Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
Does your LDL goal change in elderly patients with diabetes and hyperlipidemia who are on statin therapy?
First, what is an elderly? I will be 81 next month, and I don't consider that young, but also not too elderly to try to protect myself from an event. This patient is a high/very high risk, and if he is at a good goal on a statin, why would anyone want to change the dose? I tell my patients that surv...
Do you measure plasma metanephrines in an asymptomatic, normotensive patient with an adrenal incidentaloma below 10 Hounsfield units on non-contrast CT, given that a small proportion of pheochromocytomas can appear lipid-rich on imaging?
The probability of a positive result would be very low unless the patient is hypertensive or has suggestive symptoms.
How do you decide between repeat resection and radiosurgery when MRI imaging suggests limited residual tumor in the cavernous sinus in patients treated for acromegaly?
If residual tumor is not surgically curable, another surgery is not advisable. Given available pharmacological treatments, I do not consider XRT until I run out of medical options, particularly in young patients with intact pituitary function. Even if a patient does not respond to SRL, including pas...
Do you pursue further workup for a coexisting cause of true hyperprolactinemia, or attribute the elevation to macroprolactin and observe, when PEG precipitation confirms macroprolactinemia but the post-PEG monomeric prolactin remains above the normal range?
Macroprolactinemia can coexist with real hyperprolactinemia. The post-PEG precipitation monomeric prolactin value, rather than percent recovery alone, is the most informative parameter for distinguishing isolated macroprolactinemia from coexisting true hyperprolactinemia. If monomeric prolactin is e...
In patients with low alkaline phosphatase and high Vitamin B6 levels, does negative genetic testing for ALPL mutation rule out hypophosphatasia?
In general, the answer is no. The technical details of how the genetic testing was conducted are critically important and impact the kinds of genetic variation that can be detected. Prior knowledge about the patient and prior testing in related individuals are important factors in deciding how to ch...
How many statins do you try before considering alternative therapies like PCSK9 inhibitors or inclisiran to lower LDL levels?
In earlier years, I would try changing statins 3 to 4 times. More recently (and I use rosuvastatin almost all the time), I try to halve the dose (only lose 5 to 10% effect), and if that does not work, I try going to rosuvastatin 10 mg 1 to 2 times per week, and that gets about 25% reduction, to whic...
For which patients with type 1 diabetes on insulin pump therapy do you consider transitioning from rapid acting to ultra-rapid acting insulin?
When might faster-acting insulin analogs be considered for use in an insulin pump?Insulin pump use has rapidly become the standard of care for patients with type 1 diabetes mellitus (T1DM). Insulin pumps are generally paired with continuous glucose monitoring (CGM) and automatically adjust insulin d...
What are your top takeaways from ADA 2026?
Lots of drugs in pipeline.Amylin receptor agonists may provide better tolerability and reasonable efficacy and become the first-line nutrient-stimulated hormone (NuSH) therapy with time.Do not follow titration in the prescribing information (PI) of glucagon-like peptide-1 receptor agonist (GLP-1 RA)...
Does ongoing methimazole requirement post radioactive iodine ablation therapy for toxic multinodular goiter suggest failure of therapy and need for repeat treatment or higher dose of radioactive iodine?
Toxic multinodular goiter may require more than one treatment with radioactive iodine (RAI) in order to achieve euthyroidism. In follow-up to RAI therapy, I recommend also looking at the free T4 and free T3 levels, as the TSH may take longer to return to normal. If the free hormone levels have impro...
In MASLD patients with high cardiometabolic risk who already meet a clear metabolic indication for a GLP-1 receptor agonist, how much fibrosis-stage certainty do you require before treating it as liver-directed MASH therapy (and documenting/monitoring it as such), versus starting for metabolic benefit and using NIT trends to decide on subsequent biopsy or add-on liver-specific therapy?
If you have the option to get it for type 2 diabetes, it is often more likely to be approved by insurance. There would be no fibrosis requirements and no follow-up on continuing to prove fibrosis staging requirements. Whoever submits for prior authorization can mention if the patient is stage 2 to 3...