T Nation

TRT: Most Probable Weekly Dose Range for Treating Male Hypogonadism

Unburied this from another thread in case guys were curious about TRT dosing in the world of hypogonadism.

Google xyosted, a vastly overpriced** testosterone enanthate (TE) sub-Q delivery system designed for mass in-network medical provider use to treat hypogonadism. Then look at the three dosages (50, 75 and 100 mg of TE) available for once weekly auto injection. Then think to yourself, why would Antares spend millions of dollars to develop an fda approved product that would undermedicate the vast majority of men being treated for hypogonadism? Here’s a hint, they did not.

image

Now look at the PK data I already shared for this product in the other thread. This dosage range (50-100 mg per week equivalent) will bring the vast majority of men within physiologic range. Xyosted gives providers three dosages to choose from. Why? Then look at ALL the major medical society dosage guidelines for IM weekly injections which call for 75-100 mg per week equivalent of test ester.

Then try to compare these data to the claims I’ve wasted time trying to debate on another thread where it was claimed that (1) the vast majority of men find relief (symptoms alleviated) at free T levels of at least 25-30 ng/dL and that (2) weekly dosages of at least 150 mg/ week are routinely needed to accomplish this. Think about the where Total T levels will be if these parameters are satisfied (requires one to look at reference range for SHBG and conceptualize a distribution using statistics and math).

Then wonder about the survivorship bias involved in that claim given the limited subset of hypogonadal patients that internet coaches/“TOT” doctors work with for some type of “TOT” strategy.

From the article:

How can people avoid falling prey to these kinds of biases?

Look at your life and where you get feedback and ask, “Is that feedback selected, or am I getting unvarnished feedback?”

Whatever the claim—it could be “I’m good at blank” or “Wow, we have a high hit rate” or any sort of assessment—then you think about where the data comes from. Maybe it’s your past successes. And this is the key: Think about what the process that generated the data is. What are all the other things that could have happened that might have led me to not measure it? In other words, if I say, “I’m great at interviewing,” you say, “Okay. Well, what data are you basing that on?” “Well, my hires are great.” You can counter with, “Have you considered the people who you have not hired?”

It’s a very simple thing, where you just need to ask the question: What’s the data that’s not present?

The 75 mg per week patients are the “outliers”? Nope.

Again no judgment for TOT guys, but to suggest (give the impression) to guys on here that taking 75-100 mg per week of test ester to address hypogonadism symptoms is a statistical rarity is completely asinine. This practice will also give impressionable folks the idea that their protocol is underdosed; further reinforced with unhelpful comments they may get on forums that their dosage isn’t manly enough (“grow a pair” as I have heard on here a few times). Then these unfortunate gentlemen increase the dose and here comes the ED/Hct/E2 issues, blah blah.

Just some big picture thinking here.

In summary Dear reader: Take whatever works for you, but sweet Jesus, don’t believe this bastardization of all that is scientifically holy that 75-100 mg/week guys are outliers in the universe of hypogonadism treatment. Yes, I am confident they are a statistical rarity in the world of @dbossa and TOT. The TOT population is just a subset of the hypogonadism universe. This I pray sweet Lord. Amen.

Survivorship bias and extrapolating one’s experience to the whole population is not ideal when encountering new men who are candidates for hypogonadism treatment. No, your PCP is not trying to chemically castrate you. In reality, the truth is out there and somewhere in between the extremes of (1) very conservative Endos and (2) T mill clinics for most men. The more T you take, the more risk you take on once you pass the upper limit of human physiology. It’s an optimization.

Good luck and best wishes.

** For the record don’t use this product. Just get yourself a cheap bottle of Test ester and some 27-30 g insulin pins and save yourself big money.

Thanks for this. Can you explain that part of the study where the 50mg per week didn’t accumulate over time but 100mg did?

I’m referring to this chart:

Extend the x axis and the 100mg per week levels out too. You just haven’t gone far enough by about 3 weeks

Sure, once you take exogenous (external) testosterone, it shuts down your HPGA hypothalamus-pituitary-gonadal axis) and your brain (pituitary) stops making LH (luteinizing hormone) which signals the testicles to make testosterone (endogenous). In the graph above, 50 mg/week of the testosterone ester was enough to keep the average T levels where they were at time zero (new external testosterone replaces original internally made T). The bodies internally made T is ramping down and the external T is building in the subjects (all hidden in these data). For the 75 mg/wk case, the T levels build over 6 weeks because that dose provides for higher average T levels than the guy’s bodies were making at time 0. It takes about 5 half lives to reach the new steady value and the half life for the injectable is 4-7 days depending on the guy. Again this is all speaking in terms of mean values and individual response are buried in those bars around each data point.

From their website: " Measure total testosterone trough concentrations (measured 7 days after the most recent dose) following 6 weeks of dosing, following 6 weeks after dose adjustment, and periodically while on treatment with XYOSTED. A trough concentration between 350 ng/dL and 650 ng/dL generally provides testosterone exposures in the normal range during the entire dosing interval.

Decrease the dose by 25 mg if the total testosterone trough concentration (Ctrough) is ≥650 ng/dL. Increase the dose by 25 mg if the total testosterone Ctrough is <350 ng/dL.
Maintain the same dose if the total testosterone Ctrough is ≥350 ng/dL and <650 ng/dL."

