Diagnosis and Management of Hypothyroidism in Gulf Cooperation Council (GCC) Countries

Fahad Abdulrahman Alamri 6, Nasser R Al Juhani 7, Alhussien Sagr Alhazmi 8, Mohammad Yahya Saeedi 4 9, Saud Alsefri 10 11, Musa Daif Allah Alzahrani 12, Nadia Al Ali 13, Wiam I Hussein 14, Mohamed Ismail 15, Ahmed Adel 16, Hisham El Bahtimy 17, Eslam Abdelhamid 17

Affiliations

01 July 2020

-

doi: 10.1007/s12325-020-01382-2

Abstract

Hypothyroidism is one of the most common chronic endocrine conditions. However, as symptoms of hypothyroidism are non-specific, up to 60% of those with thyroid dysfunction are unaware of their condition. Left untreated, hypothyroidism may contribute to other chronic health conditions. In the Arabian Gulf States, hypothyroidism is thought to be common, but is underdiagnosed, and management approaches vary. An advisory board of leading Saudi endocrinologists and policy advisers was convened to discuss and formulate recommendations for the diagnosis and management of hypothyroidism in Saudi Arabia based on their clinical expertise. The final document was shared with leading endocrinologists from the other Gulf Cooperation Council (GCC) and aconsensus report was generated and summerized in this article. While there is no consensus regarding population screening of hypothyroidism, current recommendations suggest screening patients with risk factors, including those with a history of head or neck irradiation, a family history of thyroid disease or pharmacological treatment that may affect thyroid function. Evidence from a cross-sectional study in Saudi Arabia suggests screening the elderly (> 60 years), at least in the primary care setting. In Saudi Arabia, the incidence of congenital hypothyroidism is approximately 1 in every 3450 newborns. Saudi nationwide population prevalence data are lacking, but a single-centre study estimated that the prevalence of subclinical hypothyroidism in the primary care setting was 10%. Prevalence rates were higher in other cross-sectional studies exclusively in women (13-35%). The recommendations included in this article aim to streamline the diagnosis and clinical management of hypothyroidism in the GCC, especially in the primary care setting, with the intention of improving treatment outcomes. Further study on the incidence, prevalence and risk factors for, and clinical features of, hypothyroidism in the GCC countries is required.

Keywords: Hypothyroidism; L-thyroxine; Saudi Arabia; Subclinical hypothyroidism.

Similar articles

Diagnosis and management of osteoporosis in postmenopausal women in Gulf Cooperation Council (GCC) countries: consensus statement of the GCC countries' osteoporosis societies under the auspices of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO).

Al-Saleh Y, Al-Daghri NM, Sabico S, Alessa T, Al Emadi S, Alawadi F, Al Qasaabi S, Alfutaisi A, Al Izzi M, Mukhaimer J, Suhaili AR, Reginster JY, Sulimani R.Arch Osteoporos. 2020 Jul 22;15(1):109. doi: 10.1007/s11657-020-00778-5.PMID: 32700153

[Subclinical primary hypothyroidism in family practice].

Loor M, Giet D.Rev Med Liege. 2008 Oct;63(10):600-8.PMID: 19009968 Review. French.

Prevalence of subclinical hypothyroidism in pregnancy in Saudi Arabia.

Al Shanqeeti SA, Alkhudairy YN, Alabdulwahed AA, Ahmed AE, Al-Adham MS, Mahmood NM.Saudi Med J. 2018 Mar;39(3):254-260. doi: 10.15537/smj.2018.3.21621.PMID: 29543303 Free PMC article.

Hemodialysis delivery, dialysis dose achievement, and vascular access types in hemodialysis patients from the Gulf Cooperation Council countries enrolled in the dialysis outcomes and practice patterns study phase 5 (2012-2015).

