IBD Drive Time: Jared Magee, MD, on Men's Health in IBD

Drs Raymond Cross and Jared Magee discuss some of the special concerns that affect men with inflammatory bowel disease, from cardiac concerns to sexual dysfunction and assessing for anal cancer.

Raymond Cross, MD, is director of the IBD Center at Mercy Medical Center in Baltimore, Maryland, and professor of medicine at the University of Maryland. Jared Magee, MD, is a staff gastroenterologist at Walter Reed National Military Medical Center and a faculty member at the Uniformed Services University in Bethesda, Maryland.

Men’s Health in Inflammatory Bowel Disease: Preventive Care, Cardiovascular Risk, and Sexual/Reproductive Considerations

• IBD preventive health overlaps with women and requires routine screening. Core measures include up-to-date vaccinations, skin cancer screening, bone mineral density assessment, smoking cessation, and screening for depression, anxiety, and alcohol misuse. Vital signs (blood pressure, heart rate) and cardiovascular risk factors (lipids, diet, exercise) should be assessed, with improved adherence to preventive care generally seen by patients’ 30s.
• In IBD + cardiovascular disease risk inflammation control is key. Poorly controlled IBD is an atypical cardiovascular risk factor; controlling inflammation and limiting steroid exposure may reduce cardiovascular and thromboembolic risk. Baseline and annual lipid monitoring is recommended for patients on JAK inhibitors. Cardiovascular screening including lipid panels becomes more relevant after ~35 years, though primary care involvement remains essential. 
• Sexual dysfunction, fertility, and prostate/anal cancer considerations. Erectile dysfunction is common among men with IBD (reported up to 94% early disease) and may relate to vascular disease and mental health. Annual screening should include sexual health. Sulfasalazine may cause oligospermia (hold ~3 months preconception); methotrexate concerns are not supported in humans. PSA screening is increasingly requested but complex; prostate biopsy may be challenging following some IBD-related surgery. Men who have sex with men and those with perianal Crohn’s require careful attention to rule out infectious proctitis, which may be mistaken for IBD symptoms. HIV prevention (PrEP), and anal cancer screening, including anal Pap smears, should also be provided.

Dr Raymond Cross:

Welcome everyone to IBD Drive Time. I'm Raymond Cross from Mercy Medical Center, and I'm happy to have my friend and colleague, Jared Magee from Walter Reed. He's a staff gastroenterologist and is also on faculty for the Uniformed Services University. And Jared and I today are going to talk about men's health in IBD. And just as a disclaimer, not to be too politically correct, just because we're talking about men's health and IBD, doesn't mean that Jared and I aren't interested in women's health and IBD, but we acknowledge that almost 50% of my population is men and Jared's population is far greater than that and trying to identify some key health maintenance and preventive health services for our men with IBD. So Jared, welcome to IBD Drive Time.

Dr Magee:

Thank you, Ray, for having me. This is fantastic. I'm very excited to talk about this because this is something that comes into my clinic, like you said, very frequently with our population.

Dr Cross:

So the first question is thinking about health maintenance, preventive health. There are recommendations that we talk about for women. What are the ones that overlap with men? So what are the similar recommendations for both men and women?

Dr Magee:

A lot of our recommendations are going to overlap, and I would say the lion's share of the recommendations will overlap between men and women. So to do men's health correctly, you have to do the basics well, and that's making sure your vaccines are up-to-date, skin cancer screenings, bone mineral density, smoking cessation, screening for depression and anxiety, alcohol misuse. And then as people come into our clinic, getting a set of vitals just to screen for some of the more common things, which are cardiovascular disease in a male population, but also checking cholesterol, vision—everything that a good PCM would do, a lot of times we're going to be responsible for doing in our clinic, and most of these things will overlap.

Dr Cross:

And generally, I feel like there may be some bias here, but generally I feel like women are more adherent to our recommendations for health maintenance than men. You have higher numbers than me, so maybe you would counter that. But regarding vaccines, now vaccines have become political and there's hesitancy for vaccines, do you find that there's a gender differential on uptake of health maintenance in particular vaccines?

Dr Magee:

I would agree with you. It definitely seems like there is a shift between men and women in clinic. And that may be a 25-year-old woman is much more mature in managing everything that comes along with these diseases than our 25-year-old men. But for the most part, people that are diagnosed early seem to start getting things together within a couple years. And by the time both men and women are around 30s, I'm seeing good uptake in all of the preventive health and vaccinations.

