Testosterone Supplementation and Exercise in Elderly Men Protocol Number: Principal Investigator: Robert Schwartz, MD

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1 1 Title: Testosterone Supplementation and Exercise in Elderly Men Protocol Number: Principal Investigator: Robert Schwartz, MD Protocol (V 2.0) 1. Background 1.a. Physiological Changes with Aging That Affect Function Aging in men is associated with a decline in a number of physiological functions and alterations in body composition: 1) increased fat mass; 2) decreased muscle mass and strength/power; 3) a reduction in bone density and predisposition to fractures; 4) reductions in cognitive function, vigor, sexual function and sleep quality Consequences of these age-related physiological changes are diminished physical function and reduced quality of life in otherwise healthy older men, and an increased risk of frailty with subsequent disability, loss of independence, institutionalization and increased mortality. 13 These physiological alterations are associated with reductions in circulating levels of T, GH and IGF-I, dehydroepiandrosterone (DHEA) and melatonin. 14 Because these hormones act on the physiological systems whose functions are altered by aging, there has been considerable interest in "replacing" or supplementing these hormones in aging persons with the hope of preserving function and reducing frailty b. Age-Related Decline in Serum T Levels Beginning about age 40 years, serum total T concentration declines progressively with advancing age and ~30% of men over 70 years have levels below the normal range for younger men. 16,17,18 Serum levels of non-shbg-bound T (bioavailable T) and free (dialyzable or calculated) T decline to a greater extent than total T levels, and ~50% of men over 70 years have levels below normal. In contrast, concentrations of the major metabolites of T (E2 and DHT) do not change significantly with aging. A major mechanism causing the age-related decline in serum T levels appears to be primary testicular Leydig cell failure. 20,21 However, there is also evidence that hypothalamic-pituitarygonadotropin insufficiency contributes to the reduced T production with aging. The decline in T production is partially offset by reduced clearance, resulting in low normal to slightly below normal serum T levels. The physiological significance of T concentrations in this range is unclear. 1.c. Effects of T Deficiency and Replacement in Young Hypogonadal Men Hypogonadism causing T deficiency results in alterations in body composition characterized by an increase in body fat and decreases in lean mass and bone density that can result in osteoporosis, and reduced muscle mass and strength. Thus, the clinical consequences of androgen deficiency in younger men are similar to the physiological changes noted in older men. This suggests that lower T concentrations may be responsible, in part, for the physiologic alterations that occur with advancing age. Treatment of younger hypogonadal men with usual replacement doses of T that produce "physiological" serum T levels decrease fat mass; increase lean mass, bone density, and muscle strength; and improve libido, erectile function, vigor and motivation Most subjects in this proposal will not be hormone deficient by usual standards, thus, our intervention will supplement not "replace" T. The usual T replacement dosage in young hypogonadal men is mg IM every 2 weeks. However, this mode of therapy is non-physiologic and serum T concentrations frequently increase to levels above the normal range 1-2 days following injection and then decline over 2 weeks to lownormal or low levels. 34 Transdermal T patches have become available for T replacement in hypogonadal men. Currently, there are three patches in use but each has a significant drawback to use. We plan to use a T gel (AndroGel TM ; Solvay Inc) in this study. In a recent study 1, this gel produced consistent blood levels, and adherence and drop out rates well below even those with a patch. It also has a pharmacokinetic profile that will allow incremental dose adjustments. 1.d. Low-Dose T Supplementation It is clinically appreciated that anabolic effects of androgens (on muscle and bone) may be achievable with lower than usual replacement doses of T (doses that 1

2 do not consistently maintain normal serum T levels). 40,41 An anabolic effect of low-dose T enanthate (100 mg IM q 2wks; with or without growth hormone) in healthy older men has recently been noted by Munzer et al 2. They detected improvements in body composition (3.1% increase in LBM; 5.8% decrease in body fat) and in upper extremity strength. This low dose T replacement caused serum T levels to increase from 444 to 587 ng/dl. 1.e. Androgen (T and DHT) Administration in Older Men. Few studies have evaluated the benefits/risks of T administration in older men. In a 3-month, double-blinded, placebo-controlled, crossover study of TE administration (100 mg IM/wk) in 13 healthy older men with low to low-normal serum T levels 44, T treatment increased lean body mass and tended to decrease fat mass; reduced urinary hydroxyproline excretion; increased libido, motivation and feelings of well-being; and reduced total and LDL cholesterol without changing HDL cholesterol levels. The mean hematocrit increased from 43% to 47%. PSA levels increased from 2.1 to 2.7 ng/ml during T treatment, but subjects remained asymptomatic, and urine flow rate and prostate volume by TRUS were unchanged. In a 12-month single-blinded, randomized, placebo-controlled study in 32 healthy older men with low bioavailable T levels 45, the T-treated subjects had improved grip strength bilaterally but no change in body composition was found. The results of most uncontrolled studies of T replacement in older men support the above investigations and have found decreases in fat and increases in lean mass; increases in upper or lower extremity strength; increases in BMD; decreases in total and LDL cholesterol and no changes in HDL cholesterol; and increases in hematocrit of ~4-8% Not all studies agree. A recent 3-year double-blinded, placebo controlled T supplementation study using scrotal patches (6/mg/d) noted improvements in lean and fat mass in the treated group compared with placebo but no change in strength or hand grip. 51 Tenover has recently completed a 3-year, randomized, double-blinded, placebo-controlled trial of TE ( mg IM q2 wk) in older men with serum T <350 ng/dl. Compared to placebo, treatment with either T alone or T plus finasteride decreased fat mass ~15% and increased lean mass ~8% at 2 and 3 years; increased grip strength bilaterally; and increased lumbar BMD ~6% at 2 years and ~8% at 3 years, and hip BMD ~2% at 2 years and ~3% at 3 years (personal communication). In both the placebo and T-treated men, PSA and prostate size by TRUS increased only slightly. These data provide strong support for the anabolic effects of T replacement on adiposity, muscle and bone. A recent study by Kenny 52 treated older hypogonadal men with transdermal T (5mg/d) for 12 months. They found that the treated group had less loss of femoral neck BMD, and a nonsignificantly greater increase in lower body strength (38% vs. 27%; no exercise intervention). There were also improvements in fat and lean mass in the T-treated group compared to placebo. There are few published data on the interaction of T and exercise and non in older men. Bhasin recently reported that administration of a markedly supraphysiological T dose (TE, 600 mg IM/wk) for 10 weeks increased fat-free mass and muscle strength in normal young men to a similar extent as strength training. 