously administered testosterone ester alone. In this chapter the evaluation
of pharmacokinetic parameters for different testosterone esters is based on the
increases of testosterone serum concentrations over basal levels in hypogonadal
patients.
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Fig. 14.4
Testosterone ester
Testosterone propionate
Testosterone enanthate
Testosterone buciclate
Testosterone undecanoate
0.8
4.5
29.5
33.9
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Fig. 14.5
Multiple-dose pharmacokinetics of testosterone propionate after injection of 50 mg testosterone propionate twice per week (e.g. Mondays and Thursdays). Solid curve, pharmacokinetic simulation; broken lines, range of normal testosterone values.
Single-dose pharmacokinetics of testosterone enanthate after intramuscular administration of 250 mg testosterone enanthate to seven hypogonadal patients and the
best-tted pharmacokinetic prole are shown in Fig. 14.6 (Nieschlag et al. 1976).
Maximal testosterone levels in the supraphysiological range were seen shortly
after injection (39.4 nmol/l, tmax = 10 h). Testosterone levels below the normal range were observed following day 12 after injection. The calculated values
were 9911 nmol h/l for AUC, 8.5 d for MRT and 4.5 d for terminal half-life
(Table 14.2).
Based on the pharmacokinetic parameters of single-dose pharmacokinetics
multiple-dose pharmacokinetic simulations for equal doses of 250 mg testosterone
enanthate and injection intervals of one to four weeks were performed. With weekly
injection intervals supraphysiological maximal testosterone serum concentrations
up to 78 nmol/l are observed at steady state shortly after injection and supraphysiological minimal testosterone serum concentrations up to 40 nmol/l just before
the next injection (Fig. 14.7). Injecting 250 mg of testosterone enanthate every two
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Fig. 14.6
Fig. 14.7
Multiple-dose pharmacokinetics of testosterone enanthate after injection of 250 mg testosterone enanthate every week (upper panel ), every second week (upper middle panel ),
every three weeks (lower middle panel ) and every four weeks (lower panel ). Solid curves,
pharmacokinetic simulations; broken lines, range of normal testosterone values.
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Fig. 14.8
Comparative pharmacokinetics of 194 mg of testosterone enanthate and 200 mg of testosterone cypionate after intramuscular injection to 6 normal volunteers. Closed circles,
mean SEM of testosterone enanthate kinetics; open circles, mean SEM of testosterone
cypionate kinetics.
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Because testosterone cypionate, testosterone cyclohexanecarboxylate and testosterone enanthate had comparable suppressing effects on LH and consequently on
endogenous testosterone secretion, it can be concluded from these studies in normal
volunteers that all three esters with similar molecular structure possess comparable
pharmacokinetics of exogenous testosterone serum concentrations. Testosterone
cypionate or testosterone cyclohexanecarboxylate do not provide a more advantageous pharmacokinetic prole than testosterone enanthate. This observation is in
agreement with a clinical study of replacement therapy with single-dose administration of 200 mg of testosterone cypionate in 11 hypogonadal patients (Nankin
1987).
14.3.6.4 Testosterone ester combinations
Testosterone ester mixtures have been widely used for substitution therapy of
male hypogonadism (e.g. TestovironR Depot 50: 20 mg testosterone propionate and
55 mg testosterone enanthate; TestovironR Depot 100: 25 mg testosterone propionate
and 100 mg testosterone enanthate; SustanonR 250: 30 mg testosterone propionate,
60 mg testosterone phenylpropionate, 60 mg testosterone isocaproate and 100 mg
testosterone decanoate). These combinations are used following the postulate that
the so-called short-acting testosterone ester (e.g testosterone propionate) is the
effective testosterone for substitution during the rst days of treatment and the
so-called long-acting testosterone (e.g. testosterone enanthate) warrants effective
substitution for the end of injection interval. However, this assumption is not
supported by the pharmacokinetic parameters of the individual testosterone esters.
Both testosterone propionate and testosterone enanthate cause highest testosterone
serum concentrations shortly after injection (Fig. 14.4 and Fig. 14.6). Accordingly,
addition of testosterone propionate to testosterone enanthate only increases the
initial undesired testosterone peak and worsens the pharmacokinetic prole that
ideally should follow zero-order kinetics (Fig. 14.9). The computer simulation
agrees well with the limited published single-dose testosterone values that have
been measured in hypogonadal patients treated with the combination of testosterone propionate and testosterone enanthate. Maximal increases of approximately
40 nmol/l testosterone over basal values are described one day after intramuscular
administration of a testosterone ester combination of 115.7 mg testosterone enanthate and 20 mg testosterone propionate to three hypogonadal patients (Fukutani
et al. 1974).
