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Cima LN, Tarna M, Martin CS, Sirbu AE, Soare I, Panaitescu AM, Gica N, Barbu CG, Fica S. Preconceptional Counseling in Women with Hyperthyroidism. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:234. [PMID: 38399522 PMCID: PMC10890308 DOI: 10.3390/medicina60020234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/14/2024] [Accepted: 01/24/2024] [Indexed: 02/25/2024]
Abstract
Preconception evaluation of couples wishing to conceive is an important step toward a healthy pregnancy and it is especially important in people with a chronic condition or at genetic risk. The most common endocrine disorders in women at reproductive age are those involving the thyroid gland and it is well recognized that hyperthyroidism (HT), over-function of the thyroid gland, is associated with risks of maternal, fetal, and neonatal complications. The aim of this paper is to review the latest evidence regarding the components of preconception counseling in women with HT that contemplate a pregnancy. We also want to raise awareness among healthcare professionals about the importance of periconceptional counseling in improving pregnancy outcomes and avoid maternal and fetal complications related to thyroid dysfunction. In women with Graves' disease seeking pregnancy, it is essential to discuss all the treatment options along with the associated risks and benefits. Extensive prospective studies are still needed to understand the implications of current recommended strategies for the management of HT in preconception and during pregnancy.
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Affiliation(s)
- Luminita Nicoleta Cima
- Department of Endocrinology and Diabetes, Nutrition and Metabolic Diseases, "Elias" Emergency University Hospital, 011461 Bucharest, Romania
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Mihaela Tarna
- Department of Endocrinology and Diabetes, Nutrition and Metabolic Diseases, "Elias" Emergency University Hospital, 011461 Bucharest, Romania
| | - Carmen Sorina Martin
- Department of Endocrinology and Diabetes, Nutrition and Metabolic Diseases, "Elias" Emergency University Hospital, 011461 Bucharest, Romania
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Anca Elena Sirbu
- Department of Endocrinology and Diabetes, Nutrition and Metabolic Diseases, "Elias" Emergency University Hospital, 011461 Bucharest, Romania
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Iulia Soare
- Department of Endocrinology and Diabetes, Nutrition and Metabolic Diseases, "Elias" Emergency University Hospital, 011461 Bucharest, Romania
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Anca Maria Panaitescu
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- "Filantropia" Clinical Hospital, 011171 Bucharest, Romania
| | - Nicolae Gica
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- "Filantropia" Clinical Hospital, 011171 Bucharest, Romania
| | - Carmen Gabriela Barbu
- Department of Endocrinology and Diabetes, Nutrition and Metabolic Diseases, "Elias" Emergency University Hospital, 011461 Bucharest, Romania
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Simona Fica
- Department of Endocrinology and Diabetes, Nutrition and Metabolic Diseases, "Elias" Emergency University Hospital, 011461 Bucharest, Romania
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
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Liu Y, Li Q, Xu Y, Chen Y, Men Y. Comparison of the safety between propylthiouracil and methimazole with hyperthyroidism in pregnancy: A systematic review and meta-analysis. PLoS One 2023; 18:e0286097. [PMID: 37205692 DOI: 10.1371/journal.pone.0286097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 05/08/2023] [Indexed: 05/21/2023] Open
Abstract
OBJECTIVE The purpose of this meta-analysis was to assess the safety of the anti-thyroid drugs (ATDs) propylthiouracil (PTU) and methimazole (MMI) in the treatment of hyperthyroidism during pregnancy. METHOD From inception until June 2, 2022, all available studies were searched in PubMed, Web of Science, Cochrane, EBSCO, Embase, Scopus, and CNKI. RESULT Thirteen articles satisfying the inclusion criteria were examined. Our meta-analysis indicated that pregnant women treated with MMI had a higher risk of congenital anomalies than those treated with PTU (OR 0.80, 95%CI 0.69-0.92, P = 0.002, I2 = 41.9%). Shifting between MMI and PTU during pregnancy did not reduce the risk of birth defects compared to PTU alone (OR 1.18, CI 1.00 to 1.40, P = 0.061, I2 = 0.0%). There were no statistically significant differences in hepatotoxicity (OR 1.54, 95%CI 0.77-3.09, P = 0.221, I2 = 0.0%) or miscarriage (OR 0.89, 95%CI 0.72-1.11, P = 0.310, I2 = 0.0%) between PTU and MMI exposure. CONCLUSION The study confirmed propylthiouracil is a safer alternative to methimazole for treating hyperthyroidism in pregnant women, and it is appropriate to treat maternal thyroid disease with PTU during the first trimester of pregnancy. However, it is not clear whether switching between propylthiouracil and methimazole is a better option than treating PTU alone during pregnancy. Further studies on this matter may be needed to develop new evidence-based guidelines for the treatment of pregnant women with hyperthyroidism.
