Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
Would you consider starting short-term metformin in an otherwise healthy patient who is beginning high-dose glucocorticoids to prevent glucocorticoid-induced insulin resistance?
Sustained use of glucocorticoid therapy is well recognized for causing hyperglycemia in patients without known dysglycemia. Rates of 15-25% have been reported depending on the clinical situations and the doses and duration of steroid use. A safe, effective, and cost-friendly approach to prevent this...
What is the clinical significance of a paradoxical decrease in HDL cholesterol after starting statin therapy?
Whether HDL goes up, goes down or stay stable on statin therapy is honestly not of much concern to me. I do not think it is of any clinical significance since we know that statin therapy improves outcomes. In fact, studies show that the clinical benefit of statins is even stronger in individuals wit...
How do you counsel a patient with hypothyroidism who complains of persistent hypothyroid symptoms despite achieving normal TSH values with levothyroxine?
This is a complicated question without an easy answer. Many patients express dissatisfaction with their health status despite normal thyroid function (Peterson et al., PMID 29620972). Obviously, causes of symptoms other than hypothyroidism need to be ruled out such as anemia, autoimmune diseases, sl...
Are there specific populations with hypothyroidism for whom you would consider adding liothyronine to levothyroxine therapy, given observational data linking levothyroxine therapy alone to higher risks of dementia and mortality?
At this time, there is not enough evidence to routinely add T3 to Levothyroxine for the treatment of Hypothyroidism. Although there is the observational study mentioned above, the authors themselves have stated that further studies are needed to confirm the cognitive and mortality benefits of adding...
Is a baseline cortisol at 0 minutes necessary to do as part of an ACTH stimulation test when performing the test in late morning or in the afternoon?
The peak cortisol value after 250 μg cosyntropin changes a little based on when it is done. We see a bigger delta cortisol if it is done in the afternoon. One may omit the baseline cortisol to cut back on costs or if there is a time constraint (avoiding going to the lab and then coming back for an i...
Do you recommend checking plasma metanephrine levels during adrenal venous sampling to assist in assessing lateralization in primary aldosteronism?
I have not concluded yet that the measurement helps with lateralization. At this point, the best use of measuring plasma metanephrines or androstenedione in patients with hypercortisolism and bilateral adrenal pathology is to confirm accurate adrenal vein catheterization. In my opinion, the literatu...
Do you recommend treating a macroprolactinoma that is acutely undergoing spontaneous apoplexy with dopaminergic agents?
In such a case, the prolactin may decrease on its own, so I would wait to start a dopamine agonist and check for other pituitary hormone deficiencies and monitor prolactin every 2-3 months.
Do you forgo adrenal imaging in a patient with primary hyperaldosteronism who has decided against surgery?
Yes. It would be a waste of time and money. Can go straight to using spironolactone or other mineralocorticoid blocker.
Do you recommend the use of SGLT2 inhibitors to reduce the risk of liver cirrhosis in patients with Type 2 diabetes mellitus?
Metabolic dysfunction-associated steatotic liver disease (MASLD) can be found in about 30% of adults in the U.S. Diabetes is a significant co-morbidity and increases the risk of progression to metabolic dysfunction-associated steatohepatitis (MASH). I calculate a FIB-4 index in these patients to see...
What degree of prolactin elevation is typically seen in patients with end stage kidney disease on hemodialysis?
Usually, less than 50, rarely 50-100. If it is higher than 100, one should look for another cause of hyperprolactinemia.