BACKGROUND
Graves’ disease is the most common cause of hyperthyroidism. Graves’ disease is an autoimmune disorder where the immune system attacks the thyroid and turns it on, causing it to make too much thyroid hormone. This can cause significant health problems, including anxiety, shaking or tremors, increased body temperature (feeling inappropriately hot), a racing heart and atrial fibrillation (abnormal heartbeat). There are several options available for treating hyperthyroidism including antithyroid medications (ATD), such as methimazole and propylthiouracil (PTU), thyroid surgery, and radioactive iodine therapy (RAI) to destroy the thyroid. ATDs are usually the first line of treatment to get thyroid levels back to normal.

Thyroid surgery is a very effective treatment for Graves’ disease, especially with patients with very large thyroid glands. Removing the thyroid resolves the hyperthyroidism but also results in hypothyroidism, because once the thyroid has been removed, the body can no longer make thyroid hormone. This then needs to be treated with thyroid hormone (levothyroxine), which is often easier to control.

In preparing patients for surgery for Graves’ disease, iodine in the form of Lugol’s solution/LS or saturated solution of potassium iodide/SSKI is often used for several days before surgery. This treatment may help lower body thyroid hormone levels and reduce blood flow to the thyroid gland, which can limit blood loss during thyroid surgery. Despite these possible advantages, there is no clear proof showing that iodine treatment before thyroid surgery for Graves’ disease is truly beneficial. This study compares the outcomes of thyroid surgery in people diagnosed with Graves’ disease with or without pre-surgery iodine treatment.

THE FULL ARTICLE TITLE
Schiavone D et al. Role of Lugol solution before total thyroidectomy for Graves’ disease: randomized clinical trial. Br J Surg 2024;111(8):znae196; doi: 10.1093/bjs/ znae196. PMID: 39129619.

SUMMARY OF THE STUDY
Researchers studied 56 adults (ages 18-70) undergoing total thyroidectomy for Graves’ disease at their institution. A total of 29 participants took iodine (Lugol’s solution) for eight days before surgery while 27 participants did not. The care team, including the surgeon, radiologists and pathologists, did not know which patients received iodine before surgery. Only a member of the research team was aware of this information. Researchers collected data on thyroid hormone levels, ultrasound imaging and pathology results to look at the blood supply to the thyroid, blood loss from surgery, length of surgery, and complications after surgery.

The results showed that treatment with iodine before thyroid surgery for Graves’ disease resulted in lower body thyroid hormone levels on the day of surgery. However, this finding did not improve surgery outcomes. There was no significant effect on blood supply to the thyroid gland, the amount of blood loss during or after surgery, the length of surgery or the risk of complications after surgery.

WHAT ARE THE IMPLICATIONS OF THIS STUDY?
This study adds to our understanding of pre-surgery iodine treatment to improve outcomes related to thyroid surgery for treatment of Graves’ disease. Although the authors did learn that iodine treatment can decrease body thyroid hormone levels before surgery, this did not improve outcomes during or after total thyroidectomy. This suggests treatment with iodine may not be necessary before total thyroidectomy for Graves’ disease. This study did have some limitations. The small number of participants may have made it difficult to identify subtle benefits of iodine treatment prior to thyroid surgery for Graves’ disease. Also, the only surgeon involved in this study was highly experienced in thyroid surgery. A larger study with more surgeons having diverse thyroid surgery experience levels might reveal advantages to pre-surgery iodine treatment not identified by this study.

— Stacy Sebastian, MD and Jason D. Prescott, MD PhD

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Volume 18 Issue 3

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TABLE OF CONTENTS – Web Format

THYROID CANCER
Is there a link between diabetes and weight loss drugs and thyroid cancer?
GLP1 receptor agonists (GLP1-RAs) are popular medications that are used to treat diabetes and obesity. In animal studies with GLP1-RAs, an increase in C-cell tumors was seen, which are associated with medullary thyroid cancer, which is a rare form of thyroid cancer. However, it’s unclear if this risk applies to humans. This large, international study was done to clarify whether GLP1-RAs increase the risk of thyroid cancer and whether higher doses overtime make the risk bigger.
Baxter SM, et al. Glucagon-like peptide 1 receptor agonists and risk of thyroid cancer: an international multisite cohort study. Thyroid 2024; in press.

