Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
How do you manage patients who are positive for the 21-hydroxylase antibody but have no clinical or laboratory evidence of adrenal insufficiency?
I educate the patients about the signs and symptoms of adrenal insufficiency, evaluate their HPA axis at intervals, and monitor for other autoimmune disorders.
Under what circumstances would you administer subcutaneous hydrocortisone instead of IV hydrocortisone to a patient with adrenal insufficiency?
A subcutaneous route may be used instead of intramuscular injection (preferred) at home while the patient is transferred to a medical facility for further treatment. The IV route is always used in the ER setting in a patient during an adrenal crisis.
How do you manage microprolactinomas in women who are resistant to dopamine agonists, especially considering potential tumor growth during pregnancy?
Surgery should be considered in small prolactinomas (even independently from DA resistance), but this should be done by a competent neurosurgeon who specializes in pituitary surgery, meaning s/he does 50 pituitary surgeries per year or more. In expert hands, the cure rate for microprolactinomas is i...
How do you counsel younger patients regarding long-term radiologic monitoring of non-functional adrenal adenomas?
I do not think biology is so black and white. The risk of malignancy in adrenal masses according to size is a spectrum and certainly not zero just because at one point in time it is less than 5 cm (how about 4.5 cm?). Unless the radiologist can confidently diagnose a myelolipoma I think clinical jud...
Are thyroid molecular tests (such as Afirma, ThyroSeq) validated for use on FNA thyroid nodule samples that are not Bethesda class 3-4?
If the first biopsy was AUS and the second biopsy was Bethesda II, benign, the molecular test is not warranted. It is agreed that a second biopsy of a nodule that was AUS (Bethesda III) will be benign about 40% of the time. If the first biopsy was follciular neopasm/suspicioyus for FN (Bethesda IV),...
Would you recommend the use of an ACE inhibitor to patients with Type 1 diabetes mellitus who are normotensive but have persistent moderate proteinuria?
My answer would be “yes”. ADA Standards of Care 2025 notes “ACE inhibitors and ARBs remain a mainstay of management for people with CKD with albuminuria”. Specifically, Figure 11.2 shows first-line drug therapy to be RAS inhibitor at maximum tolerated dose for treatment of albuminuria or HTN. RAS bl...
How do you approach individualizing A1c goals in patients with dementia?
This is an important question for shared decision-making. And it definitely is impacted by the severity/FAST staging of the dementia, as well as the class of medication use. As we are all aware, we do not want to use the Sulfonylurea class in older adults, especially in patients with a dementia diag...
Do you recommend using intermediate-acting insulin over long-acting insulin for the management of steroid-induced hyperglycemia?
It depends on the dose of the steroids being used and whether the steroid use is for a short period or for prolonged chronic use. If the dose of the steroid is high and the use is intended for a short time, use of a short acting insulin may be preferred to combat the hyperglycemia, If the steroid us...
How do you approach therapy for severe osteoporosis after an initial 12 months of romosozumab?
After 12 months of romosozumab, most likely the patient will still need additional therapy. If you can get a bone mineral density, that can guide you into what the best next medication can be. If the patient still has significant osteoporosis or fracture during the treatment with romosozumab, I woul...
Should a different weight-based dosing algorithm for levothyroxine therapy be considered in women versus men given higher incidence of iatrogenic thyrotoxicosis in women?
I do not. For the majority of my patients, my starting dose is 1.6 mcg/kg, which is in the ATA guidelines (1.6-1.8 mcg/kg has been recommended as the starting dose in many publications). There have been some studies that show using ideal body weight is a better predictor of LT4 dose, and others tha...