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My Impressions of ENDO 2021

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This year, ENDO2021 was virtual. As my main interests are lipids, cardiovascular risk, and diabetes, I will summarize the following sessions: SGLT2 inhibitors for Type 1 diabetes (T1D), lipid management in patients with endocrine disorders, and a history of the changing face of Type 2 diabetes (T2D).

SGLT-2 inhibitors (eg., empagliflozin, canagliflozin, dapagliflozin) are FDA-approved for glycemic control in people with T2D, but not T1D. Their use in T1D is controversial; ENDO featured a debate on this topic.

Dr. Anne Peters presented the negative side and Dr. Andrew Ahmann the positive. Dr. Peters pointed out the risk, in adults with T1D, for euglycemic ketoacidosis, which is life-threatening and may not be recognized early enough. Treatment for euglycemic ketoacidosis involves ingestion of foods and/or drinks with high carbohydrate content and more insulin. These foods prevent a rapid fall in blood sugar in response to extra insulin. Monitoring ketones does not reliably ensure early detection of ketoacidosis in patients with T1D using SGLT2 inhibitors. Dr. Ahmann pointed out the possibility of a benefit on kidney and cardiovascular disease, although the evidence for these benefits is in T2D. Finally, both doctors agreed that SGLT2 inhibitors could be considered in T1D and in selected individuals who would benefit from improved glycemic control; and are willing to be educated about the risk of euglycemic ketoacidosis and ways to reduce that risk.

The session on lipid management in patients with endocrine disorders was an introduction to the new Endocrine Society Clinical Practice Guideline, Management of Lipids in Patients with Endocrine Diseases. This guideline is the first on this specific topic. Its objectives were to assess the lipid profile and cardiovascular risk factors in people with endocrine diseases, and determine whether treatment of the endocrine disease improves the lipid profile and/or reduces cardiovascular risk. The panelists were Dr. Lisa Tannock, Dr. Alan Chait, Dr. Ira Goldberg, and myself. Dr. Patrick McBride moderated the session. Three cases were presented and discussed by all the panelists.

Case 1: a 32-year-old woman with T2D, hypertension, a family history of early coronary heart disease, and LDL-C 124 mg/dL. The main question was whether to begin statin treatment or wait until age 40. The answer was to begin statin treatment now, with a high-intensity statin. The guideline recommends treating adults with T2D and multiple risk factors with a statin as an adjunct to lifestyle changes to prevent atherosclerotic cardiovascular disease and does not indicate an age threshold. The panel emphasized that women of reproductive age taking statins should use contraception.

Case 2: a 52-year-old post-menopausal woman with a family history of early-onset coronary artery disease who was healthy until she was hospitalized with acute pancreatitis and triglycerides of 2698 mg/dL and hemoglobin A1C 8.2%. The day before admission, she had three glasses of wine to celebrate her birthday. Her BMI was 27.6. A lipid panel two years before revealed LDL-C 126 mg/dL, HDL-C 46 mg/dL, and triglycerides 159 mg/dL. The first question asked about the cause of the dramatic increase in triglycerides compared to two years ago. The choices were new-onset diabetes, increased alcohol consumption the previous night, and weight gain since the onset of menopause. The correct answer was new-onset diabetes, although the other factors could have contributed. The second question asked the meaning of the positive family history of early-onset coronary artery disease and the triglyceride level of 159 mg/dL two years ago. The answer is that these suggest a baseline genetic form of hypertriglyceridemia played an important role in the development of triglyceride-induced pancreatitis. The third question was related to the prevention of recurrent pancreatitis. Dr. Chait explained that both glycemic control and a fibrate would help prevent severe elevations in triglycerides and pancreatitis. The patient would also need a statin to prevent cardiovascular disease. Statins have an interaction with some fibrates, such as gemfibrozil; the best choice for a fibrate would be fenofibrate.

Case 3: a 62-year-old woman with subclinical hypothyroidism (normal T4, slightly elevated TSH- 8.5 mIU/L), LDL-C 180 mg/dL, and borderline 10-year ASCVD risk. The main question was whether the thyroid hormone should be started. Based upon a meta-analysis of clinical trials showing that treatment of subclinical hypothyroidism reduces LDL-C, although, to a lesser extent than treatment of overt hypothyroidism, the guideline suggests consideration of thyroxine treatment to reduce LDL-C in patients with subclinical hypothyroidism.

The key message from this session was the importance of evaluating lipids and cardiovascular risk factors in patients with endocrine diseases. In patients with thyroid disease, it is important to re-assess the lipid profile when the patient has normal thyroid function tests. For patients with other endocrine disorders, an assessment of the cardiovascular disease risk will determine whether a statin as an adjunct to lifestyle therapy might be needed to reduce LDL-C cholesterol. When the decision to treat is not clear, consideration of risk enhancing factors and measurement of coronary artery calcium would help determine whether a statin might be beneficial.

The Clark T. Sawin Memorial History of Endocrinology Lecture: The Lessons Learned from the History of Identifying and Addressing Health Disparities in Endocrinology and Diabetes was given by Dr. Sherita Golden, an expert in diabetes. In brief, the presentation described the changing perceptions of the cause of T2D, which for many years was believed to be due to race or ethnicity. In the early 1900s, T2D was considered a disease of overindulgence occurring mainly in wealthy whites. As the 20th century progressed, it became apparent that Type 2 diabetes was associated with obesity and with poverty leading to obesity because of reduced access to healthy foods. In comparison to whites, T2D in the U.S. is more common in certain groups (Native American, Latino, Black, Asian American). However, the belief that T2D is due to race rather than the environment is erroneous. This history underscores the importance of social determinants of health and the need for policies to improve social conditions.

Illustration by April Brust

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