54 He also found that the combination of high-dose T and strength training had an additive effect on increasing fat-free mass and strength. The same group recently published their experience with T-enanthate replacement (100mg IM/wk) with and without PRT exercise in 61 chronically ill (>5% wt loss in 6 mo) HIV-infected men (18-50 yr) 55 The strength gains (1-RM) in men were 29-36% with PRT (alone), 17-28% with T (alone) and 10-32% with both combined. All interventions were greater than placebo but the combination was not greater than either intervention alone. The combined effects of T and exercise have not been reported in older men. Lambert et al 56 recently published a 12-week intervention of T (100mg T enanthate IM q wk) vs placebo with or without PRT (3x/wk) on the body composition of weight gain induced by megesterol acetate in non-obese older men (60-85 years old). A dramatic decline in serum T (<100 ng/dl) was noted in the megesterol acetate groups that received no T supplementation. Total T doubled in the T-treated groups. Strength increased only in the PRT groups (~19%) and there was no interaction 2 2

3 with T treatment. PRT increased fat free mass, and T-treatment reduced fat mass but no interaction between hormone treatment and PRT was found. There was a significant positive interaction between T treatment and PRT on thigh muscle mass with the combined intervention only. 1.f. Strength Exercise in Older Men The ability to increase muscle mass and strength in response to resistance exercise training is maintained even into very old age The age-related loss of muscle is increased in response to resistance exercise in the elderly as it is in young people. 59,60 Kraemer and colleagues found that resistance training resulted in a larger increase in muscle cross-sectional area in young men than in older men, possibly due to higher T levels in the young men. 63 In support of this, Hakkinen 64 found a positive relationship (r=0.61) between exercise-induced increases in strength and serum T in men aged 64 to 73 yr, but not in middle-aged men (44 to 57 yr). We, therefore, believe it is likely that even low-dose T administration will augment the muscle hypertrophy response to resistance training in older men with low normal levels of T. It now appears that the rate of force development (i.e., work per unit time, or power) is an important determinant of physical functional ability in the elderly. Among men aged 65 to 89 yr, the reduction in leg extensor power was more than double the reduction in leg extensor strength with age (-3.5% vs. -1.5%/yr) 65 Leg extensor power has been shown to be a significant determinant of functional ability in older individuals. 66 We will assess both muscle strength and power and evaluate whether power is a better determinant of physical function. 1.g. Obstructive Sleep Apnea (OSA) and Sleep Quality OSA is significantly more prevalent in men 74, particularly older men 75. T replacement can trigger or significantly worsens OSA in some hypogonadal subjects 76,77. The incidence of T-induced OSA is not known. One recent study found no statistically significant increase in the respiratory distress index (apneic plus hypopneic episodes) following usual dose T supplementation in healthy men for 3 years 78. However, the T group had a 50% increase in the index versus an 11% increase in the controls. 1.h. Significance of the Proposed Study. The results of our studies will provide unique information regarding the anabolic effects of low-dose ( ng/dL range) versus conventional replacement doses of T ( ng/dL range) in older men with low normal to slightly low baseline serum T levels. If, as we hypothesize, low-dose T supplementation has beneficial anabolic and functional effects with fewer adverse effects, this would suggest reconsidering the goal of achieving full young physiological circulating T concentrations during T treatment of elderly men. While T supplementation seems to be relatively safe in healthy older men for up to 3 years, chronic use (for many years as prevention therapy) has not been studied. Therefore, we feel that the lowest effective T dose should be defined. There are little data on the effects of T + exercise in older men and we hypothesize exercise will enhance the anabolic and functional effects of T treatment. Our proposal will be unique in using a physical functional performance test that has been demonstrated to be sensitive to change in healthy older populations to evaluate whether improvements in muscle mass, strength, and power associated with T alone, PRT alone, or the combination of T plus PRT are associated with improved physical functional capacity. Reviews of T supplementation in older men 48 have suggested issues that required further investigation. Several of these will be addressed in this proposal including: 1) accurate measures of body composition; 2) precise assessment of strength (and power); 3) assessment of the dose response of various androgen dependent physiologic processes; 4) determination of the long-term effects and side effects of supplementation; 5) evaluation of functional performance. 2. Study Objectives Aging is characterized by adverse changes in body composition and decreases in muscle strength, endurance, power and functional ability. These physiological alterations contribute significantly to 3 3