Dr Cross:

I agree. So cardiovascular disease, so that's a hot topic with increasing utilization of JAK inhibitors, the ORAL surveillance study, there's increased focus on it, and it's more common in men. And we know that now poorly controlled inflammation in IBD is an atypical risk factor for cardiovascular disease. So what's your approach to this in your patients? And do you do any cardiovascular screening in your practice?

Dr Magee:

I think when we talk about cardiovascular disease, the upfront screening we do is the set of vitals the patient gets when they check in. So checking for the blood pressure, checking for the heart rate, seeing if those things are off initially. I have to tip my hat to you because I know you published on this very topic about 2 years ago that in detail addressed cardiovascular disease in IBD, some of the pathophys behind that, and how to best manage it and best recommendations. We are doing that. And then as people get older, I think it is looking for what we used to do in internal medicine with screening for cardiovascular disease, which is your lipids, your exercise, your diet. And I will say for my 20-year-olds, I'm not as diligent, but once we get past about 35, I think your lipid screening guidelines come into play and I do take it a lot more serious.

Dr Cross:

Yeah, I think that for the listeners here, what's really empowering me as a provider is the concept that if I control inflammation through appropriate use of medications and I limit steroids, I'm going to decrease risk across the board, including cardiovascular risk and likely thromboembolic risk. So just by taking good care of your patient's IBD, you're controlling one atypical cardiovascular risk factor. So I think that's really important. And for the patients that are on JAK inhibitors, I'm sure, Jared, you're doing the same thing, you're trying to get a baseline lipid profile. And then usually once a year, I'm checking it again if the primary care doctor's not doing that.

I was at the AIBD national course and there was a section on managing IBD beyond the gut. It wasn't called that, but one of the faculty, I'm not going to name that person, was suggesting that we should be taking on cardiovascular risk cardiovascular screening. And I think we're already a bit overwhelmed as providers. And I think the message I want to send is, listen, in your patients that are getting older, you're watching the vital signs, you're limiting steroids, you're controlling disease, but our patients need a good primary care provider. We can't be expected to manage everything. Now, I don't know if you agree with that, but in my practice, I just don't have the bandwidth to do it all. I feel like if I'm controlling their IBD pretty well, I'm doing a good thing for them.

Dr Magee:

I wholeheartedly agree. Unfortunately, though, I do think we are being shifted into a more PCM and more cardiology-centric focus for patients. And some of that is access to care issues where we may be the only health contact that our patients are seeing for the year and being up-to-date on what they should be doing for preventive care is important. I think as therapies have evolved as well, we've essentially had to become a poor man's cardiologist, understanding what heart failure is and which medications to avoid, depending on their class of heart failure, interpreting our own EKGs for monitoring for those QT prolongations, for advanced heart blocks with the S1Ps, and then also making sure that we are assessing for ASCVD risk in JAKs.

Dr Cross:

So I wanted to move on to prostate cancer screening, and I don't formally test for this. Sometimes patients ask me to add this on and I'm usually reticent because I don't want to be responsible. But in our patients, are there any limitations in prostate cancer screening?

Dr Magee:

There are limitations in how to approach it. PSA, I think, is going to get a lot more attention, especially after you have a population that was watching the Super Bowl this year; Novartis did a very good job of roping in Bruce Arians to discuss PSA and his story with prostate cancer. Also, very catchy with relaxer tight end and having all the NFL's historical tight ends. So I do think it's going to be something that will increase in frequency in our populations with people asking us to check PSAs. The old adage, and one of the things I commonly get asked is, "Can you do a DRE and feel for my prostate at time of colonoscopy?" Largely, that's fallen out of favor just because we're not great at doing it, and we only assess a very small area of the prostate, but it is something that I've noticed since February or the middle of February, I've started to get more and more questions about PSAs.

Dr Cross:

And for patients that have had a subtotal colectomy and that have a Hartmann’s pouch or a J pouch, obviously the PSA, there's no limitation in doing that, but there's going to be major challenges, I think, of doing prosthetic biopsies, correct?

Dr Magee:

That is correct. The other population there would be a sewn anus, which we're seeing less commonly, but it is a challenge. And usually it does require ultrasound and urology-guided biopsy. So not something that we're necessarily doing, but can make a challenge for the patients to get the care that they need.

Dr Cross:

Gotcha. So we know that sexual dysfunction is common in men and women. So speaking about erectile dysfunction, is that more common in our patients? And are you asking patients about this in practice?

