Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
How do we decide between Gallium-DOTATATE PET/CT and MIBG scans when evaluating a patient for suspected pheochromocytoma?
Mostly availability and feasibility. Gallium-DOTATATE is very sensitive.
Do you initiate a GLP-1 receptor agonist as first-line pharmacotherapy ahead of metformin in a patient with newly diagnosed type 2 diabetes and a BMI above 35?
Yes
What are the clinical prompts that lead you to consider deprescribing bisphosphonate therapy in older adults with osteoporosis?
As a Geriatrician, the essence of my practice is to determine, on regular review (reconciliation), whether an older adult’s medication is appropriate to continue or continue at the same dosing on the basis of physiology, pathology, and/or risk modification. We know well today that medications for os...
How do you manage patients with mildly elevated free T4 levels but normal TSH and Total T3 levels who have symptoms of hyperthyroidism but negative Graves' antibodies and normal pituitary imaging?
I would make sure to double check the accuracy of the free T4 assay/measurement. If it is very mildly high (0.1 ng/dl higher than ULN) might be an assay issue, but if it is 1.5-2x ULN, then maybe a real elevation. I would make sure the patient is not on high-dose biotin or any other interfering medi...
Is thyroglobulin typically elevated in patients with Hashimoto's thyroiditis on adequate thyroid hormone replacement?
Any thyroid condition where there is an enlarged goiter or stimulated cell by a high TSH will increase the thyroglobulin levels. A long time ago, when I was a fellow, Tg's were measured to correspond with MNG growth. In those situations, I have seen levels in the 1,000's, and a large nodule can have...
Do you recommend routinely monitoring pancreatic markers such as amylase and lipase while receiving GLP1 R agonist or dual agonist therapies to determine their risk of pancreatitis?
Absolutely not. We know that changes in amylase and lipase levels on these drugs are very common. For example, if you look at the supplementary data across the SUSTAIN series of phase 3 trials with subcutaneous semaglutide, the average person had about a 15-30% rise in their amylase/lipase. Further,...
Do you use bone turnover markers to assess medical adherence in patients treated for osteoporosis?
I find the bone remodeling markers very helpful. First and foremost, I want to be sure that if I am going to put a patient on an antiresorptive medication that the patient has evidence for high bone turnover over i.e., increased osteoclastic activity. If the bone remodeling markers for both bone for...
How do you approach adjusting insulin pump settings in patients who have received intra-articular corticosteroid injections?
Managing steroid-induced hyperglycemia in patients with diabetes has always been a difficult problem, and guidelines are hard to come by. Glucocorticoids cause increased insulin resistance and an increased need for insulin. The steroid effect on glucose is greater in the post-prandial state than the...
With the advent of GLP-1 receptor agonist therapy, when (if ever) do you consider adding pioglitazone to patients' diabetes regimen?
Yes, I do still use pioglitazone, which I believe is underused. I like to consider pioglitazone in patients who have central obesity with leaner legs/arms, i.e., who have a potential mild form of lipodystrophy, and who have hypertriglyceridemia, MASLD/MASH, and insulin resistance. I find that these ...
What is the clinical significance of a low C-peptide and insulin level when glucose levels are normal?
The real readout of the adequacy of insulin secretion is always glycemia. Thus, if the glucose level is normal, whatever the insulin level is "normal," and beta-cell function is likely normal. You can double down on that if the glucose tolerance test is normal. Normal glucose with low insulin or C-p...