1. Journal Club 埼玉医科大学 総合医療センター 内分泌・糖尿病内科 Department of Endocrinology and Diabetes, Saitama Medical Center, Saitama Medical University 松田 昌文 Matsuda, Masafumi 2013 年 9 月 26 日 8:30-8:55 ８階 医局 Finkelstein JS, Lee H, Burnett-Bowie SA, Pallais JC, Yu EW, Borges LF, Jones BF, Barry CV, Wulczyn KE, Thomas BJ, Leder BZ. Gonadal steroids and body composition, strength, and sexual function in men. N Engl J Med. 2013 Sep 12;369(11):1011-22. Editorial Handelsman DJ. Mechanisms of action of testosterone--unraveling a Gordian knot. N Engl J Med. 2013 Sep 12;369(11):1058-9.

2. テストステロン Ｃ 19 ステロイドのうち，睾丸由来のテストステロンは，胎生期初期に未分化性腺を男性 型に，分化誘導し，思春期男性における二次性徴の発育促進作用を示す．女子では，副 腎と卵巣起源のアンドロステンジオンからの転換生成物として，重要である． 異常値を示す病態・疾患 上昇する疾患 先天性副腎皮質過形成、睾丸腫瘍、卵巣腫瘍、多発性多毛症、多嚢胞性卵巣症候群、 Cushing 症候群、ターナー症候群、甲状腺機能亢進症 減少する疾患 アジソン病、緊張性筋ジストロフィー、下垂体機能低下症、肝硬変、前立腺癌 エストロゲン 卵巣から，主として産生され，卵胞発育に伴い特徴的な分泌パターンを示す．妊娠中は， 胎盤性エストロゲンの一部として大量分泌される．卵巣機能，とくに卵胞発育の状態を 知るためには，不可欠の検査である． 異常値を示す病態・疾患 上昇する疾患 エストロゲン産生腫瘍、卵巣過剰刺激症候群、多胎妊娠、先天性副腎皮質過形成、肝 疾患 減少する疾患 - （非妊婦） 不妊症、神経性食欲不振症、ターナー症候群、卵巣機能低下 減少する疾患 - （妊婦） 切迫流産、重症妊娠中毒、子宮内胎児死亡、異常妊娠 (From SRL reference)

3. AndroGel is to be applied to the area of the shoulders and upper arms that will be covered by a short-sleeve T-shirt. SIDE EFFECTS: The most common side effects of Androgel are headache, high blood pressure, acne, abnormal lab tests (for example, glucose and cholesterol tests), application site reactions (for example, itching, blisters, and redness), enlarged prostate, and increased serum prostate specific antigen (PSA) levels. Testosterone prescribing is escalating at startling rates, creating a nearly $2 billion (20 億ドル！ ) annual market in which the raw drug costs only 1% of that total (Editorial N Engl J Med. 369(11):1058-9, 2013). 使用量・頻度 塗る部位 AndroGel® の場合：毎日風呂上がりに 1 ～ 2 包分（ 5~10g ）を、上腕や肩、 腹部等に塗布。調剤ジェルの場合は濃度を数倍高く作って貰えるので（ 5 ～ 10% ＋）、大体 1 日 1 ～ 2 回、 1g ほどで済む。腕や肩、腹に塗る場合、吸収率は 10% ほど。 一ヶ月当たりの費用 使用量によるが、ブランドものは $200 以上。調剤だと薬局や使用量によって 差があるが大体 $20 ～ $60 前後。 (175g gel pump of Androgel 1.62% (brand) が 370 ドル、 275g gel pump of Androgel 1% が 380 ドルくらい ) IMS Health によると Testosteron 市場規模は、 $49 million(1997) から $216 million(2002) と大きく 増加 (CBS News | Testosterone In A Tube | May 20, 2003) 。といっても規模はまだ小さく、 Androgel [Solvay] $196 million(+51;2002 年 ) と大半を占める。 しかし新規参入の Auxilium 社は 2008 年に 20 億ドルを見込む。 因みに米国以外は市場と言えるものはない。 http://www.medmk.com/mm/add/mp_androgen.htm

4. N Engl J Med 2013;369:1011-22.DOI: 10.1056/NEJMoa1206168 the Endocrine Unit, Department of Medicine (J.S.F., S.-A.M.B.-B., J.C.P., E.W.Y., L.F.B., B.F.J., C.V.B., K.E.W., B.Z.L.), Biostatistics Center (H.L.), and Department of Radiology (B.J.T.), Massachusetts General Hospital, Boston.

