Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
For patients on a bone-modifying agent for osteoporosis/severe osteopenia in the context of adjuvant AI therapy, how do you manage the bone-modifying agent once their AI course is complete?
In this case, I would be guided by the bone density (DXA) scan, if there is still osteoporosis or severe osteopenia, I would continue the BMA and repeat the DXA scan in one or two years. If the DXA shows improvement, I would discontinue the BMA, knowing that one can re-institute at a later date. Sev...
Would you consider using teriparatide beyond a cumulative maximum of two years now that the black box warning regarding osteosarcoma has been removed?
This is a very good question. Early studies with PTH compounds for osteoporosis showed you could give it for three years and still have an effect on increasing bone mass. The black box warning was for osteosarcomas that occur in young adults and children, and the black box warning was also for indiv...
Do you approach therapy differently for patients with a diagnosis of osteoporosis based on a fragility fracture rather than based on bone mineral density on DXA (assuming no secondary causes of osteoporosis)?
This is an interesting question but the question does not define the bone density results in the individual(s) in question with a history of a fragility fracture. There are people who sustain such fractures with normal bone densities and of course, many individuals sustain fragility fractures with l...
Do you routinely offer a bisphosphonate or denosumab to multiple myeloma patients without skeletal lesions?
Our practice is to give 2 years of bone-directed therapy in all comers. Preferably bisphosphonates over denosumab for cost reasons unless needed due to CKD or intolerance.I agree that the case is less compelling for patients without skeletal lesions at baseline. An old RCT of bisphosphonates versus ...
Is there a role for starting an anabolic agent in a patient that developed an atypical femoral fracture while on denosumab sooner than 6 months after the last denosumab dose?
The biology of an AFF is still being elucidated. However, there are many aspects of an AFF that are similar to a "stress fracture" in that there is a combination of osteoid and cartilage that does not fully mineralize. Fracture healing goes through a cartilaginous phase, followed by mineralization w...
How do you approach treatment of osteoporosis in patients with CKD who develop a fragility fracture while on denosumab?
The only option left at this point is a PTH compound. Please it or not, it still works every time in subjects with a secondary elevation of PTH. I would try either Forteo or Tymlos for a few months and see if the patient can tolerate it and if the calcium numbers remain stable. I am not sure about r...
How do you approach prophylaxis against glucocorticoid-induced osteoporosis in patients with end-stage renal disease on dialysis?
Treating patients with end-stage renal disease on glucocorticoids to prevent bone loss is a challenge. A patient with end-stage renal disease cannot be treated with bisphosphonates. However, denosumab the RANKL antibody has no restrictions regarding renal disease. So my suggestion is to treat a pati...
How do you diagnose and treat patients who develop uveitis while on bisphosphonate therapy for osteoporosis?
Ocular inflammation, usually anterior uveitis, can occur as a consequence of bisphosphonate therapy. Virtually always, the bisphosphonate is one that is given intravenously and the ocular inflammation begins a day or two after the treatment. Furthermore, the inflammation is generally self-limited; i...
How would you approach osteoporosis management in a patient who fractures while on denosumab therapy?
This is a scenario that we run into at times and is very difficult with data suggesting a decline in BMD after discontinuation of denosumab as well as data from DATA-Switch trial from 2015 revealed that switching from denosumab to teriparatide resulted in progressive or transient bone loss. I would ...
How do you manage anaplastic thyroid cancer that is progressing through radiation therapy?
The algorithms for ATC, a rare disease, have gotten relatively complex including the incorporation and timing of XRT. It is unclear from the question what the presentation scenario is, i.e., localized disease or metastatic, and the mutational status, as ideally at a minimum BRAF status is known. Now...