Dr Magee:

It is more common in our patients. So when we've looked at our large studies, we can see up to 94% of people are men specifically in early stages of their disease do complain about erectile dysfunction. A lot of times I am not specifically asking, "Do you have problems with erectile dysfunction specifically?" But as part of our maintenance visits here in my clinic, we do ask family planning and sexual dysfunction as part of an annual screener for their maintenance exam. So every year, man or woman, when they come in, we say, "Has anything changed with your family planning? Are you still planning to be pregnant or trying to become pregnant this year, next year? Are you still voluntary childless? And do you have any concerns about the sexual function or sexual health between you and your partner?" So it doesn't specifically address sexual dysfunction and erectile dysfunction, but we do leave that open-ended question there so we can discuss it at the annual visits.

Dr Cross:

And it also highlights what you mentioned because that my understanding, and it's been a while since I did internal medicine, but 2 of the big causes of erectile dysfunction are going to be vascular disease, which you're addressing by controlling their disease and having someone appropriately manage their cardiovascular risk factors, and certainly depression can be part of that. So addressing mental health, anxiety, depression can be important.

Before we go on to the next question, I just want to remind the listeners that IBD Drive Time is the official podcast of the AIBD Network. We are available on Spotify and Apple Podcasts. We also have our regional AIBD schedule published now. The first regional AIBD is going to be April 18th and April 19th in Cincinnati. I'm privileged to be codirecting the regionals this year again with Tina Ha, and I will be at the course in Cincinnati, lovely city, so I hope to see you there.

Coming back to men's health, Jared, any concerns about any reproductive concerns in our men?

Dr Magee:

Largely, the biggest things are, like you said, controlling the underlying disease issues. Reproduction, we haven't seen a ton of reproductive issues other than a very few medications. One of the more controversial ones was methotrexate use. That seems to have been debunked in human studies. There was the concern in mice studies that hasn't come across for humans. And then sulfasalazine, I'm practically not using a lot of sulfasalazine anymore, but it is always a concern for men that we should be recommending holding it 3 months prior to planning for pregnancy

Dr Cross:

Or at least making them aware if they're having difficulty with their partner that that could be a cause. And I think with sulfasalazine, it's oligospermia that they get with sulfasalazine. Am I remembering that correctly?

Dr Magee:

That is correct.

Dr Cross:

And there was some issue with thiopurines about they did some sperm analyses showing DNA fragmentation, but it doesn't seem to really amount to anything as far as issues with, I guess it's for combability with the partner and so forth, and certainly no link with birth defects or anything like that. So I agree. And the one thing I forgot when we were talking about erectile dysfunction is in the old days of the pouch, Jared, this is probably when you were still in college or maybe medical school, we used to have a fairly ... It wasn't uncommon to see a patient post-ileal pouch anal anastomosis with erectile dysfunction and sometimes even retrograde ejaculation. But with laparoscopic and robotic approaches, I rarely see that anymore. And I do ask patients about that after a pouch, and I don't really see that. I don't know if it's similar for you and your practice.

Dr Magee:

I do ask, and I have not seen that either. It does seem like pouches have come a long way. And in general, the IPAAs seem to be better for patients and men with their sexual function than the older ileostomies.

Dr Cross:

And another question that men will ask me, again, I hesitate to order this, is they'll ask me, can I check their testosterone? So there are commercials out there, but I think Frank Thomas was doing the low T commercials, I think, right? He was doing that and showing massive biceps, and you can go on testosterone, this is what you look like. So is this an issue for our patients? I don't think it's any contraindications with our treatment. I imagine you're probably not checking this, but what are you doing?

Dr Magee:

I usually don't check it unless there's a clinical symptom that necessitates that. What I usually ask for is, is it low libido, decreased morning erections, decreased bone mineral density or skeletal muscle? Have they developed gynecomastia or are they losing body hair? And in the absence of that, I don't put a lot of stock in it, but you're correct, with the direct consumer availability for testosterone now, it comes up quite frequently.

Dr Cross:

My concern with ordering that is I assume I'm ordering a total and a free, but I don't really know how to interpret that and what to tell them to do with it. So when you order a test, that's my concern, is that you're going to be stuck with trying to manage it, but I guess that can help prompt you to get them to their primary or get them to urologist or endocrinologist. I would assume that there's multiple specialties that manage that.

