Pioneering Technologies For

Transcription

1 presents Pioneering Technologies For CASE Lifestyle STUDIES Based Medicine MALE with Dr. Paul Savage MD

2 o Founder of Power2Practice Integrative Medicine EMR o Founder and Director of Agenixs (Chicago Medical Practice) o Practiced integrative medicine over 15 years o o o Certified in Integrative Medicine at George Washington University Fellow of the University of South Florida Stem Cell Therapy Fellow of the American Academy of Anti-Aging and Regenerative Medicine Pioneering Technologies For Lifestyle Based Medicine o Fellow of the American College of Emergency Medicine o University of Michigan Medical School o Nationally acknowledged expert in Men and Hormones Dr. Paul Savage MD

3 CASE 1 LOW T CLASSIC 55yo WM presents with the complaint of stress, fatigue, and gaining weight. Goals Improve sex drive Improve fatigue Lose weight

4 SYMPTOMS Fatigue Weight gain Low libido Depression/anxiety off my game

5 PAST MEDICAL HISTORY

6 PAST MEDICAL HISTORY

7 MEDICATIONS None

8 SUPPLEMENTS Anti-Aging DHEA 25mg 2 capsules Detox/Prevention Vitamins Multivitamins Brain Heart Fish oil Gut

9 LABS

10 INITIAL TREATMENT

11 TREATMENT PLAN Nutrition: Healthy Eating Nutritional counseling Exercise: Any! Sleep: Monitor device (FitBit) Mindfulness: 8 Minute Meditation (Davich)

12 MEDICATIONS New Testosterone Cypionate 200mg/mL 0.4ml injected intramuscularly every 7 days Maintained Discontinued

13 SUPPLEMENTS Anti-Aging DHEA 25mg 2 capsules Detox/Prevention EstroDIM Vitamins Alpha Base without Iron Vitamin D3 Heart Whey Protein Powder MCT Oil OmegaGenics 720 Brain Adapten-all Gut UltraProstatagen OrthoBiotics

14 RETURN VISIT 55yo WM presents with the complaint of stress, fatigue, and gaining weight. Goals Improve sex drive Improve fatigue Lose weight CC: Improved energy, focus, libido, erections, muscle gain, fat loss, improved sense of well-being, feel great

15 LABS

16 TAKEAWAYS PERILS AND PEARLS Testosterone Cypionate (or Enanthate) Can be given weekly, bi-weekly or monthly Most men do better on weekly injections Can be done at home or in office (financial) Major concerns are PSA elevations and HCT increases and Breast Tenderness Done in conjunction with healthy eating and exercise!

17 PATIENT PRESENTATIONS

18 CASE 2 - HCG 41yo BM presents with goal of improving work outs, gaining more muscle mass. Goals Keep exercising and working on my mobility to obtain full range of motion in all my joints (for injury prevention) and equally balanced strength and health throughout my whole body. I'd also like to get my body fat to around 10% and keep it there. Maintain healthy testosterone levels to support the goals above. Keep or improve sperm count levels while my wife and I still try for children.

19 SYMPTOMS Joint aches and pains Not lean anymore Fatigue Insomnia

20 PAST MEDICAL HISTORY

21 PAST MEDICAL HISTORY

22 MEDICATIONS None

23 SUPPLEMENTS Anti-Aging True Grit Test Booster Vitamins Alpha JYM Jym Postworkout Animal Flex BSN Noxplod ZMA Heart Detox/Prevention Warrior Greens Brain Gut

24 LABS

25 INITIAL TREATMENT

26 TREATMENT PLAN Nutrition: Body Builder Bulking per patient Exercise: He is a personal trainer Sleep: Monitor Mindfulness: 8 Minute Meditation (Davich)

27 MEDICATIONS New HCG 10,000IU/10mL inject mL SQ qam Maintained Discontinued

28 SUPPLEMENTS Anti-Aging True Grit Test Booster Vitamins Alpha JYM Jym Postworkout Animal Flex BSN Noxplod ZMA Heart Detox/Prevention Tongkat Ali Resveratrol Grape seed Extract Boron Zinc EstroDIM Brain Gut

