Writing guidelines is hard, since evidence often lacking for key items. AUA recommendations re T thresholds is excellent example. No data exist re who responds to TTh based on total T levels. So recommended threshold of <300 is ARBITRARY, not evidence-based. 1/
While I congratulate AUA for establishing #testosterone guidelines, 1st rule should be to avoid making AUA members who practice good medicine WRONG. Experienced clinicians know there are MANY men with total T >300 who benefit from TTh, esp if have low free T. 2/
Since guidelines are not laws, there is ample room for clinicians to deviate from guidelines in their own practices, and data reveals poor adherence to most medical guidelines. A big issue, tho, is that insurance often will not provide coverage based on restrictive guidelines. 3/
Who benefits from overly “conservative” (restrictive) guidelines? Not patients. Not healthcare providers. Insurance companies! They use every possible opportunity to save/make money by avoiding payment for reasonable decisions by caring MDs practicing good medicine. 4/
I recognized 25y ago that my patients’ symptoms did not correspond to total T, but tracked closely with free T. Published this >10 yrs ago, now confirmed by EMAS data in JCEM (Antonio et al). Explained by wide variability in SHBG, which binds T, rendering it unavailable. 1/
I treat symptomatic men with TTh if they have low values for either total OR free T. If there is a discrepancy between total and free T, it is usually because of a generous or abnormally high SHBG concentration. 2/ end
