Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
What is your approach to the management of incidentally elevated HDL levels in isolation and is there any utility for further ASCVD risk stratification and/or genetic testing for lipid disorders?
Although the U-shaped curve for HDLC and ASCVD was a surprise (probably missed until huge population cohorts were studied), the data have been reasonably confirmed in many studies now, with some heterogeneity regarding gender as well as CVD vs total mortality. If I see a patient now with an HDL over...
When stopping denosumab and transitioning to PO bisphosphonate, do you wait for 6 months after the last denosumab injection to start PO bisphosphonate?
Some background: In patients discontinuing denosumab without subsequent antiresorptive therapy, BMD rapidly reverts back to baseline with an elevation in vertebral fracture risk (with an enhanced risk of multiple vertebral fractures). Thus, sequential treatment regimens following denosumab have been...
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.
How do you assess and adjust treatment in patients who develops hypothyroidism after being on lithium for several years?
It depends on whether the patient is symptomatic. If not, careful monitoring is all that is needed. If there are significant symptoms, treatment with levothyroxine would be needed. Continued use of lithium is appropriate if it has been effective over time.
Can you explain the block and replace approach in the treatment of thyrotoxicosis, including when it is most appropriate to use and how it compares to other treatment options?
More than 20 years ago, Japanese researchers had data that suggest that remission rates for Graves' disease was much better with the block and replacement treatment with Methimazole/carbimazole and Levothyroxine. At least 3 US and European studies did NOT confirm this observation. I do occasionally ...
Do you recommend monitoring Free T4 or Total T4 levels in pregnant patients with central hypothyroidism?
Free T4 immunoassays are inaccurate in pregnancy. In this scenario, I would either use total T4 with a goal range of 1.5 times the normal range, or I would order a "thyroid panel" that reports a Free Thyroxine Index, calculated from the total T4 and T3 resin uptake. The FTI is more reliable in pregn...
How do you evaluate remission in acromegaly when postoperative IGF-1 and GH levels are discordant?
It depends how long after surgery. IGF-1 may take up to 3 months form curative surgery to normalize. If GH is low (<0.4 ng/mL) and IGF-1 is still abnormal and you are less than 3 months form surgery, I would just wait. If the opposite is true (Normal IGF-1 but elevated random GH), I would perform a ...
Would you favor oral bisphosphonates over intravenous formulations for patients with hormone sensitive prostate cancer and androgen deprivation therapy (ADT) related osteopenia?
If kidney function is normal, either would do. Therapy depends on the risk level. (See Cosman et al., PMID 39073912.)
Would you recommend discontinuing testosterone replacement in a male patient in his 60s with newly diagnosed favorable intermediate-risk prostate cancer who is declining surgery and will receive definitive radiation?
Historically, we (as a field) have viewed TRT as the opposite of ADT and therefore inherently problematic. I am not convinced this is logical. ADT has RCT evidence to support it, whereas withdrawing TRT has not been as cleanly studied. Let's say we stop TRT, and this drops their testosterone to 150 ...
How do you manage pregnancy associated osteoporosis in post-partum patients with vertebral fractures?
I would make certain that the patient is getting adequate calcium and vitamin D and maintaining a serum 25-hydroxy vitamin D of at least 30 ng/mL. If the patient is breastfeeding, I would not give a bone active medication until breastfeeding has been halted. I would like a lot more information about...