4 the development of physical frailty. These changes develop in the setting of a gradual reduction in serum total T (and free T) levels. The physiological significance of decreasing T levels with aging is unclear. The goal of this study is to understand the physiological significance of the age-related decline in serum testosterone (T) levels and the role of T supplementation, with and without resistance exercise, in reducing the loss of physical function and the development of frailty in older men. The specific aims and hypotheses to be tested in this proposal are: Specific Aim 1: To determine the effects of 1 year of low-dose (25 mg/d; 2.5G as AndroGel TM ) T versus usual-dose (50 mg/d; 5.0G as AndroGel TM ) T treatment on body composition, strength, power, endurance, and functional performance, as well as on hematocrit, prostate size/symptoms (and PSA) and symptoms of obstructive sleep apnea (OSA) in healthy older men with low-normal to slightly below normal serum T levels. Hypothesis 1 (Main effect of T): Long-term (1 year) T treatment in older men using a lower than usual replacement dose will have beneficial effects on body composition, strength, power, and physical functional performance. Secondary Hypothesis: Low-dose T supplementation (25 mg/d; target serum concentration of ng/dl) will produce fewer adverse effects compared to usual replacement dose T (50 mg/d; target serum concentration of ng/ml). Specific Aim 2: To determine the effects of 1 year of low vs. usual-dose T supplementation with and without a standard progressive resistance training (PRT) program on body composition, strength, power, endurance and physical functional performance, as well as on hematocrit, prostate size/symptoms and symptoms of obstructive sleep apnea (OSA) in healthy older men with lownormal to slightly below normal serum T levels. Hypothesis 2 (Interaction between T and PRT): PRT will enhance the anabolic effect of T treatment in older men, producing similar (or greater) positive anabolic effects on body composition, strength, power and physical functional performance at lower T doses. We hypothesize that low dose T + PRT will have effects greater than low-dose T or (usual) replacement dose T alone, but not as great as usual dose T + PRT (usual T+PRT > low T+PRT > usual T > low T). 3. Methods 3.a. Overall Experimental Design (see Table 1): The study will be a one-year, prospective, randomized, double-blind, placebo-controlled, complete, balanced, 2-way factorial design in healthy, community-dwelling older ( 60 yrs) men with lownormal to slightly below normal serum total T levels. The 2 factors will be T supplementation (placebo, 25mg/d, 50mg/d) crossed with PRT (3x/wk versus none). The control exercise group will be offered PRT after completion of the study (wait list control). The staff and investigators (except the research pharmacist, the Data/Safety Monitoring Board and data manager) will be blinded to the drug treatment regimens. The staff and investigators will be blinded to exercise assignment (except for the nurse coordinator and the exercise trainers). Subjects will be blinded to the drug treatment. to one of six treatment groups comprised of at least 25 subjects (completing the entire study) per group. 4 Table 1 Testosterone Dose (steady state serum T range) 0mg/d ( ng/dL) 25mg/d ( ng/dl) 50mg/d ( ng/dL) No PRT (wait list) Group 1 (n=25) Group 2 (n=25) Group 3 (n=25) PRT (3x/wk) Group 4 (n=25) Group 5 (n=25) Group 6 (n=25) 4

5 5 Drug kits (with subject numbers) containing the appropriate individual packets (active drug and/or placebo) will be prepared in advanced and securely stored by the research pharmacist. Initially, drug kits will be dispensed weekly (x 2) then every other week (x 1) and monthly thereafter. This will allow us to carefully monitor compliance at the beginning of the study. Subjects will be asked to return any unused packets at each pharmacy visit. We will measure average T level before the morning gel application and peak T level (at 52 wk) 2 hours after gel application. This design will permit evaluation of: Hypothesis 1: (T main effect)-- the potential beneficial effects of 12 months of the low-dose T supplementation (25 mg/d, ng/dl; group 2) compared to usual replacement dose T (50 mg/d, mg/dL; group 3) and placebo (0 mg/d, ng/dl; group 1) on body composition, strength/power and functional performance. Hypothesis 2: (Interaction between T and PRT)-- the effects of low-dose T + PRT (group 5) compared to usual dose T + PRT (group 6) and PRT alone (group 4) on body composition, strength/power and functional performance. We will also compare the effects of the T gel only groups (groups 1, 2 and 3) with PRT alone (group 4) and evaluate possible interactions between T supplementation and PRT. We will recruit enough subjects to permit a 15-20% dropout rate, and still complete the necessary 25 subjects per group. 4. Recruitment and Screening. Recruitment of subjects will be through advertisements in the local media (newspapers and radio) and newsletters, including those specifically targeting Hispanic and African-American populations, and through public information forums for older individuals. 4.a. Potential subjects will be screened on the telephone by reviewing the major inclusion and exclusion criteria as well as the overall time commitment (screening level 1). We usually expect to screen subjects per enrollee though our recent Denver experience has been better than this. Subjects passing the telephone screen will be invited to a group meeting (screening level 2) where details of the study design, clinic, special procedures, potential adverse effects, and time commitments will be specifically reviewed by one of the investigators (or nurse coordinator). Subjects will have an opportunity to ask questions. Interested subjects will take a copy of the consent form home to review and will be scheduled for a GCRC visit (screening level 3). 4.b. At the GCRC screening visit, the study will be further discussed in clear language, and consent form (<10 th grade reading level) will be signed, dated and placed in the permanent study record. Each potential subject screened at this level will be assigned a permanent study number. The consent form will request that subjects who are later determined to be ineligible for the study allow the recording of personal information such as age, weight and reason for exclusion. All information and the main database will contain only the permanent study number. A separate file matching name and study number will be stored in the data coordinating center with access limited to a small number of study personnel (and the DSMB). Subjects will be admitted (after an overnight fast) to the GCRC as a day patient. They will receive a complete history and physical examination (including DRE) by a physician investigator or research nurse coordinator using a standardized check-off examination form to insure complete data collection. Subjects will complete the AUA Symptom Index for BPH and BPH Impact Index (Appendix 6) 93, National Jewish Sleep Apnea Screening Tool (Appendix 7) and the Pittsburgh Sleep Quality Index (Appendix 7) 94. The following laboratory screening tests will be performed: CBC; PSA; blood chemistry battery, including serum glutamate oxalacetate transaminase (SGOT), total bilirubin, alkaline phosphatase, albumin, calcium, and phosphorus; fasting lipid panel (total cholesterol and triglyceride, HDL and LDL cholesterol), insulin and glucose; total T, TSH and prolactin; urinalysis and resting ECG. 5

