Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
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...
Would the diagnostic yield for ABIs or peripheral arterial duplex doppler in a patient with metal rods in both legs be similar or acceptable in comparison to those tests in a patient without metal rods?
Ankle-brachial index(ABI) relies on the compression of upper and lower extremity arteries with blood pressure cuffs and measuring the ratio of blood pressure between them. While I am not aware of specific studies in those with metallic rod fixation, ABI measurements should have similar utility as lo...
Does oral Wegovy have a worse side effect profile compared to its injectable version?
From a clinical standpoint, I would say that oral semaglutide does cause more nausea and other GI side effects than injectable semaglutide for comparable doses. I am not aware of any randomized trials looking at this question, but there are single-center retrospective studies corroborating my impres...
How do you approach managing patients with diabetic kidney disease and proteinuria who develop hypoglycemia after initiation of a SGLT2 inhibitor?
I would first determine if there are other medications the patient is on that reduce the blood glucose. Hypoglycemia with SGLT-2 inhibitors is usually due to something else. Another medication is most likely. Could be very poor dietary intake. Could lower the dose if not on the lowest available dose...
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 ...
How do you decide when to treat hypocalcemia in hospitalized patients?
When I think about when to treat hypocalcemia in hospitalized patients, I anchor the decision on three things: symptoms, the absolute calcium level, and the trajectory. First, it’s important to confirm true hypocalcemia: either a serum calcium <8 mg/dL or an ionized calcium <1.1 mmol/L, and to consi...
How many days prior to surgery do you recommend stopping SGLT2 inhibitors and when is it safe to resume therapy?
SGLT2-inhibitors have been known to precipitate episodes of diabetic ketoacidosis(DKA) with glucose levels far lower than are usually seen in DKA. This has been called euglycemic DKA. SGLT-2 inhibitors cause an increase in the glucagon to insulin ratio, which promotes ketosis, as well as fluid loss ...
How has your approach to de-escalating a conversation with a distressed or angry family member evolved over your career?
My approach to de-escalating conversations with distressed or angry family members has shifted from trying to solve the problem immediately to first understanding the emotion driving the conflict. Early in my career, I often responded by providing more medical information, assuming that greater clar...
How do you prioritize semaglutide versus intensive lifestyle therapy when addressing residual cardiovascular risk in a patient with established ASCVD, obesity, and no diabetes?
In a patient with established ASCVD and a BMI of 27 or greater, I discuss semaglutide therapy, in addition to lifestyle therapy, as an important and evidence-based therapy to reduce their risk of recurrent ASCVD events. This would be a shared decision with the patient based on their preferences, cov...
How do you evaluate and counsel patients on elevated SHBG levels when bioavailable free testosterone levels are normal?
If free testosterone is normal, supplementation is not required. Check for the cause of the high SHBG. Common causes include hyperthyroidism, liver disease and caloric restriction. Check the estradiol level. Many obese people have high estradiol because of the aromatase enzyme in the adipose tissue....