madman
Super Moderator
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The American Diabetes Association (ADA) “Standards of Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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* In men with diabetes who have symptoms or signs of low testosterone (hypogonadism), a morning total testosterone level should be measured using an accurate and reliable assay (157). In men who have total testosterone levels close to the lower limit, it is reasonable to determine free testosterone concentrations either directly from equilibrium dialysis assays or by calculations that use total testosterone, sex hormone binding globulin, and albumin concentrations (157). Further tests (such as luteinizing hormone and follicle-stimulating hormone levels) may be needed to further evaluate the individual.
* The best predictors of ED are age (>40 years), CVD, diabetes, hypertension, obesity, dyslipidemia, metabolic syndrome, hypogonadism, smoking, depression, and use of medications such as antidepressants and opioids (161,162). Because diabetes, poor nutrition, obesity, lack of exercise, and CVD are often interrelated, it may be challenging to identify the primary risk factor (159), although the most likely primary underlying risk factor is vascular disease (159).
* Awareness and identification of these characteristics, factors, and behaviors can guide clinicians in early screening, treatment, prevention, and counseling in all men with diabetes and particularly those at higher risk for ED (165). Given the evidence that ED is strongly associated with diabetes and CVD, men with ED should be evaluated and managed for cardiovascular and endocrine risk factors. Glycemic assessment in men not previously diagnosed with diabetes, lipid profile, and morning total testosterone should be considered mandatory in all men newly presenting with ED (168).
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Low Testosterone in Men
Recommendation
- 4.18 In men with diabetes or prediabetes, inquire about sexual health (e.g., low libido and erectile dysfunction [ED]). If symptoms and/or signs of hypogonadism are detected (e.g., low libido, ED, and depression), screen with a morning serum total testosterone level. B
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Mean levels of testosterone are lower in men with diabetes than in age-matched men without diabetes, but obesity is a major confounder (154,155). Testosterone replacement in men with symptomatic hypogonadism may have benefits, including improved sexual function, well-being, muscle mass and strength, and bone density (156). In men with diabetes who have symptoms or signs of low testosterone (hypogonadism), a morning total testosterone level should be measured using an accurate and reliable assay (157). In men who have total testosterone levels close to the lower limit, it is reasonable to determine free testosterone concentrations either directly from equilibrium dialysis assays or by calculations that use total testosterone, sex hormone binding globulin, and albumin concentrations (157). Further tests (such as luteinizing hormone and follicle-stimulating hormone levels) may be needed to further evaluate the individual. Testosterone replacement in older men with hypogonadism has been associated with increased coronary artery plaque volume, with no conclusive evidence that testosterone supplementation is associated with increased cardiovascular risk in all men with hypogonadism (157). Furthermore, erectile dysfunction (ED) is also common in people with diabetes (158), and it is reasonable to measure and correct testosterone levels close to the lower limit to address the desire component that contributes to erectile difficulties (159) (see erectile dysfunction, below, for more information on evaluation and further discussion).
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Erectile Dysfunction
Recommendation
- 4.19 In men with diabetes or prediabetes, screen for ED, particularly in those with high cardiovascular risk, retinopathy, cardiovascular disease, chronic kidney disease, peripheral or autonomic neuropathy, longer duration of diabetes, depression, and hypogonadism, and in those who are not meeting glycemic goals. B
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The most common sexual dysfunction in men is ED, with an estimated prevalence of 52.5% in men with diabetes (160). The best predictors of ED are age (>40 years), CVD, diabetes, hypertension, obesity, dyslipidemia, metabolic syndrome, hypogonadism, smoking, depression, and use of medications such as antidepressants and opioids (161,162). Because diabetes, poor nutrition, obesity, lack of exercise, and CVD are often interrelated, it may be challenging to identify the primary risk factor (159), although the most likely primary underlying risk factor is vascular disease (159).
Men with diabetes are at increased risk for both CVD and ED, and ED is a predictor of cardiovascular events in men with diabetes (163,164) as well as in men without diabetes. The significant factors associated with ED in men with diabetes are age, peripheral or autonomic neuropathy, presence of microvascular disease including retinopathy, CVD, duration of diabetes, poor glycemic management, hypogonadism, and diuretic therapy (165). Physical activity may be protective. Men with diabetes and ED report a significant decline in quality-of-life measures and an increase in depressive symptoms (166), and depression is a well-recognized risk factor for ED. Given the bidirectional relationship between ED and depression, treatment of either one can result in improvement in the other condition. CKD is also a risk factor for CVD and ED, with prevalence rates of ED >75% in men on hemodialysis (167).
Awareness and identification of these characteristics, factors, and behaviors can guide clinicians in early screening, treatment, prevention, and counseling in all men with diabetes and particularly those at higher risk for ED (165). Given the evidence that ED is strongly associated with diabetes and CVD, men with ED should be evaluated and managed for cardiovascular and endocrine risk factors. Glycemic assessment in men not previously diagnosed with diabetes, lipid profile, and morning total testosterone should be considered mandatory in all men newly presenting with ED (168).
In a recent meta-analysis, testosterone was superior to placebo in improving erectile function in men with testosterone deficiency; however, the magnitude of the effect was lower in the presence of diabetes and obesity (169).
Meta-analyses show that all phosphodiesterase type 5 inhibitors (PDE5Is) are superior to placebo in treating ED, lower dosages had effects comparable with those of higher dosages, and various PDE5Is show comparable efficacy (159). PDE5Is are associated with an increased risk of headaches, flushing, and dyspepsia (159). First-line therapy for ED in men with diabetes is PDE5Is, but men with diabetes may be less responsive than men without diabetes (160). Strategies to improve response to PDE5Is include daily therapy and optimization of comorbidities. In men with diabetes not responding to PDEIs, other potentially effective treatments may include intracavernosal injections, intraurethral prostaglandin, vacuum erection devices, and penile prosthetic surgery (160).