THYROID CANCER
What is the risk for recurrence of Medullary thyroid carcinoma?
In the setting of medullary thyroid carcinoma (MTC), calcitonin serves as a cancer marker, since the cancer cells continue to secrete calcitonin. There is controversy regarding the best cutoff calcitonin level to identify cancer that has spread outside of the neck as opposed to cancer limited to the thyroid and local lymph nodes. This study was done to determine the which factors are associated with MTC response after surgery, cancer recurrence and effective treatment without the cancer progressing.
Abou Azar S et al. Medullary thyroid cancer: single institute experience over 3 decades and risk factors for recurrence. J Clin Endocrinol Metab 2024;109(11):2729-2734; doi: 10.1210/clinem/dgae279. PMID: 38651609.

THYROID CANCER
Is lobectomy an option for patients with Medullary thyroid cancer?
Once Medullary thyroid cancer (MTC) is diagnosed, a total thyroidectomy is generally recommended for patients. However, thyroid lobectomy has become increasingly advocated for other types of thyroid cancer if there is no evidence of spread of the cancer to the opposite lobe. It is unclear whether this approach would be appropriate for treatment of MTC. This study investigated frequency of finding small foci of MTC in the lobe opposite to the lobe containing the primary cancer that was not identified on ultrasound before surgery.
Mao YV et al. Extent of surgery for medullary thyroid cancer and prevalence of occult contralateral foci. JAMA Otolaryngol Head Neck Surg 2024;150(9):838; doi: 10.1001/ jamaoto.2023.4376. PMID: 38270925

HYPERTHYROIDISM .
Hyperthyroidism treatment and risk for heart problems
Heart racing/palpitations are common symptoms of hyperthyroidism. Indeed, hyperthyroidism has been associated with increased risk of atrial fibrillation, heart attacks and death. This study sought to determine if treatment choice impacts major adverse cardiac events (MACE) and death rates (all-cause mortality). These investigators examined long term MACE and all-cause mortality in newly diagnosed hyperthyroid subjects in Taiwan based on treatment choice.
Peng CC-H, et al. MACE and hyperthyroidism treated with medication, radioactive iodine, or thyroidectomy. JAMA Netw Open 2024;7:e240904. PMID: 38436957. doi: 10.1001/ jamanetworkopen.2024.0904.

THYROID NODULES
Long-term data show that RFA remains effective and is low risk
Radiofrequency ablation (RFA) is a relatively new and nonsurgical option that has gained popularity for the management of benign thyroid nodules. RFA uses radiowave-based heat delivered by a needle to destroy abnormal tissue or lymph nodes containing cancer. This study focuses on the long-term results of RFA use in benign thyroid nodules, including response, regrowth rates, delay in surgery, and complications.
Park SI et al. Radiofrequency ablation for treatment of benign thyroid nodules: 10-year experience. Thyroid 2024;34(8):990- 998; doi: 10.1089/thy.2024.0082. PMID: 39041607.

THYROID SURGERY
Does treatment with iodine before thyroid surgery for Graves’ disease make this surgery safer?
Thyroid surgery is a very effective treatment for Graves’ disease, especially with patients with very large thyroid glands. In preparing patients for surgery for Graves’ disease, iodine in the form of Lugol’s solution/LS or saturated solution of potassium iodide/SSKI is often used for several days before surgery. This study compares the outcomes of thyroid surgery in people diagnosed with Graves’ disease with or without pre-surgery iodine treatment.
Schiavone D et al. Role of Lugol solution before total thyroidectomy for Graves’ disease: randomized clinical trial. Br J Surg 2024;111(8):znae196; doi: 10.1093/bjs/znae196. PMID: 39129619.

ATA ALLIANCE FOR THYROID PATIENT EDUCATION

FRIENDS OF THE ATA

PRESIDENT-ELECT CANDIDATES

James Hennessey, MD, Beth Israel Deaconess

Dr Hennessey is Director of Clinical Endocrinology at Beth Israel Deaconess Medical Center and Associate Professor of Medicine at the Harvard medical School.  He graduated from the Medical Faculty of the Karl Franzens University in Graz Austria. He completed a Medical Residency at the New Britain Hospital in Connecticut. He served with the USAF as an Internist/Flight Surgeon. While on active duty he completed subspecialty training in endocrinology and metabolism at the Walter Reed Army Medical Center in Washington DC where he conducted research in thyroxine bioequivalence.

