Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
How do you approach diagnosis and management in patients with persistent hypercalcemia and elevated (but improved) PTH six months after parathyroidectomy for primary hyperparathyroidism?
I believe that what is most important is to rule out familial hypocalciuric hypercalcemia as the likely cause for the persistence of an elevated PTH and persistent hypercalcemia. It is also possible that there is an extraneous parathyroid gland located either near the thymus or in the upper thorax o...
Is history of radiation an absolute contraindication to using parathyroid hormone (PTH) analogues?
Hx of prior radiation was never a contraindication, it was a warning due to the known increase in osteosarcoma in patients who had prior radiation. A contraindication requires proof of harm. There was no data that radiation plus a PTH anabolic increased the risk of osteosarcoma. With the review of 1...
How do you approach peri-operative management of anti-resorptive therapies such as denosumab in patients undergoing joint replacement?
This is a very practical question. I think it is fine to continue the denosumab on a regular 6-month schedule for patients undergoing joint replacement. The reduction in bone turnover should not affect the implant. In fact, with denosumab, there is a small anabolic effect with each treatment that mi...
Does your decision to start or continue Ozempic therapy in patients with diabetic retinopathy depend on the severity of the retinopathy?
Yes. The concern for use of semaglutide in patients with DR is based on results of the SUSTAIN-6 trial where patients at risk for cardiovascular disease were given 1 mg of semaglutide or placebo. While semaglutide decreased the progression of renal disease in this cohort, retinal complications were ...
How do you approach treatment of a patient with bilateral adrenal gland thickening & biochemical evidence of ACTH-independent hypercortisolism?
Treatment options may include removing the larger adrenal mass/hyperplasia and then assessing the HPA axis after surgery or considering medical therapy. The AVS does not have a well-established role in such patients. A nice review on this topic was recently published in Endocrine Practice (Sweeney e...
Would you recommend pharmacologic treatment with levothyroxine for a patient with subclinical hypothyroidism and CAD s/p stent placement even if the TSH is less than 10mIU/L, given a described association with reduced risk for major adverse cardiovascular events with treatment?
As always, the treatment should be individualized. The treatment of subclinical hypothyroidism can be very different in younger patients compared to the elderly. According to the European Thyroid Association, initially, if the serum TSH is elevated in the range of 4 to 10 but with a normal Free T4, ...
Would you switch a patient with glucocorticoid induced osteoporosis to romosozumab if a patient sustained a fragility fracture 1 year into treatment with teriparatide?
This is an interesting question for which there is no evidence-based medicine. It would be important to know what bone was broken. If it was a vertebral fracture I would likely suggest a change to romosozumab because vertebral fractures are usually not traumatic and are the purest osteoporotic fract...
How soon after radioactive iodine therapy for hyperthyroidism should Methimazole be resumed?
In patients pretreated with methimazole, there is a risk of recurrent hyperthyroidism following radioiodine (RAI) administration, with possible adverse cardiac effects, especially in older persons or in those with cardiac disease (reviewed in Walter et al., PMID 17309884). However, resumption of met...
What is the utility of checking reverse T3 in clinical practice?
I have never routinely ordered it, only when forced to by certain rare patients who are reading Dr. Google or other information they find. They think it will change their plan, it never does.
In a patient with low-risk papillary thyroid carcinoma in 1 thyroid lobe s/p hemithyroidectomy, how would a diagnosis of Graves' orbitopathy (euthyroid biochemically) affect your classification and TSH target for thyroid-cancer treatment?
Clinical information that would be useful include age, size of the tumor, tumor histology, presence or absence of ETE, angioinvasion, molecular marker profile (if performed) and lymph node status. Also important would be TSI and TRAB status. Directions and thoughts regarding optimal TSH level If ...