Hypothyroidism diagnosis and treatment

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
▶ 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
Rationale for the diagnosis and management of hypothyroidism roadmap

6. 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 thefollowingpatientgroups
for possible hypothyroidism
Patients with 4 or more of
the following symptoms:
Patients with a history of:
Plasma TSH measurement
Pregnant patients
with a history of:

8. 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

9. 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.

10. • 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].

11. Management of Hypothyroidism
This algorithm shows how patients with overt and sub-clinical hypothyroidism should be
managed.
Figure 3: Managementalgorithm for patient with hypothyroidism
Elevated TSH
Overt hypothyroidism Subclinical hypothyroidism
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*
Repeat
TSH in1–3
months
Observe
Treat
*Compelling indication: Infertility,
recurrent abortions, pregnancy, goiter,
childhood, significant persistent
hypothyroid symptoms

12. Levothyroxine treatment dosing schedule
The following table provides the levothryoxine dosing schedule:
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
Figure 4: How should levothyroxine be taken?1,6

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

14. Risk factors that should be considered

15. Starting dose

17. Starting dose

18. 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

19. Management of elderly patients
Figure 6. Managementof 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

20. Management of pregnant women
Figure 7. Managementof 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

22. 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)

23. 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

24. indication of levothyroxine therapy SCH

25. • 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

26. 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

28. Treatment target

29. 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

30. • 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

31. • - pregnancy by 30%

32. • 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

33. 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

35. 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

36. • 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

37. Refractory hypothyroidism

40. • 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

43. Case report

47. 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.

48. References
1. Gaitonde DY, Rowley KD, Sweeney LB. Hypothyroidism: An Update. Am Fam Physician. 2012; 86: 244–251.
2. 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.
3. 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.
4. Canaris GJ, Manowitz NR, Mayor G, Ridgway EC. The Colorado thyroid disease prevalence study. Arch Intern Med. 2000; 160:
526–534.
1. 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.
2. Jonklaas J, Bianco AC, Bauer AJ, et al,. Guidelines for the treatment of hypothyroidism.Thyroid 2014; 24: 1670–1751.
3. Surks MI, Ortiz E, Daniels GH, et al. Subclinical thyroid disease: scientific review and guidelines for diagnosis and
management. JAMA. 2004; 291: 228-238.
4. 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.
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This roadmap is made possible thanks to an educational grant received from Merck Serono Middle East FZ-LLC