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Younes YR, Cron N, Field BC, Nayyar V, Clark J, Zachariah S, Lakshmipathy K, Isuga JO, Maghsoodi N, Emmanuel J. Proposed treatment strategy for reactive hypoglycaemia. Front Endocrinol (Lausanne) 2024; 15:1332702. [PMID: 38370356 PMCID: PMC10869498 DOI: 10.3389/fendo.2024.1332702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/15/2024] [Indexed: 02/20/2024] Open
Abstract
Background/aim Managing reactive hypoglycaemia (RH) poses challenges due to limited and often ineffective treatment options. We report a case series and draw on this to propose a stepwise treatment approach consisting of lifestyle modifications, metformin, GLP-1 analogues, and the use of flash glucose monitoring technology. Method A retrospective review was conducted to analyse the management of 11 cases presenting with recurrent RH symptoms. Result Two patients experienced successful resolution of symptoms through lifestyle modifications. Metformin alone was effective in treating seven out of nine patients who received pharmacological treatment. Two patients with previous upper gastrointestinal surgery showed a partial response to metformin and benefited further from additional long-acting GLP-1 analogue. Pharmacological intervention led to significant reductions in insulin and C-peptide levels in repeat mixed meal tolerance tests (P-values 0.043 for insulin and 0.006 for C-peptide). Finally, flash glucose monitoring technology was useful in early detection and preventing episodes of hypoglycaemia in one of these patients with persistent symptoms. Conclusion These findings highlight the potential efficacy of escalated treatment strategies for RH, including the use of metformin, GLP-1 analogues, and flash glucose monitoring technology.
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Affiliation(s)
- Younes R. Younes
- Department of Diabetes & Endocrinology, East Surrey Hospital, Surrey & Sussex Healthcare NHS Trust, Redhill, United Kingdom
| | - Nicholas Cron
- Department of Statistics, London School of Economics, London, United Kingdom
| | - Benjamin C.T. Field
- Department of Diabetes & Endocrinology, East Surrey Hospital, Surrey & Sussex Healthcare NHS Trust, Redhill, United Kingdom
- Section of Clinical Medicine, Faculty of Health & Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Vidhu Nayyar
- Department of Diabetes & Endocrinology, East Surrey Hospital, Surrey & Sussex Healthcare NHS Trust, Redhill, United Kingdom
| | - James Clark
- Department of Diabetes & Endocrinology, East Surrey Hospital, Surrey & Sussex Healthcare NHS Trust, Redhill, United Kingdom
| | - Sunil Zachariah
- Department of Diabetes & Endocrinology, East Surrey Hospital, Surrey & Sussex Healthcare NHS Trust, Redhill, United Kingdom
| | - Kavitha Lakshmipathy
- Department of Diabetes & Endocrinology, East Surrey Hospital, Surrey & Sussex Healthcare NHS Trust, Redhill, United Kingdom
| | - Jimboy O. Isuga
- Department of Diabetes & Endocrinology, East Surrey Hospital, Surrey & Sussex Healthcare NHS Trust, Redhill, United Kingdom
| | - Negar Maghsoodi
- Chemical Pathology Department, University Hospitals Sussex NHS Foundation Trust, Royal Sussex County Hospital, Brighton, United Kingdom
| | - Julian Emmanuel
- Department of Diabetes & Endocrinology, East Surrey Hospital, Surrey & Sussex Healthcare NHS Trust, Redhill, United Kingdom
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Žarković M, Attanasio R, Nagy EV, Negro R, Papini E, Perros P, Cohen CA, Akarsu E, Alevizaki M, Ayvaz G, Bednarczuk T, Berta E, Bodor M, Borissova AM, Boyanov M, Buffet C, Burlacu MC, Ćirić J, Díez JJ, Dobnig H, Fadeyev V, Field BCT, Fliers E, Frølich JS, Führer D, Galofré JC, Hakala T, Jiskra J, Kopp P, Krebs M, Kršek M, Kužma M, Lantz M, Lazúrová I, Leenhardt L, Luchytskiy V, McGowan A, Melo M, Metso S, Moran C, Morgunova T, Mykola T, Beleslin BN, Niculescu DA, Perić B, Planck T, Poiana C, Puga FM, Robenshtok E, Rosselet P, Ruchala M, Riis KR, Shepelkevich A, Unuane D, Vardarli I, Visser WE, Vrionidou A, Younes YR, Yurenya E, Hegedüs L. Characteristics of specialists treating hypothyroid patients: the "THESIS" collaborative. Front