Metabolic & Endocrine Disease Summit (MEDS) Newsletter

January 2022

Rick Pope Weighs In!

Rick Pope MPAS, PA-C, DFAAPA, CPAAPA, is an Author, Clinical Professor University of Bridgeport PA Institute, Sacred Heart University PA Program, Rheumatology PA (emeritus) Department of Rheumatology, Danbury Hospital, Danbury, CT and Founder and Past President, Society of PAs in Rheumatology.

INTRODUCTION

Happy New Year! Welcome back to MEDS eNews. For this first month issue of 2023, I got a chance to speak with Rick Pope MPAS, PA-C, DFAAPA, CPAAPA. I’ve wanted to catch up with Rick since his presentations at the recent MEDS Summit because they were so well received. So I asked him here about these topics and then some other critical aspects of MEDS care. Rick is an author and Clinical Professor at the University of Bridgeport PA Institute, Sacred Heart University PA Program, Rheumatology PA (emeritus) Department of Rheumatology, Danbury Hospital, in Connecticut, and Founder and Past President of the Society of PAs in Rheumatology. Rick is a very well-respected thought leader in the MEDS community, but he’s also a great example of how this MEDS community is such a supportive, connected group that does everything it can to bolster and lift up its members. We discuss pearls from his presentations, new advances in therapeutics—including testing, screening, and recent pharmacological advances for osteoporosis, the challenge of when your patient comes off denosumab, and more. Following the interview is our Rapid Fire segment!

If you missed it, you can access the recent MEDS Summit and register here for virtual access that fits your schedule. The best resource for the most up-to-date, clinically relevant information on treatment of diabetes, obesity, Cushing’s Syndrome, PCOS, osteoporosis, hypercalcemia, and thyroid disease, it’s a one-stop shop to get you up to speed with CME!

Next month we will speak with Rick Pope, MPAS, PA-C, DFAAPA, CPAAPA. Thank you to Rick for his time here and as Medscape conference faculty! Please contact me at [email protected] with comments or suggestions. Thanks for reading! —Colleen Hutchinson

Rick Pope MPAS, PA-C, DFAAPA, CPAAPA Weighs In

Author, Clinical Professor University of Bridgeport PA Institute, Sacred Heart University PA program, Rheumatology PA (emeritus) Dept of Rheumatology, Danbury Hospital, Danbury, CT Founder and Past President Society of PAs in Rheumatology.

What are some pearls or takeaways you shared in your presentation in Session VII: Endocrine Part 2 on Part I Osteoporosis: Who We Screen, Who We Test, and Current Recommendations for Therapy at the Metabolic and Endocrine Disease Summit Fall?

Rick Pope: 1- There are medically approved easy and familiar medications that, when sequenced correctly, can dramatically improve bone density and fracture risk. 2- With the new drug pipeline tied off for the moment, we are learning now how to sequence medications especially for those in the high-risk categories for osteoporosis. Anabolics are now ready for prime time in this category with follow-on therapy with antiresorptives. Teriparatide, abaloparatide, and romosozumab have been studied with follow-on therapy with bisphosphonates and have shown clear superiority in preventing spine fractures, and significantly improving bone density over a three-year period.

Any pearls from your presentation, Part II: Case Studies in Osteoporosis?

Rick Pope:  1- Beware the wrist fracture. 2- Wrist fractures are sentinel events and should be considered a medical emergency. Workup and treatment going forward is critical as statistics show that wrist fractures are a warning signal for future fractures. BMD testing, basic lab work, and appropriate treatment for risk including patient education, and treatment with both lifestyle and medications if indicated, are critical with this common fracture.

What steps do you need to take now if your patient comes off denosumab?

Rick Pope: Stopping denosumab without a plan for follow-on therapy can lead to a significant increase in multiple vertebral fractures. The PI was changed to reflect this risk in 2017. What is very interesting is a new cell type that has been discovered called an “osteomorph.” These cells turn into active osteoclasts shortly after the first month from the last six-month injection. Multiple vertebral fractures occur as a result of these osteomorphs reactivating as osteoclasts. and thereby increase bone turnover and lead to fractures. Practitioners should embark on a clear understanding that once denosumab is started, it should not be stopped. However, a discussion of follow-on therapy is critical and, in most cases, should be a bisphosphonate.

What were some of the takeaways from the Session 8 Clinical Knowledge Session you facilitated with Scott Urquhart?

Rick Pope: Lots of questions came up about osteonecrosis of the jaw and atypical femoral fracture. The side effects are rare but more commonly seen with long-term bisphosphonate users and in those being treated for underlying malignancy with risk for metastatic bone disease. Takeaways included having a regular dental appointment prior to treatment and treating only those with highest risk of fracture with 10-year oral therapy or 6-year IV treatment. Moderate to high-risk patients should be treated up to 5 years with oral therapy and three years for IV treatment. Atypical femoral fractures are rare and can occur in the general population. Warning signs occur in 2/3 to ¾ of patients with a prodrome of hip pain and these complaints should be taken seriously. X-rays with attention to cortical thickening on both the lateral and medial sides of the cortex should be evaluated. Medication discontinued and careful close followup is critical.

Rapid Fire with Rick Pope:

Most critical new advance in my area of medicine:  Romosozumab for high-risk patients to start and then sequenced to denosumab or alendronate as a followup.
My mentor: Mike Lewiecki, MD, University of New Mexico Bone Health Tele-echo
Advice that’s helped in my career: My collaborating rheumatology MDs over a 30-year career
Best tool in my clinical arsenal: Physical exam and height measurement
What I wish the patient would remember: Selected exercises daily help keep bones strong. Balance and gait prescriptions should be used liberally.
Biggest challenge for me and my colleagues: Getting the general population to appreciate the significance of fractures as a risk for early demise. It is not just bad luck.

 

November 2022

Wendy L. Wright Weighs In!
Wendy L. Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP, is an Adult and Family Nurse Practitioner, and Owner Wright & Associates Family Healthcare, Amherst, New Hampshire.

Introduction

Welcome back to MEDS eNews! For this month’s issue, I spoke with Wendy Wright DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP. An Adult and Family Nurse Practitioner and Owner of Wright & Associates Family Healthcare in Amherst, NH, Wendy is a well-respected thought leader in the MEDS community, and served as faculty at the recent MEDS Summit and Metabolic and Endocrine Disease Summit Fall. We discuss pearls from her presentations, new advances in therapeutics—including recent pharmacological advances for weight control and type 2 diabetes, the challenge of frontline practitioners keeping current on ever-changing evidence and guidelines for common and not so common conditions, and more. Following the interview is our Rapid Fire segment! 

If you missed it, you can access the recent MEDS Summit and register here for virtual access that fits your schedule. The best resource for the most up-to-date, clinically relevant information on treatment of diabetes, obesity, Cushing’s Syndrome, PCOS, osteoporosis, hypercalcemia, and thyroid disease, it’s a one-stop shop to get you up to speed with CME! 

Next month we will speak with Rick Pope, MPAS, PA-C, DFAAPA, CPAAPA. Thank you to Wendy for her efforts and critical contribution as Medscape conference faculty. Please contact me at [email protected] with comments or suggestions. Thanks for reading! —Colleen Hutchinson

 

What are some takeaways from your talk in Session IV: Cardiovascular Disease Risk Reduction on Diagnosis and Management of Resistant Hypertension at the Metabolic and Endocrine Disease Summit Fall?
Wendy Wright:
1. Diuretics remain the gold standard for patients with resistant hypertension and, whenever possible, should be maximized; 2) the more resistant the patient’s hypertension, the more imperative it is to look for a secondary cause.

What’s something you came away with as an attendee at the meeting?
Wendy Wright:
1. The importance of optimizing the lipid profile and evidence-based strategies to reduce our patient’s CV risk.

What do you think about the recent pharmacological advances for weight control and type 2 diabetes?
Wendy Wright:
There are so many tools in our toolbox to treat type 2 diabetes while reducing the patient’s weight. The GLP1RAs are gamechangers with so many important reasons to utilize them for patients with diabesity. The SGLT2Is are also an important class in the management of patients with diabetes, particularly if coupled with CKD. Last, I am excited by the data surrounding tirzepatide and the weight loss/A1C reduction associated with this novel medication.

What is one of the biggest challenges you face in your work, and how do you manage it?
Wendy Wright:
The biggest challenges faced today in my work as a primary care NP are just the volume of the workload and the limited time facing us all. In my clinic, our visits are 30 minutes for all follow-ups and 1 hour for physical examinations. Despite this, there never seems to be enough time to address all that patients want to address, as well as the things we need to address to keep them healthy. 

Please tell us how you started Wright & Associates, and what Partners in Healthcare Education is.
Wendy Wright:
I opened Wright & Associates Family Healthcare on February 1, 2007 with 7 patients on the books that day. I mortgaged my home to open this clinic because I wanted a primary care clinic where I could create a comprehensive care model that was owned and operated by NPs, one where I also had the time to meet the needs of the patients. Today, we have 5500 patients and 11 NPs. It is so exciting to see the growth of these clinics and the work that the NPs are doing in the community. Partners in Healthcare Education is a medical education company that I founded in 1997. It is an AANP-accredited medical education company that provides evidence-based CE to NPs throughout the nation.

Optional: What are your thoughts on frontline practitioners regularly having to address (common and uncommon) metabolic conditions and disorders?
Wendy Wright:
Given the rapidly changing healthcare environment, it is imperative the NPs and PAs remain up to date on the latest evidence base on common and not so common conditions. As a primary care provider who is responsible to more than 6000 guidelines, it is impossible to know everything about everything. However, a strong NP/PA will initiate the work-up and consult or collaborate or refer to ensure the patient gets the care that is needed at the right time by the right provider. 

 

Rapid Fire (1 to 10 words gut reaction)—if you have time:
Most critical new advance in my area of medicine: Expansive point of care testing.
Where I go for continuing education: NP/PA conference, AANP – my national organization
My mentor: Margaret Fitzgerald, Mimi Secor, and Dr. Loretta Ford
Advice that has helped in my career: If you are not on the table, you are on the menu.
Best tool in my clinical arsenal: My iPhone and my apps: MDCALC
What I wish the patient would remember: That we can’t do everything in one visit and that follow-ups are needed.
Biggest challenge for me and my colleagues: The volume of messages and calls along with short staffing.

 

 

October 2022

Looking Backward to See Progress Forward
Introduction

Welcome back to MEDS eNews! For this month’s issue, we decided to look back on the numerous paradigm shifts that have taken place across different spectrums that make up MEDS and that have collectively made 2022 so far a year to remember in healthcare. Here we highlight a few clips from each issue. As you read through, you will realize how much the topics discussed reflect the changing landscape of treatment. We hope you enjoy this brief look back and the valuable and candid perspectives that our interview participants graciously shared with us.

If you missed it, you can access the Metabolic and Endocrine Disease Summit Fall that took place earlier this month. Since it’s a hybrid event, you can still register here for virtual access that fits your schedule. The best resourse for the most up-to-date, clinically relevant information on treatment of diabetes, obesity, Cushing’s Syndrome, PCOS, osteoporosis, hypercalcemia, and thyroid disease, it’s a one-stop shop to get you up to speed with CME! 
Next month we will speak with Christine Kessler, Founder, Clinical Consultant Metabolic Medicine Associates and Director, Journey's Weight Management Program in King George, Virginia. Thank you to these thought leaders featured in this issue for their continuing efforts to educate. Please contact me at [email protected] with comments or suggestions. Thanks for reading!