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Affiliation(s)
- Yue Liu
- School of Nursing, Qilu Medical University, Zibo, Shandong Province, China
| | - Qianqian Li
- School of Nursing, Qilu Medical University, Zibo, Shandong Province, China
| | - Yang Xu
- School of Nursing, Qilu Medical University, Zibo, Shandong Province, China
| | - Yixin Chen
- School of Nursing, Qilu Medical University, Zibo, Shandong Province, China
| | - Yanyan Men
- School of Nursing, Qilu Medical University, Zibo, Shandong Province, China
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Perelli F, Turrini I, Giorgi MG, Renda I, Vidiri A, Straface G, Scatena E, D’Indinosante M, Marchi L, Giusti M, Oliva A, Grassi S, De Luca C, Catania F, Vizzielli G, Restaino S, Gullo G, Eleftheriou G, Mattei A, Signore F, Lanzone A, Scambia G, Cavaliere AF. Contrast Agents during Pregnancy: Pros and Cons When Really Needed. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192416699. [PMID: 36554582 PMCID: PMC9779218 DOI: 10.3390/ijerph192416699] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/06/2022] [Accepted: 12/10/2022] [Indexed: 05/13/2023]
Abstract
Many clinical conditions require radiological diagnostic exams based on the emission of different kinds of energy and the use of contrast agents, such as computerized tomography (CT), positron emission tomography (PET), magnetic resonance (MR), ultrasound (US), and X-ray imaging. Pregnant patients who should be submitted for diagnostic examinations with contrast agents represent a group of patients with whom it is necessary to consider both maternal and fetal effects. Radiological examinations use different types of contrast media, the most used and studied are represented by iodinate contrast agents, gadolinium, fluorodeoxyglucose, gastrographin, bariumsulfate, and nanobubbles used in contrast-enhanced ultrasound (CEUS). The present paper reports the available data about each contrast agent and its effect related to the mother and fetus. This review aims to clarify the clinical practices to follow in cases where a radiodiagnostic examination with a contrast medium is indicated to be performed on a pregnant patient.
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Affiliation(s)
- Federica Perelli
- Azienda USL Toscana Centro, Gynecology and Obstetric Department, Santa Maria Annunziata Hospital, 50012 Florence, Italy
| | - Irene Turrini
- Azienda USL Toscana Centro, Gynecology and Obstetric Department, Santo Stefano Hospital, 59100 Prato, Italy
- Correspondence:
| | - Maria Gabriella Giorgi
- Azienda USL Toscana Centro, Gynecology and Obstetric Department, Santo Stefano Hospital, 59100 Prato, Italy
| | - Irene Renda
- Division of Obstetrics and Gynecology, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, 50134 Florence, Italy
| | - Annalisa Vidiri
- School of Medicine, Catholic University of the Sacred Hearth, 00168 Rome, Italy
| | - Gianluca Straface
- Obstetrics and Gynecology Unit, Policlinico Abano Terme, 35031 Abano Terme, Italy
| | - Elisa Scatena
- Azienda USL Toscana Centro, Gynecology and Obstetric Department, Santo Stefano Hospital, 59100 Prato, Italy
| | - Marco D’Indinosante
- Azienda USL Toscana Centro, Gynecology and Obstetric Department, Santo Stefano Hospital, 59100 Prato, Italy
| | - Laura Marchi
- Azienda USL Toscana Centro, Gynecology and Obstetric Department, Santo Stefano Hospital, 59100 Prato, Italy
| | - Marco Giusti
- Azienda USL Toscana Centro, Gynecology and Obstetric Department, Santa Maria Annunziata Hospital, 50012 Florence, Italy
| | - Antonio Oliva
- Department of Health Surveillance and Bioethics, Section of Legal Medicine, Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Simone Grassi
- Department of Health Surveillance and Bioethics, Section of Legal Medicine, Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Carmen De Luca
- Teratology Information Service, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Francesco Catania
- Department of Obstetrics and Gynecology, Ospedale “Santa Maria Alla Gruccia”, 52025 Montevarchi, Italy
| | - Giuseppe Vizzielli
- Department of Medicinal Area (DAME) Clinic of Obstetrics and Gynecology, Santa Maria della Misericordia Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy
| | - Stefano Restaino
- Department of Medicinal Area (DAME) Clinic of Obstetrics and Gynecology, Santa Maria della Misericordia Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy
| | - Giuseppe Gullo
- IVF Public Center, Azienda Ospedaliera Ospedali Riuniti (AOOR) Villa Sofia Cervello, University of Palermo, 90146 Palermo, Italy