Dr Hennessey served as the Chief of Endocrinology at USAF Medical Center Wright-Patterson in Ohio and later joined the faculty at Wright State University School of Medicine as the Director of Clinical Clerkships, maintaining a clinical-teaching practice at Wright State and in thyroidology at Wright-Patterson Medical Center. Upon arrival at Brown Medical School in Providence RI, he transferred to the Air National Guard as a flight surgeon and finally as Rhode Island State Surgeon, retiring after a 25 year USAF career in 2006. While at Brown, he was Associate Director for Clinical Education in the Division of Endocrinology at Rhode Island Hospital and directed the Medical School Endocrine Pathophysiology course.

Dr Hennessey’s career has focused on the clinical education of medical students, resident physicians in internal medicine, and fellows in endocrinology and metabolism. In this capacity he has conducted lectures, precepted clinical care, and carried out original and sponsored clinical research with his trainees. Currently, he is pursuing his clinical interest in thyroid disease with expanding clinical programs.

Michael McDermott, MD, University of Colorado

Michael McDermott is Professor of Medicine and Clinical Pharmacy at the University of Colorado Denver School of Medicine and Director of the Endocrinology and Diabetes Practice at the University of Colorado Hospital. He graduated Tulane Medical School in 1977. His Internal Medicine Internship and Residency (1977-1980), and Endocrinology and Metabolism Fellowship (1980-1982) were completed at Fitzsimons Army Medical Center in Aurora, Colorado. He spent 20 years in the US Army during which time he was the Chief of Endocrinology at Fitzsimons (1993-1997) and served as the Endocrinology Consultant to the Surgeon General (1994-1997). He has been a member of the ATA since 1992 and has been the ATA CME Director since 2009. He served on the ATA Board of Directors 2007-2010. He was the Program Chair for the ATA annual meeting in New York in 2007 and has served on multiple ATA committees: Program Committee, Finance and Audit Committee, Publications Committee, Website Committee, Lab Services Committee, Webinar Program Committee, Development Committee, Corporate Leadership Council and ATA Centennial Task Force.

SECRETARY-ELECT CANDIDATES

Christopher McCabe, PhD, University of Birmingham

Chris McCabe is Professor of Molecular Endocrinology at the University of Birmingham. He works on mechanisms of endocrine cancers, including thyroid, breast and head and neck tumour models. Specifically, the research of the McCabe group focuses on the action of the sodium iodide symporter NIS in thyroid tumours; assessment of the role of the proto-oncogenes PTTG and PBF in thyroid, breast, and head and neck tumours; in vitro and in vivo models exploring gene function; mechanisms of aneuploidy and genetic instability.

ENDOCRINOLOGIST DIRECTOR CANDIDATES

Mabel Ryder, MD, Mayo Clinic

Mabel Ryder is an endocrine oncologist at Mayo Clinic in Rochester, MN. She has dual appointments in endocrinology and medical oncology where she manages benign and malignant thyroid disease. She is currently the chair of the endocrine oncology tumor group, representing the Mayo Clinic Enterprise, with a goal of improving the care for patients with advanced endocrine cancers, particularly thyroid, through clinical trials and translational research.

Prior to joining Mayo Clinic, Dr. Ryder spent 7 years as a junior faculty at Memorial Sloan Kettering Cancer center. She worked in the laboratory of Dr. James Fagin with a focus on characterizing and understanding the role of the tumor microenvironment in advanced thyroid cancers. This was the first data to show that tumor-associated macrophages (TAMs) heavily infiltrate advanced poorly differentiated and anaplastic thyroid cancers. Preclinical data showed that therapeutically targeting TAMs can reverse the tumor phenotype, suggesting a potential novel strategy for patients with advanced disease.

At Mayo Clinic. Dr. Ryder continues clinical and translational research in advanced endocrine cancers through dual appointments in endocrinology and medical oncology.  The bridging of these fields led to a novel IND use of K1-70^TM, , a TSH receptor blocking antibody, in a patient with advanced follicular thyroid cancer and Graves’ eye disease, demonstrating proof-of-principle of the role of TSH receptor in these diseases (published in Thyroid). She continues to use expertise in both fields, and prior research work, in developing novel approaches for rare, advanced endocrine malignancies, including a focus on immune related approaches.

Dr. Ryder has been an ATA member since 2008 and served on membership, research, and annual program meeting committees. She was co-chair of the 2018 Annual Meeting with Dr. Greg Randolph and a recipient of a prior ATA research grant for her work above.

Dr. Ryder serves as secretary of the International Thyroid Oncology Groups (ITOG), whose mission, overlapping with the ATA, is to develop and promote novel treatments for patients with advanced thyroid cancers through multi-center collaborative research and clinical trials.

