Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
What are the treatment options for severe recurrent hypoglycemia in a patient with malignant insulinoma?
Can try increasing dose of diazoxide or adding sandostatin or octreotide. Not sure what the patient profile looks like, but would any resection be amenable. Can also consider adding corn starch a few times a day.
When do you start bisphosphonates empirically, irrespective of DEXA results, in patients going on chronic glucocorticoids?
I think this is an important question. I personally got really interested in bone in large part because of all the glucocorticoids that I was using to treat serious inflammatory diseases. I was fortunate to spend time with Dr. Howard Polley from Mayo when I was a fellow. He was on the team that gave...
Can romosozumab be used in patients on dialysis?
This is an interesting question given the common finding of osteoporosis among patients undergoing hemodialysis. There have been several individual case reports suggesting that treatment with romosozumab in this patient population can be safe and effective. The largest study (no control group) of wh...
How do you adjust your HbA1c goal for managing diabetes in elderly patients with multiple chronic illnesses but no limitations in performing self-care tasks?
There is guidance from ADA, AACE and other organizations. Most agree that an A1c target of 8% is perfectly acceptable in advanced elders and/or people with multiple comorbidities and limited life expectancies. The critical issue is to understand what a reasonable timeline for the patient is. The nat...
What is the role of radiation therapy for an elderly patient with medullary thyroid cancer who is not a surgical candidate?
We have offered definitive RT for MTC patients who are medically or surgically unresectable. Dosing is variable based on involved structures, performance status, staging, etc. We have used 5400 cGy in 18 fractions, particularly for the more elderly, poor performance status patients. Coverage of elec...
What is your approach to managing patients with new laboratory evidence of hypopituitarism (e.g. very low plasma ACTH level and low morning serum cortisol) and a remote history of trans-sphenoidal surgery for NFPA?
It is sufficient to start corticosteroids with mineralocorticoids in such patients.
What is the clinical importance of differentiating between impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) states?
IGT and IFG are different phenotypes of prediabetes. Clinical studies* suggest that IGT may be associated with higher cardiovascular risk than IFG. The molecular mechanisms and the treatments are thus different. IGT, which is due to impairments of beta cell insulin release, can be treated with reduc...
Is there any contraindication for use of Invisalign teeth aligners in patients undergoing treatment for osteoporosis?
I do not claim to be an expert in orthodontics (but I was married to an orthodontist for 20 years!). Tooth movement is somewhat complex and clearly involves both local inflammation and bone biology. The Invisalign-type device is relatively weak in terms of force on the teeth and is often reserved fo...
What evaluation do you do in patients with hypertension and persistently elevated aldosterone/renin ratio (over 20) but without an elevated aldosterone level (under 10 ng/dL)?
Patients with proven primary aldosteronism (based on pathology and postop aldosterone levels) can have plasma aldosterone levels <10 ng/dL. Repeating the levels, especially after optimizing their medications, can improve the test's sensitivity. The key in such cases is a PRA level <1 ng/dL. In the a...
What is your approach to differentiating primary from secondary hyperparathyroidism in recurrent kidney stone formers who also have chronic kidney disease, an elevated PTH, and hypercalcemia?
You have asked a complicated question. It is certainly possible for both conditions to coexist simultaneously. It would be unusual for primary hyperparathyroidism to cause secondary hyperparathyroidism, although recurrent obstructive uropathy from stones would be a possible etiology. Similarly, seco...