Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
For patients <65 with significant intermittent steroid exposure who otherwise do not have risk factors for osteoporosis, when, if ever, do you recommend considering DEXA screening?
The FRAX guidelines recommend answering "Yes" for glucocorticoid use when a patient has received the equivalent of prednisone ≥5 mg daily for more than 3 months. However, many patients with rheumatoid arthritis have been treated with intermittent courses of corticosteroids over several years, which ...
Should insulin be started early (prior to optimization of other anti-hyperglycemic medications) in patients with mild-to-moderate diabetes and hypertriglyceridemia refractory to statin and fibrates?
Not necessarily. The goal should be achieving optimal glucose control to improve triglyceride levels. This can be accomplished with non-insulin agents, such as GLP-1 agonists and others, that can have beneficial effects on triglycerides.
When do you think physicians should seriously consider prescribing PCSK9 inhibitors for the prevention of heart attack and stroke in people with ASCVD or diabetes, based on the results of the VESALIUS-CV trial?
Although I checked 'high lipoprotein (a) as a reason to go with a PCSK9 first, I would almost never do it is practice. Statins first and then add a PCSK9 if LDL is above my goal for the patient. I might use a lower dose of the statin to get 35% lowering and then add the inhibitor if the patient was ...
Would you consider adding niacin to the lipid lowering regimen in statin-intolerant patients who cannot afford PCSK9i or bempedoic acid?
Yes, in a patient who absolutely cannot take a statin or other common alternatives such as ezetimibe, PCSK9 inhibitors, or Bempedoic acid, Niacin for ASCVD risk reduction is still a reasonable choice. While the combination of statin and niacin has been shown to be unhelpful (and possibly of greater ...
What are your thoughts on trending beta-hydroxybutyrate once a diagnosis of DKA is already established?
Beta-hydroxybutyrate (BOHB) ≥3.0 mmol/L is highly sensitive and specific for diagnosing DKA and can be measured through serum or point-of-care testing. However, its role in monitoring treatment response and determining resolution remains debated. The American Diabetes Association recommends continui...
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...
Should we be less cautious with the use of GLP 1 R agonist therapy for patients with osteoporosis and obesity given recent data suggesting significantly lower fall and fracture risk?
The interaction of GLP-1 R agonist therapy and fracture risk is complicated, and I would not assume a decrease in the risk of fracture for most patients. However, there were three recent retrospective studies that all showed decreased fracture risk following use of either semaglutide or tirzepatide ...
Do you recommend continuous glucose monitoring for patients with Type 2 diabetes who are not on insulin?
I use it frequently for type 2 patients, even if for a short period of time. It can help tremendously with improving their diet and seeing the positive effects of exercise. I think everyone with High HbA1C should use it to learn their BG trends. It's more helpful than having a visit with a Diabetes ...
What therapies do you offer to young patients with secondary hypogonadism due to obesity who have lost weight but have ongoing hypogonadal symptoms and lower end of normal testosterone levels?
First of all, the symptoms may not be due to low testosterone. Keep in mind that obesity can be associated with low SHBG. Total testosterone may thus be low but free testosterone may be normal. Free testosterone assays are not the most reliable. Therefore, clinical judgment is often needed in border...
What is your process of discontinuing testosterone you prescribe to a patient?
First of all, it’s really rare that I discontinue. Proper counseling is critical, as starting TRT will result in loss of the natural ability to produce testosterone—when many men hear this, they will decide either not to start or to consider SERM therapy with clomiphene/enclomiphene. And that’s also...