Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
How do you decide between repeat resection and radiosurgery when MRI imaging suggests limited residual tumor in the cavernous sinus in patients treated for acromegaly?
If residual tumor is not surgically curable, another surgery is not advisable. Given available pharmacological treatments, I do not consider XRT until I run out of medical options, particularly in young patients with intact pituitary function. Even if a patient does not respond to SRL, including pas...
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...
How should diabetic retinopathy surveillance be adjusted for patients starting GLP-1 agonists?
As with traditional anti-hyperglycemic medications, GLP-1 agonists may cause transient worsening of diabetic retinopathy due to the initial rapid control of blood glucose. Therefore, if a patient has existing retinopathy and is about to start GLP-1 agonist therapy, I recommend closer monitoring. For...
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...
What are your preferred lipid-lowering agents and target LDL reduction goal following initiation of therapy for patients with familial hyperlipidemia without underlying CAD?
It is not easy to address this question without specifics of the 'familial hyperlipidemia," but I will give examples: Monogenic familial hypercholesterolemia - since the LDL is very high from early childhood, we tend to treat adolescents with statins with a goal of a 50% reduction (20 or 40 rosuvas...
Would you order a repeat DEXA scan 1 year later for a kidney transplant patient who had an initial DEXA scan within the first 6 months post-transplant showing osteopenia but no history of fractures, and who has been stable on glucocorticoid-free immunosuppressive therapy?
I agree with Dr. @Dr. First Last. Bone metabolism in renal transplant is woefully shy of good data. My opinion is to monitor Vitamin D levels, provide appropriate supplementation, and monitor PTH levels, using cinacalcet as needed. My target level for PTH is 1-2x the upper limit of normal, also base...
In patients with iron deficiency due to history of gastric bypass or IBD, would you consider oral iron therapy if the iron deficiency anemia is mild?
Oral iron can often be effective in iron deficiency, as long as absorption is intact. If you are concerned about absorption, performing an oral iron challenge can be useful in allowing you to avoid long trials of oral iron that will be ineffective. Simply check an iron panel at baseline, then admini...
Do you recommend restarting a GLP-1RA after bariatric surgery if the patient tolerated it before the surgery?
While there are no clear recommendations on whether/when to resume GLP-1 RA after bariatric surgery, current 2025 guideline statements (ASMBS, ADA, AACE, Obesity Society) and expert consensus documents suggest the following approach: Hold GLP-1RA in the acute perioperative period. For daily-dosed ...
Do you escalate to 7.2 mg semaglutide in a patient with obesity who has not achieved their weight loss goal on the 2.4 mg dose despite the increased risk of dysesthesia at the higher dose?
This question is raised because of a recent report (Wharton et al., PMID 40961952) looking at weight loss in obese patients titrated up to 7.2 mg/week of semaglutide compared to the usual dose of 2.4 mg/week. The study was funded by Novo Nordisk, and the authors have strong financial ties to the com...
When starting GLP-1 R agonist therapy for weight loss purposes, how do you counsel patients on duration of treatment therapy?
I counsel people that I expect this to be lifelong therapy (similar to how we don't stop blood pressure medications when blood pressure comes down to normal on them because it will go back up, we don't stop GLP1RA when we get to our weight goals, as our weight will go back up when they are stopped)....