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Bauer BS, Azcoaga-Lorenzo A, Agrawal U, Fagbamigbe AF, McCowan C. Subclinical hypothyroidism in Wales from 2000 to 2021: A descriptive cohort study based on electronic health records. PLoS One 2024; 19:e0298871. [PMID: 38771782 PMCID: PMC11108130 DOI: 10.1371/journal.pone.0298871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 02/01/2024] [Indexed: 05/23/2024] Open
Abstract
BACKGROUND Subclinical hypothyroidism (SCH) is a biochemical thyroid disorder characterised by elevated levels of Thyroid Stimulating Hormone (TSH) together with normal levels of thyroid hormones. Evidence on the benefits of treatment is limited, resulting in persistent controversies relating to its clinical management. AIM This study describes the demographic and clinical characteristics of patients identified as having subclinical hypothyroidism in Wales between 2000 and 2021, the annual cumulative incidence during this period and the testing and treatment patterns associated with this disorder. METHODS We used linked electronic health records from SAIL Databank. Eligible patients were identified using a combination of diagnostic codes and Thyroid Function Test results. Descriptive analyses were then performed. RESULTS 199,520 individuals (63.8% female) were identified as having SCH, 23.6% (n = 47,104) of whom received levothyroxine for treatment over the study period. The median study follow-up time was 5.75 person-years (IQR 2.65-9.65). Annual cumulative incidence was highest in 2012 at 502 cases per 100,000 people. 92.5% (n = 184,484) of the study population had TSH levels between the upper limit of normal and 10mIU/L on their first test. 61.9% (n = 5,071) of patients identified using Read v2 codes were in the treated group. 41.9% (n = 19,716) of treated patients had a history of a single abnormal test result before their first prescription. CONCLUSION In Wales, the number of incident cases of SCH has risen unevenly between 2000 and 2021. Most of the study population had mild SCH on their index test, but more than a third of the identified patients received levothyroxine after a single abnormal test result. Patients with clinically recorded diagnoses were more likely to be treated. Given the expectation of steadily increasing patient numbers, more evidence is required to support the clinical management of subclinical hypothyroidism.
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Affiliation(s)
- Brenda S. Bauer
- Division of Population and Behavioural Sciences, University of St Andrews School of Medicine, St Andrews, United Kingdom
| | - Amaya Azcoaga-Lorenzo
- Division of Population and Behavioural Sciences, University of St Andrews School of Medicine, St Andrews, United Kingdom
- Hospital Rey Juan Carlos, Instituto de Investigación Sanitaria Fundación Jimenez Diaz, Red de Investigación en Cronicidad, Atención Primaria y Promoción de la Salud (RICAPPs) ISCIII, Madrid, Spain
| | - Utkarsh Agrawal
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Adeniyi Francis Fagbamigbe
- Research & Evaluation Unit, Institute for Health and Wellbeing, Centre for Healthcare and Communities, Coventry University, Coventry, United Kingdom
| | - Colin McCowan
- Division of Population and Behavioural Sciences, University of St Andrews School of Medicine, St Andrews, United Kingdom
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Holley M, Razvi S, Farooq MS, Dew R, Maxwell I, Wilkes S. Cardiovascular and bone health outcomes in older people with subclinical hypothyroidism treated with levothyroxine: a systematic review and meta-analysis. Syst Rev 2024; 13:123. [PMID: 38720372 PMCID: PMC11077844 DOI: 10.1186/s13643-024-02548-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 04/29/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Thyroid dysfunction is common in older people, with females at higher risk. Evidence suggests that thyroid-stimulating hormone (TSH) levels naturally increase with age. However, as uniform serum TSH reference ranges are applied across the adult lifespan, subclinical hypothyroidism (SCH) diagnosis is more likely in older people, with some individuals also being commenced treatment with levothyroxine (LT4). It is unclear whether LT4 treatment in older people with SCH is associated with adverse cardiovascular or bone health outcomes. METHODS A systematic review and meta-analysis were performed to synthesise previous studies evaluating cardiovascular and bone health outcomes in older people with SCH, comparing LT4 treatment with no treatment. PubMed, Embase, Cochrane Library, MEDLINE, and Web of Science databases were searched from inception until March 13, 2023, and studies that evaluated cardiovascular and bone health events in people with SCH over 50 years old were selected. RESULTS Six articles that recruited 3853 participants were found, ranging from 185 to 1642 participants, with the proportion of females ranging from 45 to 80%. The paucity of data resulted in analysis for those aged over 65 years only. Additionally, a study with 12,212 participants aged 18 years and older was identified; however, only data relevant to patients aged 65 years and older were considered for inclusion in the systematic review. Of these 7 studies, 4 assessed cardiovascular outcomes, 1 assessed bone health outcomes, and 2 assessed both. A meta-analysis of cardiovascular outcomes revealed a pooled hazard ratio of 0.89 (95% CI 0.71-1.12), indicating no significant difference in cardiovascular risk between older individuals with SCH treated with LT4 compared to those without treatment. Due to overlapping sub-studies, meta-analysis for bone health outcomes was not possible. CONCLUSIONS This systematic review and meta-analysis found no significant association between LT4 use and cardiovascular and bone health outcomes in SCH participants over 65 years. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42022308006.
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Affiliation(s)
- Mia Holley
- School of Medicine, Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK.
| | - Salman Razvi
- Translational and Clinical Research Institute, Newcastle University, Newcastle-Upon-Tyne, UK
| | - Mohammed Saif Farooq
- School of Medicine, Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK
| | - Rosie Dew
- School of Medicine, Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK
| | - Ian Maxwell
- School of Medicine, Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK
| | - Scott Wilkes
- School of Medicine, Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK
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Link-Rachner CS, Göbel A, Jaschke NP, Rachner TD. Endocrine health in survivors of adult-onset cancer. Lancet Diabetes Endocrinol 2024; 12:350-364. [PMID: 38604215 DOI: 10.1016/s2213-8587(24)00088-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 04/13/2024]
Abstract
Long-term survivors of cancer (ie, the patient who is considered cured or for whom the disease is under long-term control and unlikely to recur) are at an increased risk of developing endocrine complications such as hypothalamic-pituitary dysfunctions, hypogonadisms, osteoporosis, or metabolic disorders, particularly when intensive tumour-directed therapies are applied. Symptom severity associated with these conditions ranges from mild and subclinical to highly detrimental, affecting individual health and quality of life. Although they are usually manageable, many of these endocrine pathologies remain underdiagnosed and untreated for years. To address this challenge, a higher degree of awareness, standardised screening tools, comprehensible treatment algorithms, and a close collaborative effort between endocrinologists and oncologists are essential to early identify patients who are at risk, and to implement appropriate treatment protocols. This Review highlights common symptoms and conditions related to endocrine disorders among survivors of adult-onset cancer, provides a summary of the currently available practice guidelines, and proposes a practical approach to diagnose affected patients among this group.
