Background: Hypothyroidism is a common endocrine disorder that is managed by a wide range of
physicians. There are no data on the pattern of clinical management of hypothyroidism
in the Middle East and Africa (MEA) region. Objectives: We sought to document current practices in the management of primary hypothyroidism
in the MEA region and compare these with international recommendations and practices
elsewhere. Materials and Methods: A convenience sample of physicians practicing in the MEA in relevant disciplines
were invited to take a web-based survey consisting of previously validated multiple-choice
questions dealing with investigation and treatment of an index case of overt primary
hypothyroidism in general and in three special situations. Results: Out of complete 397 responses, 368 were eligible for inclusion in the analysis. The
majority were endocrinologists and internal medicine specialists; 82.2% of them have
been in clinical practice for 10 years or more. Overt hypothyroidism would be treated
using L-T4 alone by 97.2% of respondents; 1.7% would use a combination of L-T4 and
liothyronine (L-T3) therapy. The rate of replacement would be gradual (66.5%), an
empiric dose, adjusted to achieve target levels (14.7%); or a calculated full replacement
dose (18.5%). A target thyroid-stimulating hormone (TSH) of 2.0–2.9 mU/L was favored
in the index case of overt hypothyroidism (by 34.4%) followed by a target of 3.0–3.9
mU/L (by 26.0%) of respondents. However, a target of 4.0–4.9 mU/L was the most commonly
selected TSH target for an octogenarian (by 33.5% of respondents). Persistent hypothyroid
symptoms despite achieving a target TSH would prompt testing for other causes by 86.9%
of respondents, a change to L-T4 plus L-T3 therapy by 5.8%, and an increase in the
thyroid hormone dose by 4.6%. Evaluation of persistent symptoms would include measurements
of complete blood count (82.4%), complete metabolic panel (68.7%), morning cortisol
(65.3%), Vitamin B12 levels (54.5%), and serum T3 levels (27.9%). Subclinical disease
with a TSH 7.8 mU/L would be treated without further justification by 9.0% of respondents,
or in the presence of positive thyroid peroxidase antibodies (65.3%), hypothyroid
symptoms (65.0%), high low-density lipoprotein (51.7%), or a goiter (36.7%). The TSH
target for a newly pregnant patient was 2.0–2.4 mU/L for 28.5% of respondents, with
15.8% preferring a TSH target of 1.5–1.9 mU/L. Thyroid hormone levels would be checked
every 4 weeks during pregnancy by 62.9% and every 8 weeks by an additional 17.6%.
A hypothyroid patient with a TSH of 0.5 mU/L who becomes pregnant would receive an
immediate L-T4 dose increase by only 28.5% of respondents. Conclusions: The survey revealed that (1) nearly exclusive preference for L-T4 alone for therapy,
(2) use of age-specific TSH targets for replacement therapy, (3) a low threshold for
treating mild thyroid failure, (4) complacent and variable attention to TSH targets
in the pregnant and prepregnant woman, and (5) a highly variable approach to both
the rate and means of restoring euthyroid status for overt disease. Both alignments
with and divergence from guidelines were detected. The results should help in directing
focused educational activities in the region, providing a baseline for future monitoring
of practices.
Keywords
Clinical practice guideline - pattern - persistently symptomatic hypothyroidism -
primary hypothyroidism - subclinical hypothyroidism - t4/t3 combination - thyroid
and pregnancy - thyroid antibodies - thyroxine hypothyroidism - trends