—Colleen Hutchinson

 

Looking Backward to See Progress Forward: Some MEDS Favorites from 2022

Is there anything new in research that you think will help improve treatment and outcomes for your patients?
Justine Herndon:
I enjoyed reading the article, “Opioids and pituitary function: Expert opinion” by Gadelha et al in Pituitary about the effects of opioids on pituitary function, bringing more awareness to what we need to watch for in patients on chronic opioid therapy. (Article can be found on PubMed here.)

Ashlyn Smith: There is some interesting research about the effects of COVID-19 and the emergence of adrenal insufficiency, both short- and long-term, primary and secondary, positive and negative autoimmunity. However, the jury is still out as to the true link between COVID-19 and adrenal insufficiency. 

Amy Butts: Technology like CGMs, those that integrate with automated insulin delivery devices and smart pens, have allowed a more precise insulin delivery to the patient. The novel GLP1 RA/GIP MounjaroTM medication from Lilly is also new and exciting.

Mimi Secor: The discovery that PCOS is associated with insulin resistance is a game changer that impacts treatment approaches. The inverse relationship between insulin resistance and testosterone levels also has clinical implications.

What do you think will help solve the conundrum of frontline practitioners regularly having to address (common and uncommon) metabolic conditions and disorders that they do not know how to treat or even in some cases properly diagnose? 
Dr. Urquhart: Referral times into endocrine practices is somewhere around 3-5 months and some practices not accepting new patients. When I founded MEDS, the mission and vision was and still is to educate and equip our PCP colleagues to become more familiar and comfortable addressing metabolic and endocrine diseases. By doing so, we can avoid any unnecessary referrals that can be accurately evaluated in PCP clinics.

What are some pearls from your presentation The What When How and Why of Adrenal Insufficiency? How about your presentation, Hot Topics in Hyperthyroidism?
Ashlyn Smith:
Adrenal insufficiency: Adrenal disorders are enigmatic and the identification and workup are of particular challenge in endocrinology. The most important points to leave MEDS with are knowing who and how to appropriately screen for adrenal insufficiency so as to not miss one of the only endocrine disorders that is truly life-threatening. In addition, we now have a slew of misinformation propagated about adrenal insufficiency and the so-called “adrenal fatigue.” We will talk about hands-on practical tips to navigate this conversation with patients. 
Hyperthyroidism: HYPERthyroidism is more complex than HYPOthyroidism in its many root causes and potential adverse effects. This can leave the primary care provider burdened with navigating a complicated array of tests to identify the underlying causes. The most crucial aspects of the hyperthyroidism evaluation are identifying those at risk for developing the condition and the judicious use of diagnostic testing to balance getting the necessary information without burdening our patients with unnecessary tests. 

A topic you’ve published on is long-acting gut peptide glucagon-like peptide-1 (GLP-1) and its role in type 2 diabetes management. What are some practical considerations for clinical practice? 
Amy Butts:
GLP1 RA target 6 out of the 8 defects that we see in type 2 diabetes. Although not indicated, the secondary benefit is weight loss and no hypoglycemia unless used with insulin or sulfonylurea. New research has shown benefit in reducing cardiovascular risk, reducing stroke, and kidney safety and benefit. Not all GLP1 RAs have proven this benefit. Therefore, you need to know which GLP1 RAs have the updated indications. This class has changed the way we have managed type 2 diabetes. It has delayed the need for insulin therapy.

Can you share takeaways from your MEDS presentations, Pituitary Adenomas and Incidentalomas?, and Adrenal Adenomas and Incidentalomas?
Justine Herndon:
My main point for both of these presentations is this: Do not ignore these incidentalomas! There is a specific work-up that is needed regardless if it is a benign lesion (as statistically speaking, most of what we find are benign). However, missing a hormonal hyper- or hypo-secretion, or in the rare instance the malignant tumor, increases morbidity and mortality in patients. A lot of patients may have subclinical disease as well; therefore, the appropriate screenings could help you capture that.
-Pituitary Adenomas and Incidentalomas: 

  • Prolactinomas are the most common tumor you will encounter, but keep in mind the large differential diagnosis for hyperprolactinemia, therefore a detailed history and physical exam is important.
  • Always treat a patient with hypopituitarism with cortisol first
  • Screen all pituitary adenomas for acromegaly with an IGF-1

-Adrenal Adenomas and Incidentalomas: 

  • Hounsfield units are your friend, and please ask your radiologist to add Hounsfield units from the unenhanced images to the report if they hadn’t done so. 
  • Hounsfield units < 10 – no need to screen for pheochromocytoma
  • Screen more hypertensive patients, even without a known adrenal mass, for primary hyperaldosteronism.

What is some advice that has helped you in your career? 
Ashlyn Smith:
It is ok to not know the answer. Medicine advances so quickly that it is impossible to know it all. Clinicians must feel comfortable admitting their own limitations and then doing their best to bridge that gap. To do otherwise would compromise patient care. Additionally, patients appreciate when their providers are honest and willing to grow.

In looking at endoscopic versus microscopic techniques in pituitary tumor surgery in another of your recent publications, what did you and your colleagues conclude? 
Justine Herndon:
Both surgical techniques are effective, risks associated with each operation were low, and, specifically, the incidence of hypopituitarism was similar in both groups. There are pros to each approach in different aspects, however – microscopic surgery was shorter and less costly, and endoscopic surgery had fewer subsequent treatments needed as volumetric resection was slightly higher. Experienced surgeons are important when it comes to pituitary surgery, and the positive outcomes from this study reinforce that. 

What are some pearls or takeaways you’ll be sharing in your presentations on Cushing syndrome and thyroid nodules at the 13th Annual Metabolic and Endocrine Disease Summit Summer?
Dr. Urquhart:
For Cushing’s: work-up for high index and low index suspicion cases and when to refer. For thyroid nodules: These are very common in adults. Key takeaway for this session is understanding nodule(s) size and characteristics recommendations for fine needle aspiration and those that require ongoing surveillance and when referral is necessary. 

 

 

MEDS Summit Fall 2022! – Daily 4 Wrap-up!

—by Colleen Hutchinson

Welcome to the wrap-up of Day 4 of the Metabolic and Endocrine Disease Summit Fall! If you’ve missed the majority of the MEDS presentations, don’t fear—you can access them all online right here. Just click and register and then enjoy watching the panels, On the Spot forums, and more where you want, when you want. As faculty stated, MEDS brings you critical CME on a wide range of topics in one place—“MEDS is the most clinically relevant endocrine CME available.” Don’t miss it!

Faculty Rick Pope, who will present today twice, remarked about the value of the MEDS Summit: “So many great speakers and updated guidelines. Weighing Options in Obesity will be a session I want to see. Easy to lose, hard to maintain lost weight. I want the inside medical picture.”

Some critical advice Rick will share on Day 4 in his presentations Part I Osteoporosis: Who We Screen, Who We Test, and Current Recommendations for Therapy:

  • There are medically approved, easy and familiar medications that, when sequenced correctly, can dramatically improve bone density and fracture risk. 
  • With the new drug pipeline tied off for the moment, learn what you can do to stop the tidal wave of falls and fractures that continues to affect millions of people.

Rick also shared a few focus points he will discuss in depth at today’s upcoming presentation, Part II: Case Studies in Osteoporosis: 

  • Beware the wrist fracture
  • What steps do you need to take now if your patient comes off denosumab?
  • What do we do with patients on long-term bisphosponate therapy, the drug holiday, and when is it time to restart?

Session VII Endocrine Part 2 brings us a focus on osteoporosis and a panel following composed of Scott Urquhart, Moderator and MEDS Chair, and Rick Pope. 

Attendees will interact with Scott and Rick during the Conference Wrap-Up in the Clinical Knowledge Session. Bring your questions!

We hope you enjoyed Day 3’s Session IV on Lipids and Cardiovascular Risk Management: Current Guidelines and Therapies from Joyce Ross, and Diagnosis and Management of Resistant Hypertension presented by Wendy Wright, as well as Session V: Obesity Management, which included Christine Kessler’s talk on Obesity Care and Management in the Cardio-Metabolic Patient and Weighing the Options in Obesity: Case Presentations. If you missed these panels, they can be accessed here.

Registering for the MEDS Summit online is the best way to access the most current research and clinical and practice pearls on new treatment options in metabolic disorders all in one place. And if attending virtually today, you can still interact with colleagues via the following:

  • Visit booths in the Exhibit Hall (in person or virtually if you so wish!)
  • Engage in peer-to-peer learning in the Poster Hall
  • Network with other dermatology specialists and practitioners 
  • Access the virtual platform for on-demand access

Register now to learn more about the most critical advances in diagnosis and treatment of metabolic diseases and conditions—and how to utilize them. To access all of this and more MEDS online from the comfort of your own office or home and catch up on what you’ve missed!

—by Colleen Hutchinson

 

MEDS Summit Fall 2022! – Daily 3

—by Colleen Hutchinson

Welcome to Day 3 of the 13th Annual Metabolic and Endocrine Disease Summit Fall! Day 3 brings us three sessions: Session IV on Cardiovascular Disease Risk Reduction, Session V on Obesity Management, and Session VI on Metabolic Disorders. These presentations, case studies, and Q&A sessions can be attended in person or accessed virtually. This is critical CME on a wide range of topics in one place—as faculty Ashlyn Smith stated: “MEDS is the most clinically relevant endocrine CME available.” Don’t miss it!

Ashlyn Smith, who presented on Hot Topics in Hyperthyroidism and The What When How and Why of Adrenal Insufficiency, also spoke on unique aspects of the MEDS summit:
Seeing our colleagues from around the country in person to be able to delve even deeper into the endocrine topics on the MEDS agenda, including in-person Q&A, curbside consults, and the new Expert on the Spot sessions.” She added: PAs and NPs have always brought their questions and we really dive right in!”

And if attending virtually, you can still interact with colleagues beyond the educational sessions via the following:

  • Visit booths in the Exhibit Hall (in person or virtually if you so wish!)
  • Engage in peer-to-peer learning in the Poster Hall
  • Network with other dermatology specialists and practitioners 
  • Access the virtual platform for on-demand access. 

Session IV brings us Lipids and Cardiovascular Risk Management: Current Guidelines and Therapies from Joyce Ross, Diagnosis and Management of Resistant Hypertension presented by Wendy Wright. Don’t miss!

In Session V: Obesity Management, Christine Kessler covers Obesity Care and Management in the Cardio-Metabolic Patient and Weighing the Options in Obesity: Case Presentations. This is followed by a panel composed of Christine Kessler and David Doriguzzi. Bring your questions!