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Affiliation(s)
- Cornelia S Link-Rachner
- Division of Haematology and Oncology, Department of Medicine I, Technische Universität Dresden, Dresden, Germany
| | - Andy Göbel
- Division of Endocrinology, Diabetes, and Bone Diseases, Department of Medicine III, Technische Universität Dresden, Dresden, Germany; German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Nikolai P Jaschke
- Division of Endocrinology, Diabetes, and Bone Diseases, Department of Medicine III, Technische Universität Dresden, Dresden, Germany; German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
| | - Tilman D Rachner
- Division of Endocrinology, Diabetes, and Bone Diseases, Department of Medicine III, Technische Universität Dresden, Dresden, Germany; German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany.
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Chapela SP, Simancas-Racines A, Ceriani F, Martinuzzi ALN, Russo MP, Zambrano AK, Simancas-Racines D, Verde L, Muscogiuri G, Katsanos CS, Frias-Toral E, Barrea L. Obesity and Obesity-Related Thyroid Dysfunction: Any Potential Role for the Very Low-Calorie Ketogenic Diet (VLCKD)? Curr Nutr Rep 2024:10.1007/s13668-024-00528-w. [PMID: 38526760 DOI: 10.1007/s13668-024-00528-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2024] [Indexed: 03/27/2024]
Abstract
PURPOSE OF REVIEW This review aims to explore in-depth the different aspects of the association between very low-calorie ketogenic diet (VLCKD), obesity and obesity-related thyroid dysfunction. RECENT FINDINGS The VLCKD, proposed as a non-pharmacological strategy for the management of certain chronic diseases, is becoming increasingly popular worldwide. Initially used to treat epilepsy, it has been shown to be effective in controlling body weight gain and addressing various pathophysiological conditions. Research has shown that a low-calorie, high-fat diet can affect thyroid hormone levels. Weight loss can also influence thyroid hormone levels. Studies have suggested that long-term use of VLCKD for refractory epilepsy may be related to the development of hypothyroidism, with an effect seen in various populations. In particular, women with obesity following VLCKD tend to have reduced T3 levels. We propose further research to unravel the underlying mechanisms linking VLCKD to obesity and obesity-related thyroid dysfunction.
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Affiliation(s)
- Sebastián Pablo Chapela
- Facultad de Medicina, Departamento de Bioquímica Humana, Universidad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
- Equipo de Soporte Nutricional, Hospital Británico de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Alison Simancas-Racines
- Facultad de, Ciencias Agropecuarias y Recursos Naturales, Carrera de Medicina Veterinaria, Universidad Técnica de Cotopaxi, Latacunga, 050108, Ecuador
- Centro de Investigación de Salud Pública y Epidemiología Clínica (CISPEC), Facultad de Veterinaria y Agronomía, Universidad UTE, Santo Domingo, Ecuador
| | - Florencia Ceriani
- Escuela de Nutrición, Universidad de la República Uruguay, Montevideo, Uruguay
| | | | - María Paula Russo
- Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Ana Karina Zambrano
- Centro de Investigación Genética y Genómica, Universidad UTE, Facultad de Ciencias de la Salud Eugenio Espejo, Quito, Ecuador
| | - Daniel Simancas-Racines
- Centro de Investigación de Salud Pública y Epidemiología Clínica (CISPEC), Universidad UTE, Facultad de Ciencias de la Salud Eugenio Espejo, Quito, 170129, Ecuador
| | - Ludovica Verde
- Department of Public Health, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Giovanna Muscogiuri
- Unità di Endocrinologia, Diabetologia e Andrologia, Dipartimento di Medicina Clinica e Chirurgia, Università degli Studi di Napoli Federico II, Via Sergio Pansini 5, 80131, Naples, Italy.
- Cattedra Unesco "Educazione Alla Salute E Allo Sviluppo Sostenibile", University Federico II, 80131, Naples, Italy.
| | | | - Evelyn Frias-Toral
- School of Medicine, Universidad Espíritu Santo - Samborondón, 0901952, Samborondón, Ecuador
| | - Luigi Barrea
- Dipartimento di Benessere, Nutrizione e Sport, Università Telematica Pegaso, Centro Direzionale Isola F2, Via Porzio, 80143, Naples, Italy
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Petranović Ovčariček P, Görges R, Giovanella L. Autoimmune Thyroid Diseases. Semin Nucl Med 2024; 54:219-236. [PMID: 38044176 DOI: 10.1053/j.semnuclmed.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/02/2023] [Accepted: 11/11/2023] [Indexed: 12/05/2023]
Abstract
Autoimmune thyroid diseases (AITDs) include a wide spectrum of thyroid diseases affecting more commonly women than men. The most frequent forms are Graves' Disease (GD) and Hashimoto's thyroiditis / Autoimmune Thyroiditis (AIT), but there are also other immunogenic destructive forms of thyroiditis, that is, silent and postpartum thyroiditis. In the last decade, AITDs and other inflammatory thyroid diseases related to anti-tumor molecular drugs are more frequently seen due to the widespread use of tyrosine kinase inhibitors (TKIs) and immune checkpoint inhibitors (ICPIs). Autoimmune thyroiditis related to SARS-CoV-2 infection has been a novel entity in recent years. Graves' Disease and AIT may shift from hyperthyroidism to hypothyroidism, which may complicate the differential diagnosis and further treatment strategy. Moreover, all AITDs may manifest with thyrotoxicosis (a clinical condition marked with high serum levels of thyroid hormones) which has to be distinguished from hyperthyroidism (increased thyroid hormone production and secretion as a result of hyperfunctioning thyroid gland) due to different therapeutic approaches. Nuclear medicine techniques, such as radioiodine uptake (RAIU) and thyroid scintigraphy, using 99mTc- pertechnetate (Na[99mTc]TcO4) or 123-Iodine (Na[123I]I), have a crucial role in the differential diagnosis. Measurement of thyroid antibodies, e.g. thyroid peroxidase antibodies (TPO) and thyrotropin receptor antibodies (TRAb), as well as thyroid ultrasound, are complementary methods in the evaluation of thyroid disorders.
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Affiliation(s)
- Petra Petranović Ovčariček
- Department of Oncology and Nuclear Medicine, University Hospital Center Sestre Milosrdnice, Zagreb, Croatia; School of Medicine, University of Zagreb, Zagreb, Croatia.
| | - Rainer Görges
- Department of Nuclear Medicine, University Hospital of Essen, Essen, Germany
| | - Luca Giovanella
- Clinic for Nuclear Medicine and Molecular Imaging, Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland; Clinic for Nuclear Medicine, University Hospital and University of Zürich, Zürich, Switzerland
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Baioumi A, Kolenova A, Avatapalle HB. An unusual cause of bleeding in primary hypothyroidism. Clin Pediatr Endocrinol 2024; 33:71-75. [PMID: 38572381 PMCID: PMC10985014 DOI: 10.1297/cpe.2023-0069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 12/30/2023] [Indexed: 04/05/2024] Open
Abstract
A 10-yr-old female was referred due to prolonged bleeding lasting for a week following tooth extraction. She had heavy periods since she was 9. Her height was < 0.4th centile. Tanner staging was breast stage B3-4, axillary hair A1, and pubic hair P1. Thyroid function tests showed elevated TSH, low free T4, and negative anti-TPO antibodies. Gonadotrophins showed high FSH and a prepubertal LH. Prolactin was high and ovarian cysts were found on ultrasound. Further investigations revealed low von Willebrand factor (vWF) antigen levels, leading to a diagnosis of acquired von Willebrand disease. She was started on levothyroxine therapy, with normalization of vWF antigen levels, prolactin levels, cessation of her menstrual periods and resolution of ovarian cysts.