6 4.c. Following successful completion of the above screening tests (normal PSA), subjects will be scheduled for a TRUS examination. Using a 7.5 Mhz transrectal ultrasounds probe, the prostate gland is examined using horizontal and transverse 2-dimensional views of the prostate and calculation of gland volume. This allows examination of base, middle, and apex as well as zonal anatomy of the prostate (peripheral, transitional, central zones) in both horizontal and transverse views. This will be read by Dr Meacham. Two findings will be considered as abnormal: a) increase in size/volume of the gland >15% from the baseline; b) presence of hypoechoic areas in the prostate. Potential subjects with abnormalities on either TRUS or DRE at baseline will be referred to a urologist for possible sextant biopsies. If the biopsies are negative, the subject will be potentially eligible and can continue the screening process. 4.d. Following successful completion of all of the above screening studies, subjects will be scheduled for a maximal treadmill exercise test (VO 2 max) to eliminate subjects with evidence of significant, active coronary artery disease. Subjects with contraindications to treadmill testing (recent MI, CHF, pulmonary embolus, or significant aortic stenosis) will be excluded. Subjects will have a low-intensity acclimation treadmill study prior to the maximal test. Standard stopping criteria (American College of Sports Medicine) will be used to exclude patients with high cardiac risk. These criteria include severe arrhythmia, early significant ST wave depression, significant chest pain (> mild), or blood pressure drop (or excessive elevation). A maximal test will be defined by reaching 2 of 3 criteria: 1) heart rate within 5 beats of predicted (220-age); 2) RQ > 1.10; 3) leveling off of VO 2. Subjects who do not attain a max test will be re-tested. If the second test is also submaximal (but consistent with the first) it will be called a peak effort and they will be eligible for enrollment in the study. A physician and qualified staff will conduct all maximal treadmill exercise tests. Full resuscitation equipment is available on-site. Subjects with indications of significant active coronary artery disease will be referred to their own physician for follow-up. If, on further testing (e.g. thallium), no significant coronary artery disease is found, they will be eligible for the study. After successfully passing the baseline treadmill test, subjects will be formally randomized and enrolled Consent Procedures The Investigator(s) or Study Coordinator, who will administer the informed consent process, has (or will have) completed COMIRB 101. The consent process will take place in a quiet, unhurried setting. Individuals who express interest in the study will be provided with a detailed description of the study, including risks and benefits, in a one-on-one orientation session. The recruits will be given the opportunity to read the written informed consent document in private prior to making a decision regarding participation. The Investigator(s) or Professional Research Assistant will carefully explain the randomization to one of the 6 groups and will especially emphasize that the potential subject may be randomized to get or not get exercise and to get either placebo, low dose or usual dose testosterone gel. Upon completion of the 6-month follow-up tests, participants will be informed of which group they were assigned to. Each participant will be provided with a copy of the written informed consent form, signed by the participant and the investigator(s) or Professional Research Assistant. The original signed consent form will be kept in each participant's study file. 6. Treatment/Intervention 6.a. Progressive Resistance Training: Drs Schwartz and Kohrt have many years of experience in safely and successfully strength training older (and younger) men and women. Lower extremity exercises: leg extension and flexion, leg press Upper extremity exercises: chest press, overhead pull-down, seated row, biceps curl, triceps extension, upright row. 6

7 A Masters degree exercise physiologist will monitor training three times a week for the PRT intervention. Training will begin with an initial accommodation regimen (2-3 weeks) of 3 sets of repetitions of each exercise at 50-60% of the measured 1-RM. The formal training regimen will consist of 3 sets of 6-8 repetitions of each exercise at 80% of the measured 1-RM. Resistance will be increased by 5-10% when 3 sets of 8 repetitions can be performed. The 1-RM will be measured for each exercise at least monthly, so that adjustments (relative to 1-RM) can be made. All training sessions will start and end with stretching/warm-up exercises. Exercise logs will be maintained. 6.b. Drug Treatment: The T that will be used in this study (AndroGel TM ) will be provided in packets containing 2.5G or 5.0G of T gel (25mg or 50mg of T, respectively) or placebo. To ensure blinding, each subject will apply at least 2 packets of gel daily. Initially, the placebo treatment group will apply two placebo packets daily (0 mg T/d); the low dose will apply one 2.5G T gel packet and one 2.5G placebo packet daily (25 mg T/d); the usual-dose will apply two 2.5G packets of gel daily (50 mg T/d). The research pharmacist (only) will know the placebo vs. active T packets (by packet numbers). While T treatment will be initiated at either 25 or 50mg/d, we will monitor steady state serum T levels and adjust the low dose group into steady state range of ng/dL and the usual dose group into a steady state range of ng/dL. Obviously, no active T adjustments will be made in the placebo group ( ng/dl). Gel packets containing 2.5G and 5.0G of T gel will be used to make dosage adjustments so that no subject will be required to apply more than 2 pacekts of gel daily. Sham adjustment in the placebo group will also be made using 2.5G and 5.0G T gel placebo packets. The first adjustment decision will be made from the 2-week steady state serum T concentration, using the following guidelines: 1) If T is in the desired range and is confirmed at 4 weeks, no further adjustment will be made (except for side effects). 