| | - Georgios Eleftheriou
- Poison Control Center and Teratology Information Service, Hospital Papa Giovanni XIII, 24127 Bergamo, Italy
| | - Alberto Mattei
- Azienda USL Toscana Centro, Gynecology and Obstetric Department, Santa Maria Annunziata Hospital, 50012 Florence, Italy
| | - Fabrizio Signore
- Obstetrics and Gynecology Unit, Santo Eugenio Hospital, 00144 Rome, Italy
- School of Medicine, Unicamillus University Rome, 00131 Rome, Italy
| | - Antonio Lanzone
- School of Medicine, Catholic University of the Sacred Hearth, 00168 Rome, Italy
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Giovanni Scambia
- School of Medicine, Catholic University of the Sacred Hearth, 00168 Rome, Italy
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Anna Franca Cavaliere
- School of Medicine, Catholic University of the Sacred Hearth, 00168 Rome, Italy
- Division of Gynecology and Obstetrics Fatebenefratelli Isola Tiberina, 00186 Rome, Italy
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Moretti C, Lazzarin N, Vaquero E, Dal Lago A, Campagnolo L, Valensise H. A practical approach to the management of thyroid dysfunction during pregnancy. Gynecol Endocrinol 2022; 38:1028-1034. [PMID: 36480916 DOI: 10.1080/09513590.2022.2154337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Pregnancy has an important impact on the thyroid gland and its function. Thyroid activity changes as a consequence of the novel physiological state of pregnancy and requires a complex hormonal and metabolic adaptation, which is possible only in the presence of a perfectly functioning thyroid gland. In fact, thyroid function is crucial for the success of the implantation and the progression of pregnancy. Abnormal thyroid function is very common among childbearing age women, explaining the high incidence of thyroid diseases that occur during pregnancy. Aim of this work is to analyze the adaptive events that characterize the thyroid function during pregnancy, exploring their hormonal, metabolic and molecular mechanisms. Moreover, the interpretation of the laboratory data necessary to monitor the thyroid functioning during normal pregnancy or in the presence of thyroid abnormalities will be discussed.
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Affiliation(s)
- Costanzo Moretti
- Department of Systems' Medicine, University of Rome TorVergata, Rome, Italy
| | - Natalia Lazzarin
- Department of Obstetrics and Gynecology, Policlinico Casilino Hospital, Rome, Italy
| | - Elena Vaquero
- Department of Biomedicine and Prevention of Rome TorVergata, Rome, Italy
| | - Alessandro Dal Lago
- Department of Gender Parenting Child and Adolescent Medicine Physiopathology of Reproduction and Andrology Unit, Sandro Pertini Hospital, Rome, Italy
| | - Luisa Campagnolo
- Department of Biomedicine and Prevention, University of Rome TorVergata, Rome, Italy
| | - Herbert Valensise
- Department of Obstetrics and Gynecology, Policlinico Casilino Hospital, Rome, Italy
- Department of Surgery, University of Rome Tor Vergata, Rome, Italy
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Cavaliere AF, Perelli F, Zaami S, D'Indinosante M, Turrini I, Giusti M, Gullo G, Vizzielli G, Mattei A, Scambia G, Vidiri A, Signore F. Fertility Sparing Treatments in Endometrial Cancer Patients: The Potential Role of the New Molecular Classification. Int J Mol Sci 2021; 22:12248. [PMID: 34830129 PMCID: PMC8625356 DOI: 10.3390/ijms222212248] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 11/10/2021] [Indexed: 01/13/2023] Open
Abstract
Endometrial cancer is the most frequent gynecological malignancy, and, although epidemiologically it mainly affects advanced age women, it can also affect young patients who want children and who have not yet completed their procreative project. Fertility sparing treatments are the subject of many studies and research in continuous evolution, and represent a light of hope for young cancer patients who find themselves having to face an oncological path before fulfilling their desire for motherhood. The advances in molecular biology and the more precise clinical and prognostic classification of endometrial cancer based on the 2013 The Cancer Genome Atlas classification allow for the selection of patients who can be submitted to fertility sparing treatments with increasing oncological safety. It would also be possible to predict the response to hormonal treatment by investigating the state of the genes of the mismatch repair.