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Affiliation(s)
- Alaa Baioumi
- Paediatric Endocrinology Department, Noah's Ark Children's Hospital for Wales, Cardiff, United Kingdom
| | - Alzbeta Kolenova
- Paediatric Department, Bronglais Hospital, Hywel Dda University Health Board, Aberystwyth, United Kingdom
| | - Hima Bindu Avatapalle
- Paediatric Endocrinology Department, Noah's Ark Children's Hospital for Wales, Cardiff, United Kingdom
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Cappelli C, Gatta E, Ippolito S. Levothyroxine personalized treatment: is it still a dream? Front Endocrinol (Lausanne) 2024; 14:1334292. [PMID: 38260167 PMCID: PMC10801080 DOI: 10.3389/fendo.2023.1334292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/18/2023] [Indexed: 01/24/2024] Open
Abstract
Levothyroxine is a milestone in the treatment of all causes of hypothyroidism. From 19th century till today, Levothyroxine experienced a great advancement, from hypodermic injections of an extract of the thyroid gland of a sheep to novel formulations, known to circumvent malabsorption issue. However, the rate of patients on suboptimal therapy is still high. Current Guidelines are clear, daily Levothyroxine dosage should be calculated based on body weight. However, we are still far away from the possibility to administer the right dosage to the right patient, for several reasons. We retrace the history of treatment with levothyroxine, pointing out strengths and weaknesses of different formulations, with particular attention to what keeps us away from tailored therapy. In the age of digitalization, the pharmaceutical industry has been giving rising importance to Digital therapeutics, that are known to be effective in reaching target therapies. By combining current knowledge of hypothyroidism therapy with cutting-edge technology, we also hypothesized what could be the future strategies to be developed in this field.
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Affiliation(s)
- Carlo Cappelli
- Department of Clinical and Experimental Sciences, SSD Endocrinologia, University of Brescia, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Elisa Gatta
- Department of Clinical and Experimental Sciences, SSD Endocrinologia, University of Brescia, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Salvatore Ippolito
- Consulcesi Homnya, Head of Omnichannel Strategy & Project Management, Rome, Italy
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Brigante G, Santi D, Boselli G, Margiotta G, Corleto R, Monzani ML, Craparo A, Locaso M, Sperduti S, Roy N, Casarini L, Trenti T, Tagliavini S, De Santis MC, Roli L, Rochira V, Simoni M. Randomized double-blind placebo-controlled trial on levothyroxine and liothyronine combination therapy in totally thyroidectomized subjects: the LEVOLIO study. Eur J Endocrinol 2024; 190:12-22. [PMID: 38124252 DOI: 10.1093/ejendo/lvad172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 11/28/2023] [Accepted: 12/04/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Despite having normal thyroid-stimulating hormone levels, many hypothyroid patients are dissatisfied with the treatment. The primary aim of this study was to evaluate the effect of twice-daily, combination therapy with levothyroxine (LT4) and liothyronine (LT3), at doses adapted according to TSH-level, on peripheral tissues as reflected by sex hormone binding globulin (SHBG) levels in totally thyroidectomized patients. Changes in other tissue markers and quality of life considering DIO2-rs225014 and MCT10-rs17606253 genetic variants were also assessed. DESIGN Double-blind, randomized, placebo-controlled. METHODS One hundred and forty-one subjects were randomized to LT4 + LT3 group (LT4 + LT3 in the morning and LT3 in the evening; n = 70) or placebo group (LT4 in the morning and placebo in the evening; n = 71). Pituitary-thyroid axis compensation was assessed after 6, 12, and 24 weeks. Clinical parameters, quality of life, and tissue markers (sex hormone binding globulin, serum lipids, bone markers) were evaluated at 12 and 24 weeks. DIO2 and MCT10 single nucleotide polymorphisms were genotyped. RESULTS The LT4 + LT3 group was treated with mean daily LT3 doses of 5.00 µg, with a mean daily LT4 reduction of 15 µg. After 6 months of treatment, neither SHBG and other tissue markers nor quality of life differed significantly between groups. Combination treatment required greater dose adjustments than placebo (25% vs 54%, P < .001), due to thyroid-stimulating hormone reduction, without hyperthyroidism signs or symptoms. At the end of treatment, the LT4 + placebo group had significantly lower fT3/fT4 compared to the LT4 + LT3 group (0.26 ± 0.05 vs 0.32 ± 0.08, P < .001). No preference for combination therapy was found. Genetic variants did not influence any outcomes. CONCLUSIONS Six months of combination therapy with twice-daily LT3 dose adapted according to TSH-level do not significantly change peripheral tissue response or quality of life, despite an increase in the fT3/fT4 ratio.
