Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
In ischemic stroke patients with low LDL levels (<30-50 mg/dl), would you consider lowering LDL levels to lower values without concern for any side effects?
If LDL levels are already below 70, I don’t target a lower goal. The SPARCL trial showed that reducing LDL to this range has an NNT of about 45 to prevent one stroke, which I find to be modest at best. From my perspective, lowering LDL further (<30-50 range) shifts the focus to treating a number rat...
How do you interpret the presence of GAD antibody in a middle-aged patient with diabetes when all other type 1 diabetes antibodies are absent?
It depends on patient's clinical course of diabetes, controlled on orals vs insulin, BMI, family history DM. For a brittle DM patient, high GAD titer could indicate DM1 or LADA. For stable DM patients, the recommendation is to have 2 positive antibodies to diagnose DM1.
What factors do you consider when deciding between RFA and surgery for a patient with a benign thyroid nodule causing dysphagia?
I primarily examine the risk of anesthesia/surgery and size of the biopsy-proven benign nodule when using ablation (thermal: RFA or microwave). We are still in a period where insurance companies just got a ICD9 for the procedure (RFA only) and it is not clear whether all insurance company will pay. ...
Would you stop denosumab in a patient with chronic kidney disease if they develop asymptomatic hypocalcemia after the injection?
No. Stopping denosumab leads to rebound bone resorption and loss of all gains. The hypocalcemia indicates insufficient calcium and/or calcitriol. Calcium intake should be 1,000-1,200 mg daily from food and/or supplements in divided doses with food.
Do you recommend repeat TSH testing after a patient switches from brand-name to generic levothyroxine?
Yes. Because the FDA allows for variability in generics and the fact that some patients are very sensitive to small changes in their levothyroxine dose, I do repeat TSH after a patient switches levothyroxine formulations.
Is there a role for use of GLP1 R agonist or dual agonist therapy for management of post bariatric hypoglycemia and dumping syndrome?
There is little systematically collected information in this area on which to base judgments. A case series of 5 post-bariatric surgical patients treated empirically with liraglutide described reduction of hypoglycemic events based on patient history. In an experimental study comparing several treat...
For patients with adrenal insufficiency who are on hydrocortisone replacement, would you recommend stress doses to cover for minor procedures such as dental work or thyroid fine-needle aspiration biopsies?
It is reasonable to tell patients to double their usual replacement dose on the day of minor procedures such as those involving local anesthesia. Here is a recent review: Vaidya et al., PMID 40522647.
Is a target TSH closer to the mid normal range justified in older individuals (age 70 or above) without any known cardiac ischemia or dysrhythmia or osteoporosis?
There are observational data showing decreased mortality rates and improved measures of well-being in elderly persons with TSH levels that are above the traditional reference range for the general population. Therefore, having a target TSH range of about 7 is more appropriate for elderly persons. Th...
Would you consider starting short-term metformin in an otherwise healthy patient who is beginning high-dose glucocorticoids to prevent glucocorticoid-induced insulin resistance?
Sustained use of glucocorticoid therapy is well recognized for causing hyperglycemia in patients without known dysglycemia. Rates of 15-25% have been reported depending on the clinical situations and the doses and duration of steroid use. A safe, effective, and cost-friendly approach to prevent this...
What is the clinical significance of a paradoxical decrease in HDL cholesterol after starting statin therapy?
Whether HDL goes up, goes down or stay stable on statin therapy is honestly not of much concern to me. I do not think it is of any clinical significance since we know that statin therapy improves outcomes. In fact, studies show that the clinical benefit of statins is even stronger in individuals wit...