5. Background Current approaches to diagnosing testosterone deficiency do not consider the physiological consequences of various testosterone levels or whether deficiencies of testosterone, estradiol, or both account for clinical manifestations.

6. Methods We provided 198 healthy men (Cohort 1) 20 to 50 years of age with goserelin acetate (to suppress endogenous testosterone and estradiol) and randomly assigned them to receive a placebo gel or 1.25 g, 2.5 g, 5 g, or 10 g of testosterone gel daily for 16 weeks. Another 202 healthy men (Cohort 2) received goserelin acetate, placebo gel or testosterone gel, and anastrozole (to suppress the conversion of testosterone to estradiol). Changes in the percentage of body fat and in lean mass were the primary outcomes. Subcutaneous- and intraabdominal-fat areas, thigh-muscle area and strength, and sexual function were also assessed.

7. Inclusion criteria: 1.Age 20 to 50 years: Exclusion criteria: 1. History of significant cardiac, renal, pulmonary, hepatic, benign prostatic hyperplasia, or malignant disease, current alcohol or illicit drug abuse, or major psychiatric disorders. 2. Current diagnoses of disorders known to affect bone metabolism including hyperthyroidism, hyperparathyroidism, osteomalacia, or Paget's disease. 3. Current use of medications known to affect bone metabolism including estrogens, androgens, anti-estrogens, bisphosphonates, denosumab, calcitonin, fluoride, oral or inhaled glucocorticoids, suppressive doses of thyroxine, lithium, pharmacological doses of vitamin D (greater than 2000 IU/day), or anti-convulsants. 4. Cognitive or intellectual impairment that precludes complete understanding of the study protocol. 5. History of deep vein thrombosis, pulmonary embolism, or clotting disorders. 6. Serum 25-OH vitamin D < 15 ng/mL 7. Serum PTH 65 pg/mL 8. Serum TSH 5.0 U/L 9. Serum calcium > 10.6 mg/dL 10. Serum creatinine > 2 mg/dL 11. Serum AST or ALT > 2x the upper limit of normal 12. Serum bilirubin > 2 mg/dL 13. Serum alkaline phosphatase > 150 U/L 14. Plasma hemoglobin < 11 gm/dL. 15. Fracture within the last 6 months. 16. Serum testosterone level 1070 ng/dL 17. Serum PSA level > 4 ug/L. 18. History of violent behavior.

8. Figure 1. Recruitment of Participants and Study Completion. Participants were recruited by sending letters to men in the local area who were identified with the use of commercially available mailing lists or by advertising in newspapers or on the Internet. A computerized program was used to randomly assign participants in permuted blocks. The block sizes were also randomly determined. Participants in cohort 1 (Panel A) were assigned to receive goserelin acetate plus placebo (group 1), 1.25 g of testosterone (group 2), 2.5 g of testosterone (group 3), 5 g of testosterone (group 4), or 10 g of testosterone (group 5) daily for 16 weeks. Participants in cohort 2 (Panel B) received the same study medications plus anastrozole at a dose of 1 mg per day. Participants who discontinued participation at week 8 or 12 were permitted to undergo repeat body-composition and strength testing that was planned for week 16. In cohort 1, eight men in group 1, five men in group 2, two men in group 3, and one man in group 4 underwent repeat body- composition and strength testing at week 8 or 12. In cohort 2, five men in group 1, two men in group 2, four men in group 3, one man in group 4, and one man in group 5 underwent repeat body- composition and strength testing at week 8 or 12.

