State Board of Medical Examiners
Medical Licensure Commission
January – March 2012
Volume 27, Number 1
Treating androgen defi ciency in the
aging male: a urologist perspective
Board of Medical

Matthew R. Thom, MD, Tuscaloosa urologist Introduction
Normal aging in men is accompanied by a decline in testosterone (T) production and function that may contribute to detrimental changes to overall male health. Hypogonadism Paper Prescriptions
displays numerous clinical manifestations and the degree and timing of onset is variable and not universal for all men. This can lead to diffi culty in diagnosis and treatment. A paper when prescribing controlled substances typical man with low T may be between the age of 40 to 69 and present with signs and symptoms of fatigue, low energy, depressed mood and low sexual drive.
DEA Notice
Carisoprodol is con-
What is Low T and what causes it?
Low T or symptomatic late-onset hypogonadism is a clinical and biochemical syndrome characterized by Matthew R. Thom, MD
defi ciency in androgen activity which may affect the function of multiple organ systems and result in signifi cant detriment in quality of life. More than Dispensing Physician
500,000 new cases may be diagnosed each year but remains under diagnosed and treated. Registration
All physicians who
Numerous theories to its cause are present with a combination of factors contributing to the problem. These include aging hypothalamus with decrease production of gonadotropins, primary testicular failure, changes in androgen receptor activity/function, and effects on T metabolism that lead to decrease function regardless of T levels.
What are the effects of androgen defi ciency?
PA Education
Presentation of the hypogonadal patient is variable which can make diagnosis diffi cult. Common signs and symptoms include low energy, depressed mood, sleep disturbances, depressed cognition, impotence, and low libido. But low T may also unknowingly contribute to systemic disease including metabolic syndrome, increased cardiovascular Public Actions
Dec. 2011 – March 2012
How is low T diagnosed?
Clinical diagnosis is problematic because neither low T nor symptoms are truly diagnostic. The most common symptoms – tiredness, depressed sexual drive, and dysphoria – should tip the physician to further evaluate for hypogonadism. Several screening questionnaires are available to aid in the diagnosis, but unfortunately are not specifi c. Initial testing should include T levels obtained between 8 a.m. and 11 a.m., with total T being suffi cient. Any low level should be confi rmed and may include LH, prolactin if clinically warranted. Unfortunately, there is much variability in T level reporting and the parameters for hypogonadism. This is currently under scrutiny by medical groups and societies with hope to standardized reporting to ensure better research, trials and patient care.
Issue 1 • 2012
A Message from the Executive Director
Board of Medical
Annual report of the Alabama BME
by Larry Dixon, Executive Director George C. Smith Jr., MD,
In 2011, there was another increase in the number of Chairman
newly licensed physicians in Alabama, with 769 approved applicants by endorsement and 66 approved applicants by Richard M. Freeman, MD
examination, 40 more approved applicants than in 2010. This Vice Chairman
was the second year to report Qualifi ed Alabama Controlled Substances Certifi cates (QACSCs), with 42 issued in 2011. James G. Davis, MD
The QACSC is for use by physician assistants. The Board of Birmingham
Medical Examiners and its staff have compiled the following H. Joseph Falgout, MD
Steven P. Furr, MD
Larry Dixon
a. Non-disciplinary Citation with Administrative charge .16 William E. Goetter, MD
T. Michael Harrington, MD
B. Jerome Harrison, MD
David P. Herrick, MD
John S. Meigs Jr., MD
Certifi ed Registered Nurse Practitioner Collaborations Approved . 1,167 Centreville
Certifi ed Nurse Midwife Collaborations Approved . 1 Paul M. Nagrodzki, MD
Timothy A. Stewart, MD
2. Physician Assistants Registered to Physicians (new applications) . 216 Huntsville
3. Physician Assistants Granted Temporary Licensure . 9 W. Jeff Terry, MD
4. Temporary Licensure Converted to Full Licensure (after passing exam) . 8 5. Temporary Licensees Granted Registration . 7 7. Anesthesiologist Assistants Granted Temporary License . 0 Larry Dixon
8. Anesthesia Assistants Registered to Physicians (new applications) . 2 Executive Director
Patricia Shaner
General Counsel
Carla Kruger
Staff Editor
(334) 242-4116
Issue 1 • 2012
Schedule II controlled substances DEA announcement
Under DEA regulations, paper prescriptions for Schedule II controlled concerning
substances issued on the same sheet of paper as prescriptions for other schedules of controlled substances and non-controlled drugs cannot be carisoprodol (soma)
fi lled by pharmacies without the pharmacy fi rst separating the Schedule II controlled substances prescribed from the other drugs listed. This can lengthen the amount of time it takes for patients to receive their medica- tions. It is advisable that any paper prescription order for Schedule II
controlled substances be written on a separate sheet of paper from any
other prescriptions. This should reduce any confusion for patients and
speed in the fi lling of prescriptions.
prescriptions for drugs containing carisoprodol shall comply with 21 BME Report, cont.
C.F.R. §§ 1306.03–1306.06, 1306.21, and 1306.22–1306.27.
1. ACSC Surrender / Revocation / Restriction / Reinstatement . 2 Certifi cates of Qualifi cation Denied / Surrendered . 1 Certifi cates of Qualifi cation with Agreements / Restrictions . 2 Certifi cate of Qualifi cation Restrictions Terminated . 0 prescription was issued for a legitimate 8. Complainant Formal Investigations . 121 9. Collaborative Practice Inspections . 133 practitioner is fi ve or less (21 U.S.C. § 10. Collaborative Practice Compliance Seminars . 3 fi led with Medical Licensure Commission . 34 responsible for ensuring the prescription 13. Voluntary Agreements Entered Into . 21 and regulations, both federal and state. 14. Voluntary Restrictions Entered Into . 2 responsibility for the proper prescribing Physician Monitoring Program - Physicians Currently Monitored . 90 rests with the pharmacist who fi lls the 829(b). Therefore, if a prescription for Summary Suspension B Suspension Lifted . 1 21. Voluntary Surrender of Alabama Medical License . 2 Issue 1 • 2012
Androgen defi ciency, cont.
How is T replaced?