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Affiliation(s)
- Anna Franca Cavaliere
- Azienda USL Toscana Centro, Gynecology and Obstetric Department, Santo Stefano Hospital, 59100 Prato, Italy
| | - Federica Perelli
- Azienda USL Toscana Centro, Gynecology and Obstetric Department, Santa Maria Annunziata Hospital, 50012 Florence, Italy
| | - Simona Zaami
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy
| | - Marco D'Indinosante
- Azienda USL Toscana Centro, Gynecology and Obstetric Department, Santo Stefano Hospital, 59100 Prato, Italy
| | - Irene Turrini
- Azienda USL Toscana Centro, Gynecology and Obstetric Department, Santo Stefano Hospital, 59100 Prato, Italy
| | - Marco Giusti
- Azienda USL Toscana Centro, Gynecology and Obstetric Department, Santa Maria Annunziata Hospital, 50012 Florence, Italy
| | - Giuseppe Gullo
- Azienda Ospedaliera Ospedali Riuniti (AOOR) Villa Sofia Cervello, IVF Public Center, University of Palermo, 90100 Palermo, Italy
| | - Giuseppe Vizzielli
- Clinic of Obstetrics and Gynecology, Dipartimento di Area Medica (DAME), University Hospital of Udine, University of Udine, 33100 Udine, Italy
| | - Alberto Mattei
- Azienda USL Toscana Centro, Gynecology and Obstetric Department, Santa Maria Annunziata Hospital, 50012 Florence, Italy
| | - Giovanni Scambia
- Gynecologic Oncology Unit, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00168 Rome, Italy
| | - Annalisa Vidiri
- Gynecologic Oncology Unit, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00168 Rome, Italy
| | - Fabrizio Signore
- Obstetrics and Gynecology Department, Unità Sanitaria Locale (USL) Roma 2, Sant'Eugenio Hospital, 00144 Rome, Italy
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Hyperthyroidism in Pregnancy: The Delicate Balance between Too Much or Too Little Antithyroid Drug. J Clin Med 2021; 10:jcm10163742. [PMID: 34442037 PMCID: PMC8396831 DOI: 10.3390/jcm10163742] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 08/09/2021] [Accepted: 08/20/2021] [Indexed: 01/11/2023] Open
Abstract
Overt hyperthyroidism (HT) during pregnancy is associated with a risk of maternal–fetal complications. Antithyroid drugs (ATD) have a potential risk for teratogenic effects and fetal–neonatal hypothyroidism. This study evaluated ATD treatment and thyroid function control during pregnancy, and pregnancy outcome in women with HT. Patients and methods: A retrospective analysis of 36 single fetus pregnancies in 29 consecutive women (median age 30.3 ± 4.7 years) with HT diagnosed before or during pregnancy; a control group of 39 healthy euthyroid pregnant women was used. Results: Twenty-six women had Graves’ disease (GD, 33 pregnancies), 1 had a hyperfunctioning autonomous nodule, and 2 had gestational transient thyrotoxicosis (GTT). Methimazole (MMI) was administered in 22 pregnancies (78.5%), Propylthiouracil (PTU) in 2 (7.1%), switch from MMI to PTU in 4 (14.2%), no treatment in 8 pregnancies (3 with subclinical HT, 5 euthyroid with previous GD remission before conception). In the 8 pregnancies of GD patients diagnosed during gestation or shortly before (<6 weeks), i.e., with fetal exposure to uncontrolled HT, there was 1 spontaneous abortion at 5 weeks (3.4% of all ATD-treated pregnancies), and 1 premature delivery at 32 weeks with neonatal death in 24 h (3.4%); 1 child had neonatal hyperthyroidism (3.3% of live children in GD women) and a small atrial sept defect (4% of live children in ATD treated women). In women treated more than 6 months until conception (20 pregnancies): (a) median ATD doses were lower than those in women diagnosed shortly before or during pregnancy; (b) ATD was withdrawn in 40% of pregnancies in trimester (T)1, all on MMI < 10 mg/day (relapse in 14.2%), and in up to 55% in T3; (c) TSH level was below normal in 37%, 35% and 22% of pregnancies in T1, T2 and T3 respectively; FT4 was increased in 5.8% (T1) and subnormal in 11.75% in T2 and T3; (d) no fetal birth defects were recorded; one fetal death due to a true umbilical cord knot was registered. Mean birth weight was similar in both ATD-treated and control groups. Hyperthyroidism relapsed postpartum in 83% of GD patients (at median 3 ± 2.6 months). Conclusion: In hyperthyroid women with long-term ATD treatment before conception, drugs could be withdrawn in T1 in 40% of them, the thyroid function control was better, and pregnancy and fetal complications were rarer, compared to women diagnosed during pregnancy. Frequent serum TSH and FT4 monitoring is needed to maintain optimal thyroid function during pregnancy.
