SAT-LB94 An Unusual Case of Acute Myocardial Infarction Revealing Underlying Polycythemia Secondary to Exogenous Bioidentical Testosterone Therapy

BACKGROUND: Many patients seeking testosterone therapy are turning to compound pharmacies for customized bioidentical testosterone replacement. These pharmacies market “bioidentical” hormone therapies as more effective and superior to traditional FDA-approved synthetic therapies. Bioidentical formulations are available as injections, creams, and subcutaneous pellet implants. Exogenous testosterone replacement is associated with polycythemia complicated by increased blood pressure, blood viscosity, and platelet aggregation (1). The ensuing hypercoagulable and prothrombotic changes predispose individuals to adverse cardiac events, including myocardial infarction. CLINICAL CASE: A 66-year-old male with hypertension, type 2 diabetes, and hyperlipidemia presented with chest pain and dizziness. Initial EKG was unremarkable but troponin levels were elevated and the patient was admitted to telemetry. Lexiscan indicated anterior territory ischemia and coronary angiography revealed 95% stenosis of the left anterior descending artery (LAD). He underwent percutaneous coronary intervention (PCI) with stenting of the LAD. During the patient’s workup, he was noted to have elevated hemoglobin (20) and hematocrit (60) levels and was treated with 1g hydroxyurea as phlebotomy was unavailable. JAK2 mutation and EPO level screenings were ordered and unremarkable. The patient was noted to have multiple subcutaneous testosterone pellets in his buttocks which he stated were implanted three weeks prior. Serum total testosterone was elevated at 1226 ng/dL. Hematology was consulted and the patient continued daily 1g hydroxyurea. After discharge, the patient continued outpatient follow up with hematology and received plasmapheresis for management of polycythemia. CONCLUSION: Considering polycythemia can arise secondary to exogenous testosterone use and is a known risk factor for cardiovascular events, it is likely this patient’s myocardial infarction was complicated by his use of exogenous bioidentical testosterone. Compound pharmacies providing bioidentical testosterone are not required to report adverse events, provide black box warnings, or show evidence-based safety and efficacy profiles for their products. The increasing availability and use of non-FDA-approved testosterone therapies warrants increased physician vigilance, particularly for patients with existing cardiac conditions or predisposition to hypercoagulable and prothrombotic states. The lack of regulation and research in the realm of compound pharmacy hormone products calls for further studies and reforms to protect patients from the risk of developing detrimental complications. REFERENCE: (1) Xu, L., Freeman, G., Cowling, B. et al. Testosterone therapy and cardiovascular events among men: a systematic review and meta-analysis of placebo-controlled randomized trials. BMC Med11, 108 (2013).