AlYousef A, AlGhareeb S, Al Wakeel J, Al-Ghamdi SM, Bieber BA, Hassan M, Al Maimani Y, Alkandari N, Ahmed HZ, Fawzy A, Pisoni RL; GCC-DOPPS 5 Study Group.Saudi J Kidney Dis Transpl. 2016 Nov;27(6 Suppl 1):S42-50. doi: 10.4103/1319-2442.194889.PMID: 27991478

Hypothyroidism in elderly people.

Li TM.Geriatr Nurs. 2002 Mar-Apr;23(2):88-93. doi: 10.1067/mgn.2002.124325.PMID: 11956521 Review.

Cited by

Infant With Pseudohypoparathyroidism Type 1a, Misdiagnosed as Congenital Hypothyroidism.

Sakran WA, Al-Qahtani M, Alkhalifa M, Alqahtani A.Med Arch. 2023 Feb;77(1):70-73. doi: 10.5455/medarh.2023.77.70-73.PMID: 36923733 Free PMC article. Review.

Levothyroxine Timing during Ramadan: A Randomized Clinical Trial.

Mahzari M, Al Remthi F, Ajwah I, Al Hazmi M, Moafa W, Al Shahrani A, Al Shehri S, Badri M.Int J Endocrinol. 2023 Feb 10;2023:2565031. doi: 10.1155/2023/2565031. eCollection 2023.PMID: 36818804 Free PMC article.

A cross-sectional assessment of knowledge, awareness of risk factors, and perceptions of thyroid disease (TD) among adults living in Saudi Arabia - A community based study.

Alhazmi RA, Alobaid AM, Althunayyan SM, Syed W, Al-Rawi MBA.Front Public Health. 2022 Nov 23;10:1041745. doi: 10.3389/fpubh.2022.1041745. eCollection 2022.PMID: 36504924 Free PMC article.

Association of TSHR gene single nucleotide intronic polymorphism with the risk of hypothyroid and hyperthyroid disorders in Yazd province.

Naghibi FS, Miresmaeili SM, Javid A.Sci Rep. 2022 Sep 21;12(1):15745. doi: 10.1038/s41598-022-19822-0.PMID: 36130976 Free PMC article.

SARS-CoV-2: Emerging Role in the Pathogenesis of Various Thyroid Diseases.

Murugan AK, Alzahrani AS.J Inflamm Res. 2021 Nov 24;14:6191-6221. doi: 10.2147/JIR.S332705. eCollection 2021.PMID: 34853527 Free PMC article. Review.