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Tuzil J, Bartakova J, Watt T, Dolezal T. Health-related quality of life in women with autoimmune thyroid disease during pregnancy and postpartum: systematic review including 321,850 pregnancies. Expert Rev Pharmacoecon Outcomes Res 2021; 21:1179-1193. [PMID: 34120552 DOI: 10.1080/14737167.2021.1941882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Utilities of the general population or expert estimates have been used for all published cost-effectiveness analyses of screening for thyroid disorders in pregnancy. METHODS A systematic review CRD42019120897 of studies with patient-reported outcomes (PRO) and laboratory evidence of thyroid function/autoimmunity was conducted using PubMed, Cochrane Central, EconLit, SocIndex, DARE, NHS EEDS, Annual Reviews, and CINAHL. Quality was assessed using Joanna Briggs Institute appraisal tool. RESULTS Of 664 abstracts screened, we analyzed 97 full texts. All studies describing the impact of thyroid disease on the generic QoL excluded pregnant and postpartum women. 21 reports of acceptable quality (321,850 pregnancies) determined depression and anxiety with validated tools and/or reported subjective symptoms. During pregnancy, contradictory conclusions were published on the impact of thyroid disease on PRO. Postpartum, antithyroid antibodies coincide with alexithymia and depression, postpartum thyroiditis negatively impacts mood. No conclusion could be drawn on the impact of thyroid hormonal levels. CONCLUSIONS The generic QoL in autoimmune thyroid disease during pregnancy has never been described, which represents an obstacle for the construction of economic models. We found contradictory information on the impact of thyroid disease on depression, anxiety, and specific symptoms.
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Affiliation(s)
- Jan Tuzil
- Department of Biomedical Informatics, First Faculty of Medicine, Charles University, Prague, Czech Republic.,Institute of Health Economics and Technology Assessment o.p.s (iHETA), Prague, Czech Republic
| | - Jana Bartakova
- Department of Biomedical Informatics, First Faculty of Medicine, Charles University, Prague, Czech Republic.,Department Public Health, Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Torquil Watt
- Department of Internal Medicine, Endocrinology, Herlev Gentofte Hospital, Copenhagen, Denmark
| | - Tomas Dolezal
- Institute of Health Economics and Technology Assessment o.p.s (iHETA), Prague, Czech Republic.,Department of Pharmacology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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8
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Locantore P, Corsello A, Policola C, Pontecorvi A. Subclinical thyroid diseases and isolated hypothyroxinemia during pregnancy. Minerva Endocrinol (Torino) 2021; 46:243-251. [PMID: 33792240 DOI: 10.23736/s2724-6507.21.03391-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Thyroid diseases in pregnancy are common. While data on management of overt diseases are clear, there is no consensus regarding subclinical thyroid disease. Many studies have tried to clarify the impact of subclinical thyroid disease on pregnancy outcomes without reaching universal conclusions. As several studies are present in literature, but no univocal indication is present to manage each condition, the present review tries to summarize the recent indications for such disease. The most updated guidelines are 2017 American thyroid association for thyroid disease during pregnancy, which at present represent the most accurate and reliable guide. Subclinical hyperthyroidism during pregnancy has not been associated with adverse outcomes and only needs follow up. Subclinical hypothyroidism is associated with adverse obstetric and offspring outcomes. At present thyroxine treatment is recommended in selected cases, as beneficial effects are not clear for all these patients. Data regarding the association between isolated hypothyroxinemia and adverse maternofetal outcome are controversial but treatment is not indicated. Autoimmune thyroid disease represents the main thyroid risk factor for adverse pregnancy outcomes. If patients have normal TSH values, treatment is not indicated. A possible thyroxine treatment can be evaluated on a case-by-case basis in euthyroid patients with history of abortion/infertility. In the last years, risks of subclinical thyroid dysfunction on the outcome of gestation and new-born have been scaled back. Further prospective studies are necessary to better understand thyroid dysfunction in pregnancy to perfectly target treatment in appropriate settings.