Ashlyn Smith presented twice on Day 1. If you missed it, register and check it out, and here are some pearls she shared in her talks:
Adrenal insufficiency: Adrenal disorders are enigmatic, and the identification and workup are of particular challenge in endocrinology. The most important points to leave MEDS with are knowing who and how to appropriately screen for adrenal insufficiency so as to not miss one of the only endocrine disorders that is truly life-threatening. In addition, we now have a slew of misinformation propagated about adrenal insufficiency and the so-called “adrenal fatigue.” We talked about hands-on practical tips to navigate this conversation with patients. 
Hyperthyroidism: HYPERthyroidism is more complex than HYPOthyroidism in its many root causes and potential adverse effects. This can leave the primary care provider burdened with navigating a complicated array of tests to identify the underlying causes. The most crucial aspects of the hyperthyroidism evaluation are identifying those at risk for developing the condition and the judicious use of diagnostic testing to balance getting the necessary information without burdening our patients with unnecessary tests. If the fasting target is met with basal insulin but A1C target is not met, utilize a CGM to assess post prandial excursions. 

Look for new treatment options in metabolic disorders to be shared in Session VI by Scott Urquhart, Moderator and Chair, Mimi Secor, and Kristen Ryland. Talks include Polycystic Ovary Syndrome Update: Common, Confusing and More Serious Than Ever and Not a Piece of Cake: A Comprehensive Review of Non-alcoholic Fatty Liver Disease.

Get current on emerging data in treatment of Diabetes, Obesity, Cushing’s Syndrome, PCOS, Osteoporosis, Hypercalcemia, and Thyroid Disease only at the MEDS Summit! Register now and capture Day 4 live and Days 1, 2, and 3 online!
Colleen Hutchinson

 

MEDS Summit Fall 2022! – Daily 2

—by Colleen Hutchinson

Welcome to Day 2 of the 13th Annual Metabolic and Endocrine Disease Summit Fall! Day 1 brought thought leaders from around the globe to present on the approach to both pituitary and adrenal adenomas and incidentalomas, adrenal insufficiency, Cushing Syndrome and disease, the latest on hypo- and hyperthyroidism, and thyroiditis and thyroid nodules. 
These sessions are available online for those registrants who missed it live yesterday. Faculty Justine Herndon, PA-C, who presented on Day 1, explained how the hybrid model meets everyone’s needs:

“There is a lot to be excited about at this MEDS Fall! In-person is always fun to meet faculty and attendees and network… But it’s also wonderful to have the option for livestream and be a part of the conference.” 
Having been on panels in MEDS before, she explained the panels are also critical opportunities to learn:
“We received A LOT of questions during the panels, which was great to see the engagement with the presentations in person and virtually.” So don’t miss them no matter where you are!

Faculty Amy Butts, who will present on Addressing Costs in Diabetes Treatment in Session 3 today, shared some pearls she will be presenting: 

  • The cost of diabetes medications has increased in price dramatically over the last several years. 
  • It is important to be an advocate for our patients. 
  • Utilizing patient assistance programs, copay cards for commercial insurance, and understanding the Medicare Savings Plan for our insulin patients is important to help with cost. 
  • If patients cannot afford their medications, they will not be compliant. 
  • You may need to ask them this question, as many patients are embarrassed to report this to the provider.

Scott Urquhart, Chair and Founder of the MEDS Summit, is here to give us the skinny on the meeting. When asked about new research and treatment to be learned at MEDS, he explained the take-home value for attendees:
“These topics will not only have new research included, but also up-to-date work-up and treatment guidance. Many of the topics are the more challenging endocrine disease states, so special attention is geared to help our attendees develop a pragmatic approach to work-up and when to refer.”

His presentation for Cushing’s focuses on work-up for high index and low index suspicion cases and when to refer. Take a look back at Day 1’s talk on thyroid nodules, as Urquhart states: “These are very common in adults. Key takeaway is understanding nodule(s) size and characteristics recommendations for fine needle aspiration and those that require ongoing surveillance and when referral is necessary.”

Amy Butts presents a second time today on Initiating Insulin: Why, When, and Which Types? Some pearls from this presentation include:

  • GLP1 RAs should be first injectable in patients with type 2 diabetes unless it is contraindicated or not tolerated. 
  • It is important not to delay intensification with basal insulin when the A1C target is not met to avoid microvascular complications. 
  • If the fasting target is met with basal insulin but A1C target is not met, utilize a CGM to assess post prandial excursions. 
  • When intensifying with prandial insulin, do it in a stepwise approach by adding prandial insulin to the main meal first. 
  • Prandial insulin with other meals may be added later if needed.

Day 2 also brings us Prediabetes and T2D Risk Factors, Screening, and Clinical Considerations from Lucia Novak, followed by Type 2 Diabetes-Harmonizing Glucose Management With Cardiovascular Disease, Heart Failure and Chronic Kidney Disease Risk Reduction: Case Presentations presented by both David Doriguzzi and Scott Urquhart.

Also on Day 2, attendees will hear on Diabetes Distress and Burnout from Donna Jornsay, and Adult-Onset Type 1 Diabetes: How do I Proceed… The Diabetes Sleuth, presented by Davida Kruger.

Look for new treatment options to be shared in Diabetic Kidney: New Guidelines and Clinical Applications from Kim Zuber.

If attending virtually, you can still interact with colleagues beyond the educational sessions via the following:

  • Visit booths in the Exhibit Hall (in person or virtually if you so wish!)
  • Engage in peer-to-peer learning in the Poster Hall
  • Network with other dermatology specialists and practitioners 
  • Access the virtual platform for on-demand access. 

Join us to learn more about the most critical advances in diagnosis and treatment of skin diseases—and how to utilize them. Register now online and capture Days 3 and 4 and whatever you’ve missed!
by Colleen Hutchinson

 

MEDS Summit Fall 2022! – Daily 1

—by Colleen Hutchinson

Welcome to the 13th Annual Metabolic and Endocrine Disease Summit Fall! What do you get from attending this Summit? Quite a bit! Thought leaders present on—and discuss in panels—critical insights on new research and treatments in diabetes, obesity, Cushing’s Syndrome, PCOS, osteoporosis, hypercalcemia, and thyroid disease. This year’s Summit includes presentations, case studies and Q&A sessions—all of which can be attended in person or virtually. 

Faculty Amy Butts, an Endocrinology Physician Assistant who serves as Vice President of the American Society of Endocrine Physician Assistants (ASEPA), presents on Day 2 and remarked about the value of MEDS: 

“I always enjoy the opportunity at MEDS to educate other PAs and NPs as well as learn from the entire faculty. It is a great opportunity to network with other likeminded PAs and NPs throughout the country.”

If attending virtually, you can interact with colleagues beyond the educational sessions via the following:

  • Visit booths in the Exhibit Hall (in person or virtually if you so wish!)
  • Engage in peer-to-peer learning in the Poster Hall
  • Network with other dermatology specialists and practitioners 
  • Access the virtual platform for on-demand access

Opening session presentations today include Pituitary: Approach to Adenomas and Incidentalomas and Adrenal: Approach to Adenomas and Incidentalomas from Justine Herndon, PA-C. Justine is an Assistant Professor of Medicine, Division of Endocrinology at Mayo Clinic, and shared a few pearls from her talk on Pituitary Adenomas and Incidentalomas:

  • Prolactinomas are the most common tumor you will encounter, but keep in mind the large differential diagnosis for hyperprolactinemia, therefore a detailed history and physical exam is important.
  • Always treat a patient with hypopituitarism with cortisol first
  • Screen all pituitary adenomas for acromegaly with an IGF-1

She also shares the following pearls from her second presentation on Adrenal Adenomas and Incidentalomas: 

  • Hounsfield units are your friend, and please ask your radiologist to add Hounsfield units from the unenhanced images to the report if they hadn’t done so. 
  • Hounsfield units < 10 – no need to screen for pheochromocytoma
  • Screen more hypertensive patients, even without a known adrenal mass, for primary hyperaldosteronism.

Attendees—Get current on hypo- and hyperthyroidism! Christine Kessler’s first presentation, Hypothyroidism Tips on Management, will be followed by Ashlyn Smith, MMS, PA-C, speaking on Hot Topics in Hyperthyroidism. Ashlyn also covers The What When How and Why of Adrenal Insufficiency in the same session.

Also on Day 1, Session I: Endocrine brings us MEDS Chair Scott Urquhart, PA-C, DFAAPA presenting on Cushing Syndrome/Disease. David Doriguzzi, PA-C, MPAS, gives a talk on Hot Topics in Thyroiditis, and Scott Urquhart rounds out this panel with Thyroid Nodules: Work-up, Surveillance, and Referral. Also, don’t miss the new feature event, On the Spot, hosted by Davida Kruger, MSN, APN-C, BC-ADM.

All of these topics are critical to keeping current on the latest research and practice pearls to take back to your patients. 

Join us to learn more about the most critical advances in diagnosis and treatment of these disease conditions covered at MEDS Summit 2022—You don't want to miss out!
Register now and capture Days 2, 3, and 4 and whatever you’ve missed today!
—by Colleen Hutchinson

 

September 2022

Hot Topics: Amy Butts Weighs in on the Upcoming MEDS Summit and More

Amy Butts, PA-C, DFAAPA, BC-ADM, CDCES is Endocrinology Physician Assistant, WVU Wheeling Hospital
Morgantown, West Virginia, and has been practicing endocrinology as a physician assistant for 20 years. Amy also serves as Vice President of the American Society of Endocrine Physician Assistants (ASEPA).

Introduction

Welcome back to MEDS eNews! This month Amy Butts, PA-C, DFAAPA, BC-ADM, CDCES, joins us. Amy is well known in the MEDS community, and she also serves as faculty at the recent MEDS Summit and upcoming Metabolic and Endocrine Disease Summit Fall. We discuss pearls from her presentation on Initiating Insulin: Why, When, and Which Types, a couple specific new advances in therapeutics, the problem with cost in diabetes treatments, and more. Amy is an Endocrinology Physician Assistant at WVU Wheeling Hospital in
Morgantown, WV, and has been practicing endocrinology as a physician assistant for 20 years. She also serves as Vice President of the American Society of Endocrine Physician Assistants (ASEPA). 
Following the interview is our Rapid Fire segment. Don’t miss it! 

 

Housekeeping: 

Metabolic and Endocrine Disease Summit Fall (13th Annual)

  • When: October 12-15, 2022—rapidly approaching!
  • Location: Lake Buena Vista, Florida
  • A hybrid event, you can register here to attend in person or virtually.
  • Will be the most up-to-date, clinically relevant information to assist you in the treatment of your patients with Diabetes, Obesity, Cushing’s Syndrome, PCOS, Osteoporosis, Hypercalcemia, and Thyroid Disease. 
  • Agenda to include presentations, case studies and Q & A sessions.
  • Register here: https://events.medscapelive.org/ereg/newreg.php?eventid=666538&language=eng

Thank you to Amy for her efforts here and also for her critical contribution as Medscape conference faculty. Please contact me at [email protected] with comments or suggestions. Thanks for reading!

Colleen Hutchinson

 

Catching Up with Thought Leader Amy Butts, PA-C, DFAAPA, BC-ADM, CDCES

A topic you speak on is addressing cost in diabetes treatments. What is/are the biggest problem(s) with regard to this problem and is/are there a solution(s)?
Amy Butts:
The cost of diabetes medications has increased in price dramatically over the last several years. It is important to be an advocate for our patients. Utilizing patient assistance programs, copay cards for commercial insurance, and understanding the Medicare Savings Plan for our insulin patients is important to help with cost. If patients cannot afford their medications, they will not be compliant. You may need to ask them this question. Many patients are embarrassed to report this to the provider.

