Gel or inject ?

[Rlud]

I have been using T gel for many years, 2 packets of 1% , 50mg /packet / day.
I am considering a change to injectable test/cyp, really just for the cost factor. I just moved to medicare and the deductable plus the cost of the gel is pretty high. I am wondering about the cycle of high to low between injections. Can you notice it ? And is injecting a problem getting the needles? I'm assuming a small bore needle so it isnt painful to do this.

 

[madman]

When using the lower strength (1%) big pharma transdermal gels most men will need the higher end dose of 100 mg T/day (10 g of gel) to achieve high-end or in some cases very high T levels.

Seeing as you have been using transdermal T for 2 years and most likely feel good overall then if cost is the issue I would look into a compounded transdermal T cream before jumping on injections.

You need to keep in mind that although many may tend to prefer injections over transdermal the main benefit of a transdermal application is that it provides intraday T level variations similar to normal circadian secretion.

*The daily dosing frequency of the topical gel products results in a PK profile with a resemblance to that of endogenous T in younger males

Many end up using compounded transdermal T creams as the strength is much higher 5-20%.

Much less needs to be applied let alone the overall cost of the medication is much cheaper.

Most are using 20% strength (200mg/mL) and unfortunately many end up on that 200 mg T twice daily application protocol which would surely result in absurdly high TT/FT levels let alone steady-state.

Many can easily achieve healthy let alone very high T levels on much less especially when applied strictly scrotal.

Some men prefer a once-daily application protocol.

If anything seeing as the cost may be the issue then I would at least look into using a compounded transdermal T cream before switching over to injections.

Comes down to the individual as some men prefer/feel great using transdermal T whereas many others prefer injections.

A large percentage of men are using intramuscular/subcutaneous injections using various injection protocols (once weekly, twice weekly, M/W/F, EOD, daily) and in no way are mimicking the natural 24hr circadian rhythm of a healthy young male.

Steady-state, many are running levels well into the supra-physiological range 24/7.

Top it off with the fact that when using exogenous T many are forcing levels upon themselves that the body would never produce naturally.

The closest you could get to mimicking the natural 24hr circadian rhythm would be using the T patch or transdermal T.

Natural endogenous testosterone secretion is pulsatile and diurnal.

*All IM TTh preparations result in PK profiles that are unlike those of the normal diurnal variation of healthy young or older men

You need to keep in mind that you may be in for a bumpy ride when changing a protocol (method of T, dose, injection frequency).

Comparison of Testosterone Blood Concentrations from Different TRT Products Versus Normal Diurnal Variations

Abstract Background: To improve symptoms associated with testosterone deficiency (TD), many testosterone therapies (TTh) are available that aim to restore serum testosterone (T) levels to the normal physiologic range. The magnitude, frequency, and duration between peak and trough T...

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4. Diurnal Variation in Serum T Levels

Diurnal variation in endogenous serum T levels in healthy men is well documented, with the highest T levels in the morning and lowest values in the afternoon and early evening, although the amplitudes of peak and trough levels vary by age. In 1983, a study by Bremner et al showed that there was a clear difference between serum T levels in normal young men (mean age 25.2 years) and older men (mean age 71.0 years).5 In young men, serum T levels were highest in the morning, falling to their lowest levels approximately 12 hours later and gradually increasing again to peak levels the next morning. Furthermore, a study to determine how endogenous T levels vary over clinic hours revealed that in 30- to 40-year-old men, morning total T levels are 30% to 35% higher than levels measured in the mid to late afternoon. This amplitude in daily endogenous T variation decreases with age, with a morning-to-afternoon difference of only 10% in 70-year-old men.90 The morning-to-afternoon total T ratios in young and older men were approximately 1.3 and 1.1, respectively, similar to what was observed in the Bremner study. These observations have led to recommendations in various clinical guidelines, including those of the American Urology Association in 2018, to obtain early morning blood tests for the diagnosis of TD, a threshold defined as <10.4 nmol/L (300 ng/dL). 3 While endogenous serum T exhibits a clear diurnal pattern in young men that appears to be blunted naturally as men age, there does not appear to be much diurnal variation for DHT, SHBG, LH, FSH, or E2, regardless of age.90

