Is Therapeutic Phlebotomy Covered By Insurance
Unfortunately, it can be difficult to qualify for reimbursement, or to get therapeutic phlebotomy covered by insurance.
Some physicians may write a letter of medical necessity, which the patient can take to their insurance company to justify the procedure. The CPT reimbursement codes for therapeutic phlebotomy are CPT 39107, icd9 code 289.0.
A Study Conducted On 235 Men Concluded That Frequent Blood Donors Can Develop Iron Deficiency
The group of 235 men was separated into 3 categories control group with no donations, group 2 with 2 donations per year and group 3 with 3 donations per year. The age of the donors was between 17 and 65 years and their hemoglobin values were higher than 12.5 g/dl. Donors who took iron supplements before were excluded from this study to avoid interfering with the results.
Expertly Guided Trt With Defy Medical
To identify and manage polycythemia, work with an experienced provider who monitors your hematocrit and hemoglobin levels and recommends treatment based on the results. This is why individualized care with regular follow-up is so important for a successful TRT protocol.
With Defy Medical, you access telemedicine consultations with Mens Health experts who can provide on-going guidance. You also access online ordering and doorstep delivery of medications, and a Patient Care team accessible by phone and email who can answer questions and guide you through your protocol.
Ready to learn more about polycythemia and TRT, or consult with an expert about how to manage it?
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How Often Should I Donate Blood Or Receive Therapeutic Phlebotomy
The frequency of the phlebotomy depends on individual factors, and your provider should work with you to develop a customized plan.
In general, a blood draw every two to three months is typically recommended for TRT patients experiencing polycythemia. Its important not to overdraw blood, because doing so can lead to anemia, iron deficiency, and other conditions.
You and your provider should continue measuring your hematocrit and hemoglobin after beginning therapeutic phlebotomy. Your tests results help identify whether the treatment is sufficient.
Regular testing can also let you know if your red blood cell production stabilizes. Sometimes RBC production can normalize without any specific cause.
Testosterone Replacement Therapy Formulations
Testosterone replacement therapy is recommended for men who have testosterone levels lower than 300ng/ dL. It is commonly accepted that the T levels decrease by approximately 1% per year after 35 years of age. TRT has been shown to improve the mood of the patients, correct insulin resistance problems, help increase bone density and muscle mass, among other positive benefits.
Getting testosterone into the body can be done in various ways. There are injections, gels, buccal patches, pellets, and others. Some formulations show results much quicker and each one of them has different effects on patients, depending on the dosage, administration option, etc.
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Why Does Trt Sometimes Cause Polycythemia
In addition to regulating body composition and sex drive, Testosterone can increase the bodys production of red blood cells . When you raise your Testosterone levels, you may also increase your RBC count.
Although all Testosterone delivery systems can increase the amount of red blood cells, studies show a higher incidence of polycythemia in those using intramuscular Testosterone injections compared to topical Testosterone.
Smoking has also been associated with polycythemia and may contribute to this condition. If youre a smoker and youre on TRT, consider a smoking cessation program.
In Testosteroneby Bryan Treacy
TRT is a beneficial treatment for men with age related testicular hypofunction. The risks and benefits of TRT have been debated for many years and I was taught in medical school that testosterone replacement was dangerous and most often not indicated. The literature does not support what I was taught.
Most of the things that are considered dangerous for men on TRT are, in fact, issues that are more common in men with low and low normal testosterone levels. Im sure youve seen the lawyer commercials regarding the risk of heart attacks, strokes, venous thromboembolism, and prostate cancer. All of those are actually more common in men with lower than optimal testosterone levels. While testosterone will grow a prostate cancer that already exists, it does not cause prostate cancer. Therefore, it is important to screen men for prostate cancer prior to starting TRT.
Dr. Abraham Morgentaler, of Harvard, did a study several years ago showing that in men under 60 years of age with total testosterone levels less than 350, there was a 15% incidence of asymptomatic prostate cancer. Those cancers were of the more aggressive type than prostate cancer found in men over the age of 60. Of course, many men over the age of 60 have total testosterone levels less than 350.
