Dr. Loren Grossman has been practicing endocrinology for over 25 years. He is an Assistant Professor of Medicine (adjunct) at the University of Toronto and is a member of the Endocrinology Staff at St. Michael’s Hospital. Dr. Grossman earned a Bachelor of Science (1st class honours) in 1978 and a Medical Degree (with distinction) in 1982, both at the University of Toronto.
He has specialist certificates in Internal Medicine and Endocrinology and Metabolism from the Royal College of Physicians and Surgeons of Canada, and is a Diplomat of the American Board of Internal Medicine and a Fellow of the American College of Physicians. From 1987 to 1997, he was a member of the active staff in the Department of Medicine at the Scarborough Grace Hospital, where he served as Physician-in-Chief from 1996 to 1997.
During this time he was also a member of the division of Endocrinology and Metabolism at Mt Sinai Hospital in Toronto where he engaged in clinical teaching and clinical trials. In 1997, Dr. Grossman joined Eli Lilly Canada as Associate Vice-President, Clinical Research, supporting the areas of endocrinology and cardiovascular research.
Loren D. Grossman, Assistant Professor, University of Toronto Dr Loren D Grossman Medicine Professional Corporation LMC Diabetes and Endocrinology
( Dr. Loren Grossman, Endocrinologist, Toronto, ON ) is in good standing with the College of Physicians and Surgeons.
Typical symptoms of low testosterone are actually very non-specific. Symptoms can include just general lethargy, not feeling themselves, depression, low energy. There can be increased weight, particularly increased abdominal obesity.
More specific things can include low libido or erectile dysfunction. But many of these symptoms are actually quite non-specific, so it’s important for men who have these to not only look for a low testosterone as a possible cause, but for other possible causes as well.
Men will often present to their doctor with concerns about erectile dysfunction, low libido, thinking it might be a problem with low testosterone. And while it may be, and it’s important to test for that, it’s also important to remember that there are many other causes for low libido and erectile dysfunction outside of low testosterone. So generally speaking we should test for that and make sure that’s either a problem or if it’s not a problem that men seek other potential causes for their symptoms.
So for more information about the proper assessment of low testosterone, men can see their family doctor, get the appropriate testing as we’ve discussed or perhaps refer to an endocrinologist if deemed necessary.
Local Practitioners: Endocrinologist
Diabetes is a very complicated disease. The first treatment that was discovered in the 1920s was insulin, and that was a lifesaver for type 1 diabetes. But for type 2 diabetes, we’ve had a number of other medications since about the 1950s or 60s with metformin and typically the sulfonylureas as second choice.
The problem with those is there are a number of drawbacks to those medications and side effects, so the development of newer medications is very welcome. The first new class that we had is a very long name, the TZDs, or the thiazolidinediones, particularly like pioglitazone and rosiglitazone. And they helped with the treatment of diabetes but they themselves had some problems, with one coming off the market and side effects.
Fortunately in the past five, ten years we’ve had a number of different medications that have been developed for the treatment of type 2 diabetes. These can include the DPP-4 inhibitors, that are used for second-line treatment for diabetes. There’s also what are called the sodium-glucose cotransporter-2 inhibitors, or SGLT-2 inhibitors. And we now have injectable medications, the GLP-1 or the glucagon-like protein one agonists.
Each one of these classes has their own number of medications, and each class has its own pluses and minuses for the treatment of type 2 diabetes. Generally speaking, and according to the Canadian Diabetes Association Clinical Practice Guidelines—and other international guidelines—metformin remains the first drug of choice for the treatment of diabetes. Unless of course the patient urgently needs insulin, if they are in metabolic decompensation or severe symptoms of hyperglycemia. But putting that group aside, metformin remains first choice. The guidelines then recommend individualizing our choice for second choice medication, depending on the individual patient’s needs. And here’s where the different classes of the medications come in.
For example, DPP-4 inhibitors are an excellent second choice for patients who are slightly above target, and need a little extra to get down to their target A1C. They tend to have minimal side effects, mostly gastrointestinal, but they’re also not as efficacious, and you can expect maybe a half a percentage point or so reduction in the A1C.
When not to use them would be if certain side effects occur, particularly there has been some concern about pancreatitis, and therefore if a patient has a history of pancreatitis I tend to avoid that class of medication.
SGLT-2 inhibitors work by a different mechanism. They tend to promote some weight loss and lower blood sugars to a greater degree—to maybe up to almost one percent sometimes or even more. And therefore if you have a patient who is not doing well with metformin alone, who has a significant amount of weight to lose, an SGLT-2 inhibitor would also be an excellent choice.
The other thing to keep in mind is that this class of medication has recently been shown to be a benefit in cardiovascular outcomes. And therefore, if a patient has either a history of cardiovascular disease or is at high risk, then that would be a good second choice as well.
Recent data has also suggested some of these medications can also improve patients who have mild to moderate chronic renal failure, and therefore this might be an appropriate second choice as well. Side effects to keep in mind is there will be increased urination and thirst, patients need to worry about this medication if they can’t take in oral fluids with a concurrent illness, and there is an increased risk of mycotic infection, so if that’s been an issue that may be one to avoid.
Going to injectable medications, GLP-1 agonist, the glucagon-like peptide one agonist, are an excellent choice again, for some weight loss, and they’ve also been shown to reduce cardiovascular events, so if you have a patient who has, again, cardiovascular disease, or is at high risk, and needs to lose significant weight, this may also be an excellent choice if a patient is willing to take an injectable medication.
We used to have medications that were injected on a daily basis, but now there are newer formulations that have come out that can be injected once a week. And we often find that a weekly injection is much more tolerable, and the patients are much more amenable to doing that, than a daily injection. As well, there are some newer formulations under development for the oral formulations of GLP-1, so that may be something to look at in the future.
To summarize all this, if a patient needs urgent, quick diabetes control because of metabolic decompensation or severe symptoms, they need to take insulin. For the others, metformin remains first-line therapy, unless there are contraindications, and then if patients are failing on the first-line therapy of metformin, there are a host of other options which need to be individualized to the patient’s needs, based upon individual needs, plus or minus the side effect profile.
For more information, patients should speak to their family doctor, or speak to their diabetes nurse educator or endocrinologist.
Local Practitioners: Endocrinologist