2) If the 2-week value is out-of-range by >50 ng/dl, an adjustment will be made and a follow-up will be re-measured in 2 weeks. If this value is within range and can be reconfirmed in 2 weeks, no further adjustments will be made. If serum T remains out-of-range after the first adjustment, a second adjustment will be made and follow up values determined until there are 2 values within the designated range. Thereafter, no more adjustments will be made. 3) If the 2-week value is out of range by <50 ng/dl, the serum level will be repeated and an adjustment made only if the out-of-range status is verified. No subject randomized to an active T group will receive <12.5mg/d (barring side effects) or >100mg/d. Gel packets containing 2.5G and 5.0G of T gel will be used to make dosage adjustments so that no subject will be required to apply more than 2 packets of gel daily. Sham adjustments in the placebo group will also be made using 2.5G and 5.0G T gel placebo packets. Any subjects not brought into the appropriate designated serum range within that dose range, will be maintained on the last adjustment dose. Data will be analyzed by the initial randomization group (intention-totreat). A secondary analysis will be made using the serum concentration ranges attained. As an example of the adjustment procedure: A subject who starts on 25 mg T/d is noted (by the unblinded research pharmacist) to have a steady state serum T level of only 325ng/dL at the 2- week T level. After insuring that the gel is being used correctly and there are no contraindications to increasing the dose, an additional ½ packet of active gel would be prescribed daily (37.5mg/d). If the value 2 weeks later is 415ng/dL and can be confirmed as being within range on the next sample, no further adjustment would be made. The smallest adjustment that places the subject within range (on 2 values) will be made. At the same time another subject, whose steady state level requires no adjustment would also be contacted regarding proper use of the gel and prescribed an additional ½ packet of placebo gel daily and receive appropriate follow-up T level determinations. The research pharmacist will mark any packets to be used in ½ doses. Available data suggest that a whole 2.5 G (25mg T) packet will produce an increase in serum level of 125ng/dL or ~60ng/dL from ½ packet. 7 7

8 7. Inclusion/Exclusion Criteria 7.a. Inclusion Criteria Community-dwelling men > 60 years old, in good general health Total serum T concentration <350 ng/dl and > 200 ng/dl (2 AM samples on different days). This determination will occur early to insure that subjects are eligible for further screening Taking no medications or stable medications (see below) for the previous 3 months Normal complete blood count (CBC), calcium, albumin, TSH and no clinically significant blood chemistry or urinalysis abnormalities BMI < 35 and stable weight for the last 6 months Mini Mental State Exam score > Clinical Dementia Rating Scale b. Exclusion Criteria Exercise (or otherwise) limiting neuromuscular, joint/ bone, cardiovascular, peripheral vascular, cerebrovascular or pulmonary disease. Abnormal maximal treadmill test or contraindication to testing (recent MI, CHF, pulmonary embolus; significant aortic stenosis). Severe obesity (BMI > 35) or recently unstable weight. Active liver disease (SGOT > 3x normal), liver failure, or renal failure. Diabetes mellitus (FBS 126 mg/dl) or other unstable endocrinopathy (stable levothyroxin replacement with a TSH in the normal range is allowable). Uncontrolled hypertension (blood pressure > 160/90). Major psychiatric illness, depression or cognitive impairment that could affect the ability to understand the study and/or cooperate fully. Prostate or breast cancer (present or previous). Abnormal prostate on TRUS or DRE (e.g. nodule or induration) or PSA > 4.9 ng/ml if years old or > 5.8 if over age 70 years. If the DRE or TRUS are considered abnormal, the potential subject will be offered a referral to an urologist for a possible prostate biopsy. If the biopsy is negative, the subject will be considered potentially eligible for the study. Severe symptoms of BPH (American Urological Association symptom score of 20-35). Hematocrit > 52% (this is higher than the usual limit of 50% due the higher hematocrits normally seen in Denver due to altitude. Hematocrits of up to 52 are normal in Denver and Dr Stabler does not consider phlebotomy until the hematocrit reaches 55%). Prolactin > 20 ng/ml at baseline. Significant fasting dyslipidemia (total cholesterol > 300 mg/dl, LDL cholesterol > 200 mg/dl, HDL cholesterol < 20 mg/dl or triglyceride > 400 mg/dl) or lipid lowering treatment. Chronic (or frequent intermittent) oral glucocorticoid therapy. Current use of alcohol (> 2 drinks/day), narcotics or androgenic steroids (T or other anabolic steroids), over-the-counter steroids such as androstenedione or DHEA, or saw palmetto. Inability to understand protocol or give informed consent, speak and understand English, use a telephone or fill out a written questionnaire (in English). Endurance exercise training (> 2x/wk for 20 minutes at a level that produces sweating) or any strength training exercise (> 1x/wk) in the last 6 months. 8. Selection of Study Population Only males are candidates for this study since even the low dose of T used would cause masculinization of women. We will actively attempt to recruit men from all ethnic populations. 9. Patient Accrual This is a local study and all patients will be accrued locally. As noted above in Table 1, subjects will be randomized to 6 equal-sized groups. 8

9 10. Study Timeline A minimum of 150 subjects, 25 in each of the 6 treatment groups, will complete the 52-week intervention (we will enter 30/group). With 40 subjects recruited Yr1-4 and 20 Yr5 we will be able to complete the necessary number of subjects in a total of 4 years, leaving some flexibility for startup time in year 1 and data analysis in year 5. The maximum number of subjects who need to be tested in any week (baseline, 26wk or 52wk testing) is 12. This projection also limits the number of subjects who will be in the PRT program, allowing for individualized attention so that maximal progress can be attained with a minimum risk for injury. 11. Testing, Procedures and visits 11.a. Clinic visits All subjects will be admitted to the GCRC as a day patient at baseline, 4, 12, 26, and 52 weeks. The following assessments will be performed at those visits: Interim history (including medication changes) and brief physical examination including DRE and breast examination will be performed using a standardized check-off examination form. AUA Symptom and BPH Impact Index, Pittsburgh Sleep Quality Index, National Jewish Sleep Apnea Screening Tool, and Yale Activity Questionnaire and 3-Day Diet Record will be completed. Follow-up labs (CBC, liver function tests, PSA, urinalysis) will be collected at baseline, 4, 12, 26, and 52 weeks (see table 2). 