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Affiliation(s)
- Giulia Brigante
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41124 Modena, Italy
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy
| | - Daniele Santi
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41124 Modena, Italy
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy
| | - Gisella Boselli
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Gianluca Margiotta
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Rossella Corleto
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Maria Laura Monzani
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41124 Modena, Italy
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy
| | - Andrea Craparo
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Michela Locaso
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Samantha Sperduti
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41124 Modena, Italy
- Center for Genomic Research, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Neena Roy
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Livio Casarini
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41124 Modena, Italy
- Center for Genomic Research, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Tommaso Trenti
- Department of Laboratory Medicine and Anatomy Pathology, Azienda USL Modena, 41126 Modena, Italy
| | - Simonetta Tagliavini
- Department of Laboratory Medicine and Anatomy Pathology, Azienda USL Modena, 41126 Modena, Italy
| | - Maria Cristina De Santis
- Department of Laboratory Medicine and Anatomy Pathology, Azienda USL Modena, 41126 Modena, Italy
| | - Laura Roli
- Department of Laboratory Medicine and Anatomy Pathology, Azienda USL Modena, 41126 Modena, Italy
| | - Vincenzo Rochira
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41124 Modena, Italy
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy
| | - Manuela Simoni
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41124 Modena, Italy
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy
- Center for Genomic Research, University of Modena and Reggio Emilia, 41126 Modena, Italy
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Radu AM, Carsote M, Nistor C, Dumitrascu MC, Sandru F. Crossroads between Skin and Endocrine Glands: The Interplay of Lichen Planus with Thyroid Anomalies. Biomedicines 2023; 12:77. [PMID: 38255184 PMCID: PMC10813575 DOI: 10.3390/biomedicines12010077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 12/15/2023] [Accepted: 12/23/2023] [Indexed: 01/24/2024] Open
Abstract
In this narrative review, we aimed to overview the interplay between lichen planus (LP) and thyroid conditions (TCs) from a dual perspective (dermatologic and endocrine), since a current gap in understanding LP-TC connections is found so far and the topic is still a matter of debate. We searched PubMed from Inception to October 2023 by using the key terms "lichen planus" and "thyroid", (alternatively, "endocrine" or "hormone"). We included original clinical studies in humans according to three sections: LP and TC in terms of dysfunction, autoimmunity, and neoplasia. Six studies confirmed an association between the thyroid dysfunction (exclusively hypothyroidism) and LP/OL (oral LP); of note, only one study addressed cutaneous LP. The sample size of LP/OLP groups varied from 12-14 to 1500 individuals. Hypothyroidism prevalence in OLP was of 30-50%. A higher rate of levothyroxine replacement was identified among OLP patients, at 10% versus 2.5% in controls. The highest OR (odd ratio) of treated hypothyroidism amid OLP was of 2.99 (p < 0.005). Hypothyroidism was confirmed to be associated with a milder OLP phenotype in two studies. A single cohort revealed a similar prevalence of hypothyroidism in LP versus non-LP. Non-confirmatory studies (only on OLP, not cutaneous LP) included five cohorts: a similar prevalence of hypothyroidism among OLP versus controls, and a single cohort showed that the subjects with OLP actually had a lower prevalence of hypothyroidism versus controls (1% versus 4%). Positive autoimmunity in LP/OLP was confirmed in eight studies; the size of the cohorts varied, for instance, with 619 persons with LP and with 76, 92, 105, 108, 192, 247, and 585 patients (a total of 1405) with OLP, respectively; notably, the largest control group was of 10,441 individuals. Four clusters of approaches with respect to the autoimmunity in LP/OLP were found: an analysis of HT/ATD (Hashimoto's thyroiditis/autoimmune thyroid diseases) prevalence; considerations over the specific antibody levels; sex-related features since females are more prone to autoimmunity; and associations (if any) with the clinical aspects of LP/OLP. HT prevalence in OLP versus controls was statistically significantly higher, as follows: 19% versus 5%; 12% versus 6%; and 20% versus 9.8%. A single study addressing LP found a 12% rate of ATDs. One study did not confirm a correlation between OLP-associated clinical elements (and OLP severity) and antibody values against the thyroid, and another showed that positive TPOAb (anti-thyroperoxidase antibodies) was more often found in erosive than non-erosive OLP (68% versus 33%). Just the reverse, one cohort found that OLP subjects had a statistically significantly lower rate of positive TPOAb versus controls (9% versus 15%). Five case-control studies addressed the issue of levothyroxine replacement for prior hypothyroidism in patients that were diagnosed with OLP (no study on LP was identified); three of them confirmed a higher rate of this treatment in OLP (at 8.9%, 9.7%, and 10.6%) versus controls. In conclusion, with regard to LP/OLP-TC, we note several main aspects as practical points for multidisciplinary practitioners: OLP rather than LP requires thyroid awareness; when it comes to the type of thyroid dysfunction, mostly, hypothyroidism should be expected; female patients are more prone to be associated with ATDs; a potential higher ratio of OLP subjects taking levothyroxine was found, thus a good collaboration with an endocrinology team is mandatory; and so far, OLP individuals have not been confirmed to be associated with a higher risk of thyroid nodules/cancer.
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Affiliation(s)
- Andreea-Maria Radu
- Department of Dermatovenerology, Elias University Emergency Hospital, 011461 Bucharest, Romania
| | - Mara Carsote
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Clinical Endocrinology V, C.I. Parhon National Institute of Endocrinology, 020021 Bucharest, Romania
| | - Claudiu Nistor
- Department 4—Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Thoracic Surgery Department, Dr. Carol Davila Central Military Emergency University Hospital, 010242 Bucharest, Romania
| | - Mihai Cristian Dumitrascu
- Department of Obstetrics and Gynaecology, C. Davila University of Medicine and Pharmacy & University Emergency Hospital, 050474 Bucharest, Romania;
| | - Florica Sandru
- Department of Dermatovenerology, Carol Davila University of Medicine and Pharmacy & Elias University Emergency Hospital, 011461 Bucharest, Romania;
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Ettleson MD, Ibarra S, Wan W, Peterson S, Laiteerapong N, Bianco AC. Demographic, Healthcare Access, and Dietary Factors Associated With Thyroid Hormone Treatments for Hypothyroidism. J Clin Endocrinol Metab 2023; 108:e1614-e1623. [PMID: 37327351 PMCID: PMC10655529 DOI: 10.1210/clinem/dgad331] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/27/2023] [Accepted: 06/01/2023] [Indexed: 06/18/2023]
Abstract
CONTEXT Clinical guidelines have recommended a trial of liothyronine (LT3) with levothyroxine (LT4) in select patients with hypothyroidism. However, little is known about the real-world use of LT3 and desiccated thyroid extract (DTE) and the characteristics of patients treated with LT3 and DTE. OBJECTIVES (1) Determine national trends of new LT4, LT3, and DTE prescriptions in the United States; (2) determine whether sociodemographic, healthcare access, and dietary factors are associated with different thyroid hormone (TH) therapies. METHODS Parallel cross-sectional studies were conducted using 2 datasets: (1) a national patient claims dataset (2010-2020) and (2) the National Health and Nutrition Examination Study (NHANES) dataset (1999-2016). Included participants had a diagnosis of primary or subclinical hypothyroidism. Study outcomes included the impact of demographics and healthcare access on differences in the proportion of TH therapies consisting of LT4, LT3, and DTE (patient claims) and differences in dietary behaviors between DTE-treated participants and LT4-treated matched controls (NHANES). RESULTS On an average annual basis, 47 711 adults received at least 1 new TH prescription, with 88.3% receiving LT4 monotherapy, 2.0% receiving LT3 therapy, and 9.4% receiving DTE therapy. The proportion receiving DTE therapy increased from 5.4% in 2010 to 10.2% in 2020. In the analysis between states, high primary care and endocrinology physician densities were associated with increased use of LT4 monotherapy (odds ratio 2.51, P < .001 and odds ratio 2.71, P < .001). DTE-treated NHANES participants (n = 73) consumed more dietary supplements compared to LT4-treated participants (n = 146) (4.7 vs 2.1, P < .001). CONCLUSIONS The proportion of new TH therapies containing DTE for hypothyroidism doubled since 2010 while LT3 therapies remained stable. DTE treatment was associated with decreased physician density and increased dietary supplement use.