References

  1.  
    1. Thyroid Foundation of Canada. About thyroid disease. Vol 20182018.
  2.  
    1. American Thyroid Association. General Information. Vol 2019: American Thyroid Association;2019.
  3.  
    1. De Benoist B, McLean E, Andersson M, Rogers L. Iodine deficiency in 2007: global progress since 2003. Food Nutr Bull. 2008;29(3):195–202. - PubMed
  4.  
    1. Vanderpump MP. The epidemiology of thyroid disease. Br Med Bull. 2011;99(1):39–51. - PubMed
  5.  
    1. Gaitonde DY, Rowley KD, Sweeney LB. Hypothyroidism: an update. South Afr Fam Pract. 2012;54(5):384–390.
  6.  
    1. Cooper DS. Subclinical hypothyroidism. N Engl J Med. 2001;345(4):260–265. - PubMed
  7.  
    1. La Vignera S, Vita R. Thyroid dysfunction and semen quality. Int J Immunopathol Pharmacol. 2018;32:2058738418775241. - PMC - PubMed
  8.  
    1. La Vignera S, Vita R, Condorelli RA, Mongioi LM, Presti S, Benvenga S, Calogero AE. Impact of thyroid disease on testicular function. Endocrine. 2017;58(3):397–407. - PubMed
  9.  
    1. Prevalence and consequences of thyroid dysfunction. In: Stone MB, Wallace RB, Committee on Medicare Coverage of Routine Thyroid Screening., eds. Medicare coverage of routine screening for thyroid dysfunction. Washington, D.C.: National Academy of Sciences; 2003. pp. 21–31.
  10.  
    1. Chaker L, Bianco AC, Jonklaas J, Peeters RP. Hypothyroidism. Lancet. 2017;390(10101):1550–1562. - PMC - PubMed
  11.  
    1. Hak AE, Pols HA, Visser TJ, Drexhage HA, Hofman A, Witteman JC. Subclinical hypothyroidism is an independent risk factor for atherosclerosis and myocardial infarction in elderly women: the Rotterdam Study. Ann Intern Med. 2000;132(4):270–278. - PubMed
  12.  
    1. Vanderpump MP, Tunbridge WMG. Epidemiology and prevention of clinical and subclinical hypothyroidism. Thyroid. 2002;12(10):839–847. - PubMed
  13.  
    1. Knudsen N, Jørgensen T, Rasmussen S, Christiansen E, Perrild H. The prevalence of thyroid dysfunction in a population with borderline iodine deficiency. Clin Endocrinol. 1999;51(3):361–367. - PubMed
  14.  
    1. Al Eidan E, Ur Rahman S, Al Qahtani S, Al Farhan AI, Abdulmajeed I. Prevalence of subclinical hypothyroidism in adults visiting primary health-care setting in Riyadh. J Community Hosp Internal Med Perspect. 2018;8(1):11–15. - PMC - PubMed
  15.  
    1. Hasanato R, Mirah JA, Al-Shahrahi N, Alfulayyih N, Almutairi A, Ogailan B, Fatma S. Incidence of thyroid diseases in female Saudi adults visiting a tertiary care hospital in Riyadh. Epidemiology (Sunnyvale). 2017;7(1):1000286.
  16.  
    1. Zimmermann MB, Galetti V. Iodine intake as a risk factor for thyroid cancer: a comprehensive review of animal and human studies. Thyroid Res. 2015;8(1):8. - PMC - PubMed
  17.  
    1. Hussain F, Iqbal S, Mehmood A, Bazarbashi S, ElHassan T, Chaudhri N. Incidence of thyroid cancer in the Kingdom of Saudi Arabia, 2000–2010. Hematol Oncol Stem Cell Ther. 2013;6(2):58–64. - PubMed
  18.  
    1. Islam MI, Ali MZ, Islam MS, Solayman M, Hoque S. Hypothyroidism—a new view on an old disease. KYAMC J. 2017;7(1):707–713.
  19.  
    1. Canaris GJ, Steiner JF, Ridgway EC. Do traditional symptoms of hypothyroidism correlate with biochemical disease? J Gen Intern Med. 1997;12(9):544–550. - PMC - PubMed
  20.  
    1. Ladenson PW, Singer PA, Ain KB, Bagchi N, Bigos ST, Levy EG, Smith SA, Daniels GH. American Thyroid Association guidelines for detection of thyroid dysfunction. Arch Intern Med. 2000;160(11):1573–1575. - PubMed
  21.  