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How Quickly Does Testosterone Therapy Work
Testosterone therapy and other treatments such as testosterone replacement therapy and hormone therapy can begin to work within a couple of weeks, but it may take up to a few months for you to notice the full effects. The most common side effects of taking testosterone therapy includeacne, increased hair growth, and alterations in mood, sexual desire, or libido.
If you experience any bothersome side effects, be sure to talk to your doctor. Testosterone therapy is an effective treatment for low testosterone, and it can improve your quality of life. If you are interested in starting testosterone therapy, make an appointment with your doctor to discuss whether it is right for you.
Polycythemia From Testosterone Therapy: To Treat Or Not
Darrell Hulisz, PharmD
Question
What is the clinical significance of the increase in hemoglobin and hematocrit that develops secondary to testosterone replacement?
| Response from Darrell Hulisz, PharmD Associate Professor, Case Western Reserve University School of Medicine Clinical Specialist in Family Medicine, University Hospitals, Case Medical Center, Cleveland, Ohio |
Testosterone replacement therapy is the mainstay of treatment for male hypogonadism. Hypogonadism is sometimes referred to in the lay media as low testosterone, though there are certain medical distinctions. Hypogonadism is marked by a decrease in testicular sperm production and/or a decrease in endogenous testosterone production. This may result from diseases of the testes, such as primary hypogonadism, or from secondary causes, such as diseases of the pituitary or hypothalamus.
Clinicians often encounter patients with hypogonadism in association with declining endogenous testosterone production that occurs as men age. This is sometimes referred to as andropause. Signs and symptoms of low testosterone include decreased libido, impotence, decreased body hair, decreased muscle mass, fatigue, and decreased bone mineral density.
Acknowledgement: The author wishes to thank Stephen Hoffacker for providing technical assistance.
Cite this: Darrell Hulisz. Polycythemia From Testosterone Therapy: To Treat or Not? – Medscape – Nov 01, 2012.
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Should I Stop Trt If I Have A High Red Blood Cell Count
For many patients, stopping their TRT protocol isnt the best option.
Patients typically start TRT to address life-derailing symptoms of Testosterone imbalance, including low sex drive, sexual dysfunction, lack of energy and fatigue, fat gain, and more. Without TRT, these unwanted symptoms often return.
You may also wonder if you should switch from injections to topical Testosterone, since the latter seems to have less effect on hematocrit. Many patients dont like this option, either, because their injection protocol is effective at reducing their hormone imbalance symptoms.
So, what can you do to address polycythemia caused by TRT? Read on to find out more.
Understanding The Occurrence Of High Red Blood Cells And Hematocrit On Testosterone Replacement Therapy
Erythrocytosis is a medical condition that appears when the body is making too many red blood cells. RBCs are responsible for transporting oxygen to organs and tissues. When they are too many, the blood can become too thick and cause cardiovascular complications.
There are 2 types of erythrocytosis primary and secondary. The primary erythrocytosis is usually caused by bone marrow problems. RBCs are made in the bone marrow and something might trigger an increase in their production. Secondary erythrocytosis is caused by certain diseases or drugs, including testosterone replacement therapy.
TRT is the go-to treatment for people who suffer from hypogonadism aka androgen deficiency. This type of treatment is increasingly popular especially among people over 40 years of age. It can increase libido, help to maintain muscle mass, improve mood and general wellbeing. However, one of the side effects of TRT is a simple fact that it can cause erythrocytosis.
This medical condition is represented by an increase in hemoglobin and hematocrit . When the Hb is higher than 18.5 g/dL and the Hct is higher than 52% in men, the patient suffers from erythrocytosis.
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When To Test For Polycythemia
Typically, you should test your hemoglobin and hematocrit before starting TRT to establish a baseline. Then, you and your provider should test again three months after beginning your TRT protocol.
After that, many established TRT patients move to checking hemoglobin and hematocrit every six months. .