11.b. Serum total testosterone (total T) will be measured (preapplication of gel) at baseline (2 separate days), 2, 4, 12, 26, and 52 weeks. At 52 weeks, two additional peak draws will be done (2hr and 4 hr after gel application). Additional serum levels may be needed for dose adjustment. 11.c. Lipids and other hormones will be measured at baseline, 26 and 52 weeks. Blood will be drawn after an overnight fast. These will include: free T, SHBG (for calculated free T ), DHT, E 1, E 2, LH and FSH, IGF-1and IGF BP-3, insulin, glucose, leptin, and lipid profile (total cholesterol and triglyceride, LDL and HDL cholesterol and subfractions). 11.d. Behavior and Quality of Life Questionnaires at baseline, 26 wk, 52 wk. Sexual function (including libido, sexual activity, and erectile function) will be assessed by the Daily Sexual Activity Diary; mood and behavior (including aggressive behavior) by Multiple Affect Check List, SHIM and Questionnaire; quality of life by Perceived Quality of Life Scale (PQOL) and the Medical Outcomes Survey Short Form (SF-36); Center for Epidemiological Studies Depression Scale (CES-D) 104, Fatigue Symptom Index (FSI) 103, Determine your Nutritional Health survey 105 and activity using the Yale Physical Activity Questionnaire for Older Adults. Participants will be given the opportunity to take the surveys on a computer if they wish. 11.e. PSA. Serum prostate specific antigen (PSA) will be measured by radioimmunoassay. 11.f. Special procedure visits. Limited CT scans CT slices (3) will be made at baseline and 52 wks during inspiration at the upper abdomen (L 2-3), the umbilicus (L 4-5) and mid-thigh (halfway between the greater trochanter and the superior aspect of the patella). DEXA scan (body composition) will be performed at baseline, 26, and 52 weeks using a Hologic Delphi-W. Circumferences The minimum circumference of the waist (between the xyphoid process and the umbilicus), the maximum circumference of the hips (level of the buttocks), the right midthigh (half the distance between the proximal border of the patella and the inguinal crease on the midline of the thigh), and the right mid-arm (half the distance between the acromion and olecranon processes) will be measured (baseline, 26 and 52 wks) in duplicate using an anthropometric tape measure. Strength and Power Isokinetic strength will be measured using an isokinetic dynamometer at baseline, 26, and 52 weeks in all subjects. Strength (flexion and extension at 60 o /s and 120 o /s) will be measured at the ankle, knee, hip, elbow and shoulder. Joints will be tested in a fixed order and for any joint the order of muscle speeds will be randomized. The same 9 9

10 order will be used for each individual throughout the study. The 1-RM tests will be performed on each piece of exercise equipment at baseline, at 2 weeks, and then monthly in the PRT groups to define the appropriate training progression. Non-training subjects will have 1-RM measurements at baseline, 26, and 52 weeks. Leg extensor power will be assessed at baseline, 26, and 52 weeks using a Nottingham Leg Extensor Power Rig. Daily Activity Daily activity will be measured using an accelerometer and/or step counter at baseline, 26 and 52 weeks in all subjects. These are both smaller than a pager and will be worn on the waist (belt) during waking hours for 10 days. CS-PFP The Continuous-Scale Physical Functional Performance test (CS-PFP) is comprised of up to 15 everyday tasks requiring upper and lower body strength and flexibility, balance, coordination and endurance. Participants will be instructed to complete the tasks safely, but with maximal effort. Performance (baseline, 26and 52 wks) will be measured as weight, time, or distance. Scores will be standardized and scaled from 0 to 100. A total score and separate physical domain scores will be calculated. The CS-PFP will be administered at baseline and 6 months by an experienced examiner. Prostate Health. A TRUS for prostate size and urine flow measurements, and DRE and PSA will be performed at baseline and 52 weeks. Subjects with abnormal DRE, TRUS or PSA will be referred to a urologist for further evaluation and possible biopsy. Total Body Water (Deuterium method). Baseline and 52 week saliva samples will be obtained prior to administering an oral dose of 0.12 g 2H2O per kg of total body water, which will be estimated as 73% of fat-free mass measured by DXA. Samples of the dose, diluted to simulate the enrichment in total body water, and the water used for dilution will be retained as analytical standards. Saliva samples will be obtained every 15 min from the third to fourth hour after the dose is ingested, stored in sealed vacutainers at -70C, and analyzed in triplicate for 2H2O enrichment by isotope ratio mass spectrometry in the UCHSC Mass Spectrometry Resource facility. For measurement of 2H enrichment, saliva samples are prepared by zinc reduction (33) and hydrogen is introduced into the mass spectrometer through a 10-port manifold. Computerized Memory Tests (The CNS Vital Sign Screening Battery ) A battery of computerized memory tests will be administered at baseline, 26 and 52 weeks. The CNS Vital Signs Screening Battery ( is a customized neurocognitive testing application tailored for the assessment of neurocognitive status of study subjects. The application is designed to produce millisecond precision allowing for consistent and accurate measurement of small cognitive changes, such as those associated with drug effects and other cognitive impairments. The CNS Vital Signs Screening Battery clinical system produces a one-page report categorizing the domains of: 1) memory; 2) mental speed; 3) reaction time; 4) attention; and 5) cognitive flexibility. The underlying subtests yielding these domains are: 1) verbal memory (ability to memorize words); 2) visual memory (ability to memorize geometric shapes); 3) finger tapping (motor speed & fine motor speed); 4) symbol digit coding (complex attention, visual perceptual speed, & information processing speed); 5) stroop test (executive function, reaction time; information processing speed); 6) shifting attention (executive function shifting, reaction time, information processing speed); and 7) continuous performance (sustained attention and choice reaction time). The total CNS Vital Signs rating is compiled from the sum of the domains that represents an aggregate score of each individual s areas called Neurocognitive Index Score (NCI). The battery is selfadministered with a dedicated computer in a quiet room, and takes about minutes. In addition, tests for visuospatial function will be added to the computerized cognitive battery. The visuospatial tests will be delivered after the completion of the cognitive tests above. Visuospatial function will be measure using computerized tests of the perception of objects and motion in relation to spatial position. These tests are as follow: 1) optic flow threshold perception (which is the threshold at which a subject recognizes motion expanding from a 10 10

