|
|
Hyperthyroidism Management in Saudi Arabia: Current Practices, Challenges, and Future Directions
|
Abstract:
In Saudi Arabia, the management of hyperthyroidism is influenced by several factors: genetic, environmental, and the healthcare system. Thus, a tailored approach is mandatory. A region-specific consensus is highly needed because of variations in clinical practice. A multidisciplinary expert team of endocrinologists and internal medicine experts convened to coin a local consensus on the care of hyperthyroidism. The expert meeting assessed current management methods, identified critical challenges, and provided evidence-based recommendations. The current article is the culmination of a consensus that developed through a structured, multi-phase process involving a systematic literature review, a pre-meeting survey, and expert panel discussions to assess the topic comprehensively. A literature review of databases such as PubMed and the Saudi Digital Library, focusing on publications from 2010 to 2024, evaluated the evidence on diagnosis, management, and treatment strategies, with priority given to regional guidelines, randomized controlled trials, and systematic reviews. A pre-meeting survey of medical experts revealed current practices, challenges, and unmet requirements, which informed expert discussions. The expert panel analyzed survey results and literature, then held structured discussions concerning illness burden, best practices, and gaps in care. The Delphi approach was employed to develop recommendations that ensured consensus and alignment with global standards, while also addressing region-specific issues. The finalized recommendations will be shared through conferences, seminars, and publications, with ongoing feedback to help develop and update the guidelines.
| [1] | Mirghani, H., Alquayr, S.M., Alanazi, T., Alwakeel, A.A., Al Madshush, A.M., Alali, H.A., et al. (2023) Knowledge Assessment Regarding the Differences between Hypothyroidism and Hyperthyroidism among Saudi Arabia’s Adult Population. Cureus, 15, e37830. https://doi.org/10.7759/cureus.37830 |
| [2] | Alharazi, R.M., Almarri, L.K., Ibrahim, H.M., Abdulshakour, L.S., Ahmad, M.A. and Bashool, R.A. (2024) Awareness of Thyroid Diseases and Their Risk Factors among the Residents of Jeddah, Saudi Arabia. Cureus, 16, e62113. https://doi.org/10.7759/cureus.62113 |
| [3] | Lee, S.Y. and Pearce, E.N. (2023) Hyperthyroidism. JAMA, 330, 1472-1483. https://doi.org/10.1001/jama.2023.19052 |
| [4] | Taylor, P.N., Albrecht, D., Scholz, A., Gutierrez-Buey, G., Lazarus, J.H., Dayan, C.M., et al. (2018) Global Epidemiology of Hyperthyroidism and Hypothyroidism. Nature Reviews Endocrinology, 14, 301-316. https://doi.org/10.1038/nrendo.2018.18 |
| [5] | Kargar, S., Tabatabaei, S.M., Okati-Aliabad, H. and Rad, H.I. (2024) Prevalence of Thyroid Dysfunction Disorders among Adult Populations in the Middle-East: A Systematic Review and Meta-Analysis. The Open Public Health Journal, 17, e18749445317174. https://doi.org/10.2174/0118749445317174240827052511 |
| [6] | Awad, S.A.S., Ashraf, E.M., Khaled, A.S., Salih, B.S., Yousef, S., Abeer, A.S., et al. (2016) The Epidemiology of Thyroid Diseases in the Arab World: A Systematic Review. Journal of Public Health and Epidemiology, 8, 17-26. https://doi.org/10.5897/jphe2015.0713 |
