Domperidone and Vagina Bleeding?


Question

I need to know the effect of motilium ( Domperidone) Dopamine agonist on postmenopausal women. Could it be a cause of abmnormal vaginal bleeding in this group?Thanks .Fatma Almarashi M.D. F.A.C.E. Medical Director, Dubai Healthcare City

Response

Domperidone is not used in the U.S. It is a dopamine receptor antagonist (D2 and D3). It has been used to induce lactation by increasing circulating prolactin and does not cross the blood brain barrier. Other uses are similar to metaclopramide. Since the ovaries are inactive in the menopause domperidone should not cause bleeding as it does not have estrogenic activity based on its structure to the best of my knowledge. James H. Liu, M.D.

Low Somatomedin C Level


Question

I enjoyed "endotext" and hope to stay in touch with you. Right now I have a question. A 48 y/o man with hepatitis C, HTN, probable bipolar, had for a while consistently lower hemoglobin A1C values. No certain history of hypoglycemic episodes. TSH 0.64, repeated 2.13 (?), somatomedin C 63 (normal range 94-252), glucagon 56 (40-130), BUN and creatinine tend to be low. Should we consider somatomedin-C value relevant, is his lower HgB A1C explainable by liver damage with hepatitis C? <edkorkut@hotmail.com>

Response

The relatively low IGF-I (Somatomedin C) is fully explained by the patients Hepatitis C, and should not give rise to further endocrine tests. Low HbA1c cannot be used as a diagnostic measure for hypoglycaemia. Only a fasting test will be helpful here. Low HbA1c is most likely associated with a short lifespan of erythrocytes. Best regards, Jens Sandahl Christiansen, MD

? Tshoma


Question

I was hoping for some assistance with a case: 25 year old student of chinese descent. Presents with probably thyrotoxic periodic paralysis and TSH 10, FT4 40, FT3 12. Goitre noted, intermittent tachycardia and tremor. Patient well and no aware of symptoms. Pit MRI incl sinus views normal Alpha subunit elevated x 4 ULN. SHBG 2x ULN. Uptake scan increased at 15% TRH stimulation: increase from 10 to 16 mIU/L T3 suppression: no signficant change on doppler or TSH value (10 to 9) Questions: 1. Should we image this patient further or just observe with plans for repeat MRI? 2. Should we treat this patient with a somatostatin analogue (he has no had further episode of weakness at 3 months and is very well)? 3. Do you interpret the TRH stimulation as positive, borderline or negative? 4. Please tell me where I can get advise on how I can calculate the alpha subunit to TSH molar ratio

DR Kath Williams

Response

Very interesting case, indeed. I thing we are facing a patient with a TSH-oma on the basis of these findings:

1. High serum alpha-subunit levels (unless he has high levels of gonadotropins)

2. High serum SHBG levels (serum SHBG concentrations are normal in patients with thyroid hormone resistance (RTH))

3. Impaired TSH response to TRH

4. Failure to respond to T3 suppression test (RTH patients reduce TSH, though not to a complete suppression).

I suggest:

1. More precise MRI, possibly the "dynamic" one

2. Look for a possible ECTOPIC TSHoma

3. Do an Octreoscan

4. Treat the patient for at least 3 months with octreotide LAR or lanreatide Autogel, measuring FT4, FT3 and TSH the day before the analog injection.

Let us know of the results.Paolo Beck-Peccoz, M.D. University of Milan, Email:paolo.beckpeccoz@unimi.it

Osteoporosis and Lateral Spine DXA


Question

In the new institution that I joined 1 month ago, I have already had multiple consults for osteoporosis. I have discovered that the department that does all of the DXAs at this institution routinely measures the lateral spine BMD. This was not done at any of the other institutions where I trained, and was not mentioned during my ISCD certifcation training at Endocrine University. In my brief review of up-to-date, endotext, the ISCD website, and the published medical literature, I do not see adequate information regarding the use of lateral BMD. If my impression is correct, lateral BMD measurements may be useful for interpreting and following changes in BMD in patients who have aortic calcifcations or osteophytic changes, but should not be used for the diagnosis of osteoporosis. I assume the recommendation to not use it for diagnosis is because there is no fracture risk data regarding BMD measurements using the lateral spine (is this true?). However, at this institution, I have already seen multiple patients diagnosed with osteoporosis on the basis of the lateral spine, with normal or much more mild decrements in BMD at the AP spine and hip. My concern is that primary care physicians and others who have not been trained to read DXAs or understand fracture risk assessment may be overtreating patients because of these lateral spine measurements. If you could please give me a quick overview of the current "state of the art" and guidelines regarding the use of lateral spine BMD, I would appreciate it. Furthermore, if there is data to either support or refute the use of lateral DXA in the evaluation and/or diagnosis of osteoporosis that would be greatly appreciated as well.

Response

Sorry for the delay in responding, as I was out of town. You are correct in that one cannot use the lateral spine DXA for making a diagnosis of osteoporosis, which should be based on femoral neck (or total femur) BMD and/or the AP spine BMD. In my practice, I rely on this measure, combined with the AP spine.

Tha lateral spine imaging may be useful for vertebral fracture analysis (VFA) by DXA and perhaps in research studies. Another problem with it is that the precision of lateral spine BMD seems to be worse than that for the femur neck or AP spine, so it is also problematic in terms of using it for follow up. Sundeep Khosla, MD

To Use Avandia and/or Lantus, or Not?


Question

S-I really would like to have your advice regarding two issues: first, as you know the RECORD study has reassuring results regarding the use of rosiglitazone. Do you think that it would be better if we replace it with pioglitazone as we have an offer to supply the hospital with Actos with comparable price to that of Avandia, given the adverse publicity of Avandia?

The second issue is again regarding the recent observational studies about the possible association between Lantus and some cancer. Do you think switching to Detemir would be safer or shall we continue with lantus till we get more information. what is the NICE and the UK standpoint of this issue.

Dr.Yahya Al Zaman,MD,FRCP(UK) ,Cert.(RCP)(Endocrinology&Diabetes), Salmaniya Medical Hospital, Ministry of Health, Kingdom of Bahrain.

Response

Thank you for your email.

1. I think that Actos and Avandia are equivalent and you can use either. If you feel that your patients will be more comfortable taking Actos, then I would use it.

2. I think that the data concerning Lantus and cancer are weak at best and there are no data on Detemir and cancer. At my institution we are making no changes in the treatment of our diabetics. Sincerely, Ira D. Goldfine MD