Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
What therapies do you offer to young patients with secondary hypogonadism due to obesity who have lost weight but have ongoing hypogonadal symptoms and lower end of normal testosterone levels?
First of all, the symptoms may not be due to low testosterone. Keep in mind that obesity can be associated with low SHBG. Total testosterone may thus be low but free testosterone may be normal. Free testosterone assays are not the most reliable. Therefore, clinical judgment is often needed in border...
What therapies do you offer to patients with hypophosphatasia and low bone density who do not qualify for enzyme replacement therapy?
I have seen several patients like this. I recommend vitamin D to maintain 25-hydroxyvitamin D of 40-60 ng/mL, which usually requires 3000-5000 IUs daily. A good source of dietary calcium; my preference is 1000 mg from dairy sources, which not only provides a good source of bioavailable calcium but a...
How do you recommend mitigating the risks of using beta blocker and clonidine therapy in combination for management of hypertension?
Beta blockers vary in lipophilicity, which affects blood-brain barrier permeability. Propranolol and metoprolol readily cross the blood-brain barrier, while other beta-blockers like nebivolol do not. The CNS side effects of fatigue, depression, and insomnia are more likely to worsen if using a lipop...
Do you change your pre-operative insulin dosing when patients are NPO for surgery, but also just recovering from newly resolved DKA?
I agree. As long as the patient does not need the surgery emergently, the cause of the DKA should be determined. The patient should also be monitored to ensure that the DKA does not return once it has resolved. The basal insulin should be reduced by 25%. I usually reduce the dose of basal insulin be...
Are recurrent UTIs a contraindication to SGLT2i use?
I don't view UTIs as a contraindication to SGLT2i use, but I make a risk and benefit analysis with each patient. Bacterial UTI as well as mycotic vaginal infections may be a sign that the patient has excessive glycosuria from hyperglycemia. In general, treating hyperglycemia should lessen the freque...
Which other GLP 1-R agonist, if any, would you consider re-trialing in patients who had severe gastrointestinal side effects with Ozempic?
I am curious if you mean someone who has not tolerated the lowest dose of Ozempic, or higher doses. I have had patients who have not tolerated semaglutide but who can tolerate tirzepatide (or dulaglutide or even liraglutide if a daily injection is OK). I have also used "click counting," which is uni...
Do you recommend starting a statin in youth (greater than 10 years old) with Type 1 diabetes mellitus and LDL cholesterol levels greater than 130?
In general, I probably would not consider starting a statin in a youth with T1D unless they had T1D AND Familial Hypercholesterolemia and/or an LDL >190 mg/dL or significant microvascular complications already. Recommendations are to consider statin therapy in individuals with diabetes of long durat...
How do you determine the appropriateness of starting a CGM in patients aged 75 and older with type 2 diabetes on multiple daily insulin injections?
In general, the profile of T2D on MDI is a compelling indication for CGM. The wrinkle here is "age 75 and older". Though our gut instinct is that if the base case is compelling, the case should be stronger for those aged 75 and older. Specifically, avoiding hypoglycemia is critical to keep elders we...
How do you approach persistent fatigue in a patient after thyroidectomy whose TSH is within the target range, given that fatigue affects the majority of thyroidectomy patients yet its underlying mechanisms remain poorly understood?
I tend to assess fatigue in the 6-12 months post-thyroidectomy, as the initial 4-8 weeks post-op visit can skew results, especially after larger surgeries or not always optimal TSH levels. If the TSH is in the normal range, I also look at other causes of fatigue, like iron deficiency, OSA, etc. If t...
In patients with a history of retinal vein occlusion, how should the risk of recurrent thromboembolic events influence the selection of osteoporosis therapies?
The FDA-approved prescribing information for raloxifene explicitly lists retinal vein thrombosis alongside deep vein thrombosis and pulmonary embolism as contraindications.