testosterone intranasal (Rx)

Brand and Other Names:Natesto
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

intranasal gel: Schedule III

  • 5.5mg/actuation

Testosterone Deficiency

Indicated for replacement therapy in males for conditions associated with a deficiency or absence of endogenous testosterone

11 mg (2 sprays [ie, 1 spray in each nostril]) TID (total daily dose of 33 mg)

Also see Administration

Indications

  • Primary hypogonadism (congenital or acquired): Testicular failure due to conditions such as cryptorchidism, bilateral torsion, orchitis, vanishing testis syndrome, orchiectomy, Klinefelter syndrome, chemotherapy, or toxic damage from alcohol or heavy metals; these men usually have low serum testosterone concentrations and gonadotropins (follicle-stimulating hormone [FSH], luteinizing hormone [LH]) above the normal range
  • Hypogonadotropic hypogonadism (congenital or acquired): Idiopathic gonadotropin or luteinizing hormone-releasing hormone (LHRH) deficiency or pituitary-hypothalamic injury from tumors, trauma, or radiation; these men have low testosterone serum concentrations but have gonadotropins in the normal or low range

Monitoring

  • Monitor serum total testosterone concentrations periodically, starting as soon as 1 month after initiating treatment
  • When total serum testosterone concentration consistently >1050 ng/dL, discontinue therapy
  • If the total testosterone concentration is consistently <300 ng/dL, consider an alternative treatment

Dosing Considerations

Prior to initiating therapy, confirm the diagnosis of hypogonadism by ensuring that serum testosterone concentrations have been measured in the morning on at least two separate days and that these serum testosterone concentrations are below the normal range

Limitations of use: Safety and efficacy of testosterone in men with “age-related hypogonadism” (also referred to as “late-onset hypogonadism”) have not been established.

Safety and efficacy of testosterone in males aged <18 yr have not been established

<18 years: Safety and efficacy not established

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Interactions

Interaction Checker

and testosterone intranasal

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    Contraindicated

      Serious - Use Alternative

        Significant - Monitor Closely

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            Contraindicated (0)

              Serious - Use Alternative (14)

              • betamethasone

                testosterone intranasal, betamethasone. Either increases effects of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration increases risk for edema, particularly in patients with cardiac, renal, or hepatic disease.

              • corticotropin

                testosterone intranasal, corticotropin. Either increases effects of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration increases risk for edema, particularly in patients with cardiac, renal, or hepatic disease.

              • cortisone

                testosterone intranasal, cortisone. Either increases effects of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration increases risk for edema, particularly in patients with cardiac, renal, or hepatic disease.

              • dexamethasone

                testosterone intranasal, dexamethasone. Either increases effects of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration increases risk for edema, particularly in patients with cardiac, renal, or hepatic disease.

              • fludrocortisone

                testosterone intranasal, fludrocortisone. Either increases effects of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration increases risk for edema, particularly in patients with cardiac, renal, or hepatic disease.

              • hydrocortisone

                testosterone intranasal, hydrocortisone. Either increases effects of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration increases risk for edema, particularly in patients with cardiac, renal, or hepatic disease.

              • methylprednisolone

                testosterone intranasal, methylprednisolone. Either increases effects of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration increases risk for edema, particularly in patients with cardiac, renal, or hepatic disease.

              • pexidartinib

                testosterone intranasal and pexidartinib both increase Other (see comment). Avoid or Use Alternate Drug. Pexidartinib can cause hepatotoxicity. Avoid coadministration of pexidartinib with other products know to cause hepatoxicity.

              • prednisolone

                testosterone intranasal, prednisolone. Either increases effects of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration increases risk for edema, particularly in patients with cardiac, renal, or hepatic disease.

              • prednisone

                testosterone intranasal, prednisone. Either increases effects of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration increases risk for edema, particularly in patients with cardiac, renal, or hepatic disease.

              • pretomanid

                testosterone intranasal, pretomanid. Either increases toxicity of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Pretomanid regimen associated with hepatotoxicity. Avoid alcohol and hepatotoxic agents, including herbal supplements and drugs other than bedaquiline and linezolid.

              • sotorasib

                sotorasib will decrease the level or effect of testosterone intranasal by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug. If use is unavoidable, refer to the prescribing information of the P-gp substrate for dosage modifications.

              • triamcinolone acetonide injectable suspension

                testosterone intranasal, triamcinolone acetonide injectable suspension. Either increases effects of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration increases risk for edema, particularly in patients with cardiac, renal, or hepatic disease.