9. 1. Blood studies a. CBC g. Routine chemistry panel (including calcium, liver function tests, and creatinine) h. Testosterone i. Estradiol j. Sex hormone-binding globulin (SHBG) k. PSA 2. Body composition by dual-energy x-ray absorptiometry (DXA) b. Fat and lean mass 3. Body composition by computerized tomography (CT) f. Thigh muscle and fat area g. Abdominal subcutaneous fat (at L4 level) h. Intra-abdominal fat (at L4 level) i. Paraspinal muscle area (at L4 level) j. Paraspinal fat area (at L4 level) 4. Quality-of life, fatigue, vasomotor symptoms, urinary symptoms, and erectile function 7. 1 RM leg press strength 8. Anthropometric measures (weight, height, BMI, waist and hip circumference)

10. 1. Blood studies a Osteocalcin (OC) b Amino-terminal propeptide of type 1 procollagen (P1NP) c C-telopeptide (CTX) d. Leptin e. Insulin/glucose (HOMA) f PTH g Lipid panel 5. Urine studies a NTX b Creatinine 3. Bone density and body composition by dual-energy x-ray absorptiometry (DXA) a. Whole lumbar vertebrae (DXA in the PA projection) b. Lumbar vertebral bodies (DXA in the lateral projection) c Proximal femur d Total body BMD 4. Bone microarchitecture by Xtreme CT of the distal radius and distal tibia (added per amendment 42, Cohort 2 only)

11. 5.3 Technical Methods 5.3.1 DXA total body scans. Subjects are positioned supine with their arms at their sides and at least 1-inch of space between the hands and thighs. Feet are loosely bound with at least 1 inch of separation. If the subject is too large to fit in the scan area, the left arm is extended and values for the right arm are substituted at a later time. All metal and plastic is removed if possible. Sub-regions of interest are defined according to standard procedures in Hologic's DXA manual. If correct definition of skeletal sub-regions prevents the correct definition of soft tissue sub-regions, priority is given to the former. A Hologic 4500 tissue bar is scanned separately once each week. Our short-term in vivo reproducibility for total body BMD measurements is 1.1%. 5.3.2 DXA body composition. Percentage fat body mass and percentage lean body mass are determined from the DXA total body scan using software version 11.2 as described previously (9).

12. 5.3.4 Body composition by computerized tomography. Body composition will be assessed by computerized tomography (CT) at the level of L4 and at the mid-femur with a GE Model 9800 scanner (General Electric Medical Systems; Milwaukee, WI) (29). Cross-sectional muscle area is a critical determinant of strength and overall functional status. Cross-sectional area of the thigh, thigh muscle area, and thigh fat area are determined as described previously (30). The midpoint of the femur is obtained using measurements from a scout image with extremities in a standard position. The leg is scanned with the knee fully extended and the foot perpendicular to the table. Cross-sectional area of the thigh is determined from an outline of the thigh using image analysis software. Additional contours are identified for the anterior and posterior muscle groups. Cross-sectional areas for the anterior and posterior muscle groups are recorded and summed for the thigh muscle area. The standard error for thigh muscle area determination is ±1% by this method (30). Cross-sectional areas of the abdomen, abdominal subcutaneous fat, intra-abdominal fat, and paraspinal muscles are determined at the level of the L4 vertebra as described previously (9, 10, 31). Briefly, total abdominal area is determined from an outline of the torso using image analysis software (General Electric Advantage Windows Workstation, Version 2.0). Two contours are identified: the body perimeter and deep fascia that delineates the back and abdominal wall musculature. The abdominal subcutaneous fat area is defined as the area between the two contours. Intra-abdominal fat is defined as the area within the inner contour comprising all pixels with attenuation coefficients between -50 and -250 Hounsfield units. Additional contours are identified for the psoas and erector spinae muscles. The total paraspinal area is defined as the sum of the cross-sectional areas for the psoas and erector spinae muscles. The paraspinal fat area is defined as the total paraspinal area comprising all pixels with attenuation coefficients between -50 and -250 Hounsfield units. The paraspinal muscle area is defined as the total paraspinal area minus the paraspinal fat area.

