Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
Do you have a preference between RAI therapy and antithyroid medication for patients with Graves' hyperthyroidism and moderate-to-severe Graves' orbitopathy who are on glucocorticoid treatment?
I caution using RAI in Graves' disease with moderate to severe orbitopathy if I can. Surgery, if you have access to a high-volume thyroid surgeon, may be better vs long-term antithyroidal therapy. Obviously, a lot of individual patient factors can play into this decision. I would also avoid RAI for ...
What are the indications, if any, for trending ACTH and cortisol levels in patients with adrenal insufficiency on steroid replacement therapy?
The only indication is if the patient has steroid-induced adrenal insufficiency and you are planning to wean the patient off steroids. In that case, I usually measure early AM cortisol and ACTH every 8 weeks. An increase in ACTH will be the first sign of HPA axis recovery. During this process, ACTH ...
Do you require levothyroxine to be taken on an empty stomach in patients with stable hypothyroidism, or is dosing with breakfast acceptable with dose adjustment?
Ideally, levothyroxine should be taken on empty stomach but if a patient is taking it with breakfast and has a stable normal TSH, it is okay to continue but if TSH fluctuates change to empty stomach.
What is the rationale behind the Anesthesiology recommendation to hold one dose of weekly GLP-RA prior to general anesthesia?
There is evidence that people treated with GLP-1 receptor agonists (GLP-1RA) more often have residual food in the stomach after an overnight fast and greater gastric volume. There is anecdotal evidence of aspiration events in people treated with GLP-1RA. The ASA statement raises a concern and provid...
What are your thoughts on trending beta-hydroxybutyrate once a diagnosis of DKA is already established?
Beta-hydroxybutyrate (BOHB) ≥3.0 mmol/L is highly sensitive and specific for diagnosing DKA and can be measured through serum or point-of-care testing. However, its role in monitoring treatment response and determining resolution remains debated. The American Diabetes Association recommends continui...
Do you routinely check N-telopeptide levels in patients who you suspect might have immobilization induced hypercalcemia?
No, I do not check N-telopeptide level in patients with suspected immobilization-induced hypercalcemia. Although N-telopeptide is a sensitive marker of bone resorption, elevated N-telopeptide is not specific to immobilization-induced hypercalcemia and can be elevated in other clinical conditions cha...
When would you consider using transvaginal cabergoline in the treatment of prolactinoma?
This is considered an off-label use, but I have done this a few times, and I know some of my colleagues have as well. There is not much in the literature on this, mostly case reports. I would reserve this for patients who do not tolerate the oral forms of cabergoline or bromocriptine.
How does a strong family history of breast cancer influence your decision between RAI and thyroidectomy for definitive treatment of hyperthyroidism, in light of emerging observational data suggesting a possible association between RAI and increased breast cancer risk?
There is an increased risk for solid tumors, especially breast cancer, following radioactive iodine (relative risk from 0.45-2.55). This data is strongest for those treated for thyroid cancer as opposed to Graves disease, as it is dose dependent, but studies do support an increased risk for breast c...
Does the degree of TSH suppression significantly impact the risk of differentiated thyroid carcinoma recurrence?
This is a very timely question. The new 2025 Guidelines for thyroid cancer was just published. They cite studies that recurrence and cancer dead for low and low/ intermediate risk thyroid cancer patients are not affected by TSH suppression. The recommended TSH is normal and less than 4 uU/ml. It is ...
Can carbamazepine make thyroid function test results look spuriously abnormal?
Carbamazepine can also displace thyroid hormone from binding proteins. Although in the short term this might transiently increase free T4 (with a reciprocal decrease in TSH), thyroid function tests should normalize once an equilibrium is achieved. In some assays that rely on dilution of the sample, ...