A comparison of computer-simulated testosterone serum concentrations after
multiple-dose injections of TestovironR Depot 100 (110 mg testosterone enanthate
and 25 mg testosterone propionate = 100 mg unesteried testosterone) every 10 d
and 139 mg testosterone enanthate (= 100 mg unersteried testosterone) every
10 d is shown in Fig. 14.10. As can be expected by the single-dose kinetics of the
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Fig. 14.9
Fig. 14.10
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individual esters, injection of the testosterone ester mixture (upper panel) produces
a much wider uctuation of testosterone serum concentrations relative to injection
of testosterone enanthate alone (lower panel). This simulation shows that injections
of testosterone enanthate alone produce a more favourable pharmacokinetic prole
in comparison to injections of testosterone propionate and testosterone enanthate
ester mixtures in comparable doses. For treatment of male hypogonadism there is
no advantage in combining the available short- and long-acting testosterone esters.
14.3.6.5 Testosterone buciclate
The disadvantage of all esters described so far is that they produce initially supraphysiological testosterone levels which may exceed normal levels severalfold and
then slowly decline, so that before the next injection pathologically low levels may
be reached. Some patients recognize these ups and downs of testosterone levels
in parallel variations of general well-being, sexual activity and emotional stability. Despite these disadvantages testosterone enanthate and cypionate are still the
standard therapy for male hypogonadism.
Because of these shortcomings of the available esters the World Health Organization (WHO) initiated a steroid synthesis programme (Crabbe et al. 1980) out of
which a series of new testosterone esters was developed. When tested in laboratory
rodents a specic ester was identied that showed greatly prolonged activity, namely
testosterone-trans-4-n-butylcyclohexyl-carboxylate, generic name testosterone buciclate. This preparation is injected intramuscularly in an aqueous solution, in contrast to the other testosterone esters which are dissolved in oily solution.
A rst study on the pharmacokinetics of the new WHO/NIH androgen ester
testosterone buciclate was performed in two groups of orchiectomized cynomolgus monkeys (Weinbauer et al. 1986). Intramuscular injections of testosterone
enanthate resulted in supraphysiological serum levels of testosterone for eight days,
followed by a rapid decline with levels lower than the physiological limit after three
weeks. In contrast, testosterone buciclate produced a moderate increase of serum
testosterone levels into the physiological range, and serum levels remained in this
range for a period of four months. These favourable results on the pharmacokinetics
of testosterone buciclate were conrmed in castrated rhesus monkeys (Rajalakshmi
and Ramakrishnan 1989).
To assess the pharmacokinetics of testosterone buciclate in men the rst clinical study was performed in eight men with primary hypogonadism (Behre and
Nieschlag 1992). The men were randomly assigned to two study groups and were
given either 200 (group I) or 600 mg (group II) testosterone buciclate intramuscularly. Whereas in group I serum androgen levels did not rise to normal values,
in group II androgens increased signicantly and were maintained in the normal range up to 12 weeks with maximal serum levels (cmax ) of 13.1 0.9 nmol/l
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Fig. 14.11
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While testosterone undecanoate has been available for oral substitution for more
than two decades, it was rst demonstrated in China that intramuscular administration of testosterone undecanoate in tea seed oil (125 mg/ml) has a prolonged
duration of action (Wang et al. 1991). Therefore the pharmacokinetics of testosterone undecanoate in comparison to testosterone enanthate were tested in two
groups of orchiectomized cynomolgus monkeys (Partsch et al. 1995). After injection of 10 mg/kg body weight of the respective esters serum levels of testosterone
remained above the lower limit of normal for 108 days, compared to 31 days
after testosterone enanthate injection. Pharmacokinetic analysis revealed a terminal
half-life of 25.7 4.0 days for testosterone undecanoate, compared to 10.3 1.1
days for testosterone enanthate. The maximal testosterone concentration of 72.6
11.7 nmol/l after testosterone undecanoate injection was signicantly lower than
177.0 21.3 nmol/l after testosterone enanthate injection.
In a recent monkey study it was demonstrated that biological effects of testosterone esters are determined by the pharmacokinetics and degree of aromatization
rather than the total dose administered (Weinbauer et al. 2003). Twenty adult
male cynomolgus monkeys were randomly assigned to treatment for 28 weeks with
either testosterone enanthate every four weeks, testosterone buciclate every seven
weeks, or testosterone undecanoate every ten weeks. Each injection delivered 20 mg
pure testosterone per kilogram body weight. Despite a smaller total dose of testosterone, increase in body weight or lowering effects on serum lipids were signicantly
stronger with the long-acting testosterone undecanoate or buciclate compared to
testosterone enanthate.
