Search

Context Levothyroxine (LT4) is recommended as replacement therapy for thyroid hormone deficiency. However, some hypothyroid patients receiving LT4 therapy do not feel as well as healthy subjects. This article aimed to review current knowledge regarding LT4 monotherapy versus LT4+LT3 combination therapy and propose future directions regarding LT4+slow release T3 combination treatment for hypothyroidism. Evidence acquisition We searched PubMed and Scopus using related keywords. Results The LT4 monotherapy causes higher serum free T4 (fT4), subnormal serum free T3 (fT3), and fT3/fT4 ratio in one-fourth of patients. The LT4+LT3 combination therapy increases serum T3 and fT3 concentrations and may normalize the fT3/fT4 ratio. However, the primary outcomes, including thyroid hormone deficiency, anxiety, depression, and quality of life, may not be better in LT4+LT3 combination therapy than in LT4 monotherapy. Recent surveys show that combination therapy is on the rise, in particular, due to patient demand. The LT4 plus slow-release LT3 preparation has shown promising results in improving serum thyroid hormone concentrations. Conclusions The beneficial effect of LT4+LT3 combination therapy is not clear, and the safety of long-term therapy is yet under question. More scientific well-designed research projects are required in this field.

Context: This review summarizes key findings of the Tehran thyroid study (TTS), a large scale community-based study with approximately a two decade follow-up, about the incidence, prevalence, and natural course of thyroid disorders as well as associations between thyroid diseases and metabolic syndrome (MetS), dysglycemia, and cardiovascular disease (CVD). Evidence Acquisition: PubMed, Scopus, and Web of Science databases, and the library of Research Institute for Endocrine Sciences were used to search for TTS articles. Articles were subdivided based on the fields of prevalence, incidence and natural course, and associations of thyroid function with the incident hypertension (HTN), MetS and CVDs. Results: The 2.5th and 97.5th percentiles of serum thyrotropin (TSH) were 0.32 and 5.06 mU/L, respectively. Estimated reference intervals (2.5th and 97.5th percentiles) for thyroid peroxidase antibody (TPOAb) levels were 1.5 - 32.8 and 2.1 - 35 IU/mL in men and women, respectively. Euthyroid persistency was 93.24% during 6 years. There was a negative association between free thyroxine (FT4) levels and insulin resistance. Decreasing FT4 values over time would predict MetS in euthyroid and subclinical hypothyroid subjects (TSH < 10 mU/L). The incidence of thyroid disorders in patients with diabetes, pre-diabetes and healthy controls was 14, 18, and 21 per 1000 person-years, respectively, indicating significantly lower incidence in individuals with diabetes compared to healthy controls. Serum FT4 within the reference range was positively associated with all blood pressure (BP) measures in the total population and in men; however, serum TSH was positively associated with only systolic BP (SBP), diastolic BP (DBP) and mean arterial pressure of men. No associations were found between various states of thyroid function and prevalence and incidence of CVD. Conclusions: A well designed cohort study aimed to investigate the gap in knowledge regarding thyroid disorders can generate many hypotheses to be examined in randomized controlled trials.

Context Insulin can be prescribed as a monotherapy or a combined therapy with other anti-diabetic medications. In this narrative review, the authors aimed to gather data related to comparison of insulin monotherapy versus combination of insulin and other anti-diabetic treatments with regards to different outcome measures in type 2 diabetes. Evidence acquisition This study searched and focused on the most recently published systematic reviews and their references investigating issues related to the primary aim. Results The current data available on this topic is heterogeneous and suffers from low quality with respect to most combination treatments. Considering the efficacy and safety of combination therapy of insulin with older hypoglycemic agents, in general metformin and pioglitazone have the best and worst profiles, respectively. Compared to insulin monotherapy, combination of insulin and metformin is associated with better glycemic control, reduced daily insulin dose, less hypoglycemia, and weight gain; combination of insulin and pioglitazone results in greater hypoglycemia and weight gain and is associated with increased risk of edema and heart failure. Regarding sulphonylurea, there is some concern regarding hypoglycemia and weight gain. Addition of dipeptidyl peptidase-4 inhibitors to insulin seems to be beneficial with respect to glycemic control without any significant adverse effects. New drugs, including glucagon-like peptide-1 agonists and sodium glucose co-transporter 2 inhibitors, have acceptable profiles with significant benefits regarding weight reduction when added on insulin therapy. Conclusions Considering the quality and longevity of evidence, compared to insulin monotherapy, insulin combined with metformin and pioglitazone has the best and worst profiles, respectively. New anti-diabetic medications have acceptable profiles yet are expensive. It is important for clinicians to meticulously weigh the advantages of combination therapy against the possible adverse effects with each drug class in every patient, individually.