29 FOLLOW UP VISIT

30 RETURN VISIT 41yo BM presents with goal of improving work outs, gaining more muscle mass. Goals Keep exercising and working on my mobility to obtain full range of motion in all my joints (for injury prevention) and equally balanced strength and health throughout my whole body. I'd also like to get my body fat to around 10% and keep it there. Maintain healthy testosterone levels to support the goals above. Keep or improve sperm count levels while my wife and I still try for children. CC: Joints ache less, leaning out, energy better, still with insomnia (waking up at night)

31 LABS

32 TAKEAWAYS PERILS AND PEARLS HCG More expensive than Testosterone Cypionate Need to be used daily in the morning May cause headache, increased blood pressure, peritoneal dull pain, joint aches or rash Increases sperm count Usual dose is IU daily The older, the higher the SHBG the more HCG will be needed The older the man, the less likely that HCG will work (needs intact Leydig cells)

33 PATIENT PRESENTATIONS

34 CASE 3 LOW SHBG/ELEVATED HCT 52yo WM presents with the complaint of fatigue, erectile dysfunction and gaining weight. Goals Improve fatigue Improve erections Lose weight

35 SYMPTOMS Fatigue Low libido Erectile dysfunction

36 PAST MEDICAL HISTORY

37 PAST MEDICAL HISTORY

38 MEDICATIONS None

39 SUPPLEMENTS Anti-Aging Detox/Prevention Vitamins Multivitamins Brain Heart Gut

40 LABS

41 INITIAL TREATMENT

42 TREATMENT PLAN Nutrition: Healthy Eating Exercise: 10,000 steps per day Sleep: FitBit Mindfulness: Massages

43 MEDICATIONS New Testosterone Cypionate 200mg/mL 0.25ml injected intramuscularly every 7 days Sildenafil 20mg 1-2 tablets as needed Maintained Discontinued

44 SUPPLEMENTS Anti-Aging DHEA 50mg Vitamins Multivitamins Vitamin D3 Heart Omegagenics 750 Whey Protein Detox/Prevention Brain Gut PRObiotic 225

45 FOLLOW UP VISIT

46 RETURN VISIT 52yo WM presents with the complaint of fatigue, erectile dysfunction and gaining weight. Goals Improve fatigue Improve erections Lose weight CC: Much more energy, much better libido and erections, somewhat anxious/insomnia

47 LABS

48 LABS

49 TAKEAWAYS PERILS AND PEARLS Erectile dysfunction Don t be a purist, if the man is having ED, give Viagra/Cialis until therapy working. Secondary polycythemia one of the most commonly seen adverse reactions to testosterone, especially with injections or supraphysiologic topicals. Phlebotomize in the office by withdrawing mL tubes (large tiger tops) Bi-yearly out-patient blood donations recommended

50 PATIENT PRESENTATIONS

51 CASE 4 ELEVATED PSA 54yo BM presents with the complaint of maintaining health and wellness Goals Improve health Treat low testosterone Treat high cholesterol

52 SYMPTOMS Intermittent insomnia Work outs not as productive as before Somewhat lower libido

53 PAST MEDICAL HISTORY

54 PAST MEDICAL HISTORY

55 MEDICATIONS Zetia 10mg daily Baby Aspirin 81mg daily Armour 120mg daily

56 SUPPLEMENTS Anti-Aging DHEA 50mg Vitamins Multivitamins - Mercola Heart Time Released Niacin Krill Oil Super Omega-3 Super Ubiquinol CoQ10 Detox/Prevention Ultra Natural Prostate Brain Optimized Tryptophan Super Bio-Curcumin Neuro-Mag Gut

57 LABS 18 Estradiol

58 INITIAL TREATMENT

59 TREATMENT PLAN Nutrition: Healthy Eating Nutritional counseling Exercise: Continue Cross-Fit Sleep: Sleep study Mindfulness: 1 hour a day to self

60 MEDICATIONS New Initially tried Nugenix (per patient request see set 2) without success then HCG 10,000IU/10mL inject mL SQ qam varying dose Maintained Discontinued