              • warfarin

                testosterone intranasal increases levels of warfarin by decreasing metabolism. Avoid or Use Alternate Drug. Androgens may inhibit warfarin metabolism and/or potentiate anticoagulant effects by affecting the coagulation system.

              Monitor Closely (14)

              • atogepant

                testosterone intranasal will increase the level or effect of atogepant by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • insulin aspart

                testosterone intranasal increases effects of insulin aspart by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Androgens may decrease blood glucose and, therefore, may necessitate a decrease in the dose of antidiabetic medication.

              • insulin aspart protamine/insulin aspart

                testosterone intranasal increases effects of insulin aspart protamine/insulin aspart by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Androgens may decrease blood glucose and, therefore, may necessitate a decrease in the dose of antidiabetic medication.

              • insulin degludec

                testosterone intranasal increases effects of insulin degludec by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Androgens may decrease blood glucose and, therefore, may necessitate a decrease in the dose of antidiabetic medication.

              • insulin degludec/insulin aspart

                testosterone intranasal increases effects of insulin degludec/insulin aspart by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Androgens may decrease blood glucose and, therefore, may necessitate a decrease in the dose of antidiabetic medication.

              • insulin detemir

                testosterone intranasal increases effects of insulin detemir by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Androgens may decrease blood glucose and, therefore, may necessitate a decrease in the dose of antidiabetic medication.

              • insulin glargine

                testosterone intranasal increases effects of insulin glargine by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Androgens may decrease blood glucose and, therefore, may necessitate a decrease in the dose of antidiabetic medication.

              • insulin glulisine

                testosterone intranasal increases effects of insulin glulisine by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Androgens may decrease blood glucose and, therefore, may necessitate a decrease in the dose of antidiabetic medication.

              • insulin inhaled

                testosterone intranasal increases effects of insulin inhaled by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Androgens may decrease blood glucose and, therefore, may necessitate a decrease in the dose of antidiabetic medication.

              • insulin isophane human/insulin regular human

                testosterone intranasal increases effects of insulin isophane human/insulin regular human by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Androgens may decrease blood glucose and, therefore, may necessitate a decrease in the dose of antidiabetic medication.

              • insulin lispro

                testosterone intranasal increases effects of insulin lispro by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Androgens may decrease blood glucose and, therefore, may necessitate a decrease in the dose of antidiabetic medication.

              • insulin lispro protamine/insulin lispro

                testosterone intranasal increases effects of insulin lispro protamine/insulin lispro by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Androgens may decrease blood glucose and, therefore, may necessitate a decrease in the dose of antidiabetic medication.

              • insulin NPH

                testosterone intranasal increases effects of insulin NPH by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Androgens may decrease blood glucose and, therefore, may necessitate a decrease in the dose of antidiabetic medication.

              • insulin regular human

                testosterone intranasal increases effects of insulin regular human by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Androgens may decrease blood glucose and, therefore, may necessitate a decrease in the dose of antidiabetic medication.

              Minor (0)

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                Adverse Effects

                1-10%

                Nasopharyngitis (8.2%)

                Rhinorrhea (7.8%)

                Epistaxis (6.5%)

                Nasal discomfort (5.9%)

                Increased PSA (5.1-5.8%)

                Nasal scab (5.2%)

                Parosmia (5.2%)

                Headache (3.8-4.3%)

                Upper respiratory tract infection (4.2%)

                Nasal dryness (4.2%)

                Nasal congestion (3.9%)

                Bronchitis (3.8%)

                Sinusitis (3.8%)

                ncreased blood pressure (2-3%)

                Dysgeusia (2-3%)

                Cough (2-3%)

                Postmarketing Reports

                Vascular disorders: Venous thromboembolism

                Myocardial infarction, stroke

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                Warnings

                Contraindications

                Men with carcinoma of the breast

                Men with known or suspected prostate cancer

                Pregnant or breast-feeding women; testosterone may cause fetal harm

                Cautions

                Testosterone has been subject to abuse, typically at doses higher than recommended for the approved indication and in combination with other anabolic androgenic steroids; anabolic androgenic steroid abuse can lead to serious cardiovascular and psychiatric adverse reactions

                Nasal adverse reactions reported, including nasopharyngitis, rhinorrhea, epistaxis, nasal discomfort, and nasal scabbing

                Monitor for nasal signs and symptoms; not recommended for patients with chronic nasal conditions or alterations in nasal anatomy (eg, nasal or sinus surgery, nasal fracture within previous 6 months, deviated anterior nasal septum, mucosal inflammatory disorders [Sjogren syndrome], sinus disease)

