Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
Do you add an SGLT2 inhibitor to mineralocorticoid receptor antagonist therapy in a patient with primary aldosteronism who is not a surgical candidate, given retrospective data showing significantly lower mortality and cardiorenal events with the combination?
I have expanded the use of SGLT2-INHs beyond the core indications of HFrEF, DM2, and proteinuric CKD to include CV risk reduction for those at higher risk. Patients with primary aldosteronism often have a high ASCVD risk by PREVENT risk calculator, and would benefit from SGLT2-INH use.
At what point do you stop monitoring nonfunctional pituitary adenomas given recent evidence showing no long term benefit?
The optimal surveillance schedule for patients with clinically non-functioning pituitary adenomas has not been determined. Retrospective studies suggest that about 10% of microadenomas and about 20% of macroadenomas enlarge during follow-up (4-6 years). I usually advise progressively less frequent M...
For patients with Hashimoto's thyroiditis, is there a commercially available blood test for detecting abnormalities in the type 1 deiodinase enzyme in order to identify patients who would potentially benefit from T4 and T3 combination therapy?
Most clinicians decide to use combination therapy based on a weak response to levothyroxine, with patients still complaining of symptoms related to hypothyroidism. The TSH should not be low before selecting dual replacement.
Do you raise your TSH target in a postmenopausal woman on long-term levothyroxine who develops osteoporosis to minimize the bone effects of even mild over-replacement?
I do not adjust the TSH target of the normal range in postmenopausal females with osteoporosis. There are 2 caveats. With aging and menopause, with the decrease in estrogen-stimulated TBG production, many aging females will need a small decrease in Levothyroxine dose to keep the TSH in the normal ra...
Which blood pressure medications do you favor using to manage ongoing hypertension post adrenalectomy for hyperaldosteronism?
If primary hyperaldosteronism is cured by adrenalectomy, it would be the usual management of HTN; otherwise, I would use spironolactone.
How long would you hold clomiphene before checking baseline morning testosterone levels to evaluate the need for testosterone replacement therapy initiation?
The clomiphene challenge is to initiate therapy in men with secondary hypogonadism and trial a 3-6 month course to see their symptomatic and serologic response. If gonadotrophs and testosterone normalize and the patient feels symptomatic relief and has done something to address the root cause (weigh...
Are there instances when you would recommend against pursuing adrenal vein sampling in a patient with primary hyperaldosteronism and normal adrenal imaging?
Yes, it is not uncommon for patients to choose not to pursue an adrenalectomy. I do not get the adrenal vein sampling (AVS) until I've had a discussion about the risk/benefits of adrenalectomy. Sometimes, I'll have them visit the surgeon before attempting an AVS to get a full picture of the surgery ...
For patients with Graves' disease managed on methimazole therapy who are seeking pregnancy, how long before trying to conceive do you typically recommend switching to propylthiouracil?
I typically switch from methimazole to PTU at least 6 weeks prior to planned conception. It is important to allow enough time to check thyroid function tests and ensure that they are normal on the PTU before the patient tries to conceive.
Do you add liothyronine or switch to combination therapy in an athyreotic patient on levothyroxine with persistent hypothyroid-like symptoms, a normal TSH, and a low FT3, given emerging data suggesting reduced peripheral thyroid hormone action in this subgroup?
The standard treatment for hypothyroidism remains substitution with T4 alone.Even when the TSH level is brought to the desired therapeutic range, some patients continue to complain of hypothyroid-like symptoms.In order to correct that, a combination of T4 and T3 has been tried.However, whether a com...
Is the newly approved oral PCSK9 Inhibitor, Lipfendra, as clinically efficacious as injectable versions of the drug such as Repatha?
While this new cholesterol-lowering agent, enlicitdie, has been shown to be very effective, we cannot say it is "as efficacious" as PCSK9 monoclonal antibodies. The studies were done in different populations, with different baseline LDL levels, different potential concomitant medications, etc. The o...