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Steffens B, Koch G, Gächter P, Claude F, Gotta V, Bachmann F, Schropp J, Janner M, l'Allemand D, Konrad D, Welzel T, Szinnai G, Pfister M. Clinically practical pharmacometrics computer model to evaluate and personalize pharmacotherapy in pediatric rare diseases: application to Graves' disease. Front Med (Lausanne) 2023; 10:1099470. [PMID: 37206476 PMCID: PMC10188966 DOI: 10.3389/fmed.2023.1099470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/14/2023] [Indexed: 05/21/2023] Open
Abstract
Objectives Graves' disease (GD) with onset in childhood or adolescence is a rare disease (ORPHA:525731). Current pharmacotherapeutic approaches use antithyroid drugs, such as carbimazole, as monotherapy or in combination with thyroxine hormone substitutes, such as levothyroxine, as block-and-replace therapy to normalize thyroid function and improve patients' quality of life. However, in the context of fluctuating disease activity, especially during puberty, a considerable proportion of pediatric patients with GD is suffering from thyroid hormone concentrations outside the therapeutic reference ranges. Our main goal was to develop a clinically practical pharmacometrics computer model that characterizes and predicts individual disease activity in children with various severity of GD under pharmacotherapy. Methods Retrospectively collected clinical data from children and adolescents with GD under up to two years of treatment at four different pediatric hospitals in Switzerland were analyzed. Development of the pharmacometrics computer model is based on the non-linear mixed effects approach accounting for inter-individual variability and incorporating individual patient characteristics. Disease severity groups were defined based on free thyroxine (FT4) measurements at diagnosis. Results Data from 44 children with GD (75% female, median age 11 years, 62% receiving monotherapy) were analyzed. FT4 measurements were collected in 13, 15, and 16 pediatric patients with mild, moderate, or severe GD, with a median FT4 at diagnosis of 59.9 pmol/l (IQR 48.4, 76.8), and a total of 494 FT4 measurements during a median follow-up of 1.89 years (IQR 1.69, 1.97). We observed no notable difference between severity groups in terms of patient characteristics, daily carbimazole starting doses, and patient years. The final pharmacometrics computer model was developed based on FT4 measurements and on carbimazole or on carbimazole and levothyroxine doses involving two clinically relevant covariate effects: age at diagnosis and disease severity. Discussion We present a tailored pharmacometrics computer model that is able to describe individual FT4 dynamics under both, carbimazole monotherapy and carbimazole/levothyroxine block-and-replace therapy accounting for inter-individual disease progression and treatment response in children and adolescents with GD. Such clinically practical and predictive computer model has the potential to facilitate and enhance personalized pharmacotherapy in pediatric GD, reducing over- and underdosing and avoiding negative short- and long-term consequences. Prospective randomized validation trials are warranted to further validate and fine-tune computer-supported personalized dosing in pediatric GD and other rare pediatric diseases.
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Affiliation(s)
- Britta Steffens
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel UKBB, University of Basel, Basel, Switzerland
- *Correspondence: Britta Steffens
| | - Gilbert Koch
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel UKBB, University of Basel, Basel, Switzerland
| | - Pascal Gächter
- Pediatric Endocrinology and Diabetology, University Children's Hospital Basel UKBB, University of Basel, Basel, Switzerland
| | - Fabien Claude
- Pediatric Endocrinology and Diabetology, University Children's Hospital Basel UKBB, University of Basel, Basel, Switzerland
| | - Verena Gotta
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel UKBB, University of Basel, Basel, Switzerland
| | - Freya Bachmann
- Department of Mathematics and Statistics, University of Konstanz, Konstanz, Germany
| | - Johannes Schropp
- Department of Mathematics and Statistics, University of Konstanz, Konstanz, Germany
| | - Marco Janner
- Division of Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dagmar l'Allemand
- Department of Pediatric Endocrinology and Diabetology, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland
| | - Daniel Konrad
- Division of Pediatric Endocrinology and Diabetology and Children's Research Centre, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Tatjana Welzel
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel UKBB, University of Basel, Basel, Switzerland
| | - Gabor Szinnai
- Pediatric Endocrinology and Diabetology, University Children's Hospital Basel UKBB, University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Marc Pfister
