Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
In MASLD patients with high cardiometabolic risk who already meet a clear metabolic indication for a GLP-1 receptor agonist, how much fibrosis-stage certainty do you require before treating it as liver-directed MASH therapy (and documenting/monitoring it as such), versus starting for metabolic benefit and using NIT trends to decide on subsequent biopsy or add-on liver-specific therapy?
If you have the option to get it for type 2 diabetes, it is often more likely to be approved by insurance. There would be no fibrosis requirements and no follow-up on continuing to prove fibrosis staging requirements. Whoever submits for prior authorization can mention if the patient is stage 2 to 3...
How do you recommend mitigating the risks of using beta blocker and clonidine therapy in combination for management of hypertension?
Beta blockers vary in lipophilicity, which affects blood-brain barrier permeability. Propranolol and metoprolol readily cross the blood-brain barrier, while other beta-blockers like nebivolol do not. The CNS side effects of fatigue, depression, and insomnia are more likely to worsen if using a lipop...
How many days prior to elective major surgery do you recommend holding oral GLP 1 R agonist therapy?
Zero. Or, I suppose, if you're having surgery early in the morning, one.This has gone back and forth, but the most recent guidance from the ASA (with other societies concurring) has been that most patients can continue their GLP medications as normal preoperatively, with higher-risk people being rec...
Are recurrent UTIs a contraindication to SGLT2i use?
I don't view UTIs as a contraindication to SGLT2i use, but I make a risk and benefit analysis with each patient. Bacterial UTI as well as mycotic vaginal infections may be a sign that the patient has excessive glycosuria from hyperglycemia. In general, treating hyperglycemia should lessen the freque...
How do you approach the choice of basal-bolus insulin vs correctional insulin alone to manage hyperglycemia in a hospitalized older adult with type 2 diabetes and significant frailty?
Frail older adults with type 2 diabetes, compared to their less-frail counterparts, may have less predictable oral intake, and you may have more difficulty obtaining an accurate medication reconciliation. You may need to review facility records or speak to multiple collateral historians to find out ...
Do you routinely prescribe vitamin D to reduce the risk of fall-related fractures in elderly patients regardless of their serum levels?
Right now, the evidence would NOT support daily vitamin D in older adults who are not deficient just for the purposes of fall prevention. Kahwati et al., PMID 33847712However, lots get missed on fall prevention - so be sure to review all risk factors and make a personalized plan (STEADI resources ar...
When do you consider changing a patient's levothyroxine dose during hospitalization due to abnormal TFTs, but without clinical evidence of thyrotoxicosis or hypothyroidism?
Thank you for your question. I think this is something we commonly get in the hospital, and we often overreact to it. This was a "Things We Do For No Reason" some time back, and I think they outline the issues well.When people are acutely ill, TSH testing is unreliable. The times when TSH testing is...
Do you have safety concerns when prescribing GLP-1 medications in patients on corticosteroids or immunosuppressive therapy?
I think we need to be particularly careful when co-prescribing with systemic corticosteroids because of the risk of sarcopenia. We know that rapid weight loss is accompanied not only by a loss of fat tissue but also of muscle. Corticosteroids can also have myotoxicity and cause muscle atrophy. I the...
What is your treatment strategy for pregnant patients with newly discovered prolactinomas?
There are a few factors in this decision, with lots of subtle variations. Some factors to consider are: 1) how big is the tumor (microadenoma versus macroadenoma), and 2) are there any symptoms other than elevated prolactin (e.g., visual field defect)? Assuming there are no major compressive symptom...
In routine practice where repeat biopsy and outcomes data are not available, what longitudinal NIT pattern (e.g., VCTE/ELF ± MRI-PDFF/ALT trajectory) do you consider sufficient to continue semaglutide specifically for MASH, and what trajectory would trigger a “futility” decision to stop or switch despite weight loss?
Aligned with clinical practice guidance that GLP-1 RAs primarily improve steatosis and inflammation rather than established fibrosis, I look for a concordant metabolic response, including ≥30% PDFF reduction with ALT improvement of ≥17 IU/L or ≥20%, alongside at least stability or modest improvement...