Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
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...
What is the utility of near-infrared autofluorescence (NIRAF) imaging during parathyroid surgery?
Parathyroid tissue emits auto fluorescence (AF) in the near infrared spectral range of 700-900 nm when excited by a 785 nm diode laser. It was thought that this technology during surgery could identify parathyroid gland disease from normal parathyroid glands. Thus near-infrared auto fluorescence (NI...
Do you recommend Alpha Lipoic Acid to patients with diabetic polyneuropathy?
Recommend is a strong word. I mention it to my patients as there's some 'evidence' supporting it. It has minimal side effects and virtually no risk, so it's worth a try. However, it's important to note that very few of my patients report any benefit from it.
What clinical sign or symptom do you consider to be the most specific for Cushing syndrome?
Cushing's syndrome is a rare disease. The following symptoms and signs are suggestive. Symptoms: weight gain, especially in the middle, muscle weakness, and easy bruising Signs: Moon facies Central obesity with relatively thin arms and legs Pad of fat behind the neck (Buffalo hump), thin skin, pur...