Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
How would you counsel a female to male transgender patient regarding VTE risk with testosterone therapy, who has additional mild-moderate risk factors for thrombosis?
If physiologic concentrations of testosterone are not exceeded and the hematocrit is monitored to avoid a pathologic level of erythrocytosis, the risk for thrombosis from testosterone GAHT does not appear to in excess of the general population. I would refer you to the following two articles that pr...
What work up do you recommend for persistent subclinical hyperthyroidism with decreased RAI uptake and negative thyroid antibody tests?
If the RAIU is very low, then this may be subacute thyroiditis. Lymphocytic or silent has no biochemical confirmatory tests. If there is pain, this suggest pseudogranulomatis subacute thyroiditis associated with a high URI and a recent viral infection. The other choice is they have some nodular thyr...
Would you consider PTH analogue in a patient with mildly elevated PTH?
This is a complicated question because there is not any substantial literature. Almost all clinical trials with teriparatide and abaloparatide excluded patients with elevated PTH levels. However, there is considerable anecdotal experience. I have surveyed many colleagues with considerable experience...
How do you approach a patient with elevated bone specific ALP (>2X the normal limit), but no other evidence of Paget's disease?
There are other causes of elevated bone alkaline phosphatase e.g. osteomalacia. Check blood calcium, magnesium and phosphate, PTH and 25-OH-vitamin D. If PTH is elevated and no CKD, check 24-hour urinary calcium and creatinine.
What is your preferred method for confirming the diagnosis of primary aldosteronism in a patient with an elevated plasma aldosterone to renin ratio?
The endocrine guidelines on primary aldo diagnosis (1) allow for 3 confirmatory tests: 24-hour urine, fludrocortisone suppression testing, and response to saline infusion. At UAB, we use the 24-hour urine collection. Most of our patients do not need additional salt loading during the 24-hour collect...
Which medications do you deem necessary to stop prior to measuring plasma renin and plasma aldosterone when evaluating a patient for possible primary aldosteronism?
The most important medications to stop before checking renin and aldo levels are spironolactone, amiloride, triamterene, finerenone, and eplerenone. Ideally, patients should be off these meds for at least 6 weeks before testing. A pathologic primary aldo can be detected while taking beta blockers or...
In patients presenting with classical findings of primary hyperparathyroidism (i.e mild hypercalcemia, high 24hr urine calcium, elevated 1,25 Vit D but normal PTH), can spontaneous normalization of calcium be explained by episodic hypersecretion of PTH?
PTH secretion is always about 70% basal, related to the mass of parathyroid tissue, and about 30% episodic. Patients with primary hyperparathyroidism can have superimposed secondary hyperparathyroidism. High urinary calcium suggests a negative calcium balance. PTH is not "normal" if calcium levels a...
What is the optimal management of pain and loss of function due to pathologic compression fractures?
I explain to my patients if they have an acute compression fracture that they are likely to experience pain for approximately 2-3 weeks that will gradually resolve. I often give them some type of pain relief using Tylenol or ibuprofen and if severe, a more potent analgesic for a short period of time...
How do you approach the use of metformin in the management of prediabetes for patients who are neither obese nor have a family history of diabetes?
When considering the approach to a patient with a diagnosis of pre-diabetes, I think it is important to be sure the patient actually meets criteria. Most of us screen patients at risk with A1C levels because it is so much easier. However, A1C levels do not fully correspond to glucose levels and may ...
When do you recommend using trabecular bone score (TBS) for managing osteoporosis?
Trabecular bone score is a valuable tool in the evaluation of osteoporosis and risk of fracture. It is an indirect indicator of bone microarchitecture. Although TBS predicts fracture risk, it should not be used alone but in conjunction with BMD for deciding whether to treat the osteoporosis and if s...