Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
In patients with confirmed hypercortisolism with a high/normal unsuppressed ACTH who have both a pituitary adenoma and adrenal adenoma identified on imaging, can you reliably use DHEA-S to determine the source of cortisol production?
There is a difference between high-normal and unsuppressed ACTH. If ACTH is high-normal, this is ACTH-dependent Cushing. However, you can have mild adrenal Cushing without fully suppressed ACTH (e.g., ACTH in the 10-20 pg/ml range and sometimes even above 20). I don't think you can rely on DHEAS in ...
How do you decide when to evaluate for central hypothyroidism in a patient with low-normal TSH and low free T4?
The differential in these patients is 1) mild subclinical hyperthyroidism 2) central hypothyroidism 3) normal variant related to assay detection limitations. It would be important to obtain a good history and try to identify any hypothyroid or hyperthyroid symptoms. Having said that, patients will u...
How do you approach osteoporosis screening in men?
While osteoporosis is more prevalent in postmenopausal women, it is often under-recognized in men. The risk of mortality after hip fracture is higher in men, and that risk may extend over 10 years after injury. Men who sustain a wrist fracture are more likely to have severe osteoporosis and a higher...
When do you think physicians should seriously consider prescribing PCSK9 inhibitors for the prevention of heart attack and stroke in people with ASCVD or diabetes, based on the results of the VESALIUS-CV trial?
Although I checked 'high lipoprotein (a) as a reason to go with a PCSK9 first, I would almost never do it is practice. Statins first and then add a PCSK9 if LDL is above my goal for the patient. I might use a lower dose of the statin to get 35% lowering and then add the inhibitor if the patient was ...
What patient specific factors outside of health insurance coverage do you use to decide which GLP1 R agonist or dual agonist therapy to start in patients with diabetes?
The class of drugs called GLP 1 RA continues to grow. Single agonist drugs include dulaglutide and semaglutide. There is now a “dual agonist” available for use, tirzepatide, which really is a GLP 1 RA and GIP RA. There are “triple agonists” which also bind the glucagon receptor that are close to FDA...
In patients with MASLD, would you consider management with off-label metformin, pioglitazone (despite weight gain risk), GLP-1 RA, or simply intensify lifestyle and monitor?
In 2025, we should be assessing if patients are developing F2-F3 fibrosis especially with the use of non-invasive assessments (FIB-4 score, transient elastography, or MRI elastography), and then offering either Semaglutide or Resmetirom for these individuals w/ F2-F3, which are the only FDA approved...
How frequently do you monitor for hypocalcemia in patients on romosozumab?
I do not know the clinical safety data well. In my own practice, I never saw anybody get hypocalcemia. I assume the potential cause of hypocalcemia is the anti-resorptive effect of the drug. Before any osteoporosis drug. I get a good chemistry panel, PTH level, vitamin D level, and when appropriate ...
Is there a role for monitoring PTH levels in patients with advanced chronic kidney disease who are receiving denosumab in order to assess for adynamic bone disease?
It is more important to monitor PTH and bone-specific alkaline phosphatase prior to the initiation of denosumab. If PTH and bone-specific alkaline phosphatase are suggestive of adynamic bone disease, I would recommend a bone biopsy to rule out adynamic bone disease prior to the initiation of denosum...
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...
How do you decide which patients with chronic hypoparathyroidism you move from calcium and active vitamin D to PTH replacement therapy?
My preference, if the patient has good insurance or has the ability to pay for the therapy, is PTH replacement therapy. Calcitriol plus calcium can work reasonably well in maintaining serum calcium concentrations. However, the major issue is the serum phosphate. Patients with a high-normal or elevat...