Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
How many days prior to elective major surgery do you recommend holding oral GLP 1 R agonist therapy?
Zero. Or, I suppose, if you're having surgery early in the morning, one.This has gone back and forth, but the most recent guidance from the ASA (with other societies concurring) has been that most patients can continue their GLP medications as normal preoperatively, with higher-risk people being rec...
Can estrogen priming therapy during IVF treatment lead to transient TSH elevation without clinical hypothyroidism?
A large number of hypothyroid women taking Levothyroxine will need to increase the dose of Levothyroxine after IVF. IVF results in extremely high levels of estrogen, which increases the thyroid-binding globulin that in terns require an dose increase of about 30%. Generally, it is recommended to incr...
How do you determine osteoporosis treatment response when patients have discrepant DEXA scan results during monitoring (eg improved BMD of the hip and spine but worsening BMD of the femoral neck)?
This is not all that uncommon. The first thing I do is ask if they have fractured since we started the therapy. If not, I relax a little. This is a nice scenario for using bone turnover markers as part of initial work up. If PINP goes up by >10 I am happy that an anabolic drug is working... more you...
What other considerations for hyperlipidemia management would you have for a patient with multiple prior PCIs whose LDL remains above goal on high intensity statin, ezetimibe, and evolocumab, assuming the patient is compliant with medications?
There are a few options, most of which depend on insurance coverage and patient preferences. But first, would do a chart biopsy to assess the efficacy of each of the therapies to better understand the reason for persistent LDL elevation. Perhaps they have a dysfunctional LDL receptor, so upregulatio...
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 mineralocorticoid receptor antagonist in patients with unilateral primary aldosteronism while they are awaiting adrenalectomy?
It depends on their blood pressure and potassium levels. Some of our patients are already on MRA at the time of their diagnosis without a need to get off the medication. Others may be started or returned to MRA after completing their biochemical workup. We recommend stopping MRA on the day of surger...
When should you consider adding clonidine to an antihypertensive regimen for patients with advanced CKD?
Clonidine patch is useful in severely uncontrolled hypertension. In patients with CKD, not responding to conventional medications - like calcium blockers. Though the side effect profile is not great, it is less expensive and practical.
Do you foresee any added benefit of triple agonist therapy (GLP-1, GIP and glucagon) for glycemic control in patients with Type 1 diabetes mellitus?
This is actually a speculative question, given that there is no available data to address this. But what data do we have that might inform a decision to use a triple agonist in the T1DM patient population? A recent NEJM Evidence article (Shah et al., PMID 40550013) looked at the use of semaglutide, ...
How do you interpret the presence of GAD antibody in a middle-aged patient with diabetes when all other type 1 diabetes antibodies are absent?
I tend to order these antibodies in those adults who do not have a very clear clinical picture to diagnose them as either 1 or 2, like a middle aged normal built male/female with no other comorbid conditions and negative family history too. Then, if GAD is negative, chance of have T1 is very very lo...
How do you counsel patients with metabolic syndrome who decline statin therapy and have low coronary calcium scores regarding their long-term CVD risk?
This is a great question with many ramifications, and I can only give an incomplete answer that includes personal opinion. First, what is the risk? The MESA Risk Score Calculator (check it out) gives a CAC percentile score as well as a 10-year risk. The 10-year risk may be low, but a high percentile...