Jennifer Sipos, MD, Ohio State University

Jennifer A. Sipos is a Professor of Medicine and Vice Chair for Diversity, Equity and Inclusion for the Department of Medicine at the Ohio State University.  She also serves as the Medical Director of the Neuroendocrine Cancer Program at The Arthur G. James Comprehensive Cancer Center.  She obtained her medical degree and Internal Medicine residency training at Wake Forest University.  She completed her Endocrinology and Metabolism Fellowship at the University of North Carolina in Chapel Hill.

Dr. Sipos has developed an interest in the use of ultrasonography for the diagnosis and management of thyroid nodules and cancer and has taught and served as a course director for numerous ultrasound courses nationally and internationally.  Additionally, she is actively involved in several clinical research projects with a particular interest in factors implicated in the development of salivary damage after radioiodine therapy, clinical trials for the evaluation of targeted therapies in refractory thyroid cancer, and the diagnostic use of molecular markers in thyroid nodules.

She is an invited member of the International Thyroid Nodule Ultrasound Working Group to create an international TIRADS for thyroid nodule ultrasound risk stratification and management. She is also a member of the Thyroid Carcinoma Panel of the NCCN Clinical Practice Guidelines. Additionally, she served on the American Association of Endocrine Surgeons Thyroidectomy Guidelines Task Force.

Dr. Sipos has been an active member of the ATA since 2006, previously serving as chair of the former Website/Communications committee, co-chair of the Trainees and Career Advancement Committee, and member of the Editorial Board for Thyroid.  She is a current member of the DEI Committee and the Centennial Task Force and is on the Thyroid Nodule Guidelines Task Force.

PEDIATRIC ENDOCRINOLOGIST DIRECTOR CANDIDATES

Liuska Pesce, MD, University of Iowa

Dr. Pesce completed medical school at the Universidad Central de Venezuela, research postdoctoral fellowship at Northwestern University, pediatric residency at the University of Illinois in Chicago and fellowship in pediatric endocrinology at Northwestern University. She is currently a Clinical Professor at the University of Iowa, Carver College of Medicine in Iowa City, Iowa and the Founder and Director of the Pediatric Thyroid Clinic at the Stead Family Children’s Hospital.

She was involved in basic research as a postdoctoral fellow studying the role of signal transduction pathways in regulating the sodium potassium ATPase in epithelial cells. During her pediatric endocrinology fellowship, she studied the regulation of pendrin and apical iodine transport.

Following her completion of training, she has dedicated her career to become a Master clinician and educator and to create and grow a multidisciplinary Pediatric Thyroid Clinic at the University of Iowa.

Most recently, she has published on iodine transport in health and disease and has collaborated with neonatology, radiology, endocrine surgeons and oculoplastics to improve the care of children and adolescents with thyroid disorders. She also has been the author of several book chapters and a faculty for the Pediatric Endocrinology Self-assessment program for the Endocrine Society since 2015, which she has chaired since 2020.

She has been an active member of the American Thyroid Association (ATA) since 2011, was a member of the ATA Clinical Affairs Committee for six years, member of the editorial board of Clinical Thyroidology for the Public for 2 years and she has been member of the Patient Affairs & Education Committee since 2019. She was asked to serve the BOD in 2019 when the position became vacant for unforeseen reasons and has since served as member of the Public Health Committee as Board Liaison.

She was awarded the prestigious Clinical Coaching Award at the University of Iowa, Carver College of Medicine and received the Top 10% in the Nation Patient’s Choice Award for Patience Experience.

Ari Wassner, MD, Boston Children’s Hospital

Ari Wassner is Medical Director of the Boston Children’s Hospital Thyroid Center and Assistant Professor of Pediatrics at Harvard Medical School. Dr. Wassner attended Harvard Medical School and completed pediatric residency and pediatric endocrinology fellowship at Boston Children’s Hospital prior to joining the faculty. In addition to leading the BCH Thyroid Center, Dr. Wassner holds multiple leadership positions in medical education, including Director of the Pediatric Endocrinology fellowship program at Boston Children’s Hospital and director of preclinical endocrinology education at Harvard Medical School.

Dr. Wassner’s clinical and research activities focus on pediatric thyroid disease, with a particular interest in thyroid neoplasia in children and on congenital hypothyroidism.  A primary focus of his research has been to elucidate the differences between pediatric and adult thyroid nodules and cancer to optimize evidence-based care of pediatric thyroid neoplasia.  Dr. Wassner has also published extensively about congenital hypothyroidism and serves as ATA Liaison Representative to the American Academy of Pediatrics congenital hypothyroidism clinical guideline writing group. A national and international expert in pediatric thyroid disease, Dr. Wassner has published 35 research articles and over 40 invited chapters and reviews.

