Nelson Vergel
Founder, ExcelMale.com
Excellent points were made by Dr. Morgentaler and Dr. Khera about things they do not agree with in the American Urologic Association Guidelines.
"Our greatest area of disagreement is with the overly conservative
diagnostic threshold of 300 ng/dL. Most experienced clinicians do not follow this threshold, and its application will result in many men suffering from classic symptoms of TD, denied treatment. We hope this threshold value will be liberalized in future Guidelines. We also believe that free testosterone plays an important role in diagnosing TD, and we encourage ordering this test as well as SHBG to evaluate the man presenting with symptoms suggestive of TD."
Their comments are attached (registered members can view and download them).
The file is a critique of the American Urological Association (AUA) guidelines on testosterone deficiency (TD). The authors, Abraham Morgentaler, Abdulmaged M. Traish, and Mohit Khera, commend the AUA for creating useful guidelines but also express several areas of disagreement. Here are the main points:
1. The authors appreciate the AUA Guidelines' recognition of the utility of testosterone therapy (TTh) in selected men with prostate cancer.
2. They disagree with the diagnostic threshold of 300 ng/dL for TD, considering it overly conservative.
3. They argue that free testosterone and sex hormone-binding globulin (SHBG) should be considered in diagnosing TD.
4. They criticize the lack of consensus on a discrete testosterone threshold at which symptoms resolve.
5. They believe that a threshold of 300 ng/dL is too stringent and will result in many appropriate candidates being denied valuable treatment.
6. They emphasize the importance of free testosterone as a more reliable indicator of symptoms than total testosterone.
7. They suggest that TTh should be offered to symptomatic men with low free testosterone even if total testosterone is normal.
8. They disagree with the recommendation against using compounded testosterone products from compounding pharmacies.
9. They argue against the recommended treatment goal of 450-600 ng/dL, suggesting that treatment must be individualized.
10. They question the recommendation to delay TTh for 3 to 6 months in patients with a history of cardiovascular events.
11. They critique the reliance on evidence to support recommendations, noting that many recommendations represent opinions rather than clear interpretations of high-quality data.
12. They disagree with the suggestion that many men are treated improperly due to unwarranted fears.
13. They question the recommendation to diagnose low testosterone only after two total testosterone measurements are taken on separate occasions.
14. They argue that lifestyle modifications should be counseled as a treatment strategy for all men with testosterone deficiency.
15. They note that guidelines are not just summaries of the evidence but also interpretations of that evidence by guideline authors who bring their own biases.
16. They highlight the importance of incorporating solid existing practices with the best research evidence in new guidelines.
17. They point out the poor compliance with guidelines across many fields.
18. They argue that the most important goal of guidelines is to provide an effective and evidence-based set of recommendations for the evaluation and management of a clinically important condition.
19. They question the accuracy of the reported rate of absent testing associated with endocrinology visits.
20. They recommend individualizing decisions regarding initiation of TTh following cardiovascular events.
"Our greatest area of disagreement is with the overly conservative
diagnostic threshold of 300 ng/dL. Most experienced clinicians do not follow this threshold, and its application will result in many men suffering from classic symptoms of TD, denied treatment. We hope this threshold value will be liberalized in future Guidelines. We also believe that free testosterone plays an important role in diagnosing TD, and we encourage ordering this test as well as SHBG to evaluate the man presenting with symptoms suggestive of TD."
Their comments are attached (registered members can view and download them).
The file is a critique of the American Urological Association (AUA) guidelines on testosterone deficiency (TD). The authors, Abraham Morgentaler, Abdulmaged M. Traish, and Mohit Khera, commend the AUA for creating useful guidelines but also express several areas of disagreement. Here are the main points:
1. The authors appreciate the AUA Guidelines' recognition of the utility of testosterone therapy (TTh) in selected men with prostate cancer.
2. They disagree with the diagnostic threshold of 300 ng/dL for TD, considering it overly conservative.
3. They argue that free testosterone and sex hormone-binding globulin (SHBG) should be considered in diagnosing TD.
4. They criticize the lack of consensus on a discrete testosterone threshold at which symptoms resolve.
5. They believe that a threshold of 300 ng/dL is too stringent and will result in many appropriate candidates being denied valuable treatment.
6. They emphasize the importance of free testosterone as a more reliable indicator of symptoms than total testosterone.
7. They suggest that TTh should be offered to symptomatic men with low free testosterone even if total testosterone is normal.
8. They disagree with the recommendation against using compounded testosterone products from compounding pharmacies.
9. They argue against the recommended treatment goal of 450-600 ng/dL, suggesting that treatment must be individualized.
10. They question the recommendation to delay TTh for 3 to 6 months in patients with a history of cardiovascular events.
11. They critique the reliance on evidence to support recommendations, noting that many recommendations represent opinions rather than clear interpretations of high-quality data.
12. They disagree with the suggestion that many men are treated improperly due to unwarranted fears.
13. They question the recommendation to diagnose low testosterone only after two total testosterone measurements are taken on separate occasions.
14. They argue that lifestyle modifications should be counseled as a treatment strategy for all men with testosterone deficiency.
15. They note that guidelines are not just summaries of the evidence but also interpretations of that evidence by guideline authors who bring their own biases.
16. They highlight the importance of incorporating solid existing practices with the best research evidence in new guidelines.
17. They point out the poor compliance with guidelines across many fields.
18. They argue that the most important goal of guidelines is to provide an effective and evidence-based set of recommendations for the evaluation and management of a clinically important condition.
19. They question the accuracy of the reported rate of absent testing associated with endocrinology visits.
20. They recommend individualizing decisions regarding initiation of TTh following cardiovascular events.
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