11 central point) and 2) kinetopsic object recognition (which is the point in rotation of an object at which a subject recognizes the object). Visuospatial functioning will be assessed by showing representative images on the screen and it will take approximately 20 minutes. To ensure proper environmental conditions for computerized memory tests in the elderly, a brief questionnaire including questions about vision will be given to each participant prior performing cognitive battery. In addition, to validate and compare the CNS Vital Signs score with the traditional paper and pencil versions of these tests, subjects will be asked to also complete a similar battery of paper and pencil tests that will be administered using a standard interview format. Within the validation tests are the Saint Louis Mental Status Examination83, Mayo Clinic Short Mental Status 84, and Trail Making Test 85. Resting Metabolic Rate (RMR) will be measured at the beginning of the study and at baseline, 26 and 52 weeks. This will require that subjects come to the laboratory in the morning after an overnight fast and rest quietly for about 1 hour. Then subjects will be asked to breathe into a special mask for 30 minutes while they continue to rest. Arterial Ultrasound Measurement The following measurements will be performed in the Ultrasound Facility at the UCD Exercise Testing and Training Center at baseline, 26 and 52 weeks. All measurements will be performed following at least a four hour fast, and will occur at the same time of day before and after the interventions. During the experimental sessions, participants will be examined after 10 minutes of supine rest in a quiet, temperature-controlled room. The testing will begin with arterial applanation tonometry, followed by pulse wave velocity (PWV), carotid artery ultrasound, and then brachial artery flow-mediated vasodilation (FMD). This entire procedure is expected to take minutes. Brachial artery blood pressure will be measured both sitting (after 10 minutes of rest) and supine under quiet, comfortable ambient laboratory conditions. Blood pressure will be measured in triplicate using an oscillometric technique (Dinamap). The pressure waveform and amplitude (Arterial Applanation Tonometry) will be obtained from the common carotid artery with a high-fidelity strain gauge transducer (Millar Instruments). This tonometer has been shown to register a pressure wave with harmonic content that does not differ from that of an intra-arterially recorded wave, and the use of the tonometer on an exposed artery records a waveform identical to that recorded intra-arterially. The combination of ultrasound imaging of the common carotid artery with simultaneous applanation tonometric-obtained arterial pressure waveforms from the contralateral artery permits noninvasive determination of carotid artery arterial compliance. Common carotid artery diameter will be measured from the images derived from an ultrasound machine (Toshiba SSH-140) equipped with a linear array transducer. A longitudinal image of the cephalic portion of the carotid artery will be acquired ~1 cm distal to the carotid bulb. These images will be recorded on a computer and 86 & 92. on a super VHS recorder for later off-line analysis The computer images will be digitized with a video-frame grabber (DT-3152, Data Translation, Marlboro, MA) and stored in a PC computer. Carotid diameter image will be analyzed using image analysis software (Image Tool 2.00, University of Texas Health Sciences Center at San Antonio). Time points that correspond with systolic expansion of the carotid artery (within 60 ms of the ECG T- wave) and basal diastolic relaxation (concurrent with the onset of the ECG R-wave) will be selected. Then the distance (or the diameter) between the vessel far-wall boundary, corresponding to the interface between the lumen and intima, and a near-wall boundary corresponding to the interface of the adventitia and media will be measured. Ultrasound measurements of brachial artery FMD during forearm reactive hyperemia, a well-established measure of vascular endothelium-dependent vasodilation, will be performed according to the method originally described by Celermajer et al. 86 and as performed for the past 3 years in our laboratory 92. An ~2 cm segment of brachial artery will be located 3-5 cm above the antecubital crease. A blood pressure tourniquet will be placed around the forearm distal to the target artery and inflated to 250 mmhg. The cuff will be deflated after 5 min, and the 11 11

12 brachial artery scanned continuously for 5 minutes after cuff release. Brachial artery diameter will be measured from the images derived from the ultrasound machine (described above under Carotid Artery Image Analysis). Ultrasound images will be recorded on a super VHS videocassette recorder for later off-line analysis. The computer images will be digitized as described above under Carotid Artery Image Analysis. Cardiac Echocardiogram left ventricular function and structure will be assessed using M- mode, two-dimensional, and Doppler echocardiography with a 2.5 or 3.5 MHz transducer using ultrasound as previously described 197, 214, 216. Left ventricular mass will be estimated using the approach of Devereux and Reichek 59. Ejection fraction will be calculated from the formula: [(LVEDV 3 -LVESV 3 )/LVEDV 3 ] x 100, where LVEDV is end-diastolic and LVESV is end-systolic volume (as derived from dimensions 3 ). Left ventricular end-systolic wall stress will be estimated as described by Grossman et al. 90. Early and late transmitral diastolic peak flow velocities will be determined at the apex of mitral valve excursion. The ratio of early to late peak flow velocity will be used as a measure of ventricular diastolic function. This measurement will take place following the vascular measures described above. 