| [7] | Okati-Aliabad, H., Ansari-Moghaddam, A., Kargar, S. and Jabbari, N. (2022) Prevalence of Obesity and Overweight among Adults in the Middle East Countries from 2000 to 2020: A Systematic Review and Meta-Analysis. Journal of Obesity, 2022, Article ID: 8074837. https://doi.org/10.1155/2022/8074837 |
| [8] | Wahba, H.M.A. and Ali, D.A.A. (2024) Causes of Thyroid Disease and Its Relationship to Dietary Habits and Its Prevalence in Al-Baha Region, KSA. Open Access Library Journal, 11, 1-13. https://doi.org/10.4236/oalib.1111685 |
| [9] | Alqahtani, S.A.M. (2021) Prevalence and Characteristics of Thyroid Abnormalities and Its Association with Anemia in ASIR Region of Saudi Arabia: A Cross-Sectional Study. Clinics and Practice, 11, 494-504. https://doi.org/10.3390/clinpract11030065 |
| [10] | Alanazi, S.L., Abo El-Fetoh, N.M. and Alenezi, H.M. (2018) Pattern of Thyroid Diseases in Arar City, Northern Saudi Arabia. The Egyptian Journal of Hospital Medicine, 70, 1834-1841. https://doi.org/10.12816/0044762 |
| [11] | Elmisbah, H.O., Laham, R.Y., Almisbah, H.O., Alanazi, H.T., Alanazi, T.A., Alanzi, R.M., et al. (2024) Prevalence of Thyroid Disorders among the Diabetic Population in Arar, Saudi Arabia. Saudi Medical Journal, 45, 591-597. https://doi.org/10.15537/smj.2024.45.6.20240144 |
| [12] | Brancatella, A., Viola, N., Santini, F. and Latrofa, F. (2023) Covid-Induced Thyroid Autoimmunity. Best Practice & Research Clinical Endocrinology & Metabolism, 37, Article ID: 101742. https://doi.org/10.1016/j.beem.2023.101742 |
| [13] | Viola, N., Brancatella, A., Sgrò, D., Santini, F. and Latrofa, F. (2022) Clinical, Biochemical Features and Functional Outcome of Patients with SARS-CoV-2-Related Subacute Thyroiditis: A Review. Endocrine, 79, 448-454. https://doi.org/10.1007/s12020-022-03247-w |
| [14] | Takedani, K., Notsu, M., Ishiai, N., Asami, Y., Uchida, K. and Kanasaki, K. (2023) Graves’ Disease after Exposure to the SARS-CoV-2 Vaccine: A Case Report and Review of the Literature. BMC Endocrine Disorders, 23, Article No. 132. https://doi.org/10.1186/s12902-023-01387-2 |
| [15] | Barajas Galindo, D.E., Ramos Bachiller, B., González Roza, L., García Ruiz de Morales, J.M., Sánchez Lasheras, F., González Arnáiz, E., et al. (2022) Increased Incidence of Graves’ Disease during the SARS-CoV-2 Pandemic. Clinical Endocrinology, 98, 730-737. https://doi.org/10.1111/cen.14860 |
| [16] | Ross, D.S., Burch, H.B., Cooper, D.S., Greenlee, M.C., Laurberg, P., Maia, A.L., et al. (2016) 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid, 26, 1343-1421. https://doi.org/10.1089/thy.2016.0229 |
| [17] | Hussein, M., Toraih, E., Issa, P.P., Omar, M., Aboueisha, M., Buti, Y., et al. (2024) From Ablation to Operation: Unraveling the Surgical Outcomes and Complications of Thyroidectomy after Radiofrequency Ablation. Surgery, 175, 146-152. https://doi.org/10.1016/j.surg.2023.09.025 |
| [18] | Vasileiou, M., Gilbert, J., Fishburn, S. and Boelaert, K. (2020) Thyroid Disease Assessment and Management: Summary of NICE Guidance. BMJ, 368, m41. https://doi.org/10.1136/bmj.m41 |
| [19] | D’Aurizio, F. (2021) The Role of Laboratory Medicine in the Diagnosis of the Hyperthyroidism. The Quarterly Journal of Nuclear Medicine and Molecular Imaging, 65, 91-101. https://doi.org/10.23736/s1824-4785.21.03344-6 |
| [20] | Lytton, S.D. (2018) Functional Diagnostics for Thyrotropin Hormone Receptor Autoantibodies Bioassays Prevail over Binding Assays. Frontiers in Bioscience, 23, 2028-2043. https://doi.org/10.2741/4687 |
