Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
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...
Which blood pressure medications do you favor using to manage ongoing hypertension post adrenalectomy for hyperaldosteronism?
If primary hyperaldosteronism is cured by adrenalectomy, it would be the usual management of HTN; otherwise, I would use spironolactone.
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....
What is the preferred first-line non-insulin agent in patients with ketosis-prone diabetes during "remission" and evidence of preserved beta cell function?
Ketosis-prone diabetes (KPD) is an atypical form of diabetes that has been found in various racial and ethnic groups (Asian Indian, South American, West African, African American and others). People with KPD may present with DKA without the autoimmune findings of Type 1 diabetes. After the DKA episo...
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...
Do you raise your TSH target in a postmenopausal woman on long-term levothyroxine who develops osteoporosis to minimize the bone effects of even mild over-replacement?
I do not adjust the TSH target of the normal range in postmenopausal females with osteoporosis. There are 2 caveats. With aging and menopause, with the decrease in estrogen-stimulated TBG production, many aging females will need a small decrease in Levothyroxine dose to keep the TSH in the normal ra...
Which other GLP-1 R agonist, if any, would you consider re-trialing in patients who had severe gastrointestinal side effects with Ozempic?
I am curious if you mean someone who has not tolerated the lowest dose of Ozempic, or higher doses. I have had patients who have not tolerated semaglutide but who can tolerate tirzepatide (or dulaglutide or even liraglutide if a daily injection is OK). I have also used "click counting," which is uni...
What is your approach to treating concomitant hypernatremia and hyperglycemia in patients with encephalopathy?
The risk-benefit assessment begins by identifying the primary physiologic problem. In patients with concomitant hypernatremia and hyperglycemia, the dominant abnormality is usually a profound free water deficit from osmotic diuresis. My goal is to restore normal physiology by replacing that free wat...
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...
Do you consent patients for diabetes insipidus following SRS or fractionated radiation for pituitary tumors?
This, and more broadly hypopituitarism of any type, is an important consideration and likely under-addressed topic in consent.Untreated hypopituitarism in adult life is associated with reduced all-cause life expectancy, and by one study 2x mortality rate compared with age/sex matched controls. [1]Th...