Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
When and how do you taper off cabergoline therapy for treatment of microprolactinoma?
If patient does not desire fertility and microprolactinoma is stable or smaller, cabergoline can be tapered off.
Do patients with an elevated IGF-1 level and features of acromegaly need to have confirmatory growth hormone suppression testing with OGTT?
OGTT is not always needed. In the presence of clinical features of acromegaly, a frankly elevated IGF-1, and a pituitary adenoma visible by MRI glucose suppression test is not necessary.
Does preoperative use of somatostatin receptor ligand improve remission rates after surgery for acromegaly?
This is still an open question. Two well-known papers (one from Norway and one from China) addressed this and suggested that a 4-6 month treatment increased the chance of surgical cure for GH-secreting macroadenomas, but both papers had methodological issues. I have done this occasionally for macros...
Should patients with non-functional pituitary macroadenomas with persistent, but tolerable, headaches be recommended for surgery?
It depends on the size of the adenoma and stability of the imaging. It is sometimes difficult to know if the headaches are related. In a younger patient, I would consider surgery.
Are you offering GLP-1 agonists to patients with CKD and diabetes mellitus?
According to KDIGO 2022, GLP-1RA are second line DM Rx (see fig 3: Rossing et al., PMID 36272755); this class of medications still awaiting a CKD-dedicated RCT such as FLOW (Rossing et al., PMID 36651820). However, secondary outcomes of CVOT show kidney protective effects for some GLP-1RAs (non-exen...
Is there any role for 25-OH Vitamin D testing in patients older than 75 years old in the general population?
The recent Endocrine Society Guideline on Vitamin D no longer recommends testing for vitamin D status unless there are unusual circumstances. The Guideline however recognized that approximately 20% of adults greater than 75 years of age are vitamin D deficient i.e. 25-hydroxyvitamin D <20 ng/mL. The...
For a TSH producing microadenoma, would you recommend surgery vs methimazole if the patient is elderly and the tumor is relatively small?
In general, treating TSHomas with methimazole is not a good idea, as the adenoma may grow. If she is a candidate for surgery, this should probably be advised. Most TSHomas respond very well to somatostatin receptor ligands (better than GH-secreting adenomas).
How do you distinguish between primary and tertiary hyperparathyroidism in a patient with ESRD?
Almost all patients with hypercalcemia, hyperparathyroidism, and ESRD are going to have tertiary HPTH and not primary. Imaging will show diffuse hyperplasia and multiple nodules in tertiary and in the rare case of primary would expect to see a solitary nodule without hyperplasia of the other glands....
What are the clinical indications and major limitations of lipoprotein apheresis?
LDL apheresis is a procedure that selectively removes apo B-containing lipoproteins (so primarily LDL particles) from the circulation. Very simply - venous blood is withdrawn via IV, plasma separated by the machine (liposorber, FDA approved in the US), passed through a column which binds the apo B c...
What kinds of dental work do you particularly worry about and try to avoid in patients on bisphosphonates?
Firstly, the incidence of BRONJ (bisphosphonate-related osteonecrosis of the jaw) is very low with all drugs of this class. However, many patients and dentists are concerned about the possibility of this problem. Generally, BRONJ occurs after an extraction and subsequent poor healing at the extracti...