Dr. Wassner has been an American Thyroid Association member since 2011 and has served on the ATA Trainees & Career Advancement Committee (2013-2019), Awards Committee (2020- present), and Pediatric Thyroid Cancer Guidelines Task Force (2019-present).  He is also a member of the Pediatric Endocrine Society and the Endocrine Society.

TRAINEE OBSERVERS (BY APPOINTMENT)

Carol Chiung-Hui Peng, MD, Boston University

Carol Chiung-Hui Peng, originally from Taiwan, is an adult endocrinology fellow at Boston Medical Center and clinical instructor of medicine at Boston University. She is also a registered yoga instructor. Carol has a special interest in the thyroid. Bringing new scientific evidence related to clinical practice is her research enthusiasm. Starting from being an internal medicine trainee, she has demonstrated her dedication and talent in multiple major endocrinology annual meetings by winning top awards. Her works have been published in top-tier journals and reported by medical and non-medical media. Carol’s cheerful personality always brings peals of laughter at work.

Rhea Udyavar, MD, Johns Hopkins University

Rhea Udyavar, MD is currently in the process of transitioning from Endocrine Surgery fellowship at Johns Hopkins Hospital to a faculty position as Assistant Professor of Surgery at the University of Washington, where she will begin her career as an academic surgeon. Her clinical area of interest is in diseases of the thyroid, parathyroid, and adrenal glands, and she hopes to establish a high-volume thyroid cancer practice in Seattle.

Dr. Udyavar’s academic interest is in healthcare disparities and the intersection of race, socioeconomic variables, systemic racism, and disparities in surgical care. Beyond the impact of patient race and disease biology on health outcome and access disparities, the racial background and lived experiences of the surgeon may also play a role in the ongoing inequities observed in the United States healthcare system. Dr. Udyavar hopes to continue to uncover these sources of disparities to identify interventions targeted at the surgeon component of the patient/surgeon dyad.

After completing medical school at George Washington University, Dr. Udyavar began general surgery training at Duke University prior to completing a research fellowship at Brigham and Women’s Hospital, where she completed the remainder of her residency training. While at Brigham and Women’s Hospital, Dr. Udyavar served as the inaugural Chief Resident for Diversity, Equity, and Inclusion. Her research interests provided a solid foundation and served as a natural transition into this type of work, and expanding organizational principles of inclusivity is an ongoing passion of Dr. Udyavar’s. She hopes to continue to serve in leadership roles for DEI initiatives, particularly with regard to ensuring that trainees who are underrepresented in medicine not only have access to competitive training opportunities, but are also given the resources to thrive. Dr. Udyavar is currently a member of the ATA’s DEI committee and will be serving as a member of the DEI committee for the American Association of Endocrine Surgeons this year.

She has published widely on surgical disparities, and has written several review articles for Clinical Thyroidology.

Diversity, Equity, and Inclusion

Annually, the Board of Directors discusses its composition and the balance of specialty, practice area, and other demographic and geographic attributes for the next governance cycle. After evaluating its needs with an emphasis and focus on diversity, equity and inclusion, the Board of Directors then recommends that the Nominating Committee select individuals in designated practice and specialty areas.  In addition to electing a President-elect, the recommendation for the 2022 Ballot was to elect new members of the Board of Directors in the areas of: Endocrinologist and Pediatric Endocrinologist.  Eligibility for the Board of Directors requires five years of membership, five years of recent meeting attendance, previous committee service and disclosure of conflicts of interest. The Nominating Committee will consider nominees who were not selected this year during future nomination cycles.  Additionally, the Board of Directors asked that the Nominating Committee identify and appoint two Trainee Observers to a one-year term on the Board of Directors.

Nominating Committee Process

We encouraged our members to nominate their colleagues for the Board by sending out a Call for Nominations through our various communication platforms including: Members Only, emails and newsletters, social media, colleague to colleague, and personalized emails to specific groups (i.e. WIT).  Out of the 53 new nominations, 35 nominees agreed to be considered for the ATA Board.  The Nominating Committee is charged with presenting two candidates for each designated slot. To select the candidates, the committee reviews all the nominations and meets several times to consider, discuss and rank the final candidates. We appreciate the Nominating Committee’s service and dedication to the process.