In a clinical study in Asian hypogonadal men, eight patients received one intramuscular injection of 500 mg and 7 of the initial 8 hypogonadal patients one injection of 1000 mg testosterone undecanoate (in eight milliliters tea seed oil) in a
cross-over design (Zhang et al. 1998). Follow-up blood samples were obtained
weekly up to week 9 after injection. In both study groups, mean serum levels of
testosterone were above the upper limit of normal during the rst two weeks after
injection. Thereafter, mean serum concentration remained in the normal range
up to week 7 after injection in the 500 mg-dose group and at least up to week 9
in the 1000 mg-dose group. The terminal elimination half-lives were 18.3 2.3
and 23.7 2.7 days for the 500 mg-dose und 1000 mg-dose groups, respectively.
Administration of 500 mg of this testosterone preparation every four weeks, after
an initial loading dose of 1000 mg, for up to 12 months to 308 healthy men for male
contraception maintained serum levels of testosterone in the normal range when
measured directly before the next injection (Gu et al. 2003).
In the rst study in Caucasian men, intramuscular injections of 250 mg or
1000 mg testosterone undecanoate in tea seed oil were given to 14 hypogonadal
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Fig. 14.12
Serum concentrations (mean SEM) of testosterone after single-dose intramuscular injections of 1000 mg testosterone undecanoate in tea seed oil in 7 hypogonadal men (squares)
or castor oil in 14 hypogonadal men (circles). Broken lines indicate normal range of testosterone (adapted from Behre et al. 1999a, reproduced by permission of the European Journal
of Endocrinology).
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Fig. 14.13
Serum concentrations (mean SEM) of testosterone after multiple intramuscular injections of 1000 mg testosterone undecanoate in castor oil in 13 hypogonadal men. Broken
lines indicate normal range of testosterone (adapted with permission from Nieschlag et al.
1999, copyright 1999, Blackwell Publishing).
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Testosterone
(nmol/L)
30
25
13th injection
20
15
1st Injection
10
5
0
0
14
21
28
35
42
49
59
63
70
77
84
days
Fig. 14.14
Serum concentrations (mean SD) of testosterone after single injection of 1000 mg testosterone undecanoate in castor oil in 14 hypogonadal men (open circles) and during multiple
injections with the same dose every 12 weeks. Broken lines indicate normal range of testosterone (adapted with permission from von Eckardstein and Nieschlag. 2002).
of etonogestrel implants. Nadir testosterone levels before the next injection were
in the lower normal range, whereas serum levels were at the upper normal limit
one week after injection. From these limited data it can be concluded that testosterone decanoate seems to have an improved pharmacokinetic prole over testosterone enanthate, but does not allow similar prolonged injection intervals of about
12 weeks, as demonstrated for testosterone undecanoate in hypogonadal men.
14.3.6.8 Testosterone microspheres
Drugs can be incorporated into biodegradable microspheres. When injected intramuscularly, such drug-loaded microspheres provide controlled release of the substance for several weeks or even months. As an example, microencapsulated GnRH
agonists have become a valuable modality in the treatment of prostatic carcinoma.
Testosterone has been incorporated into poly(DL-lactide-co-glycolide) microspheres. When rst tested in castrated monkeys single injections resulted in an
elevation of serum levels above the lower limit of normal for several months (Asch
et al. 1986). When similar microsphere injections containing 315 mg of testosterone
were given to eight hypogonadal men, serum testosterone levels slowly increased to
peak levels at about eight weeks and fell thereafter to reach pathological levels again
by 11 weeks (Burris et al. 1988). In a later study the size-range and the testosterone
loading of the microspheres were adjusted so that in hypogonadal men single intramuscular injections resulted in relatively constant serum levels within the normal
range for about 70 days (Bhasin et al. 1992). These two clinical studies demonstrated
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that the microspheres can be adapted to the required needs and the results were
encouraging. However, this formulation of microspheres is technically difcult to
manufacture consistently and requires two painful, large-volume intramuscular
injections that limits its appeal for long-term therapy.
