CONSENSUS STATEMENT

Year : 2020  |  Volume : 17  |  Issue : 1  |  Page : 4-6

Coronavirus disease 2019 and thyroid disease: Position statement of Indian Thyroid Society

Rajesh Rajput¹, Amit Agarwal², Mohd Ashraf Ganie³, CS Bal⁴, DC Sharma⁵, Krishna Seshadri⁶, Jabbar Puttiyaveettil⁷, Narendra Kotwal⁸, KM Prasanna Kumar⁹, RV Jayakumar¹⁰, Sarita Bajaj¹¹, Shashank Joshi¹², Subhankar Chowdhury¹³, Sujoy Ghosh^13
1 Department of Endocrinolog, PGIMS, Rohtak, India
² Department of Endocrine Surgery, SGPGI, Lucknow, India
³ SKIMS, Srinagar, India
⁴ Department of Nuclear Medicine, AIIMS, New Delhi, India
⁵ Consultant Endocrinologist, Udaipur, Rajasthan, India
⁶ Consultant Endocrinologist, Apollo Speciality Hospitals Vanagaram, India
⁷ Department of Endocrinology, Government Medical College, Thiruvananthapuram, India
⁸ Army Research and Referral Hospital, New Delhi, India
⁹ Director & Consultant Endocrinologist, Centre for Diabetes and Endocrine Care- Bengaluru, India
¹⁰ Senior Consultant Endocrinologist, Aster Medcity Hospital, Kochi, India
¹¹ Department of Medicine, MLN Medical College, Prayagraj, India
¹² Consultant Endocrinologsit, Lilavati Hospital, Maharashtra, Mumbai, India
¹³ Department of Endocrinology, Institute of Post Graduate Medical Education & Research, Kolkata, India

Correspondence Address:
Dr. Rajesh Rajput
Department of Endocrinology, PGIMS, Rohtak - 124 001, Haryana
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/trp.trp_28_20

About Coronavirus and Coronavirus Disease 2019

Thyroid Disorders in India

• Among adult people in India, the prevalence of hypothyroidism is 10.95% (approximately 1 in 10 adults). The prevalence of subclinical hypothyroidism was also high in this study, the value being 8%^[3]
• Congenital hypothyroidism (CH) is the most common cause of preventable mental retardation. A study conducted by the Indian Council of Medical Research between 2007 and 2012 reported the overall incidence of CH to be 1:1130 newborns^[4]
• In India, the overall prevalence of hyperthyroidism is reported to be 0.6%–1.9% which can be overt or subclinical^[3],[5]
• In India, the age-adjusted incidence rates of thyroid cancer per 100,000 are about 1 for male and 1.8 for female and the most common type of thyroid cancer is papillary thyroid cancer, followed by follicular thyroid cancer^[5]
• Patients with hypothyroidism show a greater propensity for comorbidities and complications as compared to the general population



• Diabetes: Hypothyroidism and diabetes mellitus (DM) are the most common endocrine disorders in clinical practice and are often associated in the same individual. The prevalence of hypothyroidism in type 2 DM (T2DM) in India was found to be about 24%^[6]
• Dyslipidemia: Hypothyroidism has significant impact on lipids as well as other cardiovascular risk factors. Fifteen percent of dyslipidemics may have hypothyroidism as underlying cause^[7]
• Hypertension: Hypothyroidism is a remediable cause of hypertension. The prevalence of hypothyroidism in T2DM and hypertension in India was found to be about 33%.^[6]

Hypothyroidism and Coronavirus Disease 2019

• There is no information on how it affects individuals with hypothyroidism. As such patients with hypothyroidism are not at increased risk of viral infections in general and there is no association between hypothyroidism and severity of viral infection^[8]
• It is recommended that patients with hypothyroidism should continue taking their levothyroxine treatment as suggested
• Hypothyroidism in pregnancy:^[9]



• There is no evidence that suggests that pregnant women are at increased risk of COVID-19
• Pregnancy alters the body's immune system and response to viral infections in general, which can occasionally be related to more severe symptoms, and this will be the same for COVID-19
• Pregnant patients with hypothyroidism should continue taking levothyroxine treatment.



• Patients with hypothyroidism and other comorbidities:



• Most distinctive comorbidities reported with COVID-19 patients are diabetes, coronary heart diseases, cerebrovascular disease, and hypertension^[10]
• Diabetes: Both diabetes type 1 and 2 can increase risk of contraction of COVID-19 due to immune dysfunction^[11]
• Patients with hypothyroidism and other comorbidities such as diabetes, cardiac disease, and hypertension are at high risk for severe COVID-19 infection and such patients need to take more precautions.