What are you most excited about in research and development that will help improve treatment options and outcomes?
Amy Butts:
Technology like CGMs, those that integrate with automated insulin delivery devices and smart pens, have allowed a more precise insulin delivery to the patient. The novel GLP1 RA/GIP MounjaroTM medication from Lilly is also new and exciting.

What do you most look forward to at the upcoming hybrid 13th Annual Metabolic and Endocrine Disease Summit Fall?
Amy Butts:
I always enjoy the opportunity to educate other PAs and NPs as well as learn from the entire faculty. It is a great opportunity to network with other likeminded PAs and NPs throughout the country.

From July’s MEDS Summit Summer, can you give us a few takeaways from your talk on Initiating Insulin: Why, When, and Which Types?
Amy Butts: GLP1 RAs should be first injectable in patients with type 2 diabetes unless it is contraindicated or not tolerated. It is important not to delay intensification with basal insulin when the A1C target is not met to avoid microvascular complications. If the fasting target is met with basal insulin but A1C target is not met, utilize a CGM to assess post prandial excursions. When intensifying with prandial insulin, do it in a stepwise approach by adding prandial insulin to the main meal first. Prandial insulin with other meals may be added later if needed.

A topic you’ve published on is long-acting gut peptide glucagon-like peptide-1 (GLP-1) and its role in type 2 diabetes management. What are some practical considerations for clinical practice? 
Amy Butts:
GLP1 RA target 6 out of the 8 defects that we see in type 2 diabetes. Although not indicated, the secondary benefit is weight loss and no hypoglycemia unless used with insulin or sulfonylurea. New research has shown benefit in reducing cardiovascular risk, reducing stroke, and kidney safety and benefit. Not all GLP1 RAs have proven this benefit. Therefore, you need to know which GLP1 RAs have the updated indications. This class has changed the way we have managed type 2 diabetes. It has delayed the need for insulin therapy.

 

Rapid Fire with Amy Butts:

Most critical new advance in endocrinology

Technology with CGM integration with pumps and smart delivery devices

Advice that has helped in my career

Listen!!! Most of your diagnosis comes from your history

Best tool in my clinical arsenal

CGM

Women in academia in my area of medicine

Davida Kruger, Lucia Novak, Ashlyn Smith

What I wish the patient would remember

You haven’t failed until you quit trying

Where I go for continuing education

Endo Society, ADA, AACE, Medscape, POCN

My mentor

Dr. Sean Nolan

Biggest challenge for me and my colleagues

Balancing life

 

 

August 2022

Hot Topics: Justine S. Herndon, PA-C, Weighs in on the Upcoming MEDS Summit and More

Justine S. Herndon PA-C, is an Assistant Professor of Medicine in the Department of Medicine, Division of Endocrinology at Mayo Clinic and the Clinical Co-Director of Evaluation at the Mayo Clinic PA Program, Mayo Clinic, Rochester, Minnesota.

Introduction

Welcome back to MEDS eNews! This month Justine Herndon, PA-C, joins us. Justine is a well known thought leader in the MEDS community, and she also serves as faculty at the recent MEDS Summit and upcoming Metabolic and Endocrine Disease Summit Fall. We discuss pearls from her presentations on Pituitary and Adrenal Adenomas and Incidentalomas, new advances in diagnostics and therapeutics, the conundrum of frontline practitioners having to address (metabolic conditions, the role of the nurse practitioner and the role of exercise in combating the obesity epidemic, and more. Justine is an Assistant Professor of Medicine in the Department of Medicine, Division of Endocrinology at Mayo Clinic and the Clinical Co-Director of Evaluation at the Mayo Clinic PA Program, Mayo Clinic, in Rochester, Minnesota. 
Following the interview is our Rapid Fire segment. Don’t miss that or Justine’s KOL Suggested Reading—a not-to-be-missed in-depth review of adrenal incidentalomas.

 
Housekeeping: 

Metabolic and Endocrine Disease Summit Fall (13th Annual)

  • When: October 12-15, 2022—rapidly approaching!
  • Location: Lake Buena Vista, Florida
  • A hybrid event, you can register here to attend in person or virtually.
  • Will be the most up-to-date, clinically relevant information to assist you in the treatment of your patients with Diabetes, Obesity, Cushing’s Syndrome, PCOS, Osteoporosis, Hypercalcemia, and Thyroid Disease. 
  • Agenda to include presentations, case studies and Q & A sessions.
  • Register here: https://events.medscapelive.org/ereg/newreg.php?eventid=666538&language=eng

Thank you to Justine for her efforts here and also for her critical contribution as Medscape conference faculty. Please contact me at [email protected] with comments or suggestions. Thanks for reading!

Colleen Hutchinson

 

Catching Up with Thought Leader Justine Herndon, PA-C

What do you most look forward to at the upcoming hybrid 13th Annual Metabolic and Endocrine Disease Summit Fall?
Justine Herndon:
There is a lot to be excited about the upcoming MEDS Fall conference! In-person is always fun to meet faculty and attendees, network, etc, but still wonderful to have the option for livestream and be a part of the conference. We received A LOT of questions during the summer conference, which was great to see the engagement with the presentations in person and virtually. 

From July’s Metabolic and Endocrine Disease Summit Summer, can you give us a few takeaways from your presentations on Pituitary Adenomas and Incidentalomas?, and Adrenal Adenomas and Incidentalomas?
Justine Herndon:
My main point for both of these presentations is this: Do not ignore these incidentalomas! There is a specific work-up that is needed regardless if it is a benign lesion (as statistically speaking, most of what we find are benign). However, missing a hormonal hyper- or hypo-secretion, or in the rare instance the malignant tumor, increases morbidity and mortality in patients. A lot of patients may have subclinical disease as well; therefore, the appropriate screenings could help you capture that.

-Pituitary Adenomas and Incidentalomas: 

  • Prolactinomas are the most common tumor you will encounter, but keep in mind the large differential diagnosis for hyperprolactinemia, therefore a detailed history and physical exam is important.
  • Always treat a patient with hypopituitarism with cortisol first
  • Screen all pituitary adenomas for acromegaly with an IGF-1

-Adrenal Adenomas and Incidentalomas: 

  • Hounsfield units are your friend, and please ask your radiologist to add Hounsfield units from the unenhanced images to the report if they hadn’t done so. 
  • Hounsfield units < 10 – no need to screen for pheochromocytoma
  • Screen more hypertensive patients, even without a known adrenal mass, for primary hyperaldosteronism.

Is there anything new in research that you think will help improve treatment and outcomes for your patients?
Justine Herndon:
I enjoyed reading the article, “Opioids and pituitary function: Expert opinion” by Gadelha et al in Pituitary about the effects of opioids on pituitary function, bringing more awareness to what we need to watch for in patients on chronic opioid therapy. (Article can be found on PubMed here.)

What were your main findings in your 2021 publication, “The Effect of Curative Treatment on Hyperglycemia in Patients With Cushing Syndrome”?
Justine Herndon:
The majority of patients with Cushing syndrome (two-thirds) will show improvement in hyperglycemia, whether that be improvement in A1c and/or reducing the number of medication/dosages they take for diabetes. This was shown to be statistically more likely in patients with more severe Cushing’s and those with ACTH-dependent Cushing’s. This highlights the need for close follow-up of diabetes in patients who are cured, especially within the first year, as their treatments will likely require adjustments.

In looking at endoscopic versus microscopic techniques in pituitary tumor surgery in another of your recent publications, what did you and your colleagues conclude? 
Justine Herndon:
Both surgical techniques are effective, risks associated with each operation were low, and, specifically, the incidence of hypopituitarism was similar in both groups. There are pros to each approach in different aspects, however – microscopic surgery was shorter and less costly, and endoscopic surgery had fewer subsequent treatments needed as volumetric resection was slightly higher. Experienced surgeons are important when it comes to pituitary surgery, and the positive outcomes from this study reinforce that. 

 

Rapid Fire with Justine Herndon:

Most critical new advance in endocrinology

There are many to list here. Specifically for pituitary/adrenal disorders, glucocorticoid withdrawal symptom management.

Advice that has helped in my career

Keep asking questions. Many of my research projects have come from asking a question and not finding a lot of help/answers in the literature.

Best tool in my clinical arsenal

Listening. Even when I have been unable to offer any help from the endocrinology perspective, patients have shared their thanks for allowing the time to share their story and concerns.

Women in academia in my area of medicine

Wow, so many – how many pages do I get to list them all out?

What I wish the patient would remember

Please set up an appointment if you call or send an online message with multiple questions – that will be the best utilization of time on both sides.

Biggest challenge for me and my colleagues

Lack of time with patients, especially with complex medical conditions.

 

Thought Leader Suggested Reading:

Article: Approach to the Patient With Adrenal Incidentaloma. Bancos I and Prete A. J Clin Endocrinol Metab 2021 Oct 21;106(11):3331-3353. Found here: https://pubmed.ncbi.nlm.nih.gov/34260734/

Justine Herndon: This is an excellent, in-depth review of adrenal incidentalomas with a detailed breakdown of work-up, imaging characteristics, and different management strategies – everything I wish I could fit into a 45-minute presentation but cannot.
 

 

July 2022

Hot Topics with Ashlyn Smith, MMS, PA-C

Ashlyn Smith has practiced adult endocrinology in Phoenix, Arizona, since 2013 after practicing in internal medicine and pediatric endocrinology. She currently serves as President on the board of directors for the American Society of Endocrine Physician Assistants and is Adjunct Assistant Professor at Midwestern University in Glendale, Arizona. 

Welcome back to MEDS eNews! We are back in your inbox this month with an interview with Ashlyn Smith, MMS, PA-C, a well known and respected thought leader in the MEDS community, and faculty at the recent MEDS summit and other conferences. Ashlyn and I discuss a number of topics, including pearls from her presentations on The What When How and Why of Adrenal Insufficiency and Hot Topics in Hyperthyroidism, new advances in diagnostics and therapeutics, the conundrum of frontline practitioners having to address (metabolic conditions, the role of the nurse practitioner and the role of exercise in combating the obesity epidemic, and more. Ashlyn is an Adult Endocrine Physician Assistant, and Adjunct Assistant Professor, Midwestern University, Scottsdale, Arizona. She is also the President of the American Society of Endocrine Physician Assistants. 
Following the interview is our Rapid Fire segment in which Mimi shares the most critical new advance in this area of medicine, the advice that has most helped in her career, women in academia, best tool in her clinical arsenal, and more. Read on for more!

Presented hybrid this year, with the recent MEDS summit being live streamed and recorded, you can register and access it here. #MEDSsummer22 addressed the most relevant topics in #metabolic and #endocrine to improve outcomes. The four-day meeting featured a cutting edge agenda, bonus presentations, and a NEW Expert on the Spot forum, where in-person attendees can connect, network, and discuss conference topics with select faculty in an intimate small group setting. Get familiar with emerging data around Diabetes, Obesity, Cushing’s Syndrome, PCOS, Osteoporosis, Hypercalcemia, and Thyroid Disease!

Thank you to Ashlyn Smith for her time and her critical contribution as Medscape conference faculty. Please contact me at [email protected] with comments or suggestions. Thanks for reading!

