Testosterone Pellets, Sublingual and Buccal (Mouth)

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Nelson Vergel

Founder, ExcelMale.com
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Testosterone Pellets (Testopel or compounded pellets)

By Nelson Vergel
From the book: Testosterone: A Man's Guide

One other option for testosterone replacement therapy is the use pellets inserted under the skin. These are small, sterile cylinders about the size of a grain of rice that are produced by compressing medicated powders. A doctor implants these pellets underneath the skin in the upper buttock area by the hip. They can be used whenever a prolonged continuous absorption of hormones is desired. Men who have problems remembering daily applications, who are afraid of needles, or that travel a lot, may find this option a very practical one.


Men receiving the pellet implants enjoy the convenience of not having to worry about daily dosing normally or weekly injections associated with other delivery systems. Testosterone implants have been around for many years, but many doctors shy away from for several reasons:

• Doctors need special training to learn the insertion technique;
• it is difficult to determine the optimal initial number of pellets, and is inconvenient to insert addition pellets if needed;
• the risks of infections in the insertion site.
• some users have reported problems with the pellets working their way out from under the skin (called extrusion).

Doctors can charge for the pellets (sold only to doctors), for the procedure, and all blood tests required, so pellets can be a good source of income for them.

The Testopel pellet—the only one approved by the FDA—contains 75 mg of testosterone. Testopel® Pellets (testosterone) are cylindrically shaped pellets 3.2mm (1/8 inch) in diameter and approximately 8-9mm in length. Each sterile pellet weighs approximately 77mg (75mg testosterone) and is ready for implantation. Depending on your body weight and metabolism, and pellet dose, 6–14 pellets are inserted in one procedure. The insertion of the pellets is quick and usually done using a local anesthetic. Pellets typically last for 3 to 4 months. Most patients return to work the day of or the day after implantation, but are advised to avoid bending or vigorous physical activity during this time.

Testopel’s package insert says that the number of pellets to be implanted depends upon the minimal daily requirements of testosterone propionate determined by a gradual reduction of the amount administered parenterally. The usual dosage is as follows: implant two 75 mg pellets for each 25 mg testosterone propionate required weekly. Thus when a patient requires injections containing 100 mg per week, it is usually necessary to implant 600 mg of the pellet (8 pellets, each containing 75 mg).

Pellet implantation is much less flexible for dosage adjustment than is oral administration of or intramuscular injections of oil based esters. Therefore, great care should be used when estimating the amount of testosterone needed.

In the face of complications where the effects of testosterone should be discontinued, the pellets would have to be removed.

In addition, there are times when the pellets may slough out (extrusion). This accident is usually linked to superficial implantation or neglect in regard to aseptic precautions.

Some compounding pharmacies can also make testosterone pellets, though it is difficult to determine how effective they are. Compounded pellets can vary from 75 mg to 200 mg a pellet. Compounded pellets have been used for years for the treatment of low testosterone in women.

Medicaid reimburses $67.50 per pellet, and a 200-pound man usually needs 8-12 pellets to reach adequate blood levels, even though Testopel’s package insert recommends 6 pellets. I have talked to some men that did not have insurance and both paid around $1,000 as a total cost for the pellets and doctor’s fees. If this therapy is effective for four months, then the cost amounts to $250 a month. Several insurance companies do not reimburse for the pellets, but many are starting to do so. Medicare pays for them. But you will have to find a physician who has been trained on subcutaneous implantation of the pellets.

There is very little data on DHT or estrogen conversion of pellets, but it is speculated that they tend to have the fewest problems in that area for men.

Pellets are definitely an option to consider if you cannot adhere to daily gels or weekly injections. Some doctors are better than others at inserting them and at getting insurance to pay for this option. Make sure you ask the doctor how long he/she has been inserting pellets and what is his/her infection/extrusion rate.

PERSONAL COMMENT: I have used Testopel with great results. Twelve pellets were inserted under the skin of my upper buttocks area. My total testosterone went up from 350 NG/dL to 650 ng/dL and it stayed around 500 ng/dL for three and half months. It was so great not having to worry about remembering to inject every week or apply gel every day. The tiny pellets were not noticeable to the naked eye after the procedure and disappeared after four months. I want to send a big “thank you” to Dr. Richard Cavender in Ohio who did a great job inserting my pellets quickly and painlessly. testopel.jpg He has a comprehensive wellness clinic with fancy computerized exercise equipment, nutritionists, and a whole gamut of wellness services. Definitely ahead of his time! I understand that he trains physicians on proper pellet insertion techniques. If my insurance paid for this option and I found a good doctor in Houston who would administer this option, I would probably use it as my first option since I have a busy life style and love not having to worry about weekly injections or daily gels.

Sublingual/buccal testosterone

The sublingual and buccal testosterone forms work by placing either a dissolving tablet under your tongue (sublingual) or a tablet against the surface of the gums (buccal). It is different from an oral delivery in that very little of the substance is swallowed, avoiding potential liver toxicity.


Sublingual

Sublingual testosterone can be obtained through compounding pharmacies as flavored, dissolvable tablets.

Usually 15 mg twice a day will bring total testosterone levels to over 500 ng/dL. Some men may need only once a day dosing. It is still good to check your testosterone blood levels two weeks after daily use to see whether the dose is right for you. It is claimed that no liver toxicities are associated with this option. Some men report a short-term boost in testosterone that may help with arousal right before sex.

PERSONAL COMMENT: I have tried some compounding pharmacies mint-tasting products. I experienced no increase in my liver enzymes. However, it’s twice a day application was not practical for my busy lifestyle.

Buccal

In 2003, the FDA approved Striant, a sustained-release buccal testosterone tablet. It is placed in the small depression in the mouth where the gum meets the upper lip, above the front teeth. Once applied, the tablet softens and delivers testosterone through the buccal mucosa, or gums. It is then absorbed directly into the bloodstream, bypassing the liver and the rest of the gastrointestinal system. The recommended dosage for Striant is to replace the tablet about every 12 hours, though a different dosing schedule or number of tablets might be required depending on the total testosterone levels of the patient. Some men complain that the tablets fall off a few hours after application.


striant-04.jpg
Some patients find this treatment too cumbersome. Others are concerned about the system shifting out of place or transferring testosterone to sexual partners via the saliva. Others may object to twice-daily dosing and would just as soon use daily gels. A bitter taste and gum inflammation can occur but usually resolves after the first week.

The average wholesale price of a 30-day supply of 30 mg buccal tablets for twice-daily dosing is US$190.30, or approximately US$6.34 a day.

This option has not really caught on, probably for obvious reasons.

PERSONAL COMMENT: I have not tried this option. No particular reason; I guess I was too busy trying other options and the thought of having something stuck to my gums was not really appealing. And the risk of transferring testosterone to someone you kiss is definitely there.

A new TRT option:

FDA Approved Natesto Nasal Gel to Treat Men with Low Testosterone
 

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