61 SUPPLEMENTS Anti-Aging DHEA 50mg Nugenix (initially see set 2) Vitamins Multivitamins - Mercola Heart Time Released Niacin Krill Oil Super Omega-3 Super Ubiquinol CoQ10 Detox/Prevention Ultra Natural Prostate Brain Optimized Tryptophan Super Bio-Curcumin Neuro-Mag Gut

62 FOLLOW UP VISIT

63 RETURN VISIT 54yo BM presents with the complaint of maintaining health and wellness Goals Improve health Treat low testosterone Treat high cholesterol CC: Sleep study CPAP improved sleep, libido and workouts improved ( can I use more HCG? )

64 LABS 18 Estradiol

65 Prostate-specific antigen velocity (PSAV) risk count improves the specificity of screening for clinically significant prostate cancer. Sustained rises in PSA indicate a significantly greater risk of prostate cancer, particularly high-grade disease. Compared with men with a risk count of 1, those with two PSAV measurements of >0.4 ng/ml/year (risk count 2) had an 8-fold increased risk of prostate cancer Compared to PSA alone, PSAV risk count may be useful in reducing unnecessary biopsies and the diagnosis of low-risk prostate cancer.

66 TAKEAWAYS PERILS AND PEARLS HCG eventually fails as testicles decline the older the man, the more HCG will be required until eventually it will no longer work PSA velocity monitoring PSAV >0.4 ng/dl/year is often seen in patients with prostate cancer PSAV = (PSA now PSA then)/(# months/12) Sudden jumps in PSA is NOT likely prostate cancer but prostatitis (inflammation vs infectious) When in doubt, MRI

67 PATIENT PRESENTATIONS

68 CASE 5 HEART ATTACK 53yo WM presents with the complaint of "I am tired of being tired. Feel like crap physically and mentally most of the time. Low to NO enthusiasm for mostly anything Goals Endurance/Strength - I want to be normal again I want to feel good again and look healthy Increase libido and ability for normal sex

69 SYMPTOMS Fatigue Low libido Erectile dysfunction Depression/anxiety Lack of focus

70 PAST MEDICAL HISTORY

71 PAST MEDICAL HISTORY

72 MEDICATIONS Has not taken any of his prescribed medications including statins

73 SUPPLEMENTS Anti-Aging Detox/Prevention Vitamins Brain Heart Gut

74 LABS

75 LABS

76 LABS

77 INITIAL TREATMENT

78 TREATMENT PLAN Nutrition: Heart Healthy Diet/Weight Loss Cardiac Nutritionist Exercise: Walking only Sleep: Monitor device (FitBit) Mindfulness: Yoga

79 MEDICATIONS New Testosterone Cypionate 200mg/mL 0.4ml injected intramuscularly every 7 days Maintained Lipitor 20mg by mouth daily (restarted) Discontinued

80 SUPPLEMENTS Anti-Aging DHEA 25mg 2 capsules Vitamins Alpha Base without Iron Vitamin D3 Heart Whey Protein Powder ad MCT Oil qd OmegaGenics 720 bid Berberine 400mg bid CoQ10 300mg qd Detox/Prevention EstroDIM Brain Adapten-all Gut UltraProstatagen OrthoBiotics

81 FOLLOW UP VISIT

82 RETURN VISIT 55yo WM presents with the complaint of stress, fatigue, and gaining weight. Had severe gastritis one month after initial consult with sudden death in ER. Revived. Stents x2 CC: Improved energy, focus, libido, erections, muscle gain, fat loss, improved sense of well-being, feel great

83 LABS

84 LABS

85 LABS

86 TAKEAWAYS PERILS AND PEARLS After examining the best available scientific evidence, Morgentaler and colleagues who included experts with specialties in urology, endocrinology, diabetes, internal medicine, and basic science research agreed on the following: 1. TD is a well-established, clinically significant medical condition that negatively affects male sexuality, reproduction, general health and quality of life. 2. Symptoms and signs of TD occur as a result of low levels of testosterone and may benefit from treatment regardless of whether there is an identified underlying origin. 3. TD is a global public health concern. 4. Testosterone therapy for men with TD is effective, rational, and evidence-based. 5. There is no testosterone concentration threshold that reliably distinguishes those who will respond to treatment from those who will not. 6. There is no scientific basis for any age-specific recommendations against the use of testosterone therapy in adult males. 7. The evidence does not support increased risks of cardiovascular events with testosterone therapy. 8. The evidence does not support increased risk of prostate cancer with testosterone therapy. 9. The evidence supports a major research initiative to explore possible benefits of testosterone therapy for cardiometabolic disease, including diabetes. Mayo Clinic Proceedings June 2016

