Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
Do you discontinue statin therapy when patients reach LDL levels way below their target goal with PCSK9 inhibitor therapy?
I will not routinely adjust statin dosing in patients on PCSK9 inhibitors unless their LDL levels fall below 15-25 mg/dl. In which case, I will reduce statin dosing to allow the LDL to rise above 15-25 mg/dl.
Under what clinical circumstances, if any, would you prescribe fenofibrate along with statin therapy?
Yes, I do sometimes combine fibrates and statins. Usually, it’s in the setting of needing to treat severe hypertriglyceridemia with the fibrate in a patient who also has hypercholesterolemia and an indication for a statin. If a patient is on a statin and still has mild to moderate hypertriglyceridem...
Would you start a mineralocorticoid receptor antagonist in patients with unilateral primary aldosteronism while they are awaiting adrenalectomy?
It depends on their blood pressure and potassium levels. Some of our patients are already on MRA at the time of their diagnosis without a need to get off the medication. Others may be started or returned to MRA after completing their biochemical workup. We recommend stopping MRA on the day of surger...
In patients with MASLD/MASH, do you perform any cardiac testing to create a patient's risk profile, given that cardiac complications are the top cause of morbidity and mortality in this patient population (especially those with advanced fibrosis)?
This is a very important question, particularly because the new ACC guidelines suggest the use of more advanced lipid markers, like Apolipoprotein B and Lipoprotein (a), in individuals who are deemed "high risk" for cardiac disease. Unfortunately, they didn't specifically mention MASLD/MASH as a ris...
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...
How do you approach individualizing A1c goals in patients with dementia?
This is an important question for shared decision-making. And it definitely is impacted by the severity/FAST staging of the dementia, as well as the class of medication use. As we are all aware, we do not want to use the Sulfonylurea class in older adults, especially in patients with a dementia diag...
Is there a role for cinacalcet in the management of PTHrP-mediated hypercalcemia?
Cinacalcet is a calcimimetic, meaning that it mimics calcium and interacts with the calcium sensor in the parathyroid glands, which is a signal to decrease the production of PTH. Cinacalcet will not decrease the production of PTHRP in cancer cells. However, cinacalcet will decrease the production of...
Is there an evidence-based consensus on CT-derived Hounsfield unit thresholds for opportunistic assessment of osteoporosis, and how should such measurements be applied when DXA results are inconclusive or do not meet diagnostic criteria?
Per the International Society for Clinical Densitometry's official positions: "Opportunistic CT-based attenuation using Hounsfield Units (HU) can be used to estimate the likelihood of osteoporosis (L1 HU < 100) and normal (L1 HU > 150) bone density to support decisions regarding bone health assessm...
What is your approach to diagnosing insulin allergy in patients with diabetes?
Insulin allergy, though uncommon since the advent of recombinant human insulin (estimated prevalence ~2%), remains a serious clinical concern. It can manifest as type I (IgE-mediated), type III (immune complex-mediated), or type IV (T-cell-mediated) hypersensitivity, ranging from local cutaneous rea...
Should GLP-1 agonists be held during chemotherapy?
I think there are several aspects to this question. First, is there evidence that as a class GLP-1 RAs increase the risk of cancer or worsen prognosis during cancer? I could find nothing to raise concerns about outcomes. One recent report even showed a decreased risk of some cancers with GLP-1 RA co...