The worldwide spread of the novel coronavirus, COVID-19, has recently been declared a pandemic. This presents many challenges to those of us working in healthcare, and will especially impact individuals with some chronic conditions.
Members of the British Thyroid Association(BTA) and the Society for Endocrinology (SfE)have received numerous queries regarding how this pandemic may affect management of patients with thyroid disease, so we have formulated responses to these questions in order to assist our endocrine and primary care colleaguesduring this extraordinary time. We acknowledge that the situation is changingrapidly and also that local practice may differ depending on available resources and infrastructure.
The British Thyroid Foundation (BTF) and Thyroid Cancer Forum-UK (TCF-UK) have already provided very helpful information for doctors and patients, both of which we endorse. The BTA wish to reinforce some of this advice and address additional issues specific to thyroid disease.
Are individuals with autoimmune thyroid disease at increased risk of COVID-19 infection?
COVID-19 is a novel virus, so we have no information on how it affects individuals with thyroid disease, however thyroid disease (TD) is not known to be associated with increased risk of viral infections in general, nor is there an association between TD and severity of viral infection.
Does control of thyroid disease affect infection risk?
There is no evidence that those with poorly controlled thyroid disease are more likely to contract viral infections in general. However,it is possible that patients with uncontrolled thyroid disease (especially thyrotoxicosis) may be at higher risk of complications (for example thyroid storm)fromany infection. We strongly recommend that patients with thyroid disease continue taking their thyroid medication(s) to reduce this risk.
Are individuals taking antithyroid drugs at higher risk of infection?
Antithyroid drugs (ATDs) are not known to increase the risk of infection, unless they result in neutropenia, which is very rare. We do not consider patients on ATDs to be at higher risk of contracting COVID-19 or of developing more severe disease in the event of contracting the infection. A patient infected with COVID-19 can continue ATDs unless neutropenia (neutrophil count of <1.0 x109/L) is present. Of note, lymphopenia seems common with COVID-19 infection and is not an indication to stop ATDs.
How should we advise patients who are at risk of neutropenia due to ATD therapy?
Patients takingATDs are at risk of developing neutropenia, although this side effect is rare. Symptoms of neutropenia(sore throat, mouth ulceration, fever, flu-like illness) may overlap with symptoms of COVID-19 infection (fever, new continuous cough, flu-like illness). It will be difficult, if not impossible, for patients and physicians to distinguish between these two diagnoses clinically. At present, the UK government has recommended against testing for COVID-19 infection in patients with only mild symptoms.
We recommend that patients on antithyroid drugs (ATDs) with any symptoms suggestive ofneutropeniashould STOP the ATD and have an urgent full blood count(FBC) performed to measure white cell count/differential. At theirdoctor’s discretion, testing for COVID-19 may also be performed. As per standard practice, we recommend all patients starting ATDs be given written information with instructions on what to do if they develop symptoms suggestive of neutropenia.
Should healthcare resources be severely limited over the coming weeks/months, it may not be possible to check a FBC at the onset of symptoms suggestive of neutropenia; in this extraordinary situation, we suggest that patients stop the ATD and restart one week later if symptoms have resolved. If symptoms worsen during the period off ATDs or recur after recommencing the drug, the patient should seek urgent medical attention; in such situations performing a FBC is essential.
How should we advise patients on steroid treatment for thyroid eye disease?
How should blood testing be performed for individuals on treatment for thyrotoxicosis?
Where possible, management of thyrotoxicosis should continue to be informed by results of thyroid function tests. Currently, or in the future, it may be difficult or impossible to perform such biochemical monitoring; in this exceptional circumstance, we suggest that a block & replace regimen for management of thyrotoxicosis is considered. A suggested regimen is outlined in ‘Management of thyrotoxicosis during COVID-19.’
Are there alternatives to face -to-face consultations for thyroid disease?
We support the cancellation of routine appointments for individuals with thyroid disease to help limit the spread of COVID-19 to healthcare workers and other patients. Alternatively, appointments can be converted to telephone or video consultation, assumingongoing availability of healthcare staff to conduct these.
Is it safe to defer definitive treatment for thyrotoxicosis?
The NHS has instructed hospitals to postpone all non-urgent surgery (6), so it is unlikely that those awaiting thyroidectomy for benign disease will have thyroid surgery during the outbreak. In addition, it is highly likely thatadministration of radioiodinefor hyperthyroidism will need to be deferred; most Trusts have already cancelled planned, elective radioiodine treatments. This is based on prioritisation of delivery of emergency care as well as anticipated difficulties with patients being unable to adhere to radiation protection guidance during the COVID-19 pandemic.We would like to reassure patients and physicians that, in most cases, we agree that these measures are safe and acceptable. We have formulated a suggested letter, which can be sent to patients whose radioiodine treatment has been postponed/cancelled.
On a case-by-case basis, uncontrolled thyrotoxicosis may require urgent surgery. It is also important to identify those patients who have recently undergone radioiodine treatment for hyperthyroidism, with a low threshold for commencing thyroxine therapy if hypothyroid symptoms develop; and to monitor thyroid function in those who have not been started on levothyroxine if possible.
Are patients who have had radioiodine therapy or thyroid surgery at higher risk of coronavirus infection?
There is no evidence that patients who have recently had radioiodine or thyroid surgery for benign thyroid disease are at increased risk of general viral (and therefore COVID-19) infection.
Are there any considerations regarding supply of medication?
During the outbreak, stockpiling of any medication should be avoided, in order to ensure sufficient supply for all in the community (8). We recommend that patients have adequate supply of medication and also that they adhere to social distancing guidelines when ordering and collecting medication. Requests for repeat prescriptions should be made early as we anticipate primary care will be under substantial pressure.