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Affiliation(s)
- Pietro Locantore
- Unit of Endocrinology, Fondazione Policlinico Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy -
| | - Andrea Corsello
- Unit of Endocrinology, Fondazione Policlinico Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Caterina Policola
- Unit of Endocrinology, Fondazione Policlinico Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alfredo Pontecorvi
- Unit of Endocrinology, Fondazione Policlinico Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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9
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Žarković M, Wiersinga W, Perros P, Bartalena L, Donati S, Okosieme O, Morris D, Fichter N, Lareida J, Daumerie C, Burlacu MC, Kahaly GJ, Pitz S, Beleslin B, Ćirić J, Ayvaz G, Konuk O, Törüner FB, Salvi M, Covelli D, Curro N, Hegedüs L, Brix T. Antithyroid drugs in Graves' hyperthyroidism: differences between "block and replace" and "titration" regimes in frequency of euthyroidism and Graves' orbitopathy during treatment. J Endocrinol Invest 2021; 44:371-378. [PMID: 32524368 DOI: 10.1007/s40618-020-01320-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 05/30/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE Whereas antithyroid drugs (ATD) are the preferred treatment modality for Graves' hyperthyroidism (GH), there is still controversy about the optimal regimen for delivering ATD. To evaluate whether 'Block and Replace' (B + R) and 'Titration' (T) regimes are equivalent in terms of frequency of euthyroidism and Graves' Orbitopathy (GO) during ATD therapy. METHODS A prospective multicentre observational cohort study of 344 patients with GH but no GO at baseline. Patients were treated with ATD for 18 months according to B + R or T regimen in line with their institution's policy. RESULTS Baseline characteristics were similar in both groups. In the treatment period between 6 and 18 months thyrotropin (TSH) slightly increased in both groups, but TSH was on average 0.59 mU/L (95% CI 0.27-0.85) lower in the B + R group at all time points (p = 0.026). Serum free thyroxine (FT4) remained stable during the same interval, with a tendency to higher values in the B + R group. The point-prevalence of euthyroidism (TSH and FT4 within their reference ranges) increased with longer duration of ATD in both groups; it was always higher in the T group than in the B + R group: 48 and 24%, respectively, at 6 months, 81 and 58% at 12 months, and 87 and 63% at 18 months (p < 0.002). There were no significant differences between the B + R and T regimens with respect to the fall in thyrotropin binding inhibiting immunoglobulins (TBII) or thyroid peroxidase antibodies (TPO-Ab). GO developed in 15.9% of all patients: 9.1 and 17.8% in B + R group and T group, respectively, (p = 0.096). GO was mild in 13% and moderate-to-severe in 2%. CONCLUSION The prevalence of biochemical euthyroidism during treatment with antithyroid drugs is higher during T compared to B + R regimen. De novo development of GO did not differ significantly between the two regimens, although it tended to be higher in the T group. Whether one regimen is clinically more advantageous than the other remains unclear.
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Affiliation(s)
- M Žarković
- School of Medicine, University of Belgrade, Belgrade, Serbia.
- Clinic of Endocrinology Clinical Centre of Serbia, Belgrade, Serbia.
