Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
Is there any role for 25-OH Vitamin D testing in patients older than 75 years old in the general population?
The recent Endocrine Society Guideline on Vitamin D no longer recommends testing for vitamin D status unless there are unusual circumstances. The Guideline however recognized that approximately 20% of adults greater than 75 years of age are vitamin D deficient i.e. 25-hydroxyvitamin D <20 ng/mL. The...
For a TSH producing microadenoma, would you recommend surgery vs methimazole if the patient is elderly and the tumor is relatively small?
In general, treating TSHomas with methimazole is not a good idea, as the adenoma may grow. If she is a candidate for surgery, this should probably be advised. Most TSHomas respond very well to somatostatin receptor ligands (better than GH-secreting adenomas).
How do you distinguish between primary and tertiary hyperparathyroidism in a patient with ESRD?
Almost all patients with hypercalcemia, hyperparathyroidism, and ESRD are going to have tertiary HPTH and not primary. Imaging will show diffuse hyperplasia and multiple nodules in tertiary and in the rare case of primary would expect to see a solitary nodule without hyperplasia of the other glands....
What are the clinical indications and major limitations of lipoprotein apheresis?
LDL apheresis is a procedure that selectively removes apo B-containing lipoproteins (so primarily LDL particles) from the circulation. Very simply - venous blood is withdrawn via IV, plasma separated by the machine (liposorber, FDA approved in the US), passed through a column which binds the apo B c...
What kinds of dental work do you particularly worry about and try to avoid in patients on bisphosphonates?
Firstly, the incidence of BRONJ (bisphosphonate-related osteonecrosis of the jaw) is very low with all drugs of this class. However, many patients and dentists are concerned about the possibility of this problem. Generally, BRONJ occurs after an extraction and subsequent poor healing at the extracti...
What work-up should be considered in patients with significantly worsening A1c despite steady diet, lifestyle, and medication adherence?
For patients with unexpected decompensation in glycemic control, I would start off by ensuring that their fingerstick or CGM glucose data correlates with their rising A1c. New medications (such as immunosuppressants or protease inhibitors) and anemia can falsely elevate A1c. I would then make sure t...
Do you avoid empagliflozin in patients with history of amputation?
To be clear, you can prescribe any SGLT2i to a patient with an amputation or at high risk for an amputation due to prior foot ulcers, insensate foot, peripheral vascular disease. The "warning" (not contraindication) in the canagliflozin PI is "Consider factors that may increase the risk of amputatio...
Do you use denosumab for castration-sensitive prostate cancer with osseous metastases?
This is an important question but a complex one. Several issues are critical to consider: 1) bone anti-resorptive therapies like zoledronic acid have NOT been established to improve survival or reduce skeletal events in this setting of bone metastatic HSPC as compared to waiting for mCRPC. See CALGB...
Which screening method for diabetes do you consider to be the most sensitive?
I don’t usually think about which screening method for diabetes is the most sensitive. I am more likely to consider which is most appropriate for my patient. I never order OGTT for non-pregnant patients. They are cumbersome and, compared to FPG and A1C, they don’t significantly change my recommenda...
How long do you wait before reassessing a 24 hour urine calcium level in patients with recurrent nephrolithiasis, hypercalciuria, and osteoporosis who are initiated on bisphosphonate therapy?
Thank you for your excellent question. This is a relatively common concern, and yet I am aware of very little hard data. Opinions will differ; here is mine: In this scenario, it is my practice to have the patient visit with our Stone Clinic dietitian regarding dietary recommendations for calcium, so...