Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
What further work-up (if any) should be considered in patients with pituitary microadenoma and stigmata of Cushing's disease but low ACTH and repeatedly normal plasma, urinary, and salivary cortisol levels?
I would obtain history of alcohol intake, depression and anxiety, and will assess the pituitary adrenal axis by overnight dexamethasone suppression test.
Is it possible to have undetectable cortisol levels in secondary adrenal insufficiency?
Yes, you can certainly have undetectable cortisol in central AI. Low IGF-1 and low-normal FT4 would suggest hypopituitarism. Do you have a testosterone level? I would perform a GH stimulation test. An abnormal test would confirm pituitary pathology. Before this, however, I would carefully investigat...
How often would you repeat testing in a patient suspected of Cyclic Cushing's?
24-hour urine-free cortisol and MN saliva cortisol are preferred tests over ON dex suppression. The exact frequency depends on the severity of the symptoms, generally about every 3 months.
In patients with secondary osteoporosis due to primary hyperparathyroidism, should parathyroidectomy be recommended in the setting of recent prior bisphosphonate use?
I would recommend parathyroid surgery in a person with confirmed primary hyperparathyroidism and osteoporosis as the bone density will increase in most patients after surgery. Many of the patients with osteoporosis may have received bisphosphonates. In rare situations, a patient may have received a ...
Would you give a second round of therapeutic RAI in a patient with PTC s/p total thyroidectomy and I-131 ablation who is found to have recurrent disease in cervical lymph nodes s/p repeat neck dissection?
There is very limited clinical information provided. Thoughts and possible direction for further work up. RAI is not routinely indicated after cervical "recurrence" in a previously RAI-treated patient. Also depends on the extent of residual cancer status post-recent neck dissection surgery. What wa...
Aside from lifestyle measures such as calcium intake, vitamin D repletion, and weight-bearing exercises and ruling out all secondary causes, what is the preferred approach to managing osteoporosis in young women with Z score of less than -2.5 and planning to get pregnant soon?
It is very helpful to have some knowledge as to the reason for the Z score of <2.5. Young women with low BMI can have a low Z score just due to the unloading of the skeleton. Increasing body weight can often improve BMD in these women. Presumably, she has a normal menstrual cycle. If not, the instit...
When do you refer a patient with MODY3 to GI/Hepatology for monitoring/management of hepatic adenomas?
As you know, maturity-onset diabetes of the young type 3 (MODY 3) is a consequence of heterozygous germ-line mutations in HNF1A. In addition, hepatocellular adenoma (HCA) may be caused by somatic HNF1A mutations. There are approximately a dozen cases reported of individuals with MODY 3 and HCA (1). ...
Under what circumstances would you refer a patient with mild autonomous cortisol secretion without features of Cushing syndrome for adrenalectomy?
This depends on a number of factors, including the number and severity of comorbidities, the degree of abnormality in the 1 mg DST, and other biochemical testing, such as ACTH and DHEAS levels. The age of the patient may also have some impact on decision making being more aggressive in younger patie...
Should patients who develop primary hyperparathyroidism after 5 years of Prolia treatment for osteoporosis be referred for parathyroidectomy?
There are other reasons to treat primary hyperparathyroidism surgically beyond osteoporosis, what is response to treat as far as BMD?
Would you recommend switching a diabetic CKD patient on oral semaglutide to the subcutaneous form since the benefits in CKD have primarily been reported in studies using subcutaneous GLP-1 receptor agonists?
Personally, I would not do so today. Obviously, the patient was prescribed oral semaglutide (SEMA) as opposed to injected SEMA for some reason. Assuming that the reason persists (e.g., preference for oral, greater availability) and the response with respect to A1c and weight has been reasonable, I w...