Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
Statistically speaking, approximately what percentage of thyroid nodule FNA biopsies are Bethesda category 1 (= nondiagnostic or unsatisfactory), and what percentage are indeterminate (Bethesda category 3 and 4)?
This is highly institution-specific, but on average: About 10% of biopsies will be nondiagnostic. About 15-30% of biopsies will be indeterminate (Bethesda 3 or 4).
Do you recommend increased screening for hypercortisolism in older patients given recent evidence that older patients do not commonly display hallmark symptoms of Cushing's Disease?
Well, the study you are referring reports that "younger patients were more likely to present with abdominal striae, acne, facial rounding, hirsutism, menstrual irregularities, and weight gain". Obviously, menstrual irregularities cannot be seen in postmenopausal women. As for the rest, I am not sure...
Would you consider PCSK9 inhibitors for patients with elevated coronary calcium score or coronary calcification for primary prevention in lieu of statins/ezetimibe and/or bempedoic acid?
Absolutely! The VESALIUS trial confirms that lower is better even in people without a prior event. I wouldn’t use a PCSK9i in lieu of a statin, though. I would add it to the statin if someone’s LDL-C is still elevated. If someone has a high CAC score, I target an LDL-C and apoB <55 mg/dL. Ezetimibe ...
Is Evenity appropriate for a patient with severe osteoporosis (T-score -3.1) unresponsive to bisphosphonates and persistent primary hyperparathyroidism despite two surgeries?
Before, I would institute therapy, I would like to know what the situation is with the primary hyperparathyroidism. Is this primary or FHH? Although a 24-hour urine calcium creatinine ratio is no longer helpful, I find that the serum phosphate and 1,25-dihydroxyvitamin D, along with 25-hydroxyvitami...
Would you consider anabolic osteoporosis therapy in a young adult male with multiple non-traumatic vertebral compression fractures and low bone density for age (Z-score -2.6)?
I think a young male with multiple minimal trauma vert fractures and low BMD is appropriate to consider anabolic therapy. Of course, a thorough workup needs to be done to determine if there are any treatable causes of bone loss. If it is determined that he has “idiopathic osteoporosis” then treatmen...
Would you continue Forteo treatment past the recommended 2 years if T scores remain low and procollagen (P1NP) is elevated and if so, how would you monitor response?
I would offer a third year of a PTH analogue if the BMD response is less than a -2.5 T Score. I would follow quarterly serum calcium levels and a BMD for 1 year to assess the effects.
Would you consider transitioning patients older than 75 years of age with coronary disease from statins and/or other lipid-lowering agents to PCSK9 inhibitors given concerns for polypharmacy, provided their LDL levels remain at or below goal?
We do not have any data to suggest PCSK9i are better than statins, and all of the PCSK9i outcomes data are on top of statins. Data show generally that lower is better, and there isn’t a “floor” to benefit. That said, if I have someone on statin + ezetimibe who then gets LDL-C very low on a PCSK9i, I...
How do you manage patients who are positive for the 21-hydroxylase antibody but have no clinical or laboratory evidence of adrenal insufficiency?
I educate the patients about the signs and symptoms of adrenal insufficiency, evaluate their HPA axis at intervals, and monitor for other autoimmune disorders.
Under what circumstances would you administer subcutaneous hydrocortisone instead of IV hydrocortisone to a patient with adrenal insufficiency?
A subcutaneous route may be used instead of intramuscular injection (preferred) at home while the patient is transferred to a medical facility for further treatment. The IV route is always used in the ER setting in a patient during an adrenal crisis.
How do you counsel younger patients regarding long-term radiologic monitoring of non-functional adrenal adenomas?
I do not think biology is so black and white. The risk of malignancy in adrenal masses according to size is a spectrum and certainly not zero just because at one point in time it is less than 5 cm (how about 4.5 cm?). Unless the radiologist can confidently diagnose a myelolipoma I think clinical jud...