87 PATIENT PRESENTATIONS

88 CASE 6 OTC STEROIDS 25yo WM presents with the complaint that since discontinuing use of Superdrol over the counter (which worked REALLY well in building muscle) has experienced severe depression, erectile dysfunction, low libido and loss of a lot of muscle. Goals A normal life

89 SUPERDROL

90 SYMPTOMS Depression Low libido No erections Significant loss of muscle Fatigue, unable to stay awake at work

91 PAST MEDICAL HISTORY

92 PAST MEDICAL HISTORY

93 MEDICATIONS None

94 SUPPLEMENTS Anti-Aging Detox/Prevention Vitamins Brain Heart Gut

95 LABS

96 INITIAL TREATMENT

97 TREATMENT PLAN Nutrition: Healthy Eating Exercise: Weight Resistance (per your routine) Sleep: Monitor device (FitBit) Mindfulness: Meditation

98 MEDICATIONS New HCG 10,000/10mL inject mL SQ qam Maintained Discontinued

99 SUPPLEMENTS Anti-Aging DHEA 25mg 2 capsules Detox/Prevention EstroDIM Vitamins Alpha Base without Iron Vitamin D3 Heart Whey Protein Powder ad MCT Oil qd OmegaGenics 720 bid Nox2plode Brain Serenagen 2 capsules tid Gut OrthoBiotics

100 FOLLOW UP VISIT

101 RETURN VISIT 25yo WM presents with the complaint that since discontinuing use of Superdrol over the counter (which worked REALLY well in building muscle) has experienced severe depression, erectile dysfunction, low libido and loss of a lot of muscle. Goals A normal life CC: No change

102 LABS

103 TAKEAWAYS PERILS AND PEARLS CAUTION on OVER THE COUNTER Testosterone Boosters Over the counter steroids are often designer steroids Typically, no problem, however there are occasions where it appears to turn of the HPT permanently HERBALS Zinc, Magnesium, Boron, D3, B6, K2, BioPerine, asian ginseng, mucuna, nettle root, tribulus, tomkat ali, oyster extract, fenugreek, suma root, ashwagandha PROTEINS D-Aspartic acid, BCAA, amino acids PROHORMONES 1-AD, 1-Testosterone, Anavar, Androdiol, Bulasterone, Superdrol

104 PATIENT PRESENTATIONS

105 CASE 7 DOSED LATE 53yo BM presents with the complaint of "Overall health assessment. Develop healthier lifestyle program." Goals Weight Loss Increased Energy Cardiovascular Health

106 SYMPTOMS Fatigue Weight gain Low libido Depression/anxiety

107 PAST MEDICAL HISTORY

108 PAST MEDICAL HISTORY

109 MEDICATIONS None

110 SUPPLEMENTS Anti-Aging Detox/Prevention Vitamins Brain Heart Gut

111 LABS

112 INITIAL TREATMENT

113 TREATMENT PLAN Nutrition: Nutritional counseling Heart Healthy Diet Exercise: Walking Sleep: Monitor device (FitBit) Mindfulness: Relaxation breathing

114 MEDICATIONS New Testosterone Cypionate 200mg/mL 0.35ml injected intramuscularly every 7 days Maintained Discontinued

115 SUPPLEMENTS Anti-Aging Vitamins Alpha Base without Iron Vitamin D3 Heart Whey Protein Powder MCT Oil OmegaGenics 720 Detox/Prevention EstroDIM Brain Serenagen 2 tid Gut UltraProstatagen OrthoBiotics

116 FOLLOW UP VISIT

117 RETURN VISIT 53yo BM presents with the complaint of "Overall health assessment. Develop healthier lifestyle program." Goals Weight Loss Increased Energy Cardiovascular Health CC: Weight loss, much improved energy, increased sense of wellbeing, improved libido

