WARNINGS
Included as part of the PRECAUTIONS section.
PRECAUTIONS
Worsening Of Benign Prostatic Hyperplasia (BPH) And Potential
Risk Of Prostate Cancer
- Patients with BPH treated with androgens are at an
increased risk for worsening of signs and symptoms of BPH. Monitor patients
with BPH for worsening signs and symptoms.
- Patients treated with androgens may be at increased risk
for prostate cancer. Evaluate patients for prostate cancer prior to initiating
and during treatment with androgens [see CONTRAINDICATIONS].
Potential For Secondary Exposure To Testosterone
Cases of secondary exposure resulting in virilization of
children have been reported in postmarketing surveillance. Signs and symptoms
have included enlargement of the penis or clitoris, development of pubic hair,
increased erections and libido, aggressive behavior, and advanced bone age. In
most cases, these signs and symptoms regressed with removal of the exposure to
testosterone gel. In a few cases, however, enlarged genitalia did not fully
return to age-appropriate normal size, and bone age remained modestly greater
than chronological age. The risk of transfer was increased in some of these
cases by not adhering to precautions for the appropriate use of the topical
testosterone product. Children and women should avoid contact with unwashed or
unclothed application sites in men using Testim [see DOSAGE AND
ADMINISTRATION, Use in Specific Populations and CLINICAL
PHARMACOLOGY].
Inappropriate changes in genital size or development of
pubic hair or libido in children, or changes in body hair distribution,
significant increase in acne, or other signs of virilization in adult women
should be brought to the attention of a physician and the possibility of
secondary exposure to testosterone gel should also be brought to the attention
of a physician. Testosterone gel should be promptly discontinued until the
cause of virilization has been identified.
Polycythemia
Increases in hematocrit, reflective of increases in red
blood cell mass, may require lowering or discontinuation of testosterone. Check
hematocrit prior to initiating treatment. It would also be appropriate to
re-evaluate the hematocrit 3 to 6 months after starting treatment, and then
annually. If hematocrit becomes elevated, stop therapy until hematocrit
decreases to an acceptable concentration. An increase in red blood cell mass
may increase the risk of thromboembolic events.
Venous Thromboembolism
There have been postmarketing reports of venous
thromboembolic events, including deep vein thrombosis (DVT) and pulmonary
embolism (PE), in patients using testosterone products, such as Testim.
Evaluate patients who report symptoms of pain, edema, warmth and erythema in
the lower extremity for DVT and those who present with acute shortness of
breath for PE. If a venous thromboembolic event is suspected, discontinue
treatment with Testim and initiate appropriate workup and management [see ADVERSE
REACTIONS].
Cardiovascular Risk
Long term clinical safety trials have not been conducted
to assess the cardiovascular outcomes of testosterone replacement therapy in
men. To date, epidemiologic studies and randomized controlled trials have been
inconclusive for determining the risk of major adverse cardiovascular events
(MACE), such as non-fatal myocardial infarction, non-fatal stroke, and
cardiovascular death, with the use of testosterone compared to non-use. Some
studies, but not all, have reported an increased risk of MACE in association
with use of testosterone replacement therapy in men. Patients should be
informed of this possible risk when deciding whether to use or to continue to
use Testim.
Use in Women
Due to lack of controlled evaluations in women and
potential virilizing effects, Testim is not indicated for use in women [see
CONTRAINDICATIONS and Use in Specific Populations].
Potential For Adverse Effects On Spermatogenesis
With large doses of exogenous androgens, including
Testim, spermatogenesis may be suppressed through feedback inhibition of pituitary
follicle-stimulating hormone (FSH) which could possibly lead to adverse effects
on semen parameters including sperm count.
Hepatic Adverse Effects
Prolonged use of high doses of orally active
17-alpha-alkyl androgens (e.g., methyltestosterone) has been associated with
serious hepatic adverse effects (peliosis hepatis, hepatic neoplasms,
cholestatic hepatitis, and jaundice). Peliosis hepatis can be a
life-threatening or fatal complication. Long-term therapy with intramuscular
testosterone enanthate, which elevates blood levels for prolonged periods, has
produced multiple hepatic adenomas. Testim is not known to cause these adverse
effects. Nonetheless, patients should be instructed to report any signs or
symptoms of hepatic dysfunction (e.g., jaundice). If these occur, promptly
discontinue Testim while the cause is evaluated.
Edema
Androgens, including Testim, may promote retention of
sodium and water. Edema, with or without congestive heart failure, may be a
serious complication in patients with preexisting cardiac, renal, or hepatic
disease. In addition to discontinuation of the drug, diuretic therapy may be
required.
Gynecomastia
Gynecomastia occasionally develops and occasionally
persists in patients being treated for hypogonadism [see ADVERSE REACTIONS].
Sleep Apnea
The treatment of hypogonadal men with testosterone may
potentiate sleep apnea in some patients, especially those with risk factors
such as obesity or chronic lung diseases.
Lipids
Changes in the serum lipid profile may occur. Monitor the
lipid profile periodically, particularly after starting testosterone therapy
and after dose increases.
Hypercalcemia
Androgens, including Testim, should be used with caution
in cancer patients at risk of hypercalcemia (and associated hypercalciuria).
Regular monitoring of serum calcium concentrations is recommended in these
patients.
Decreased Thyroxine-binding Globulin
Androgens, including Testim, may decrease concentrations
of thyroxine-binding globulins, resulting in decreased total T4 serum
concentrations and increased resin uptake of T3 and T4.
Free thyroid hormone concentrations remain unchanged,
however, and there is no clinical evidence of thyroid dysfunction.
