A joint webinar series of the Philippine Thyroid Association (PTA) - PSGS - PAHNSI - PSUS Thyroid Symposium delivered via Zoom.

1. Options in Managing Hyperthyroidism in the Time of Covid-19
Jeremy F. Robles, MD, FPCP, FPSEDM
PSGS - PAHNSI - PSUS - PTA Thyroid Symposium
MAY 22, 2020 Online Series via Zoom

2. Outline
• Philippine Prevalence of thyroid disease / hyperthyroidism
• Pre-covid management of Hyperthyroidism
• Peri-Covid 19 management of Hyperthyroidism
• Issues on Covid-19 and Hyperthyroidism
• Keypoints and Perspectives

3. The Philippine Thyroid Diseases Study (PhilTiDeS 1):
Prevalence of Thyroid Disorders Among Adults in the
Philippines
The Philippine Thyroid Diseases Study (PhilTiDeS 1) JAFES Vol. 27 No. 1 May 2012
• Philippine Prevalence of thyroid dysfunction = 8.53%.
• Half of the hyperthyroid patients have goiter
• Distribution based on thyroid Function Status
Thyroid Function Status Prevalence, N
(%)Normal 4480 (91.47)
Subclinical Hyperthyroidism 258 (5.33)
Subclinical Hypothyroidism 110 (2.18)
True Hyperthyroidism 30 (0.61)
True Hypothyroidism 19 (0.41)
Total 4897 (100)

4. Demographic & Biochemical
Characteristics of the Population
The Philippine Thyroid Diseases Study (PhilTiDeS 1) JAFES Vol. 27 No. 1 May 2012
• Mean Age 51 yo
• Females predominate (23:7)
• Mean FT4: 2.77 ng/dl
• Mean TSH: 0.10 uIU/ml
• Mean Age 43 yo
• Female to Male (1:1)
• Mean FT4: 1.05 ng/dl
• Mean TSH: 1.9 uIU/ml

5. 2016 American Thyroid Association Guidelines for
Diagnosis and Management of Hyperthyroidism
and Other Causes of Thyrotoxicosis
2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis
• United States prevalence of hyperthyroidism is approximately
1.2% (0.5% overt and 0.7% subclinical)
• Most Common causes include Graves’ disease (GD) then toxic
multinodular goiter (TMNG), and toxic adenoma (TA)
• GD is an autoimmune disorder in which the Thyroid Stimulating
Hormone Receptor Antibody (TRAb) stimulate the receptor
increasing thyroid hormone production & release

6. Causes of Thyrotoxicosis
2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis
• Normal or Elevated
RAI uptake on neck
• Grave’s Disease
• Toxic Adenoma
• Trophoblastic Disease
• TSH Pituitary adenoma
• Resistance to thyroid
hormone
• Near absent RAI uptake on neck
• Painless Thyroiditis
• Amiodarone Induced Thyroiditis
• Acute / Subacute Thyroiditis
• Palpation Thyroiditis
• Iatrogenic Thyroiditis
• Factitious Ingestion thyroid hormone
• Struma ovarii
• Metastasis from FTC

7. Approach to Hyperthyroidism
2018 European Thyroid Association Guideline for the Management of Graves’ Hyperthyroidism

8. Smith TJ, Hegedüs L. N Engl J Med 2016;375:1552-1565.
Beta Blockers
Antithyroids
Radioiodine Tx
Thyroidectomy
Therapeutic Options for Grave’s Disease

9. Clinical Situations That Favor a Particular Modality as
Treatment for Graves’ Hyperthyroidism
2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis
Clinical Situations RAI ATD Surgery
Pregnancy X // ! / !
Co-morbidities w/ increased surgical risk &/or morbid // / X
Liver disease // ! /
Major adverse reactions to ATD // X /
Previously operated or externally irradiated necks // / !
Lack of access to high volume Thyroid Surgeon // / !
High Likelihood of Remission / // /
Patients with Periodic Paralysis // / //
Patients with right Pulmonary Hypertension or CHF // / !
Elderly with comorbidities / / !
Thyroid Malignancy confirmed or suspected X - //
One of more large thyroid nodules - / //
Coexisting primary hyperparathyroidism for surgery - - //
// = preferred therapy; / = acceptable therapy; ! = cautious use;
- = not first-line therapy but may be acceptable depending on the clinical circumstances; X = contraindication

10. Radioiodine Therapy in the
Treatment of Grave’s Disease
2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis
• Beta Blockers for all patients with symptomatic thyrotoxicosis.
• Pretreatment with Methimazole (MMI) in patients with increased risk for
complications and discontinued 2 - 3 days prior to RAI therapy.
• Medical therapy of any co-morbid conditions optimized prior to RAI
therapy.
• Consider resuming MMI 3-7 days post RAI for high risk for complications
• Follow up post RAI after 1–2 months which include an assessment of
free T4, total T3, and TSH. Biochemical monitoring should be continued
at 4- to 6-week intervals for 6 months, or until the patient becomes
hypothyroid and is stable on thyroid hormone replacement.