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Affiliation(s)
- Matthew D Ettleson
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, IL 60637, USA
| | - Sabrina Ibarra
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, IL 60637, USA
| | - Wen Wan
- Department of Medicine, Section of General Internal Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Sarah Peterson
- Department of Clinical Nutrition, Rush University Medical Center, Chicago, IL 60612, USA
| | - Neda Laiteerapong
- Department of Medicine, Section of General Internal Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Antonio C Bianco
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, IL 60637, USA
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Holley M, Razvi S, Dew R, Maxwell I, Wilkes S. Assessing the cardiovascular effects of levothyroxine use in an ageing United Kingdom population (ACEL-UK) protocol: a cohort and target trial emulation study. Thyroid Res 2023; 16:43. [PMID: 37953303 PMCID: PMC10641939 DOI: 10.1186/s13044-023-00186-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/16/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND Subclinical hypothyroidism is diagnosed when serum thyroid stimulating hormone levels are higher whilst free thyroxine levels remain within their respective reference ranges. These reference ranges are uniformly applied in all adults, despite serum thyroid stimulating hormone levels naturally increasing with age. Research has found that mildly elevated thyroid stimulating hormone levels may be associated with some benefits in ageing patients, including reduced mortality and better cardiorespiratory fitness. Levothyroxine is typically prescribed to patients with hypothyroidism, but no conclusive evidence exists on whether levothyroxine therapy is beneficial or detrimental in older subclinical hypothyroid patients. Despite this, prescriptions for levothyroxine are increasing year-on-year. This study aims to determine if receiving levothyroxine affects the cardiovascular and bone health outcomes of subclinical patients in primary care aged 50 years and over. METHODS This project includes a retrospective cohort analysis and a target trial emulation study using electronic patient records collected between 2006 and 2021 and recorded in The Health Improvement Network database. The primary outcome of this study is to compare the cardiovascular outcomes of subclinical hypothyroid patients aged over 50 years treated with levothyroxine compared to those untreated. Secondary outcomes are bone health and all-cause mortality outcomes. Descriptive and inferential statistics will both be employed to analyse the data. Secondary analysis will explore confounding factors, including age, sex, smoking status, body mass index, co-morbidities, and levothyroxine dosage. DISCUSSION There needs to be a greater understanding of the potential risks of the current treatment for older patients with subclinical hypothyroidism in a primary care setting. We will investigate the clinical importance of this issue and whether older subclinical hypothyroid patients have poorer outcomes when treated. Clarifying this concern may help address the healthcare resource implications of ageing patients being misclassified as having mild hypothyroidism, as these patients are more likely to repeat their blood tests. This could reduce prescription wastage and improve patient outcomes and quality of life in the ageing population. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Mia Holley
- School of Medicine, Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK.
| | - Salman Razvi
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Rosie Dew
- School of Medicine, Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK
| | - Ian Maxwell
- School of Medicine, Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK
| | - Scott Wilkes
- School of Medicine, Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK
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Mustafa M, Ali E, McGowan A, McCabe L, Hegedüs L, Attanasio R, Nagy EV, Papini E, Perros P, Moran C. Use of Thyroid Hormones in Hypothyroid and Euthyroid Patients: A THESIS questionnaire survey of members of the Irish Endocrine Society. Ir J Med Sci 2023; 192:2179-2187. [PMID: 36482281 PMCID: PMC10522726 DOI: 10.1007/s11845-022-03235-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/21/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Replacement of thyroid hormones (TH) with Levothyroxine (LT4) is the treatment of choice for hypothyroidism, however, there are aspects of treatment where uncertainties exist and practice varies. Factors influencing initiation and choice of TH replacement may impact patient satisfaction, safety, and health care costs. METHODS The aim of the study was to examine the attitudes of Irish endocrinologists regarding the treatment of hypothyroid and euthyroid patients with TH. Members of the Irish Endocrine Society (IES) were invited to participate in an online survey. RESULTS Forty-eight invitations were sent, and 39 (81.3%) participants responded. All respondents favoured LT4 tablet therapy for treatment of hypothyroidism, but 20.5% prescribed combination therapy (LT4 and liothyronine), and 13% regularly used desiccated thyroid extract. A significant proportion (51%) might prescribe TH in euthyroid patients; 41% for thyroid auto-antibody positive women seeking pregnancy, 18% for goitre and 5% for unexplained fatigue. Many (38%) consider combination therapy in patients with persistent symptoms. Respondents reported seeing LT4 treated patients with persistent symptomatology more frequently and perceive psychosocial factors and comorbidities to be the most common reasons for such symptoms. CONCLUSION LT4 tablets are the treatment of choice for hypothyroidism in Ireland. Approximately a third of Irish endocrinologists either regularly use, or would consider, liothyronine for hypothyroid patients. A significant proportion would give TH to euthyroid individuals in specific circumstances. The prescription of TH amongst Irish endocrinologists was generally in keeping with recommended practice, and areas where practice deviated from guidance were typically where evidence was conflicting or insufficient.
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Affiliation(s)
- Mohamad Mustafa
- Robert Graves Institute, Tallaght University Hospital, Dublin, Ireland
| | - Elsheikh Ali
- Robert Graves Institute, Tallaght University Hospital, Dublin, Ireland
| | - Anne McGowan
- Robert Graves Institute, Tallaght University Hospital, Dublin, Ireland
| | - Laura McCabe
- Pharmacy Department, Tallaght University Hospital, Dublin, Ireland
| | - Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Roberto Attanasio
- Scientific Committee Associazione Medici Endocrinologi, Milan, Italy
| | - Endre V. Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Enrico Papini
- Department of Endocrinology and Metabolism, Opsedale Regina Apostolorum, Rome, Italy
| | - Petros Perros
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Carla Moran
- Diabetes & Endocrinology Section, Beacon Hospital, Sandyford, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
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Cassemiro JF, Ilera V, Batalles S, Reyes A, Nagy EV, Papini E, Perros P, Hegedüs L, Ramos HE. Use of thyroid hormones in hypothyroid and euthyroid patients: a 2022 THESIS questionnaire survey of members of the Latin American Thyroid Society (LATS). Thyroid Res 2023; 16:40. [PMID: 37773072 PMCID: PMC10542243 DOI: 10.1186/s13044-023-00182-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 09/15/2023] [Indexed: 09/30/2023] Open
Abstract
PURPOSE Inconsistencies in the medical management of hypothyroidism have been reported between endocrinologists in different countries. This study aimed to identify the attitudes of Latin America thyroid specialists towards the use of thyroid hormones. METHODS Online survey of members of the Latin America Thyroid Society. RESULTS 81/446 (18.2%) completed the questionnaire. Levothyroxine (LT4) was the initial treatment of choice for all respondents. 56.8% would consider LT4 use in biochemically euthyroid patients: infertile women with elevated anti-thyroid antibodies (46.9%), resistant depression (17.3%) and growing goiter (12%). Most respondents preferred tablets (39.5%) over liquid formulations (21.0%) or soft gel capsules (22.2%) and would not consider switching formulations in patients with persistent symptoms. 39.5% would never use LT4 + liothyronine (LT3) combination therapy in symptomatic euthyroid patients, due to low quality evidence for benefit. 60.5% reported that persistence of symptoms despite normal TSH is rare (below 5% of patients) and its prevalence has been stable over the last five years. Psychosocial factors (84.0%), comorbidities (86.4%) and the patient unrealistic expectation (72.8%) were considered the top three explanations for this phenomenon. CONCLUSION LT4 tablets is the treatment of choice for hypothyroidism. A significant proportion of respondents would use LT4 in some groups of euthyroid individuals, contrasting the recommendations of the major clinical practice guideline indications. LT4 + LT3 combination treatment in euthyroid symptomatic patients was considered by nearly 50%. Practices based on weak or absent evidence included use of thyroid hormones for euthyroid subjects by 56.8% of respondents and use of LT4 + LT3 treatment by 60.5% of respondents for patients with persistent symptoms. In contrast to many European countries, LATS respondents report a low and unchanged proportion of dissatisfied patients over the last five years.
