Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
Is abnormally elevated estradiol an expected finding in patients with PCOS?
High levels of estrogen can occur in PCOS, which can be prolonged due to lack of ovulation and insufficient amounts of progesterone. Particularly as these levels are expected to fluctuate throughout the cycle, I would not say there is a cut off necessarily for concern but would consider referring to...
How do you titrate the dose of an ACE inhibitor in a patient with type 1 diabetes mellitus who is normotensive but has moderately increased albuminuria?
I think the main goal would be to get some level of ACE inhibitor on board. The dose can be increased slowly as long as the patient is not having symptomatic orthostasis.
Do you prefer kidney ultrasound or a non-contrast CT scan to evaluate for nephrolithiasis in an asymptomatic patient with primary hyperparathyroidism?
I first order an ultrasound due to the lack of concern for radiation exposure and if it is equivocal then follow-up with a CT scan. Ultrasound is not as sensitive as a CT scan especially for very small stones.
What is your approach to patients who insist on testosterone replacement therapy despite normal testosterone levels on repeated labs?
I explain that with a normal testosterone level there is no indication for testosterone replacement. Hormone replacement is always about evaluating risks and benefits. With a normal testosterone level the risks outweigh the benefit. I offer to evaluate causes for patient’s symptoms such as sleep apn...
What are the indications for use of inclisiran over anti-PCSK9 monoclonal antibody therapies?
Dr. @Dr. First Last has summarized the case for inclisiran in some patients very well. There is a growing sense that it's important to administer the injection as directed, that is, subcutaneously, not intramuscularly.
In a patient with severe hyponatremia and acute kidney injury in the setting of hypovolemic shock, would fluid resuscitation take precedence over the rate at which sodium is corrected?
Normal saline, or a balanced fluid, e.g., Lactated Ringers or Plasmalye, if you are believers in balanced fluids. Shock trumps ANY concerns over rate of Na rise. Also if someone is in shock they are not going to have a water diuresis from volume.
Do you recommend osteoporosis medication in postmenopausal females on anastrozole with very low Vitamin D (4.5)?
A vitamin D level of 4 is very low and should be corrected before any osteoporosis therapy is considered. Severe low D is associated with decreased Ca absorption and sometimes low serum Ca. Giving an anti-resorptive could result in hypocalcemia. Sometimes D levels that low are associated with muscul...
Is there any difference in the cardiovascular risk reduction profile of brand name Vascepa versus generic icosapent ethyl for patients with hypertriglyceridemia?
The major clinical trial data (Bhatt et al., PMID 30415628) showing benefit for Icosapent Ethyl were with medication provided by the company that ultimately branded the medication. That is no different from the clinical trials showing the benefit of statins or anti-hyperglycemic medications. We do n...
How do you manage or monitor hypogonadal men on clomiphene citrate?
I typically monitor men being treated for hypogonadism on clomiphene citrate the same as other hypogonadal men. There is less concern for timing of ordering testosterone levels to assess response in regard to treatment administration. There is also theoretically less concern for abnormal hematocrit ...
How would you advise medical oncologists who recommend checkpoint inhibitors for a patient with baseline type 1 diabetes?
T1DM means near-complete beta-cell deficiency. These patients aren’t making enough insulin to impact blood glucose control. We always treat the cancer first, with the most appropriate medications, and worry about the diabetes later. We even advise oncologists to continue ICIs after a patient develop...