Hematocrit Trt Study Material And Methods
264 patients were admitted to the sleep unit to undertake a polysomnographic evaluation and were subsequently diagnosed with OSAS. 116 of these patients met the criteria of the study and agreed to participate. These patients reported frequent unpleasant symptoms such as daytime sleepiness, severe snoring at nighttime, etc.
The exclusion criteria left out patients who had various types of medical conditions that might have interfered with the results of the study. For example, patients who had known cardiovascular diseases, were smokers, had diabetes mellitus, lung disease or hypertension were not included in the study.
The 116 patients who participated in the study were divided into several groups, depending on the apnea-hypopnea index which basically indicates the severity of the sleep apnea. There were 3 groups mild , moderate and severe . There was also a control group of 62 individuals who had an apnea-hypopnea index of less than 5.
The study was performed using polysomnographic methods. Researchers have attached suprasternal microphones to assess the airflow of the patients during sleep. Blood samples were also drawn using a 21-gauge needle syringe after a fasting period of 8 hours. The apnea was defined as a stop of airflow for 10 seconds or more during sleep. Hypopnea was defined as a reduction of airflow between 30% and 50% as well as a decrease in capillary oxygen saturation.
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Are There Other Causes Of Polycythemia Besides Trt
There are different types of polycythemia, which can be caused by different things.
Primary polycythemia occurs because of a genetic mutation inside the bone marrow, which causes it to overproduce red blood cells.
Secondary polycythemia can be caused by:
- Sleep apnea or a breathing obstruction
- Chronic Obstructive Pulmonary Disease
- Certain cancers and/or endocrine tumors
- Performance enhancing drugs
Your risk of developing polycythemia may increase if you have any of these conditions and also begin Testosterone Replacement Therapy.
Erythrocytosis And Thromboembolic Risk
Several studies have attempted to evaluate the relationship between erythrocytosis and endothelial dysfunction. In 1978, Pearson and Wetherley-Mein observed a positive correlation between packed red cell volume and vascular venocclusive episodes . Though not testosterone-induced, an increased thromboembolic risk from elevated Hct was demonstrated. In 2010, Braekkan et. al., in a large, prospective, population-based study found that a 5% increase in Hct in men resulted in an increased risk of VTE ) this relationship remained significant in the multivariable model adjusted for age, smoking, and BMI . Unfortunately, smoking was assessed as a dichotomous variable and the authors acknowledged this as a limitation, as they were unable to take into account the potential dose-dependent effect. Also, there were limited data on underlying medical diseases which may have acted as cofounding variables. In a 2013 study, Marchioli et al. randomized 365 adults with polycythemia vera to a more intensive or less intensive treatment group with primary endpoint of time until death from cardiovascular causes or major thromboembolic event. After 31 months of follow up, the less intensive treatment group experienced significantly more events than the more intensive treatment group .
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Therapeutic Phlebotomy For Polycythemia
Therapeutic phlebotomy is similar donating blood, but this procedure is prescribed by physicians as a way to bring down blood hematocrit and viscosity. Removing one pint of blood generally lowers hematocrit by around 3% .
Depending on your unique circumstances, your provider may recommend regular therapeutic phlebotomy every 8-12 weeks.
The procedure is simple and performed in the same manner as a blood donation. Successful therapeutic phlebotomy typically decreases hematocrit, hemoglobin, and blood iron in less than one hour.
The Risk Of Elevated Hct And/or Haemoglobin
With an increase in RBCs and subsequent HCT, we will ultimately see an increase in arterial blood pressure. This is due to an increase in blood viscosity and the reversal of hypoxic vasodilation 10. Hypoxia causes blood vessels to relax and increase in diameter, which will lower blood pressure due to having an increased area, where pressure is defined as force divided by the area:
Furthermore, high haemoglobin concentration, or HCT, is a known risk factor or major atherosclerotic cardiovascular events 11. This will be due to elevated blood pressure, cardiac load, and friction with the blood vessel wall, leading to damage and build-up of atherosclerotic plaque as a result in men 12.