Flammability
Alcohol-based products, including Testim, are
flammable; therefore, patients should be advised to avoid fire, flame or
smoking until the Testim has dried.
Patient Counseling Information
See FDA-approved patient
labeling (Medication Guide).
Advise patients of the
following:
Men With Known Or Suspected
Carcinoma Of The Breast Or Prostate
Men with known or suspected prostate or breast cancer
should not use Testim® [see CONTRAINDICATIONS and WARNINGS AND PRECAUTIONS].
Potential For Secondary Exposure To Testosterone And Steps
To Prevent Secondary Exposure
Secondary exposure to
testosterone in children and women can occur with the use of testosterone gel
in men. Cases of secondary exposure to testosterone have been reported in
children.
Physicians should advise patients of the reported signs
and symptoms of secondary exposure which may include the following:
- In children; unexpected sexual development including
inappropriate enlargement of the penis or clitoris, premature development of
pubic hair, increased erections, and aggressive behavior
- In women; changes in hair distribution, increase in acne,
or other signs of testosterone effects
- The possibility of secondary exposure to testosterone gel
should be brought to the attention of a healthcare provider
- Testim should be promptly discontinued until the cause of
virilization is identified
Strict adherence to the following precautions is advised
to minimize the potential for secondary exposure to testosterone from
testosterone gel in men [see Medication Guide]:
- Children and women should avoid contact with unwashed
or unclothed application site(s) of men using testosterone gel
- Patients using Testim should apply the product as
directed and strictly adhere to the following:
- Wash hands with soap and water immediately after
application
- Cover the application site(s) with clothing after
the gel has dried
- Wash the application site(s) thoroughly with soap
and water prior to any situation where skin-to-skin contact of the application
site with another person is anticipated
- In the event that unwashed or unclothed skin to which
Testim has been applied comes in contact with the skin of another person, the
general area of contact on the other person should be washed with soap and
water as soon as possible [see DOSAGE AND ADMINISTRATION, WARNINGS AND PRECAUTIONS and CLINICAL
PHARMACOLOGY].
Potential Adverse Reactions With Androgens
Patients should be informed that treatment with androgens
may lead to adverse reactions which include:
- Changes in urinary habits, such as increased urination at
night, trouble starting the urine stream, passing urine many times during the
day, having an urge to go the bathroom right away, having a urine accident, or
being unable to pass urine or weak urine flow
- Breathing disturbances, including those associated with
sleep or excessive daytime sleepiness.
- Too frequent or persistent erections of the penis
- Nausea, vomiting, changes in skin color, or ankle
swelling
Patients Should Be Advised Of The Following Instructions For
Use
- Read the Medication Guide before starting Testim
therapy and reread it each time the prescription is renewed.
- Testim should be applied and used appropriately to
maximize the benefits and to minimize the risk of secondary exposure in
children and women
- Keep Testim out of the reach of children. The package
is not child resistant.
- Testim is an alcohol-based product and is flammable;
therefore avoid fire, flame or smoking until the gel has dried
- It is important to adhere to all recommended
monitoring
- Report any changes in their state of health, such as
changes in urinary habits, breathing, sleep, and mood
- Testim is prescribed to meet the patientâ⬙s specific
needs; therefore, the patient should never share Testim with anyone.
- Testim should be applied once daily at approximately the
same time each day to clean dry skin of the shoulders and/or upper arms.
- Testim should not be applied to the scrotum, penis, or
abdomen.
- Wait 2 hours before swimming or washing following
application of Testim. This will ensure that the greatest amount of Testim is
absorbed into their system.
Nonclinical Toxicology
Carcinogenesis, Mutagenesis, Impairment Of Fertility
Carcinogenicity
Testosterone has been tested by subcutaneous injection
and implantation in mice and rats. In mice, the implant induced cervical-uterine
tumors, which metastasized in some cases. There is suggestive evidence that
injection of testosterone into some strains of female mice increases their
susceptibility to hepatoma. Testosterone is also known to increase the number
of tumors and decrease the degree of differentiation of chemically induced
carcinomas of the liver in rats.
Mutagenesis
Testosterone was negative in the in vitro Ames and in the
in vivo mouse micronucleus assays.
Impairment Of Fertility
The administration of exogenous testosterone has been
reported to suppress spermatogenesis in the rat, dog and non-human primates,
which was reversible on cessation of the treatment.
Use In Specific Populations
Pregnancy
Pregnancy Category X [see CONTRAINDICATIONS]:
Testim® is contraindicated in pregnant women or in women who may become
pregnant. Testosterone is teratogenic and may cause fetal harm. Exposure of a
fetus to androgens, such as testosterone, may result in varying degrees of
virilization. If this drug is used during pregnancy or if the patient becomes
pregnant while taking this drug, the patient should be made aware of the
potential hazard to the fetus.
Nursing Mothers
Although it is not known how much testosterone transfers
into human milk, Testim is contraindicated in nursing women because of the
potential for serious adverse reactions in nursing infants [see
CONTRAINDICATIONS].
Pediatric Use
The safety and effectiveness of Testim in pediatric
patients less than 18 years old have not been established. Improper use may
result in acceleration of bone age and premature closure of epiphyses.
Geriatric Use
There is insufficient long-term safety data in geriatric
patients to assess the potentially increased risks of cardiovascular disease
and prostate cancer [see WARNINGS AND PRECAUTIONS].
Renal Impairment
No studies were conducted in patients with renal
impairment.
Hepatic Impairment
No studies were conducted in patients with hepatic
impairment.