Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
Should a different weight-based dosing algorithm for levothyroxine therapy be considered in women versus men given higher incidence of iatrogenic thyrotoxicosis in women?
I do not. For the majority of my patients, my starting dose is 1.6 mcg/kg, which is in the ATA guidelines (1.6-1.8 mcg/kg has been recommended as the starting dose in many publications). There have been some studies that show using ideal body weight is a better predictor of LT4 dose, and others tha...
How often and in what way do you monitor patients who are receiving teprotumumab (Tepezza) for thyroid eye disease?
A week or two after completion unless having an issue.
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...
Would you start romosozumab in an active smoker?
This is not simple! But we are good at assessment of risk vs benefit (or benefit vs risk!)First I would reassess fracture risk, prior treatments, reason to consider romo. Then I would do a deep dive into risk assessment for cardiovascular disease: how much do they smoke, prior cardiovascular disease...
How is your office streamlining the administrative process for eligible Medicare patients attempting to participate in the Bridge Program for GLP-1 agonists that started July 1st?
As an obesity medicine practice, we are very fortunate to have hired our own pharmacist to manage dose titrations, and she has helped to ensure a smooth transition to the Bridge Program. Additionally, I created an Epic SmartPhrase to guide everyone as to the specific exclusions, BMI requirements, an...
What is your approach to IV fluid management for the treatment of hypercalcemia of malignancy?
At this point, I believe one can use either saline or lactated Ringer's. There is some evidence that low-chloride-containing solutions have advantages in general, which may well be the case, but we need more data on that. The amount of calcium in LR is very small and should not make a difference (1....
Should GLP1 R agonist therapy be offered to women at high risk for breast cancer given recent data showing protective benefits?
Obesity is a key modifiable risk factor for breast cancer. While it is true that some observational studies have suggested that the use of GLP-1 RA is associated with a lower incidence of breast cancer (McDonald et al., PMID 42227662), this is an association. The authors of this study correctly poin...
In postmenopausal osteoporosis, would you switch to romosozumab (rather than a PTH/PTHrP analog) if a patient fractures while on denosumab?
This is an interesting question because it raises the subject of how one defines "treatment failure" among patients who are using bone-strengthening medications. I remind patients that our drugs are most effective at preventing spinal fractures with efficacy that can exceed 70% relative risk reducti...
What is your approach to patients with persistent low libido despite normal testosterone levels after use of exogenous testosterone replacement therapy?
The key point is understanding a man’s mental health and relationship status. I will always screen for depression and strongly encourage sex therapy. My unvalidated but effective screening question is asking when their last vacation was and how their libido and erections were. It’s surprising how ma...
How do you approach a patient with Paget’s disease of bone with elevated alkaline phosphatase and history of chronic kidney disease?
You can give Zol IV, which is clearly the optimal treatment for active Paget's. Those in the field that treat many such patients just administer this very slowly over 1-2 hours and assure good hydration concomitantly. I have treated a number of patients like this, with this scenario, without any pro...