Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
Do you anticipate added benefit of triple agonist therapy for patients with early type 2 diabetes mellitus and MASLD given evidence of glucagon resistance?
I anticipate triple agonist therapy will offer added benefits over dual agonist therapy in patients with diabetes and obesity. There are studies showing greater weight loss with triple agonist therapy with retatrutide (24 to 30%; Jastreboff et al., PMID 37366315, Triumph-4 trial data released by Lil...
What is the evidence, if any, for the use of low dose naltrexone in the treatment of autoimmune thyroiditis?
I do not prescribe naltrexone for thyroid disease because I have not found data to support its use. In theory, low dose naltrexone (LDN) could decrease inflammation and thus potentially block development of overt hypothyroidism in TPO positive patients. But, at this time, it is anecdotal, with no ha...
Would you recommend discontinuing testosterone replacement in a male patient in his 60s with newly diagnosed favorable intermediate-risk prostate cancer who is declining surgery and will receive definitive radiation?
Historically, we (as a field) have viewed TRT as the opposite of ADT and therefore inherently problematic. I am not convinced this is logical. ADT has RCT evidence to support it, whereas withdrawing TRT has not been as cleanly studied. Let's say we stop TRT, and this drops their testosterone to 150 ...
Has the recent large observational data suggesting that continuing metformin during hospitalization is associated with lower post-discharge mortality and hypoglycemia changed your approach to holding it on admission in stable, non-critically ill patients with T2DM?
I really like this paper, but I don't think it is plausible that a 5-day difference in receipt of metformin (the median length of stay was 5 days) could really affect 90-day mortality.The study question is a good one because the evidence that metformin causes lactic acidosis is extremely limited. In...
Would you recommend getting a PET scan or an iodine whole body scan in a patient with recurrence of thyroid cancer in the neck previously treated with total thyroidectomy and 2 radioactive iodine ablations in the past?
The usual patient who has had 2 doses of I131 is not usually iodine-avid or iodine-sensitive. You will be able to determine with this information: When were the 2 doses of I-131? What did the post-therapy scan show after the last dose of I-131 and Was the tumor responsive either by Tg or tumor size...
Do you recommend starting a statin in youth (greater than 10 years old) with Type 1 diabetes mellitus and LDL cholesterol levels greater than 130?
In general, I probably would not consider starting a statin in a youth with T1D unless they had T1D AND Familial Hypercholesterolemia and/or an LDL >190 mg/dL or significant microvascular complications already. Recommendations are to consider statin therapy in individuals with diabetes of long durat...
How should diabetic retinopathy surveillance be adjusted for patients starting GLP-1 agonists?
As with traditional anti-hyperglycemic medications, GLP-1 agonists may cause transient worsening of diabetic retinopathy due to the initial rapid control of blood glucose. Therefore, if a patient has existing retinopathy and is about to start GLP-1 agonist therapy, I recommend closer monitoring. For...
What are your preferred lipid-lowering agents and target LDL reduction goal following initiation of therapy for patients with familial hyperlipidemia without underlying CAD?
It is not easy to address this question without specifics of the 'familial hyperlipidemia," but I will give examples: Monogenic familial hypercholesterolemia - since the LDL is very high from early childhood, we tend to treat adolescents with statins with a goal of a 50% reduction (20 or 40 rosuvas...
Would you order a repeat DEXA scan 1 year later for a kidney transplant patient who had an initial DEXA scan within the first 6 months post-transplant showing osteopenia but no history of fractures, and who has been stable on glucocorticoid-free immunosuppressive therapy?
I agree with Dr. @Dr. First Last. Bone metabolism in renal transplant is woefully shy of good data. My opinion is to monitor Vitamin D levels, provide appropriate supplementation, and monitor PTH levels, using cinacalcet as needed. My target level for PTH is 1-2x the upper limit of normal, also base...
Do you recommend restarting a GLP-1RA after bariatric surgery if the patient tolerated it before the surgery?
While there are no clear recommendations on whether/when to resume GLP-1 RA after bariatric surgery, current 2025 guideline statements (ASMBS, ADA, AACE, Obesity Society) and expert consensus documents suggest the following approach: Hold GLP-1RA in the acute perioperative period. For daily-dosed ...