Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
When do you consider changing a patient's levothyroxine dose during hospitalization due to abnormal TFTs, but without clinical evidence of thyrotoxicosis or hypothyroidism?
Thank you for your question. I think this is something we commonly get in the hospital, and we often overreact to it. This was a "Things We Do For No Reason" some time back, and I think they outline the issues well.When people are acutely ill, TSH testing is unreliable. The times when TSH testing is...
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...
What are some practical tips in distinguishing between metabolic bone disease due to chronic kidney disease and osteoporosis?
The biggest difference between osteoporosis and CKD-MBD has to do with the underlying bone mineral laboratories. Generally, with osteoporosis, bone chemistries are relatively normal; there may be a decrease in Vit D. However, with CKD-MBD, there is usually an increase in PTH, potentially abnormaliti...
Do you routinely check N-telopeptide levels in patients who you suspect might have immobilization induced hypercalcemia?
No, I do not check N-telopeptide level in patients with suspected immobilization-induced hypercalcemia. Although N-telopeptide is a sensitive marker of bone resorption, elevated N-telopeptide is not specific to immobilization-induced hypercalcemia and can be elevated in other clinical conditions cha...
Do you temporarily hold diuretics when measuring 24-hour urine calcium levels in the evaluation of primary hyperparathyroidism?
It is mandatory to stop diuretics at least 2 weeks before evaluating a patient for PHPT. One should have a fasting blood sample on the morning of the end of the collection for calcium phosphate and PTH to complement the urine collection. Thiazide-type diuretics raise serum calcium and lower urine ca...
How do you counsel patients with metabolic syndrome who decline statin therapy and have low coronary calcium scores regarding their long-term CVD risk?
This is a great question with many ramifications, and I can only give an incomplete answer that includes personal opinion. First, what is the risk? The MESA Risk Score Calculator (check it out) gives a CAC percentile score as well as a 10-year risk. The 10-year risk may be low, but a high percentile...
What triggers you to choose urgent thyroidectomy versus therapeutic plasma exchange versus continued medical management for refractory thyroid storm despite 12-24 hours of guideline-concordant therapy?
A very important factor is the comfort level of the ICU doctors and the Anesthesiologists at the institution. We usually do not recommend proceeding with urgent thyroidectomy given the increased risks, unless FT4 and TT3 are normalizing. Usually, a combination of PTU (or Methimazole), stress dose st...
When would you consider using transvaginal cabergoline in the treatment of prolactinoma?
This is considered an off-label use, but I have done this a few times, and I know some of my colleagues have as well. There is not much in the literature on this, mostly case reports. I would reserve this for patients who do not tolerate the oral forms of cabergoline or bromocriptine.
How does a strong family history of breast cancer influence your decision between RAI and thyroidectomy for definitive treatment of hyperthyroidism, in light of emerging observational data suggesting a possible association between RAI and increased breast cancer risk?
There is an increased risk for solid tumors, especially breast cancer, following radioactive iodine (relative risk from 0.45-2.55). This data is strongest for those treated for thyroid cancer as opposed to Graves disease, as it is dose dependent, but studies do support an increased risk for breast c...
Does the degree of TSH suppression significantly impact the risk of differentiated thyroid carcinoma recurrence?
This is a very timely question. The new 2025 Guidelines for thyroid cancer was just published. They cite studies that recurrence and cancer dead for low and low/ intermediate risk thyroid cancer patients are not affected by TSH suppression. The recommended TSH is normal and less than 4 uU/ml. It is ...