Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
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...
How do you approach checking an aldosterone to renin ratio in an outpatient with hypertension and hypokalemia that is difficult to correct with oral potassium replacement?
It is well known that hypokalemia can affect the aldosterone-renin ratio (ARR). Since hypokalemia directly inhibits aldosterone production, this can lead to false negative results when using ARR to screen for primary aldosteronism. If it is difficult to correct hypokalemia with oral potassium repla...
Would you consider a history of pancreatitis an indication for parathyroidectomy in patients with mild hypercalcemia secondary to primary hyperparathyroidism?
The association of pancreatitis with primary hyperparathyroidism (PHPT) has been a classic one, although an uncommon complication of PHPT. Studies vary in reporting an incidence of pancreatitis between 4-16% in patients with PHPT (usually single institution consecutive series). I think most people f...
When treating osteoporosis, does your duration of maintenance bisphosphonate therapy post anabolic therapy with PTH analogue change based on C-telopeptide levels?
I have treated many patients with teriparatide and conducted non-clinical studies on PTH/PTHrP receptors. Despite the fact that there are no PTH/PTHrP receptors on osteoclasts, when PTH stimulates osteoblast activity, the normal coupling via osteoprotegerin is intact, and about 4 weeks after one det...