Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
How should diabetic retinopathy surveillance be adjusted for patients starting GLP-1 agonists?
As with traditional anti-hyperglycemic medications, GLP-1 agonists may cause transient worsening of diabetic retinopathy due to the initial rapid control of blood glucose. Therefore, if a patient has existing retinopathy and is about to start GLP-1 agonist therapy, I recommend closer monitoring. For...
Do you escalate to 7.2 mg semaglutide in a patient with obesity who has not achieved their weight loss goal on the 2.4 mg dose despite the increased risk of dysesthesia at the higher dose?
This question is raised because of a recent report (Wharton et al., PMID 40961952) looking at weight loss in obese patients titrated up to 7.2 mg/week of semaglutide compared to the usual dose of 2.4 mg/week. The study was funded by Novo Nordisk, and the authors have strong financial ties to the com...
When starting GLP-1 R agonist therapy for weight loss purposes, how do you counsel patients on duration of treatment therapy?
I counsel people that I expect this to be lifelong therapy (similar to how we don't stop blood pressure medications when blood pressure comes down to normal on them because it will go back up, we don't stop GLP1RA when we get to our weight goals, as our weight will go back up when they are stopped)....
How do you counsel patients on semaglutide or tirzepatide in light of potential cancer risks?
Use of GLP 1 RAs has sky-rocketed in recent years due to what seems to be a positive class effect on T2DM, weight loss, renal outcomes, cardiac outcomes and hepatic outcomes. I am not aware of any signals of increased malignancy risk. A brief literature review found meta-analyses showing possible be...
How do you decide when to act upon TFT derangements in hospitalized patients (e.g., start/adjust thyroid replacement therapy) vs attribute to NTIS (formerly euthyroid sick syndrome) and advise repeat TFTs as an outpatient?
It is not always easy to discern, but typically in NTIS, T3, T4, and TSH are all low or normal (TSH may be slightly elevated but not markedly elevated). True hypothyroid (requiring new medication or adjustments of existing medications) typically has a high TSH and low Free T4, and the patient may ha...
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...
Has the TRAVERSE trial, which showed testosterone therapy was noninferior to placebo for MACE but raised signals for pulmonary embolism and atrial fibrillation, changed how you counsel middle-aged men who specifically cite cardiovascular safety when requesting TRT?
Results from the TRAVERSE trial have made my discussions a bit more streamlined, but I have always used a handout discussing known risks of TRT, such as infertility, testis atrophy, and erythrocytosis, and associated risks based on poor literature dating back to 2011. This trial confirmed what most ...
How long do you continue a first-line somatostatin receptor ligand before concluding inadequate biochemical response and escalating therapy in a patient with persistent acromegaly after transsphenoidal surgery?
First-generation somatostatin receptor ligands (SRLs) are often used as first-line therapy for patients with persistent acromegaly after surgery. Several factors can predict biochemical responses to such therapy, including older age, lower baseline insulin-like growth factor I (IGF-I), paradoxical g...
What empiric dose change, if any, do you make for patients already taking liquid or softgel levothyroxine preconception upon confirmation of a positive pregnancy test?
Based on the Alexander et al., PMID 15254282, it is recommended to increase Levothryoxine from 7 to 9 tablets/week and check TSH and Free T4 when possible. Repeat TFT should be checked every 4 weeks until after 20 weeks of gestation with T4 adjustment to keep TSH.
What therapies do you offer to young patients with secondary hypogonadism due to obesity who have lost weight but have ongoing hypogonadal symptoms and lower end of normal testosterone levels?
First of all, the symptoms may not be due to low testosterone. Keep in mind that obesity can be associated with low SHBG. Total testosterone may thus be low but free testosterone may be normal. Free testosterone assays are not the most reliable. Therefore, clinical judgment is often needed in border...