Background and Objectives: Thyroid disorders during pregnancy are important health problems worldwide. The aim of this study was to assess the knowledge of general practitioners (GPs) about thyroid disorders during pregnancy. Methods: In this cross sectional study, 120 GPs were randomly selected among participants of a continuous medical education (CME) program, entitled “practical endocrinology”. To assess the knowledge and educational requirements of GPs regarding thyroid disorders during pregnancy, a validated and localized multiple-choice questionnaire was used. Results: A total of 100 GPs completed the questionnaire. The mean age of the participants was 37.0 years, and 41.4% were men. The mean knowledge score of GPs was 39.9%. On average, the rate of correct response to questions concerning the definition, pathophysiology, diagnosis, complications, and treatment of thyroid disorders was 39.0%, 39.3%, 48.8%, 34.3%, and 44.6%, respectively. There was a significant difference in knowledge among GPs, who had and had not passed the training course on thyroid disorders. In addition, GPs who had passed continuous medical education programs obtained higher knowledge scores regarding diagnosis and treatment (P < 0.05). Conclusions: GPs attending pregnant women in Iran lack sufficient information on the pathophysiology, diagnosis, and management of thyroid disorders during pregnancy. Considering the key role of GPs in the public healthcare system, design of high-quality educational programs and development of specific educational packages about thyroid disorders and pregnancy are necessary.

Context: Neonatal mass screening program for congenital hypothyroidism provides the best tool for prevention of its devastating effects on mental development. Despite the overall success of the screening programs in detecting congenital hypothyroidism and eliminating its sequelae and new developments made in the program design, high recall rate and false positive results impose a great challenge worldwide. Lower recall rate and false positive results may properly organize project expenses by reducing the un- necessary repeated laboratory tests, increase physicians and parents’ assurance and cooperation, as well as reduce the psychological effects in families. Evidence Acquisition: In this review, we assessed the recall rate in different programs and its risk factors worldwide. Methods: Publications reporting the results of the CH screening program from 1997 to 2016 focusing on the recall rate have been searched. Results: Recall rates vary from 0.01% to 13.3% in different programs; this wide range may be due to different protocols of screening (use of T4 or TSH or both), different laboratory techniques, site of sample collection, recall cutoff, iodine status, human error, and even CH incidence as affected by social, cultural, and regional factors of the population. Conclusions: It is suggested to implement suitable interventions to reduce the contributing factors by improving the quality of laboratory tests, selecting conservative cut off points, control iodine deficiency, use of iodine free antiseptic during delivery, and use of more specific markers or molecular tests. Applying an age dependent criteria for thyrotropin levels can be helpful in regions with a varied time of discharge after delivery or for preterm babies.

Background: Maternal thyroid disease in pregnancy is associated with adverse impact on both mother and fetus. Both the American thyroid association and the endocrine society have recently published guidelines for the management of thyroid disease in pregnancy. Objectives: The objective of this survey was to assess and compare the current practices of various East-Asian physicians in the screening and management of thyroid disease in pregnancy. Materials and Methods: Completed survey questionnaires were collected from 112 physicians of six East-Asian countries. The survey was based on clinical case scenarios, asking questions about the clinical practices related to diagnosis and management of thyroid disease during pregnancy. Reponses from 76 endocrinologists and 33 internists and general practitioners (generalists) were analyzed. Results: There were minor differences in treatment preferences for Graves’ disease in pregnancy and tests to monitor antithyroid drugs between endocrinologists and generalists; the major difference being targeted free thyroxin, and also thyroxin, depicted in the upper end of normal range, by the majority of endocrinologist and within the normal range, by generalists. Compared to generalists, endocrinologists perform more targeted screening and are more familiar with its risk factors. Predominantly, endocrinologists increase levothyroxine dose in hypothyroid women, upon confirmation of pregnancy and also indicate full dose in a pregnant woman, diagnosed with overt hypothyroidism, and treat thyroid peroxidase antibody positive or negative pregnant women with thyroid stimulating hormone (2.5 - 5 mU/L), as compared to generalists. Conclusions: There is wide variation in the clinical practices of screening and management of thyroid disorders during pregnancy in East-Asia, with many clinicians, in particular general practitioners, not adhering to clinical practice guidelines, unfortunately.