Endocrinol (Lausanne) 2023; 14:1225202. [PMID: 38027187 PMCID: PMC10660282 DOI: 10.3389/fendo.2023.1225202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Thyroid specialists influence how hypothyroid patients are treated, including patients managed in primary care. Given that physician characteristics influence patient care, this study aimed to explore thyroid specialist profiles and associations with geo-economic factors. Methods Thyroid specialists from 28 countries were invited to respond to a questionnaire, Treatment of Hypothyroidism in Europe by Specialists: an International Survey (THESIS). Geographic regions were defined according to the United Nations Statistics Division. The national economic status was estimated using World Bank data on the gross national income per capita (GNI per capita). Results 5,695 valid responses were received (response rate 33·0%). The mean age was 49 years, and 65·0% were female. The proportion of female respondents was lowest in Northern (45·6%) and highest in Eastern Europe (77·2%) (p <0·001). Respondent work volume, university affiliation and private practice differed significantly between countries (p<0·001). Age and GNI per capita were correlated inversely with the proportion of female respondents (p<0·01). GNI per capita was inversely related to the proportion of respondents working exclusively in private practice (p<0·011) and the proportion of respondents who treated >100 patients annually (p<0·01). Discussion THESIS has demonstrated differences in characteristics of thyroid specialists at national and regional levels, strongly associated with GNI per capita. Hypothyroid patients in middle-income countries are more likely to encounter female thyroid specialists working in private practice, with a high workload, compared to high-income countries. Whether these differences influence the quality of care and patient satisfaction is unknown, but merits further study.
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Affiliation(s)
- Miloš Žarković
- University of Belgrade Faculty of Medicine, Internal Medicine, Belgrade, Serbia
- Clinic of Endocrinology, Diabetes and Diseases of Metabolism, Thyroid Department, Belgrade, Serbia
| | - Roberto Attanasio
- Associazione Medici Endocrinologi, Scientific Committee, Milan, Italy
| | - Endre V. Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Roberto Negro
- Ospedale Vito Fazzi, Department of Endocrinology, Lecce, Italy
| | - Enrico Papini
- Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Albano Laziale, Roma, Italy
| | - Petros Perros
- Institute of Translational and Clinical Research, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | | | - Ersin Akarsu
- Department of Internal Medicine, Division of Endocrinology, Faculty of Medicine, Gaziantep University, Gaziantep, Türkiye
| | - Maria Alevizaki
- Endocrine Unit and Diabetes Centre, Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens Faculty of Medicine, Athens, Greece
| | - Göksun Ayvaz
- Department of Endocrinology and Metabolism, Koru Ankara Hospital, Ankara, Türkiye
| | - Tomasz Bednarczuk
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Eszter Berta
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Miklos Bodor
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Anna Maria Borissova
- Sofia University Saint Kliment Ohridski, Medical Faculty, Clinic of Endocrinology and Metabolism, University Hospital “Sofiamed”, Sofia, Bulgaria
| | - Mihail Boyanov
- University Hospital Alexandrovska, Clinic of Endocrinology and Metabolism, Medical University-Sofia, Internal Medicine, Sofia, Bulgaria
| | - Camille Buffet
- GRC n 16, GRC Thyroid Tumors, Thyroid Disease and Endocrine Tumor Department, AP-HP, Hôpital Pitié Salpêtrière, Sorbonne University, Paris, France
| | - Maria-Cristina Burlacu
- Department of Endocrinology and Nutrition, Cliniques Universitaires St-Luc, Université Catholique De Louvain, Brussels, Belgium
| | - Jasmina Ćirić
- University of Belgrade Faculty of Medicine, Internal Medicine, Belgrade, Serbia
- Clinic of Endocrinology, Diabetes and Diseases of Metabolism, Thyroid Department, Belgrade, Serbia
| | - Juan J. Díez
