Pharmacoepidemiology of testosterone prescribing in Australia, 1992–2010

To the Editor: The recent article by Handelsman describes the pattern of testosterone prescribing in Australia from January 1992 to December 2010.1 The author concludes that the progressive increase in Pharmaceutical Benefits Scheme (PBS)-subsidised testosterone prescribing is likely to be due to promotion-driven prescribing for speculative, non-approved indications.1

The article does not make any reference to the prescribing of testosterone for opioid-induced androgen deficiency. The use of testosterone for this indication may account for some of the increased prescribing of testosterone over the period measured, although it is unclear to what extent. While androgen deficiency is a common complication of opioid use, it also seems to be a problem that tends to go undiagnosed.

There has been a substantial increase in the number of PBS opioid prescriptions over the past two decades, particularly for oxycodone.2 Opioid medications, particularly potent, long-acting narcotic analgesics such as methadone, controlled-release morphine, transdermal fentanyl patches and controlled-release oxycodone, can profoundly suppress gonadotropin secretion and result in severe androgen deficiency. United States data suggest that hypogonadal opioid users may experience improvement in sexual function and mood with testosterone replacement.3

Prescribing testosterone in the context of opioid-induced androgen deficiency may on occasion be quite appropriate. However, in some cases, the opioid prescription may be unnecessary or inappropriate, and the low testosterone is best managed by withdrawing the opiate medication and using alternative pain management.

Opioid-induced androgen deficiency is a common clinical scenario that may be contributing to the increased prescription of testosterone. I wish to highlight the role of testosterone in this context and emphasise the need for careful assessment of its use.