Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
How do you approach a young patient with metastatic poorly differentiated thyroid cancer with rhabdoid/non-anaplastic features?
Unfortunately, this patient has a very poor prognosis. Due to the nature of her tumor being poorly differentiated, her disease is more likely than not to be refractory to radioiodine. If her disease in the thyroid and neck has not been addressed, external beam radiation therapy should be offered for...
What strategies do you employ for adjusting the dosage of levothyroxine in hypothyroid patients who experience significant weight loss or are initiated on GLP-1 receptor agonists?
In spite of significant weight loss, some patients may not require a dosage change for levothyroxine while others may require a dosage reduction. It is very reasonable to recheck a TSH with free T4 after a 10% weight loss to see if a dose adjustment is needed. Rapid weight loss may lead to a tempora...
For patients with metabolic syndrome, is it reasonable to wait for the effect of tirzepatide therapy on their lipid profile prior to starting statin therapy?
While tirzepatide has shown significant improvements in lipid profiles, including reductions in total cholesterol, LDL cholesterol, and triglycerides, and increases in HDL cholesterol, these effects should be considered complementary to, rather than a replacement for, statin therapy.
What is your approach to management of hyperlipidemia in patients taking JAK inhibitors?
The ORAL Surveillance Study published in the NEJM in 2022 was a phase IIIb/IV open-label noninferiority study in RA patients over the age of 50 with at least one cardiovascular risk factor. The aim was to demonstrate that JAK inhibitors were non-inferior in terms of major adverse cardiovascular even...
Do you recommend the use of GLP1 R agonist therapy in patients with T1DM for weight loss?
GLP-1 agonists can be used as off-label in patients with Type 1 DM and obesity to help with weight loss; improve Hb A1c and decrease insulin requirements.A meta-analysis by Tan et al., PMID 38249345 of 11 RCT comprising 2,856 patients with Type 1 Diabetes and the use of GLP1 agonists as an adjunctiv...
Do you recommend parathyroid adenoma resection or ablation for patients with primary hyperparathyroidism and recurrent nephrolithiasis who are found to have a single gland adenoma on parathyroid ultrasound and nuclear medicine imaging?
Yes. My two indications for ablation/resection of a proven parathyroid adenoma are (1) metabolically active calcium-based kidney stone disease and/or (2) osteopenia/porosis as identified by bone scan. I think there is strong evidence that primary hyperparathyroidism can cause either or both. In the ...
Would you recommend cinacalcet for patients with recurrent nephrolithiasis who have hypercalciuria despite thiazide diuretic use and who also have an elevated PTH level without localizing parathyroid adenoma on imaging?
This is a tricky question with a nuanced answer. If the hyperparathyroidism is secondary, cinacalcet may have a role in treatment along with normalizing serum phosphorus and vitamin D. However, metabolically active kidney stones are unusual in advanced chronic kidney disease. If the hyperparathyroid...
In your practice, when do you opt to treat unilateral primary hyperaldosteronism medically rather than surgically?
There should be a good reason for not pursuing surgery in a patient with unilateral primary aldosteronism. The surgery is more cost-effective. Some but not all data suggest a faster decrease in cardiovascular morbidity, a lower risk of atrial fibrillation, arterial stiffness, left ventricular mass, ...
What is the optimal anti androgen dose of spironolactone when treating female hirsutism?
My experience with this issue has primarily been in treating women with PCOS who have hirsutism and so these comments are limited to that condition. First, it is important to establish normal renal function and electrolytes before starting. It is also important to know if the patient is on an ACE-I ...
Under what circumstances would you test for hypercortisolism in a patient with insulin resistance?
The American Diabetes Association meeting that just finished up featured the CATALYST study that found hypercortisolism by an abnormal dexamethasone suppression test was present in 24% of patients with difficult-to-control type 2 diabetes. For insulin resistance alone, I suspect the prevalence would...