| [21] | Vadiveloo, T., Donnan, P.T., Cochrane, L. and Leese, G.P. (2011) The Thyroid Epidemiology, Audit, and Research Study (TEARS): Morbidity in Patients with Endogenous Subclinical Hyperthyroidism. The Journal of Clinical Endocrinology & Metabolism, 96, 1344-1351. https://doi.org/10.1210/jc.2010-2693 |
| [22] | Schouten, B.J., Brownlie, B.E.W., Frampton, C.M. and Turner, J.G. (2011) Subclinical Thyrotoxicosis in an Outpatient Population—Predictors of Outcome. Clinical Endocrinology, 74, 257-261. https://doi.org/10.1111/j.1365-2265.2010.03908.x |
| [23] | Kim, S., Ryu, V., Miyashita, S., Korkmaz, F., Lizneva, D., Gera, S., et al. (2021) Thyrotropin, Hyperthyroidism, and Bone Mass. The Journal of Clinical Endocrinology & Metabolism, 106, e4809-e4821. https://doi.org/10.1210/clinem/dgab548 |
| [24] | Smedegaard, S.B., Riis, A.L., Christiansen, M.K. and Linde, J.K.S. (2020) Subclinical Hyperthyroidism and the Risk of Developing Cardiovascular Disease—A Systematic Review. Danish Medical Journal, 67, A12190701. |
| [25] | Azizi, F., Abdi, H., Cheraghi, L. and Amouzegar, A. (2021) Treatment of Subclinical Hyperthyroidism in the Elderly: Comparison of Radioiodine and Long-Term Methimazole Treatment. Thyroid, 31, 545-551. https://doi.org/10.1089/thy.2020.0433 |
| [26] | Biondi, B., Bartalena, L., Cooper, D.S., Hegedüs, L., Laurberg, P. and Kahaly, G.J. (2015) The 2015 European Thyroid Association Guidelines on Diagnosis and Treatment of Endogenous Subclinical Hyperthyroidism. European Thyroid Journal, 4, 149-163. https://doi.org/10.1159/000438750 |
| [27] | Mattesi, G., Di Michele, S., Mele, D., Rigato, I., Bariani, R., Fiorencis, A., et al. (2022) Thyroid Dysfunction on the Heart: Clinical Effects, Prognostic Impact and Management Strategies. Monaldi Archives for Chest Disease, 92, Article 2145. https://doi.org/10.4081/monaldi.2022.2145 |
| [28] | Lindo, A., Breikert, A., Lakwijk, P., Lundberg, C., Lunner, K., Johansson, B., et al. (2023) Patient Needs and Care: Moves toward Person-Centered Care for Graves’ Disease in Sweden. European Thyroid Journal, 12, e230010. https://doi.org/10.1530/etj-23-0010 |
| [29] | Senn, J.R., Löliger, R.C., Fischer, J.G.W., Bur, F., Maushart, C.I. and Betz, M.J. (2023) Acute Effect of Propranolol on Resting Energy Expenditure in Hyperthyroid Patients. Frontiers in Endocrinology, 13, Article 1026998. https://doi.org/10.3389/fendo.2022.1026998 |
| [30] | Brito, J.P., Payne, S., Singh Ospina, N., Rodriguez-Gutierrez, R., Maraka, S., Sangaralingham, L.R., et al. (2020) Patterns of Use, Efficacy, and Safety of Treatment Options for Patients with Graves’ Disease: A Nationwide Population-Based Study. Thyroid, 30, 357-364. https://doi.org/10.1089/thy.2019.0132 |
| [31] | Benker, G. and Reinwein, D. (1982) Pharmacokinetics of Antithyroid Drugs. Klinische Wochenschrift, 60, 531-539. https://doi.org/10.1007/bf01724208 |
| [32] | Li, J., Bai, L., Wei, F., Wei, M., Xiao, Y., Yan, W., et al. (2021) Effect of Addition of Thyroxine in the Treatment of Graves’ Disease: A Systematic Review. Frontiers in Endocrinology, 11, Article 560157. https://doi.org/10.3389/fendo.2020.560157 |
| [33] | Laurberg, P., Wallin, G., Tallstedt, L., Abraham-Nordling, M., Lundell, G. and Tørring, O. (2008) TSH-Receptor Autoimmunity in Graves’ Disease after Therapy with Anti-Thyroid Drugs, Surgery, or Radioiodine: A 5-Year Prospective Randomized Study. European Journal of Endocrinology, 158, 69-75. https://doi.org/10.1530/eje-07-0450 |