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Affiliation(s)
- Jessica F Cassemiro
- Department of Bioregulation, Health & Science Institute, Federal University of Bahia, Avenida Reitor Miguel Calmon, S/N. Vale do Canela. Room 325, Salvador, Bahia, Brazil
| | - Veronica Ilera
- Department of Endocrinology, Hospital Ramos Mejía, Caba, Argentina
| | | | - Adriana Reyes
- Department of Endocrinology, Hospital Ramos Mejía, Caba, Argentina
| | - Endre V Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Enrico Papini
- Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy
| | - Petros Perros
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Helton Estrela Ramos
- Department of Bioregulation, Health & Science Institute, Federal University of Bahia, Avenida Reitor Miguel Calmon, S/N. Vale do Canela. Room 325, Salvador, Bahia, Brazil.
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14
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Amin MS, Pabani UK, Lohano S, Khan Z. Myxedema Coma Precipitated by Sepsis in a Patient With a Complex Mental Health History. Cureus 2023; 15:e43574. [PMID: 37719600 PMCID: PMC10503452 DOI: 10.7759/cureus.43574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2023] [Indexed: 09/19/2023] Open
Abstract
Myxedema coma is a rare and life-threatening manifestation of severe hypothyroidism. Myxedema refers to altered mental status observed in these patients. Clinical characteristics observed include hypothermia, bradycardia, respiratory failure, hyponatremia, and altered mental status. We present the case of a 57-year-old female who was brought into the hospital with a history of collapse and a long lie. On initial assessment, she was hypothermic, hypotensive, bradycardic, and hypoglycemic with elevated infection markers, acute kidney injury, and electrolyte derangement. Her thyroid function tests on admission were severely impaired with a TSH (thyroid stimulating hormone) level of 144.46 mU/L and Free T4 (thyroxine) levels of 3.4 pmol/L. She was admitted to the intensive care unit and was started on intravenous antibiotics, intravenous liothyronine, oral levothyroxine, and intravenous hydrocortisone. Initially, her hypothermia and bradycardia were slow to respond to treatment measures, but following the introduction of liothyronine, she showed marked improvement. Over the next few days, her infection markers improved, her acute kidney injury resolved, and her thyroid function tests normalized. Liothyronine was stopped after 6 days, levothyroxine was continued at her regular dose of 175 micrograms, and she was safely discharged with outpatient endocrinology follow-up.
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Affiliation(s)
- Mehul S Amin
- Internal Medicine, Southend University Hospital, London, GBR
| | - Umesh Kumar Pabani
- Internal Medicine, Mid and South Essex NHS Foundation Trust, Southend-on-Sea, GBR
| | | | - Zahid Khan
- Acute Medicine, Mid and South Essex NHS Foundation Trust, Southend-on-Sea, GBR
- Cardiology, Bart's Heart Centre UK, London, GBR
- Cardiology and General Medicine, Barking, Havering and Redbridge University Hospitals NHS Trust, London, GBR
- Cardiology, Royal Free Hospital, London, GBR
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Ahluwalia R, Baldeweg SE, Boelaert K, Chatterjee K, Dayan C, Okosieme O, Priestley J, Taylor P, Vaidya B, Zammitt N, Pearce SH. Use of liothyronine (T3) in hypothyroidism: Joint British Thyroid Association/Society for endocrinology consensus statement. Clin Endocrinol (Oxf) 2023; 99:206-216. [PMID: 37272400 DOI: 10.1111/cen.14935] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 05/18/2023] [Accepted: 05/19/2023] [Indexed: 06/06/2023]
Abstract
Persistent symptoms in patients treated for hypothyroidism are common. Despite more than 20 years of debate, the use of liothyronine for this indication remains controversial, as numerous randomised trials have failed to show a benefit of treatment regimens that combine liothyronine (T3) with levothyroxine over levothyroxine monotherapy. This consensus statement attempts to provide practical guidance to clinicians faced with patients who have persistent symptoms during thyroid hormone replacement therapy. It applies to non-pregnant adults and is focussed on care delivered within the UK National Health Service, although it may be relevant in other healthcare environments. The statement emphasises several key clinical practice points for patients dissatisfied with treatment for hypothyroidism. Firstly, it is important to establish a diagnosis of overt hypothyroidism; patients with persistent symptoms during thyroid hormone replacement but with no clear biochemical evidence of overt hypothyroidism should first have a trial without thyroid hormone replacement. In those with established overt hypothyroidism, levothyroxine doses should be optimised aiming for a TSH in the 0.3-2.0 mU/L range for 3 to 6 months before a therapeutic response can be assessed. In some patients, it may be acceptable to have serum TSH below reference range (e.g. 0.1-0.3 mU/L), but not fully suppressed in the long term. We suggest that for some patients with confirmed overt hypothyroidism and persistent symptoms who have had adequate treatment with levothyroxine and in whom other comorbidities have been excluded, a trial of liothyronine/levothyroxine combined therapy may be warranted. The decision to start treatment with liothyronine should be a shared decision between patient and clinician. However, individual clinicians should not feel obliged to start liothyronine or to continue liothyronine medication provided by other health care practitioners or accessed without medical advice, if they judge this not to be in the patient's best interest.
