In this Exclusive Interview transcript, Michael Irwig talks with Diabetes in Control publisher Steve Freed during the AACE 2018 convention in Boston about treating low testosterone and how diabetes and obesity can affect testosterone levels.
Freed: This is Steve Freed with Diabetes in Control and we’re here at AACE 2018 in Boston. And we’re here with a very special guest, Dr. Michael Irwig. And maybe we can start off with, you could give us a little background of what you do and the type of practice.
Irwig: So, I’m a General Endocrinologist. I practice at George Washington University in Washington DC at the Medical Faculty Associates. And I see patients of all types, a lot of diabetes, a lot of thyroid. I also do a lot with testosterone and androgens, and with transgender.
Freed: And you did a presentation or you’re going to do a presentation. And what’s the title of that presentation?
Irwig: So, the presentation that was in the pre-congress was Treatment Options for Male Hypogonadism, which is the treatment of low testosterone.
Freed: Okay. Maybe we can start off with why do so many men with diabetes have lower testosterone levels with diabetes?
Irwig: So, men are getting their testosterone levels checked a lot more frequently than they did decades ago. And so, the more people you check, the more people who you’re going to have with low levels. Now, men with type 2 diabetes often have comorbid overweight or obesity and that can affect the reproductive access. So, when you’re overweight or when you’re obese that can affect sex hormone-binding globulin which is a protein that binds to testosterone. And you can have lower levels of this protein, so that when you measure the testosterone it appears lower than it would otherwise. So, if you compare normal weight man to obese man, obese man will often have 25% lower total testosterone levels. Now, one other mechanism is that in fat tissue testosterone gets converted into estrogen. And then that estrogen gives a feedback to the brain to kind of slow down the reproductive system. So, often men who are obese will have low total but also low free testosterone as well.
Freed: And what are the symptoms of low testosterone? I mean, if a patient comes into your office, he’s a type 2 patient, he’s obese, do you automatically recommend the testosterone levels?
Irwig: So, I would take a careful history like in any case and see what symptoms are bothering this patient. If he’s not having any symptoms, I would definitely not go ahead and test. But the problem is that a lot of the symptoms are nonspecific, which means that they overlap with a million other things. So, a lot of times men have fatigue or they’re not sleeping enough or they have a depressed mood, these are all linked to low testosterone but they’re also linked to a million other things. So, that’s why using the symptoms is tricky. The more specific symptoms are the three sexual symptoms, so having low sexual desire or low libido, morning erections, and then erectile function. But even with these symptoms, these again are often nonspecific because erectile dysfunction often correlates to a man’s age. It goes up as men get older. It also can be a complication of diabetes, due to nerve damage, hypertension, high cholesterol. It could be a side effect of the many medicines that our patients are on.
Freed: So, if you wanted to get a testosterone test for one of your patients, as far as the ICD-9 codes, et cetera, that you’re required to have in order for the insurance to pay for it, what type of things must you put in there — what type of symptoms, so the insurance companies will actually pay for it?
Irwig: Usually erectile dysfunction is a good symptom that will be covered. Fatigue is also covered, I know. Sometimes I’ve had problems in the past with the low libido and sometimes that code was not covered for that particular lab.
Freed: And what is the relationship between diabetes and sexual dysfunction that we hear so much about?
Irwig: As men get older testosterone levels can decline. So, roughly after age 40, testosterone levels go down very slowly as men age. But for men who have chronic conditions such as diabetes, the testosterone level can go down more rapidly than if they didn’t have diabetes, so that’s one possibility. So, testosterone is clearly linked to other medical conditions. So, the more medical conditions somebody has and then the more chronic illnesses, they’re more likely to have lower testosterone levels. And then diabetes can do damage. So, diabetes can cause nerve damage; it’s a very common cause of erectile dysfunction for example.
Freed: If a person lowers their A1C more into the normal ranges, will the testosterone go back up?
Irwig: So, there are very interesting studies looking at testosterone concentrations and insulin resistance. And some of the studies do show a relationship that’s a bidirectional. So, low testosterone can be linked to insulin resistance and vice versa. And we’re always wondering is it the chicken or the egg? Which one is causing which, or are they just associations?
Freed: And is there more than one way to test for testosterone?
Irwig: This is a very complicated question because if you go to just LabCorp or one of the major labs you can often have a menu of over 15 different testosterone labs to choose from. So, which do you pick? There’s total testosterone. There’s free testosterone. There’s bioavailable testosterone. You could actually calculate some of thes, like the free and the bioavailable, if you have the sex hormone-binding globulin. And then even within these individual tests, there are different ways to do it. So, for total testosterone, liquid chromatography mass spec is the most accurate method. And so, that’s definitely the preferable way to go. And men should have their levels tested in the morning and fasting because that’s on average when they’re going to be highest. So, have nothing to eat or drink in the morning other than water until they get their blood test and then they can have breakfast.
Freed: Is it necessary to test the other aspects of testosterone like you just mentioned?
Irwig: So, I definitely would with a man who has diabetes due to overweight or due to obesity because they can have this abnormality with the sex hormone-biding globulin. So, what happens is that their total testosterone may end up being low, but their free testosterone or bioavailable may actually be normal.
