Remission of type 2 diabetes in a young, hypogonadal man under long-term testosterone therapy: A case report

The increasing incidence of obesity in younger populations constitutes a serious problem both in terms of personal health and resulting health-care costs. Young adulthood obesity strongly increases the risk of T2DM, hypertension, myocardial infarction, stroke or venous thromboembolism [1]. Young T2DM men, in particular in combination with overweight or obesity, have a very high prevalence (>50%) of low testosterone concentrations indicating eugonadotropic hypogonadism [2,3]. Testosterone defi ciency disturbs physiological processes such as muscle and bone formation and promotes further fat mass gain. Moreover, lack of testosterone negatively impacts sexual function and reproductive capacity during the young patients’ peak reproductive years.


Background
The increasing incidence of obesity in younger populations constitutes a serious problem both in terms of personal health and resulting health-care costs. Young adulthood obesity strongly increases the risk of T2DM, hypertension, myocardial infarction, stroke or venous thromboembolism [1]. Young T2DM men, in particular in combination with overweight or obesity, have a very high prevalence (>50%) of low testosterone concentrations indicating eugonadotropic hypogonadism [2,3].
Testosterone defi ciency disturbs physiological processes such as muscle and bone formation and promotes further fat mass gain. Moreover, lack of testosterone negatively impacts sexual function and reproductive capacity during the young patients' peak reproductive years.
For young obese men, the combination of T2DM and hypogonadism means a profound health burden and a loss in quality of life. Left untreated, the risk is manifested to develop life-threatening diseases. Thus, an appropriate treatment at an early stage is of utmost importance.
Citation: Mskhalaya  In this report we present a case of a young type 2 diabetic man with low testosterone level who benefi tted from TTh in terms of considerable weight loss and complete remission of T2DM.    The 20-year-old patient presented here was not just obese but had very severe class III obesity at a very young age. So not only the existing impact of obesity but also the threatening consequences of long-term obesity required effective actions.

Case presentation
Diet and physical activity are key recommendations for obese patients, but it is a well-known fact that in most cases patients do not succeed in achieving effective and sustained weight reduction [12][13][14][15][16]. In a relatively recent meta-analysis serum testosterone level was signifi cantly lower in patients with diabetes mellitus compared with those without, with a mean difference of 76.6 ng/dL and a signifi cant correlation was found between low testosterone level and different components of metabolic syndrome, even after adjusting for age, BMI, and race [17].
A possible reason for the diffi culty in losing weight is a lack of testosterone as this plays a crucial role in several regulatory processes including fat reduction and increase in muscle mass.
Thus, an existing but undetected testosterone defi ciency will substantially hamper weight loss or render it impossible. In these cases, restoring testosterone to the normal range is a pre-condition to successfully fi ght obesity. Testosterone may play a role in reducing proinfl ammatory cytokines in vitro and in vivo, increasing insulin sensitivity in both muscle and adipose tissue and promoting catecholamine-induced lipolysis [18][19][20][21]. Recent study showed that long-term TTh may prevent prediabetes progression to T2D in men with hypogonadism, improve glycemic and lipid metabolism [22].
Under TTh the patient continuously lost weight and baseline class III obesity (BMI 44 kg/m 2 ) was reduced to overweight (BMI <30 kg/m 2 ) (Figure 3). This effect of TTh has also been shown in a number of long-term studies with observation   Triglycerides (mmol/l) Figure 6: Triglycerides returned to normal range after month 3 and 6, resp., and remained in the normal range onwards. TTh [23,24]. The weight reduction due to normalization of testosterone level does not only refer to the reduction of body fat but also comprises an increase of lean body mass which refers primarily to muscle mass [25,26]. In a recent metaanalysis study (59 trials included enrolling more than 5,000 patients) testosterone therapy was associated with a signifi cant reduction in fat and with an increase in lean mass as well as with a reduction of fasting glycaemia and insulin resistance [Corona 2015] [27]. In other words, getting testosterone back to normal range does not only mean to reduce body weight but also to improve body composition. This considerable improvement was also documented for the patient presented here. and lipid profi le remained within the normal limits and he did not regain weight. We conclude that TTh worked as a necessary stimulus along with standard therapy for consequential facilitation of weight reduction and associated recovery of the body's own production of testosterone in particular in terms of a complete remission of T2DM.