118 LABS

119 TAKEAWAYS PERILS AND PEARLS Testosterone Cypionate (or Enanthate) Know when the shot is given (see drop in Testosterone level in this 3 rd example) Lower the SHBG, the lower the dosage Free Testosterone levels come in handy PSA generally increases by 10% with addition of testosterone Growth hormone (IGF-1) generally increases with healthy living, testosterone and health improvements

120 PATIENT PRESENTATIONS

121 CASE 8 OLDER MALE ON T-GEL 66yo WM presents with the complaint of "Blood test to ensure I have the right bio-identical hormones. Goals Take advantage of bio-identical hormones to be able to keep my vigor Lose a bit of weight off my belly and boobs Safeguard against cancer, ALS, dementia that plague people growing old

122 SYMPTOMS Low libido Fatty breasts, nipple tenderness

123 PAST MEDICAL HISTORY

124 PAST MEDICAL HISTORY

125 MEDICATIONS Testosterone Gel 180mg/mL per day

126 SUPPLEMENTS Anti-Aging Vitamins D Vit K2 Total B Complex Heart Natural Vit E Ubiquinol 100mg Carlson s Finest Fish oil Detox/Prevention Resveratrol Brain Melatonin 3mg Gut 50 Billion Probiotic

127 LABS

128 INITIAL TREATMENT

129 TREATMENT PLAN Nutrition: Nutritional counseling Exercise: Walking Sleep: Monitor device (FitBit) Mindfulness: Relaxation, Tai-Chi

130 MEDICATIONS New Testosterone Cypionate 200mg/mL 0.30ml injected intramuscularly every 7 days Maintained Discontinued Testosterone Gel 180mg/mL per day

131 SUPPLEMENTS Anti-Aging Vitamins D Vit K2 Total B Complex Heart Natural Vit E Ubiquinol 100mg Carlson s Finest Fish oil Whey Protein Powder MCT Oil Detox/Prevention Resveratrol Brain Melatonin 3mg Serenagen 2 tid Phosphotidyl Serine 150mg qhs Gut 50 Billion Probiotic

132 FOLLOW UP VISIT

133 RETURN VISIT 66yo WM presents with the complaint of "Blood test to ensure I have the right bio-identical hormones. Goals Take advantage of bio-identical hormones to be able to keep my vigor Lose a bit of weight off my belly and boobs Safeguard against cancer, ALS, dementia that plague people growing old CC: Much better libido, no nipple tenderness, breast size not reducing

134 LABS

135 TAKEAWAYS PERILS AND PEARLS Testosterone Cypionate (or Enanthate) Testosterone Gel not monitored well with serum blood testing High physiologic dosing gives spill over to estrogens Estradiol is not the only estrogen and is often normal even though symptoms of high estrogen (think Estrone) Physiologic dosing of gels is important to treat the patient safely

136 PATIENT PRESENTATIONS

137 CASE 9 COMPLEX 19yo WM present with history of viral infection 2/2015 after which he started to experience hypersensitivity to tip and ventral of penis, fatigue, loss of testicular and penile size, inability to gain muscle even though working out hard daily, depression, anxiety and erectile dysfunction. Has been seen by urology who ruled out prostatitis, interstitial cystitis and urethritis. Normal male development which has noted regression of teste size and penile size in past 14 months.

138 CASE 9 COMPLEX Goals Raise my testosterone levels and regain my normal function and be able to build muscle. This is a priority for me. I do not want to be broken or end up infertile. I want to have a normal sex life and I want to be strong and physically fit. Heal my penile tip pain and pelvic pain so I can enjoy being active and being social. I feel uncomfortable with movement. The pain changes in intensity but never goes away. I have flare ups that make me feel I will never heal from this. Help me to have normal sleep patterns. I want to have overall good health so I can get stronger and go back to being an athlete. I want to feel good again and have a future of good health.

