Testosterone Use in Patients with Liver Failure

Introduction to Testosterone Therapy

The American Association for the Study of Liver Diseases (AASLD) recommends that testosterone therapy may be considered in select men with cirrhosis and documented low testosterone levels, but the risk/benefit profile must be carefully weighed against the increased risks of hepatocellular carcinoma (HCC) and thrombophilia 1, 2, 3

The AASLD guidelines state that testosterone therapy carries increased risk for HCC and thrombophilia in cirrhotic patients, with relative contraindications including personal or family history of HCC, history of prostate cancer, and history of thrombophilia or prior thrombotic events 1, 2, 4
The European Association for the Study of the Liver (EASL) guidelines note that restoring testosterone levels in cirrhotic patients is concerning due to the increased risk of hepatocellular carcinoma 5, 6

Testosterone replacement may be indicated in men with cirrhosis who do not have contraindications, when documented hypogonadism is present with total testosterone <12 nmol/L or free testosterone <230 pmol/L 1, 2
The presence of sarcopenia or frailty that could benefit from anabolic intervention is also a consideration for testosterone replacement 1, 3
Baseline testosterone levels should be checked before initiating therapy 3

The AASLD guidelines note that testosterone therapy can increase muscle mass, decrease fat mass, and improve glucose metabolism in cirrhotic patients 1, 2, 4
Testosterone supplementation has anabolic effects on muscle, relating to suppression of muscle cell apoptosis and myostatin production 1, 2

Mandatory monitoring for patients on testosterone includes hematocrit levels for polycythemia, liver function tests due to potential hepatotoxicity, signs of thromboembolism, serum testosterone concentrations, and lipid profile 7
Transdermal testosterone is preferred over oral formulations to avoid hepatotoxic effects 7

In males with hemochromatosis and hypogonadism, testosterone supplementation combined with venesection is considered effective and appropriate 8, 6

Testosterone deficiency with functional sarcopenia is common in the post-transplant setting, and short-term testosterone replacement therapy combined with active exercise may improve patient and graft survival 8, 6