Testosterone (Testosterone Cypionate) - Side Effects and Adverse Reactions

ADVERSE REACTIONS

Clinical Trial Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

Clinical Trials in Hypogonadal Men

Table 2 shows the incidence of all adverse reactions with testosterone gel and reported by > 1% of patients in a 180 Day, Phase 3 study.

Table 2: Adverse Reactions to Testosterone Gel in the 180 Day Controlled Clinical Trial

Dose of Testosterone
Adverse Reaction	50 mg	75 mg	100 mg
	N = 77	N = 40	N = 78
Acne	1%	3%	8%
Alopecia	1%	0%	1%
Application Site Reaction	5%	3%	4%
Asthenia	0%	3%	1%
Depression	1%	0%	1%
Emotional Lability	0%	3%	3%
Gynecomastia	1%	0%	3%
Headache	4%	3%	0%
Hypertension	3%	0%	3%
Abnormal Lab Tests*	6%	5%	3%
Libido Decreased	0%	3%	1%
Nervousness	0%	3%	1%
Pain Breast	1%	3%	1%
Prostate Disorder**	3%	3%	5%
Testis Disorder***	3%	0%	0%

*Abnormal lab tests occurred in nine patients with one or more of the following events reported: elevated hemoglobin or hematocrit, hyperlipidemia, elevated triglycerides, hypokalemia, decreased HDL, elevated glucose, elevated creatinine, elevated total bilirubin.

**Prostate disorders included five patients with enlarged prostate, one with BPH, and one with elevated PSA results.

***Testis disorders were reported in two patients: one with left varicocele and one with slight sensitivity of left testis.

Other less common adverse reactions, reported in fewer than 1% of patients included: amnesia, anxiety, discolored hair, dizziness, dry skin, hirsutism, hostility, impaired urination, paresthesia, penis disorder, peripheral edema, sweating, and vasodilation.

In this 180 day clinical trial, skin reactions at the site of application were reported with testosterone gel, but none was severe enough to require treatment or discontinuation of drug.

Six patients (4%) in this trial had adverse reactions that led to discontinuation of testosterone gel. These reactions included: cerebral hemorrhage, convulsion, depression, sadness, memory loss, elevated prostate specific antigen, and hypertension. No patients on testosterone gel discontinued due to skin reactions.

In a separate uncontrolled pharmacokinetic study of 10 patients, two had adverse reactions; these were asthenia and depression in one patient and increased libido and hyperkinesia in the other.

In a 3 year, flexible dose, extension study, the incidence of all adverse reactions to testosterone gel and reported by > 1% of patients is shown in Table 3:

Table 3: Adverse Reactions to Testosterone gel in the 3 Year, Flexible Dose, Extension Study

Adverse Reaction	Percent of Subjects
	(N = 162)
Abnormal Lab Tests+	9.3
Skin dry	1.9
Application Site Reaction	5.6
Acne	3.1
Pruritus	1.9
Enlarged Prostate	11.7
Carcinoma of Prostate	1.2
Urinary Symptoms*	3.7
Testis Disorder**	1.9
Gynecomastia	2.5
Anemia	2.5

+Abnormal lab tests occurred in 15 patients with one or more of the following events reported: elevated AST, elevated ALT, elevated testosterone, elevated hemoglobin or hematocrit, elevated cholesterol, elevated cholesterol/LDL ratio, elevated triglycerides, elevated HDL, elevated serum creatinine.

*Urinary symptoms included nocturia, urinary hesitancy, urinary incontinence, urinary retention, urinary urgency and weak urinary stream.

**Testis disorders included three patients. There were two with a non-palpable testis and one with slight right testicular tenderness.

Two patients reported serious adverse reactions considered possibly related to treatment: deep vein thrombosis (DVT) and prostate disorder requiring a transurethral resection of the prostate (TURP).

Discontinuation for adverse reactions in this study included: two patients with application site reactions, one with kidney failure, and five with prostate disorders (including increase in serum PSA in 4 patients, and increase in PSA with prostate enlargement in a fifth patient).

Increases in Serum PSA Observed in Clinical Trials of Hypogonadal Men

During the initial 6-month study, the mean change in PSA values had a statistically significant increase of 0.26 ng/mL. Serum PSA was measured every 6 months thereafter in the 162 hypogonadal men on testosterone gel in the 3 year extension study. There was no additional statistically significant increase observed in mean PSA from 6 months through 36 months. However, there were increases in serum PSA observed in approximately 18% of individual patients. The overall mean change from baseline in serum PSA values for the entire group from month 6 to 36 was 0.11 ng/mL.