| [34] | Azizi, F., Amouzegar, A., Tohidi, M., Hedayati, M., Khalili, D., Cheraghi, L., et al. (2019) Increased Remission Rates after Long-Term Methimazole Therapy in Patients with Graves’ Disease: Results of a Randomized Clinical Trial. Thyroid, 29, 1192-1200. https://doi.org/10.1089/thy.2019.0180 |
| [35] | Mahzari, M.M., Alanazi, M.M., Alabdulkareem, Y.M., Alharbi, W.A., Alzahrani, A.S., Alqahtani, N.A., et al. (2024) Efficacy of Anti-Thyroid Medications in Patients with Graves’ Disease. BMC Endocrine Disorders, 24, Article No. 180. https://doi.org/10.1186/s12902-024-01707-0 |
| [36] | Shi, H., Sheng, R., Hu, Y., Liu, X., Jiang, L., Wang, Z., et al. (2020) Risk Factors for the Relapse of Graves’ Disease Treated with Antithyroid Drugs: A Systematic Review and Meta-Analysis. Clinical Therapeutics, 42, 662-675.e4. https://doi.org/10.1016/j.clinthera.2020.01.022 |
| [37] | Vos, X.G., Endert, E., Zwinderman, A.H., Tijssen, J.G.P. and Wiersinga, W.M. (2016) Predicting the Risk of Recurrence before the Start of Antithyroid Drug Therapy in Patients with Graves’ Hyperthyroidism. The Journal of Clinical Endocrinology & Metabolism, 101, 1381-1389. https://doi.org/10.1210/jc.2015-3644 |
| [38] | Park, S.Y., Kim, B.H., Kim, M., Hong, A.R., Park, J., Park, H., et al. (2021) The Longer the Antithyroid Drug Is Used, the Lower the Relapse Rate in Graves’ Disease: A Retrospective Multicenter Cohort Study in Korea. Endocrine, 74, 120-127. https://doi.org/10.1007/s12020-021-02725-x |
| [39] | Sjölin, G., Holmberg, M., Törring, O., Byström, K., Khamisi, S., de Laval, D., et al. (2019) The Long-Term Outcome of Treatment for Graves’ Hyperthyroidism. Thyroid, 29, 1545-1557. https://doi.org/10.1089/thy.2019.0085 |
| [40] | Sundaresh, V., Brito, J.P., Wang, Z., Prokop, L.J., Stan, M.N., Murad, M.H., et al. (2013) Comparative Effectiveness of Therapies for Graves’ Hyperthyroidism: A Systematic Review and Network Meta-Analysis. The Journal of Clinical Endocrinology & Metabolism, 98, 3671-3677. https://doi.org/10.1210/jc.2013-1954 |
| [41] | Yu, W., Wu, N., Li, L., Wang, J., OuYang, H. and Shen, H. (2020) Side Effects of PTU and MMI in the Treatment of Hyperthyroidism: A Systematic Review and Meta-Analysis. Endocrine Practice, 26, 207-217. https://doi.org/10.4158/ep-2019-0221 |
| [42] | Vicente, N., Cardoso, L., Barros, L. and Carrilho, F. (2017) Antithyroid Drug-Induced Agranulocytosis: State of the Art on Diagnosis and Management. Drugs in R&D, 17, 91-96. https://doi.org/10.1007/s40268-017-0172-1 |
| [43] | Balavoine, A., Glinoer, D., Dubucquoi, S. and Wémeau, J. (2015) Antineutrophil Cytoplasmic Antibody-Positive Small-Vessel Vasculitis Associated with Antithyroid Drug Therapy: How Significant Is the Clinical Problem? Thyroid, 25, 1273-1281. https://doi.org/10.1089/thy.2014.0603 |
| [44] | Guo, J., Chang, C. and Chen, C. (2020) Association between Thionamides and Acute Pancreatitis: A Case-Control Study. Thyroid, 30, 1574-1578. https://doi.org/10.1089/thy.2019.0589 |
| [45] | Pecere, A., Caputo, M., Sarro, A., Ucciero, A., Zibetti, A., Aimaretti, G., et al. (2020) Methimazole Treatment and Risk of Acute Pancreatitis: A Population-Based Cohort Study. The Journal of Clinical Endocrinology & Metabolism, 105, e4527-e4530. https://doi.org/10.1210/clinem/dgaa544 |