- Department of Endocrinology, Hospital Universitario Puerta De Hierro Majadahonda, Madrid, Spain
- Instituto De Investigación Sanitaria Puerta De Hierro Segovia De Arana, Majadahonda, Madrid, Spain
- Department of Medicine, Universidad Autónoma De Madrid, Madrid, Spain
| | - Harald Dobnig
- Thyroid Endocrinology, Osteoporosis Institute Dobnig, Graz, Austria
| | - Valentin Fadeyev
- Department of Endocrinology No. 1, N.V. Sklifosovsky Institute of Clinical Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Benjamin C. T. Field
- University of Surrey Faculty of Health and Medical Sciences, Section of Clinical Medicine, Prague, United Kingdom
| | - Eric Fliers
- Department of Endocrinology & Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | | | - Dagmar Führer
- University Hospital Essen, Department of Endocrinology, Diabetes and Metabolism, University-Duisburg-Essen, Essen, Germany
| | - Juan Carlos Galofré
- Departmento De Endocrinologia e Nutrición, Clínica Universidad De Navarra, Pamplona, Spain
| | - Tommi Hakala
- Department of Surgery, Tampere University Hospital, Tampere, Finland
| | - Jan Jiskra
- 3rd Department of Medicine, 1st Faculty of Medicine, Charles University, General University Hospital, Prague, Czechia
| | - Peter Kopp
- Division of Endocrinology, Diabetology and Metabolism, University of Lausanne, Lausanne, Switzerland
| | - Michael Krebs
- Department of Medicine III, Division of Endocrinology, Medical University of Vienna, Vienna, Austria
| | - Michal Kršek
- 3rd Department of Medicine, 1st Faculty of Medicine, Charles University, General University Hospital, Prague, Czechia
| | - Martin Kužma
- 5th Department of Internal Medicine, Medical Faculty of Commenius University and University Hospital, Bratislava, Slovakia
| | - Mikael Lantz
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
| | - Ivica Lazúrová
- P. J. Šafárik University Košice, 1st Department of Internal Medicine of the Medical Faculty, Košice, Slovakia
| | - Laurence Leenhardt
- Hopital Pitie-Salpetriere, Thyroid and Endocrine Tumors Unit, Institut of Endocrinology, Sorbonne University, Paris, France
| | - Vitaliy Luchytskiy
- Department of Reproductive Endocrinogy, Institute of Endocrinology and Metabolism named after V.P. Komissarenko, National Academy of Medical Science of Ukraine, Kyiv, Ukraine
| | - Anne McGowan
- Robert Graves Institute, Tallaght University Hospital, Dublin, Ireland
| | - Miguel Melo
- Department of Endocrinology, Diabetes and Metabolism, Medical Faculty, University of Coimbra, Coimbra, Portugal
| | - Saara Metso
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Carla Moran
- Diabetes & Endocrinology Section, Beacon Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Tatyana Morgunova
- Department of Endocrinology No. 1, N.V. Sklifosovsky Institute of Clinical Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Tronko Mykola
- Institute of Endocrinology and Metabolism named after V.P. Komissarenko, National Academy of Medical Science of Ukraine, Kyiv, Ukraine
| | - Biljana Nedeljković Beleslin
- University of Belgrade Faculty of Medicine, Internal Medicine, Belgrade, Serbia
- Clinic of Endocrinology, Diabetes and Diseases of Metabolism, Thyroid Department, Belgrade, Serbia
| | - Dan Alexandru Niculescu
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Božidar Perić
- Department of Endocrinology, Diabetes and Metabolic Diseases “Mladen Sekso”, University Hospital Center “Sisters of Mercy”, Zagreb, Croatia
| | - Tereza Planck
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
| | - Catalina Poiana
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Francisca Marques Puga
- Endocrinology, Diabetes and Metabolism Service, Porto Hospital and University Centre, Porto, Portugal
| | - Eyal Robenshtok
- Endocrinology Institute, Rabin Medical Center, Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | | | - Marek Ruchala
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Kamilla Ryom Riis
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Alla Shepelkevich
- Department of Endocrinology, Belarusian State Medical University, Minsk, Belarus
| | - David Unuane