139 SYMPTOMS Penile tip sensitivity Peroneal discomfort Fatigue Depression/anxiety Low libido Erectile dysfunction Unable to gain muscle

140 PAST MEDICAL HISTORY

141 PAST MEDICAL HISTORY

142 MEDICATIONS None

143 SUPPLEMENTS Anti-Aging Detox/Prevention Vitamins Alpha Base multi-vitamin Free & Easy Wanderer Pluss Corydalis Methyl B Complex Vitamin D 50,000IU Heart Fish Oil Brain Gut Prostate Formula Polyporus & Dianthus Ortho-Biotic

144 LABS Heavy Metals: Negative MRI pituitary: Negative Karyotype: 46, XY Sperm: low viability

145 INITIAL TREATMENT

146 TREATMENT PLAN Nutrition: Nutritional counseling Exercise: Walking Sleep: Monitor device (FitBit) Mindfulness: Relaxation, Tai-Chi

147 MEDICATIONS New Testosterone Cypionate 200mg/mL 0.30ml injected intramuscularly every 7 days Maintained Discontinued Testosterone Gel 180mg/mL per day

148 SUPPLEMENTS Anti-Aging Vitamins D Vit K2 Total B Complex Heart Natural Vit E Ubiquinol 100mg Carlson s Finest Fish oil Whey Protein Powder MCT Oil Detox/Prevention Resveratrol Brain Melatonin 3mg Serenagen 2 tid Phosphotidyl Serine 150mg qhs Gut 50 Billion Probiotic

149 FOLLOW UP VISIT

150 RETURN VISIT 19yo WM present with history of viral infection 2/2015 after which he started to experience hypersensitivity to tip and ventral of penis, fatigue, loss of testicular and penile size, inability to gain muscle even though working out hard daily, depression, anxiety and erectile dysfunction. Has been seen by urology who ruled out prostatitis, interstitial cystitis and urethritis. Normal male development which has noted regression of teste size and penile size in past 14 months.

151 RETURN VISIT Goals Raise my testosterone levels and regain my normal function and be able to build muscle. This is a priority for me. I do not want to be broken or end up infertile. I want to have a normal sex life and I want to be strong and physically fit. Heal my penile tip pain and pelvic pain so I can enjoy being active and being social. I feel uncomfortable with movement. The pain changes in intensity but never goes away. I have flare ups that make me feel I will never heal from this. Help me to have normal sleep patterns. I want to have overall good health so I can get stronger and go back to being an athlete. I want to feel good again and have a future of good health. CC: No improvement with therapy, disappointed

152 LABS Heavy Metals: Negative MRI pituitary: Negative Karyotype: 46, XY Sperm: low viability

153 TAKEAWAYS PERILS AND PEARLS Young males with low Testosterone Consider prior steroid use (including OTC steroids) Consider Endocrinologist evaluation Do: Prolactin, Karyotype, Sperm Analysis, Magnetic resonance imaging (MRI) Do not: Be shy about treating with HCG and if necessary Testosterone

154 PATIENT PRESENTATIONS

155 CASE 10 T AND STATINS 66yo WM present with history of fatigue, muscle aches and pains, loss of muscle, erectile dysfunction (cannot keep it up). My testosterone is low Goals Treat low testosterone Treat high cholesterol Improve health and wellness

156 SYMPTOMS Fatigue Muscle aches and pains Loss of muscle Erectile dysfunction Lower Libido Night sweats Depressed/irritable

157 PAST MEDICAL HISTORY

158 PAST MEDICAL HISTORY

159 MEDICATIONS Lipitor 80mg Zetia 10 mg Levothyroxine 137 mcg Valsartan 80 mg Cialis 20 mg Aspirin 325 mg

160 SUPPLEMENTS Anti-Aging Detox/Prevention Vitamins Brain Heart Gut

161 LABS

162 LABS

163 INITIAL TREATMENT

164 TREATMENT PLAN Nutrition: Nutritional counseling Exercise: Walking Sleep: Monitor device (FitBit) Mindfulness: Relaxation, Tai-Chi

165 MEDICATIONS New Lipitor 20mg Viagra 50mg Maintained Zetia 10 mg Levothyroxine 137 mcg Valsartan 80 mg Cialis 20 mg Aspirin 325 mg Discontinued Lipitor 80mg

166 SUPPLEMENTS Anti-Aging Vitamins Alpha Base D Heart Natural Vit E Ubiquinol 100mg Carlson s Finest Fish oil Whey Protein Powder MCT Oil Berberine 800mg Detox/Prevention Prostate Formula Brain Gut Probiotic