13. 5.3.5 Muscle strength After a 5 minute warm up on a stationary bike, effort-dependent lower extremity strength will be assessed on the basis of maximum weight lifted for one repetition (1-RM) using a leg press (Air 300 Leg Press; Keiser Corporation) (36). To minimize the confounding influence of the learning effect, testing is repeated after a two day rest and greater of the two values is recorded as the 1-RM strength. If the two values differ by more than 5%, testing is repeated a third time and the greatest of the three values is recorded as the 1- RM strength. 5.3.6 Quality of life, fatigue, vasomotor symptoms, sexual function, and hypogonadism symptoms: 5.3.6.1 Quality of life. Quality of life will be assessed using a 30-item questionnaire that includes questions about activities of daily life, fatigue, pain, sexual functioning, interference with social life, and psychological distress (37-39). The questionnaire evaluates eight domains: pain, social functioning, emotional well being, vitality, activity limitation, bed disability, overall health, physical capacity, sexual interest, and sexual functioning. This 30-item questionnaire has been validated in previous studies in which men were rendered hypogonadal using androgen receptor blockade (37-39). 5.3.6.2 Fatigue. Fatigue will be evaluated using the Fatigue Severity Scale, a nine-item questionnaire. Scores range between 9 (indicating minimum fatigue) to 63 (indicating maximum fatigue). The Fatigue Severity Scale has been used successfully to evaluate fatigue in men receiving androgen deprivation therapy (40).

14. 5.3.6.3 Sexual function. Sexual function will be assessed at each visit using the following instruments: a. The International Index of Erectile Function (IIEF) (41). This is a well-validated, 15 item, self-administered scale that assesses 5 domains of male sexual function (erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction). Subjects will be asked to keep daily logs of sexual activity for 7 consecutive days before each visit. b. Items from the Health-Related Quality of Life questionnaire designed to assess sexual desire and erectile function). c. An interviewer-administered question asking subjects to rate their sex drive in comparison to just before the study began (-2 = much less; -1 = somewhat less; 0 = the same; +1 = somewhat more; +2 = much more) Note: :Prior to conducting the data analysis, the authors designated method “b” to be used as the primary measure of erectile function and method “c” as the primary measure of sexual desire. The IIEF was not selected because it was designed specifically for men with stable sexual partners for evaluation of phosphodiesterase inhibitors. Method “c” was preferred to assess sexual desire because it was interviewer administered (thus no missing data) and it reflects changes in sexual desire due to the study procedures rather than the subjects’ baseline level of sexual desire, which could be high or low independent of group assignment..Results from all methods were very similar (data available on request).

15. 5.3.6.4 Hypogonadism symptoms. In addition making detailed assessments of individual symptoms of hypogonadism, we will administer the Androgen Deficiency in Aging Males (ADAM) questionnaire. ADAM is a 10 item scale that evaluates libido, potency, strength, mood, enjoyment of life, sleepiness work performance, and ability to play sports. In a group of 316 men aged 40- 62, it had an 88% sensitivity and 60% specificity for detecting low bioavailable T levels. The reproducibility of the scale was 11.5% when administered twice at an interval of 2-4 weeks. Eighteen of 21 hypogonadal men treated with T had improvement in the ADAM scores (42).

16. * Plus–minus values are means ±SD. There were no significant differences between cohort 1 and cohort 2 for groups assigned to the same testosterone dose unless otherwise indicated. To convert the values for testosterone to nanomoles per liter, multiply by 0.03467. To convert the values for estradiol to picomoles per liter, multiply by 3.671. To convert the values for leg press to kilograms, multiply by 0.45. † P<0.01 with the use of a nonpaired t-test for the comparison with cohort 2. ‡ P<0.05 with the use of a nonpaired t-test for the comparison with cohort 2. § The body-mass index is the weight in kilograms divided by the square of the height in meters. ¶ P<0.05 with the use of one-way analysis of variance for comparisons across dose groups in cohort 1.

17. Physical Functioning, Vitality, and Overall Health. Self-reported physical functioning, vitality, and overall health were assessed using a validated modification of the Short-Form General Health Survey. All 3 measures declined significantly (P<0.05) (or exhibited a borderline (P<0.1) decline) compared with baseline values in men treated with placebo or 1.25 grams of testosterone daily in both cohorts, demonstrating an effect of testosterone on these measures (Table 2). The cohort testosterone dose interaction terms for self-reported physical functioning (P=0.258), vitality (P=0.370), and overall health status (P=0.075) were not significantly different nor were the mean changes in these measures between groups receiving testosterone with or without aromatase blockade, suggesting that estradiol did not affect these measures.