| [46] | Scappaticcio, L., Longo, M., Maiorino, M.I., Pernice, V., Caruso, P., Esposito, K., et al. (2021) Abnormal Liver Blood Tests in Patients with Hyperthyroidism: Systematic Review and Meta-analysis. Thyroid, 31, 884-894. https://doi.org/10.1089/thy.2020.0715 |
| [47] | Vija Racaru, L., Fontan, C., Bauriaud-Mallet, M., Brillouet, S., Caselles, O., Zerdoud, S., et al. (2017) Clinical Outcomes 1 Year after Empiric 131I Therapy for Hyperthyroid Disorders: Real Life Experience and Predictive Factors of Functional Response. Nuclear Medicine Communications, 38, 756-763. https://doi.org/10.1097/mnm.0000000000000705 |
| [48] | Shalaby, M., Hadedeya, D., Toraih, E.A., Razavi, M.A., Lee, G.S., Hussein, M.H., et al. (2022) Predictive Factors of Radioiodine Therapy Failure in Graves’ Disease: A Meta-Analysis. The American Journal of Surgery, 223, 287-296. https://doi.org/10.1016/j.amjsurg.2021.03.068 |
| [49] | Zakavi, S.R., Khazaei, G., Sadeghi, R., Ayati, N., Davachi, B., Bonakdaran, S., et al. (2015) Methimazole Discontinuation before Radioiodine Therapy in Patients with Graves’ Disease. Nuclear Medicine Communications, 36, 1202-1207. https://doi.org/10.1097/mnm.0000000000000384 |
| [50] | Ceccarelli, C., Bencivelli, W., Vitti, P., Grasso, L. and Pinchera, A. (2005) Outcome of Radioiodine‐131 Therapy in Hyperfunctioning Thyroid Nodules: A 20 Years’ Retrospective Study. Clinical Endocrinology, 62, 331-335. https://doi.org/10.1111/j.1365-2265.2005.02218.x |
| [51] | Demir, B.K., Karakilic, E., Saygili, E.S., Araci, N. and Ozdemir, S. (2022) Predictors of Hypothyroidism Following Empirical Dose Radioiodine in Toxic Thyroid Nodules: Real-Life Experience. Endocrine Practice, 28, 749-753. https://doi.org/10.1016/j.eprac.2022.05.001 |
| [52] | Bartalena, L., Kahaly, G.J., Baldeschi, L., Dayan, C.M., Eckstein, A., Marcocci, C., et al. (2021) The 2021 European Group on Graves’ Orbitopathy (EUGOGO) Clinical Practice Guidelines for the Medical Management of Graves’ Orbitopathy. European Journal of Endocrinology, 185, G43-G67. https://doi.org/10.1530/eje-21-0479 |
| [53] | Shim, S.R., Kitahara, C.M., Cha, E.S., Kim, S., Bang, Y.J. and Lee, W.J. (2021) Cancer Risk after Radioactive Iodine Treatment for Hyperthyroidism: A Systematic Review and Meta-Analysis. JAMA Network Open, 4, e2125072. https://doi.org/10.1001/jamanetworkopen.2021.25072 |
| [54] | Yakoop Abdullah, M., Alkanderi, R.A., Alqahtani, A.M., Alsayed, A.I., Alnafisi, S.T., Alorabi, M.F., et al. (2023) Assessment and Management of Thyroid Disorders in Primary Care. International Journal of Community Medicine and Public Health, 10, 4962-4966. https://doi.org/10.18203/2394-6040.ijcmph20233531 |
| [55] | Lee, S.Y. and Pearce, E.N. (2022) Assessment and Treatment of Thyroid Disorders in Pregnancy and the Postpartum Period. Nature Reviews Endocrinology, 18, 158-171. https://doi.org/10.1038/s41574-021-00604-z |
| [56] | Kinomoto-Kondo, S., Umehara, N., Sato, S., Ogawa, K., Fujiwara, T., Arata, N., et al. (2016) The Effects of Gestational Transient Thyrotoxicosis on the Perinatal Outcomes: A Case-Control Study. Archives of Gynecology and Obstetrics, 295, 87-93. https://doi.org/10.1007/s00404-016-4219-2 |
| [57] | Alexander, E.K., Pearce, E.N., Brent, G.A., Brown, R.S., Chen, H., Dosiou, C., et al. (2017) 2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease during Pregnancy and the Postpartum. Thyroid, 27, 315-389. https://doi.org/10.1089/thy.2016.0457 |
