Meas Pharmacokinetics, safety, and patient acceptability of subcutaneous versus intramuscular testosterone injection for gender-affirming therapy: A pilot study David M. Wilson, M.D., CFP, iri nd Department of Farnhy Facully of Medicine, University of Brush Columba, Vancouver Canada ‘Tony K, L Kiang, B.Se(Pharm), PhD., AGPR, Faculty of Parmacy anc Pharmaceutics Sciences, Universty of INber'a, ESmontan, Caras Mary HH, Ensom, Pharm.D. FASHP, FCCP, FCSHP, FCAHS, Facuty of Pharmaceutiesl Seenoes, Universty of Bish Columbia. Vancouver, Canad. Sn Chierens ard Women's Heath Gente of Brtizh Columbia. Vancouver, Canada, Adaress correspondence te Dr Wilson (croaviwisoreshavrcal Copyright ©2018, American Soc Health-System Pharmaciss Ine reserved. 1079-2082/18/0902-095%, ol 10.2146/ahpt70160, Purpose. Results of a study comparing testosterone exposure and toler- ability with subcutaneous versus im, administration are presented. Methods. In a prospective, open-label, crossover study, adult participants already on stable xm. testosterone testosterone cypionate or enanthat ‘gender-affirming therapy selt-injected (2m. for 3 wooks followed by subcu- taneous injections for 8 weeks. Trough serum testosterone concentrations, ‘were determined weekly, and serial total serum testosterone (TST) concen- trations were determined on postinjection days 1, 3, and § of weeks 3 and 11. Hemoglobin and alanine transamit se (ALT) levels were measured at week 3 (the first visit), with repeat measurements at week 11 (the final visi) ‘The dose-normalized area under the time-concentration curve (AUC) was. calculated during weeks 3 and 11. Results. Fourteen transgender males (mean age, 30 + 10 years) partici pated in the study. The mean hemoglobin values atthe frst and final visits ‘were 1609 and 153.19 g/L, respectively (o > 0.05); the mean ALT values, were 18 + 6 and 21 + 10 IU/L (p > 0.08}. Total testosterone exposure was, ‘comparable with subcutaneous versus im. injection (mean AUC, 1.7=0.8 ‘nmol days/L/mg versus 1.9 + 0.6 n collected via weekly questionnaires ‘was more tolerable, with lower sé ymol-days/L/mg; p > 0.08). Information indicated that the subcutaneous route reported scores for preinjection anxi- ‘ty, pain during injection, and postinjection pain. Conclusion. The subcutaneous route forthe injection of testosterone was ‘well tolerated and appeared to be as effective as Lm. injection in delivering ‘equivalent TST levels, although there was wide intrapatient and interpa- tient variability. Keyword: transgender male pharmacokinetics, subcutaneous injections, testosterone, ‘Am J Health-Syst Pharm. 2018; 75:351-8 Terteteone iste commensane of pharmacotherapy for transgen- der males {individuals born female ‘who identify as male or along the ‘male spectrum). To medically tran- sition to a more masculine presen- tation, most transgender males use iim. testosterone either cypionate ‘or enanthate) weekly or biweekly.** Others also use long-acting testos- terone undecanoate every 10-12 ‘weeks, which has been described as [AMA HEALTH-SYST PHARM. | VOLUME effective in hypogonadal males. IM. testosterone is often associated with discomfort and occasionally with pain; requires substantial patient teach- ing for self-administration; presents bleeding concems if the patient is receiving anticoagulant therapy or hhas a bleeding disorder; may produce Jarge fluctuations in ciculating serum testosterone, leading to variability in ‘mood, energy, and libido’; and may be associated with mastalgia in males* 75 | NUMBERS | maRcH 5.2018 354Co While ism, injection has traditionally bbeen the most common route of tes- tosterone injection, the subcutaneous route (considered an off-label use, as is testosterone therapy for females) is gaining popularity in the transgen- der community largely because it is perceived as more comfortable and assumed to be as effective" The overwhelming majority of hormonal research has focused on hypogonadal males, including studies of the set- ting of target serum testosterone lev- ls 7"! The target range adopted by 2 local community laboratory in the Vancouver area of British Columbia, Canada (LifeLabs Medical Laborato- ries), is 8-28 nmol/L and is accepted bby most local transgender healthcare providers as the target range for thera- peutic effectiveness. Despite minimal published data regarding testoster- ‘one administration by these different routes in transgender males, most clinicians continue to assume equiva- lency of response, Olson et al? suggested that ef fective masculinization could be achieved with subcutaneous versus im, testosterone but did not compare the 2 routes in their study of 36 young ‘wansgender males, Olshan et al re- ported “therapeutic serum concen- ‘uations at doses generally lower than requited for im. injections” and no adverse reactions with the use of sub- cutaneous testosterone in § tansgen- der and 2 hypogonadal males, In other reports on research involving hypogo- nadal males, target levels of testoster- fone were achieved via subeutaneous administration with few adverse ef- fects or safety concerns." Patients and clinicians are acute- ly aware of the potential risks asso- ciated with exogenous testosterone and generally ty to find the lowest effective dose possible. Some cli- nicians have suggested that effec- tive therapy with lower testosterone doses is possible using the subcuta- neous route, but to our knowledge there is no evidence to suppor this. There are mixed reports of adverse events associated with testoster- Nee) KEY POINTS + Results ofa pilot study i cated that the subcutaneous route for injection of testoster- ‘one appears to be as effective {asthe iim. route for attainment of target sorum testosterone levels, albeit wth wide intrapa. tiont and interpationt varabilty + The subcutaneous route of tes tosterone administration is well tolerated and appears to be ‘avery reasonable alternative to_im. injections for gender affirming therapy. + Future larger studies to con- firm the findings of the first- ‘of-its-kind pilot project are warranted, one, specifically cardiovascular risks and venous thromboembolic (VTE) events." Conflicting results have been published, including data from, atrial involving use of topical gel that, was discontinued due to an increase in cardiovascular events. Reports published over the past 5-8 years did not indicate an increase in VTE events with testosterone administra tion." Results of a study compar ing the safety of testosterone gels, patches, and ism. injections suggest- ced increased cardiovascular events in the im, group and decreased events ‘with gels and patches." In another report, the oral route was associ- ated with significantly increased car- diovascular risk, while the im, and transdermal routes were not.” ‘We conducted a pilot study whose primary objective was to compare testosterone pharmacokinetics ie, exposure) with im, versus subeuta- neous administration in transgender males; the secondary objective was to compare patient acceptance and tol erability of im, and subcutaneous tes- 952 AMJHEALTH-SYST PHARM | VOLUME7S | NUMBERS | MARCH 15,2008 {osterone therapy, as measured with @ self-administered questionnaire. Methods The study was a prospective, open-label, crossover study involv: ing adult patients already receiving weekly testosterone im. injections (eypionate or enanthate). The inclu: sion criteria required that enrolled Participants be 19 years of age or older, on a stable dose of ism, tes tosterone for a minimum of 8 weeks, medically stable, and under the care of 1 of 4 transgender care specialists a1 of2 designated community health centers in Vancouver. Participants were recruited by specialists or nurses in the clinic setting or self-referred via clinic posters, word of mouth, or the ClinicatTrials.gov website, Bthics ap- proval was received from the Universi ty of British Columbia clinical research ethics board (application 14-0862), and the study was submitted to the ClinicatTtials gov Protocol Registration and Results System, As the proposed use of testosterone and the target pop- ulation were outside the parameters of injectable testosterone administra tion previously approved in Canada, a clinical trial application was submit ted to Health Canada; the application (9427-V0742-21C) was approved. After providing written informed consent, patients continued their es tablished im. testasterone dosage for 3 weeks and then switched to subcu: taneous injections for 8 weeks, using the same testosterone formulation and dosage previously used for im. administration, Trough (predose) total serum testosterone (TST) concentra: tions were determined weekly, and blood samples for serial TST concen- ‘rations were collected 1,3, and 5 days after the injection during week 3 (dur- ing the im. phase) and week 11 {atthe end of the subcutaneous phase) for exposure determination (appendin) These weeks (3 and 11) ate described asthe intensive pharmacokinetic weeks because of the 3 additional TST tests conducted. With testoster one eypionate’s estimated half-life of6-8 days and testosterone enanthate’s half-life of 5-7 days, we assumed that fan 8-week im, observation period would allow steady-state conditions to be attained by the period's end,""* Weekly, participants used a 10-point scale to describe 10 variables