    1. Baskin HJ, Cobin RH, Duick DS, Gharib H, Guttler RB, Kaplan MM, Segal RL, Garber JR, Hamilton CR, Jr., Handelsman Y, Hellman R, Kukora JS, Levy P, Palumbo PJ, Petak SM, Rettinger HI, Rodbard HW, Service FJ, Shankar TP, Stoffer SS, Tourtelot JB. American Association of Clinical Endocrinologists Medical Guidelines for clinical practice for the evaluation and treatment of hyperthyroidism and hypothyroidism. Endocr Pract. 2002;8(6):457–469 - PubMed
  22.  
    1. American Academy of Family Physicians . Summary of policy recommendations for periodic health examination. Leawood: American Academy of Family Physicians; 2002.
  23.  
    1. Surks MI, Ortiz E, Daniels GH, Sawin CT, Col NF, Cobin RH, Franklyn JA, Hershman JM, Burman KD, Denke MA. Subclinical thyroid disease: scientific review and guidelines for diagnosis and management. JAMA. 2004;291(2):228–238. - PubMed
  24.  
    1. Vanderpump MP, Ahlquist JA, Franklyn JA, Clayton RN. Consensus statement for good practice and audit measures in the management of hypothyroidism and hyperthyroidism. The Research Unit of the Royal College of Physicians of London, the Endocrinology and Diabetes Committee of the Royal College of Physicians of London, and the Society for Endocrinology. BMJ. 1996;313(7056):539–544. - PMC - PubMed
  25.  
    1. Helfand M. Screening for subclinical thyroid dysfunction in nonpregnant adults: a summary of the evidence for the U.S. preventive services task force. Ann Internal Med. 2004;140(2):128–141. - PubMed
  26.  
    1. Garber JR, Cobin RH, Gharib H, Hennessey JV, Klein I, Mechanick JI, Pessah-Pollack R, Singer PA, Woeber KA, for the American Association of Clinical Endocrinologists and American Thyroid Association Taskforce on Hypothyroidism in Adults. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Thyroid. 2012;22(12):1200–1235. - PubMed
  27.  
    1. Ross DS. Laboratory assessment of thyroid function. UpToDate, Cooper, DS (Ed), UpToDate, Waltham, MA. 2013.
  28.  
    1. Pearce SH, Brabant G, Duntas LH, Monzani F, Peeters RP, Razvi S, Wemeau JL. 2013 ETA Guideline: management of Subclinical Hypothyroidism. Eur Thyroid J. 2013;2(4):215–228. - PMC - PubMed
  29.  
    1. Wardle CA, Fraser WD, Squire CR. Pitfalls in the use of thyrotropin concentration as a first-line thyroid-function test. Lancet. 2001;357(9261):1013–1014. - PubMed
  30.  
    1. DeMartino L, McMahon R, Caggana M, Tavakoli NP. Gender disparities in screening for congenital hypothyroidism using thyroxine as a primary screen. Eur J Endocrinol. 2018;179(3):161–167. - PubMed
  31.  
    1. Jonklaas J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, Cooper DS, Kim BW, Peeters RP, Rosenthal MS. Guidelines for the treatment of hypothyroidism: prepared by the American Thyroid Association Task Force on Thyroid Hormone Replacement. Thyroid. 2014;24(12):1670–1751. - PMC - PubMed
  32.  
    1. Abbott Laboratories. Synthroid (levothyroxine sodium tablets, USP) [package insert]. Vol 12 April 2018. North Chicago, Ill2018.
  33.  
    1. Taylor PN, Eligar V, Muller I, Scholz A, Dayan C, Okosieme O. Combination thyroid hormone replacement; knowns and unknowns. Front Endocrinol (Lausanne). 2019;10:706. - PMC - PubMed
  34.  
    1. Saudi Arabia and Gulf Thyroid Advisory Board . Protocol for management of hypothyroidism: a consensus of GCC countries. A roadmap. London: Springer; 2018.
  35.  
    1. Vita R, Fallahi P, Antonelli A, Benvenga S. The administration of l-thyroxine as soft gel capsule or liquid solution. Expert Opin Drug Deliv. 2014;11(7):1103–1111. - PubMed