167 FOLLOW UP VISIT

168 RETURN VISIT 66yo WM present with history of fatigue, muscle aches and pains, loss of muscle, erectile dysfunction (cannot keep it up). My testosterone is low Goals Treat low testosterone Treat high cholesterol Improve health and wellness CC: More energy, much less aches and pains, still with erectile dysfunction

169 LABS

170 LABS

171 TAKEAWAYS PERILS AND PEARLS Many drugs lower Testosterone. Think Anti-anything Statins, Opioids, Cimetidine, Spironolactone, Beta-blockers, Sulfonylurea, anti-psychotics, anti-fungals, tranquilizers, anti-depressants, chemotherapy, anti-histamines, etc.

172 PATIENT PRESENTATIONS

173 CASE 11 T GEL 73yo WM present with history of fatigue, getting old, losing bone and muscle, erectile dysfunction Goals Treat low testosterone Maintain a strong body Age well

174 SYMPTOMS Fatigue Loss of bone and muscle Erectile dysfunction Lower Libido

175 PAST MEDICAL HISTORY

176 PAST MEDICAL HISTORY

177 MEDICATIONS Levothyroxine 88 mcg Flomax 0.4mg Warfarin 2.5mg Tylenol as needed

178 SUPPLEMENTS Anti-Aging Detox/Prevention Vitamins Heart Savior Vitamin D3 Trader Joe s Multi-Vitamin Heart Trader Joe s Fish Oil Brain Gut ProstaGuard

179 LABS

180 INITIAL TREATMENT

181 TREATMENT PLAN Nutrition: Nutritional counseling Exercise: Weight training and Cardioaerobics and Core fitness and Flexibility Sleep: Home Monitoring Device Mindfulness: Relaxation, Tai-Chi

182 MEDICATIONS New Testosterone Gel 15mg/mL apply 1mL nightly before bed Maintained Levothyroxine 88 mcg Flomax 0.4mg Warfarin 2.5mg Tylenol as needed Discontinued

183 SUPPLEMENTS Anti-Aging TA-65 Elysium Basic Vitamins Heart Savior Vitamin D3 Trader Joe s Multi-Vitamin Heart Trader Joe s Fish Oil Detox/Prevention Brain Prevagen Gut ProstaGuard Probiotic 50b cfu

184 FOLLOW UP VISIT

185 RETURN VISIT 73yo WM present with history of fatigue, getting old, losing bone and muscle, erectile dysfunction Goals Treat low testosterone Maintain a strong body Age well CC: Feels a bit stronger, nipple tenderness, more hair loss

186 LABS

187 SECOND TREATMENT

188 MEDICATIONS New Testosterone 600mg pellet implantation Arimidex 0.5mg compounded once a week Maintained Levothyroxine 88 mcg Flomax 0.4mg Warfarin 2.5mg Tylenol as needed Discontinued Testosterone Gel 15mg/mL apply 1mL nightly before bed

189 SUPPLEMENTS Anti-Aging TA-65 Elysium Basic Vitamins Heart Savior Vitamin D3 Trader Joe s Multi-Vitamin Heart Trader Joe s Fish Oil Detox/Prevention Brain Prevagen Gut ProstaGuard Probiotic 50b cfu

190 FOLLOW UP VISIT

191 RETURN VISIT 73yo WM present with history of fatigue, getting old, losing bone and muscle, erectile dysfunction Goals Treat low testosterone Maintain a strong body Age well CC: Feels much better

192 LABS

193 TAKEAWAYS PERILS AND PEARLS Testosterone gels are easier to apply especially to the older single male Testosterone gels may cause increased conversion to estradiol and DHT Pellet therapy start with 800mg pellets, lower by 200mg if older, fatter, sedentary of low SHBG and increase if younger, leaner, more active or higher SHBG Anastrazole therapy, if needed, typically needs only small amounts (0.5-1mg once to twice a week)

194 PATIENT PRESENTATIONS

195 CASE 12 T PELLETS 53yo WM present with history of stress (work and home), off-game, lack of work passion. Desires "Overall health assessment. Develop healthier lifestyle program." Goals Weight loss Increased energy Cardiovascular health