- Department of Internal Medicine, Endocrine Unit, UZ Brussel, Vrije Universiteit Brussel, Brussel, Belgium
| | - Irfan Vardarli
- Department of Medicine I, Klinikum Vest GmbH, Knappschaftskrankenhaus Recklinghausen, Recklinghausen, Germany
- 5th Medical Department, Division of Endocrinology and Diabetes, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - W. Edward Visser
- Rotterdam Thyroid Center, Department of Internal Medicine, Erasmus MC, Rotterdam, Netherlands
| | - Andromachi Vrionidou
- Department of Endocrinology and Diabetes Centre, Hellenic Red Cross Hospital, Athens, Greece
| | - Younes R. Younes
- East Surrey Hospital, Surrey & Sussex Healthcare NHS Trust, Redhill, Surrey, United Kingdom
| | | | - Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
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Younes YR, Perros P, Hegedüs L, Papini E, Nagy EV, Attanasio R, Negro R, Field BCT. Use of thyroid hormones in hypothyroid and euthyroid patients: A THESIS questionnaire survey of UK endocrinologists. Clin Endocrinol (Oxf) 2023; 98:238-248. [PMID: 35975405 PMCID: PMC10087612 DOI: 10.1111/cen.14812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/25/2022] [Accepted: 08/02/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Management of hypothyroidism is controversial because of medication cost pressures and scientific uncertainty on how to address treatment dissatisfaction experienced by some patients. The objective was to investigate the experience and preferences of UK endocrinologists in use of thyroid hormones. DESIGN Web-based survey. PATIENTS UK endocrinologists were invited to participate. MEASUREMENTS Responses to questionnaire. RESULTS The response rate was 21% (272/1295). While levothyroxine monotherapy is regarded as the treatment of choice for hypothyroidism, 51% of respondents stated that combined treatment with levothyroxine and liothyronine could be considered for levothyroxine-treated patients whose symptoms persist despite normalisation of serum thyroid stimulating hormone (TSH) concentration. However, only 40% are currently prescribing such treatment, and just 23% would consider taking it themselves. A small minority prescribe desiccated thyroid extract, and those most likely to do so are aged over 60 years. Most respondents stated that they have no influence over brand or formulation of levothyroxine dispensed to their patients and expect no major differences in efficacy between different formulations. A total of 9% would prescribe levothyroxine for euthyroid enlarging goitre, and 29% for euthyroid female infertility with high titre thyroid peroxidase antibodies, despite recent trials finding no benefit. CONCLUSIONS UK endocrine practice in management of hypothyroidism is broadly in line with international guidance. However, a minority of respondents would consider thyroid hormone supplementation in euthyroid individuals for female infertility, enlarging goitre, and other indications in which evidence of efficacy is lacking. Willingness to consider prescribing combined levothyroxine and liothyronine, for hypothyroid symptoms which persist despite normalised TSH, has increased in comparison to previous international surveys, despite inconsistent evidence of benefit.
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Affiliation(s)
- Younes R Younes
- Department of Endocrinology, East Surrey Hospital, Surrey & Sussex Healthcare NHS Trust, Redhill, Surrey, UK
| | - Petros Perros
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Laszlo Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
| | - Enrico Papini
- Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy
| | - Endre V Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Roberto Attanasio
- Scientific Committee, Associazione Medici Endocrinologi, Milan, Italy
| | - Roberto Negro
- Division of Endocrinology, V. Fazzi Hospital, Lecce, Italy
| | - Benjamin C T Field
- Department of Endocrinology, East Surrey Hospital, Surrey & Sussex Healthcare NHS Trust, Redhill, Surrey, UK
- Section of Clinical Medicine, Faculty of Health & Medical Sciences, University of Surrey, Guildford, Surrey, UK
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