                Monitor patients with benign prostatic hyperplasia (BPH) for worsening of signs and symptoms

                Increased hematocrit (polycythemia), reflective of increased red blood cell mass, may require discontinuation; increases risk for thromboemolism

                Venous thromboembolism, including DVT and PE reported in patients using testosterone products; these observations have included patients with and without polycythemia; evaluate signs or symptoms consistent with DVT or PE; if venous thromboembolic event suspected, discontinue treatment with testosterone and initiate appropriate workup and management

                Women and children should not use testosterone intranasal

                Prolonged use of high doses of orally active 17-alpha-alkyl androgens (methyltestosterone) has been associated with serious hepatic adverse effects (peliosis hepatitis, hepatic neoplasms, cholestatic hepatitis, and jaundice)

                Edema with or without CHF may be a complication in patients with preexisting cardiac, renal, or hepatic disease

                Exogenous administration of androgens may lead to azoospermia

                Gynecomastia may develop and may persist in patients being treated with androgens

                Sleep apnea may occur in those with risk factors

                Androgens should be used with caution in cancer patients at risk of hypercalcemia (and associated hypercalciuria)

                Androgens may decrease concentrations of thyroxine-binding globulins, resulting in decreased total T4 serum concentrations and increased resin uptake of T3 and T4

                Monitor serum testosterone, prostate-specific antigen (PSA), hemoglobin, hematocrit, liver function tests, and lipid concentrations periodically

                Some postmarketing studies have shown an increased risk of myocardial infarction and stroke associated with the use of testosterone replacement therapy

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                Pregnancy & Lactation

                Pregnancy Category: X

                Lactation: Contraindicated; unknown if excreted into human breast milk

                Pregnancy Categories

                A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

                B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

                C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

                D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

                X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

                NA: Information not available.

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                Pharmacology

                Mechanism of Action

                Endogenous androgen; promotes growth and development of male sex organs and maintains secondary sex characteristics in androgen-deficient males

                Absorption

                Peak plasma time: 40 minutes

                Average daily plasma concentration: 421 ng/dL

                Provides circulating testosterone concentrations that approximate normal concentrations (ie, 300-1,050 ng/dL)

                Serum total testosterone concentrations decreased by 21-24% in males with symptomatic allergic rhinitis, whether treated with nasal decongestants (eg, oxymetazoline) or left untreated

                Distribution

                Protein bound in the serum to sex hormone-binding globulin (SHBG) and albumin

                ~40% of testosterone in plasma is bound to SHBG, 2% remains unbound (free), and the rest is loosely bound to albumin and other proteins

                Metabolism

                Metabolized in liver to various 17-keto steroids through 2 different pathways

                Major active metabolites are estradiol and dihydrotestosterone (DHT)

                DHT concentrations increased in parallel with testosterone concentrations; after 90 days, the mean DHT/testosterone ratio was 0.09 (within the normal range)

                Elimination

                Half-life: 10-100 minutes

                Excretion (data from IM administration): 90% urine (as glucuronic and sulfuric acid conjugates); 6% feces (unconjugated form)

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                Administration

                Intranasal Administration

                Blow nose prior to use

                Administer 3 times daily; once in the morning, once in the afternoon, and once in the evening (6-8 hr apart), preferably at the same time each day

                Patients should be instructed to completely depress the pump 1 time in each nostril to receive the total dose

                Use a clean, dry tissue to wipe actuator tip, then replace the cap on the dispenser

                Press on the nostrils at a point just below the bridge of the nose and lightly massage

                Refrain from blowing the nose or sniffing for 1 hr after administration

                Do not administer to other parts of the body

                Not recommended for use with intranasal drugs (except for sympathomimetic decongestants)

                Discontinue temporarily if severe rhinitis occurs

                Prime the pump

                • Before using for the first time, instruct patient to prime the pump by inverting the pump, depressing the pump 10 times, and discarding any small amount of product dispensed directly into a sink and then washing the gel away thoroughly with warm water
                • The tip should be wiped with a clean, dry tissue
                • If the patient gets gel on his hands, it is recommended that he wash his hands with warm water and soap This priming should be done only prior to the first use of each dispenser
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                Patient Handout

                A Patient Handout is not currently available for this monograph.
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                Formulary

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                The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

                Tier Description
                1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
                2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
                3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
                4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
                5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
                6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
                NC NOT COVERED – Drugs that are not covered by the plan.
                Code Definition
                PA Prior Authorization
                Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
                QL Quantity Limits
                Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
                ST Step Therapy
                Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
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                Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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                Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.