Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
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...
What would be your next step in treating a patient with osteoporosis who developed AFF on denosumab and who then completed one year of romosozumab?
There is no evidence-based answer for this question. First of all, the development of AFF while on osteoporosis doses of denosumab is very rare. It usually occurs in people who have previously been on bisphosphonates. I would most appropriately assess fracture risk after the romo and then determine ...
Do you recommend stopping Vitamin D supplementation in a patient with hypercalcemia and a low 25(OH)D level?
Even though nutritional vitamin D does not normally cause hypercalcemia except in very high doses, I'm not so confident that it is not a contributing factor to the problem in dialysis patients. The reason is mainly a lack of data in this population which has some unique issues related to PTH levels,...
How would you approach choosing osteoporosis treatment in a patient with a T score -3.3 in lumbar spine and no prior fracture history who has squamous cell cancer and received radiation therapy?
This is an interesting question and a not unfamiliar clinical situation. I would like to know the age of the patient of course and her general medical health including renal function as that might influence the choice of drug to be recommended. The underlying premise here (I assume) is the option of...
Should insulin be started early (prior to optimization of other anti-hyperglycemic medications) in patients with mild-to-moderate diabetes and hypertriglyceridemia refractory to statin and fibrates?
Not necessarily. The goal should be achieving optimal glucose control to improve triglyceride levels. This can be accomplished with non-insulin agents, such as GLP-1 agonists and others, that can have beneficial effects on triglycerides.
Should Orlistat be considered in the management of hypertriglyceridemia?
While there are no controlled trials addressing this issue, it is certainly a reasonable option which I have used in some patients with Familial Chylomicronemia Syndrome. It will help to reduce the generation of chylomicrons and therefore the subsequent risk for hypertriglyceridemic pancreatitis. Ma...
How should very low T scores (worse than -3) be interpreted in very thin patients (BMI < 18)?
It would be very helpful to know the age of the patients. Age is well documented to be independently inversely related to fracture risk for the same T score. Low BMI places less stress on the skeleton and in response the skeleton maintains lower bone mineral content i.e. bone mineral density. There ...
Should thyroid hormone replacement be initiated in patients with very prolonged critical illness with associated low thyroid hormone levels?
There is no evidence that LT4 is of benefit in such patients.