Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
Do you discontinue statin therapy when patients reach LDL levels way below their target goal with PCSK9 inhibitor therapy?
I would never stop the statin when addtition of the PCSK9i lowered LDL "way below their target". First, if there target is 55 mg/d and their LDL is in the 20-40 range on the two drugs, I might be very happy with that result depending on the patient's level of risk. If the patient is concerned and/or...
With the advent of GLP-1 receptor agonist therapy, when (if ever) do you consider adding pioglitazone to patients' diabetes regimen?
Yes, I do still use pioglitazone, which I believe is underused. I like to consider pioglitazone in patients who have central obesity with leaner legs/arms, i.e., who have a potential mild form of lipodystrophy, and who have hypertriglyceridemia, MASLD/MASH, and insulin resistance. I find that these ...
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...
In patients with iron deficiency due to history of gastric bypass or IBD, would you consider oral iron therapy if the iron deficiency anemia is mild?
Oral iron can often be effective in iron deficiency, as long as absorption is intact. If you are concerned about absorption, performing an oral iron challenge can be useful in allowing you to avoid long trials of oral iron that will be ineffective. Simply check an iron panel at baseline, then admini...
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 approach vitamin D supplementation in patients with chronic kidney disease, given the findings that vitamin D2 supplementation may lead to decreased conversion of 25-hydroxyvitamin D3 to 1,25-dihydroxyvitamin D3?
In early 2000, there was a publication suggesting that ingesting vitamin D2 increases the destruction of vitamin D3 and therefore could increase the risk for vitamin D deficiency. Although I had never seen this happen in my clinic, we decided to conduct a study to evaluate what the effect of vitamin...
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...
How do you approach the frequency of DEXA scan monitoring for older adults on bisphosphonate therapy during the course of therapy?
Depends who you read. ACP: Recommendation 4: ACP recommends against bone density monitoring during the 5-year pharmacologic treatment period for osteoporosis in women. (Grade: weak recommendation; low-quality evidence) [1] Monitoring wasn't addressed in the 2023 update. ACR: For adults continuing...
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 ...
Which anti-hypertensives do you hold and for how long when screening for hyperaldosteronism in a patient with resistant hypertension and initial screening with unsuppressed renin but elevated aldosterone >20 while on anti-hypertensive therapy?
Only spironolactone for 2-3 weeks. Suppressed renin is the most sensitive test to diagnose primary hyperaldosteronism.