Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
In patients with differentiated thyroid cancer, do you consider pathology characteristics not found in the ATA risk stratification guidelines (ie microscopic margins or multifocal cancer) when determining recurrence risk and management?
Minimal invasive carcinoma with only capsule invasion is considered low risk. Multifocal disease with a size of more than 1 cm requires completion thyroidectomy. Overall, these factors do not appear to increase recurrence risk. Details are available at jnccn.org.
Would you increase or maintain the same initial dose of methimazole for treatment of hyperthyroidism if symptoms and thyroid tests improve but are not normalized?
Starting a hyperthyroid patient on the correct dose of methimazole (MMI) is of paramount importance. According to the 2015 ATA guidelines on the management of hyperthyroidism (Ross et al., PMID 27521067), the initial methimazole dose should be based on the patient's serum free T4 level: Free T4 2-3 ...
Is there a role for cinacalcet suppression testing when evaluating patients for suspected primary hyperparathyroidism who also have recurrent calcium containing kidney stone disease?
I understand the physiology upon which the cinacalcet suppression test is based. However, I have not used it in my practice. Once I see a discordant result between a parathyroid hormone level and its main determinants: serum calcium, phosphorus, and vitamin D (or 1, 25-vitamin-D), I use a sestamibi ...
Is there a role for calcitriol in dialysis patients regardless of PTH level?
I believe the general consensus among endocrinologists is that the origin of circulating calcitriol is from the kidney and this is considered the traditional endocrine pathway of vitamin D influencing bone and intestinal mineral absorption. However, many tissues have the ability to synthesize calcit...
What is your approach to managing osteoporosis in patients with end stage kidney disease?
I don't believe you can make a diagnosis of osteoporosis in patients with ESRD. They have to be treated based on the disorders associated with CKD-MBD and not solely based on the results of a bone density scan. In some patients with documented low turnover disease and mineralization defect, some may...
Would you expect cinacalcet to lower calcium levels in a patient with Familial Hypocalciuric Hypercalcemia (FHH)?
The hypercalcemia in FHH is not primarily driven by overactive PTH secretion, so targeting the CaSR pharmacologically would not address the underlying pathophysiology. However, I suppose inducing hypoparathyroidism with Cinacalcet would induce calciuria, though at the expense of hypocalcemia.
Do you recommend adjusting the duration of a drug holiday based on the specific bisphosphonate used when treating osteoporosis?
If there has been a satisfactory response, the drug holiday for alendronate can be 2 years while zoledronic acid, which is more tightly bound to bone, can be stopped for three years.
Do patients with central adrenal insufficiency on maintenance hydrocortisone therapy require doubling of their corticosteroid during chemotherapy cycles?
I would follow the same sick day rules. If the patient is not feeling well with nausea, diarrhea, or worsening fatigue, the same rules of doubling the GC dose would apply. In cases of severe vomiting and not being able to keep the double dose of GC, parenteral GC injection and going to the ED for fl...
What is your approach to differentiating diabetes insipidus from primary polydipsia in the outpatient setting?
I usually do overnight dehydration tests for 12 hours and if fasting AM urine osmolality is >600 DI is less likely. If urine osmolality is low with high serum sodium it indicates DI, whereas with primary polydipsia the serum sodium is low with low urine osmolality.
Does papillary thyroid cancer with extensive squamous differentiation require specialized treatment beyond RAI and TSH suppression?
Squamous differentiation associated with PTC represents an aggressive pathologic feature with poor long-term outcomes. I would consider this as a step towards dedifferentiation. This disease is not chemo sensitive unfortunately. Chemo can be considered for advanced disease that requires rapid treatm...