Last week a young woman with type 1 diabetes on an insulin pump came for a follow up appointment. Unfortunately, she brought in very few recorded blood glucoses. She had been testing once or twice a day, sometimes not at all.

Before I could find out what happened, she asked: "Would it be a problem for me to come off the pump for a while?"

Apparently she had been placed on an insulin pump when she was pregnant with her last child. Her doctor had then told her it would improve her diabetes control. Her glycemic control was indeed improved — at least initially and then it deteriorated.

She admitted that since going on the insulin pump she had "gotten lazy." It was easier for her to give herself a bolus of insulin without thinking about or testing her blood glucose. In her mind, it would be better to go back on a subcutaneous multiple injection insulin regimen "because then I would have to test my blood glucoses every time I gave insulin."

"I have no problem with you stopping the pump and switching back to injections," I told my patient. "Just put the pump in a drawer and when you are ready, you can go back on it."

Patients may come off of their insulin pumps and go back to injections for a variety of reasons. We call this a "Pump Holiday."

Sometimes it is because the patient is going on a trip. They would prefer to not have to deal with the pump while traveling or at the beach. I had one patient who went on a mission for several months in Africa. It was easier for them to use injections and carry syringes with them than it was to deal with the pump and get the required supplies sent to them in a timely manner. As soon as that patient returned home, we reinitiated the pump.

Occasionally patients go on an unintentional pump holiday due to pump malfunction. All patients using insulin pumps must understand how to transition back to subcutaneous insulin injections in the event of an emergency. Obviously, they must have a supply of insulin and injection supplies available to use when this happens.

Then there are those patients who were placed on a pump never entirely understanding or being educated on such therapy. Some non-endocrinologists have a misconception that "if you'd only go on a pump, then everything would be better." Although insulin pumps are a useful and effective tool, in the hands of someone who is not ready or fully trained, they can be a disaster.

I have had such patients arrive at my practice without ever having been educated or supported on how to use a pump. For safety reasons, we stop the pump and go back to injections. Once they have received education and we are sure they are safe to go back on the pump, we might reinitiate.

Some of these patients do so well, however, that we decide to continue the multiple injection basal bolus regimen indefinitely. These are patients who should never have been started on an insulin pump in the first place. They needed diabetes education, not an insulin pump.

Finally there are some patients who would like to go on a pump holiday just because they need a break. I have no problem with that. An insulin pump can be an effective and powerful tool. It does require understanding and commitment to use it to its full potential. If anything, people on insulin pump therapy need to pay attention and test their blood glucoses more often. The benefit can be improved glycemic control with more flexibility.

There is no strict protocol for transitioning a patient from an insulin pump back to a subcutaneous insulin injection regimen. Usually the bolus insulin correction dose and insulin-to-carbohydrate ratio stays the same or is similar to what it was while on the pump.

The basal dose of insulin depends on the patient. In a patient with type 1 diabetes who has frequent hypoglycemia, I would decrease the dose of basal insulin from the total basal insulin in units per day by 10% or even more. Basal insulins such as glargine and detemir are not supposed to have pronounced peak, but in some very insulin sensitive patients they do. It is better to be careful when uncertain.

In other patients who are not having hypoglycemia or in an insulin-resistant, insulin-requiring patients with type 2 diabetes on a pump, I start the basal dose at exactly the same units as their total daily dose of basal insulin was with the pump.

Usually the patient injects their first dose of basal insulin and then they remove the pump2 to 4 hours afterwards. As I said, it all depends on the patient and their unique situation.

There is much in the literature written about the benefits of and how to initiate pump therapy. I do not see much written, however, on when and how to take a patient off of an insulin pump.

Readers: Do you have experience with transitioning patients off of insulin pumps? I am interested in hearing your thoughts.

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Jennifer's bone density report stated that lumbar spine bone mineral density was + 3.2 and that bone density was "normal". Each vertebra, L1-L4, had a BMD T-score greater than +2.0. To report this as "normal" was clearly wrong, but I have become so used to misread reports from this center that nothing surprises me any more. Hopefully, some day, these rogue "Osteoporosis Centers" will be recognized as such. But I am not holding my breath.

There are many circumstances where BMD might indeed be greater than +2.0, either at the spine or proximal femur, and possibly the forearm, but I cannot recall offhand a high forearm BMD. Each occurrence requires correct reporting with a follow-up imaging study to ascertain the reason for the high bone density.

In the lumbar spine, degenerative disc disease is common and will occasionally result in such high values, as was the case in my patient. Paget's disease affecting the spine and/or proximal femur is often associated with high bone mass and that diagnosis might be made on careful review of the BMD images. Paget's disease in the spine does not often involve contiguous vertebrae such that an affected vertebra will be denser and larger than the others. Adjacent vertebrae not affected by Paget's would not have high BMD values. Paget's affecting the proximal femur is usually characterized by an unusual shape (bending) or coarse architecture and there may also be changes in the pelvic brim visible in some DXA studies. Osteoblastic metastases are also common in the spine but involvement of four contiguous vertebrae is not common.

Any T-score greater than +2.0 at any skeletal site requires careful review of the original DXA scan and, if confirmed, appropriate imaging!!

"Rugger jersey"¹ spine (see figures below) is seen in a variety of genetic skeletal disorders collectively grouped as osteosclerosis ² and also in some patients with advanced renal osteodystrophy. In most of these cases, the diagnosis is well established before any bone mineral testing is considered. The genetics of inherited disorders with high bone mass is being unraveled³.

The two citations in PubMed are worth reading should you encounter a patient with a high BMD that cannot be accounted for by sloppy technology.

For more information:

• ¹"Rugger jersey" is descriptive of the striped jerseys often worn in the past by rugby union and rugby league teams. Based on the recent Rugby World Cup in New Zealand over the last few months the stripes have gone out of fashion.
• ² Ihde LL. Radiographics. 2011; 31:1865-1882.
• ³ Bénichou O. Am J Hum Genet. 2001; 69:647-54.

Radiological features of female patient CII-2 at age 45 years.

Figure A: Lumbar-spine standard radiograph showing thickened and sclerotic vertebral end plates. This feature, usually named "Rugger-Jersey spine," is characteristic of ADO type II.	Figure B: Pelvic-front standard radiograph with bone-within-bone sign-usually consisting of concentric bands of sclerosis in round and flat bones, especially in the iliac wings.

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A 47-year-old woman came to see me regarding hyperthyroidism. She had previously been treated for hyperthyroidism due to Graves' disease 8 years earlier. At that time, she decided on management with antithyroid medication. After 18 months of therapy, the methimazole was stopped. She remained euthyroid until recently.

Her primary care provider told her that the best option would now be radioactive iodine therapy, given that she had been previously treated with antithyroid medication and the hyperthyroidism had recurred. She requested to see me for a second opinion.

I am often asked by both patients and referring colleagues: what is the best treatment of hyperthyroidism? There is no single best treatment. The chosen treatment depends on the situation and the needs and desires of the patient.

Endocrinologists have successfully used radioactive iodine therapy for treatment of hyperthyroidism for decades. It often "cures" the hyperthyroidism, but results in iatrogenic hypothyroidism, with most patients requiring lifelong thyroid hormone replacement therapy. However, it cannot be used in women who are pregnant or who are planning on becoming pregnant in the near future. In patients with milder hyperthyroidism and/or those who are unsure about proceeding with something so permanent, radioactive iodine therapy may not be the best option, at least not immediately.

Antithyroid medication has the benefit of being reversible and is not permanent. Many patients go into remission after being on antithyroid medication for a time. In a patient who is unsure of how to proceed, I often offer a trial of methimazole to start. If antithyroid medication is ineffective or the patient decides to proceed with more permanent treatment, then radioactive iodine or surgery may be considered. Antithyroid medication does have the potential for rare but serious side effects, including leukopenia and hepatotoxicity, which is usually, but not always, reversible with cessation of therapy.

Finally, surgery may be considered. It is the treatment of choice in people who need rapid control of hyperthyroidism (such as in severe thyrotoxicosis or thyroid storm); those who do not respond, cannot take or choose not to proceed with antithyroid medication or radioactive iodine; or those with other specific situations (such as a patient who also has a nodule suspicious for cancer). However, there are potential risks associated with surgery, including nerve injury or hypoparathyroidism.

After discussion, the patient and I decided to try methimazole again. It worked in the past without side effects. It may be effective again now. If not, we have other options to discuss.

The American Association of Clinical Endocrinologists and the American Thyroid Association released updated guidelines for the management of hyperthyroidism earlier this year. The guidelines suggest physicians explain the benefits and disadvantages of each treatment option with the patient in detail "to allow the final decision to incorporate the personal values and preferences of the patient." This last statement seems obvious to clinicians. Nonetheless, I am glad that the authors included it. The preferences of the patient must always be taken into account!

What is the best treatment of hyperthyroidism? It depends!

For more information:

• AACE Hyperthyroidism Management Guidelines, Endocr Pract. 2011; 17(No. 3) (https://www.aace.com/sites/default/files/HyperGuidelines2011.pdf )

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