Editorial 2

Editorial
Hyperthyroidism and Bone Health
Amrish Mithal* and Dinesh Kumar Dhanwal**
The importance of thyroid hormone in skeletal development is signified by childhood hypothyroidism
which leads to delayed skeletal maturation and growth arrest and thyrotoxicosis, which is associated
with accelerated skeletal development in children. In adults, thyrotoxicosis results in increased bone
remodeling [1]. Both hypothyroidism and hyperthyroidism affect bone mineral density (BMD) and are
associated with increased risk of fragility fracture [2]. Thyrotoxicosis affects bone much more than
hypothyroidism and is an important cause of secondary osteoporosis. Like other systemic
manifestations of thyrotoxicosis, bone disease in Indian patients is more severe due to the fact that
Indian patients present late during the disease course. Thyroid hormones directly affect the remodeling
process by their action on osteoblasts, which indirectly stimulate the osteoclasts through cytokines.
Osteoclast activity is increased by thyroid hormone but only in the presence of osteoblasts. The
duration of remodeling cycle is reduced by 50%. The uncoupling of remodeling process leads to a net
bone loss that can amount to 10% of mineralized bone per cycle in severe cases of thyrotoxicosis [3].

Effect of hyperthyroidism has been reported from western world in early eighties [4] but interest of bone
disease in hyperthyroidism in India is quite recent and the first report was from South India [5]. In this
study Udayakumar et al. showed that 60% of thyrotoxicosis patients have osteoporosis, which
improves with antithyroid drugs. Subsequently Dhanwal et al. reported that 30% of these patients have
severe vitamin D deficiency, which exacerbates bone loss [6]. Further same authors showed that after
one-year treatment with this bone loss reverses towards normalcy at lumbar spine and hip but not at
forearm [7]. Jyotsana et al. have reported that age and BMI adjusted bone density decreases at the end of
two years treatment in hyperthyroidism. Another feature is that hypercalcemia which is frequently seen
in western patients of hyperthyroidism is not seen in Indian subjects. In fact, some of these patients can
have hypocalcemia [6].

In this issue, Dhanwal et al., in a study of 70 cases of hyperthyroidism, studied vitamin D levels and
bone density and compared that with age and sex matched controls [6]. Vitamin D deficiency and
secondary hyperthyroidism were significantly higher in patients group compared to controls. Almost
three forth of patients had vitamin D deficiency and secondary hyperparathyroidism. Further, bone
density was significantly lower in patient group and both osteoporosis and osteopenia were
significantly higher in thyrotoxicosis group. Results of this study confirm the findings of earlier
researchers that Indian patients with hyperthyroidism have vitamin D deficiency, which affects bone
health adversely leading to secondary osteoporosis. This is fairly a large study comprising of both
premenopausal and postmenopausal women and men. It will be interesting to know whether effect of
thyrotoxicosis is different in postmenopausal women as compared to younger women. Further studies
should explore this aspect. Also more research is needed to study effect of subclinical thyrotoxicosis
due to other causes such as overtreatment of hypothyroidism on their bone health. Finally, we need to
know the effect of vitamin D supplementation on vitamin D levels and bone density so that guidelines
can state about universal vitamin D supplementation in subjects with hyperthyroidism.

*
Chairman, Department of Endocrinology, Medanata Medicity, Gurgaon
**
Director Professor of Medicine and Endocrinologist, Maulana Azad Medical College, New Delhi

Correspondence to: Dr. Dinesh Dhanwal, Director Professor of Medicine and Endocrinologist, Maulana Azad
Medical College, New Delhi. E- mail: dineshdhanwal@hotmail.com

J. Adv. Res. Med. 2014; 1(1): 2- 3.

3 Editorial

References
1. Kempers MJ, Vulsma T, Wiedijk BM et al., The effect of life-long thyroxine treatment and
physical activity on bone mineral density in young adult women with congenital
hypothyroidism, “J Pediatr Endocrinol Metab.”, 2006 Dec;19(12):1405-12p.

2. Vestergaard P, Rejnmark L, Weeke J et al., “Fracture risk in patients treated for

hyperthyroidism”, Thyroid. 2000 Apr; 10(4):341-48p.

3. Eriksen EF, Mosekilde L, Melsen F, “Trabecular bone remodeling and bone balance in
hyperthyroidism”, Bone. 1985; 6(6):421-28p.

4. Mosekilde L, Eriksen EF, Charles P, “Effects of thyroid hormones on bone and mineral
metabolism”, Endocrinol Metab Clin North Am. 1990 Mar;19(1):35-63p.

5. Udayakumar N, Chandrasekaran M, Rasheed M H et al., Evaluation of bone mineral density

in Thyrotoxicosis, “Singapore Med J” 2006; 47(11) : 947p.

6. Dhanwal DK, Kochupillai N, Gupta N et al., Hypovitaminosis

D and bone mineral metabolism and bone density in hyperthyroidism, “J Clin
Densitom.” 2010 Oct-Dec; 13(4):462-66p.

7. Dhanwal DK, Gupta N, Bone mineral density trends in Indian patients with hyperthyroidism –
Effect of Antithyroid therapy, “JAPI” Sep 2011; 59: 561-67p.

8. Viveka P. Jyotsna, Abhay Sahoo, Singh Achouba Ksh et al., Bone mineral density in patients
of Graves disease pre- & post- treatment in a predominantly vitamin D deficient population,
“Indian J Med Res”, 2012; 135:36-41p.

J. Adv. Res. Med. 2014; 1(1): 2- 3.