Freed: And you see so many commercials out there. First, let me ask you about products that are available without prescription and you hear them on the radio all day long, testosterone replacement therapies, especially for sexual dysfunction, are any of those workable? Do any of them work even?
Irwig: So, testosterone is a prescription only medication in the United States. And in fact, it’s a controlled substance. And so, you can’t prescribe it for more than six months. There are many different ways to give testosterone. We currently don’t have an oral formulation in the United States yet. So, most of them are going to be topical, so gels that men rub on their shoulders once a day or a patch that they change once a day. There are injections into the muscle. There’s one that’s given every two weeks and that we can teach patients how to do. There’s one that given every four to six months. There are pellets that can implanted into the subcutaneous fat in the buttocks for example. There’s a new nasal spray that a man can squirt into his nose two or three times a day. There’s an adhesive that a guy can put above the incisor tooth twice a day and that gets delivered through the gums. So, those are all the prescription testosterone and they can be really pricey except for the older esters. So, a lot of the newer formulations can run without insurance, in like retail price, as often a thousand dollars or more per month. Now, there are all these other products that you’ll hear advertised that are kind of nutraceutical or kind of non-FDA kind of sexual function things. And the problem with this area is you never know what you’re getting. So, people actually have gone into kind of nutrition supplement stores and they purchase these products. And they’ve looked to see what’s inside of them. Often they contain things that are not on the label. So, they contain the same active ingredient as say Viagra would. They just don’t say that. So, that’s why it works because it has that ingredient. So, they’re often spiked with things like a phosphodiesterase 5 inhibitors. They may actually be spiked with anabolic steroids as well and not label that in there. So, whenever you get on the internet or you go to a foreign country or you’re buying something that’s not FDA approved, you never really know how safe it is and what it’s going to contain. So, I definitely advise patients against taking those types of supplements.
Freed: What do you find is the most effective treatment for low testosterone?
Irwig: So, I would say they’re all effective. They can all get a man’s testosterone into the normal range. Some of them are a little bit more easier to titrate than others. So, the intramuscular injections tend to give pretty robust levels. Sometimes people with the gels and the patches don’t get adequate levels and you just have to keep increasing the dose. But a lot of times the decision of which testosterone to prescribe is based on the patient’s insurance and the formulary whether it’s tier 1, 2, 3, or 4. And that often kind of dictates the options based on the co-pays. But a lot of patients have different preferences as well. I have some patients who don’t like needles and who just want to rub on a gel once a day. They like that. I have other patients who don’t like putting medicines on once a day and would much rather do something once every two weeks. So, there are a lot of personal preferences as well.
Freed: A lot of patients like to do things naturally. Is there a way to increase testosterone with diet and exercise?
Irwig: Yes, that’s an excellent point. So, for men who are obese or overweight who have low testosterone, the best and safest management option for them is weight loss because weight loss is going to help them with all of their comorbidities. It’s going to help them not only with their obesity or overweight, but if they have sleep apnea it’s going to help with that. It’s going to help with high blood pressure. And just all of their other conditions, high cholesterol, and also their cardiovascular health, so their fitness is going to improve. So, I would definitely recommend weight loss through diet and exercise for men with diabetes who have low testosterone as a first line agent. If men lose just 10% of their body weight, their own testosterone levels can shoot up dramatically into the normal range.
Freed: Testosterone is a prescription item and there’s a lot of reasons for that because it can be dangerous. What are some of the side effects from testosterone or too much testosterone?
Irwig: Testosterone in the short term can cause an increase in the red blood cell count, and so, erythrocytosis, and so that has to be carefully monitored just to make sure that a man’s blood cell count doesn’t get too high. The thought is that if the blood cell gets too high that could be associated with increase in viscosity and maybe lead to things like blood clots and strokes. Testosterone can sometimes cause hypertension, acne, oily skin. We don’t have a large long-term randomized control trial to look at safety of testosterone over many years. So, we don’t really know what to tell patients who are going to be on this for 10, 15, 20 years in terms of is this going to impact any major outcomes such as heart attack, cancers, prostate cancer, bone health, fractures. So, we’re lacking that data from randomized trials but we do have data from other studies that can help to inform us. There is no evidence that testosterone causes prostate cancer but men who get put on the testosterone treatment get more PSA testing, they get more digital rectal exams, so there’s more detection of sub-clinical prostate cancer. And it is known from studies back in the 1940s that if you have a man with advanced prostate cancer that’s metastatic, testosterone can fuel that fire. So, you don’t want to give testosterone to a man who has metastatic prostate cancer.
Freed: So, it has been chosen for men that have prostate cancer that you would want lower testosterone because it’s the fuel for the cancer. Is that the understanding?
Irwig: Right. So, one treatment for advanced prostate cancer is actually androgen deprivation therapy. It’s to get that testosterone level really low either through physical castration or through medical castration, but then that brings into the side effects of kind of low energy and increase in body fat and those side effects.
Freed: Well, I want to thank you for your time. Really appreciated it. I’ve learned something and I hope our audiences learned something also. Enjoy the rest of your stay here in Boston.
Irwig: Thank you so much!
Freed: Thank you!