Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
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 the results of the ESPRIT trial, which evaluated the impact of an SBP target of <120 mmHg on preventing major cardiovascular events, influence your blood pressure management goals for hypertensive patients with diabetes or a history of stroke?
The ESPRIT trial largely validates findings from SPRINT in a Chinese population. One major difference is that 38% of ESPRIT participants had diabetes mellitus (DM). A reduction in death from a CV cause drove the significance in the primary outcome (similar to SPRINT), and BP was measured 3x after a ...
Is the combination of SGLT2i and GLP 1 R agonist therapy contraindicated in patients who develop an episode of euglycemic DKA?
Therapy always needs to be individualized, but in most cases, SGLT2 inhibitors should be stopped in patients who have had euglycemic DKA. Such individuals likely have low endogenous insulin production. GLP1R agonists could further increase the risk of recurrent euglycemic DKA, and I agree with Mehta...
Does vitamin D supplementation in primary hyperparathyroidism increase the risk of kidney stones?
Hyperparathyroidism does increase the risk of developing kidney stones. A study in New England Journal of Medicine, Broadus et al., PMID 7351950, reported that patients with elevated concentrations of 1,25-dihydroxyvitamin D are at increased risk for kidney stones. The reason is that 1,25-dihydroxyv...
How do you interpret the presence of GAD antibody in a middle-aged patient with diabetes when all other type 1 diabetes antibodies are absent?
It depends on patient's clinical course of diabetes, controlled on orals vs insulin, BMI, family history DM. For a brittle DM patient, high GAD titer could indicate DM1 or LADA. For stable DM patients, the recommendation is to have 2 positive antibodies to diagnose DM1.
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...
Which osteoporosis medications are safe to offer a patient with severe osteoporosis who is strictly vegan?
It would be helpful to know what severe osteoporosis means and what the T-scores are in the hip and spine. For patients who are strictly vegan, I would put them on an appropriate osteoporotic medication, making sure that they have an adequate calcium intake either from their diet or supplements, alo...
Would you consider reducing physiological replacement doses of steroids for secondary adrenal insufficiency in patients who develop steroid induced complications such as avascular necrosis of the joints?
That depends on what you mean by "physiological replacement dose". I usually tell patients to use the lowest dose that keeps them feeling well, and sometimes they are able to reduce the dose on less stressful days, such as weekends. Most patients function well with less than 20 mg of hydrocortisone ...
How would you empirically manage a large sellar/suprasellar mass with encasement of the right cavernous and terminal internal carotid arteries?
Knowing the histology of the mass would really help in creating more accurate treatment recommendations. A biopsy of a sellar mass is usually accomplished by an endonasal-endoscopic transsphenoidal approach utilizing the expertise of an ENT surgeon and a skull-base neurosurgeon. However, in this cas...
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 ...