Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
How would you counsel patients with type 1 or type 2 diabetes mellitus and heart failure on the use of SGLT-2 inhibitors when they have a history of DKA?
Making a recommendation to prescribe this class will really require a case-by-case clinical assessment. It is clear that SGLT-2 inhibitors are very effective in preventing hospitalization for heart failure, and so we will want to suggest their use whenever possible. But it is also clear that DKA (mo...
How many statins do you try before considering alternative therapies like PCSK9 inhibitors or inclisiran to lower LDL levels?
In earlier years, I would try changing statins 3-4 times. More recently (and I use rosuva almost all the time) I try to halve the dose (only lose 5-10% effect) and if that does not work, I try going to rosuva 10 = 1-2x/week and that gets about 25% reduction to which I can add ezetimibe. If I am far ...
How do you decide when to act upon TFT derangements in hospitalized patients (e.g. start/adjust thyroid replacement therapy) vs attribute to NTIS (formerly euthyroid sick syndrome) and advise repeat TFTs as an outpatient?
It is not always easy to discern, but typically in NTIS, T3, T4, and TSH are all low or normal (TSH may be slight elevated but not markedly elevated). True hypothyroid (requiring new medication or adjustments of existing medications) typically has a high TSH and low Free T4, and the patient may have...
For a patient with a large pheochromocytoma, how would you evaluate for possible autonomous cortisol co-secretion prior to adrenalectomy to assess need for risk of glucocorticoid withdrawal postoperatively?
From a practical standpoint, and given that this is rare, it is reasonable to check a postoperative day 1 (POD1) AM cortisol and decide then whether cortisol replacement is needed. You can also check ACTH, AM and PM cortisol to assess diurnal variation, and DHEAS pre-op to get some idea.
Has the TRAVERSE trial, which showed testosterone therapy was noninferior to placebo for MACE but raised signals for pulmonary embolism and atrial fibrillation, changed how you counsel middle-aged men who specifically cite cardiovascular safety when requesting TRT?
Results from the TRAVERSE trial have made my discussions a bit more streamlined, but I have always used a handout discussing known risks of TRT, such as infertility, testis atrophy, and erythrocytosis, and associated risks based on poor literature dating back to 2011. This trial confirmed what most ...
In patients with osteoporosis at high fracture risk, what factors most influence your decision to prescribe teriparatide versus abaloparatide?
Both abaloparatide and teriparatide are very effective anabolic agents to reduce vertebral and nonvertebral fracture risk in patients with osteoporosis (although clinical trials did not demonstrate reduction of hip fracture risk). The two agents are more similar than different and both induce an an...
Should teprotumumab be used in patients with active, moderate Graves thyroid eye disease in the absence of proptosis?
Teprotumumab is NOT a benign therapy with multiple serious side effects and complications. In the setting of acute TED with significant disease, it has a place. For the average patient, there are multiple other treatments and other Biologics with fewer complications.
What are your top takeaways from ADA 2026?
Lots of drugs in pipeline.Amylin receptor agonists may provide better tolerability and reasonable efficacy and become the first-line nutrient-stimulated hormone (NuSH) therapy with time.Do not follow titration in the prescribing information (PI) of glucagon-like peptide-1 receptor agonist (GLP-1 RA)...
Is there any role for bisphosphonate or alternative bone-modifying agents use in SMM in the absence of other indications for its use?
The short answer is no, unless the patient has an indication like osteoporosis. Bisphosphonates have been evaluated in smoldering multiple myeloma in studies performed over 10 years ago. Treatment with pamidronate (D’Arena et al., 2011) or zoledronic acid (Musto et al., 2008) did not affect the time...
In an obese male with low testosterone, would you initiate testosterone replacement therapy at the initial visit, or start tirzepatide first and monitor for improvement in testosterone levels and erectile function?
Dr. @Dr. First Last has given a thoughtful answer. Assuming no evidence of a structural hypothalamic-pituitary-testicular (HPT) disease (normal prolactin, LH, and FSH in the low-normal to normal range, normal free T4), the best approach is weight loss for these men. Whether to try lifestyle changes ...