Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
After what time frame off GLP-1 RA therapy should you restart at the lowest starting dose?
When a patient has stopped an incretin agonist for more than 2 weeks, I suggest at least restarting at a reduced dose. After 3-4 weeks, I would suggest restarting at the lowest or next to lowest dose. Restarting at a higher dose with anti-nausea medication such as ondansetron may be an option for so...
Do you recommend using a 24-hour urinary cortisol/urinary creatinine ratio over a 24 hour urine cortisol to screen patients for Cushing's syndrome?
There are several tests available to look for a diagnosis of Cushing's syndrome in patients suspected to have this entity. These include AM and PM cortisol to look for altered diurnal variations. Salivary cortisol test and 24-hour Urinary cortisol. However, in my opinion, the overnight Dexamethasone...
What hormonal workup is recommended for a male with abnormally high serum testosterone not on supplements or hormone replacement therapy?
First, one has to make a distinction between a high serum total testosterone and a high serum free testosterone concentrations measured by an accurate methodology. A high total serum testosterone with a normal serum free testosterone occurs with patients with high concentrations of proteins that bin...
Would you recommend HRT to treat hypogonadism in a male patient in his 80s?
If the patient is symptomatic, cautious use of a small dose can be considered with close monitoring.
Do you recommend the use of diazoxide for the management of reactive hypoglycemia in patients who have not responded to acarbose or dietary modifications?
I use uncooked starch as the next step as used with glycogen storage disorders.
In patients with confirmed hypercortisolism with a high/normal unsuppressed ACTH who have both a pituitary adenoma and adrenal adenoma identified on imaging, can you reliably use DHEA-S to determine the source of cortisol production?
There is a difference between high-normal and unsuppressed ACTH. If ACTH is high-normal, this is ACTH-dependent Cushing. However, you can have mild adrenal Cushing without fully suppressed ACTH (e.g., ACTH in the 10-20 pg/ml range and sometimes even above 20). I don't think you can rely on DHEAS in ...
Do you recommend that patients with type 2 diabetes who regularly drink artificially sweetened beverages continue their current consumption, gradually reduce their intake, or switch entirely to water in light of the SODAS trial?
Interestingly, this study showed no glycemic benefit for participants who switched from artificially sweetened drinks (ASB) to water. On the contrary, there was some deterioration of the glycemic profile on switching to water, although not clinically significant. Therefore, strictly from the glycemi...
Is the Enhanced Liver Fibrosis (ELF) test superior to the FIB-4 test in the diagnosis of MASLD?
In terms of diagnostic accuracy for advanced fibrosis in MASLD, ELF is superior to FIB-4; however, here are the caveats to consider: FIB-4 is a simple and readily available test that is best used to rule out advanced fibrosis (high negative predictive value), and ELF is best used to rule in advanced...
When starting stress dose steroids for patient with primary adrenal insufficiency, how do you decide whether to start hydrocortisone 100 mg every 8 hours versus 50 mg every 6 hours?
Stress doses of steroids in patients with primary adrenal insufficiency depend on the anticipated stress. The dose of steroids can be doubled or tripled depending on the stress. For example, in cases of maximal stress such as major surgery, the dose can be similar to the dose used for an adrenal cri...
Can fatty liver disease present with elevations in alkaline phosphatase without other liver enzyme elevations (AST and ALT)?
It is very atypical but can occur. Patients usually have elevations in aminotransferases (usually ALT higher than AST) and there can be very mild concurrent elevations in alkaline phosphatase. An isolated alkaline phosphatase elevation should however prompt a more extensive serological work up as we...