| | - W Wiersinga
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - P Perros
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - L Bartalena
- School of Medicine, University of Insubria, Varese, Italy
| | - S Donati
- School of Medicine, University of Insubria, Varese, Italy
| | - O Okosieme
- Department of Endocrinology, Institute of Molecular and Experimental Medicine, Cardiff University School of Medicine, Cardiff, UK
| | - D Morris
- Cardiff Eye Unit, University Hospital of Wales, Cardiff, UK
| | - N Fichter
- Interdisciplinary Centre for Graves' Orbitopathy, Olten and University Eye Hospital, Basel, Switzerland
| | - J Lareida
- Interdisciplinary Centre for Graves' Orbitopathy, Olten and University Eye Hospital, Basel, Switzerland
| | - C Daumerie
- Department of Endocrinology, Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - M-C Burlacu
- Department of Endocrinology, Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - G J Kahaly
- Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - S Pitz
- Orbital Center, Ophthalmic Clinic, Buergerhospital, Frankfurt, Germany
| | - B Beleslin
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic of Endocrinology Clinical Centre of Serbia, Belgrade, Serbia
| | - J Ćirić
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic of Endocrinology Clinical Centre of Serbia, Belgrade, Serbia
| | - G Ayvaz
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - O Konuk
- Department of Ophthalmology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - F B Törüner
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - M Salvi
- Graves' Orbitopathy Unit, Department of Clinical Science and Community Health, Fondazione Ca'Granda IRCCS, University of Milan, Milan, Italy
| | - D Covelli
- Graves' Orbitopathy Unit, Department of Clinical Science and Community Health, Fondazione Ca'Granda IRCCS, University of Milan, Milan, Italy
| | - N Curro
- Department of Ophthalmology, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - L Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - T Brix
- Department of Endocrinology and Metabolism, Odense University Hospital, University of Southern Denmark, Odense, Denmark
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10
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Bartalena L, Piantanida E, Tanda ML. Methimazole Treatment and Acute Pancreatitis: Both Caution and Reassurance Are Needed. J Clin Endocrinol Metab 2020; 105:5902592. [PMID: 32895723 DOI: 10.1210/clinem/dgaa636] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 09/04/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Luigi Bartalena
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Eliana Piantanida
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Maria Laura Tanda
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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11
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Piantanida E, Ippolito S, Gallo D, Masiello E, Premoli P, Cusini C, Rosetti S, Sabatino J, Segato S, Trimarchi F, Bartalena L, Tanda ML. The interplay between thyroid and liver: implications for clinical practice. J Endocrinol Invest 2020; 43:885-899. [PMID: 32166702 DOI: 10.1007/s40618-020-01208-6] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 02/27/2020] [Indexed: 02/07/2023]
Abstract
A complex relationship exists between thyroid and liver in health and disease. Liver plays an essential physiological role in thyroid hormone activation and inactivation, transport, and metabolism. Conversely, thyroid hormones affect activities of hepatocytes and hepatic metabolism. Serum liver enzyme abnormalities observed in hypothyroidism may be related to impaired lipid metabolism, hepatic steatosis or hypothyroidism-induced myopathy. Severe hypothyroidism may have biochemical and clinical features, such as hyperammonemia and ascites, mimicking those of liver failure. Liver function tests are frequently abnormal also in hyperthyroidism, due to oxidative stress, cholestasis, or enhanced osteoblastic activity. Antithyroid drug-associated hepatotoxicity is a rare event, likely related mainly to an idiosyncratic mechanism, ranging from a mild hepatocellular damage to liver failure. Propylthiouracil-induced liver damage is usually more severe than that caused by methimazole. On the other hand, thyroid abnormalities can be found in liver diseases, such as chronic hepatitis C, liver cirrhosis, hepatocellular carcinoma, and cholangiocarcinoma. In particular, autoimmune thyroid diseases are frequently found in patients with hepatitis C virus infection. These patients, especially if thyroid autoimmunity preexists, are at risk of hypothyroidism or, less frequently, thyrotoxicosis, during and after treatment with interpheron-alpha alone or in combination with ribavirin, commonly used before the introduction of new antiviral drugs. The present review summarizes both liver abnormalities related to thyroid disorders and their treatment, and thyroid abnormalities related to liver diseases and their treatment.
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Affiliation(s)
- E Piantanida
- Endocrine Unit, Department of Medicine and Surgery, Ospedale Di Circolo, ASST Dei Sette Laghi, University of Insubria, Viale Borri, 57, Varese, Italy.
| | - S Ippolito
- Endocrine Unit, Department of Medicine and Surgery, Ospedale Di Circolo, ASST Dei Sette Laghi, University of Insubria, Viale Borri, 57, Varese, Italy
| | - D Gallo
- Endocrine Unit, Department of Medicine and Surgery, Ospedale Di Circolo, ASST Dei Sette Laghi, University of Insubria, Viale Borri, 57, Varese, Italy
| | - E Masiello
- Endocrine Unit, Department of Medicine and Surgery, Ospedale Di Circolo, ASST Dei Sette Laghi, University of Insubria, Viale Borri, 57, Varese, Italy
| | - P Premoli
- Endocrine Unit, Department of Medicine and Surgery, Ospedale Di Circolo, ASST Dei Sette Laghi, University of Insubria, Viale Borri, 57, Varese, Italy
| | - C Cusini
- Endocrine Unit, Department of Medicine and Surgery, Ospedale Di Circolo, ASST Dei Sette Laghi, University of Insubria, Viale Borri, 57, Varese, Italy
| | - S Rosetti
- Endocrine Unit, Department of Medicine and Surgery, Ospedale Di Circolo, ASST Dei Sette Laghi, University of Insubria, Viale Borri, 57, Varese, Italy
| | - J Sabatino
- Endocrine Unit, Department of Medicine and Surgery, Ospedale Di Circolo, ASST Dei Sette Laghi, University of Insubria, Viale Borri, 57, Varese, Italy
| | - S Segato
- Gastroenterology and Gastrointestinal Endoscopic Unit, Department of Specialistic Medicine, ASST Dei Sette Laghi, Varese, Italy
| | - F Trimarchi
- Accademia Peloritana Dei Pericolanti, University of Messina, Messina, Italy
| | - L Bartalena
- Endocrine Unit, Department of Medicine and Surgery, Ospedale Di Circolo, ASST Dei Sette Laghi, University of Insubria, Viale Borri, 57, Varese, Italy.
