Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
Do you routinely check N-telopeptide levels in patients who you suspect might have immobilization induced hypercalcemia?
No, I do not check N-telopeptide level in patients with suspected immobilization-induced hypercalcemia. Although N-telopeptide is a sensitive marker of bone resorption, elevated N-telopeptide is not specific to immobilization-induced hypercalcemia and can be elevated in other clinical conditions cha...
In adults ≥80 years with TSH 6–10 mIU/L and minimal symptoms, do you initiate levothyroxine, monitor, or avoid treatment entirely?
I tend to check free T4 in this situation. Aging is associated with some elevation in TSH value up to 10 mIU/L with normal free T4, and in those patients, levothyroxine is not needed. In some patients, I have seen it rise above 10 with normal free T4. Supplementing levothyroxine to lower serum TSH w...
Do 5HT4 agonists such as Metoclopramide actually lead to improvement in symptoms for patients with diabetes related gastroparesis?
Yes, sometimes when the gastroparesis is frequent or the symptoms are tough, I do use Reglan to help. By the time they wind up in the hospital, they are really willing to have me use anything on them that might help. I explain to every patient the side effects of Reglan, including tartive dyskinesia...
Is thyroglobulin typically elevated in patients with Hashimoto's thyroiditis on adequate thyroid hormone replacement?
Any thyroid condition where there is an enlarged goiter or stimulated cell by a high TSH will increase the thyroglobulin levels. A long time ago, when I was a fellow, Tg's were measured to correspond with MNG growth. In those situations, I have seen levels in the 1,000's, and a large nodule can have...
Do you temporarily hold diuretics when measuring 24-hour urine calcium levels in the evaluation of primary hyperparathyroidism?
It is mandatory to stop diuretics at least 2 weeks before evaluating a patient for PHPT. One should have a fasting blood sample on the morning of the end of the collection for calcium phosphate and PTH to complement the urine collection. Thiazide-type diuretics raise serum calcium and lower urine ca...
How do you counsel patients with metabolic syndrome who decline statin therapy and have low coronary calcium scores regarding their long-term CVD risk?
This is a great question with many ramifications, and I can only give an incomplete answer that includes personal opinion. First, what is the risk? The MESA Risk Score Calculator (check it out) gives a CAC percentile score as well as a 10-year risk. The 10-year risk may be low, but a high percentile...
In an obese male with low testosterone, would you initiate testosterone replacement therapy at the initial visit, or start tirzepatide first and monitor for improvement in testosterone levels and erectile function?
Dr. @Dr. First Last has given a thoughtful answer. Assuming no evidence of a structural hypothalamic-pituitary-testicular (HPT) disease (normal prolactin, LH, and FSH in the low-normal to normal range, normal free T4), the best approach is weight loss for these men. Whether to try lifestyle changes ...
What triggers you to choose urgent thyroidectomy versus therapeutic plasma exchange versus continued medical management for refractory thyroid storm despite 12-24 hours of guideline-concordant therapy?
A very important factor is the comfort level of the ICU doctors and the Anesthesiologists at the institution. We usually do not recommend proceeding with urgent thyroidectomy given the increased risks, unless FT4 and TT3 are normalizing. Usually, a combination of PTU (or Methimazole), stress dose st...
When would you consider using transvaginal cabergoline in the treatment of prolactinoma?
This is considered an off-label use, but I have done this a few times, and I know some of my colleagues have as well. There is not much in the literature on this, mostly case reports. I would reserve this for patients who do not tolerate the oral forms of cabergoline or bromocriptine.
In patients with MASLD, would you consider management with off-label metformin, pioglitazone (despite weight gain risk), GLP-1 RA, or simply intensify lifestyle and monitor?
In 2025, we should be assessing if patients are developing F2-F3 fibrosis especially with the use of non-invasive assessments (FIB-4 score, transient elastography, or MRI elastography), and then offering either Semaglutide or Resmetirom for these individuals w/ F2-F3, which are the only FDA approved...