—Colleen Hutchinson

 

What are some pearls or takeaways shared in your presentation on the Endocrine panel on The What When How and Why of Adrenal Insufficiency at the 13th Annual Metabolic and Endocrine Disease Summit Summer? How about your presentation, Hot Topics in Hyperthyroidism?
Ashlyn Smith: Adrenal insufficiency: Adrenal disorders are enigmatic and the identification and workup are of particular challenge in endocrinology. The most important points to leave MEDS with are knowing who and how to appropriately screen for adrenal insufficiency so as to not miss one of the only endocrine disorders that is truly life-threatening. In addition, we now have a slew of misinformation propagated about adrenal insufficiency and the so-called “adrenal fatigue.” We will talk about hands-on practical tips to navigate this conversation with patients. 
Hyperthyroidism: HYPERthyroidism is more complex than HYPOthyroidism in its many root causes and potential adverse effects. This can leave the primary care provider burdened with navigating a complicated array of tests to identify the underlying causes. The most crucial aspects of the hyperthyroidism evaluation is identifying those at risk for developing the condition and the judicious use of diagnostic testing to balance getting the necessary information without burdening our patients with unnecessary tests. 

Is there anything new or on the horizon in research and development that you think will help improve treatment options and patient outcomes?
Ashlyn Smith: There is some interesting research about the effects of COVID-19 and the emergence of adrenal insufficiency, both short- and long-term, primary and secondary, positive and negative autoimmunity. However, the jury is still out as to the true link between COVID-19 and adrenal insufficiency. 

What do you think will help solve the conundrum of frontline practitioners regularly having to address (common and uncommon) metabolic conditions and disorders that they do not know how to treat or even in some cases properly diagnose? 
Ashlyn Smith: Lack of time is the major limiting factor for frontline providers. Short clinic visits and packed schedules make it difficult to manage the complexities of diagnosing, educating patients, and managing chronic medical conditions such as metabolic disorders. Furthermore, the increasing sub-specialization of medicine make this task all the more difficult. At MEDS, we strive to give providers clinically relevant pearls and tips to be able to make realistic and meaningful changes in patient care within their busy clinic settings.  

How would you characterize both the role of the nurse practitioner and the role of exercise in combating the obesity epidemic?
Ashlyn Smith: PAs and NPs play a critical role in combating the obesity epidemic. Obesity affects many areas of medicine, including endocrinology/diabetology, orthopedics, sleep medicine, psychiatry and more. PAs and NPs can “subspecialize” in obesity medicine in a manner of speaking, making their role the cornerstone for weight management in their practice or facility. This is a great opportunity for PAs and NPs to showcase leadership skills and optimal patient care.

What were you looking forward to at the MEDS summit?
Ashlyn Smith: Seeing our colleagues from around the country in person to be able to delve even deeper into the endocrine topics on the MEDS agenda, including in-person Q&A, curbside consults, and the new Expert on the Spot sessions. PAs and NPs brought their questions and we really dove in!

 

Rapid Fire with Ashlyn Smith, MMS, PA-C:

Most critical new advance in my area of medicine: Pharmacogenomics is the new frontier in medicine, which will help providers curate a personalized medication regimen based on a person’s genetic profile. This will help limit medication intolerances, reduce non-adherence, and improve long-term outcomes for chronic medical conditions.

Where I go for continuing education: MEDS is the most clinically-relevant endocrine CME available. UpToDate is another great source of current medical updates and we gain CME by reviewing content. DANATech is a great source of current and emerging DM tech information. I also love the ADA website for all things diabetes, from the nuts and bolts of the newest guidelines to concurrently caring for our patients' mental health and DM. 

My mentor: My wonderful colleagues who, by example, push me to be the most current and well-rounded clinician possible. 

Advice that has helped in my career: It is ok to not know the answer. Medicine advances so quickly that it is impossible to know it all. Clinicians must feel comfortable admitting their own limitations and then doing their best to bridge that gap. To do otherwise would compromise patient care. Additionally, patients appreciate when their providers are honest and willing to grow.

Best tool in my clinical arsenal: Empathy. Even on the most stressful days when burnout is at its peak, it is essential to remember that the person sitting across from you in the exam room has expectations, fears, hopes, and more. Tapping into my humanity helps cut through the stress and lack of time and connect with my patients to provide the best care possible. 

Women in academia in my area of medicine: Notable mentions are PAs Ellen Mendel, Courtney Bennet Wilke, and Eve Hoover.
What I wish the patient would remember: The best outcomes come when provider and patient partner together on the course of treatment. 

Biggest challenge for me and my colleagues: Lack of time is such a pervasive problem in medicine. Recently, misinformation has become an additional challenge after someone “researches” their problem with information that may or may not be accurate online or from their peers. Then the clinician is faced with undoing the misinformation before re-educating patients with the correct information.  
 

Relevant disclosures:
Xeris Pharmaceuticals: Speaker’s Bureau
Sanofi: Advisor
Radius Health: Advisor

 

 

June 2022

Medscape MEDS E-News: Special Edition with Scott Urquhart, PA-C, DFAAPA

Scott Urquhart is Founder and Chair of the Metabolic and Endocrine Disease Summit (MEDS), and Adjunct Clinical Professor, James Madison University PA Program, Clinical Instructor, George Washington University PA Program, Diabetes and Thyroid Associates, Fredericksburg, Virginia.

It’s a Special Edition here of MEDS eNews in your inbox! Scott Urquhart, Chair and Founder of the upcoming 13th Annual Metabolic and Endocrine Disease Summit Summer—#MEDSsummer22, is here to give us the skinny on the meeting, which is in a few short weeks from July 13th to 16th, in Newport Beach, California. You’ll want to attend in person or virtually once you read this, so if you haven’t already signed up, register here. Read on for some meeting tidbits and a Rapid Fire segment with Scott! 

You can check out the agenda and register for the upcoming summit here. Presented hybrid this year, can attend live at the Renaissance Newport Beach or virtually with the conference being livestreamed. #MEDSsummer22 features a cutting edge agenda, bonus presentations, and a NEW Expert on the Spot forum, where in-person attendees connect, network, and discuss conference topics with faculty in an intimate small group setting. One faculty member will meet with five conference attendees in 15-minute intervals in one-hour time blocks. Don’t miss it—reserve your spot now!

Be the first to know emerging data around Diabetes, Obesity, Cushing’s Syndrome, PCOS, Osteoporosis, Hypercalcemia, and Thyroid Disease. Only at #MEDSsummer22! Thanks for reading, and hope to see you online or in person in Newport Beach on July 13!—Colleen Hutchinson

 
What are some pearls or takeaways you’ll be sharing in your presentations on Cushing syndrome and thyroid nodules at the 13th Annual Metabolic and Endocrine Disease Summit Summer?
Dr. Urquhart:
Well, for Cushing’s: work-up for high index and low index suspicion cases and when to refer.
Thyroid nodules: These are very common in adults. Key takeaway for this session is understanding nodule(s) size and characteristics recommendations for fine needle aspiration and those that require ongoing surveillance and when referral is necessary. 

Can you tell us a little bit about Session IV: Cardiovascular Disease Risk Reduction?
Dr. Urquhart:
Utilizing multiple patient cases, this session will cover important non-glycemic considerations (ASCVD, CKD, HF) when treating patients with T2D.

All of Session 1 is comprised of Endocrine Parts 1, 2, and 3, and you chair Session 7 Endocrine Part 4. Is there a lot in the way of new research and treatment to be learned?
Dr. Urquhart:
Yes, these topics will not only have new research included but also up to date work-up and treatment guidance. Many of the topics in these sessions are the more challenging endocrine disease states so special attention is geared to helping our attendees develop a pragmatic approach to work-up and when to refer.

What other presentations do you think attendees will find particularly valuable to hear?
Dr. Urquhart:
This year’s agenda like all others over the past 12 years will be very pertinent and comprehensive. We have included other sessions such Non-alcoholic fatty liver disease and the initial approach to resistant hypertension in the primary care setting.

What do you most look forward to at this meeting?
Dr. Urquhart:
For me, finally returning to the live in-person format while simultaneously providing a virtual platform!

What do you think will help solve the conundrum of frontline practitioners regularly having to address (common and uncommon) metabolic conditions and disorders that they do not know how to treat or even in some cases properly diagnose? 
Dr. Urquhart: Referral times into endocrine practices is somewhere around 3-5 months and some practices not accepting new patients. When I founded MEDS, the mission and vision was and still is to educate and equip our PCP colleagues to become more familiar and comfortable addressing metabolic and endocrine diseases. By doing so, we can avoid any unnecessary referrals that can be accurately evaluated in PCP clinics

 
Rapid Fire with Scott Urquhart:

Most critical new advance in my area of medicine: Many new advances in medication recently and in the near future. I would say diabetes technology, continuous glucose monitoring stand-alone and sensor augmented insulin pump delivery systems.

Where I go for continuing education: Preferably for me, live in person events and early during the pandemic it was virtual meetings.

My mentor: I have had many incredible mentors just prior to entering PA school and then about 5 strong encouraging mentors early in my career. Each of the spoke wisdom, encouragement, and challenged me to strive for excellence in medicine and patient care.  

Advice that has helped in my career: Early in my career when I was practicing Internal Medicine, my mentors said learn as much as you can from each and every patient case.  If you don’t know the disease state very well, go home and read it that evening.  If you refer a patient to a specialist, make sure you read the entire consult note from the specialist.  

Best tool in my clinical arsenal: 
“My brain” if you will.  Not only for gaining and retaining medical knowledge but for continuing to refine it for the strong empathetic communication required for “healthcare.”

What I wish the patient would remember ( or just understand):  Most of the things I have told and taught them.  That the practice of medicine has changed significantly over the past 10 years and this has created much higher workloads for clinicians.  So please be forgiving and understanding if we are running behind in our daily patient schedules while trying to give 100% of all we have in a somewhat time-limited patient visit.

Biggest challenge for me and my colleagues: Addressing the volumes of patients that need to be seen in a timely manner. Also knowing and experiencing first-hand the number of colleagues that have left the medical profession from burn-out – especially in the past 2 years.  This is true in specialty settings and now even more so in PCP clinics.

 

June 2022

Hot Topics with Mimi Secor, DNP, FNP-BC, FAANP, FAAN

Welcome back to MEDS eNews! After a brief hiatus, we are back in your inbox this month! Mimi Secor, well known thought leader in the MEDS community and faculty at the upcoming MEDS summit—#MEDSsummer22, gives us some time and shares her thoughts on new advances in diagnostics and therapeutics, what’s cutting edge right now in MEDS, the role of the nurse practitioner and the role of exercise in combating the obesity epidemic, the microbiome, and what promises to be highlights of the upcoming 13th Annual Metabolic and Endocrine Disease Summit Summer. Mimi is Senior Faculty, Advance Practice Education Associates, in Onset, Massachusetts. Following this interview, we have a new Rapid Fire segment in which Mimi shares the most critical new advance in this area of medicine, the advice that has most helped in her career, biggest challenge for herself and colleagues, and best tool in her clinical arsenal. And don’t miss the new Suggested Reading as well to top it off. Read on for more!