196 SYMPTOMS Stress Weight gain Lack of passion Erectile dysfunction Fatigue in early evening (after work crashes) Irritable

197 PAST MEDICAL HISTORY

198 PAST MEDICAL HISTORY

199 MEDICATIONS None

200 SUPPLEMENTS Anti-Aging Detox/Prevention Vitamins Brain Heart Gut

201 LABS

202 LABS

203 LABS

204 INITIAL TREATMENT

205 TREATMENT PLAN Nutrition: Nutritional counseling Ketogenic diet Exercise: Cardioaerobic and Weights Sleep: Monitor device (FitBit) Mindfulness: Relaxation, Tai-Chi

206 MEDICATIONS New Lipitor 20mg Testosterone 800mg pellets Maintained Discontinued

207 SUPPLEMENTS Anti-Aging Vitamins Alpha Base w/o iron Heart Natural Vit E CoQ10 200mg Carlson s Finest Fish oil Whey Protein Powder MCT Oil Berberine 800mg Detox/Prevention Prostate Formula Brain Gut Probiotic Amazing Grass

208 FOLLOW UP VISIT

209 RETURN VISIT 53yo WM present with history of stress (work and home), off-game, lack of work passion. Desires "Overall health assessment. Develop healthier lifestyle program." Goals Weight loss Increased energy Cardiovascular health CC: Feels great!

210 LABS

211 LABS

212 TAKEAWAYS PERILS AND PEARLS Hormone replacement therapy with testosterone implants is superior to oral and topical (both the patch and gel) hormone replacement therapy for bone density (Savvas 88, 92, Davis 95, Anderson 97). Testosterone pellets were generally well tolerated. (McCullough, AR. A Multi-institutional observational study of testosterone pellets) Hormone replacement therapy with pellet implantation has an extremely low incidence of side effects (Cardoza 84, Barlow 86, Ganger 89, Pirwany 02) and high compliance rate (Gambrell 06). For delivering a consistent dose over the long term, pellets are the best option. Pellets deliver consistent, physiologic levels of hormones and avoid the fluctuations of hormone levels seen with other methods of delivery (Greenblatt 49, Thom 81, Cantrill 84 Stanczyk 88). Testosterone pellet implants release testosterone at a steady rate of 1.3 mg/200 mg implant/day. (Kelleher, S. Testosterone release rate and duration of action of testosterone pellet implant).

213 TAKEAWAYS PERILS AND PEARLS Hormones delivered by the subcutaneous implants bypass the liver, do not affect clotting factors and do not increase the risk of thrombosis (Notelovitz 87, Seed 00). Testosterone delivered subcutaneously by pellet implant is cardiac protective (Sands 97, Worboys 00). Testosterone delivered by pellet implantation, does not adversely affect blood pressure, lipid levels, glucose or liver functions (Burger 84, Farish 84, Fletcher 86, Barlow 86, Notelovitz 84, Stanczyk 88, Davis 95, 00, Sands 97, Seed 00,Cravioto 01). The pellets not only prevent bone loss but also actually increase bone density (Savvas 88, Studd 90, Garnett 91, Savvas 92, Naessen 93, Holland 94, Studd 94, Davis 95, Anderson 97, Seed 00, Panay 00). Testosterone replacement with long-acting Testopel pellets had a lower rate of infection (0.3%) as compared with historical data from the Organon testosterone pellet ( %). The rate of pellet extrusion was substantially lower (0.3%) as compared with historical data (8.5 12%). Patient satisfaction was high and serum hormone values were improved. (Cavender 2009)

214 TAKEAWAYS PERILS AND PEARLS Testosterone pellets Start with T200mg x4 Increase by 200mg if younger, leaner, more stressed, more active, higher SHBG Decrease by 200mg if older, fatter, less active, more illnesses, lower SHBG Repeat labs 1 month after first implant Usual testosterone 5-10mg/day burn rate

215 TAKEAWAYS PERILS AND PEARLS Adverse Reactions Pellet extrusion % Pain at insertion site: 5-8% Infection at the site of insertion % Nipple Tenderness 3-5% Bleeding at insertion site %

216 Paul Savage MD, FACEP FFARM THANK YOU! If you would like a copy of this presentation, please contact: