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Check out this file: protocol of management of hypothyroidism aconsensus of GCC (1)

Diagnosis and treatment of hypothyroidism

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Check out this file: protocol of management of hypothyroidism aconsensus of GCC (1)

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  1. Protocol for Management of Hypothyroidism: A consensus of GCC Countries A Thyroid Roadmap Guidance for healthcare professionals addressing the management of hypothyroidism in GCC Countries. Written by the Saudi Arabia and Gulf Thyroid Advisory Board Presented by Professor mohammed Ahmed Bamashmos (MD)

  2. Objectives • to educate the health care physicians on the protocol for management of hypothyroidism • After attending this lecture the HCP will be able to know how to do patient screening • Will understand how to manage hypothyroidism in pregnancy, new born and obese patients • will know the algorithm of hypothyroidism management. • Will know the exact dosing of levothyroxine to be used with each patients

  3. Disclosures PB is in receipt of an honorarium from Merck during this Meeting lecture. However, Merck have had no influence on the content and views expressed during this lecture

  4. Introduction Rationale for the diagnosis and management of hypothyroidism roadmap • Hypothyroidism is caused by inadequate production of thyroid hormones or inadequate replacement following thyroidectomy which leads to low circulating and tissue levels of thyroid hormones1 • As hypothyroidism is common and frequently underdiagnosed, millions of people worldwide are unaware that they have the disease and remain untreated1 • In the GCC (Gulf Cooperation Council) countries, the prevalence of hypothyroidism ranges from 7% to 41%, and rates of subclinical hypothyroidism are typically more than twice that reported in the USA2,3 • A high prevalence rate of hypothyroidism is typical among pregnant women in the GCC countries4 • Untreated hypothyroidism can contribute to hypertension, dyslipidemia, infertility, cognitive impairment, and neuromuscular dysfunction1 • There are currently inconsistency and some controversies in the management of hypothyroidism in the GCC countries • This roadmap has been developed by leading GCC endocrinologists and policy advisors to provide recommendations on the diagnosis and management of hypothyroidism in the GCC countries

  5. Patient Screening It is recommended that the following patients be screened for hypothyroidism by measurement of plasma Thyroid stimulating hormone (TSH) level. Figure 1: Screening recommendations5 Figure 1: Screening recommendations5 Screen the following patient groups for possible hypothyroidism Pregnant patients with a history of: Patients with 4 or more of the following symptoms: Patients with a history of: Plasma TSH measurement

  6. Diagnosis of hypothyroidism  Patients who are found to have an elevated TSH level are classified into two groups according to their free thyroxine (FT4) level; subclinical and overt hypothyroidism. Figure 2: Determining pathways for hypothyroidism patients1,6,7 Patient tested for TSH and FT4 levels TSH is elevated (>10 mu/l) and FT4 is low Patient has elevated TSH, but normal FT4 Diagnosed as having overt hypothyroidism  and should be treated Diagnosed as having subclinical hypothyroidism and the management algorithm on the next page is recommended to be followed

  7. When administration of levothyroxine is necessary • Hypothyroidism is a common endocrine disease that requires timely and lifelong treatment since, if left untreated, it can contribute to hypertension, dyslipidaemia, and heart failure and induce reversible dementia and infertility, as well as neurosensory, musculoskeletal, and gastrointestinal symptoms [7]. There is currently no other treatment for hypothyroidism, other than providing thyroid hormone replacement.

  8. Due to its long half-life of about 7 days, in patients in the clinically euthyroid state, levothyroxine is the preferred first-line treatment for primary hypothyroidism and has been the most commonly prescribed treatment since the 1980s [8].

  9. Management of Hypothyroidism  This algorithm shows how patients with overt and sub-clinical hypothyroidism should be managed.  Figure 3: Management algorithm for patient with hypothyroidism  Elevated TSH Overt hypothyroidism Subclinical hypothyroidism Repeat TSH in1–3 months TSH > 10 mU/I for second time TSH level 5-10 mU/I for second time Thyroid peroxidase (TPO) - antibody positive Thyroid peroxidase (TPO) - antibody negative Compelling indication* No compelling indication* *Compelling indication: Infertility, recurrent abortions, pregnancy, goiter, childhood, significant persistent hypothyroid symptoms Treat Observe

  10. Levothyroxine treatment dosing schedule  The following table provides the levothryoxine dosing schedule: Figure 4: How should levothyroxine be taken?1,6 Levothyroxine should be taken:  • On an empty stomach  • At least 1 hour before the meal, usually the breakfast  These drugs should be administered at least 4 hours either side of levothyroxine dose to minimize possible interactions:  • Calcium supplements  • Proton-pump inhibitors  • Bile acid sequestrants (cholestyramine and colesevelam)  • Biophosphonates  • Ferrous sulfate  • Aluminium-containing antacids  • Sucralfate  • Anticonvulsants

  11. Factors that should be considered • 1- age • 2- sex • 3- body weight • 4- pregnancy • 5- medical conditions • 6- medication

  12. Risk factors that should be considered

  13. Starting dose

  14. Starting dose

  15. Management of adults Figure 5: Management of adult patients6 Newly diagnosed, healthy, young to middle aged patients (<65 years of age) who have no comorbidities or cardiovascular risk factors Full levothyroxine starting dose: 1.6 μg/kg body weight

  16. Management of elderly patients Figure 6. Management of elderly patients 6,8 In the elderly, the TSH level may normally be slightly over the normal range and therefore should not be automatically treated. It is recommended to look for the following before initiating treatment Symptoms or signs suggestive of hypothyroidism, associated cardiovascular disease or multiple risk factors for cardiovascular disease, and/or positive anti TPO antibodies No signs or symptoms Levothyroxine therapy could be considered at starting dose of 25–50mcg/day, raised by 25mcg every 1–2 weeks until the full dose is reached A period of observation and reassessment is recommended

  17. Management of pregnant women Figure 7. Management of pregnant women8 Levothyroxine-titrated dose to keep TSH within trimester-specific range  • First trimester: 0.1–2.5 mU/l  • Second trimester: 0.2–3.0 mU/l  • Third trimester: 0.3–3.0 mU/l Serum thyrotropin levels assessed every 4 weeks during first half of pregnancy to allow dose adjustment  Serum thyrotropin reassessed during second half of pregnancy every 4-6 weeks to allow dose adjustment 

  18. Body weight • Weight in kg × 1.6ug/ kg / day • Or the following formula weight in Kg – ( age in years + 125) levothyroxine dose = 107 + ( 0.69 ×TSH)

  19. According to etiology • 1 – autoimmune • Full dose • 2– post surgical • - subtotal . Total • in case of total thyroidectomy or autoimmune thyroiditis , starting dose is 1.6 ug /kg /day • In case of total thyroidectomy due to cancer give suppressive dose of levothyroxine 2-2.5 ug to keep Ft4 is about 1/3 above the reference range

  20. indication of levothyroxine therapy SCH

  21. Subclinical hypothyroidism • TSH ≤ 10 miu per L 50 mcq daily increase by 25 mcq daily every 6 weeks until TSH = .3- 5.5 miu per L • TSH ≥ 10 miu per L ; 1. 6 mcq / kg ./ day

  22. Treatment target • Levothyroxine starting dose  • • Neonates to 6 months: 10-15 mcg/kg/day  • • 6 months to 1 year: 8-10 mcg/kg/day  • • 1-2 years: 6-8 mcg/kg/day  • • Older than 2 years: 5-6 mcg/kg/day

  23. Treatment target

  24. Treatment adjustment factors that could be considered 1- age and sex 2- body weight 3- patients adherence 4- timing of dose 5- pregnancy 6- use of certaion medication 7- associated medical diseases 8- ovoid over or under replacements