Diurnal variation appears to be absent in men with TD. Using a population mixed-effect analysis, Gupta et al showed that no circadian rhythm was detected in men with TD, and the mean endogenous T levels in men with TD (serum T levels <10.4 nmol/L, or 300 ng/dL) were much lower than in healthy young (mean age, 28 years) or older (mean age, 71 years) men. 91 Consistent with the literature, their modeling of circadian T in healthy young and older men revealed peak-to-trough ratios of 1.3 and 1.2, respectively. Additionally, univariate analysis of cross-sectional data from 3,007 older men (≥40 years) showed that the proportion of men with serum T levels <10.4 nmol/L (300 ng/dL) did not significantly change during the day (P<0.11), further supporting that endogenous T diurnal variation is absent in men with TD.92 Results from a study by Shlykova et al evaluating endogenous T levels over a 24-hour period in 21 healthy male volunteers showed that men with baseline serum T levels <10.4 nmol/L (300 ng/dL) did not demonstrate diurnal variation within the 24-hour sampling period. 93 To understand the circadian rhythmicity of T levels in men with TD, a population kinetic model built by Gonzales-Sales et al, using baseline T profiles from 859 men with TD, predicted a base T value of 8.3 nmol/L (239 ng/dL), with the amplitude of oscillation estimated to be 1.1 nmol/L (32.4 ng/dL). 94 Their model also predicted that a stretched cosine function was more suitable to describe the circadian behavior of T levels of men with TD, as trough levels occurred approximately 5 hours after peak T levels, and levels then increased until the next peak occurred approximately 19 hours later.94

A variety of exogenous TTh are available to increase serum T to physiologic levels in males with TD and may alleviate symptoms associated with TD.2 Some T replacement options more closely mimic the circadian levels of T identified in older men, whereas other options seem to provide PK profiles closer to those of younger men (Fig. 1 [Please put figure as close as possible to this callout] and Table 1). Some TTh options provide profiles that exceed the frequency of the natural T circadian rhythmicity.




*Once-weekly SC TE injections bring mean T levels into the physiologic range within 24 hours after the first dose, with a total T Cmax/Cmin ratio of 1.8. The PK profile appears to mimic the flatter profile of older males’ endogenous T.95

*IM T injections can cause both supratherapeutic T levels post-injection and subtherapeutic levels during the dosing interval, and depending on the formulation and dosage, peak-to-trough ratios of IM TC and TE range between 2 and 5.3.

*Longer-lasting TU injections do not demonstrate the supratherapeutic peaks of other IM formulations, with trough levels occurring at later time points after each injection and a peak-to-trough ratio of approximately 2.6 to 2.8.

*All IM TTh preparations result in PK profiles that are unlike those of the normal diurnal variation of healthy young or older men

*Daily transdermal gels and solutions, and nasal and oral T products, provide a consistent serum T level within the physiologic range in most patients. The daily dosing frequency of the topical gel products results in a PK profile with a resemblance to that of endogenous T in younger males

*Men using nasal and oral T products are able to achieve mean serum T levels that are within the normal range, but they experience several T peaks and troughs throughout the day because of the multiple daily dosing regimens required (2 or 3 times/day). This results in a PK profile that significantly deviates from the endogenous PK profiles of both younger and older patients

*No single formulation appears to provide an exposure profile that would resemble diurnal variation of both young and older men

 

[Systemlord]

I am wondering about the cycle of high to low between injections. Can you notice it ?

If you don't inject often enough, you can notice it.

I was able to get T-cream 20% 200mg from Empower Pharmacy for about $50 per month.

You can get your endo to write the prescription for you.

There's also another option you may not have considered, an oral formulation, Jatenzo, but is only viable if covered by insurance.

The only way I was able to get Medicare to pay for Jatenzo was (medical exception) treatment failure for years on injections, creams and gels.

 

[madman]

I have been using T gel for many years, 2 packets of 1% , 50mg /packet / day.
I am considering a change to injectable test/cyp, really just for the cost factor. I just moved to medicare and the deductable plus the cost of the gel is pretty high. I am wondering about the cycle of high to low between injections. Can you notice it ? And is injecting a problem getting the needles? I'm assuming a small bore needle so it isnt painful to do this.

