Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
Do you plan to initiate combination therapy with an SGLT-2 inhibitor and finerenone, instead of an SGLT-2 inhibitor alone, when treating patients with proteinuric chronic kidney disease and type 2 diabetes in light of the CONFIDENCE trial findings?
I would start one (typically the SGLT-2 inhibitor), then add finerenone potentially later. If both are started simultaneously and there is an AE, then both may have to be stopped. I prefer to see that one is tolerated, then start another.
What oral contraceptives pills do you favor for treatment of PCOS?
Oral contraceptives in women with PCOS are used for multiple indications, including pregnancy prevention, endometrial protection, menstrual irregularity, and cosmetic issues (hirsutism, acne, alopecia). Combination OCPs can accomplish all these goals. One concern with combination OCPs is that the pr...
Is inositol just as effective as metformin in treating insulin resistance associated with PCOS?
Myo-inositol (MYI) and its metabolite D-chiro inositol (DCI) are over-the-countersupplements that have been suggested to improve insulin action in patients with PCOS. Outside of the PCOS world, there doesn’t seem to be much traction to using MYI over metformin for pre-diabetes and I believe it is no...
Do you recommend checking both TSI and TBII antibodies for Graves' disease diagnosis and monitoring?
The two assays correlate with one another to a great degree, but they are not identical. The TRAb or TBII test measures all antibodies directed against the TSH receptor that could be stimulatory, neutral, or blocking. The TSI test only measures stimulatory antibodies, and is therefore clinically mor...
What is the likelihood of recovery of parathyroid gland function for patients who underwent total thyroidectomy, found to have embedded parathyroid glands intra-operatively and then subsequently had them re-implanted into neck muscle?
Recovery of parathyroid function after total thyroidectomy in which parathyroid tissue was found embedded in the thyroid depends upon many factors. How many glands were found in the thyroid? Was the surgery extensive, and thus perhaps led to compromise of the vascular supply of the parathyroid gland...
When interpreting a 24-hour urinary calcium, which is more accurate: 24 hour urine calcium (mg/day) or 24-hour calcium-to-creatinine ratio (mg/g)?
In my opinion, the answer is unequivocal, i.e. calcium to creatinine ratio is the only way to interpret a 24-hour urine calcium. It is essentially impossible to collect an exact urine sample of 24 hours. The only way to do this, which is often unrealistic, is for the patient to empty the bladder and...
How do you counsel patients on the use of compounded weight loss medications?
It is a difficult question that is being asked more frequently, recently, because of the shortage of these drugs. I handle it the same way that I used to handle when patients asked about the use of herbs as food supplements. The important fact is that we don't know the reliability of these products....
In patients with hypertension and suspected primary aldosteronism who have undergone negative confirmatory testing, what follow-up and monitoring strategies would you recommend to ensure early detection of potential aldosteronism?
If the screening test is convincing (PRA suppressed and plasma Aldosterone >15) I would repeat confirmatory testing. If the first test was saline suppression I would do salt loading and a 24 h urine collection, and vice versa. These confirmatory tests are useful but do not have high sensitivity. If ...
Should we be using a cut off of 20 rather than the traditional 10 Hounsfield units to distinguish between benign and malignant adrenocortical tumors on imaging?
A higher CT density cut-off of 20 (even 30 in most cases) may be used to rule out ACC. However, some metastatic lesions can have a non-contrast CT density between 10 and 20 HU. A combination of a tumor size <4 cm and CT density <20 HU is pretty good in excluding almost all malignant lesions.
Is adequate BP control sufficient enough when titrating spironolactone therapy for primary hyperaldosteronism treatment?
Good blood pressure control is one of the three major goals of medical treatment of primary aldosteronism. Titrating spironolactone (or eplerenone) to an adequate blood pressure (often with reduction or cessation of other anti-hypertensives) is often the first goal met with dose adjustment. The seco...