COVID-19 is a new disease and there is limited information regarding risk factors for severe disease. Based on currently available information and clinical expertise, older adults and people of any age who have serious underlying medical conditions might be at higher risk for severe illness from COVID-19.
Based on what we know now, those at high-risk for severe illness from COVID-19 are:
People who live in a nursing home or long-term care facility
People of all ages with underlying medical conditions, particularly if not well controlled, including:
People with chronic lung disease or moderate to severe asthma
People who have serious heart conditions
People who are immunocompromised
Many conditions can cause a person to be immunocompromised, including cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune weakening medications
People with severe obesity (body mass index [BMI] of 40 or higher)
People with diabetes
People with chronic kidney disease undergoing dialysis
Type 2 diabetes can be defined as a chronic disease that restrains your body from using insulin efficiently. This progressive health condition can also be termed as insulin resistance.
Usually, middle and older aged people have higher chances of having type 2 diabetes, therefore, it can also be known as adult-onset diabetes, but it doesn’t mean it cannot affect young adults and children. However, these are uncommon cases.
On the other hand, the onset of this condition can be slow and gradual and symptoms happen to be milder in the early stages.
Here are some of the most common causes and symptoms of type 2 diabetes.
The pancreas creates a hormone – insulin – that functions to turn glucose from food into energy. With the onset of type 2 diabetes, the pancreas creates insulin but the cells don’t utilize it effectively to turn glucose into energy, which ultimately leads to chronic fatigue and weakness.
The following are some of the most common causes of type 2 diabetes.
The most common cause of this condition is your genes. If your family has a history of type 2 diabetes, you have higher chances of having it.
Obesity or being overweight can cause insulin resistance.
Metabolic syndrome is a collective term for different types of health conditions. Insulin resistant people tend to have obesity, high cholesterol, high blood pressure, and high blood sugar levels.
Improper Communication Between Body Cells
At times, as a result of certain ailments, our cells don’t send signals or receive messages from the brain correctly, which causes potential health issues like an impaired chain reaction of insulin and glucose that leads to type 2 diabetes.
The symptoms of type 2 diabetes can be mild in the beginning that they remain unnoticeable, including:
Sudden weight loss
Constant thirst that won’t go away
Itchy skin or skin rashes
Some alarming symptoms may include:
Slow healing of wounds
Pain in legs and feet
Numbness and tingling in limbs
Dark skin around or back of the neck and armpits
If you notice a group of any of these symptoms, do not resist speaking with your doctor to manage the disease during its early onset to avoid potential health risks like heart disease, loss of vision, kidney impairment, and sexual problems.
Treatment to Manage the Symptoms
Your doctor will effectively guide you to manage your symptoms. Here are some measures you can take to keep a balance in your health.
Take meals with fiber-rich foods and take healthy carbs by eating vegetables, fruits, nuts, and whole grains.
Only eat to curb your hunger.
Have meals at regular intervals.
Engage in low-intensity workout or aerobics to control weight gain and improve heart health and boost energy levels.
Your doctor can also help you create a healthy diet plan. Making simple lifestyle changes can help you manage most of the symptoms of type 2 diabetes and encourage healthy living and overall well-being.
Arthritis and osteoporosis are two of the most common bone conditions that mostly occur in older adults. But it doesn’t give young adults and children the leverage to take their bone health for granted.
According to research, the risk of developing weak bones is high in one in four males and one in two females. However, the onset of bone diseased isn’t found to be too early, but it is wise to care for your health from an early age to alleviate the risk of potential bone issues in the later years.
Here are some useful and easy tips for people of all ages to keep their bone structure healthy.
Take High Protein Diet
Eating protein is essential for healthy bones. A low protein diet can compromise calcium absorption, thus affects the growth of bone. Foods like lean meat, red beans, lentils, poultry, fish, seeds, and nuts are great sources of protein. Moreover, postmenopausal women are likely to develop fragile bones, therefore, following a protein-rich diet can be helpful for bone health and overall well-being.
Limit Caffeine and Soda
According to some studies, lower bone density is highly related to caffeinated drinks like coffee and energy drinks. Moreover, sodas and carbonated drinks contain artificial sweeteners that can lead to obesity, so if you have fragile bones, being overweight can put extra strain on your bones and lead to fractures. If you need to drink coffee or tea in your daily life, limit it to one or two cups a day.
Engage in Cardiovascular Exercise
Aerobics or cardiovascular exercises target lean muscles and reduce excess body fat. It makes your muscles strong enough to help you carry out day-to-day functions without general aches and pains. Regular exercise will strengthen the muscles that support your bones and consequently will reduce your chances of fracture. A total of 150-minute workout a week is enough to keep your body structure healthy and strong.
Add Milk In Your Diet (Add High Calcium Foods if Vegan/Lactose Intolerant)
The key to bone health is calcium consumption. Milk and other dairy items like cheese and yogurt are the major sources of calcium to your body. If you cannot add dairy to your diet due to lactose intolerance or if you happen to be a vegan, you can opt for dark leafy greens like spinach, broccoli, soybeans, okra, and kale to satisfy your body’s calcium needs.
Don’t Neglect Vitamin D
Vitamin D and calcium go hand-in-hand when it comes to bone health. Just like protein, vitamin D is essential for the proper absorption of calcium in the bones. You can simply take a 15 min stroll daily in the morning sunlight to get vitamin D or consume yogurt, tuna, eggs, and even opt for fortified foods like orange juice and dietary supplements.
Having healthy bones is essential for overall health at any age. If you want to take dietary supplements, speak with your doctor for a suitable option according to your health.
Dr A.Mustafa is an established and highly skilled Hormone and Endocrine Specialist with over 20 years of experience which include General Internal Medicine and Hormonal problems.