  36.  
    1. Bolk N, Visser TJ, Nijman J, Jongste IJ, Tijssen JG, Berghout A. Effects of evening vs morning levothyroxine intake: a randomized double-blind crossover trial. Arch Intern Med. 2010;170(22):1996–2003. - PubMed
  37.  
    1. Perez CLS, Araki FS, Graf H, de Carvalho GA. Serum thyrotropin levels following levothyroxine administration at breakfast. Thyroid. 2013;23(7):779–784. - PubMed
  38.  
    1. Irving SA, Vadiveloo T, Leese GP. Drugs that interact with levothyroxine: an observational study from the Thyroid Epidemiology, Audit and Research Study (TEARS) Clin Endocrinol. 2015;82(1):136–141. - PubMed
  39.  
    1. Liwanpo L, Hershman JM. Conditions and drugs interfering with thyroxine absorption. Best Pract Res Clin Endocrinol Metab. 2009;23(6):781–792. - PubMed
  40.  
    1. Benvenga S, Di Bari F, Vita R. Undertreated hypothyroidism due to calcium or iron supplementation corrected by oral liquid levothyroxine. Endocrine. 2017;56(1):138–145. - PubMed
  41.  
    1. Trifirò G, Parrino F, Sultana J, Giorgianni F, Ferrajolo C, Bianchini E, Medea G, Benvenga S, Cricelli I, Cricelli C. Drug interactions with levothyroxine therapy in patients with hypothyroidism: observational study in general practice. Clin Drug Investig. 2015;35(3):187–195. - PubMed
  42.  
    1. Chakera AJ, Pearce SH, Vaidya B. Treatment for primary hypothyroidism: current approaches and future possibilities. Drug Des Devel Ther. 2012;6:1–11. - PMC - PubMed
  43.  
    1. Greenspan SL, Greenspan FS. THe effect of thyroid hormone on skeletal integrity. Ann Intern Med. 1999;130(9):750–758. - PubMed
  44.  
    1. Schneider R, Schneider M, Reiners C, Schneider P. Effects of levothyroxine on bone mineral density, muscle force, and bone turnover markers: a cohort study. J Clin Endocrinol Metab. 2012;97(11):3926–3934. - PubMed
  45.  
    1. Faggiano A, Del Prete M, Marciello F, Marotta V, Ramundo V, Colao A. Thyroid diseases in elderly. Minerva Endocrinol. 2011;36(3):211. - PubMed
  46.  
    1. Alexander EK, Pearce EN, Brent GA, Brown RS, Chen H, Dosiou C, Grobman WA, Laurberg P, Lazarus JH, Mandel SJ, Peeters RP, Sullivan S. 2017 Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and the postpartum. Thyroid. 2017;27(3):315–389. - PubMed
  47.  
    1. Amr NH. Thyroid disorders in subjects with down syndrome: an update. Acta Biomed. 2018;89(1):132–139. - PMC - PubMed
  48.  
    1. Zou M, Alzahrani AS, Al-Odaib A, Alqahtani MA, Babiker O, Al-Rijjal RA, BinEssa HA, Kattan WE, Al-Enezi AF, Al Qarni A. Molecular analysis of congenital hypothyroidism in Saudi Arabia: SLC26A7 mutation is a novel defect in thyroid dyshormonogenesis. J Clin Endocrinol Metabol. 2018;103(5):1889–1898. doi: 10.1210/jc.2017-02202. - DOI - PubMed
  49.  
    1. De Felice M, Di Lauro R. Thyroid development and its disorders: genetics and molecular mechanisms. Endocr Rev. 2004;25(5):722–746. - PubMed
  50.  
    1. Grasberger H, Refetoff S. Genetic causes of congenital hypothyroidism due to dyshormonogenesis. Curr Opin Pediatr. 2011;23(4):421. - PMC - PubMed
  51.  
    1. Al-Jurayyan N, Al-Nuaim A, Redha M, El-Desouki M, Al AH, Abo AB, Al AS, Al YM, Al AD. Neonatal screening for congenital hypothyroidism in Riyadh: analysis of six year’s experience. Ann Saudi Med. 1996;16(1):20–23. - PubMed
  52.  
    1. Al-Jurayyan NA, Al-Herbish AS, El-Desouki MI, Al-Nuaim AA, Abo-Bakr AM, Al-Husain MA. Congenital anomalies in infants with congenital hypothyroidism: is it a coincidental or an associated finding? Hum Hered. 1997;47(1):33–37. - PubMed