Twenty-nine patients (18%) met the per-protocol criterion for increase in serum PSA, defined as > 2X the baseline or any single serum PSA > 6 ng/mL. Most of these (25/29) met this criterion by at least doubling of their PSA from baseline. In most cases where PSA at least doubled (22/25), the maximum serum PSA value was still < 2 ng/mL. The first occurrence of a pre-specified, post-baseline increase in serum PSA was seen at or prior to Month 12 in most of the patients who met this criterion (23 of 29; 79%).

Four patients met this criterion by having a serum PSA > 6 ng/mL and in these, maximum serum PSA values were 6.2 ng/mL, 6.6 ng/mL, 6.7 ng/mL, and 10.7 ng/mL. In two of these patients, prostate cancer was detected on biopsy. The first patient’s PSA levels were 4.7 ng/mL and 6.2 ng/mL at baseline and at Month 6/Final, respectively. The second patient’s PSA levels were 4.2 ng/mL, 5.2 ng/mL, 5.8 ng/mL, and 6.6 ng/mL at baseline, Month 6, Month 12, and Final, respectively.

Postmarketing Experience

The following adverse reactions have been identified during post approval use of testosterone gel. Because the reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure (Table 4):

•   Table 4: Adverse Reactions from Postmarketing Experience of Testosterone Gel by MedDRA System Organ Class

Secondary Exposure to Testosterone in Children

Cases of secondary exposure to testosterone resulting in virilization of children have been reported in postmarket surveillance. Signs and symptoms of these reported cases have included enlargement of the clitoris (with surgical intervention) or the penis, development of pubic hair, increased erections and libido, aggressive behavior, and advanced bone age. In most cases with a reported outcome, these signs and symptoms were reported to have regressed with removal of the testosterone gel exposure. In a few cases, however, enlarged genitalia did not fully return to age appropriate normal size, and bone age remained modestly greater than chronological age. In some of the cases, direct contact with the sites of application on the skin of men using testosterone gel was reported. In at least one reported case, the reporter considered the possibility of secondary exposure from items such as the testosterone gel user’s shirts and/or other fabric, such as towels and sheets [see Warnings and Precautions (5.2)].

REPORTS OF SUSPECTED TESTOSTERONE SIDE EFFECTS / ADVERSE REACTIONS

Possible Testosterone side effects / adverse reactions in 10 month old male

Reported by a physician from United States on 2011-10-12

Patient: 10 month old male weighing 11.3 kg (24.9 pounds)

Reactions: Blood Testosterone Increased, Blood Androstenedione Increased, Precocious Puberty, Hair Growth Abnormal, Penis Disorder, Skin Hyperpigmentation, Accidental Exposure

Suspect drug(s):
Testosterone
    Dosage: 200 mg daily
    Administration route: Topical
    Indication: Hypogonadism Male
    Start date: 2006-04-01
    End date: 2006-05-01

Testosterone
    Dosage: gel, 150 mg daily
    Administration route: Topical
    Indication: Hypogonadism
    Start date: 2006-02-08
    End date: 2006-04-01

Possible Testosterone side effects / adverse reactions in 10 month old male

Reported by a physician from United States on 2011-10-21

Patient: 10 month old male weighing 11.3 kg (24.9 pounds)

Reactions: Blood Testosterone Increased, Blood Androstenedione Increased, Precocious Puberty, Hair Growth Abnormal, Penis Disorder, Skin Hyperpigmentation, Accidental Exposure

Suspect drug(s):
Testosterone
    Administration route: Topical
    Indication: Accidental Exposure

Testosterone
    Dosage: 200 mg daily
    Administration route: Topical
    Indication: Hypogonadism Male
    Start date: 2006-04-01
    End date: 2006-05-01

Possible Testosterone side effects / adverse reactions in 44 year old female

Reported by a health professional (non-physician/pharmacist) from United States on 2011-10-24

Patient: 44 year old female weighing 67.1 kg (147.7 pounds)

Reactions: Vomiting, Nausea

Suspect drug(s):
Testosterone

Other drugs received by patient: Estradiol