Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
Do you recommend the use of CGM for monitoring of postbariatric hypoglycemia given recent evidence of reduced accuracy in dynamic postprandial conditions?
I have always been concerned about accurately detecting hypoglycemia in patients because of the higher MARD in the hypoglycemic range with most CGM sensors. A recent review found the MARD in hospitalized patients to be 15% in the hypoglycemic range, which is much higher than in the euglycemic or hyp...
How do you recommend mitigating the risks of using beta blocker and clonidine therapy in combination for management of hypertension?
Beta blockers vary in lipophilicity, which affects blood-brain barrier permeability. Propranolol and metoprolol readily cross the blood-brain barrier, while other beta-blockers like nebivolol do not. The CNS side effects of fatigue, depression, and insomnia are more likely to worsen if using a lipop...
How do you decide between adding oral orforglipron or starting prandial insulin in a patient with type 2 diabetes above goal on basal insulin?
This is a timely question in that it is clinically relevant, and in June 2026, the ACHIEVE-5 trial was published online in JAMA, which studied adding orforglipron to basal insulin.If the patient is judged to be significantly insulinopenic--thin, low dose of basal insulin requirement, and high postpr...
Is there any role for bisphosphonate or alternative bone-modifying agents use in SMM in the absence of other indications for its use?
The short answer is no, unless the patient has an indication like osteoporosis. Bisphosphonates have been evaluated in smoldering multiple myeloma in studies performed over 10 years ago. Treatment with pamidronate (D’Arena et al., 2011) or zoledronic acid (Musto et al., 2008) did not affect the time...
Do you order MODY genetic testing to discontinue unnecessary treatments such as insulin or metformin in patients misdiagnosed as either Type 1 diabetes or Type 2 diabetes?
First, I like the term Monogenic Diabetes better than MODY because it captures the concept of a single-gene mutation to distinguish it from the multi-gene/environmental factors in T1DM and T2DM. I think screening for monogenic diabetes should be considered in patients with atypical features of T1DM ...
In compensated MASH cirrhosis with frailty/sarcopenia, how do you use GLP-1 receptor agonists safely—what lean-mass or functional monitoring strategy (and stopping/adjustment thresholds) do you use to prevent harmful weight-loss–associated muscle loss while pursuing cardiometabolic benefit?
In compensated MASH cirrhosis with frailty or sarcopenia, I use GLP-1 receptor agonists cautiously (and for non-MASH indications) and pair them with structured resistance exercise 2 days a week, adequate protein intake (1.2-1.5 g/kg/day), and baseline functional assessment rather than focusing on we...
Are thyroid molecular tests (such as Afirma, ThyroSeq) validated for use on FNA thyroid nodule samples that are not Bethesda class 3-4?
If the first biopsy was AUS and the second biopsy was Bethesda II, benign, the molecular test is not warranted. It is agreed that a second biopsy of a nodule that was AUS (Bethesda III) will be benign about 40% of the time. If the first biopsy was follciular neopasm/suspicioyus for FN (Bethesda IV),...
Do you forgo adrenal imaging in a patient with primary hyperaldosteronism who has decided against surgery?
Yes. It would be a waste of time and money. Can go straight to using spironolactone or other mineralocorticoid blocker.
Are there any concerns with live vaccine innoculation and patients who are on denosumab?
This is a complicated question because while denosumab is a biologic therapeutic that has immunomodulatory effects on innate and adaptive immunity its association with serious infections complications appears modest. An increased rate of background infections and some increase in serious infections ...
Do you have safety concerns when prescribing GLP-1 medications in patients on corticosteroids or immunosuppressive therapy?
I think we need to be particularly careful when co-prescribing with systemic corticosteroids because of the risk of sarcopenia. We know that rapid weight loss is accompanied not only by a loss of fat tissue but also of muscle. Corticosteroids can also have myotoxicity and cause muscle atrophy. I the...