PL is a 52-year old man who has been experiencing symptoms of hypogonadism over the past couple of months. PL brings a prescription for Androgel 1.62%: Apply two pumps once daily to the upper arms or shoulder. 

PMH: Hypertension, Atrial Fibrillation

Other medications:

Avalide 150/12.5 mg PO QDAY

Lopressor 50 mg PO BID

Xarelto 20 mg PO once a day with evening meal

Vitals:

Ht: 6’0" ft

Wt: 220 lbs

BP: 112/72 mmHg

HR: 72 BPM

What counseling points should you mention to PL? Select all that apply. 

A. You may experience symptoms of low blood pressure and should monitor regularly

B. There is an increased risk of bleeding with Xarelto and Androgel due to drug interaction

C. Children and women should not touch where the Androgel is applied

D. Avoid getting the application area wet for at least 2 hours

E. Testosterone levels should be monitored every 3 to 6 weeks for safety and efficacy

Answers with rationale:

Hypogonadism is common in about 40% of men over the age of 45. Some consequences of hypogonadism include infertility, impotence, male pseudohermaphroditism.  Hypogonadism is diagnosed with a total testosterone (TT) level <12 nmol/L. Testosterone should only be used in patients with a TT level that is subtherapeutic. Monitoring should include serum testosterone, PSA, CBC, lipid panel, and hepatic panel. There are many different testosterone products available, such as IM or subcutaneous injection, buccal or oral tablets, intranasal, and different gel products. Knowing how to counsel patients on testosterone is essential to ensure safe and effective therapy. 

Answer A is incorrect. Testosterone can cause an increase in high blood pressure, so PL should monitor his blood pressure while taking his Androgel and report any changes from baseline or symptoms of high blood pressure such as headache, chest pain, nausea, or vomiting.

Answer B is incorrect. There is no interaction between Xarelto and Androgel. Androgel and warfarin would require an increase in INR monitoring because of the potential increased risk of bleeding.

Answer C is correct. If women and children touch the area where Androgel was applied it could cause virilization. Virilization is exaggerated masculine characteristics because of an increase in androgens. 

Answer D is correct. PL should be advised to wait to go swimming, get the area wet, or shower for at least 2 hours after Androgel 1.62% is applied. For older Androgel products (1%), it is recommended to avoid getting the area wet for at least 5 hours. 

Answer E is incorrect. Baseline labs prior to starting testosterone should be obtained, so trends in the patient’s levels, such as TT for efficacy and other laboratory findings for safety such as CBC, lipid panel, and hepatic panel, can be monitored appropriately. This timeframe is short and generally is monitored over a number of months, such as 3 or 6 months. 

Brand/Generics covered:

Testosterone (Androgel), Irbesartan/Hydrochlorothiazide (Avalide), Metoprolol succinate (Lopressor), Rivaroxaban (Xarelto)

Naplex Competencies Covered:

1.4 - From medical records: medication history

2.2 - Brand or generic names

3.2 - Therapeutic goals

3.8 - Drug interactions

5.5 - Techniques for drug administration

5.6 - Handling