Ironically, athletes will see an immediate decrease in haematocrit post training due to increase plasma volume, which leads to sports anaemia which isnt detrimental to performance. True anaemia is however common among athletes due to iron deficiency, especially in female athletes. Though, in the long term they have will also have a greater HCT and RBC mass compared to sedentary individuals, as they require more oxygen a by-product of training 15,16. Still, excess HCT/Haemoglobin will cause issues even in athletes its not healthy in the long run.
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Are There Other Treatments For Polycythemia
For general heart health and to help prevent heart attacks, some doctors may recommend daily aspirin and/or omega-3 fatty acids .
These can be an important part of a heart health regimen, but they are not typically alternatives for therapeutic phlebotomy if you have polycythemia and want to continue TRT.
There are prescription medications that slow the production of red blood cells directly, but patients often prefer trying therapeutic phlebotomy first. The latter has a good safety profile and has been shown to be effective for many patients.
Risk For Vte With Increased Hct
Whether TRTinduced increases in Hct lead to an increased risk for venothrombotic events remains uncertain. Although it is known that enhanced blood viscosity poses a threat for ischemic sequela, the relationship between Hct and the risk for developing VTE remains controversial 11, 73. The direct relationship between TRTinduced elevations in Hct and subsequent risk for VTE has not been investigated through randomized controlled trials . The literature on this topic consists primarily of
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Erythrocytosis And Polycythemia As Adverse Drug Events During Trt
Contemporary controversy surrounding TRT centers on the risk for potential venous thromboembolism . The Food and Drug Administration recently mandated that testosterone manufacturers include a warning label stating that testosterone may increase risk of VTE . It has been proposed that the risk for VTE was due to the secondary blood profile changes however, reports of VTE not associated with erythrocytosis or polycythemia have questioned this notion. As the
Taking Testosterone Watch For Polycythemia And Sleep Apnea Experts Warn
Men undergoing testosterone replacement therapy should be aware of links between obstructive sleep apnea and polycythemia, an abnormal amount of circulating red blood cells in the bloodstream, suggests a recent Journal of Sexual Medicine study.
TRT has grown in popularity over the years. It is generally approved for men whose bodies dont produce enough testosterone on their own due to problems in the testes or areas of the brain that trigger testosterone production.
However, mens testosterone levels gradually decline as they get older, too. Some take testosterone to manage symptoms like low libido, moodiness, and fatigue.
TRT does have side effects. One is polycythemia . As the number of red blood cells grows, the blood can thicken, increasing the risk for stroke. Usually, men who develop polycythemia can lower their testosterone dose or switch to a different formulation.
Polycythemia is also associated with obstructive sleep apnea, a disorder that causes a person to stop breathing for short intervals while asleep. Studies have found that men with low testosterone, and those on TRT, might be more likely to have OSA.
The authors of the current study wanted to learn more about the relationship among TRT, polycythemia, and OSA.
They analyzed the medical charts of 474 men in their clinic who were on TRT. About 13% of the men were diagnosed with polycythemia. Of this group, 52% were also diagnosed with OSA.
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Hematocrit Elevation Following Testosterone Therapy Does It Increase Risk Of Blood Clots
In discussions about side effects of testosterone treatment, prostate cancer and heart disease get most attention. However, as we have described in several study reports published here in the Research News section, the widespread fear of prostate cancer and heart disease is unfounded and not supported by medical research.
The expected potential side effect of testosterone treatment – which in fact is a therapeutic effect in men with anemia – is an increased level of red blood cells, known as erythrocytosis or polycythemia. In the context of testosterone treatment, erythrocytosis and polycythemia are used interchangeably to refer to an abnormal increase of red blood cells or hematocrit, which may increase blood viscosity .
However, it should be pointed out that technically, erythrocytosis is just red blood cell elevation, while polycythemia involves elevation of red blood cells, white blood cells, and platelets. Using these terms as synonyms can cause confusion. In polycythemia, it is likely the increase in platelets that is the major culprit of blood clots.
Elevated hematocrit is the most common side-effect of testosterone treatment. The clinical significance of a high hematocrit level is unclear, but it may theoretically be associated with an increased risk of thrombosis .