14.3.7 Subdermal application
14.3.7.1 Testosterone pellets
Subdermal testosterone pellet implantation was among the earliest effective modalities employed for clinical application of testosterone which became an established
form of androgen replacement therapy by 1940 (Deansley and Parks 1938; Vest and
Howard 1939). With the advent of other modalities, e.g. intramuscular testosterone
ester injections, they went out of general use. However, investigations in the 1990s
redened the favourable pharmacokinetic proles and clinical pharmacology of
testosterone implants (Handelsman et al. 1990; Jockenhovel et al. 1996).
The original testosterone implants were manufactured by high-pressure tableting of crystalline steroid with a cholesterol excipient. These proved brittle, hard to
standardize or sterilize and exhibited surface unevenness and fragmentation during
in-vivo absorption to produce an uneven late release rate. These limitations were
overcome in the 1950s by switching to high-temperature moulding whereby molten
testosterone was cast into cylindrical moulds to produce more robust implants.
These have more uniform composition, resulting in a more steady and prolonged
release and reduced tissue reaction. Sterilization is achieved by a combination of
high-temperature exposure during manufacture together with surface sterilization
or, more recently, gamma-irradiation. The testosterone implants are currently available in two sizes with a common diameter of 4.5 mm: 6 mm length for the 100 mg
and 12 mm length for the 200 mg implant. Pellets are usually implanted under
the skin of the lower abdominal wall under sterile conditions using a trochar and
cannula.
The estimated half-life of absorption of testosterone from subdermal implants is
2.5 months. On average, approximately 1.3 mg of testosterone are released per day
from the 200 mg pellet. Testosterone implants demonstrate a minor and transient
accelerated initial burst release, which lasts for 12 days (Jockenhovel et al. 1996).
The most comprehensive pharmacokinetic evaluation of testosterone implants was
done in a random-sequence, cross-over clinical study of 43 androgen-decient men
with primary or secondary hypogonadism (Handelsman et al. 1990). Patients were
treated sequentially with 3 regimens six 100 mg, three 200 mg or six 200 mg
implants at intervals of at least six months. Implantation of testosterone pellets
resulted in a highly reproducible and dose-dependent time-course for circulation
of total and free testosterone. Testosterone concentrations reached baseline by six
months after either of the 600 mg dose regimens but remained signicantly elevated
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Testosterone (nmol/l)
40
30
20
10
0
0
Time (months)
Fig. 14.15
Blood total testosterone in 43 hypogonadal men receiving four 200 mg pellets (800 mg)
implanted either under the skin of the lateral abdominal wall (in 4 tracks [filled circles], n = 9;
or in 2 tracks [open circles], n = 16) or in the hip region (filled squares, n = 18) (adapted
with permission from Kelleher et al. 2001, copyright 2001, Blackwell Publishing).
after six months following the 1200 mg dose. The standard dose for hypogonadal
men is 800 mg every six months, which can be titrated individually (Fig. 14.15).
Pellet implantation has few side-effects and is generally well tolerated. Adverse
events after implantations were extrusions (8.512% per procedure), bruising
(2.38.8%) and infections (0.64%) (Handelsman et al. 1997; Kelleher et al. 1999).
Due to the long-lasting effect and the inconvenience of removal, preferably pellets
should be used by men in whom the benecial effects and tolerance for androgen
replacement therapy have already been established by treatment with shorter-acting
testosterone preparations.
14.3.7.2 Testosterone microcapsules
Testosterone can be encapsuled in a biodegradable matrix composed of lactide/glycolide copolymer which is suitable for subcutaneous injection. The pharmacokinetics and pharmacodynamics of this microcapsule formulation were tested
in fourteen hypogonadal men in an open-label, prospective study (Amory et al.
2002). Patients received either 267 mg (n = 7, injection of 2.5 ml of the formulation) or 534 mg of testosterone (n = 7, two injections of 2.5 ml). Peak serum
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concentrations were already seen at the rst follow-up examination on day 1. In the
higher-dose group, mean serum concentrations were at the upper limit of normal at
this time-point. Thereafter, testosterone levels declined rapidly in both groups with
mean serum levels below 10 nmol/l after 5 and 7 weeks, respectively. In the higherdose group, serum levels of free testosterone, bioavailable testosterone, estradiol
and DHT exceeded the normal range for at least the rst week after injection.
Two subjects complained of transient tenderness and fullness at the injection sites.
Multiple-dose studies are still outstanding, and therefore the appropriate injection
interval for long-term therapy has not yet been determined. One disadvantage of
the testosterone microcapsule formulation seems to be the early burst release of
testosterone, which limits the clinically acceptable dose and shortens the maximal
injection interval.