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Affiliation(s)
- Rupa Ahluwalia
- Department of Diabetes & Endocrinology, Norfolk and Norwich University Hospitals NHS Trust, Norwich, UK
| | - Stephanie E Baldeweg
- Department of Diabetes & Endocrinology, University College London, London, UK
- Centre for Obesity & Metabolism, Department of Experimental & Translational Medicine, Division of Medicine, University College London Hospitals, London, UK
- The RCP Joint Specialties Committee and The Clinical Committee, Society for Endocrinology, Bristol, UK
| | - Kristien Boelaert
- Institute for Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Krishna Chatterjee
- Wellcome-MRC Institute of Metabolic Sciences, University of Cambridge, Cambridge, UK
| | - Colin Dayan
- Thyroid Research Group, Heath Park, Cardiff University, Cardiff, UK
| | | | | | - Peter Taylor
- Thyroid Research Group, Heath Park, Cardiff University, Cardiff, UK
| | - Bijay Vaidya
- Department of Endocrinology, Royal Devon University Hospital |University of Exeter Medical School, Exeter, UK
| | - Nicola Zammitt
- Edinburgh Centre for Endocrinology and Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Simon H Pearce
- BioMedicine West, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
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Hennessey JV. Levothyroxine Monotherapy: What Works Better for the Individual With Hypothyroidism? Endocr Pract 2023; 29:572-580. [PMID: 37419564 DOI: 10.1016/j.eprac.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 12/16/2022] [Indexed: 07/09/2023]
Abstract
OBJECTIVE I explore objective data not supporting the addition of liothyronine (medication) (LT3) to levothyroxine (medication) (LT4) in patients with hypothyroidism. Accurate identification of patients with symptomatic (almost exclusively overt) hypothyroidism is important in evaluating clinical outcomes of therapies. Recent studies have documented that nearly a third of individuals who are offered thyroid hormone are euthyroid at the time of initiation. Additionally, others are clinically diagnosed without biochemical confirmation, so a sizable proportion of those started on LT4 are not hypothyroid. The assumption that nonhypothyroid symptoms will resolve with LT4 is problematic. The true underlying cause of these symptoms remains unidentified and untreated. METHODS In a narrative fashion I will review the positive predictive value of and correlation of symptoms consistent with hypothyroidism and confirmed hypothyroidism likely to favorably respond to thyroid hormone replacement. RESULTS Following a review of the reliability of thyroid-stimulating hormone (TSH) in predicting a euthyroid state, the correlation of circulating triiodothyronine (serum measurement) (T3) levels with symptoms and predictive value of T3 to forecast the outcome of adding LT3 to LT4 will be reviewed. The utility of striving for high, middle, or low TSH set points within the expected range to predict changes in clinical quality of life and the ability of blinded patients to sense subtle differences along this spectrum will be documented. In addition, the clinical impact of single nucleotide polymorphisms in the type 2 deiodinase gene will be reviewed. Finally, the overall satisfaction of selected patients with their thyroid hormone treatments will be outlined and preferences for T3-containing treatments from blinded studies will be summarized. CONCLUSION Basing thyroid hormone treatment decisions on patient symptoms likely results in missed diagnoses We should encourage primary care physicians to assess a differential diagnosis, exclude other diagnoses, and not assume a thyroid etiology when TSH is normal. Modifying treatment to a particular TSH target or adjusting based on a low T3 level does not seem to enhance patient outcomes. Finally, pending further trials of "symptomatic" participants, using sustained release LT3 to mimic normal physiology, and including monocarboxylate 10 transporter and Type 2 deiodinase polymorphisms and objective outcomes, I will continue to depend on therapy with LT4 monotherapy and seek alternative explanations for my patients' nonspecific symptoms.
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Affiliation(s)
- James V Hennessey
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.
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Trovato M, Valenti A. Medical Applications of Molecular Biotechnologies in the Context of Hashimoto's Thyroiditis. Diagnostics (Basel) 2023; 13:2114. [PMID: 37371008 DOI: 10.3390/diagnostics13122114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
Hashimoto's thyroiditis (HT) is a gender autoimmune disease that is manifested by chronic inflammation of the thyroid. Clinical trial studies (CTSs) use molecular biotechnologies (MB) to approach HT appearance. The aims of this study were to analyze the applications of MB in CTSs carried out in HT populations (HT-CTSs). Further, to evaluate the role of MB in the context of the hygiene hypothesis (HH). From 75 HT-CTSs found at clinicaltrials.gov web place, forty-five were considered for this investigation. Finally, six HT-CTSs were reported as molecular HT-CTSs (mHT-CTSs) because these were planning to utilize MB. Two of mHT-CTSs were programmed on the French population to isolate DNA viral sequences. Blood, urine, and thyroid tissue biospecimens were analyzed to pick out the parvo and polyoma viruses. Two mHT-CTSs carried out in China aimed to identify oral and fecal microbiotas by measuring PCR sequencing of the 16S rRNA gene. Two mHT-CTSs were programmed in the USA and Greece, respectively, for interception of DNA polymorphisms to associate with genetic susceptibility to HT. In conclusion, MB are mainly employed in HT-CTSs for infective pathogenesis and genetic fingerprinting of HT. Furthermore, MB do not provide evidence of HH; however, they are useful for providing direct evidence of the presence of viruses.
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Affiliation(s)
- Maria Trovato
- Department of Clinical and Experimental Medicine, University Hospital, 98125 Messina, Italy
| | - Andrea Valenti
- Department of Clinical and Experimental Medicine, University Hospital, 98125 Messina, Italy
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Montagna C, Zangelidis A. Labour market implications of thyroid dysfunctions. Econ Hum Biol 2023; 50:101247. [PMID: 37148629 DOI: 10.1016/j.ehb.2023.101247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 03/17/2023] [Accepted: 04/19/2023] [Indexed: 05/08/2023]
Abstract
This paper aims to shed some light on the labour market implications of thyroid disease. Undetected hypothyroidism has adverse effects on wages for female workers,thus widening the existing gender wage gap. However, once female individuals are diagnosed (and therefore assumed to be treated) with hypothyroidism, they experience wage gains and have a higher employment probability. In relation to other labour market outcomes, thyroid disease does not appear to play a significant role on individuals' labour force participation decision and their working hours. Results suggest that productivity gains may drive the improvement in wages.
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Affiliation(s)
- Catia Montagna
- Economics, Centre for Labour Market Research, Business School, University of Aberdeen, Aberdeen, AB24 3QY, Scotland, UK
| | - Alexandros Zangelidis
- Economics, Centre for Labour Market Research, Business School, University of Aberdeen, Aberdeen, AB24 3QY, Scotland, UK.
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Perros P, Van Der Feltz-Cornelis C, Papini E, Nagy EV, Weetman AP, Hegedüs L. The enigma of persistent symptoms in hypothyroid patients treated with levothyroxine: A narrative review. Clin Endocrinol (Oxf) 2023; 98:461-468. [PMID: 33783849 DOI: 10.1111/cen.14473] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 03/24/2021] [Accepted: 03/25/2021] [Indexed: 12/19/2022]
Abstract
A significant minority of patients with hypothyroidism report persistent symptoms despite achieving normal thyroid biochemistry after levothyroxine (L-T4) replacement. Four principal lines of thinking, which are not mutually exclusive, may explain this enigma. The 'low tissue liothyronine hypothesis' emphasizes the potential imperfections of L-T4 replacement therapy that may lead to hypothyroidism in some tissues such as the brain, while others (eg hypothalamus) are euthyroid. The 'Somatic Symptom and Related Disorders hypothesis' draws attention to an incidental coexistence of a diagnosis of Somatic Symptom and Related Disorders in patients with treated hypothyroidism. The 'autoimmune neuroinflammation hypothesis' highlights the potential consequences of inflammatory mediators due to thyroid autoimmunity (the commonest cause of hypothyroidism) on the brain. The 'comorbidities and psychosocial hypothesis' implicates a variety of physical and psychosocial factors that have been noted to be associated with a diagnosis of hypothyroidism, which may be primarily the cause of persistent complaints. Over the past twenty years, a great deal of time and effort has been expended pursuing the 'low tissue liothyronine hypothesis', which has failed to yield results that translate to patient benefits. This has skewed the balance in clinical practice, in favour of pursuing answers relating to L-T4 and liothyronine combination treatment, while the alternative explanations have been downplayed and potentially useful interventions have been given insufficient attention.
