Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
How do you approach a patient with elevated bone specific ALP (>2X the normal limit), but no other evidence of Paget's disease?
There are other causes of elevated bone alkaline phosphatase e.g. osteomalacia. Check blood calcium, magnesium and phosphate, PTH and 25-OH-vitamin D. If PTH is elevated and no CKD, check 24-hour urinary calcium and creatinine.
Which medications do you deem necessary to stop prior to measuring plasma renin and plasma aldosterone when evaluating a patient for possible primary aldosteronism?
The most important medications to stop before checking renin and aldo levels are spironolactone, amiloride, triamterene, finerenone, and eplerenone. Ideally, patients should be off these meds for at least 6 weeks before testing. A pathologic primary aldo can be detected while taking beta blockers or...
In patients presenting with classical findings of primary hyperparathyroidism (i.e mild hypercalcemia, high 24hr urine calcium, elevated 1,25 Vit D but normal PTH), can spontaneous normalization of calcium be explained by episodic hypersecretion of PTH?
PTH secretion is always about 70% basal, related to the mass of parathyroid tissue, and about 30% episodic. Patients with primary hyperparathyroidism can have superimposed secondary hyperparathyroidism. High urinary calcium suggests a negative calcium balance. PTH is not "normal" if calcium levels a...
How do you approach the use of metformin in the management of prediabetes for patients who are neither obese nor have a family history of diabetes?
When considering the approach to a patient with a diagnosis of pre-diabetes, I think it is important to be sure the patient actually meets criteria. Most of us screen patients at risk with A1C levels because it is so much easier. However, A1C levels do not fully correspond to glucose levels and may ...
When do you recommend using trabecular bone score (TBS) for managing osteoporosis?
Trabecular bone score is a valuable tool in the evaluation of osteoporosis and risk of fracture. It is an indirect indicator of bone microarchitecture. Although TBS predicts fracture risk, it should not be used alone but in conjunction with BMD for deciding whether to treat the osteoporosis and if s...
Do you adjust the dose or the timing of levothyroxine ingestion in patients on anti-acid medications?
Actually, adjusting the timing of levothyroxine ingestion probably doesn’t help much, since the proton pump inhibitors, and other similar drugs, have a duration of action of 12–24 hours. I would recommend checking serum TSH levels after the patient has been on the gastric acid medication for 4–6 wee...
Is ABI (Ankle Brachial index) lower limb arterial doppler not recommended if patient already has arterial stents in the legs, and if so, what other imaging modality would you consider as first-line?
ABI is still helpful in follow-up of patients with arterial stents but only gives a sense of global perfusion to the distal limb and may not be helpful in patients with calcified non-compressible vessels, (e.g. CKD, diabetics), so a better assessment is arterial duplex that can visualize the entire ...
Is intermittent fasting effective for weight loss?
Intermittent fasting is a weight loss strategy that cycles between periods of unrestricted eating and brief periods of fasting, with either no food or significant calorie reduction. A wide range of intermittent fasting strategies (e.g. alternate-day fasting and time-restricted daily eating), have be...
How do you counsel patients with elevated Thyroglobulin Peroxidase antibody levels, diffuse thyroiditis features on ultrasound, non-specific symptoms of fatigue, but normal biochemical thyroid function labs?
Assuming this is a female patient and TSH and free T4 are both quite normal, the patient does have asymptomatic Hashimoto’s thyroiditis. The fatigue is unrelated to the thyroiditis. She will need periodic monitoring of TSH and thyroid supplementation only if the TSH is high on two measurements.Howev...
Aside from adrenal insufficiency and thyroid toxicities, how do you approach other hormonal imbalances during treatment with immune checkpoint inhibitors?
A systematic review (Barroso-Sousa et al., PMID 28973656) indicated that hypophysitis can occur in 3.2% of patients treated with ipilimumab (Yervoy) and this increased to 6.4% when combined with nivolumab (Opdivo). Obviously, adrenal and thyroid functions need to be assessed first but other function...