For argument purposes, I would suggest that a 650ng/dL TT reading at 7 days trough is going to yield an average TT of over 1000ng/dL.

I couldn’t find anything on their site suggesting you only use 1 vial a week. Just to increase the dose by 25mg until the trough is between 350ng/dL and 650ng/dL.

1 Like

More math and charts. FML. What is the point of taking a treatment where a number is targeted if the number doesn’t resolve symptoms? Why would anyone take a treatment to continue to feel like shit, which is why they did the treatment to begin with, only to look good on paper?

You’ll never understand this stuff. This much is clear.

More evidence that Emeric and his 10mg a day protocol is vindicated. If this gets cheaper and becomes the standard of care TRT forums will go the way of the dodo bird.

Shared this with you on other thread but also linking here:

Up to the individual to do there own legwork on the hypothesis based on your question as to whether 1 autoinjector per week will be enough.

This would suggest there’s nothing sinister about their intentions with the dose options on the autoinjector. Most PCP/in-network doctors who do TRT will not take a patient above physiologic given the strict standard of care guidelines of their department.
image

Again you have to be a student of the literature and almost be a professional MD guideline writer to make sense of the literature and get into patient satisfaction scores while being treated with TRT that puts you in range. The only way @dbossa’s claims make sense is if most men have to be above range in order to alleviate their symptoms. The data I’ve shared shows that 50-100 mg/week of Test ester will put most men in range. So I leave it to the reader to determine what’s most plausible if you interviewed every physician in the entire world and put together a poll and distribution of what they treat their patients with. Another hint: that patient population is much larger than 10,000 guys or whatever is on the good old Facebook group.

Clinical trials require a primary endpoint. 100% of the time that endpoint is a numerical expression of a result. Resolving symptoms is not the primary goal of the trial. The one and only goal is to show statistically significant changes from the placebo group. If symptoms resolve then that’s a nice secondary endpoint. But that’s not what they’re studying and certainly not what they’re counting on when seeking approval. “Our drug purports to have X result in this measurement of Thing A. These studies show it does just that.” That’s the goal. The difference between what a doctor is doing for a patient and what a trial is doing for a drug is like the difference between teaching your son to throw a baseball and reading a box score of last night’s game.

You have now demonstrated yourself to be an absolute moron. Congratulations.

That is not my position whatsoever. My position, again and again and again and again is as follows:

TAKE THE MINIMUM AMOUNT REQUIRED TO RESOLVE SYMTPOMS

I’ll repeat:

TAKE THE MINIMUM AMOUNT REQUIRED TO RESOLVE SYMTPOMS

One more time:

TAKE THE MINIMUM AMOUNT REQUIRED TO RESOLVE SYMTPOMS

Just in case you still didn’t get it… which I know you won’t:

TAKE THE MINIMUM AMOUNT REQUIRED TO RESOLVE SYMTPOMS

I never ONCE said that men HAVE TO BE above range. I never EVER said that EVER.

You continue to take things I say out of context no matter how simply I clarify things. So either you’re just an asshole and doing it on purpose or you’re a moron that can’t understand basic English.

Which one is it? Those are the only two logical possibilities at this point. Pick one.

If it worked, everyone would be doing it, because the physicians I use prescribe the MINIMUM AMOUNT REQUIRED TO RESOLVE SYMPTOMS. If 10mg a day was resolving symptoms, that’s what they would be doing. Daily shots typically does not work well with high SHBG guys. I only have about a few thousand examples of this so what do I know.

7mg a day will chemically castrate most men

100mg a week rarely puts a man in supra range

Self fucking explanatory.

Please DEMONSTRATE when I stated that men NEED TO HAVE supra levels. Show me.

Emeric’s not set on the daily 10mg protocol. In the thread he mentioned you can split it up other ways. The main take-away from that thread besides the huge number of people finally finding happiness with TRT is that you go 70mg MAX.

You’d have to be able to read figures and do math to understand the self-consistency of my statements.

It’s not an opinion. Once you understand the PK of test cypionate or enanthate and the distribution of clearance rates in the human male, you will understand that 150 mg/week of test ester will put MOST men in the supra range.

I’ve got a few dozen docs that will call BS. They use the minimum amount to get the job done. It is an extremely rare thing to get it done using less than 100mg a week.

You can argue it all you want. Nobody, and I mean NOBODY in this place has the the sheer amount of feedback that I get. One website where one doc claims most do better is not evidence. Find 50 physicians across the globe doing the same with ALL their patients and having ALL their patients raving about being symptom free and finally feel normal and I’ll eat not just one but both my shoes.

@dbossa

Go back and read my first post. Read and learn about selection/survivorship bias. My hypothesis (the hypothesis) I put forth in this post, is that the individuals you have worked with are not a random sample from the larger population of hyponagonal patients in the TRT world. That’s all. The data I’ve shared reasonably supports my claim. Nothing personal in my opening post, this is science. Nothing personal.

I am convinced you are doing great work. But please do read the Scientific American article I posted up at the top. Ask yourself those questions. Thanks again for your service in helping men who don’t get it through more traditional health care options.

Feedback from several dozen physicians caring for tens of thousands of patients isn’t just a ‘random sample’. It’s a hell of a lot bigger than any study you could possibly send me.