Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
At what point do you stop monitoring nonfunctional pituitary adenomas given recent evidence showing no long term benefit?
The optimal surveillance schedule for patients with clinically non-functioning pituitary adenomas has not been determined. Retrospective studies suggest that about 10% of microadenomas and about 20% of macroadenomas enlarge during follow-up (4-6 years). I usually advise progressively less frequent M...
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...
When would you consider switching from standard calcium replacement therapy to the newly approved Encaleret therapy for treatment of hypocalcemia secondary to hypoparathyroidism?
Encaleret at this time is not used to treat other hypocalcemic disorders other than autosomal dominant hypocalcemia type I (ADH 1). This genetic disorder is caused by a specific genetic gain-of-function mutation in the CASR gene that tricks the body into sensing that calcium levels are too high, eve...
When do you check vitamin D levels in patients with depressive symptoms?
I routinely check 25-OH D in all my patients. Given that half the population is deficient and that we now know the role of vitamin D not only for bones but in mood, cognition, and immunity. We need to be aware of deficiencies and replete if low. Moreover, ideal levels are 60-80, not just over 29 as ...
What is your approach to the use of GLP-1 agonists in older adults with diabetes with or at risk of sarcopenia?
This is an important question to keep an eye on, given the broadening use and effectiveness of GLP-1 agonists for various conditions, especially diabetes, and for weight loss. Unfortunately, as is so often the case, major clinical trials in this area do not reflect the heterogeneity of older adults ...
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.
Do you raise your TSH target in a postmenopausal woman on long-term levothyroxine who develops osteoporosis to minimize the bone effects of even mild over-replacement?
I do not adjust the TSH target of the normal range in postmenopausal females with osteoporosis. There are 2 caveats. With aging and menopause, with the decrease in estrogen-stimulated TBG production, many aging females will need a small decrease in Levothyroxine dose to keep the TSH in the normal ra...
Which blood pressure medications do you favor using to manage ongoing hypertension post adrenalectomy for hyperaldosteronism?
If primary hyperaldosteronism is cured by adrenalectomy, it would be the usual management of HTN; otherwise, I would use spironolactone.
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 ...
How long would you hold clomiphene before checking baseline morning testosterone levels to evaluate the need for testosterone replacement therapy initiation?
The clomiphene challenge is to initiate therapy in men with secondary hypogonadism and trial a 3-6 month course to see their symptomatic and serologic response. If gonadotrophs and testosterone normalize and the patient feels symptomatic relief and has done something to address the root cause (weigh...