Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
How do you prioritize semaglutide versus intensive lifestyle therapy when addressing residual cardiovascular risk in a patient with established ASCVD, obesity, and no diabetes?
In a patient with established ASCVD and a BMI of 27 or greater, I discuss semaglutide therapy, in addition to lifestyle therapy, as an important and evidence-based therapy to reduce their risk of recurrent ASCVD events. This would be a shared decision with the patient based on their preferences, cov...
Does oral Wegovy have a worse side effect profile compared to its injectable version?
From a clinical standpoint, I would say that oral semaglutide does cause more nausea and other GI side effects than injectable semaglutide for comparable doses. I am not aware of any randomized trials looking at this question, but there are single-center retrospective studies corroborating my impres...
In ischemic stroke patients with low LDL levels (<30-50 mg/dl), would you consider lowering LDL levels to lower values without concern for any side effects?
If LDL levels are already below 70, I don’t target a lower goal. The SPARCL trial showed that reducing LDL to this range has an NNT of about 45 to prevent one stroke, which I find to be modest at best. From my perspective, lowering LDL further (<30-50 range) shifts the focus to treating a number rat...
How do you evaluate and counsel patients on elevated SHBG levels when bioavailable free testosterone levels are normal?
If free testosterone is normal, supplementation is not required. Check for the cause of the high SHBG. Common causes include hyperthyroidism, liver disease and caloric restriction. Check the estradiol level. Many obese people have high estradiol because of the aromatase enzyme in the adipose tissue....
Can estrogen priming therapy during IVF treatment lead to transient TSH elevation without clinical hypothyroidism?
A large number of hypothyroid women taking Levothyroxine will need to increase the dose of Levothyroxine after IVF. IVF results in extremely high levels of estrogen, which increases the thyroid-binding globulin that in terns require an dose increase of about 30%. Generally, it is recommended to incr...
How do you counsel patients with metabolic syndrome who decline statin therapy and have low coronary calcium scores regarding their long-term CVD risk?
This is a great question with many ramifications, and I can only give an incomplete answer that includes personal opinion. First, what is the risk? The MESA Risk Score Calculator (check it out) gives a CAC percentile score as well as a 10-year risk. The 10-year risk may be low, but a high percentile...
Is there a specific triglyceride level at which you discourage patients with metabolic syndrome from starting GLP-1R agonist therapy due to the risk of pancreatitis?
Overwhelming data show that acute pancreatitis is not directly due to GLP-1 use but rather the indirect effect of rapid weight loss leading to cholelithiasis and subsequent acute biliary pancreatitis in GLP-1 users. Hypertriglyceridemic pancreatitis is rare even among those with elevated TG levels (...
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...
How often and for how long do you monitor pituitary gland function in a patient with empty sella (radiologic finding only)?
I have never seen pituitary function showing progressive loss after an empty sella is diagnosed. Therefore, I usually assess it only once. In one study progression of hormonal deficit was seen only in 3%, and it occurred in patients who had partial ES and progressed to complete ES. Carosi et al., PM...
In middle-aged adults with TSH 5–10 mIU/L and no symptoms, would you start levothyroxine or monitor, and does your threshold change with cardiovascular risk factors?
In a middle-aged patient with a TSH between 5-10 and no symptoms, I would initially monitor their thyroid levels. I would consider checking a TPO antibody titer; if positive, the rate of transition to overt hypothyroidism is greater. I would also screen for other medical issues that could be impacte...