includ: {ng mood, pain, and acne Participants established individual testing schedules within the confines of the protocol, received supplies and « personalized study binder, and had a short personal teaching session on subcutaneous injections from the study coordinator or a specialized clinic nurse. Height and weight were recorded during the fist visit to cal culate body mass index. Hemoglobin (as part of a complete blood count), alanine transaminase (ALT), and TST wore measured at the first visit to the laboratory. Thereafter, trough TST concentrations were measured week: Jy, and additional TST determinations were made 3 other times during the designated intensive pharmacokinetic ‘weeks. Final laboratory tests included determinations of TST, hemoglobin and ALT. Materials. Participants contin: uued to use their regular testosterone product, either testosterone cypio: nate 100 mg/mL (Depo-Testosterone, Pfizer Canada Inc, Kirkland, Canada) fr testosterone enanthate 200 mg/ ml (Delatestryl, Valeant Canada LP, Laval, Canada) at the same dosage. A 25-gauge, 5/8-inch needle was used for subcutaneous injections, Most participants were already using a 21- fr 22-gauge, 15-inch needle for im. injections. Participants were encour ‘aged to warm the filled syringe in their aulllae prior to injection, ‘TST determination, TST con- centrations were measured using the lecsys Testosterone I electrochemi luminescence immunoassay and Co- bas e802 immunoassay analyzer (both from Roche Diagnosties, Mannheim, Germany) standardized via isotope dilution gas chromatography-mass spectometry® The assay has the following characteristics: simple (oithin-run) and complex (run-to G run} precision (percent coefficient of variation, <2.5% and <45%, respec- tively); specificity for testosterone, with cross-reactivity of <2.5% for oth- cer steroid compounds and <0.86% for Sa-cihydrotestoserone; sensitivity of 0,087 nmol/l; and a reportable range ‘of 0,10-52.0 nmol/L. Pharmacokinetic analysis, Phar- ‘macokinetic parameters forthe weekly petiods (im. and subcutaneous), cal- ‘culated via noncompartmental analy- sis, included maximum concentration, efined as the highest concentration observed during the weeks of inten- sive pharmacokinetic testing: trough orminimum concentration, defined as ‘the concentration obtained 1-6 hours belore the weekly dose; and area under the concentration-time curve (AUC), as ameasure of testosterone exposure, calculated using the trapezoid rule and normalized to testosterone dose, Pharmacodynamic analysis. ‘To quantitatively assess the effects of route of testosterone adminis- tation on patient tolerability and acceptance, mean scores from the weekly questionnaire were calcu- lated. Descriptive information from patient diaries was extracted but not included in the statistical analysis Statistical analysis. Consistent with other exploratory pharmacoki- netic studies, a convenience sample Esa eae size was determined according to the number of participants who volun: teered to participate in the study and ‘met the inclusion criteria, Descriptive statistics for patient demographics and questionnaire results and results of Wileoxon signed rank testing for pharmacokinetic parameters, as cal culated using SigmaStat 35 (Systat Software, Inc, San Jose, CA), were used to describe and compare results of subcutaneous and im. testosterone administration, The a priori level of significance was 0.05, Results Altogether, 15 participants signed consent forms and began the study, bbut | dropped out after I week, There fore, the reported data represent the 14 participants who completed the I-week study. Table 1 summarizes selected data about the participants. The mean + $.D. weekly testosterone dose (expressed in terms of testos terone cypionate or enanthate) was 67.9 + 23.3 mg (range, 30-110 mg) While not formally recorded, the total length of time of exposure to testos terone prior to the start of the study varied from 8 months to 22 years. Most patients had received testoster- one for 3-6 years, and 7 of the 14 had hysterectomy-oophorectomy as part of their gender-affirming transi- Variable (mean £8.D) snatnate used oy 4 parieparts Table 1. Selected Demographic and Laboratory Data (n ‘Age Ot) 0210 Body mass index i) aa Original weeky testosterone dose (na) 6792733 Hemaglebin concentration (o/s Wek 1 151208 Week 1 153208 Serum alanine vansaminase concenvation (uns/L Week t Tare Week 11 m0 “Data ae for partopavis who complies he sy. "Dore expressed n tems of esanerne eyporaejted by 10 parepsn) ot teststerene "p> 005 or aererce between weks 1 and 17. (AM JHEALTH-SYST PHARM. | VOLUME7S | NUMBERS | MARCH 5.2018 353.