Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
In a patient who completed 5 years of oral bisphosphonate and has a T score persistently in osteoporotic range, what factors help you decide whether it is appropriate to start a drug holiday vs. switch to an alternative agent?
This is an interesting question concerning a common clinical issue. Unfortunately, I am unaware of any data (evidence-based medicine) that is helpful in answering the question. My response is thus only anecdotal. There is some good data that patients with an inadequate bone density response to three...
Should a toe-brachial index be obtained in lieu of resting ABI as an initial screen for PAD in high-risk patients such as those with longstanding diabetes or advanced age with stiffened vessels?
Yes, a TBI should be used instead of an ABI in patients with diabetes and chronic kidney disease as the ABI is likely to be inaccurate due to non-compressible vessels. An arterial duplex and TBI should be the test of choice in this patient population.
What recommendations do you have for a transgender female patient with history of prothrombin gene mutation who is interested in starting gender affirming hormone therapy?
A review of the literature suggests that the risk of VTE associated with hormone therapy in this setting is quite low, even in the presence of other risk factors for clotting (see, for example, Mullins et al., PMID 33753543). Furthermore, the presence of an asymptomatic prothrombotic genotype is rar...
How do you manage calcium and vitamin D replacement in scleroderma and myositis patients with dysphagia and malabsorption?
Dietary calcium is a good choice. I recommended that my patients with dysphasia caused by scleroderma drink 2-3 glasses of skim milk daily. 8 ounces contain 300 mg of calcium which is highly bioavailable. It also provides a good source of whey protein that contains all the essential amino acids. Ano...
Is history of radiation therapy for uterine cancer an absolute contraindication to parathyroid hormone/parathyroid hormone related protein analogues such as teriparatide and abaloparatide in a patient with severe osteoporosis with multiple spine fractures?
I agree with Dr. @Dr. First Last. The initial studies in young rats given high doses of PTH compounds for most of their lifespan (I think until either 24 or 36 months of age) resulted in a higher-than-expected number of incident osteosarcomas. However, the black box warning about skeletal radiation ...
Do you treat secondary erythrocytosis caused by SGLT2 inhibitor?
I have seen this once, and stopped the SGLT2 inhibitor, and recommended they identify an alternative strategy to treat his DM. It seemed to help overall.
Where do you place romosozumab in your treatment sequence for osteoporosis management?
I agree. It is very effective as first-line therapy in patients at high risk for fracture. It can also be useful post bisphosphonate therapy. I have used it successfully multiple times to transition patients from long-term Prolia therapy without loss of bone mass.
Do you treat low 25-OH vitamin D levels in those with end stage kidney disease?
Low 25-OH vitamin D levels in those with end-stage kidney disease should absolutely be treated. The assumption that calcitriol administration satisfies all the vitamin D needs of the body is incorrect. While it is true regarding the endocrine effects of calcitriol (calcium and phosphate homeostasis)...
What is your approach to using bisphosphonates in those with severe hypercalcemia and chronic kidney disease?
Epocrates says for pamidronate under renal dosing "severe impairment avoid use". I have used it many times but at a reduced dose, 30 mg IV once, and wait, takes a few days to kick in. Maybe once I used 60 mg. Use at your own discretion, as it is not advised as above. I avoid zoledronic acid (even th...
What is your approach to managing hypocalcemia following a parathyroidectomy in patients with end stage kidney disease?
The hungry bone syndrome can be tricky and insidious. I have seen patients go home after a pth-ectomy without evidence of it and then a few days later show up in the ED with symptoms of hypocalcemia. Hemodialysis may mask it (as well as treat it) by supplying a large IV calcium load. If you dialyze ...