You can check out the agenda and register for the upcoming 13th Annual Metabolic and Endocrine Disease Summit Summer, July 13 to 16, in Newport Beach, California. Presented hybrid this year, you will have the option of attending live at the Renaissance Newport Beach or virtually with the conference being live streamed. #MEDSsummer22 addresses the most relevant topics in #metabolic and #endocrine to improve outcomes. The four-day meeting features a cutting edge agenda, bonus presentations, and a NEW Expert on the Spot forum, where in-person attendees can connect, network, and discuss conference topics with select faculty in an intimate small group setting. One faculty member will meet with five conference attendees in 15-minute intervals in one-hour time blocks. Don’t miss it—reserve your spot now!

Be the first to know emerging data around Diabetes, Obesity, Cushing’s Syndrome, PCOS, Osteoporosis, Hypercalcemia, and Thyroid Disease. Only at #MEDSsummer22.

Thank you to Mimi Secor for her time and her critical contribution as Medscape conference faculty. Please contact me at [email protected] with comments or suggestions. Thanks for reading!—Colleen Hutchinson

 
Mimi, what do you most look forward to at this meeting? 
Response:
 Interacting with attendees and the faculty. This meeting is unique in that the faculty enjoy listening to each other and engaging in conversations relative to each other’s presentations. This rarely happens at other professional NP or PA meetings.

Mimi, what are some pearls or takeaways from your presentation on the Metabolic Disorders panel on Polycystic Ovary Syndrome (PCOS) Update: Common, Confusing and More Serious Than Ever at the 13th Annual Metabolic and Endocrine Disease Summit Summer?
Response: Polycystic Ovary Syndrome (PCOS) is a common, complex, and fascinating reproductive endocrine condition that involves an increasingly complex differential. The pathophysiology is also complex, and clinicians must understand this to appreciate the underlying rationale for treatment options.

Is there anything new or on the horizon in research and development that you think will help improve treatment options and patient outcomes?
Response:
 The discovery that PCOS is associated with insulin resistance is a game changer that impacts treatment approaches. The inverse relationship between insulin resistance and testosterone levels also has clinical implications. 

How would you characterize both the role of the nurse practitioner and the role of exercise in combating the obesity epidemic? 
Response:
The nurse practitioner’s role is essential in educating, counseling, and coaching the patient on lifestyle changes that will positively impact the patient with PCOS. Unfortunately, exercise plays a relatively minimal role in contributing to weight loss; however, the impact of exercise on insulin resistance is very positive and should be encouraged. 

We hear a lot now about the microbiome and its effects in all aspects of medicine. How would you characterize the role of the microbiome as it pertains to your patient base?
Response:
 Elevated testosterone associated with PCOS has been recently linked to a less diverse microbiome. The clinical implications are not well understood but ongoing research is being conducted. This is a fascinating and timely topic!

 

Rapid Fire:

Most critical new advance in my area of medicine: The pathophysiologic complexity of PCOS particularly the Gut microbiome research. 
Where I go for continuing education: Various NP conferences. 
My mentor: I’ve had many including Dr Loreta Ford, the cofounder of the NP Profession. 
Advice that has helped in my career: Keep learning and find mentors to work with. 
Best tool in my clinical arsenal: Listening to the patient and taking an active role as a health coach to help patients make meaningful lifestyle changes. 
Female practitioners in my area of medicine: there are many. 
What I wish the patient would remember: That only one problem should be addressed with each appointment. 
Biggest challenge for me and my colleagues: Dealing with the shorter appointments while patients seem to be increasingly complex. 

 
Suggested Reading

Article: Gut and Vaginal Microbiomes in PCOS: Implications for Women's Health. Gu Y, Zhou G, Zhou F, et al. Frontiers in Endocrinology 2022:13;808508. 
https://pubmed.ncbi.nlm.nih.gov/35282446/ 

Mimi Secor: I recommend this article because it reviews our current understanding of the impact of the gut/vaginal microbiota on PCOS and vice versa. This is a new area of research with clinical implications for future innovative treatment of PCOS including such interventions as fecal transplantation. This research offers an intriguing perspective on our understanding of PCOS etiology, pathophysiology, and treatment. 

 

September 2021

Kim Zuber, PA-C 
By:  Ellen D. Mandel, DMH, MPA, PA-C, RDN

Just Measure the Albumin - Will Ya!

Kim Zuber will make you believe the kidney is the most important organ in the body.  Her passion for keeping the kidneys healthy, especially in the presence of diabetes is a key component of her lecture titled, “Diabetic Kidney Disease - Screening, Risk Factors, and Treatment,” which is on the agenda for the fall MEDS.  Kim, a MEDS faculty member since its inception has an uncanny ability to transform the complicated physiologic work of the kidney from cloudy to clear with real-life case studies and guideline reviews.

Considering the complexity of kidney disease, one might be surprised of Kim’s career path.  Kim was a Navy brat, living on military bases while her father worked as an engineer.  She cheekily recounts, with five daughters, “one of them had to be the engineer apprentice.”  She loved putting things together and had early exposure to tools, saws, and building.  However, her family received medical care from PAs, so she realized early on what PAs could do.  Following a teaching stint as a High School math and science teacher, she decided to go to PA school.  Her love of tools and putting things together helped her excel in orthopedics. Then the birth of her daughter caused a rapid shift in family life demands; Kim recounts: “I needed family friendly.”  Luckily, one of her surgical PA friends told her of a part-time job in a nephrology practice.  Kim realized how often kidney disease occurred in her ortho patients and “went out and bought a stethoscope” after many years of not owning one. 

Kim loves the MEDS attendees.  They bring interesting cases to her to assess. She really loves the dialogue and the opportunity to educate and learn from attendees.  She often gleans good cases from attendees – the give and take is the best part of MEDS.  She admits of all her nephrology meetings, MEDS is the best one for metabolic disorders.

One inquiry often rises to the top of the MEDS question list: when to refer a patient for kidney evaluation by a specialist.  Kim explains there is a massive shortage of nephrology clinicians now and sometimes patients are referred too early.  She will detail how referral makes good sense such as (1) when kidney function has diminished by 25% over six months, (2) BP cannot be controlled with three medications, or (3) if the eGFR is <30ml/min.  She emphatically states that she wants patients on SGLT2s now.  There are several new treatment guidelines for chronic kidney disease including FDA approved use of one of the SGLT2s for the treatment of kidney disease in patients WITHOUT diabetes! 

When asked to give one piece of advice to primary care clinicians she said, “I want them to order urinary albumin – this is the first marker for early kidney disease.” Beyond diabetes, measuring urinary albumin is beneficial in patients with hypertension, older age, history of nephrolithiasis or gout, or recurrent urinary tract infections. In other words, there are so many reasons to show me the albumin!

Kim has always felt the internal drive to give back as she packs food for Meals on Wheels 2 days/week. She has volunteered with the National Kidney Foundation since the early 2000s and was the 2003/2004 chair of the NKF/council of advanced practitioners.  

Join Kim as she filters out waste, leaving your knowledge crystal clear.  Kidney disease is serious, often asymptomatic and may be irreversible.  Kim will convince you to follow the albumin and provide excellent kidney care to your patients.
 

References:

1) Joint statement from the American Society of Nephrology and the National Kidney Foundation, March 9, 2020, https://www.asn-online.org/g/blast/files/NKF-ASN-eGFR-March2021.pdf, Accessed 9Mar2020.

2) United States Renal Data System. 2020 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2020.

3) Delgado C, Baweja M, Burrows NR, et al for the NKF/ASN Task Force on Race. Reassessing the Inclusion of Race in Diagnosing Kidney Diseases: An Interim Report from the NKF-ASN Task Force, AJKD (2021)

4) Center for Disease Control and Prevention. Chronic Kidney Disease in the United States, 2021, https://www.cdc.gov/kidneydisease/pdf/Chronic-Kidney-Disease-in-the-US-2021-h.pdf 

5) Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group. KDGIO 2020 Clinical Practice Guidelines for Diabetes Management in Chronic Kidney Disease. Kidney Int. 2020;98(4S):S1-S115.

6) Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group. KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int. 2021; 99(3S):S1-S87.

7) ASN and NKF form joint task force to focus on use of race in eGFR.  
https://www.kidney.org/newsletter/nkf-and-asn-form-joint-task-force-to-focus-use-race-egfr, Accessed 24Jun2021

8) Food and Drug Administration (2021). FDA Approves Treatment for Chronic Kidney Disease. U.S. Food and Drug Administration. https://www.fda.gov/news-events/press-announcements/fda-approves-treatment-chronic-kidney-disease

 

Joyce Ross, CRNP, CLS
By:  Ellen D. Mandel, DMH, PA-C, RDN

Lipids: Care Versus Cure is My Mantra

Joyce Ross, wife, mother of five children and grandmother of 13 has managed to climb the ladder of success to become the first ever NP to be President of the National Lipid Association in 2016.  She has accomplished this through grit and determination, along with a strong spiritual core of caregiving and volunteerism.  She claims being a bedside nurse was a great first step, however; her schooling to become an NP really “scratched her itch” to dig deeper into the growing area of lipid research and treatment.

Joyce joined the MEDS faculty early on and has been an integral part of educating attendees about the importance of lipid management in diabetes care.  She has presented on many new classes of lipid pharmaceutical interventions over the past ten years.  This fall she will be presenting on “CV Risk Reduction Beyond T2D CVOTs: Focus on Lipids.” However, what sets her lectures apart from others is her awareness of the family side of abnormalities from untreated lipid disorders.  The impact of lipid abnormalities really hit Joyce right in the heart as her husband has Familial Hypercholesterolemia (FH). He lost his parents from it early in life. According to the CDC website (https://www.cdc.gov/genomics/disease/fh/FH.htm), FH is a genetic disorder that affects about 1 in 250 people and increases the likelihood of having coronary heart disease at a younger age. People with FH have increased blood levels of low-density lipoprotein (LDL) cholesterol that requires far more than lifestyle change. It is genetic and therefore transmits to children of parents with FH requiring that statin therapy start in childhood, often by ages eight to ten.

As a nurse, Joyce embraces the whole patient and this patient care framework is welcomed at MEDS.  Her years working as a bedside nurse and then as an NP, allow her to apply her experiential wisdom supporting the power of teamwork.  She notes that NPs are not adjunct caregivers, but are first-class providers!  Collaborating with the MEDS faculty of PAs and NPs helped her to better understand their respective roles and educational value, and how these translate into improved patient care for the chronic condition of dyslipidemias. 

When it comes to diabetes and lipids, Joyce stresses that clinically nothing happens in isolation.  There may be an underlying genetic disorder worth investigating, but people with diabetes will often have elevated triglycerides (TG) due to diabetes’s physiology.  The diabetes must generally be in control in order for the TG to be lowered.  TGs are highly atherogenic and we now understand this contribution to cardiovascular disease.  Nutrition plays a big role in TG management, however; the diabetes will also need to be managed. Interestingly Joyce notes that while investigating what appears to be a lipid consultation, she has found concomitant diabetes or thyroid disease. “I can’t tell you how many patients I’ve diagnosed with diabetes when they were referred for high TG.”  Fortunately today, we now have new classes of medications that traverse several specialties such as endocrinology, cardiology, and lipid specialties. Of note, cardiovascular outcome trials are moving cardiologists out of their comfort zone to include diabetes in their assessment and treatment of cardiovascular risk factors.  This has taken a lot of hard work from clinicians like Joyce and provides more options for primary care clinicians to better manage these conditions in their patients.

