Subclinical hypothyroidism in the elderly

Subclinical hypothyroidism in the elderly

Personalized therapy is crucial in good clinical practice, and in the management of older patients with subclinical hypothyroidism, multiple factors must be considered, including age-dependent TSH cutoffs, thyroid autoimmunity, the burden of comorbidities, and the possible presence of frailty. 

Levothyroxine is the drug of choice for the treatment of hypothyroid older people, but the risk of overtreatment, potential adverse drug reactions, and patient compliance should always be considered and thyroid status periodically reassessed.

JES

Artificial pancreas in the hospital

Artificial pancreas in the hospital

The automated insulin pump has already shown great results in type 1 diabetes in an ambulatory setting. This study shows that it is as useful in type 2 diabetes patients treated in the hospital. Patients utilizing the “artificial pancreas” had better glycemic control, without an increased risk of hypoglycemia. I anticipate that closed-loop, automated insulin devices will become the “standard of care” for hospitalized patients with type 1 and type 2 diabetes in the future.

GT

Coffee and Diabetes

Coffee and Diabetes

About 4,000 adults ages 20-70 were followed for 6 years. Pre-diabetes and type 2 diabetes rates were lower in those who consumed coffee vs. non-consumers. Risk reduction on average was 30%. Nutritional benefits of coffee on insulin resistance are mounting, as shown in this article.

GT

LCAT, key to HDL particle formation

LCAT, key to HDL particle formation

Lecithin-cholesterol acyltransferase (LCAT) is a critical enzyme in cholesterol metabolism. It helps transport the cholesterol from the periphery, including diseased coronary arteries, back to the liver via formation of mature HDL particles (“good cholesterol”).

LCAT deficiency due to genetic mutations is rare. It leads to a profound low HDL-cholesterol level <10 mg/dL, in turn causing corneal opacities, target cell hemolytic anemia, and renal failure. Treatment is mainly supportive.

Authors have identified here an acquired immune-mediated form of LCAT deficiency. It is the 7th case worldwide. It caused nephrotic syndrome, but the patient responded well to the anti-inflammatory agent, prednisolone.

Although these are rare illnesses, they help us understand lipid physiology deeper, and more importantly to provide quick and efficient treatment.

GT

Prolactin Resistance

Prolactin Resistance

This is a nice case of prolactin resistance due to loss-of-function variant in the prolactin receptor (PRL-R) gene. A 35 year old female with hyperprolactinemia became pregnant twice, but was unable to lactate. It would take some time before the PRL-R genetic testing becomes available in clinical practice. Nonetheless, the case expands our knowledge of prolactin pathogenesis.

GT

Novel Approach: Verapamil for Type 1 Diabetes

Novel Approach: Verapamil for Type 1 Diabetes

Old drug, new approach. Verapamil has classically been used to treat hypertension and cardiac arrhythmias. This randomized phase 2 clinical trial shows a novel use of the drug by improving pancreatic beta cell function in recently diagnosed type 1 diabetes. Verapamil helped patients use lower doses of insulin as well as experiencing less hypoglycemia. These are exciting and promising results.

GT

New FDA Approval: Subcutaneous Testosterone Pen

New FDA Approval: Subcutaneous Testosterone Pen

FDA has now approved the first subcutaneous testosterone auto-injector pen (Xyosted) for symptomatic patients with low testosterone levels. It is self-administered once weekly. It comes in three doses, 50 mg, 75, and 100 mg. Recommended starting dose is 75 mg per week. It can increase blood pressure, thus caution is advised in patients predisposed to hypertension and those at increased risk for cardiovascular events. Patients need to be monitor carefully after its initiation. Xyosted is not approved for women or males younger than age 18.

GT

More troubles for Prolia

More troubles for Prolia

The FREEDOM study shows that vertebral fracture risk goes up once prolia is discontinued. This is consistent with prior case reports on the subject. Adults with previous vertebral fractures are at the highest risk. Authors advise that if prolia is stopped, high-risk patients should be switched to other antiresorptive agents. Bisphosphonates are a natural option given their long half-life.

GT

2018 Testosterone Therapy Guidelines

2018 Testosterone Therapy Guidelines

This is an update of previous guidelines published in 2010.

We recommend T therapy for men with symptomatic T deficiency to induce and maintain secondary sex characteristics and correct symptoms of hypogonadism after discussing the potential benefits and risks of therapy and involving the patient in decision making. 

We suggest that when clinicians institute T therapy, they aim at achieving T concentrations in the mid-normal range during treatment with any of the approved formulations.

Clinicians should monitor men receiving T therapy using a standardized plan that includes: evaluating symptoms, adverse effects, and compliance; measuring serum T and hematocrit concentrations; and evaluating prostate cancer risk during the first year after initiating T therapy.

JCEM

Intramuscular testosterone injection

Intramuscular testosterone injection

Patients with low testosterone levels could have decreased libido, erections and stamina. They could also suffer from reduced bone mass, muscle mass, and physical capacity. Intramuscular testosterone injection is an efficient and safe way to help patients with testosterone deficiency. The following video shows how to self-administer the testosterone injection.

GT