Endocrine

Part I- Subclinical Thyroid Dysfunction: To Treat or Not to Treat?

July 31, 2007

Commentary by Melissa Freeman MD, PGY2

Modern day science has revealed to us the intricate relationships that thyroid hormones have with multiple systems of the human body. Many of today’s physicians find themselves checking patients’ thyroid function tests (TFTs) almost as reflexively as a baseline basic metabolic panel. Yet, what seems to the physician to be a harmless bit of thoroughness can often turn into hours of inquisitive head scratching if the TFTs reveal subclinical thyroid dysfunction, especially since automated assays for TFTs…

Meeting Perspectives: The ADA Scientific Sessions: Advances in the Pharmacologic Management of Type 2 Diabetes Mellitus

July 5, 2007

Commentary by Mitchell Charap MD, Senior Associate Program Director, NYU Internal Medicine Residency Program

Caveat: What follows below reflects my perspective on new and old pharmacologic approaches to Type 2 Diabetes. It is not intended to be a comprehensive review of this topic.

TZDs

The ADA did not mount a serious attack on the Nissen NEJM metanalysis of Rosiglitazone. They suggested that patients speak to their physicians regarding the drug. I missed the Nissen/ADA debate that occurred, but gather…

How Do you Approach a Patient with Primary Hyperaldosteronism?

June 28, 2007

An 80 year old male with atrial fibrillation, hypertension, hypokalemia is diagnosed with hyperaldosteronism with an aldosterone to renin ratio of 34.5/0.15=230 . CT scan reveals a right adrenal 1 cm presumed adenoma

Questions:
1. How do you accurately diagnose primary hyperaldosteronism?
2. Do medications which the patient is taking influence the work-up?
3. Can you have primary hyperaldosteronism in the absence of hypokalemia?
4. Can the adrenal mass be incidental? Should the patient have additional testing?

-Anna Dvorak PGY-3…

Clinical Commentary: The Travesty of Grinding Axes with Science: Rosiglitazone and Cardiac Risk

June 12, 2007

Welcome to our first blog commentary. One of the purposes of the blog is to generate discussion about issues in health care. This “Clinical Commentary” section is an invitation to our housestaff and faculty to submit their own thoughts and viewpoints on current issues. The views expressed in this section are soley those of the authors and do not necessarily represent the views of Clinical Correlations.

Commentary by Gregory Mints MD and Nirav Shah MD, MPH

The meta-analysis of Rosiglitazone’s effect on cardiovascular events…

Can you switch a patient from insulin to oral agents?

June 6, 2007

A 48 year old male is diagnosed with type 2 Diabetes Mellitus after presenting to the emergency room with symptoms of hyperglycemia. He was immediately started on insulin and has been very compliant with his regimen. His initial Hemoglobin A1C at the time of diagnosis was 15. However, over the past few months, due to hypoglycemia, his insulin dosage has been titrated down. He is currently on low doses of NPH and aspart, with an A1C of 6.6. Would it be possible to…

Not So Rosi…

May 24, 2007

Commentary by Seagram Villagomez MD, Chief Resident

Since its approval in 1999, nearly 1 million Americans have used the thiazolidinedione (TZD) rosiglitazone (Avandia – GlaxoSmithKline) for the treatment of Type 2 Diabetes. However, in a drug class which seems plagued by concerns, the safety profile associated with rosiglitazone has been brought to question. Previously, troglitazone (Rezulin) was pulled off the market secondary to hepatoxicity, while muraglitazar was not approved by the FDA given adverse cardiovascular events during early clinical trials. In a…

Statin Pleiotropy: Unique Roles for a Common Medication

April 26, 2007

By: Melissa Freeman, MD, PGY1

For over a decade now, statins, or 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, have facilitated millions of patients in the management of their atherosclerosis. Statins are known for their ability to reduce hepatic lipoproteins, up-regulate hepatic LDL receptors, and increase apoprotein E- and B-containing lipoproteins. They have become a household name in the genre of lipid-lowering and a touted hero in cardiovascular risk reduction amongst physicians. Excitingly, research has found that statins may be valuable in disease…

More Breaking News for the Glitazones…

March 15, 2007

Coming right on the heels of the recent warning from the FDA about the risk of fractures and Rosiglitazone, the FDA announced on March 9th that pioglitazone (Actos) has also been linked to an increased occurrence of arm, hand, and foot fractures among women taking the drug for treatment of type 2 diabetes. In an analysis of over 15,000 patients followed for up to 3.5 years, the risk of fracture was 1.9 fractures per 100 patient years in the pioglitazone group, compared to 1.0…

When Should You Order a Serum Fructosamine Level for a Diabetic Patient?

March 14, 2007

Commentary By: Christopher Johnson, MSIV and Glenn Matfin, MD Clinical Associate Professor of Medicine, Divsion of Endocrinology

When was the last time you had a diabetic patient in clinic whose hemoglobin A1C was elevated, prompting you to modify their diabetic regimen? You may have scheduled a repeat hemoglobin A1C in 3 months, since you know A1C measures glycemic control over a 3 month period. A serum fructosamine may help give you a snapshot of more recent control.

What is fructosamine?
Fructosamine is…

More Breaking News: Rosiglitazone Linked to Fractures

March 6, 2007

Commentary By: Cara Litvin PGY-3

The FDA recently informed physicians of a report issued by GlaxoSmithKline acknowledging that Avandia (rosiglitazone) has been linked to increased fractures in females (1). The report stems from a review of the safety data from ADOPT (A Diabetes Outcome and Progression Trial) (2), which was a recently published randomized trial of 4,360 patients designed to compare glycemic control with rosiglitazone relative to metformin and glyburide monotherapies. In the published study, there were no unexpected adverse events reported, although…

A Bad Break for the Purple Pill…

January 8, 2007

Commentary By Josh Remick, PGY-2

In the December 27th 2006 issue of JAMA, Yang et al. reported the results of a nested case-control study of United Kingdom patients entitled “Long-term Proton Pump Inhibitor Therapy and Risk of Hip Fracture.” Using the General Practice Research Database (GPRD), a computerized medical record system used by several of the general medical practices in the UK, new hip fracture cases were found in patients at least 50 years old (n=13,556) and matched them with…

How do you approach a patient with asymptomatic primary hyperparathyroidism?

December 6, 2006

56 year old Hispanic female with a history of hypertension, type 2 diabetes on oral medications, hyperlipidemia and normal renal function. Over the past 2 years she has been noted to have mild hypercalcemia (11.0-11.5) on several basic metabolic panels. On her last visit, intact PTH was checked and was elevated at 66 (normal range 7-57). In patients such as this, with apparent asymptomatic primary hyperparathyroidism, what further diagnostic tests should be done and in whom is surgery indicated?…

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