Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
What is your preferred method for confirming the diagnosis of primary aldosteronism in a patient with an elevated plasma aldosterone to renin ratio?
The endocrine guidelines on primary aldo diagnosis (1) allow for 3 confirmatory tests: 24-hour urine, fludrocortisone suppression testing, and response to saline infusion. At UAB, we use the 24-hour urine collection. Most of our patients do not need additional salt loading during the 24-hour collect...
In patients with confirmed hypercortisolism with a high/normal unsuppressed ACTH who have both a pituitary adenoma and adrenal adenoma identified on imaging, can you reliably use DHEA-S to determine the source of cortisol production?
There is a difference between high-normal and unsuppressed ACTH. If ACTH is high-normal, this is ACTH-dependent Cushing. However, you can have mild adrenal Cushing without fully suppressed ACTH (e.g., ACTH in the 10-20 pg/ml range and sometimes even above 20). I don't think you can rely on DHEAS in ...
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...
How do you approach osteoporosis screening in men?
While osteoporosis is more prevalent in postmenopausal women, it is often under-recognized in men. The risk of mortality after hip fracture is higher in men, and that risk may extend over 10 years after injury. Men who sustain a wrist fracture are more likely to have severe osteoporosis and a higher...
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 ...
How do you manage dose titration and nutrition to avoid sarcopenia when prescribing a GLP-1 receptor agonist in a frail older adult with MASLD?
GLP-1 and GLP-1/GIP receptor agonists as a class have been found to be effective in improving MASLD (Loomba et al., PMID 38856224) in patients with and without diabetes. This large class of drugs(more are on the way) also causes significant weight loss, and newer iterations may lower BMI into the no...
What patient specific factors outside of health insurance coverage do you use to decide which GLP1 R agonist or dual agonist therapy to start in patients with diabetes?
The class of drugs called GLP 1 RA continues to grow. Single agonist drugs include dulaglutide and semaglutide. There is now a “dual agonist” available for use, tirzepatide, which really is a GLP 1 RA and GIP RA. There are “triple agonists” which also bind the glucagon receptor that are close to FDA...
Would you consider PCSK9 inhibitors for patients with elevated coronary calcium score or coronary calcification for primary prevention in lieu of statins/ezetimibe and/or bempedoic acid?
Absolutely! The VESALIUS trial confirms that lower is better even in people without a prior event. I wouldn’t use a PCSK9i in lieu of a statin, though. I would add it to the statin if someone’s LDL-C is still elevated. If someone has a high CAC score, I target an LDL-C and apoB <55 mg/dL. Ezetimibe ...
In patients with MASLD, would you consider management with off-label metformin, pioglitazone (despite weight gain risk), GLP-1 RA, or simply intensify lifestyle and monitor?
In 2025, we should be assessing if patients are developing F2-F3 fibrosis especially with the use of non-invasive assessments (FIB-4 score, transient elastography, or MRI elastography), and then offering either Semaglutide or Resmetirom for these individuals w/ F2-F3, which are the only FDA approved...
Do you recommend monitoring Free T4 or Total T4 levels in pregnant patients with central hypothyroidism?
I would recommend monitoring only free T4 (not total T4) during pregnancy with central hypothyroidism. Serum TBG normally rises during pregnancy as a result of the estrogenic milieu, thereby inflating total T4 levels.