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel UKBB, University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel and University Hospital Basel, Basel, Switzerland
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Lisco G, De Tullio A, Jirillo E, Giagulli VA, De Pergola G, Guastamacchia E, Triggiani V. Thyroid and COVID-19: a review on pathophysiological, clinical and organizational aspects. J Endocrinol Invest 2021; 44:1801-1814. [PMID: 33765288 PMCID: PMC7992516 DOI: 10.1007/s40618-021-01554-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/10/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Thyroid dysfunction has been observed in patients with COVID-19, and endocrinologists are requested to understand this clinical issue. Pandemic-related restrictions and reorganization of healthcare services may affect thyroid disease management. OBJECTIVE AND METHODS To analyze and discuss the relationship between COVID-19 and thyroid diseases from several perspectives. PubMed/MEDLINE, Google Scholar, Scopus, ClinicalTrial.gov were searched for this purpose by using free text words and medical subject headings as follows: "sars cov 2", "covid 19", "subacute thyroiditis", "atypical thyroiditis", "chronic thyroiditis", "hashimoto's thyroiditis", "graves' disease", "thyroid nodule", "differentiated thyroid cancer", "medullary thyroid cancer", "methimazole", "levothyroxine", "multikinase inhibitor", "remdesivir", "tocilizumab". Data were collected, analyzed, and discussed to answer the following clinical questions: "What evidence suggests that COVID-19 may induce detrimental consequences on thyroid function?"; "Could previous or concomitant thyroid diseases deteriorate the prognosis of COVID-19 once the infection has occurred?"; "Could medical management of thyroid diseases influence the clinical course of COVID-19?"; "Does medical management of COVID-19 interfere with thyroid function?"; "Are there defined strategies to better manage endocrine diseases despite restrictive measures and in-hospital and ambulatory activities reorganizations?". RESULTS SARS-CoV-2 may induce thyroid dysfunction that is usually reversible, including subclinical and atypical thyroiditis. Patients with baseline thyroid diseases are not at higher risk of contracting or transmitting SARS-CoV-2, and baseline thyroid dysfunction does not foster a worse progression of COVID-19. However, it is unclear whether low levels of free triiodothyronine, observed in seriously ill patients with COVID-19, may worsen the disease's clinical progression and, consequently, if triiodothyronine supplementation could be a tool for reducing this burden. Glucocorticoids and heparin may affect thyroid hormone secretion and measurement, respectively, leading to possible misdiagnosis of thyroid dysfunction in severe cases of COVID-19. High-risk thyroid nodules require a fine-needle aspiration without relevant delay, whereas other non-urgent diagnostic procedures and therapeutic interventions should be postponed. DISCUSSION Currently, we know that SARS-CoV-2 could lead to short-term and reversible thyroid dysfunction, but thyroid diseases seem not to affect the progression of COVID-19. Adequate management of patients with thyroid diseases remains essential during the pandemic, but it could be compromised because of healthcare service restrictions. Endocrine care centers should continuously recognize and classify priority cases for in-person visits and therapeutic procedures. Telemedicine may be a useful tool for managing patients not requiring in-person visits.
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Affiliation(s)
- G Lisco
- Interdisciplinary Department of Medicine, Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, School of Medicine, University of Bari "Aldo Moro", Bari, Apulia, Italy.
| | - A De Tullio
- Interdisciplinary Department of Medicine, Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, School of Medicine, University of Bari "Aldo Moro", Bari, Apulia, Italy
| | - E Jirillo
- Department of Basic Medical Science, Neuroscience and Sensory Organs, University of Bari Aldo Moro, Bari, Apulia, Italy
| | - V A Giagulli
- Interdisciplinary Department of Medicine, Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, School of Medicine, University of Bari "Aldo Moro", Bari, Apulia, Italy
| | - G De Pergola
- Department of Biomedical Sciences and Human Oncology, Section of Internal Medicine and Clinical Oncology, University of Bari Aldo Moro, Bari, Apulia, Italy
| | - E Guastamacchia
- Interdisciplinary Department of Medicine, Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, School of Medicine, University of Bari "Aldo Moro", Bari, Apulia, Italy
| | - V Triggiani
- Interdisciplinary Department of Medicine, Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, School of Medicine, University of Bari "Aldo Moro", Bari, Apulia, Italy.