Dr Magee:

Absolutely. And my go-to has been endocrinology because they have been the most apt to want to manage this, but I think a PCM would be fine or a urologist. I do kind of draw hesitancy though when I have men that come in with other cardiovascular risk, particularly if they're at risk for OSA because testosterone supplementation can make the OSA worse and precipitate nonfatal arrhythmias. So that is the population I do worry about testosterone with.

Dr Cross:

Yeah. Also, there was an interesting ... I'm pretty sure it was published in the American Journal of Gastro. I should know because I'm one of the editors, but they looked at the transgender population and in general, hormone replacement therapy did not seem to impact the risk of clinical relapse. However, obviously active disease at baseline, that makes sense that you're more likely to relapse, but the testosterone-based regimens, there was a signal there that perhaps those patients had a higher risk, so you should monitor them more closely. But anecdotally in my patients that get testosterone supplementation, I haven't seen that they have a higher risk of relapse. I think that's a different patient population.

What about men who have sex with men, Jared? What are your recommendations there?

Dr Magee:

Largely not too much changes. I oftentimes will ask about sexual behavior to see if I need to refer them for PrEP, because we have a very robust PrEP population here and in HIV prevention, a clinic. So that is an option for my patients that I readily try to offer them if they qualify.

The other thing for men who have sex with men is just keeping your differential broad. Where I've clinically seen this and I think has been well put out in studies is we oftentimes will misdiagnose proctitis and overdose IBD when it could be infectious proctitis. One study I read said it was a delay of diagnosis up to 3 years for some patients, which grossly changes how their life is and what we're doing with the disease process if it was all along a infection-driven process.

Dr Cross:

Yeah, we published something in Digestive Disease Sciences with a case of syphilitic proctitis. So you do have to keep your differential broad. At Mercy, we finally have our anal Pap smear program up and running. Are you offering something like that for anal cancer screening in your high-risk patients, including men who have sex with men?

Dr Magee:

We do not offer it in our clinic. I do offer a referral because it is part of our PrEP clinic. So if they are plugged in there, they are getting the anal Pap just to assess for risk. And I believe you and I were sitting together when we were going through some of this data about how prevalent HSIL and anal cancer is in this population and that we may be under appreciating it and not screening enough.

Dr Cross:

Yeah, absolutely. The men who have sex with men are a high-risk subgroup, particularly if they're living with HIV. And then also the perianal Crohn's population has a high risk. And then you're adding the immune suppression, particularly things that affect viral replication like thiopurines and JAK inhibitors, and maybe to some degree, the anti-TNFs.

And so in the audience here, most practices don't have the ability to do anal Pap smears or high-resolution endoscopy, although colorectal surgeons often can do the latter. But at the very least, you can once a year in your patients when they're 35 and over for the higher-risk groups— perianal Crohn's, prior cervical dysplasia, HPV type infections, 45— for everyone else you can simply just do a perianal exam, a digital rectal exam on years of not having a colonoscopy and see if you see anything that looks abnormal, if you feel anything abnormal, and promptly getting them to colorectal surgery.

There's also a review article in the American Journal of Gastro that talks about some of that. So at the very least, you can just do a good old-fashioned perianal digital rectal exam. It's better than nothing. So good practice.

All right, Jared, we're down to the fun fact. So tell the listeners something, tell us your fun fact. What do we need to know about you?

Dr Magee:

So my fun fact, I think I will leave it as I love to cook. That is one of the greatest enjoyments of my life. I do that to destress. I grew up a little bit north of New Orleans, so I am very facile in all the Cajun cuisine and all the deep Southern cuisine.

Dr Cross:

Wow. So we actually interviewed Shirley Mekelburg Cohen last week, and her episode will be published before yours, but she also is an avid cook. In fact, this weekend, I'm going to use her famous meatball recipe and make homemade sauce for my wife and my boys. So I'm going to have to give feedback the next time I'm on about how her meatball recipe came out.

Dr Magee:

And I've heard you say enough at this point that you do not put sugar in your tomato sauce.

Dr Cross:

I do not. I put salt in my tomato sauce. I do not put sugar. That's true. All right, Jared, this has been really great. Hopefully you and I are not going to be stoned to death for doing men's health and IBD, and I think the listeners are going to enjoy this and hopefully we can get you back on Drive Time soon.

Dr Magee:

Absolutely. Thank you so much for hosting me, Ray, and it was a great topic that you brought up and one I think is underappreciated.