In closing, Joyce’s lecture will reinforce clinicians need to pay more attention to the numbers explaining  “we now shoot for an LDL of <70 or even lower in the presence of cardiovascular disease and other risk factors.”  Joyce knows clinicians are not always able to keep up with the ever-changing guidelines and she will carefully outline them as well as update MEDS attendees on the latest research and medications to treat lipids as they relate to diabetes.  Since MEDS captures new providers, she’s looking forward to improved lipid management and caring for the entire patient; remember her mantra: care versus cure! 

 

References:

1)  Jacobson, T., Maki, K., PhD, Orringer, C., MD et al. On behalf of the NLA Expert Panel.  National Lipid Association Recommendations for Patient-centered Management of Dyslipidemia Part 2.  J Clin Lipidol. Nov-Dec 2015;9(6 Suppl):S1-122.e1. doi: 10.1016/j.jacl.2015.09.002. Epub 2015 Sep 18.

2) Michael H. Davidson (Editor), Peter P. Toth  (Editor), Kevin C. Maki (Editor) et al. Therapeutic Lipidology 2nd ed. 2021. Chapter 34. The Allied Professional’s Role in the Management of Dyslipidemia.

3) Grundy, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/M/ADA/AGS/ ACP/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary.  A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol.2019 Jun 25;73(24):3168-3209.  doi: 10.1016/j.jacc.2018.11.002. Epub 2018 Nov 10.

 

June 2021

Amy Butts PA-C, BC-ADM 
By:  Ellen D. Mandel DMH, MS, PA-C, RDN

Aesop’s Fable:  How Smart Insulin Pen Technology Wins the Race

MEDS welcomes Amy Butts PA, a talented and experienced clinician to its faculty ranks.  Amy has been an Endocrine PA for more than two decades and her passion for this clinical area precedes her PA education.  Amy credits her strong family history of both types 1 and 2 diabetes mellitus combined with a PA rotation scheduling glitch as the reason for her out-of-the-gate PA job.  As she explains, her cardiovascular rotation was canceled leaving her with an open rotation slot.  Being resourceful, she contacted the Endocrinologist with whom she had a previous rotation and secured more time with him.  Lucky for Amy and MEDS, she did such a great job; she was offered the position upon graduation.  She has a roster of over 4,000 patients now. Life is like that!

In addition to her employment, Amy applies her passion to improving diabetes patient care nationally with her American Diabetes Association (ADA) membership on their Primary Care Advisory Group and by serving on the Editorial Board for Clinical Diabetes.  Additionally, she is Education Committee Chair of the American Society of Endocrine PAs (ASEPA).  As with many MEDS faculty members, where does she find the time?
A love of technology drove her decision to become an insulin pump trainer early on.  She describes how she loves “pushing buttons and playing around” with devices.  This logically led to pioneering usage of smart insulin pen technology in her practice.  Amy will be discussing how to incorporate this technology as it becomes increasingly prevalent due to more companies securing FDA approval and as its use expands to children. 

Amy thinks there are many challenges with insulin delivery for people with diabetes (PWD) - missed doses, forgetting devices, and skipping meals. She notes that missing just two-mealtime injections/week can elevate A1c by 0.3% - 0.4%.  Further, bringing continuous glucose monitoring (CGM) into patient care and integrating it to smart insulin pen technology provides a vehicle for patients to understand how their behaviors impact their own glucose control.

Amy will be presenting with two other lecturers on the topic of “Diabetes Technology” for the July MEDS.  She will weave her philosophy of how patient empowerment builds essential trust and directly supports diabetes technology inclusion in her clinical practice.  With the application of CGM and smart insulin pen technology, an improved time in range (TIR) is attainable.  Amy notes, “We as a medical community have been taught and engaged with A1c, it is our ‘go to’ in evaluating patient control.  However, CGM has opened our eyes to how using only the A1c has limited our knowledge.” Amy contends that the A1c alone is not really the best approach.  TIR, glycemic variability, and eliminating extreme excursions are also major players.  MEDS attendees will learn how to incorporate this technology into their practice. 

During Amy’s career, she has been exposed to implicit clinician bias; it’s not always the patient’s fault when goals are not attained.  For example, clinicians bear some responsibility when considering recent data from the “T1D Exchange” clinic registry, which demonstrates that only a minority of adults and youth with T1DM meet ADA goals for HbA1c.  Further, although CGM use has substantially increased in recent years, racial disparities remain in both technology use and glycemic control. 

Amy will explain how to combat numeracy challenges, the ability to understand and work with numbers, and how smart insulin pen technology helps. She consistently sees how it can be successfully used in carbohydrate counting leading to a better quality of life as well as improved TIR for her patients. 

Amy’s philosophy will resonate with MEDS attendees.  She stresses a patient centric model of care, with individualization, collaboration, and mutual goal setting.  Aesop’s Fable of the Tortoise and the Hare exemplifies her strong belief in positive thinking and patient empowerment.  Minimizing negativity reduces patient discouragement and deflation. Amy says, “Focus on what works and remember that slow and steady wins the race.”  She wants her patients to enjoy their office visits and look forward to seeing her; showing up is a key to care. MEDS attendees will want to see Amy’s presentation too!

 

Reference: 

Devices & Technology: “What is a smart insulin pen?”
https://www.diabetes.org/healthy-living/devices-technology/smart-insulin-pen  Accessed 20210614.

Foster NC, Beck RW, Miller KM et al. State of Type 1 Diabetes Management and Outcomes from the T1D Exchange in 2016–2018 Diabetes Technology & Therapeutics, 2019;21(2):66-72. doi: 10.1089/dia.2018.0384 
https://investor.lilly.com/news-releases/news-release-details/lilly-collaborates-internationally-leading-diabetes-technology.  Accessed 20210614.

https://www.medtronicdiabetes.com/products/inpen-smart-insulin-pen-system.  Accessed 20210607.

https://www.novonordisk.com/our-products/smart-pens/novopen-6.html.  Accessed 20210607.

Randlov I, and Poulsen JU. How Much Do Forgotten Insulin Injections Matter to Hemoglobin A1c in People with Diabetes? A Simulation Study.  J Diabetes Sci Technology. 2008;Mar; 2(2): 229–235. doi: 10.1177/193229680800200209. 

Warshaw H, Isaacs D, and MacLeod J.  The Reference Guide to Integrate Smart Insulin Pens into Data-Driven Diabetes Care and Education Services.  The Diabetes Educator. 2020; Vol. 46, Supplement 4: 3S – 20S. doi.org/10.1177/0145721720930183

 

 

May 2021

The Endocrine World of AI
Interview With: Ashlyn Smith PA-C 

By:  Ellen D. Mandel DMH, MS, PA-C, RDN

In the world of endocrine disorders, AI has nothing in common with artificial intelligence and Ashlyn Smith can tell us why. As a PA working for nearly ten years in Endocrinology, she has seen many cases of adrenal insufficiency, the real AI of endocrine disorders. Ashlyn explains that her love of Endocrinology grew from an initial undergraduate knowledge deficit, which she strove to correct through intentional PA school rotations and intensive study.  She now works full time in an adult Endocrine practice in Arizona, where she balances her leadership role as president of the American Society of Endocrine PAs, along with teaching for Midwestern University.  Fortunately for us, MEDS attendees will gain important knowledge about AI during the July virtual sessions. 

Ashlyn is one of the newer members of the MEDS faculty, joining during the pandemic, and she quickly came to recognize the quality and passion of her faculty peers.  She describes her realization that there were essentially no other symposia that specifically catered to the NP/PA audience, and how MEDS filled an essential patient care niche across the country.

When it comes to AI and the Primary Care clinician, Ashlyn has a few pointers. First, AI does not always present in a textbook manner.  While classic primary AI presentation includes hypotension, hyponatremia, hyperkalemia, abdominal pain and hyperpigmentation, not all cases fit this pattern.  AI may present due to secondary causes such as prolonged use of steroids used to treat many common medical disorders including autoimmune diseases, rheumatologic conditions, COPD and even severe migraines. As with many endocrine disorders, the patient’s past medical history—often a complex puzzle—may seem like, yet not result in, an AI diagnosis.  

A key point, which Ashlyn will describe in greater detail during MEDS, is the importance of the appropriate selection and timing of laboratory testing.  She provides examples of clinicians using random testing of adrenal and pituitary hormones resulting in either misdiagnosis or missed diagnoses of AI and other endocrine disorders. Ashlyn will also describe how she finesses her approach to patients who have self-diagnosed AI or been led to erroneously believe they have AI through internet searches or care given by non-allopathically medically trained providers.  With so much misinformation, Ashlyn’s endocrine acumen comes into play as she stays abreast of research on this topic and applies cutting edge decision-making and treatment options for her patients.

Many MEDS attendees hail from Primary Care practices, and may be challenged in making an AI diagnosis.  Ashlyn will detail the how and when of testing and proper referrals.  She will explain how common co-morbidities such as depression, anxiety, obesity, trauma and medication classes may mimic AI and interfere with diagnostic testing, leading the clinician down an unnecessary and costly diagnostic trail.  AI is not a clear-cut diagnosis, but Ashlyn reassures Primary Care clinicians that they can correctly begin the diagnostic process by following the simple rules she will describe at MEDS.

Ashlyn has worked throughout the COVID pandemic, dealing with self-referred patients with legitimate complaints of fatigue, insomnia, weight gain and lethargy.  Ashlyn explains that empathy is essential and must be combined with appropriate testing and diagnosis.  As patients return to their pre-COVID lives, they may notice weight gain and increased fatigue with activities of daily living.  Some will seek out an endocrine causality.  Those who experienced a COVID infection may develop as-yet-unknown effects of the virus and its treatment on their adrenals and other endocrine organs.  Ashlyn plans to cover a significant amount of vital information to correctly diagnose and treat AI, demonstrating that there is nothing artificial to her endocrine intelligence.  
 

References:  

Bornstein SR, Allolio B, Arlt W et al.  Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline.  J Clin Endocrinol Metab. 2016;101(2):364-389.

Fleseriu M, Hashim IA, Karavitaki N et al.  Hormonal Replacement in Hypopituitarism in Adults:  An Endocrine Society Clinical Practice Guideline.  J Clin Endocrinol Metab. 2016;101(11):3888-3921.

 

PCOS:  A Common Female Endocrinopathy
Interview With: Mimi Secor, DNP, FNP-BC 

By: Ellen D. Mandel, DMH, MS, PA-C, RDN

Stein and Leventhal initially described what is now called Polycystic Ovarian Syndrome (PCOS) in 1935, and likely would not have predicted how much remains unknown of a condition with an estimated prevalence of 5-15%, which supports the difficulty of its diagnosis. PCOS, now considered one of the most common endocrinopathies affecting women is near and dear to Mimi Secor’s heart.  Mimi has had an interesting career, beginning as an ER nurse, moving along into GYN practices, and starting her own business, while fitting in 10 years as an NP in Alaska.  And keep in mind—Mimi was not around in 1935.  

When asked how she gravitated to this specialty area, she replied that in the course of her workday, she saw so many women in distress with PCOS-like symptoms, and felt that she could be helpful. Challenged with this opportunity, she dug into learning as much as possible, noting that “We often don’t like what we don’t have adequate knowledge and experience in.”  This mantra is why MEDS is so fortunate to have Mimi as faculty from its inception and how attendees rave about her lectures. Conversely, Mimi is also fueled by the sophistication of questions from the PA/NP attendees.