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Williams A, Walsh CG, Griffith ML. Telehealth for Endocrinology: Experience and Effect on Utilization in the Prepandemic Era. Endocr Pract 2021; 27:1017-1021. [PMID: 34147691 DOI: 10.1016/j.eprac.2021.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/17/2021] [Accepted: 06/11/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Telehealth (TH) use in endocrinology was limited before the COVID-19 pandemic but will remain a major modality of care postpandemic. Reimbursement policies have been limited historically due to concerns of overutilization of visits and testing. Additionally, there is limited literature on endocrinology care delivered via TH for conditions other than diabetes. We assess real-world TH use for endocrinology in a prepandemic environment with the hypothesis that TH would not increase the utilization of total visits or related ancillary testing services compared with conventional (CVL) face-to-face office visits. METHODS A single-institution retrospective cohort study assessing the prepandemic use of TH in endocrinology, consisting of 75 patients seen via TH and 225 patients seen in CVL visits. For most patients, TH was conducted via a clinic-to-clinic model. Outcomes measured were total endocrine visit frequency and frequency of related laboratory and radiology testing per patient, hemoglobin A1C, microalbumin, low-density lipoprotein, thyroid-stimulating hormone, thyroglobulin, and thyroid ultrasounds. RESULTS For all endocrine visits, TH patients had a median of 0.24 (interquartile range, 0.015-0.36) visits per month. CVL patients had a median of 0.20 visits per month (interquartile range, 0.11-0.37). Total visits per month did not vary significantly between groups (P = .051). Hemoglobin A1C outcomes were equivalent and there was no increase in ancillary laboratory testing for the TH group. CONCLUSION Our observations demonstrate that, in a prepandemic health care setting, TH visits can provide equivalent care for endocrinology patients, without increasing utilization of total visits or ancillary services.
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Affiliation(s)
- Alexander Williams
- Vanderbilt University Medical Center, Department of Medicine, Division of Diabetes, Endocrinology, and Metabolism, Nashville, Tennessee
| | - Colin G Walsh
- Vanderbilt University Medical Center, Departments of Biomedical Informatics, Medicine, and Psychiatry and Behavioral Sciences, Nashville, Tennessee
| | - Michelle L Griffith
- Vanderbilt University Medical Center, Department of Medicine, Division of Diabetes, Endocrinology, and Metabolism, Nashville, Tennessee.
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Martins JRM, Villagelin DGP, Carvalho GA, Vaisman F, Teixeira PFS, Scheffel RS, Sgarbi JA. Management of thyroid disorders during the COVID-19 outbreak: a position statement from the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism (SBEM). ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2021; 65:368-375. [PMID: 33844898 PMCID: PMC10065338 DOI: 10.20945/2359-3997000000352] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This position statement was prepared to guide endocrinologists on the best approach to managing thyroid disorders during the coronavirus disease (COVID-19) pandemic. The most frequent thyroid hormonal findings in patients with COVID-19, particularly in individuals with severe disease, are similar to those present in the non-thyroidal illness syndrome and require no intervention. Subacute thyroiditis has also been reported during COVID-19 infection. Diagnosis and treatment of hypothyroidism during the COVID-19 pandemic may follow usual practice; however, should avoid frequent laboratory tests in patients with previous controlled disease. Well-controlled hypo and hyperthyroidism are not associated with an increased risk of COVID-19 infection or severity. Newly diagnosed hyperthyroidism during the pandemic should be preferably treated with antithyroid drugs (ATDs), bearing in mind the possibility of rare side effects with these medications, particularly agranulocytosis, which requires immediate intervention. Definitive treatment of hyperthyroidism (radioiodine therapy or surgery) may be considered in those cases that protective protocols can be followed to avoid COVID-19 contamination or once the pandemic is over. In patients with moderate Graves' ophthalmopathy (GO) not at risk of visual loss, glucocorticoids at immunosuppressive doses should be avoided, while in those with severe GO without COVID-19 and at risk of vision loss, intravenous glucocorticoid is the therapeutic choice. Considering that most of the thyroid cancer cases are low risk and associated with an excellent prognosis, surgical procedures could and should be postponed safely during the pandemic period. Additionally, when indicated, radioiodine therapy could also be safely postponed as long as it is possible.