Nominating Committee Members

BACKGROUND
Graves’ disease is the most common cause of hyperthyroidism (overactive thyroid) in the United States. Women are affected 7-8 times more frequently than men and many are in the pre-menopausal age group. This results in Graves’ disease being the most common cause of hyperthyroidism during pregnancy. Treatment of Graves’ disease includes anti-thyroid medications, surgery and radioactive iodine therapy. During pregnancy, radioactive iodine therapy is contraindicated and surgery is only safe to be performed during the second trimester. This leaves anti-thyroid medications as the main treatment option for Graves’ disease during pregnancy. Both of the available anti-thyroid medications, propylthiouracil (PTU) and methimazole, can affect the baby, although the risk is very low. Methimazole is the safer medication during pregnancy, since the risk is less than PTU and can be limited by maintaining the lowest possible dose during pregnancy. However, the possibility of identifying an alternative medical therapy for Graves’ disease in early pregnancy without side effects in the baby is highly appealing.

Potassium iodide (KI) has been used to prepare patients with Graves’ disease for surgery and has occasionally been used to control hyperthyroidism by itself. The major drawback to KI as a treatment option is that it can occasionally make the hyperthyroidism worse and more difficult to treat. A prior study by the current research group suggests that the risk of side effects on the baby is less with KI than with methimazole. However, in some patients, the switch from methimazole to KI did indeed make the hyperthyroidism worse. This study aimed to identify predictors of both clinical improvement and worsening hyperthyroidism following the switch from methimazole to KI treatment in hyperthyroid pregnant women.

THE FULL ARTICLE TITLE
Yoshihara A et al 2020 The characteristics of patients with Graves’ disease whose thyroid hormone level increases after substituting potassium iodide for methimazole in the first trimester of pregnancy. Thyroid. Epub 2020 Jan 13. PMID: 31928169.

SUMMARY OF THE STUDY
This study was conducted at Ito Hospital in Tokyo. Pregnant women with Graves’ disease whose treatment was switched from methimazole to KI during the first trimester and who gave birth between 2005 and 2018 were included. The switch from methimazole to KI was made at the first visit following confirmation of the pregnancy. KI was given from 10 to 30 mg/day in a solution or in the form of 38-mg tablets.

Level of serum TSH, free T₃, free T₄ levels and TSH receptor antibodies (the cause of Graves’ disease) were measured during the first trimester both before and then 2 to 4 weeks after changing from methimazole to KI treatment. After the change of therapy, the KI dose was decreased if the free T₄ was low or increased if the free T₄ was elevated. If hyperthyroidism persisted in the second trimester of pregnancy, an anti-thyroid drug was either added to the KI or substituted for it.

The average age of the 240 women at the time of delivery was 33 years. The switch from methimazole to KI treatment occurred at an average of 6 weeks of pregnancy. Of the 133 (55%) patients who were able to taper off of all medication during pregnancy, 4 became hypothyroid and needed levothyroxine by the time of delivery. Women who were able to discontinue therapy required lower methimazole doses prior to the switch to KI, had lower antibody and higher serum TSH levels and were on lower KI doses as compared with women who needed treatment for hyperthyroidism throughout the pregnancy. The only significant predictor of the ability to discontinue therapy was the level of the TSH receptor antibody. A continued high level of thyroid receptor antibody predicted a need to continue medication. Worsened hyperthyroidism occurred in 22 patients (9.2%) following the switch to KI, requiring higher methimazole doses by the third trimester than before the medication switch. There was no clinical sign or level of thyroid hormone or antibody level that predicted which patient would get worse with KI therapy.

WHAT ARE THE IMPLICATIONS OF THIS STUDY?
This study shows that ~9% of pregnant women with Graves’ disease who were switched from methimazole to KI in the first trimester of pregnancy are at risk for worsening hyperthyroidism during the pregnancy. No clear predictors for this observation could be identified. Thus, while KI may have a lower risk of developing rare side effects in the baby, the increased risk of worsening hyperthyroidism supports the current American Thyroid Association guideline that recommends that KI treatment for Graves’ disease in pregnancy is not recommended outside Japan until more evidence on safety and efficacy is available. Therefore, staying with methimazole in pregnant women with Graves’ disease continues to be the safer option for both the mother and the developing baby.

