Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
For a patient with idiopathic hypercalciuria and a history of calcium kidney stones who has not normalized 24-hr urine calcium level on thiazide diuretic, is there evidence for targeting a certain urine calcium level for decreased future risk of nephrolithiasis and osteoporosis?
A good question, and the answer depends on your definition of a "normal" urine calcium level. If you use the standard definition of abnormal, the upper 5 percentile, depending on your laboratory, you will get values for upper normal calciuria in the 250-300 mg per day. However, approximately 10% of ...
Under what circumstances would you prioritize injectable semaglutide over oral semaglutide in patients with type 2 diabetes with atherosclerotic cardiovascular disease or chronic kidney disease?
The use of oral semaglutide may be preferable for many patients in this category, based on the results of the SOUL study. Injectable semaglutide may be preferred in patients who have a history of surgical procedures that might affect absorption of the drug or in individuals in whom higher doses are ...
How do you adjust levothyroxine dose for elderly individuals with decompensated heart failure on low dose levothyroxine therapy presenting with TSH >10?
I think this depends on what the FT4 is. If subclinical hypothyroidism vs overt hypothyroidism. With elderly who have decompensated heart disease, etc, it may be best to start low (12.5 - 25 mcg of levothyroxine daily) and titrate up by 12.5 - 25 mcg every 2 weeks or so. If >80 years of age, don't f...
What is your experience with metformin for improving cognitive impairment in schizophrenia?
I have not found that it does much. But there was a recent promising study for using TMS on a particular brain region that is hopeful.
Would you start once-weekly tirzepatide over once daily basal insulin in a patient with Type 2 diabetes with inadequate control on oral antihyperglycemia drugs?
The issue examined in the paper cited of whether insulin or GLP-1RA is a better strategy in the setting of inadequate control of T2D was a hot question in the first part of this century but has been examined repeatedly and is now codified in global guidelines -- GLP-1RA should be used before insulin...
Do you recommend parathyroid imaging testing for patients with recurrent nephrolithiasis who are incidentally found to have an elevated PTH but who do not have hypercalciuria, hypercalcemia, hypovitaminosis D, or chronic kidney disease?
Yes, but with caveats. The “yes” is because hyperparathyroidism is a surgically curable disease if done by an experienced parathyroid surgeon. The caveat is if previous stone analyses have not shown a substantial calcium phosphate component, the stone formation may be due to other causes and unaffec...
Do you recommend obtaining a DEXA scan for patients with recurrent nephrolithiasis and hypercalciuria of unknown etiology?
I think this is an important question. I agree with Dr. @Dr. First Last. In my practice, if the patient is female, especially peri- or postmenopausal, I generally recommend a DEXA scan. If bone density is borderline or low, I typically refer the patient to an endocrinologist in our Bone Clinic for c...
What factors aside from progression do you consider most important in determining whether a patient with metastatic papillary thyroid carcinoma is radioactive iodine refractory?
RAI refractory or resistant is defined as: Progression despite adequate RAI RX within the prior year after therapy Tumor that does not take up RAI either on a diagnostic or post-therapy whole body scan
Do you recommend low dose RAI ablation for low risk papillary thyroid cancer with lymphatic invasion alone (no angio-invasion or known nodal involvement)?
No. Unless other factors, such as grossly positive margins.
What is your approach to treating subacute thyroiditis in a patient presenting with recurrent fevers?
Has ultrasound been done to rule out suppurative thyroiditis? If so, consider prednisone taper over a few weeks, particularly if painful thyroiditis and they failed a short course of NSAIDs already.