November 13, 2013

DynaMed EBM Journal Volume 8, Issue 46

DynaMed Weekly Updates

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Physicians: .25 AMA PRA Category ICreditsTM

Family Physicians: .25 Prescribed credits

Nurse Practitioners: .25 Contact hours

Release Date: November 13, 2013

Expiration Date: November 13, 2014

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon at the end of the article.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:
1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD - Assistant Clinical Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Senior Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP - Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company


Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote EducationCompany and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: Enduring Material activity, DynaMed EBM Focus, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 7, 2012. Term of approval is for one year from this date with the option of yearly renewal. Each EBM Focus is worth .25 Prescribed credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 0.25 contact hour of continuing education by the American Academy of Nurse Practitioners.

Program ID: 1304159B


Last week 819 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 251 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," one article of significant interest was selected by the DynaMed Editorial Team.

Testosterone Therapy Associated Increased Cardiovascular Events in Men with Low Testosterone levels and High Cardiovascular Risk
Reference: (JAMA 2013 Nov 6;310(17):1829) (level 2 [mid-level] evidence)

Testosterone replacement therapy has become increasingly common in recent years and has shown efficacy for improving sexual dysfunction, bone mineral density, exercise capacity, and metabolic parameters in men with androgen deficiency or chronic conditions including heart failure and diabetes. However, efficacy trials have generally been of relatively short duration, which may limit the ability to assess potential harms. A recent 6-month randomized trial evaluating testosterone gel in frail elderly men was terminated early due to increased rates of cardiovascular events in the testosterone group (N Engl J Med 2010 Jul 8;363(2):109) raising concerns about whether this was specific to this trial or might reflect a larger problem. Now, a new retrospective cohort study has assessed long-term risks of testosterone therapy in men with low testosterone levels and high cardiovascular risk.

A total of 8,709 men who visited a Veteran’s Administration facility for coronary angiography from 2005 to 2011 and subsequently had serum testosterone < 300 ng/dL (< 10.4 nmol/L), were followed for mean 27.5 months. At the time of angiography, 20% had a previous myocardial infarction (MI), 50% had diabetes. More than 80% had at least 20% stenosis in ≥ 1 epicardial vessel on angiography. Following angiography, 14% began testosterone therapy at some point during the follow-up period (63.3% had testosterone patch, 35.7% had injection, and 1.1% had gel). The median time from angiography to beginning of therapy was 531 days. The primary outcome was a composite of all-cause mortality, MI and ischemic stroke.

There were a number of baseline differences between men who had testosterone therapy and men who did not. The no-testosterone group was older (mean difference 3 years) and had significantly higher rates of coronary artery obstruction, hypertension, hyperlipidemia, heart failure, previous MI, COPD, peripheral vascular disease and cerebrovascular disease. In an analysis weighted by the probability of treatment with testosterone and adjusted for comorbidities, testosterone therapy was associated with an increased risk of primary outcome events (adjusted hazard ratio 1.29, 95% CI 1.04-1.58). At 3 years, the cumulative event rates were 25.7% in testosterone group vs. 19.9% in no-testosterone group. These data are consistent with the results of a recent systematic review assessing the effects of testosterone therapy in 2,994 with low testosterone or chronic diseases (BMC Med 2013 Apr 18;11:108).

While it may be difficult to minimize bias in an observational study of this type, results from studies like this will often prompt longer follow-up in subsequent randomized trials. That would certainly be helpful in this case. However, until such data are available, this information and its limitations should be part of the discussion for men considering testosterone replacement therapy.

For more information, see the Testosterone therapy in men topic in DynaMed.

Earn CME Credit for reading this e-Newsletter.
For more information on this educational activity, see the CME sidebar.

DynaMed Events

American Society of Hematology (ASH), December 7-10, 2013
Representatives will be attending the ASH conference, held at the Ernest N. Morial Convention Center in New Orleans, Louisiana. Stop by booth 3907 to discuss peer review, mobile access, and free trial information.

Visit the ASH website to learn more about the event and for registration information.

If you would like to meet with a DynaMed representative at an event, please contact us at

Call for Peer Reviews

We are currently seeking reviewers for:

Testosterone therapy

Testosterone therapy in men

DynaMed Careers

Looking for a change? The DynaMed editorial team is expanding and looking for talented and driven individuals. Visit the links below to learn about these exciting opportunities.

Deputy Editor of Cardiology
Deputy Editor of Oncology
Medical Writer
Medical Editor
Associate Editor