Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
What is your daily correction goal for those patients being treated for hypernatremia?
There is no correction per se. Although, older guidelines recommend a correction of no more than 8-10 mEq/dL in 24 hours. The theoretical risk of correcting hypernatremia too fast is the development of cerebral edema. However, a recent study (Chauhan et al., PMID 30948456) showed no evidence of cere...
For a patient who would benefit from an anabolic agent for osteoporosis, do you prefer romosuzumab over teriparatide in the absence of contraindications to either agent?
Both teriparatide and romozosumab are excellent drugs to treat osteoporosis with documented risk reduction in fractures. TPTD reduces spine fracture about 85% and romozosumab about 75%. Both are excellent. They have very different biologies with TPTD being a remodeling-based anabolic and romozosumab...
What treatment would you use in a patient with osteoporosis on denosumab for 10 years who develops ONJ at a site of an old implant?
A bone formative agent as teriparatide.
When do you consider stopping denosumab when a patient with osteoporosis is otherwise tolerating it without issues?
This is a matter of "style" more than anything. I continue Prolia and have many patients now exceeding 10 years - up to12 years, without any apparent safety issues. I realize we are in a "data-free" zone after 10 years, but as rheumatologists, we are frequently giving monoclonal antibodies for perio...
In a patient who fractures after several years of denosumab therapy, would you wait 6 months after the last denosumab injection to start an anabolic agent or could start an anabolic agent sooner?
In a patient on any antiresorptive drug who fractures, we should consider an anabolic drug. A fracture does not always mean the drug has failed but we should consider changing to an anabolic since we have good evidence that anabolics have superior fracture risk reduction. Denosumab is of course mor...
When would you offer radiation for poorly differentiated thyroid cancer?
PD thyroid cancers are rare, of follicular origin, often iodine unresponsive, and can be addressed with surgery and postop RT. More advanced disease presentation is a much larger issue and DM rates are as high as 60% with poor response to systemic therapy to date. Unlike anaplastic thyroid cancers t...
Would you give transdermal hormone replacement therapy to a woman with remote history of provoked pulmonary embolism?
There is good evidence that transdermal HRT does not pose the same risks as oral HRT (Morris and Talaulikar, PMID 36573625). ASA or DOAC prophylaxis is likely not indicated.
Are there any concerns regarding side effects in changing from denosumab to zolendronic acid or vice versa?
In patients with advanced solid tumors and bone metastases, the anti-resorptive agents, zoledronic acid (ZA) or denosumab (D) are administered to prevent skeletal related events (SREs). The key toxicity of concern is medication-related osteonecrosis of the jaw (MRONJ). While patient and oral health ...
How would you manage a patient with osteoporosis on denosumab who develops significant renal insufficiency where it is difficult to continue denosumab due to increased risk of hypocalcemia (i.e. eGFR in the low 20’s)?
This is an interesting question. Denosumab, unlike bisphosphonates, does not have a warning about use with renal insufficiency. However, denosumab does reduce osteoclast activity for a few weeks after the injection, and this can cause hypocalcemia in patients with renal insufficiency as these patien...
In which patients with chronic kidney disease and low 25-OH vitamin D levels do you prefer weekly ergocalciferol to daily cholecalciferol supplementation?
Ergocalciferol (D2), the plant-based form of Vitamin D, and cholecalciferol (D3), the animal-based form, are essentially equivalent in potency with perhaps a small, clinically insignificant edge favoring D3. They both can be given at long interdose intervals; monthly doses provide the same impact on...