| | - M L Tanda
- Endocrine Unit, Department of Medicine and Surgery, Ospedale Di Circolo, ASST Dei Sette Laghi, University of Insubria, Viale Borri, 57, Varese, Italy
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12
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Francis N, Francis T, Lazarus JH, Okosieme OE. Current controversies in the management of Graves' hyperthyroidism. Expert Rev Endocrinol Metab 2020; 15:159-169. [PMID: 32315207 DOI: 10.1080/17446651.2020.1754192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 04/07/2020] [Indexed: 12/12/2022]
Abstract
Introduction: The management of Graves' disease centers on the use of effective and well-established therapies, namely thionamide antithyroid drugs, radioactive iodine, and thyroidectomy. Optimal treatment strategies are however controversial and vary significantly across centers.Areas covered: This review addresses specific controversies in Graves' disease management including the choice of primary therapy, the approach to women planning pregnancy, and optimal strategies for antithyroid drug and radioiodine therapy.Expert opinion: Important considerations in choosing therapy include treatment efficacy, adverse effects, patient convenience, and resource settings. Recent data suggest that early and effective control of hyperthyroidism is key to improving cardiovascular morbidity and mortality. Studies addressing cancer risk in radioiodine-treated patients face methodological challenges and require clarification in appropriately designed studies. Remission rates with antithyroid drugs are comparable when thionamides are used alone (titration-regimen) or in combination with levothyroxine (block and replace) and can be optimized by extending treatment for at least 12-18 months. Fixed and calculated radioiodine activity regimens are both effective but entail a trade-off between convenience and precision in the administered activity. Optimal preconception strategies are still evolving but ablative treatment in advance of pregnancy offers the most pragmatic means of reducing adverse effects of hyperthyroidism in subsequent pregnancy.
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Affiliation(s)
- Niroshan Francis
- Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK
| | - Thanuya Francis
- Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK
| | - John H Lazarus
- Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, UK
| | - Onyebuchi E Okosieme
- Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK
- Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, UK
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13
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Francis T, Francis N, Lazarus JH, Okosieme OE. Safety of antithyroid drugs in pregnancy: update and therapy implications. Expert Opin Drug Saf 2020; 19:565-576. [PMID: 32223355 DOI: 10.1080/14740338.2020.1748007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Introduction: The thionamide antithyroid drugs, methimazole (MMI), its pro-drug derivative carbimazole (CMZ), and propylthiouracil (PTU) are the mainstay of treatment for hyperthyroidism in pregnancy. However, antithyroid drugs carry risks of adverse effects that can affect fetal and maternal well-being.Areas covered: This review provides an update on the safety of antithyroid drugs in pregnancy, focusing on the most serious concerns of severe liver disease and congenital anomalies.Expert opinion: PTU-induced liver disease is uncommon but can run a catastrophic course in pregnancy with a risk of liver failure and threats to maternal or fetal survival. Acute pancreatitis is a relatively rare occurrence that has been linked to thionamide use in a handful of reports in non-pregnant individuals. Observational studies on the risk of birth defects with antithyroid drug exposure in pregnancy overall show an increase in birth defect risk with exposure to CMZ/MMI, and to a lesser extent, PTU. Further studies are required to determine whether the currently recommended approach of switching between thionamide drugs in pregnancy improves outcomes. Ultimately, a preventative strategy of offering definitive therapy to hyperthyroid women of childbearing potential offers the best approach to truly reduce the risks of antithyroid drug adverse effects in pregnancy.
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Affiliation(s)
- Thanuya Francis
- Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK
| | - Niroshan Francis
- Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK
| | - John H Lazarus
- Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, UK
| | - Onyebuchi E Okosieme
- Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK.,Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, UK
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