11. Smith TJ, Hegedüs L. N Engl J Med 2016;375:1552-1565.
Beta Blockers
Antithyroids
Radioiodine Tx
Thyroidectomy
Therapeutic Options for Grave’s Disease
During
COVID-19
Pandemic
X (relative)
X
Limited
Options

12. Then came COVID-19 . . .

13. Global Pandemic with local implications
https://ourworldindata.org/grapher/coronavirus
Philippine CFR (6.47 %)
is at par
with the Global CFR (6.64 %)

14. A new Era of Healthcare
• Community Quarantine restrict
movement of people.
• Medical priorities revised
(Covid-19 directed)
• Limited Surgical and Nuclear
Medicine procedures
• Outpatient clinics closed, no
access to healthcare providers
• Telemedicine and e-health
solutions
• Global initiatives to find
cure/ vaccine
• Social consciousness and
heightened awareness
Problems Solutions

15. Limited Data on Thyroid Management
during Covid-19 pandemic

16. BTA/SFE statement regarding issues specific to thyroid dysfunction
during the COVID -19 pandemic (hyperthyroidism)
• Are individuals taking antithyroid drugs at higher risk of infection?
• ATDs not known to increase infection, unless with neutropenia, (very rare)
• Lymphopenia common w/ COVID-19 infection & is not an indication to stop ATDs.
• How should we advise patients who are at risk of neutropenia due to ATD
therapy?
• Symptoms of neutropenia (sore throat, mouth ulceration, fever, flu-like illness) may
overlap with COVID-19 infection (fever, new continuous cough, flu-like illness)
• Doctors discretion to check for COVID-19. Patients may stop the ATD and restart
one week later if symptoms have resolved. If symptoms worsen during the period
off ATDs or recur after recommencing the drug, the patient should seek urgent
medical attention; in such situations performing a FBC is essential.
https://www.british-thyroid-association.org/sandbox/bta2016/management-of-thyroid-dysfunction-during-covid-19_final.pdf
BTA/SFE Advice regarding resource-limited treatment of
thyrotoxicosis during the COVID-19 pandemic

17. BTA/SFE statement regarding issues specific to thyroid dysfunction
during the COVID -19 pandemic (hyperthyroidism)
• How should blood testing be performed for individuals on treatment for
thyrotoxicosis?
• Management of thyrotoxicosis should continue to be informed by results of TFT’s.
• May be difficult or impossible to perform such biochemical monitoring; in this
exceptional circumstance, we suggest that a block & replace regimen for
management of thyrotoxicosis is considered.
https://www.british-thyroid-association.org/sandbox/bta2016/management-of-thyroid-dysfunction-during-covid-19_final.pdf
BTA/SFE Advice regarding resource-limited treatment of
thyrotoxicosis during the COVID-19 pandemic
•Is it safe to defer definitive treatment for thyrotoxicosis?
• Defer radioiodine treatment . . .based on prioritization of delivery of emergency
care as well as anticipated difficulties with patients being unable to adhere to
radiation protection guidance during the COVID-19 pandemic.
• Uncontrolled thyrotoxicosis may require urgent surgery
• Post RAI - low threshold for commencing thyroxine therapy, monitor

18. BTA/SFE statement regarding issues specific to thyroid dysfunction
during the COVID -19 pandemic (hyperthyroidism)
•Are patients who have had radioiodine therapy or thyroid surgery at higher
risk of coronavirus infection? There is no evidence that patients who have
recently had radioiodine or thyroid surgery for benign thyroid disease are at
increased risk of general viral infection.
https://www.british-thyroid-association.org/sandbox/bta2016/management-of-thyroid-dysfunction-during-covid-19_final.pdf
BTA/SFE Advice regarding resource-limited treatment of
thyrotoxicosis during the COVID-19 pandemic
•Are there any considerations regarding supply of medication?
• . . . stockpiling of any medication should be avoided, in order to ensure sufficient
supply for all in the community.
• . . . adequate supply of medication and also that they adhere to social distancing
guidelines when ordering and collecting medication. Requests for repeat
prescriptions should be made early.

