Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
Would you do active surveillance or completion thyroidectomy in a patient with 1.6 cm tall cell PTC with posterior margin’s indeterminate and 7 mm isoechoic solid nodule on other side?
May qualify for monitoring with full disclosure to the patient (aggressive histology) and if the following histologic and clinical features are met. Reassessing the path is recommended if the report is unclear. No extrathyroidal spread or invasion No angio-invasion Clear surgical margins Pre surgi...
For patients with central hypothyroidism and a clear etiology (such as recent head irradiation), do you recommend brain imaging prior to starting thyroid hormone replacement therapy?
Levothyroxine does not cause tumor growth, and therefore you do not need to image before starting therapy. However, in general, it takes a long time for central hypothyroidism to develop after radiation, therefore in the presence of an early reduction in FT4 you must consider the possibility of the ...
In a patient with bisphosphonate induced bilateral atypical femur fractures, how would you approach timing of alternative osteoporosis treatments and surgical management?
Unfortunately, this is still a very common problem. Although the information that oral bisphosphonates should likely be limited to 5 years duration has been available for many years, my large orthopaedic practice continues to see 2-4 atypical femur fractures per month and often the patient has been ...
Which brand/preparation of levothyroxine do you recommend to treat hypothyroid patients with alpha-gal allergy?
Alpha-gal syndrome is a type of food allergy to meats. None of the generic or brand-name thyroid medication tablets contain meat. In general, in patients with food intolerances, I recommend Tirosint capsules which contain only levothyroxine and glycerol BUT the capsule is made of gelatin derived fro...
How do you approach a young patient with metastatic poorly differentiated thyroid cancer with rhabdoid/non-anaplastic features?
Unfortunately, this patient has a very poor prognosis. Due to the nature of her tumor being poorly differentiated, her disease is more likely than not to be refractory to radioiodine. If her disease in the thyroid and neck has not been addressed, external beam radiation therapy should be offered for...
What strategies do you employ for adjusting the dosage of levothyroxine in hypothyroid patients who experience significant weight loss or are initiated on GLP-1 receptor agonists?
In spite of significant weight loss, some patients may not require a dosage change for levothyroxine while others may require a dosage reduction. It is very reasonable to recheck a TSH with free T4 after a 10% weight loss to see if a dose adjustment is needed. Rapid weight loss may lead to a tempora...
For patients with metabolic syndrome, is it reasonable to wait for the effect of tirzepatide therapy on their lipid profile prior to starting statin therapy?
While tirzepatide has shown significant improvements in lipid profiles, including reductions in total cholesterol, LDL cholesterol, and triglycerides, and increases in HDL cholesterol, these effects should be considered complementary to, rather than a replacement for, statin therapy.
What is your approach to management of hyperlipidemia in patients taking JAK inhibitors?
The ORAL Surveillance Study published in the NEJM in 2022 was a phase IIIb/IV open-label noninferiority study in RA patients over the age of 50 with at least one cardiovascular risk factor. The aim was to demonstrate that JAK inhibitors were non-inferior in terms of major adverse cardiovascular even...
Do you recommend the use of GLP1 R agonist therapy in patients with T1DM for weight loss?
GLP-1 agonists can be used as off-label in patients with Type 1 DM and obesity to help with weight loss; improve Hb A1c and decrease insulin requirements.A meta-analysis by Tan et al., PMID 38249345 of 11 RCT comprising 2,856 patients with Type 1 Diabetes and the use of GLP1 agonists as an adjunctiv...
Do you recommend parathyroid adenoma resection or ablation for patients with primary hyperparathyroidism and recurrent nephrolithiasis who are found to have a single gland adenoma on parathyroid ultrasound and nuclear medicine imaging?
Yes. My two indications for ablation/resection of a proven parathyroid adenoma are (1) metabolically active calcium-based kidney stone disease and/or (2) osteopenia/porosis as identified by bone scan. I think there is strong evidence that primary hyperparathyroidism can cause either or both. In the ...