— Alan P. Farwell, MD, FACE

Table of Contents | PDF File for Saving and Printing

Volume 13 Issue 10

Available in pdf format for saving and printing and Web page format for viewing online

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Clinical Thyroidology for the Public Volume 13 Issue 10 (PDF file, 7.5 MB)

TABLE OF CONTENTS – Web Format

EDITOR’S COMMENTS

COVID-19 AND THYROID DISEASE
COVID-19 infection and thyroid function
COVID-19 infection can range from a very mild or asymptomatic presentation to critical illness and death. Along with multiple organ systems that may be affected by COVID-19 is the thyroid gland. These investigators sought to characterize thyroid function in patients hospitalized with COVID-19 infection.
Lania A et al on behalf of Humanitas COVID-19 Task Force. Thyrotoxicosis in patients with COIVD-19: the THYRCOV study. Eur J Endocrinol. 2020. doi: 10.1530/EJE-20-0335. PMID: 32698147
Muller et al report the association of subacute thyroiditis and COVID-19. The aim of this study was to evaluate the frequency subacute thyroiditis in COVID-19 patients as compared to non-COVID patients admitted to the intensive care unit in Italy.
(PDF File for saving and printing, 1.2 MB)

HYPERTHYROIDISM
Substituting potassium iodide for methimazole in first-trimester pregnant women with Graves’ disease may unpredictably worsen hyperthyroidism
Methimazole is the main treatment option for Graves’ disease during pregnancy. Potassium iodide (KI) has occasionally been used to control hyperthyroidism and may have less side effects on the baby but may make the hyperthyroidism worse. This study aimed to identify predictors of both clinical improvement and worsening hyperthyroidism following the switch from methimazole to KI treatment in hyperthyroid pregnant women.
Yoshihara A et al 2020 The characteristics of patients with Graves’ disease whose thyroid hormone level increases after substituting potassium iodide for methimazole in the first trimester of pregnancy. Thyroid. Epub 2020 Jan 13. PMID: 31928169.
(PDF File for saving and printing, 744 KB)

HYPOTHYROIDISM
Thyroid hormone use doubled in the United States from 1997 to 2016
Thyroid hormone is the most frequently prescribed medication in the United States, and the proportion of adults who report taking thyroid hormone has increased in recent years. The authors of this study sought to understand the proportion of adult individuals using thyroid hormone by age, sex, race/ethnicity from 1996 though 2016. They also aimed to study the costs associated with all thyroid hormone prescriptions during that time.
Johansen ME, Marcinek JP, Doo Young Yun J 2020 Thyroid hormone use in the United States, 1997–2016. J Am Board Fam Med 33:284–288. PMID: 32179
(PDF File for saving and printing, 736 KB)

THYROID AND PREGNANCY
A high proportion of women with history of miscarriage or infertility may have mild hypothyroidism or positive thyroid antibody status
Currently, the American Thyroid Association recommends checking TSH levels in high-risk women with a history of miscarriage or infertility. However, testing and treatment for subclinical hypothyroidism in pregnancy is still debated because clinical trials have not shown a clear benefit. This study was done to determine how frequent subclinical hypothyroidism or a positive TPOAb level is seen among high-risk women with a history of miscarriage or infertility.
Dhillon-Smith RK et al 2020 The prevalence of thyroid dysfunction and autoimmunity in women with history of miscarriage or subfertility. J Clin Endocrinol Metab 105:dgaa302. PMID: 32593174.
(PDF File for saving and printing, 751 KB)
HYPOTHYROIDISM
Effects of increasing levothyroxine doses on mood in older patients with hypothyroidism
Depression is more common in older adults in general and they are more prone to develop depression as the result of hypothyroidism. Prior studies have not shown a beneficial effect on mood after starting levothyroxine in depressed older individuals with subclinical hypothyroidism. The current study examined the effect of increasing the levothyroxine dose in older hypothyroid patients with depressive symptoms.
Moon JH et al 2020 Effect of increased levothyroxine dose on depressive mood in older adults undergoing thyroid hormone replacement therapy. Clin Endocrinol. Epub 2020 Apr 13. PMID: 32282957.
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THYROID CANCER
Patients with papillary microcarcinoma under active surveillance are proceeding to have surgery less frequently.
Active surveillance in patients with papillary microcarcinoma involves frequent neck ultrasounds to make sure the cancer is stable. Over time, patients under active surveillance eventually undergo surgery for a variety of reasons. In this study, the authors examined the trends and reasons for surgery after the initiation of active surveillance.
Sasaki T et al. 2020 Marked decrease over time in conversion surgery after active surveillance of low-risk papillary thyroid microcarcinoma. Thyroid. Epub 2020 Jul 14. PMID: 32664805.
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BACKGROUND
Iodine is essential for the production of thyroid hormone and for normal development of the baby during pregnancy. During pregnancy and breastfeeding there is an increased requirement for iodine both because of a need for higher thyroid hormone production and for secretion of iodine into breast milk. Many studies have shown that iodine deficiency has been associated with adverse effects in babies and infants that range from severe mental retardation to mild brain deficits. Therefore, organizations such as the American Thyroid Association and the American Academy of Pediatrics have recommended that women who are planning a pregnancy, are pregnant or are breastfeeding should ingest a daily supplement that contains 150 mcgs of iodine.

