Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
Do you routinely check morning cortisol before discharging a patient who received more than 3 days of high-dose corticosteroids during a hospitalization for an acute illness?
No. In general, persistent HPA suppression does not occur when a single steroid treatment is shorter than 2 weeks.
Which anti-hypertensives do you hold and for how long when screening for hyperaldosteronism in a patient with resistant hypertension and initial screening with unsuppressed renin but elevated aldosterone >20 while on anti-hypertensive therapy?
Only spironolactone for 2-3 weeks. Suppressed renin is the most sensitive test to diagnose primary hyperaldosteronism.
In ischemic stroke patients with low LDL levels (<30-50 mg/dl), would you consider lowering LDL levels to lower values without concern for any side effects?
If LDL levels are already below 70, I don’t target a lower goal. The SPARCL trial showed that reducing LDL to this range has an NNT of about 45 to prevent one stroke, which I find to be modest at best. From my perspective, lowering LDL further (<30-50 range) shifts the focus to treating a number rat...
Do you forgo adrenal imaging in a patient with primary hyperaldosteronism who has decided against surgery?
Yes. It would be a waste of time and money. Can go straight to using spironolactone or other mineralocorticoid blocker.
Can cinacalcet be used in primary hyperparathyroidism to determine if mild/moderate hypercalcemia is responsible for non-specific complaints?
Cinacalcet is primarily used in patients with hyperparathyroidism who are less-than-optimal surgical candidates. However, it is effective in about 80% of patients with hyperparathyroidism to normalize their serum calcium and reduce their PTH levels. The main issue with using cinacalcet for the deter...
Is anabolic therapy for treatment of severe osteoporosis less effective when not taken continuously for the 12 to 24 month duration of therapy?
I have had experience with Forteo. When it was first introduced and was very expensive and not always covered by insurance, I would use it intermittently with good success. In some cases, I would use it twice a week and follow the bone remodeling markers, which were a good indicator of its effective...
In middle-aged adults with TSH 5–10 mIU/L and no symptoms, would you start levothyroxine or monitor, and does your threshold change with cardiovascular risk factors?
In a middle-aged patient with a TSH between 5-10 and no symptoms, I would initially monitor their thyroid levels. I would consider checking a TPO antibody titer; if positive, the rate of transition to overt hypothyroidism is greater. I would also screen for other medical issues that could be impacte...
How would you empirically manage a large sellar/suprasellar mass with encasement of the right cavernous and terminal internal carotid arteries?
Knowing the histology of the mass would really help in creating more accurate treatment recommendations. A biopsy of a sellar mass is usually accomplished by an endonasal-endoscopic transsphenoidal approach utilizing the expertise of an ENT surgeon and a skull-base neurosurgeon. However, in this cas...
How do you explain the use of an AI scribe to patients the first time it is used in their care?
I use an AI scribe in my outpatient clinic, and around 90–95% of my patients agree to it. I obtain consent at the start of each visit and make it clear that it's completely optional—that they can say no at the start or change their mind at any point in the visit, with no impact on their care. I also...
How do you counsel patients on ways to boost their HDL cholesterol levels while on lipid lowering therapy?
I don't set high-density lipoprotein (HDL) cholesterol goals for my patients per se, nor do I spend a lot of time counseling them on ways to boost their HDL. Having said that, I recommend a heart-healthy dietary pattern and increased physical activity as ways to improve their overall health, which w...