  53.  
    1. Elbualy M, Bold A, De Silva V, Gibbons U. Congenital hypothyroid screening: the Oman experience. J Trop Ped. 1998;44(2):81–83. - PubMed
  54.  
    1. Ordookhani A, Mirmiran P, Moharamzadeh M, Hedayati M, Azizi F. A high prevalence of consanguineous and severe congenital hypothyroidism in an Iranian population. J Pediatr Endocrinol Metab. 2004;17(9):1201–1209. - PubMed
  55.  
    1. Fu C, Wang J, Luo S, Yang Q, Li Q, Zheng H, Hu X, Su J, Zhang S, Chen R. Next-generation sequencing analysis of TSHR in 384 Chinese subclinical congenital hypothyroidism (CH) and CH patients. Clin Chim Acta. 2016;462:127–132. - PubMed
  56.  
    1. Alenazi SA, Abdalla SH, Mohamed HT, Balla AA, Abukanna AM. Prevalence of congenital hypothyroidism in northern border region of Kingdom of Saudi Arabia. Indian Pediatr. 2017;54(2):154–155. - PubMed
  57.  
    1. Al-Jurayyan NA, Shaheen FI, Al-Nuaim AA, El-Desouki MI, Faiz A, Al Herbish AS, Abo Bakr AM, Al-Swailem AA, Al Mazrou YY. Congenital hypothyroidism: increased incidence in Najran province, Saudi Arabia. J Trop Pediatr. 1996;42(6):348–351. - PubMed
  58.  
    1. Saadallah AA, Rashed MS. Newborn screening: experiences in the Middle East and North Africa. J Inherit Metab Dis. 2007;30(4):482. - PubMed
  59.  
    1. Akbar DH, Ahmed MM, Hijazi NA. Subclinical hypothyroidism in elderly women attending an outpatient clinic. Med Sci Monit. 2004;10(5):CR229–CR232. - PubMed
  60.  
    1. 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. Endocr Abstr. 2011;25:P312.
  61.  
    1. Al Shanqeeti SA, Alkhudairy YN, Alabdulwahed AA, Ahmed AE, Al-Adham MS, Mahmood NM. Prevalence of subclinical hypothyroidism in pregnancy in Saudi Arabia. Saudi Med J. 2018;39(3):254–260. - PMC - PubMed
  62.  
    1. Stagnaro-Green A, Abalovich M, Alexander E, Azizi F, Mestman J, Negro R, Nixon A, Pearce EN, Soldin OP, Sullivan S. Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and postpartum. Thyroid. 2011;21(10):1081–1125. - PMC - PubMed
  63.  
    1. Bahammam SA, Sharif MM, Jammah AA, Bahammam AS. Prevalence of thyroid disease in patients with obstructive sleep apnea. Respir Med. 2011;105(11):1755–1760. - PubMed
  64.  
    1. Lamfon HA. Thyroid disorders in Makkah, Saudi Arabia. Ozean J Appl Sci. 2008;1(1):52–58.
  65.  
    1. Kahaly GJ. Cardiovascular and atherogenic aspects of subclinical hypothyroidism. Thyroid. 2000;10(8):665–679. - PubMed
  66.  
    1. Canaris GJ, Manowitz NR, Mayor G, Ridgway EC. The Colorado thyroid disease prevalence study. Arch Intern Med. 2000;160(4):526–534. - PubMed
  67.  
    1. AlGhalayini K. Prevalence of hypothyroidism in a cohort of Saudi women with heart failure and effect on systolic and diastolic function. J Pak Med Assoc. 2015;65(12):1300–1304. - PubMed
  68.  
    1. Refaat B. Prevalence and characteristics of anemia associated with thyroid disorders in non-pregnant Saudi women during the childbearing age: a cross-sectional study. Biomed J. 2015;38(4):307–316. - PubMed
  69.  
    1. Schlienger J, Anceau A, Chabrier G, North M, Stephan F. Effect of diabetic control on the level of circulating thyroid hormones. Diabetologia. 1982;22(6):486–488. - PubMed
  70.  
    1. Akbar DH, Ahmed MM, Al-Mughales J. Thyroid dysfunction and thyroid autoimmunity in Saudi type 2 diabetics. Acta Diabetol. 2006;43(1):14–18. - PubMed
  71.  
    1. Hajieh S, Behbahani M, Mohtashami AZ. Prevalence of thyroid dysfunction and thyroid auto antibodies in type 2 diabetic patients. Pak J Med Sci. 2011;27(5).

Page Navigation