Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
What workup do you recommend for patients requiring higher-than-expected levothyroxine doses for their weight?
If someone is on a significantly greater than expected dose of levothyroxine for their weight, I take a careful history to confirm they are taking the medication appropriately. Usually, the issue is mistiming of medication with regards to proximity to food or supplements - or even simple nonadherenc...
In patients with T1DM, when would you consider the use of amylin analogues for control of post prandial hyperglycemia?
Pramlintide was FDA-approved in 2005 after demonstrating modest A1C reduction, improvement in post-prandial hyperglycemia, no increase in hypoglycemia, and some weight loss. I prescribed it to several of my patients with type 1 diabetes. Unfortunately, many of them had challenges such as GI side eff...
Do you escalate to 7.2 mg semaglutide in a patient with obesity who has not achieved their weight loss goal on the 2.4 mg dose despite the increased risk of dysesthesia at the higher dose?
This question is raised because of a recent report (Wharton et al., PMID 40961952) looking at weight loss in obese patients titrated up to 7.2 mg/week of semaglutide compared to the usual dose of 2.4 mg/week. The study was funded by Novo Nordisk, and the authors have strong financial ties to the com...
How should clinicians balance the use of finerenone with other heart failure treatments like SGLT2 inhibitors, considering their glycemic benefits?
Finerenone could replace spironolactone or eplerenone since the likelihood of adverse effects are less. Unfortunately, RCTs of finerenone have compared it placebo. Until superiority to spironolactone (a cheap and very effective drug for heart failure) is shown we cannot justify the cost.
Would you favor the use of denosumab over bisphosphonate therapy for treatment of osteoporosis in patients who are at high risk for osteoarthritis given recent data suggesting reduced risk of developing knee OA?
Although the overall data to date concerning the impact of denosumab to reduce incident knee OA or lessen established disease remain limited, there are sufficient signals that warrant further investigation and support the need for an appropriately powered RCT with endpoints that include both patient...
In patients with severe osteoporosis, history of retinal artery occlusion, and hypercalciuria, would you favor PTH analogue therapy or Evenity?
Assuming that PTH and vitamin D are normal, neither. Chlorthalidone is the treatment of choice in this scenario. Chlorthalidone is usually better than HCTZ, as HCTZ often must be given BID, whereas chlorthalidone can be given daily. I have seen very large improvements in BMD with thiazide therapy, o...
Do 5HT4 agonists such as Metoclopramide actually lead to improvement in symptoms for patients with diabetes related gastroparesis?
Yes, sometimes when the gastroparesis is frequent or the symptoms are tough, I do use Reglan to help. By the time they wind up in the hospital, they are really willing to have me use anything on them that might help. I explain to every patient the side effects of Reglan, including tartive dyskinesia...
In patients using a tandem insulin pump on auto-mode/Control-IQ, would decreasing the basal settings on the profile actually reduce the delivered hourly insulin dose or is that only relevant if they switch to manual mode?
In the control IQ, the basal adjustment IS relevant in Auto-mode. The algorithm uses predicted CGM reading in 30 minutes (in the future) and responds to keep the glucose by CGM in the targeted range. See below: Above 160 mg/dL, basal insulin rate increases Above 180 mg/dL, a correction bolus is giv...
Do you avoid the use of GLP-1 R agonist therapy for treatment of obesity in patients with known gastroparesis?
Short answer: yes. Gastroparesis is a well-known side effect of GLP-1 RA therapy. It is dose-dependent, so some patients may tolerate smaller doses but not the highest ones. A recent head-to-head trial of semaglutide vs tirzepatide in obesity (Aronne et al., PMID 40353578) found similar rates of gas...
Would you start a GLP-1 receptor agonist for the treatment of type 2 diabetes in patients with remote family history of medullary thyroid cancer without genetic testing?
No, I would not start a GLP-1 RA in a patient with a family history of MTC. What do you even mean by remote?