14.3.8 Transdermal application
The skin easily absorbs steroids and other drugs and transdermal drug delivery has
become a widely used therapeutic modality. The scrotum shows the highest rate of
steroid absorption, about 40-fold higher than the forearm (Feldmann and Maibach
1967). This difference in absorption rates has been exploited for the development
of a transdermal therapeutic system (TTS) to deliver testosterone. 40 and 60 cm2
large polymeric membranes loaded with 10 or 15 mg testosterone when attached
to the scrotal skin deliver sufcient amounts of the steroid to provide hypogonadal
men with serum levels in the physiological range (Bals-Pratsch et al. 1986; 1988;
Findlay et al. 1987; Korenmann et al. 1987). The application of the patch to scrotal skin requires hair clipping or shaving to optimize adherence. The membranes
need to be renewed every day. When applied in the morning and worn until the
next morning the resulting serum testosterone levels resemble the normal diurnal
variations of serum testosterone in normal men without supraphysiological peaks
(Bals-Pratsch et al. 1988). Long-term therapy up to ten years with daily administration of the scrotal patch in 11 hypogonadal men produced steady-state serum
levels of testosterone and estradiol in the normal range and serum levels of DHT at
or slightly above the higher limit of normal without signicant adverse side-effects
(Fig. 14.16) (Behre et al. 1999b).
While testosterone is readily absorbed by genital skin, transdermal systems for use
on non-genital skin require enhancers to facilitate sufcient testosterone passage
through the skin. The permeation enhanced testosterone patch delivers 2.5 mg/day
testosterone when applied to non-scrotal skin. If one or two such systems are worn
for 24 hours physiologic serum testosterone levels can be mimicked, as with scrotal
patches (Fig. 14.17) (Brocks et al. 1996; Meikle et al. 1996). Due to the alcoholic
enhancer used and the occlusive nature of the systems, the application is associated
with skin irritation in up to 60% of the subjects, with most users discontinuing
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Fig. 14.16
Fig. 14.17
Serum concentrations (mean SD) of testosterone during and after nighttime application
of two non-scrotal testosterone systems to the backs of 34 hypogonadal men. Shaded area
indicates normal range of testosterone (adapted with permission from Meikle et al. 1996,
copyright 1996, The Endocrine Society).
application because of the skin irritation (Jordan 1997; Parker and Armitage 1999).
Preapplication of corticosteroid cream to the skin has been reported to decrease the
severity of skin irritation, although the effects on pharmacokinetics of testosterone
are unclear. Another larger non-scrotal patch causes less skin irritation (about 12%
itching and 3% erythema) but may create adherence problems (Jordan et al. 1998).
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Fig. 14.18
Serum concentrations (mean SEM) of testosterone before (day 0) and after transdermal
testosterone applications on days 1, 30, 90, and 180. Time 0 was 0800 h, when blood
sampling usually began. On day 90, the dose in the subjects applying testosterone gel 50
or 100 mg was up- or down-titrated if their preapplicaton serum testosterone levels were
below or above the normal adult male range, respectively. Dotted lines denote the adult
normal range (adapted with permission from Swerdolff et al. 2000, copyright 2000, The
Endocrine Society).
of testosterone serum levels to the normal range in hypogonadal men after 90 days
of application of 5 g/d or 10 g/d of another hydroalcoholic topical gel containing 1%
testosterone compared to non-scrotal testosterone patches (n = 208, McNicholas et
al. 2003) or compared to non-scrotal testosterone patches and placebo gel (n = 406,
Steidle et al. 2003). Application of 5 g/d of a 2.5% hydroalcoholic gel increased serum
levels of testosterone to the normal range in 14 gonadotropin-suppressed normal
men (Rolf et al. 2002a). Washing of the skin after 10 min. did not inuence the
pharmacokinetic prole. No interpersonal testosterone transfer could be detected
after evaporation of the alcohol vehicle of this testosterone gel (Rolf et al. 2002b).
This gel preparation can also be administered at a dose of 1 g/d to the scrotal
skin. Ongoing randomized controlled studies in hypogonadal patients indicate the
efcacy and practicability of administration of this gel to normal or scrotal skin.
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14.5 R E F E R E N C E S
Aakvaag A, Stromme SB (1974) The effect of mesterolone administration to normal men on the
pituitary-testicular function. Acta Endocrinol 77:380386
Alkalay D, Khemani L, Wagner WE, Bartlett MF (1973) Sublingual and oral administration of
methyltestosterone. A comparison of drug bioavailability. J Clin Pharmac 13:142151
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