18. Figure 2. Mean Serum Testosterone and Estradiol Levels from Weeks 4 to 16, According to Testosterone Dose and Cohort. T bars indicate standard errors. Teststerone M 131 ～ 871 F 11 ～ 47(ng/dL) Estradiol http://www.srl.info/srlinfo/kensa_ref_CD/

21. Figure S1. Serum Testosterone Levels versus Percent Change in Body Fat (upper panel) and Lean Mass (lower panel) Measured by DXA in Men Receiving Goserelin Acetate Plus 0 (placebo), 1.25, 2.5, 5, or 10 g of Testosterone Gel Daily Without Anastrozole (“COHORT 1” blue dots) or the Same Treatments Plus Anastrozole (“COHORT 2” red dots). For each subject the serum testosterone level represents the mean of values collected at weeks 4, 8, 12, and 16, unless the subject withdrew from the study before completion. The regression lines representing the best fit for “COHORT 1” and “COHORT 2” and the R values for each regression are shown. There was a moderate to strong association between serum testosterone levels and the change in percent fat in “COHORT 1” (R=0.55) but virtually no significant relationship in “COHORT 2” (R=0.05). Because serum estradiol levels vary according to serum testosterone levels in “COHORT 1” but are very low in all subjects in “COHORT 2”, these results provide strong evidence that fat accumulation in hypogonadal men is primarily, and possibly exclusively, due to estrogen deficiency. In contrast, for lean mass there was a moderate association between serum testosterone levels and the change in percent fat in both “COHORT 1” (R=0.41) and in “COHORT 2” (R=0.41) and the regression curves were super-imposable. These results demonstrate that the relationship between the serum testosterone levels and the change in lean mass is not affected by the difference in estradiol levels in “COHORT 1” and “COHORT 2” and strongly support the conclusion that changes in lean mass in hypogonadal men are exclusively due to androgen deficiency.

22. Figure 4. Mean Absolute Change from Baseline in Sexual Desire and Erectile Function, According to Testosterone Dose and Cohort. Sexual desire (Panel A) was assessed at each visit by asking participants to rate their sex drive as compared with their sex drive before the study began (−2 indicates much less, −1 somewhat less, 0 the same, 1 somewhat more, and 2 much more). Erectile function (Panel B) was evaluated by asking each man to consider the prior month and rate the degree to which each of the following three statements most closely applied to himself: “I had difficulty becoming sexually aroused,” “I had difficulty getting or maintaining an erection,” and “I had difficulty reaching orgasm,” with 1 indicating not at all, 2 a little, 3 some, 4 quite a bit, and 5 a great deal. For each man, the mean value at the final visit was then subtracted from the mean value at the baseline visit. T bars indicate standard errors. Within each cohort, bars with the same number indicate no significant difference between dose groups. P values are for the cohort–testosterone dose interaction terms in analyses of variance comparing changes in each outcome measure between cohorts 1 and 2.

23. Results The percentage of body fat increased in groups receiving placebo or 1.25 g or 2.5 g of testosterone daily without anastrozole (mean testosterone level, 44±13 ng per deciliter, 191±78 ng per deciliter, and 337±173 ng per deciliter, respectively). Lean mass and thigh- muscle area decreased in men receiving placebo and in those receiving 1.25 g of testosterone daily without anastrozole. Leg-press strength fell only with placebo administration. In general, sexual desire declined as the testosterone dose was reduced.

24. Conclusions The amount of testosterone required to maintain lean mass, fat mass, strength, and sexual function varied widely in men. Androgen deficiency accounted for decreases in lean mass, muscle size, and strength; estrogen deficiency primarily accounted for increases in body fat; and both contributed to the decline in sexual function. Our findings support changes in the approach to evaluation and management of hypogonadism in men. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number, NCT00114114.)

25. Message 血中テストステロン濃度の生理学的影響を無作為化試験 で検討した試験。 アナストロゾール投与群と非投与群に分け、それぞれ、 テストステロン (1.25-10g/day) とエストラジオールを ゴセレリン酢酸塩で抑制した 20-50 歳の健常男性 400 人 を対象に投与した。 アナストロゾール投与以外で、プラセボ群、低用量テス トテトロン群において体脂肪率が上昇し、除脂肪体重と 大腿筋断面積が低下した。テストステロン用量が低いほ ど性欲が低下した。 テストステロンの効果をエストラジオールの有無で検証 しているが、ゴセレリン酢酸塩やアナストロゾールで抑 制し、用量依存的に観察している！ ともかく 米国で年間 20 億ドルも売れているとはびっくりです。