Endocrinology
Physician discussions on diabetes management, thyroid disorders, hormonal imbalances, and metabolic conditions.
Recent Discussions
What triggers you to choose urgent thyroidectomy versus therapeutic plasma exchange versus continued medical management for refractory thyroid storm despite 12-24 hours of guideline-concordant therapy?
A very important factor is the comfort level of the ICU doctors and the Anesthesiologists at the institution. We usually do not recommend proceeding with urgent thyroidectomy given the increased risks, unless FT4 and TT3 are normalizing. Usually, a combination of PTU (or Methimazole), stress dose st...
When would you consider using transvaginal cabergoline in the treatment of prolactinoma?
This is considered an off-label use, but I have done this a few times, and I know some of my colleagues have as well. There is not much in the literature on this, mostly case reports. I would reserve this for patients who do not tolerate the oral forms of cabergoline or bromocriptine.
In patients with MASLD, would you consider management with off-label metformin, pioglitazone (despite weight gain risk), GLP-1 RA, or simply intensify lifestyle and monitor?
In 2025, we should be assessing if patients are developing F2-F3 fibrosis especially with the use of non-invasive assessments (FIB-4 score, transient elastography, or MRI elastography), and then offering either Semaglutide or Resmetirom for these individuals w/ F2-F3, which are the only FDA approved...
How does a strong family history of breast cancer influence your decision between RAI and thyroidectomy for definitive treatment of hyperthyroidism, in light of emerging observational data suggesting a possible association between RAI and increased breast cancer risk?
There is an increased risk for solid tumors, especially breast cancer, following radioactive iodine (relative risk from 0.45-2.55). This data is strongest for those treated for thyroid cancer as opposed to Graves disease, as it is dose dependent, but studies do support an increased risk for breast c...
Does the degree of TSH suppression significantly impact the risk of differentiated thyroid carcinoma recurrence?
This is a very timely question. The new 2025 Guidelines for thyroid cancer was just published. They cite studies that recurrence and cancer dead for low and low/ intermediate risk thyroid cancer patients are not affected by TSH suppression. The recommended TSH is normal and less than 4 uU/ml. It is ...
Can carbamazepine make thyroid function test results look spuriously abnormal?
Carbamazepine can also displace thyroid hormone from binding proteins. Although in the short term this might transiently increase free T4 (with a reciprocal decrease in TSH), thyroid function tests should normalize once an equilibrium is achieved. In some assays that rely on dilution of the sample, ...
Would you recommend RAI ablation therapy to patients with PTC who are s/p hemi-thyroidectomy and decline completion thyroidectomy despite meeting criteria based on pathology results?
RAI therapy will work to ablate the remaining thyroid lobe with about a 69% success rate using a high dose of I-131. However, extra-thyroidal tumor cells will likely not pick up I-131 with this treatment. A good reference is the 2020 meta-analysis in the Journal of Nuclear Medicine: Piccardo et al.,...
If a patient requires more than 5 mg per day of methimazole long term do you recommend alternative treatment options such as radio-iodine ablation or surgery?
Long term use of methimazole is generally safe as long as no history of LFT elevation or abnormally low white blood cell counts. Typically, toxic multinodular goiters respond well to low dose methimazole and patients can be managed in this fashion long-term without any issues. Graves patients may re...
What is the evidence, if any, for the use of low dose naltrexone in the treatment of autoimmune thyroiditis?
I do not prescribe naltrexone for thyroid disease because I have not found data to support its use. In theory, low dose naltrexone (LDN) could decrease inflammation and thus potentially block development of overt hypothyroidism in TPO positive patients. But, at this time, it is anecdotal, with no ha...
Which antidiabetic agents would you recommend to treat hyperglycemia secondary to PI3K and AKT inhibitor therapy?
In the patients I have seen with this condition, typically insulin is what works best.