Testosterone Therapy After Ischemic Stroke: Safety Considerations

Key Safety Concerns

The American College of Physicians' 2020 clinical practice guideline provides low-certainty evidence from 14 trials showing a small increase to no difference in adverse cardiovascular events (Peto odds ratio, 1.22 [CI, 0.66 to 2.23]) in patients with low testosterone, with most studies excluding men with recent cardiovascular disease, limiting the generalizability of safety data to patients with prior stroke 1, 2
Most studies excluded men with recent cardiovascular disease, limiting the generalizability of safety data to patients with prior stroke, according to the American College of Physicians' 2020 clinical practice guideline 1, 2, 3
Evidence for long-term safety is lacking, with most trials lasting less than 1 year, as noted in the American College of Physicians' 2020 clinical practice guideline 3
The presence of other cardiovascular risk factors, such as hypertension, diabetes, hyperlipidemia, and atrial fibrillation, significantly increases recurrent stroke risk, as reported in the journal Stroke 5

If testosterone therapy is being considered despite stroke history, patients must be counseled to immediately report cardiovascular symptoms including chest pain, shortness of breath, dizziness, or neurological symptoms, and hemoglobin/hematocrit monitoring is critical, as increases occur rapidly within 3 months; hematocrit >54% warrants dose reduction or temporary discontinuation, according to Praxis Medical Insights 6
First follow-up at 1-2 months to assess both efficacy and safety parameters is recommended if testosterone therapy is initiated, as suggested by Praxis Medical Insights 6

Lifestyle modifications including weight loss and increased physical activity, which can independently improve testosterone levels and symptoms, should be prioritized before considering testosterone therapy in a stroke survivor, according to Praxis Medical Insights 6

The theoretical benefits of testosterone therapy (small improvements in sexual function and quality of life) must be weighed against the potential for catastrophic outcomes (recurrent stroke, MI, death) in this high-risk population, as noted in the American College of Physicians' 2020 clinical practice guideline and Praxis Medical Insights 1, 2, 6