12 a. Obstructive Sleep Apnea (OSA) The DSMB will leave it to the team to decide on adverse event criteria. OSA will be determined by using daytime hypoxemia (O 2 sat 88) or Epworth Sleepiness score of > 16 as exclusion criteria. AHI will continue to be assessed as a possible adverse event but only hypoxemia or an Epworth score of > 16 would be considered a severe adverse event. The DSMB did not want to establish and stop criteria based on either of these two endpoints. Subjects excluded based on these criteria will be referred for OSA diagnosis and treatment. If successfully treated with CPAP for 1 month, the testosterone will be redrawn to make sure it remains in range, before the subject is randomized. Subjects developing either of the 2 exclusion criteria while in the study will stop their drug and be referred for diagnosis and treatment. If successfully treated they will restart drug and continue in the study. If they refuse diagnosis or treatment, they will continue in the study drug. The DSMB has made this suggestion on the basis of previous published randomized trial by Snyder in a similar group of older men with borderline hypogonadism and the recent completion of a large unpublished study by one of its members (Dr Nair) that followed a similar group of older men with testosterone supplementation. It should also be noted that review of our baseline data show that low T levels are associated with higher AHI scores, suggesting that T supplementation would either improve AHI or have not significant effect. This is supported by Dr Nair s data (private communication). Sleep apnea is very prevalent in older men We previously excluded patients if they: 1) reported an established diagnosis of obstructive sleep apnea (OSA); 2) were found to be at high risk for having obstructive sleep apnea when screened using the National Jewish Sleep Apnea Screening Tool (NJSAST); or 3) had evidence of OSA on an overnight home cardiorespiratory test (StarDust; Respironics, Inc., Murrayville, PA; (apnea/hypopnea index (AHI) of 10). If subjects developed sleep apnea during the study they would be referred to their physician for further evaluation and treatment, but those who refused (or failed) treatment would be subsequently dropped from the study. This proposal was based upon the concept that testosterone supplementation might increase the incidence of sleep apnea in some older men, an assumption mostly derived from a single study by Liu et al 94. This study demonstrated an association between high dose intramuscular testosterone (either 250 or 500 mg/week for 3 weeks) and worsening of apnea/hypopnea index (AHI), and an associated reduction in total sleep time and increase in sleepassociated hypoxemia. However, this short term study (3 weeks) was derived from only 17 subjects and evaluated only large parenteral doses of testosterone. Other untoward consequences of sleep apnea were not found in this study. The conclusions by Liu et al. (2003) are not supported by a larger and longer study (96 men treated for 3 years) by Snyder, et al

13 There is evidence that OSA may cause and low testosterone levels in men. Santamaria et al 96 measured serum testosterone in 24 men referred for suspected sleep apnea, and observed that the 15 patients with confirmed sleep apnea had significantly lower testosterone levels than the 9 patients found to be simple snorers. Subsequent uvulopalato-pharyngoplasty in 12 of the OSA patients improved sleep parameters and increased their serum total testosterone levels ~25% (at 3 months). In a cross-sectional study of 225 men referred for suspected sleep apnea, Grunstein et al. 97 observed that serum testosterone levels were inversely related to severity of sleep apnea, and found an 18% increase in testosterone levels in 43 patients treated for 3 months with nasal CPAP. These observations suggest that subjects with low testosterone levels who present for therapeutic testosterone supplementation are more likely to have OSA. Stardust home cardiorespiratory monitoring StarDust Cardiorespiratory Monitor: This device utilizes noninvasive sensors to monitor airflow at the nose and mouth, breathing effort, oxygen level in the blood, heart rate, position and movement in bed. Subjects will be carefully instructed on the appropriate setup and startup of this device, and they will take the device home along with further written instructions. They will also be asked to keep a sleep diary, in which they will report the time of lights off, estimate the time of sleep onset, indicate any nighttime awakenings, estimate awakening time and the time they get out of bed. The subjects will return the device to the research laboratory at the University of Colorado Health Sciences Center. The stored data will be downloaded for analysis at that time. For the study to be deemed interpretable, we will require that a minimum of 4 hours of adequate data be recorded during the patients designated sleep time. This will be defined by the recording demonstrating acceptable oximetry data, respiratory effort, airflow, with an absence of movement that would be consistent with wakefulness. If 4 hours of such data are not available, the subject will be asked to return home with the cardiorespiratory recording device for a second attempt. No subject will be asked to make a third attempt unless the cause of the first two failures is obvious and remediable. The study will be scored based upon the following criteria: 1) apneas will be defined as 10-second cessations of respiratory airflow. Obstructive apneas will be defined by the absence of airflow in the presence of continued respiratory effort, while central apneas will be defined by the absence of airflow in the absence of continuing respiratory effort; 2) hypopneas will be defined by at least a 30% reduction in detectable airflow that lasts at least 10 seconds and generates > 4% oxygen desaturation; and 3) apneas and hypopneas will be combined and reported as an AHI (per hr of study time). If, at any time during our entire study, a subject demonstrates an AHI of >20 they will be referred for OSA education. 13 Appointed OSA Experts by DSMB: David P. White, MD Gerald E. McGinnis Professor of Medicine Harvard Medical School Allan Pack, M.D. University of Pennsylvania PROPOSED PROTOCOL CHANGES (see flow diagram; Fig 1) We propose to amend the current protocol: We will now include subjects with treated OSA who meet other entry criteria. A StarDust study will be done at baseline, 12 and 52 weeks as part of the protocol but this information will not be used to exclude subjects or change treatment. Neck circumference and the OSA questionnaire will not be used to exclude subjects. Subjects with significant daytime sleepiness (Epworth score >16) or daytime hypoxemia (O 2 sat 88) at screening will be referred for OSA education and to their PCP (or sleep lab). If they refuse diagnosis or treatment they will be excluded from entering the study. If the receive OSA treatment 13