19. BTA/SFE Advice regarding resource-limited treatment of
thyrotoxicosis during the COVID-19 pandemic
“block and replace regimen”
v1 25th March 2020
• “block” hormone production from the
thyroid gland
• “replace” thyroid hormone by addition
of thyroxine once the patient is
euthyroid
• Allows euthyroidism to be achieved
and maintained, irrespective of
aetiology
https://www.british-thyroid-association.org/sandbox/bta2016/
management-of-thyrotoxicosis-during-covid-19_final.pdf

20. https://www.thyroid.org/covid-19/coronavirus-frequently-asked-questions/
Differentiating Covid-19 and Methimazole side effects
• Agranulocytosis - rare side-effect of antithyroid medications (0.2-0.5 %)
• Immune cells fighting infection decrease - fever, sore throat
• Signs and symptoms of antithyroid side-effect can overlap with Covid-19 infection.
• Quarantine at home if this occurs.
• Seek immediate medical attention if symptoms that seem urgent of life threatening.
• Any patient with new fever, cough, or other typical symptoms of COVID-19 infection
should seek medical attention immediately, regardless of methimazole use.
• Best to contact your Endocrinologist or other provider to determine how best to be
evaluated.

21. BTA/SFE statement regarding issues specific to thyroid dysfunction
during the COVID -19 pandemic (hyperthyroidism)
Graves’ Disease or Hyperthyroidism
• There is currently no evidence that individuals with autoimmune thyroid disease
have an increased risk of COVID-19 infection.
• It is crucial to continue taking your medications as prescribed. If your condition is
not being treated appropriately, you may be at increased risk of viral infection or
complications.
• Although rare, anti-thyroid medications used to treat Graves’ disease may cause
side effects that resemble symptoms of COVID-19, such as fever, sore throat and
muscle pain, as a result of a decrease in white blood cell count. If you experience
these symptoms, contact your healthcare provider immediately and mention that
you take thyroid medications.
https://www.aace.com/recent-news-and-updates/aace-position-statement-coronavirus-covid-19-and-people-thyroid-disease
AACE Position Statement: Coronavirus (COVID-19) and
People with Thyroid Disease

22. BTA/SFE statement regarding issues specific to thyroid dysfunction
during the COVID -19 pandemic (hyperthyroidism)
• Patients on maintenance Levothyroxine for hypothyroidism should continue their
prescribed doses of the drug until the ECQ is lifted and they are able to go back to
their physicians for follow up.
PTAAdvisory 2020
2020 PTA Advisory to Patients taking medications for thyroid
disorders during the Covid-19 Crisis (May 2, 2020)
• Patients taking antithyroid drugs, like methimazole, carbimazole or PTU to continue
their prescribed doses of these drugs until the ECQ is lifted and they are able to go
back to their physicians for follow up.
• Seek emergency consult should they experience sore throat, fever, chills to rule
out probable drug-related side effects
• We encourage everyone to stay indoors while we are on quarantine.

23. • 18 yo Female presented with sudden fever (37.5 °C), fatigue,
palpitations and anterior neck pain radiated to the jaw, Covid 19 (+)
Initial
Steroids
started
• March 20th the patient
started prednisone (25 mg/d)
gradually tapered with
improvement w/in 2 weeks
• First reported case of
subacute thyroiditis which
has been previously related to
viral infections

24. • Covid-19 pandemic is an unprecedented phenomenon. Extraordinary
measures required to keep everybody safe.
• Clinical presentation of Covid-19 may mimic a rare side effect of antithyroid
drugs. Immediate medical evaluation maybe warranted.
• Thyroid diseases not known to be associated with increased risk of viral
infections in general.
•Thyroid medications does not suppress the immune system.
• We ask patients to continue their antithyroid medications. Since delays on ff up
are expected. Dose adjustment may be needed based on clinical parameters if
labs are not feasible.
• Consult your doctor for further management is you suspect that you are not well.
Telemedicine maybe an option that you can consider.
Keypoints and Perspectives

25. Life after COVID-19
What will change?
• An unprecedented toll
on healthcare workers
• Diminishing trust in the
globalized world
• Focus on the healthcare
system
What can change?
• Get your new travel
document: the immunity
passport
• Surveillance as an
ongoing public health
measure
• Brand-new habits
What should change?
• Artificial intelligence as
a necessary tool
• A shift in the point-of-
care
• Sustainable solutions
https://medicalfuturist.com/life-after-covid-19-what-will-change/#
life will be significantly different after Covid-19 . . .

26. Options in Managing Hyperthyroidism in the Time of Covid-19
Jeremy F. Robles, MD, FPCP, FPSEDM
PSGS - PAHNSI - PSUS - PTA Thyroid Symposium
MAY 22, 2020 Online Series via Zoom