| [58] | (2020) Thyroid Disease in Pregnancy: ACOG Practice Bulletin, Number 223. Obstetrics & Gynecology, 135, e261-e274. |
| [59] | Alves Junior, J.M., Bernardo, W.M., Ward, L.S. and Villagelin, D. (2022) Effect of Hyperthyroidism Control during Pregnancy on Maternal and Fetal Outcome: A Systematic Review and Meta-Analysis. Frontiers in Endocrinology, 13, Article 800257. https://doi.org/10.3389/fendo.2022.800257 |
| [60] | Agrawal, M., Lewis, S., Premawardhana, L., Dayan, C.M., Taylor, P.N. and Okosieme, O.E. (2021) Antithyroid Drug Therapy in Pregnancy and Risk of Congenital Anomalies: Systematic Review and Meta-Analysis. Clinical Endocrinology, 96, 857-868. https://doi.org/10.1111/cen.14646 |
| [61] | Brzozowska, M. and Roach, P.J. (2006) Timing and Potential Role of Diagnostic I-123 Scintigraphy in Assessing Radioiodine Breast Uptake before Ablation in Postpartum Women with Thyroid Cancer: A Case Series. Clinical Nuclear Medicine, 31, 683-687. https://doi.org/10.1097/01.rlu.0000242600.23386.1a |
| [62] | Patel, K.N., Yip, L., Lubitz, C.C., Grubbs, E.G., Miller, B.S., Shen, W., et al. (2020) The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults. Annals of Surgery, 271, e21-e93. https://doi.org/10.1097/sla.0000000000003580 |
| [63] | Lipson, A., Nickoloff, E.L., Hsu, T.H., Kasecamp, W.R., Drew, H.M., et al. (1979) A Study of Age-Dependent Changes in Thyroid Function Tests in Adults. Journal of Nuclear Medicine, 20, 1124-1130. |
| [64] | Hesch, R., Gatz, J., Pape, J., Schmidt, E. and van zur Mühlen, A. (1976) Total and Free Triiodothyronine and Thyroid-Binding Globulin Concentration in Elderly Human Persons. European Journal of Clinical Investigation, 6, 139-145. https://doi.org/10.1111/j.1365-2362.1976.tb00504.x |
| [65] | Mariotti, S., Barbesino, G., Caturegli, P., Bartalena, L., Sansoni, P., Fagnoni, F., et al. (1993) Complex Alteration of Thyroid Function in Healthy Centenarians. The Journal of Clinical Endocrinology & Metabolism, 77, 1130-1134. https://doi.org/10.1210/jcem.77.5.8077303 |
| [66] | Trivalle, C., Doucet, J., Chassagne, P., Landrin, I., Kadri, N., Menard, J., et al. (1996) Differences in the Signs and Symptoms of Hyperthyroidism in Older and Younger Patients. Journal of the American Geriatrics Society, 44, 50-53. https://doi.org/10.1111/j.1532-5415.1996.tb05637.x |
| [67] | Boelaert, K., Torlinska, B., Holder, R.L. and Franklyn, J.A. (2010) Older Subjects with Hyperthyroidism Present with a Paucity of Symptoms and Signs: A Large Cross-Sectional Study. The Journal of Clinical Endocrinology & Metabolism, 95, 2715-2726. https://doi.org/10.1210/jc.2009-2495 |
| [68] | Bailes, B.K. (1999) Hyperthyroidism in Elderly Patients. AORN Journal, 69, 254-258. https://doi.org/10.1016/s0001-2092(06)62774-9 |
| [69] | Martin, F.I.R. and Deam, D.R. (1996) Hyperthyroidism in Elderly Hospitalised Patients: Clinical Features and Treatment Outcomes. Medical Journal of Australia, 164, 200-203. https://doi.org/10.5694/j.1326-5377.1996.tb94135.x |
| [70] | Papaleontiou, M. and Haymart, M.R. (2012) Approach to and Treatment of Thyroid Disorders in the Elderly. Medical Clinics of North America, 96, 297-310. https://doi.org/10.1016/j.mcna.2012.01.013 |
| [71] | Thiruvengadam, S. and Luthra, P. (2021) Thyroid Disorders in Elderly: A Comprehensive Review. Disease-a-Month, 67, Article ID: 101223. https://doi.org/10.1016/j.disamonth.2021.101223 |