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Affiliation(s)
- João Roberto M Martins
- Departamento de Tireoide, Sociedade Brasileira de Endocrinologia e Metabologia, Rio de Janeiro, RJ, Brasil.,Laboratório de Endocrinologia Molecular e Translacional, Disciplina de Endocrinologia e Metabologia, Departamento de Medicina, Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp/EPM), São Paulo, SP, Brasil
| | - Danilo G P Villagelin
- Departamento de Tireoide, Sociedade Brasileira de Endocrinologia e Metabologia, Rio de Janeiro, RJ, Brasil.,Endocrinologia e Metabolismo, Hospital da PUC-Campinas, Campinas, SP, Brasil.,Pós-graduação em Clínica Médica, Unicamp, Campinas, SP, Brasil
| | - Gisah A Carvalho
- Departamento de Tireoide, Sociedade Brasileira de Endocrinologia e Metabologia, Rio de Janeiro, RJ, Brasil.,Departamento de Endocrinologia e Metabologia (SEMPR), Hospital de Clínicas da Universidade Federal do Paraná (HC-UFPR),Curitiba, PR, Brasil
| | - Fernanda Vaisman
- Departamento de Tireoide, Sociedade Brasileira de Endocrinologia e Metabologia, Rio de Janeiro, RJ, Brasil.,Unidade de Endocrinologia Oncológica, Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA), Rio de Janeiro, RJ, Brasil
| | - Patrícia F S Teixeira
- Departamento de Tireoide, Sociedade Brasileira de Endocrinologia e Metabologia, Rio de Janeiro, RJ, Brasil.,Faculdade de Medicina, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brasil
| | - Rafael S Scheffel
- Departamento de Tireoide, Sociedade Brasileira de Endocrinologia e Metabologia, Rio de Janeiro, RJ, Brasil.,Unidade de Tireoide, Hospital de Clínicas de Porto Alegre, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - José A Sgarbi
- Departamento de Tireoide, Sociedade Brasileira de Endocrinologia e Metabologia, Rio de Janeiro, RJ, Brasil.,Unidade de Tireoide, Disciplina de Endocrinologia e Metabolismo, Departamento de Medicina, Faculdade de Medicina de Marília, Marília, SP, Brasil,
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Neinstein AB, Masharani U. Letter to the Editor: "Approach to the Patient with Thyrotoxicosis Using Telemedicine". J Clin Endocrinol Metab 2021; 106:e1060-e1061. [PMID: 33038240 DOI: 10.1210/clinem/dgaa723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 10/06/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Aaron B Neinstein
- Department of Medicine, University of California, San Francisco, San Francisco, California
- UCSF Center for Digital Health Innovation, San Francisco, California
| | - Umesh Masharani
- Department of Medicine, University of California, San Francisco, San Francisco, California
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Thyroid disorders and SARS-CoV-2 infection: From pathophysiological mechanism to patient management. ANNALES D'ENDOCRINOLOGIE 2020; 81:507-510. [PMID: 32950466 PMCID: PMC7498405 DOI: 10.1016/j.ando.2020.09.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The World Health Organization (WHO) declared the COVID-19 epidemic to be a global pandemic in March 2020. COVID-19 is an infection caused by SARS-CoV-2, a coronavirus that utilizes the angiotensin-2 converting enzyme to penetrate thyroid and pituitary cells, and may result in a “cytokine storm”. Based on the pathophysiological involvement of the pituitary-thyroid axis, the current review discusses the diagnosis of abnormal thyroid function test, and the management of patients presenting with thyrotoxicosis, thyroid-associated orbitopathy and hypothyroidism in the context of SARS-CoV-2 infection.
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Kaur D, Galloway GK, Oyibo SO. Patient Satisfaction With the Use of Telemedicine in the Management of Hyperthyroidism. Cureus 2020; 12:e9859. [PMID: 32832308 PMCID: PMC7437122 DOI: 10.7759/cureus.9859] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Introduction We have been using telemedicine in the management of hyperthyroidism since 2010. Although telemedicine has been used in different areas of healthcare management for several years, its importance was highlighted during the current coronavirus (COVID-19) pandemic. The aim of this survey was to assess patient satisfaction with the use of telemedicine in the management of hyperthyroidism. Materials and methods A postal survey was administered to all patients who had received at least one telemedicine session during the months January to May 2020 for the management of hyperthyroidism. Patients were asked to respond to nine statements using the five-point Likert scale. A suggestion box was included for comments and suggestions for improvement. Results There were 106 patients (26 males vs 80 females) with an average age of 53 years who received one to three calls over a five-month study period. A total of 65 respondents returned completed survey forms (61.3% response rate). Approximately 97% of respondents were satisfied with the overall quality of service provided during the use of telemedicine in the management of hyperthyroidism. The telemedicine service was time saving and met their needs. Approximately 14% of respondents were undecided about whether telemedicine was as good as the traditional face-to-face consultation. The respondents also made useful comments and suggestions concerning the provision of adequate time slots, occasional face-to-face appointments, and the introduction of text messaging and emailing to the telemedicine service. Conclusions This survey has demonstrated that the use of telemedicine in the management of hyperthyroidism is desirable to a majority of patients, as long as adequate time slots are dedicated to the telemedicine sessions and patients are reassured of the availability of face-to-face consultation sessions. Regular patient feedback is necessary to perfect the use of telemedicine in a patient-centered healthcare service.
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Affiliation(s)
- Devinder Kaur
- Diabetes and Endocrinology, Peterborough City Hospital, Peterborough, GBR
| | | | - Samson O Oyibo
- Diabetes and Endocrinology, Peterborough City Hospital, Peterborough, GBR
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