Intramuscular injections reliably increase T levels for hypogonadal men but T levels may reach supraphysiologic levels and the normal circadian rhythm is absent. This will make patients complain of a “roller coaster effect”. Also, current preparations available require repeat injections typically every 2-3 weeks. Oral preparations are rarely used in US due to erratic effects on T levels and problems with liver toxicity and hyperlipidemia. Transdermal patches and gels are popular yet require daily administration with defi nite risk for transference to others. One of the newer formulations available is T pellets implanted subcutaneously every 3-6 months. It has benefi ts with fewer administrations and no risk of transference. But T pellet implantation requires a procedure and there is risk of extrusion of pellets, poor absorption and other procedure site side-effects.
What are the adverse effects of T replacement?
A prior history of prostate or breast cancer is considered an absolute contraindication for hormone replacement. This “truth” has been questioned particularly in light of current treatment of low risk prostate cancer. Hormone replacement in hypogonadal men with clinically cured or untreated low risk disease has been studied showing no signifi cant increase risk of recurrence or progression. However, most practicing urologists discourage T replacement for these men. Neither an increased prostate size nor an increased PSA, with associated lower urinary tract symptoms or increased risk of prostate cancer, has been demonstrated in several short-term studies. Long term effects of T replacement are not well known at this time. T replacement may also lead to increase red blood cell mass and hemoglobin. Side effects from excessive supplementation of T and other rare problems include infertility, testicular atrophy, priapism, fl uid retention, liver toxicity (uncommon DEA, cont.
with current preparations), hepatitis and hepatic tumors, sleep apnea and gynecomastia. Infertility caused by T supplementation may require treatment with gonadotropins to increase testosterone and attempt to restore normal spermatogenesis. Side-effects from the route of administration may also occur.
fi ve) must be dispensed no later than six months after the date the Conclusion
Hypogonadism is a common yet under recognized problem in aging men. Not only will low T level lead to sexual side effects it may also effect psychological, physical and overall well-being of older men. Replacement is indicated for men who have signs and symptoms of hypogonadism accompanied by subnormal serum T levels. T supplementation can provide important health benefi ts to these hypogonadal men. T supplementation requires medical surveillance in order to identify early signs of possible adverse effects. Although the benefi ts and risks of long-term T supplementation have not been defi nitely established, the weight of current evidence does not suggest an increased risk of heart disease or prostate 11, 2012, persons who prescribe, administer, or dispense carisoprodol References
1. Bhasin S, Cunningham GR, Hayes FJ, et al. Testosterone therapy in men with androgen defi ciency syndromes: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2010; 95:2536-59 2. Morales A, Morley J and Heaton JPW. Androgen defi ciency in the aging male. Campbell Walsh-Urology, 9th Edition. Philadelphia, WB Saunders Elsevier; 3. Morgentaler A, Lipshultz LI, Bennett R, et al. Testosterone therapy in men with untreated prostate cancer. J Urol. 2011; Apr: 185(4): 1256-61 4. Rhoden EL and Morgentaler A. Risks of testosterone replacement therapy and recommendations for monitoring. N Engl J. 2004; 350: 482-92 5. Traish AM, Guay A, Feeley R, et al. The dark side of testosterone defi ciency: Metabolic syndrome and erectile dysfunction. J Androl. 2009; 30: 10-22 Issue 1 • 2012
Dispensing physician registration
Opportunities for 2012
not to have
March 31-April 1
If you allow another individual
Prescribing and Pharmacology of
to complete this registration
Controlled Drugs: Critical Issues and
for you, accurate information
Common Pitfalls
remains your responsibility.
Ensuring Quality in the Collaborative
substances purchased with a hospital’s April 13-14
Health, which in turn reports those
MASA’s Annual Session: Ready. Set.
not reported to the Prescription Drug
August 10-12
Do not register as a dispensing
Prescribing and Pharmacology of
Controlled Drugs: Critical Issues and

