Daily Dose: Cardiovascular Safety of Testosterone-Replacement Therapy in Men with Hypogonadism

Patient Care brings primary care clinicians a lot of medical news every day—it’s easy to miss an important study. The Daily Dose provides a concise summary of one of the website's leading stories you may not have seen.

On June 20, 2023, we reported on a study presented at ENDO 2023, the Endocrine Society's annual meeting.

The study

The TRAVERSE (Testosterone Replacement Therapy for Assessment of Long-term Vascular Events and Efficacy Response in Hypogonadal Men) phase 4 study was a randomized, double-blind, placebo-controlled, noninferiority, event-driven trial conducted at 316 sites in the US.

The final cohort of 5024 participants were men aged 45 to 80 years with ≥1 symptom of hypogonadism, 2 fasting serum testosterone levels <300 ng/dL, and preexisting CVD or elevated CV risk. The cohort was randomly assigned in 1:1 fashion to receive daily transdermal 1.62% testosterone gel (2601) or matching placebo gel (2603).

The trial’s primary safety endpoint was the first occurrence of any component of a composite or of death from CV mortality, nonfatal myocardial infarction, or nonfatal stroke, assessed in a time-to-event analysis. A secondary endpoint was first occurrence of any death from CV causes, nonfatal MI, nonfatal stroke, or coronary revascularization. Noninferiority required an upper limit of less than 1.5 for the 95% confidence interval of the hazard ratio among patients receiving at least one dose of testosterone or placebo.

The investigators reported the median testosterone level was 227 ng/dL at study baseline. The mean length of treatment was 21.8 months for those receiving testosterone and 21.6 months for those receiving placebo. Mean follow-up was 33.1 months in the testosterone group and 32.9 months in the placebo group.

The findings

The testosterone group had an increase of 148 ng/dL in serum testosterone at 12 months.

The TRAVERSE research team identified 182 patients (7.0%) in the testosterone group and in 190 patients (7.3%) in the placebo group with a first major cardiovascular event (HR, 0.96; 95% CI, 0.78-1.17; P<.001 for noninferiority). They reported similar findings after a sensitivity analysis, which censored data on events occurring more than 365 days after the final dose or events occurring more than 30 days after the last dose or interruption of treatment. That analysis revealed a primary endpoint event in 154 patients (5.9%) in the testosterone group and 152 patients (5.8%) in the placebo group (HR, 1.02; 95% CI, 0.81-1.27; P<.001 for noninferiority).

Investigators also reported, however, a higher incidence of atrial fibrillation that required intervention among those in the testosterone group 134 (5.2%) compared to 87 (3.3%) among the placebo group (P= .001) and a higher incidence of acute kidney injury, observed in 2.3% of the testosterone group and 1.5% of the placebo group (P=.04).

A note from authors

"Because testosterone deficiency is not a life-threatening condition, uncertainty about cardiovascular outcomes has weighed on treatment decisions by clinicians and patients. Our findings may facilitate a more informed consideration of the potential benefits and risks of testosterone therapy among middle-aged and older men with hypogonadism.”

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