Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
Do you recommend non-bypass bariatric surgeries over intestinal bypass procedures for kidney transplant-eligible candidates to prevent oxalate nephropathy, given the higher risk of kidney oxalate deposition with intestinal bypass?
Yes, my preference is for non-bypass bariatric surgery in my patients with severe obesity and sleeve gastrectomy is preferred. However, the GLP-1 agonists have really had an impact on weight loss in transplant patients and transplant candidates alike. There was a nice editorial by Lorden and Parajul...
Would you discontinue romosozumab in a patient who develops a hemorrhagic stroke while on therapy?
The question is why did he have an intracranial bleed? Did he have hypertension? I tend to avoid R with cardiovascular disease including hypertension because of the black box warning. Also, this drug has not lived up to what we thought it would be with the phase 3 study showing a very elevated NNT.
How do you manage osteoporosis treatment following parathyroidectomy for primary hyperparathyroidism?
Good question and I usually do this with input from an endocrinologist. I monitor serum and urine calcium and provide supplements and if the bone mass declines, I consult an endocrinologist on the next steps. As a rheumatologist, I am not an expert on this issue.
How should patients time the ingestion of their alendronate and levothyroxine given issues with food/drug interactions?
Since the half-life of levothyroxine is 7-10 days, you can double the dose of Levothyroxine on 1 day and then the next day take only the alendronate. There will not be a significant change in T4 levels.
What factors guide you in adjusting the dose of fludrocortisone in a patient with primary adrenal insufficiency?
Adjustment of the dose is generally based on clinical factors. Orthostatic blood pressure should be measured on each visit with normalization of blood pressure as a goal. Also electrolytes should be measured each visit to make sure potassium levels are normal and a supplement added if need it. Lower...
What is the typical timeline for remission of autoimmune hypoglycemia?
Insulin autoimmune syndrome (IAS) or Hirata disease is a rare disorder characterized by hypoglycemic episodes due to the presence of high titers of insulin autoantibodies (IAA). The disease was first described in 1970. Because of its rarity, large clinical experiences with this disorder are limited....
What work up do you recommend in post bariatric surgery patients who are slowly gaining back the weight despite no changes in diet?
Depending on which surgical procedure they had and how long ago they had it, patients may need evaluation by their surgeon. Meanwhile, I approach these patients similarly to patients who have not had surgery. I look for reasons for their weight gain such as change in diet (even if patient denies it ...
Would you do active surveillance or completion thyroidectomy in a patient with 1.6 cm tall cell PTC with posterior margin’s indeterminate and 7 mm isoechoic solid nodule on other side?
May qualify for monitoring with full disclosure to the patient (aggressive histology) and if the following histologic and clinical features are met. Reassessing the path is recommended if the report is unclear. No extrathyroidal spread or invasion No angio-invasion Clear surgical margins Pre surgi...
For patients with central hypothyroidism and a clear etiology (such as recent head irradiation), do you recommend brain imaging prior to starting thyroid hormone replacement therapy?
Levothyroxine does not cause tumor growth, and therefore you do not need to image before starting therapy. However, in general, it takes a long time for central hypothyroidism to develop after radiation, therefore in the presence of an early reduction in FT4 you must consider the possibility of the ...
In a patient with bisphosphonate induced bilateral atypical femur fractures, how would you approach timing of alternative osteoporosis treatments and surgical management?
Unfortunately, this is still a very common problem. Although the information that oral bisphosphonates should likely be limited to 5 years duration has been available for many years, my large orthopaedic practice continues to see 2-4 atypical femur fractures per month and often the patient has been ...