physician “just in case” it applies to
Common Pitfalls
you; physicians should be certain
that they are dispensing controlled
November 17-18
substances within the meaning of
Prescribing and Pharmacology of
this registration, it is the physician’s the rules before registering. This is
Controlled Drugs: Critical Issues and
not a determination to be made by
Common Pitfalls
someone other than the physician.
November 29
Ensuring Quality in the Collaborative
December 15
Ethics Education
Visit www.masalink.org
for more information.
Your Medical License
As a physician, your license to practice medicine in the State of Alabama
is one of your most important assets. It allows you to apply what you learned during
years of school and post-graduate training to earn a livelihood to support your family.
Exercise care to protect this asset.
Issue 1 • 2012
A Call to Preceptors
guide the next generation of certifi ed, students and help them perfect skills in licensed physician assistants by students, clinical preceptors are able to medical care through this “hands on” pave the way for the next generation.
e Medical Association of the State of Alabama, the Alabama Board of Medical Examiners and the Alabama Board of Nursing present.
Ensuring Quality in the Collaborative Practice
Working together to deliver quality healthcare
• Charlene Cotton, MSN, RN, Nurse Consultant for Advanced Practice Nursing of the
Alabama Board of Nursing
• Pat Ward, RN, Collaborative Practice Inspector of the Alabama Board of Medical Examiners
• Ray Hudson, MD, Collaborative Practice Consultant to the Alabama Board of Exminers
• Cheryl Th
omas, MSM, RN, Collaborative Practice Inspector of the Alabama Board of Learning Objectives
Aft er attending this course, participants will be able to: April 13, 2012
• Cite the application, approval and renewal requirements for CRNPs and CNMs in a collaborative practice relationship.
• List the credentials a CRNP or CNM is required to have to enter into a collaborative • List the responsibilities of both physicians and nurses in a collaborative practice agreement.
• Describe common problems seen in a collaborative practice and the methods to apply to • Cite the regulations for prescribing drugs, participating in a quality assurance review and practicing in various practice settings, including remote sites.
November 29, 2012
4 p.m. to 7 p.m.
For more information about the course, call MASA’s Education Department
at (334) 954-2500 or visit www.masalink.org/CollaborativePractice.
Registration Fee: $100
Issue 1 • 2012
Report of Public Actions of the Medical Licensure
Commission and Board of Medical Examiners
MLC – December 2011

Oscar V. Fadul, MD, license number
Substances Certifi cate of Brian E.
Cressman, MD, ACSC number
restricted status the license to practice Michael David Williams, DO, license  On Feb. 10, the Commission en-
number DO.426, Tuscaloosa, AL.
Alabama of Stephen Chalko Jacob,
MD, license number MD.18772,
William E. Feist, MD, ACSC number
David G. Morrison, MD, license
BME – March 2012
subject to certain conditions, including of qualifi cation and license to practice medicine in Alabama of Benjamin
medicine of Eloise K.L. Alexander,
BME – January 2012
H. Johnson, MD, license number
MD, license number MD.13907,
Voluntary Surrender of the Alabama Controlled Substances Certifi cate of Actions taken regarding failure
Jose Gonzalo Zavaleta, MD, ACSC
to comply with 2010 CME
requirements (fi ne, additional
cine in Alabama of Anthony Lessa,
CME required):
MLC – February 2012
MD, license number MD.26315,
• Frank S. Pair, MD, license number
mand, fi ne, additional CME required).
Venkatreddy Akkanti, MD, license
ing the license to practice medicine in
Alabama of Wade Anderson Young,
MD, license number MD.14717, Tus-
BLS courses
practice medicine in Alabama of Scott
H. Boswell, MD, license number
authority of Scott H. Boswell, MD, li-
cine in Alabama of Morris Wayne
Cochran, MD, license number
plan of Allan C. Walls, MD, license
BME – February 2012
to terminate restrictions on the license Issue 1 • 2012
Alabama Board of Medical Examiners
P.O. Box 946
Montgomery, AL 36102-0946
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Issue 1 • 2012

Source: https://www.albme.org/Documents/Newsletters/2012V27No1.pdf


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