  25. Levothyroxine dose Escalation therapy Time ; every 1-3 or 3-4 weeks Increase dose according to • Age Middle and young people increase by 50 -75 Old age by 25 – 50ug Old age with CVD by 12.5 - 25 • Weight. : same as adult

  26. - pregnancy by 30%

  27. Medical conditions as CVD , osteoporosis : by 12.5 • Follow up increase or decrease levothyroxine dose every 1--3 weeks or 3-4 weeks until TSH is within target range then every 4-6 months then annually Sequels ; • patients with TSH level are within target range but still suffering from symptoms of hypothyroidism • Consider the underlying causes

  28. Treatment follow up After 4- 6 weeks of starting levothyroxine dose If treatment target is reached Then check TSH every 6 months then annually If treatment target is reached and patients still have symptoms of hypothyroidism Consider the following

  29. If treatment target is not reached Increase levothyroxine dose by 12.5 to 25 ug per day and recheck TSH level after 4- 6 weeks If patients receive optimal dose of levothyroxine 2ug / kg /day and TSH level is not in the target range and patients still suffering from symptoms of hypothyroidism consider refractory hypothyroidism P

  30. Patients who receive optimal dose of levothyroxine 2ug /kg /day and TSH level still not in target range and patients still suffering from symptoms and signs of hypothyroidism ; consider refractory hypothyroidism

  31. Refractory hypothyroidism

  32. Treatment of refractory hypothyroidism • 1- verify adherence , check for interfering medication • If patients is adherence and no interfering medication • so increase dose by 12.5 to 25 mcq daily • if no improvement in TSH or symptoms . Refer to endocrinologist

  33. Case report

  34. Key summary points Hypothyroidism is common, but often underdiagnosed disease. All patients at-risk or possible risk of hypothyroidism should undergo measurement of plasma TSH level. The decision to initiate treatment depends on multiple factors including baseline TSH and FT4 levels, symptoms and signs, TPO-positivity, comorbidities, patient age, fertility, thyroid size and other factors. Pregnant women, elderly patients, and children have different clinical considerations and/or TSH cut-off levels which require different thyroid replacement approaches and doses. These expert recommendations should help to guide clinicians in the diagnosis and management of patients with hypothyroidism in GCC countries. 

  35. References  • Gaitonde DY, Rowley KD, Sweeney LB. Hypothyroidism: An Update. Am Fam Physician. 2012; 86: 244–251. • Al Shahrani AS, El-Metwally A, Al-Surimi K, et al. The epidemiology of thyroid diseases in the Arab world: A systematic review. J Public Health Epidemiol. 2016; 8: 17–26. • Taha I, Alhazmi J. Prevalence of overt and subclinical hypothyroidism among Saudi pregnant women attending tow referral hospitals in Saudi Arabia and associated maternal and fetal complications. Endocrine Abstracts 2011; 25: P312.  • Canaris GJ, Manowitz NR, Mayor G, Ridgway EC. The Colorado thyroid disease prevalence study. Arch Intern Med. 2000; 160: 526–534. • Garber JR, Cobin RH, Gharib H, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. 2012; 18: 988-1027.  • Jonklaas J, Bianco AC, Bauer AJ, et al,. Guidelines for the treatment of hypothyroidism.Thyroid 2014; 24: 1670–1751. • Surks MI, Ortiz E, Daniels GH, et al. Subclinical thyroid disease: scientific review and guidelines for diagnosis and management. JAMA. 2004; 291: 228-238. • Stagnaro-Green A, Abalovich M, Alexander E, et al.Guidelines of the American Thyroid Association forthe diagnosis and management of thyroid disease during pregnancy and postpartum. Thyroid 2011; 21:1081–1125. Contact details For further information, please contact medicaleducation@springer.com ©2018 Springer Healthcare This roadmap is made possible thanks to an educational grant received from Merck Serono Middle East FZ-LLC

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