Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
How do you decide when to act upon TFT derangements in hospitalized patients (e.g., start/adjust thyroid replacement therapy) vs attribute to NTIS (formerly euthyroid sick syndrome) and advise repeat TFTs as an outpatient?
It is not always easy to discern, but typically in NTIS, T3, T4, and TSH are all low or normal (TSH may be slightly elevated but not markedly elevated). True hypothyroid (requiring new medication or adjustments of existing medications) typically has a high TSH and low Free T4, and the patient may ha...
How many statins do you try before considering alternative therapies like PCSK9 inhibitors or inclisiran to lower LDL levels?
In earlier years, I would try changing statins 3 to 4 times. More recently (and I use rosuvastatin almost all the time), I try to halve the dose (only lose 5 to 10% effect), and if that does not work, I try going to rosuvastatin 10 mg 1 to 2 times per week, and that gets about 25% reduction, to whic...
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...
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 ...
For patients with Hashimoto's thyroiditis, is there a commercially available blood test for detecting abnormalities in the type 1 deiodinase enzyme in order to identify patients who would potentially benefit from T4 and T3 combination therapy?
Most clinicians decide to use combination therapy based on a weak response to levothyroxine, with patients still complaining of symptoms related to hypothyroidism. The TSH should not be low before selecting dual replacement.
How do you decide when to evaluate for central hypothyroidism in a patient with low-normal TSH and low free T4?
The differential in these patients is 1) mild subclinical hyperthyroidism 2) central hypothyroidism 3) normal variant related to assay detection limitations. It would be important to obtain a good history and try to identify any hypothyroid or hyperthyroid symptoms. Having said that, patients will u...
What triggers you to choose urgent thyroidectomy versus therapeutic plasma exchange versus continued medical management for refractory thyroid storm despite 12-24 hours of guideline-concordant therapy?
A very important factor is the comfort level of the ICU doctors and the Anesthesiologists at the institution. We usually do not recommend proceeding with urgent thyroidectomy given the increased risks, unless FT4 and TT3 are normalizing. Usually, a combination of PTU (or Methimazole), stress dose st...
Can autoimmune thyroiditis present with recurrent angioedema and bronchospasm?
There is an association between angioedema and autoimmune thyroid disease, although the incidence is not known. Activated CD4+ T lymphocytes, monocytes, and eosinophils. The incidence of thyroid autoimmunity in chronic urticaria is similar to the background population, but there is a cluster of angi...
How would you counsel patients with type 1 or type 2 diabetes mellitus and heart failure on the use of SGLT-2 inhibitors when they have a history of DKA?
Making a recommendation to prescribe this class will really require a case-by-case clinical assessment. It is clear that SGLT-2 inhibitors are very effective in preventing hospitalization for heart failure, and so we will want to suggest their use whenever possible. But it is also clear that DKA (mo...
For a patient with a large pheochromocytoma, how would you evaluate for possible autonomous cortisol co-secretion prior to adrenalectomy to assess need for risk of glucocorticoid withdrawal postoperatively?
From a practical standpoint, and given that this is rare, it is reasonable to check a postoperative day 1 (POD1) AM cortisol and decide then whether cortisol replacement is needed. You can also check ACTH, AM and PM cortisol to assess diurnal variation, and DHEAS pre-op to get some idea.