Thyrotoxicosis and Coronavirus Disease 2019

• There is no information on how it affects individuals with thyrotoxicosis. However, uncontrolled thyrotoxicosis may be at higher risk of complications (such as thyroid storm) from any infection. It is recommended that patients with thyrotoxicosis continue taking their thyroid medication(s) to reduce this risk^[8]
• Antithyroid drugs (ATDs) are not known to increase the risk of infection, unless they result in neutropenia, which is very rare. Patients on ATDs are not at higher risk of contracting COVID-19 or of developing more severe disease in the event of contracting the infection^[8]
• Patients on corticosteroids or immunosuppressive agents for thyroid eye disease are more susceptible and are at high risk of severe illness from COVID-19, and such patients need to take more precautions^[12]
• Any nonurgent surgeries or procedures for definitive treatment for thyrotoxicosis should be postponed^[8]

Thyroid Cancer and Coronavirus Disease 2019

• There is no evidence that patients who have recently had radioiodine therapy or thyroid surgery for thyroid cancer are at increased risk of COVID-19^[13]
• All elective surgeries for thyroid cancer should be postponed
• Patients on suppressive doses of levothyroxine should continue their current dose. Being on suppressive dose of levothyroxine does not increase the risk of COVID-19 infection.

Recommendations for Thyroid Function Test in Patients With Coronavirus Disease 2019 Infection

• In COVID-19 patients with existing thyroid disease and on thyroid medications, if there is no indication, thyroid function test (TFT) should not be repeated
• In COVID-19 patients admitted in the intensive care unit, routine TFT is not recommended. There is no benefit of levothyroxine treatment in patients with euthyroid sick syndrome.

Protective Measures to Avoid Infection

• Patients should continue taking prescribed medications
• It is recommended that patients should have adequate supply of medications but should avoid overstocking
• Regularly and thoroughly clean hands with an alcohol-based hand rub or wash them with soap and water
• Avoid touching eyes, nose and mouth
• Keep a distance of at least 1 m from people with a cough, cold, or flu
• Patients should adhere to social distancing guidelines.

References

1.	Cascella M, Rajnik M, Cuomo A, Dulebohn SC, Napoli DR. Features, Evaluation and Treatment Coronavirus (COVID-19). In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020. [Last updated on 2020 Mar 20].
2.	Available from: https://www.mohfw.gov.in/. [Last accessed on 2020 Apr 01].
3.	Unnikrishnan AG, Kalra S, Sahay RK, Bantwal G, John M, Tewari N. Prevalence of hypothyroidism in adults: An epidemiological study in eight cities of India. Indian J Endocrinol Metab 2013;17:647-52.
4.	Verma IC, Bijarnia-Mahay S, Jhingan G, Verma J. Newborn screening: Need of the hour in India. Indian J Pediatr 2015;82:61-70.
5.	Unnikrishnan AG, Menon UV. Thyroid disorders in India: An epidemiological perspective. Indian J Endocrinol Metab 2011;15:S78-81.
6.	Talwalkar P, Deshmukh V, Bhole M. Prevalence of hypothyroidism in patients with type 2 diabetes mellitus and hypertension in India: A cross-sectional observational study. Diabetes Metab Syndr Obes 2019;12:369-76.
7.	Willard DL, Leung AM, Pearce EN. Thyroid function testing in patients with newly diagnosed hyperlipidemia. JAMA Intern Med 2014;174: 287-9.
8.	BTA/SFE Statement Regarding Issues Specific to Thyroid Dysfunction During the COVID-19 Pandemic. Available from: https://www.british-thyroid-association.org/sandbox/bta2016/management-of-thyroid-dysfunction-during-covid-19_final.pdf. [Last accessed on 2020 Apr 01].
9.	Guidance for Maternal Medicine in the Evolving Coronavirus (COVID-19) Pandemic. Available from: https://www.rcog.org.uk/globalassets/documents/guidelines/2020-03-30-guidance-for-maternal-medicine-in-the-evolving-coronavirus-covid-19-pandemic.pdf. [Last accessed on 2020 Apr 01].
10.	Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? Lancet Respir Med 2020;8:e21.
11.	AACE Position Statement: Coronavirus (COVID-19) and People with Diabetes. Available from: https://www.aace.com/recent-news-and-updates/aace-position-statement-coronavirus-covid-19-and-people-diabetes. [Last accessed on 2020 Apr 01].
12.	Available from: https://www.endocrine.org/news-and-advocacy/news-room/2020/individuals-taking-class-of-steroid-medications-at-high-risk-for-covid. [Last accessed on 2020 Apr 01].
13.	Thyroid Cancer and Coronavirus (COVID-19). Available from: https://www.btf-thyroid.org/thyroid-cancer-and-coronavirus. [Last accessed on 2020 Apr 01].

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