Comes down to your T-dose/injection frequency let alone where your SHBG sits.

Most on trt are injecting 100-200 mg T/week whether once weekly, twice weekly (every 3.5 days), M/W/F, EOD, or daily.

Some may need what would be considered the higher-end dose but it is far from common.

Most can easily achieve a healthy, high let alone absurdly high FT level on 100-150 mg T/week when split into twice weekly (every 3.5 days), M/W/F, EOD let alone daily injections.

Although some men will do well injecting once weekly many men on trt tend to inject more frequently as in twice weekly (every 3.5 days), M/W/F/, EOD, or even daily.

I would be more concerned with where your TT/SHBG sits as not only will it have a significant impact on free testosterone but can also dictate what injection frequency may suit you best.

If your SHBG is high/highish then you may fair well using once-weekly/twice-weekly injections especially if you inject strictly sub-q.

Although it is not a given as some men with high/high SHBG inject more frequently.

Keep in mind that when injecting once weekly that there will be a significant difference in peak--->trough especially when injecting strictly IM let alone blood levels will not be as stable throughout the week which can result in having a negative impact on one's mood, energy, libido, erectile function, recovery throughout the week.

In cases of low/lowish SHBG, many tend to fair better injecting more frequently
(daily/EOD).

Injecting more frequently as in daily or EOD will clip the peak--->trough and result in more stable blood levels throughout the week.

Comes down to the individual and what works best.

Some men prefer the highs--->lows when injecting once weekly.

Others not so much!

Whether one is injecting strictly sub-q or shallow IM most are using LDSS fixed insulin syringes 27-31G various needle lengths.

Numerous benefits using an LDSS fixed insulin syringe as injections are virtually pain-free, minimal trauma to the tissue, minimizing any waste of medication, easier for many to measure accurate doses when injecting lower volumes and you can draw/inject using the same needle to boot.

“Fixed insulin type syringes have no void space at the point where the needle joins the syringe, and so are known as Low Dead Space Syringes, which is sometimes abbreviated in the literature to LDSS. They are made like this so that the full accurate dose is delivered, and there is no waste”

 

[madman]

Principles of Testosterone and hCG Injection Technique

Selecting the Devices There are many different syringes and needles, suiting many different procedures. It is important to choose the needles and syringes carefully according to the type of injection to be administered. For example, the length and gauge of the needle and type of syringe must...

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[Rlud]

Wow, that's a lot of information. Thank you !
I have no idea what my other levels are just what my primary Dr.
Measures. (Probably total T) not even sure what to ask for or who to do it. Then if I can even get those tests covered by medicare.
I have some serious reading to do here.
Thanks again.

 

[madman]

*Natural testosterone is viewed as the best androgen for substitution in hypogonadal men. The reason behind the selection is that testosterone can be converted to DHT and E2, thus developing the full spectrum of testosterone activities in long-term substitution

*Diurnal variation in endogenous serum T levels in healthy men is well documented, with the highest T levels in the morning and lowest values in the afternoon and early evening, although the amplitudes of peak and trough levels vary by age

*The ideal treatment for hypogonadism should provide physiological testosterone levels, exhibit appropriate circadian rhythms, and be modulated by the HPG axis. No formulation of testosterone has been able to achieve this

*The daily dosing frequency of the topical gel products results in a PK profile with a resemblance to that of endogenous T in younger males

*All IM TTh preparations result in PK profiles that are unlike those of the normal diurnal variation of healthy young or older men

*No single formulation appears to provide an exposure profile that would resemble diurnal variation of both young and older men

 

[Nelson Vergel]

I have been using T gel for many years, 2 packets of 1% , 50mg /packet / day.
I am considering a change to injectable test/cyp, really just for the cost factor.

Consider this. About $40 per month. No Medicare to worry about.

New Atrevis Hydrogel Based Testosterone Cream from Empower: Surprising Results!

After a month of using the new hydrogel cream from Empower Pharmacy at 1 ml per day (4 clicks of 0.25 mg each) my testosterone increased dramatically higher than it was even on 200 mg per week of injectable testosterone cypionate. and this was after using the cream plus pregnenolone 100 mg...

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