In part 4 of this Exclusive Interview, Michael Irwig talks with Diabetes in Control Publisher Steve Freed about testosterone replacement therapy, various testosterone products that are offered without prescription and best suggested treatments.
Michael Irwig, MD, FACE, is a general endocrinologist at George Washington University in Washington, D.C.
Transcript of this video segment:
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.