As common as PCOS is, its diagnosis is not always so straightforward, and there is more than one set of guidelines in the literature. Mimi will explain, a PCOS diagnosis is primarily clinical, not laboratory based and has core findings of hyperandrogenism, insulin resistance, and chronic anovulation.  

However, the plot thickens as one considers how anovulation manifests with such menstrual questions as frequency, missed or skipped, and duration of each bleed along with the possibility of pregnancy.   Also, when should the clock start ticking relative to an expected normalcy of menstrual cycles?  

A clinical diagnosis is often challenging, as clinicians might prefer a firm set of laboratory tests to establish the diagnosis.  NPs and PAs may recall the commonly published ovary ultrasound textbook image of the “string of pearls.”  Mimi will explain how this textbook image may contribute to, but not make the actual diagnosis. 

Mimi’s many years working with women with PCOS has heightened her skill set in broaching the topic of family planning.  Clinicians know that abnormal menses bodes poorly for conception success.  Similar to many endocrine disorders, PCOS seems to run in families.  Therefore, women may come to a Primary Care office for a PCOS work-up already stressed about their chances of current or future childbearing.  They may know of aunts, siblings or grandmothers with worst-case stories about failed conception outcomes.  Through case studies, Mimi will expound on broaching the conception topic, which is pertinent to women even with no immediate interest in conception.

An interesting idea is the possibility that PCOS is another variant of diabetes.  Years ago, clinicians concerned themselves with juvenile and maturity onset diabetes only, until laboratory and genetic testing revealed the diagnostic in-between.  Another point that Mimi will discuss is the role of a new laboratory marker, sex hormone-binding globulin (SHBG) as a diagnostic tool. SHBG is a glycoprotein, which regulates the bioavailability of sex steroid hormones (think testosterone) and has an inverse association with PCOS, obesity, insulin resistance, metabolic syndrome, and type 2 diabetes mellitus.   At times, Primary Care clinicians note the availability of a new lab test and feel compelled to order it.  Mimi will explain why this approach may not be in the best interest of the patient while it drives up healthcare costs. 

Stein and Leventhal bear the eponymous precursor to PCOS and there is much to learn.  Are there any cardiometabolic risks associated with PCOS?  How can we best minimize future morbidity and mortality through early identification and treatment?  What lab tests might you consider as you work through PCOS lookalikes? Does the microbiome hold any answers to PCOS?  Mimi will teach us that PCOS is not a just a string of pearls, but a potentially life altering condition which Primary Care attendees may translate into real world diagnosis and management. 
 

References:

Bednarska S and Siejka A.  The Pathogenesis and Treatment of Polycystic Ovary Syndrome: What’s New?”  Adv Clin Exp Med. 2017;26(2):359-367.

Deswal R, Yadav A and Dang AS.  Sex Hormone Binding Globulin – an Important Biomarker for Predicting PCOS Risk:  A Systematic Review and Meta-Analysis.  Biology in Reproductive Medicine. 2018;64(1):12-24.

Lagana AS, Vitale SG, Noventa M and Vitagliano A.  Editorial: Current Management of Polycystic Ovary Syndrome: From Bench to Bedside.  International Journal of Endocrinology. 2018; https://doi.org/10.1155/2018/7234543.

Rasquin Leon LI and Mayrin JV.  Polycystic Ovarian Disease. https://www.ncbi.nlm.nih.gov/books/NBK459251/.  Last Updated July 10, 2020.  Accessed May 8, 2021.

 

April 2021

Introducing MEDS for 2021: Essential Endocrinology Topics for Essential Clinicians

Diabetes, thyroid conditions, kidney disease, obesity and lipid disorders are all singular non-communicable epidemics and taken together are a global pandemic. In 2021, this is not news. However, more than a decade ago, a pioneering Physician Assistant (PA), Scott Urquhart had a vision; how can cost-effective and high-quality medical care for endocrine related conditions be delivered with a relative national shortage of Endocrinologists? 

Working as an Endocrine PA in a busy practice in West Virginia, he knew first-hand the toll these common endocrine disorders were taking and wanted to make a real and bigger difference. He knew that advance practice providers, Nurse Practitioners and PAs teaming up with physicians held the answer to the ever-expanding patient care void. He had his endgame in sight but needed other players on board to bring it to fruition.

Fortunately, he discovered a willing and progressive partner and MEDS – Metabolic & Endocrine Disease Summit was born. This partnership was the beginning of a now ten-year success story of bringing practical endocrine management strategies to NPs and PAs working in primary care and other related specialty offices across the country. An aggressive presentation schedule was implemented with MEDS offered twice a year in family-friendly venues (what better way to bring together primary care clinicians). As pharmacotherapeutics and technology were taking off, clinicians needed to be ahead of the curve, and just as important, needed to build and assure their confidence in safely and efficiently applying these treatment game-changers. Scott was proven right, as a capacity crowd filled the room for the first ever MEDS in Orlando, Florida. 

As the vision took shape, selecting the right faculty was imperative. Faculty needed advanced knowledge and experience, along with excellent translational skills. With a high bar, MEDS faculty focused on the mantra of translating the complex language of endocrine; the why, who, how, and when of endocrine disorders into practical, doable advice for dedicated clinicians to carry back to their offices.

Scott collaborated with Christine Kessler, an NP leader in the endocrine community to draw experts in diabetes, disorders of the thyroid, adrenal, bone, and pituitary as well as lipids, nutrition, PCOS, and testosterone. Both CME and non-CME learning were included to achieve affordable registration fees and bring the newest options to the Summit.

As MEDS enters its eleventh year, the physician-NP-PA team has markedly expanded as MEDS’ “graduates” spread out across the nation with the word of how great MEDS is and what it does for their patient care capabilities. Since its inception, MEDS has educated over 10,000 clinicians, offering an average of 22 affordable CME/CEUs per Symposium. MEDS anticipates 1000 registrants for its upcoming virtual meeting. Many registrants attend more than once for knowledge updates and refreshers, while friendships flourish with the mutual desire to provide excellent patient care. 

MEDS has been nimble as it partnered with MedscapeLive! to continue its mission. For the present time, it has pivoted to a virtual platform, streamlined its offerings, and continues to engage excellent clinician educators. MEDS offers core endocrine educational offerings coupled with the new and exciting. 
 
Take a sneak peek at the lecture and case-based learning topics of MEDS 2021 for July and October – you’ll see there is nothing static or boring about endocrinology! The Agenda may be found here.

— Ellen D. Mandel, DMH, MS, PA-C, RDN

 

Interview
Meet Rick Pope PA-C

Rick Pope, PA-C, a founding MEDS lecturer will join us again for our July 2021 virtual symposium.  His topic: “Osteoporosis – Who We Screen, Who Needs Bone-Density? FRAX, and Current Recommendations for Therapy” is not just for “boneheads,” a term Rick uses with the utmost respect.  Indeed, osteoporosis (OP), defined by a statistically significant loss of bone mineral density, leads to significant morbidity, mortality and is commonly seen in both Primary Care and Rheumatology/Endocrine practices.

Rick should know, he spent the bulk of his 30-plus year clinical career as a Rheumatology PA, having been recruited away from Pediatrics by a Rheumatologist desiring a PA in his practice. Rick presently teaches rheumatology topics to all five Connecticut PA programs as well as DNP students at the University of California (Irvine). He notes that the American College of Rheumatology now endorses hiring NPs and PAs due to a long-standing, nationwide shortage of Rheumatologists.  The rising numbers of OP cannot be ignored. The National Osteoporosis Foundation (NOF) reports that 10 million Americans have OP and another 44 million have low bone density, placing them at risk for future OP: it is estimated to be responsible for 3 million fractures costing greater than $25 billion by 2025. As OP numbers continue to rise, primary care clinicians can tackle its diagnosis and management; Rick aims to tell us how.

OP treatment options have continued to evolve, with real advancements in the past few years, moving beyond bisphosphonates, a decade’s old drug. Rick explains that proper diagnosis and treatment is like a bone matrix, a puzzle of sorts whereby patients’ age, gender, ethnicity, activity pattern, smoking history, calcium, and vitamin D intakes along with socio-economic status all come together to formulate risk and help direct treatment strategies.  It is more than just adequate vitamin D and calcium intake.  He specifically wants to dispel the myth that hip fracture, or any OP related fracture  (i.e. Colles, vertebral) is simply bad luck.  Social determinants of health, a long-ignored concept plays an impactful role in OP.  Rick points out that lifelong habits, as well as medical IQ affect OP risk.  How do people learn about OP prevention, find a clinician and learn the right questions to ask to secure their own best care?  Medically trained people have a high medical IQ, not so of most people.  This supports his desire to educate NPs and PAs with MEDS.

There are a number of key updates to OP pharmacotherapeutics, which will be detailed at the upcoming MEDS.  Rick will describe the recent (November 2020) removal of the FDA’s Black Box warning on teriparatide (Bonsity, Forteo) for patients using this PTH analog. Although the two-year use maximum has been removed, just how long they can be used remains open. Think bone markers!

Another OP concern has been balancing the risk of fragility fracture with the risk of atypical femur fracture with long-term bisphosphonate therapy. A 2020 publication in the New England Journal of Medicine followed >197,000 women (Kaiser Permanente) over the age of 50 years for a ten-year period and provides answers to this key question with some unexpected results.  Rick will detail a helpful response to your patients’ questions about long-term risks of bisphosphonate therapy and ethnicity’s role. 

Another question often posed by patients with existing OP relates to the risk of high impact exercise. Will it promote fractures, worsen osteopenia, or provide benefit?  A recently published Australian study in the Journal of Bone and Mineral Research, examines the impact of high-intensity resistance and impact training’s effect on bone mineral density, as well as physical function in postmenopausal women with both osteopenia and OP. Rick will explain how the results of this LIFTMOR study may impact exercise decisions. 

If you think OP is a dull topic, there are new, literally hot-off-the-press screening guidelines issued by the United States Preventive Services Task Force (USPSTF) for vitamin D.  Rick has a lot to say about these guidelines and plans to review their translation and application for the general population versus those with OP.  For example, which form of vitamin D (D2 or D3) might be more beneficial? There is so much to learn about bone health and Rick plans to cover as much terrain as possible.  His lecture style converts complicated concepts to advice you can take back to your office.  Rick continues to crack the code of bone health, helping to ease patient conversation and provide the best treatment options. 

 

References: 

1. Osteoporosis – Fast Facts.pdf

https://cdn.nof.org/wp-content/uploads/2015/12/Osteoporosis-Fast-Facts.pdf
Accessed 20140222.

2. Highlights of Prescribing Information: Forteo.  Forteo-pi.pdf  Accessed 20210422.

3. Black DM, Geiger EJ, Eastell R, et al. Atypical Femur Fracture Risk versus Fragility Fracture Prevention with Bisphosphonates. New England Journal of Medicine. 2020:383(8);743-53.

4. Watson SL, Weeks BK, Weis LJ, et al. High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial. Journal of Bone and Mineral Research. 2018;33(2):211-220. 

5. Screening for Vitamin D Deficiency in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2021:325(14);1436-1442.

— Ellen D. Mandel, DMH, MS, PA-C, RDN