Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
Do you give bisphosphonates after completing adjuvant anti-HER2 therapy and chemotherapy for HER2+ breast cancer to reduce the risk of recurrence?
Bisphosphonates and the RANK-ligand inhibitor, denosumab, are bone-modifying agents that are indicated to decrease the risk of bone fragility fractures in at-risk populations without cancer, and to decrease pain and complications related to metastatic bone disease. In the adjuvant setting for postme...
Do you offer adjuvant bisphosphonates to high-risk premenopausal women on ovarian suppression for early-stage breast cancer who would want to consider pregnancy in the future?
ASCO guidelines from 1/2022 recommend a discussion of bisphosphonate therapy in post-menopausal women or women on ovarian suppression who are candidates for adjuvant therapy, but risks and benefits should be carefully weighed.In a large meta-analysis of adjuvant bisphosphonate therapy in early breas...
Do you prioritize dietary modifications and exercise over early pharmacologic interventions, such as metformin or insulin, for women diagnosed with gestational diabetes?
Most women with gestational diabetes are diagnosed in their late second/ early third trimester after a standard oral glucose tolerance test. Some women may be diagnosed earlier in their pregnancy and perhaps even had undiagnosed pre-gestational diabetes. Rarely, a patient can develop type 1 diabetes...
How often should TSH levels be monitored in patients with a history of Graves' disease who are in remission with negative TSI/TBII antibodies and off medical therapy?
If Anti-thyroid drugs are discontinued when an TSH receptor antibodies are still positive, recurrent hyperthyroidism often develops within a few months. On the other hand, if the drug is discontinued when antibodies are negative (not “normal“ but still detectable), then recurrent hyperthyroidism is ...
Do you recommend adding low-dose Aspirin for primary prevention in patients with Type 2 Diabetes on Eliquis for another indication?
Most guidelines and standards of care do not generally recommend aspirin therapy for primary prevention in patients with type 2 diabetes. As such, I do not generally recommend it unless their 10-year ASCVD risk is > 20% then I would have a discussion with the patient about low-dose (81 mg) aspirin t...
Can you explain the block and replace approach in the treatment of thyrotoxicosis, including when it is most appropriate to use and how it compares to other treatment options?
More than 20 years ago, Japanese researchers had data that suggest that remission rates for Graves' disease was much better with the block and replacement treatment with Methimazole/carbimazole and Levothyroxine. At least 3 US and European studies did NOT confirm this observation. I do occasionally ...
What is the next step in management of a thyroid nodule that was biopsied and classified as Bethesda III, but Afirma genetic testing reveals parathyroid signature?
This is not an uncommon clinical presentation of intrathyroidal parathyroid adenomas, diagnosed incidentally on molecular profiling of cytological indeterminate nodules (CIN). These adenomas most often have the imaging features of a TIRADS 4 thyroid nodule (with well-demarcated margins, solid, profo...
How do you approach the use of GLP-1 receptor agonists for the management of patients with metabolically healthy obesity?
I want to define my understanding of the term “metabolically healthy obesity”. Generally, this is meant to describe patients with a BMI in the obese range but without hypertension, dysglycemia or dyslipidemia. Obesity is associated with a wide range of medical conditions beyond those three such as o...
Do you recommend the use of Korlym (Mifepristone) for patients with difficult to control diabetes and evidence of mild endogenous hypercortisolism of unknown source?
This is an ongoing question - stimulated by the CATALYST study. The impetus for the study is the observation that many persons with uncontrolled Type 2 DM will fail an overnight 1-mg dexamethasone suppression test (~25%). Subjects with ACTH-dependent hypercortisolism were excluded from further study...
What is your approach to treating osteoporosis in patients post bariatric surgery?
While there is no guidance from the bariatric surgeons, I tend to avoid oral bisphosphonates in all patients with prior bariatric surgery. I am worried about the pill getting stuck independent of the type of surgery. Since we have IV bisphosphonates and denosumab I have good alternatives to oral bis...