In the US, it has been challenging to identify the sources of dietary iodine, because most food packaging does not detail their contents for this element. Dairy products and seafood are two important sources, but the consumption of these two types of foods is highly variable across the US population. Although in many regions of the world, universal salt iodization has been successful in preventing iodine deficiency, iodization of salt has never been mandated in the US. Currently, only 53% of salt sold for use in homes contains iodine and salt used in processed foods typically is not iodized.

Due to the variable intake of iodine content in food sources and different types of diets followed by the US population, there is concern that some groups of people are at risk for iodine deficiency. Specifically, mild iodine deficiency has been recently documented to be present among pregnant US women. The importance of multivitamin supplements as a source of iodine for pregnant and non-pregnant US adults is not well understood. A study reviewing the use of multivitamin supplements in the US and Canada reported that supplement use ranged from 7% to 85%, showing how difficult it is to accurately determine the extent of multivitamin use. In addition, it has been reported that only 60% of the different types of prenatal multivitamin supplements marketed in the US list iodine among the ingredients. It also has been shown that iodine content is the most variable and least accurately labeled nutrient contained in US adult multivitamins.

This study aimed to assess whether multivitamins are a significant source of iodine in nonpregnant and pregnant adults by looking at the iodine content reported in the most frequently purchased US adult and prenatal multivitamin preparations, knowing how many purchases for these supplements were made over the course of one year.

THE FULL ARTICLE TITLE:
Patel A et al 2018 Iodine content of the best-selling United States adult and prenatal multivitamin preparations. Thyroid. Epub 2018 Oct 30. PMID: 30266075.

SUMMARY OF THE STUDY
Data for this study was obtained from Information Resources, Inc. (Chicago, IL), a market research firm. It provided information about the 99 US adult and 60 prenatal multivitamins with the largest market share from July 2016 to July 2017. Supplements sold at food, drug, value chains, mass merchandise and military stores were included. However, not included were sales made over the Internet, direct selling and specialty stores. The iodine content and its source was determined using the product labels. Ten products from the adult multivitamin group and one from the prenatal group were excluded because their label was either unavailable or the iodine content could not be determined.

Nearly 74% of the adult multivitamin brands contained iodine, and approximately 75% of these contained 150 mcg per daily dose. The source of the iodine was potassium iodide in all these products. Although some products contained as little as 38 mcgs, none exceeded 150 mcgs per daily dose. Of the prenatal multivitamins, almost 58% of products contained iodine, and 91% contained 150 mcgs per daily dose. The iodine source was potassium iodide in about 75% of the brands, and the sources for the rest was kelp and one brand used inactivated yeast. These last two sources have previously been shown to be variable in their iodine content. Overall, the price of prenatal vitamins is higher than the general adult multivitamin.

WHAT ARE THE IMPLICATIONS OF THIS STUDY?
Although the majority of the best-selling US brands of adult multivitamins contain iodine, a relatively high proportion (25%) do not. Among the prenatal multivitamins, 40% do not contain iodine. Even though most products contain the recommended amount, there is a wide range in iodine content going from as little as 25 mcgs to 93% higher than the recommended daily dose.

The limitations of this study include the fact that it relied on the manufacturers’ listed iodine content, which may not match the actual content. Also, although using consumer data it was possible to determine how many doses were purchased, it was unclear how many doses were actually consumed, and data from products purchased for example, on the internet was not included.

In summary, multivitamin products appear to be a significant source of iodine nutrition for many US adults. However, in spite of recommendations regarding iodine content in prenatal vitamins, about 40% of the evaluated products do not contain iodine. Therefore, it is extremely important that women, especially when pregnant, breastfeeding or planning a pregnancy, read the labels of their multivitamin supplements to ensure that they are receiving an adequate amount of iodine.

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