Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
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 ...
How do you explain the use of an AI scribe to patients the first time it is used in their care?
I use an AI scribe in my outpatient clinic, and around 90–95% of my patients agree to it. I obtain consent at the start of each visit and make it clear that it's completely optional—that they can say no at the start or change their mind at any point in the visit, with no impact on their care. I also...
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 ...
When should patients with diabetes mellitus be screened for osteoporosis?
Hip fracture risk is higher in patients with diabetes (T1DM almost 7 times and T2DM 38% higher than controls without diabetes) (Vestergaard, PMID 17068657), and BMD scores underestimate true risk. That has led the ADA to suggest considering treatment for bone densities with T-score <-2.0, rather tha...
How would you define failure of anabolic therapy for severe osteoporosis and when would you consider ordering a second round of Evenity or PTH analogue therapy?
“Failure” of any therapy is often in the eyes of the beholder. The most efficient way to determine if there is anabolic activity is to measure a serum PINP (does not need fasting) and, for the PTH anabolic recheck, the PINP 2-3 months later. IF the delta is >10, you can be confident there is more pr...
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...
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.
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 ...
Is there a role for use of GLP1 R agonist or dual agonist therapy for management of post bariatric hypoglycemia and dumping syndrome?
There is little systematically collected information in this area on which to base judgments. A case series of 5 post-bariatric surgical patients treated empirically with liraglutide described reduction of hypoglycemic events based on patient history. In an experimental study comparing several treat...
When stopping denosumab and transitioning to PO bisphosphonate, do you wait for 6 months after the last denosumab injection to start PO bisphosphonate?
Some background: In patients discontinuing denosumab without subsequent antiresorptive therapy, BMD rapidly reverts back to baseline with an elevation in vertebral fracture risk (with an enhanced risk of multiple vertebral fractures). Thus, sequential treatment regimens following denosumab have been...