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Affiliation(s)
- Petros Perros
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | | | - Enrico Papini
- Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Albano, Rome, Italy
| | - Endre V Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Anthony P Weetman
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
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20
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Abstract
Subclinical hypothyroidism (SCH) is diagnosed when serum thyroid stimulation hormone (thyrotropin; TSH) levels are above the reference range, accompanied by levels of free thyroxine within its reference range. The management of SCH remains a diagnostic and therapeutic challenge despite many years of research relating to its epidemiology, aetiology, effectiveness of treatment and safety. European Thyroid Association (ETA) guidelines for the management of SCH were published almost a decade ago. This narrative review summarizes the clinical literature relating to SCH and outcomes since the publication of these guidelines. Clinical evidence emerging during the previous decade generally supports the view that SCH is associated with adverse outcomes to an extent that is intermediate between euthyroidism and overt hypothyroidism although evidence that treatment with thyroid hormone replacement is beneficial is lacking. Accordingly, the rationale for the recommendations for intervention in the ETA guidelines based on the age of the patient, level of serum TSH, symptoms and comorbidities remains valid today.
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Affiliation(s)
| | - Salman Razvi
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK
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21
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Younes YR, Perros P, Hegedüs L, Papini E, Nagy EV, Attanasio R, Negro R, Field BCT. Use of thyroid hormones in hypothyroid and euthyroid patients: A THESIS questionnaire survey of UK endocrinologists. Clin Endocrinol (Oxf) 2023; 98:238-248. [PMID: 35975405 PMCID: PMC10087612 DOI: 10.1111/cen.14812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/25/2022] [Accepted: 08/02/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Management of hypothyroidism is controversial because of medication cost pressures and scientific uncertainty on how to address treatment dissatisfaction experienced by some patients. The objective was to investigate the experience and preferences of UK endocrinologists in use of thyroid hormones. DESIGN Web-based survey. PATIENTS UK endocrinologists were invited to participate. MEASUREMENTS Responses to questionnaire. RESULTS The response rate was 21% (272/1295). While levothyroxine monotherapy is regarded as the treatment of choice for hypothyroidism, 51% of respondents stated that combined treatment with levothyroxine and liothyronine could be considered for levothyroxine-treated patients whose symptoms persist despite normalisation of serum thyroid stimulating hormone (TSH) concentration. However, only 40% are currently prescribing such treatment, and just 23% would consider taking it themselves. A small minority prescribe desiccated thyroid extract, and those most likely to do so are aged over 60 years. Most respondents stated that they have no influence over brand or formulation of levothyroxine dispensed to their patients and expect no major differences in efficacy between different formulations. A total of 9% would prescribe levothyroxine for euthyroid enlarging goitre, and 29% for euthyroid female infertility with high titre thyroid peroxidase antibodies, despite recent trials finding no benefit. CONCLUSIONS UK endocrine practice in management of hypothyroidism is broadly in line with international guidance. However, a minority of respondents would consider thyroid hormone supplementation in euthyroid individuals for female infertility, enlarging goitre, and other indications in which evidence of efficacy is lacking. Willingness to consider prescribing combined levothyroxine and liothyronine, for hypothyroid symptoms which persist despite normalised TSH, has increased in comparison to previous international surveys, despite inconsistent evidence of benefit.
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Affiliation(s)
- Younes R Younes
- Department of Endocrinology, East Surrey Hospital, Surrey & Sussex Healthcare NHS Trust, Redhill, Surrey, UK
| | - Petros Perros
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Laszlo Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
| | - Enrico Papini
- Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy
| | - Endre V Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Roberto Attanasio
- Scientific Committee, Associazione Medici Endocrinologi, Milan, Italy
| | - Roberto Negro
- Division of Endocrinology, V. Fazzi Hospital, Lecce, Italy
| | - Benjamin C T Field
- Department of Endocrinology, East Surrey Hospital, Surrey & Sussex Healthcare NHS Trust, Redhill, Surrey, UK
- Section of Clinical Medicine, Faculty of Health & Medical Sciences, University of Surrey, Guildford, Surrey, UK
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22
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Kalra S, Dhingra A, Kapoor N, Sahay R. Practical and Pragmatic Usage of T3 in Hypothyroidism. Indian J Endocrinol Metab 2023; 27:25-27. [PMID: 37215274 PMCID: PMC10198187 DOI: 10.4103/ijem.ijem_441_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/26/2023] [Accepted: 01/27/2023] [Indexed: 03/05/2023] Open
Abstract
Hypothyroidism is one of the common endocrine disorders encountered in clinical practice. Though thyroxine (T4) remains the treatment of choice in most clinical situations, with the recent introduction of oral triiodothyronine (T3) in South Asian countries, it is important to know about its utility in clinical practice. In this brief communication, we delineate potential clinical indications for T3 therapy, while highlighting possible concerns and caveats.
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Affiliation(s)
- Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, Haryana, India
- University Center for Research and Development, Chandigarh University, Chandigarh, India
| | - Atul Dhingra
- Department of Endocrinology, Gangaram Bansal Hospital, Sriganganagar, Rajasthan, India
| | - Nitin Kapoor
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamil Nadu, India
- Non Communicable Disease Unit, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Rakesh Sahay
- Department of Endocrinology, Osmania Medical College, Hyderabad, Telangana, India
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23
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Wang X, Li M, Liu X, Liang J, Guo H, Chen G. Diagnosis and Treatment of Nonfunctioning Pituitary Adenomas with Thyroid Disorders. Int J Endocrinol 2023; 2023:2846601. [PMID: 37020857 PMCID: PMC10070024 DOI: 10.1155/2023/2846601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/04/2023] [Accepted: 03/07/2023] [Indexed: 03/29/2023] Open
Abstract
OBJECTIVE Patients with nonfunctioning pituitary adenoma (NFPA) can present with different types of thyroid disorders, which are easily misdiagnosed or missed and can even result in serious clinical consequences. This study was to summarize the different types of thyroid disorders in patients with NFPA with the aim of providing references for the diagnosis and treatment of such patients. MATERIALS AND METHODS The data of pituitary adenoma (PA) patients who underwent surgical treatment at Xuanwu Hospital, Capital Medical University, from 2017 to 2021 were retrospectively analyzed, and NFPA patients with preoperative thyroid disorders were screened out to analyze their imaging, endocrine, treatment, and prognosis data. Also, thyroid disorders were classified to summarize diagnostic methods and treatment principles for different types of thyroid disorders. RESULTS A total of 399 NFPA patients were included in this study, of which 67 (16.8%) had thyroid disorders before surgery. Fifty-four patients had (13.5%) central hypothyroidism (CH) caused by NFPA and were treated with levothyroxine (L-T4) supplementation before and after operation. Eleven patients (2.8%) had primary hypothyroidism and were treated with L-T4 during the perioperative period, and long-term treatment of primary hypothyroidism was provided after surgery. Two NFPA patients (0.5%) were combined with primary hyperthyroidism and treated with medication for primary hyperthyroidism after tumor resection. CONCLUSION Thyroid disorders are relatively common in patients with NFPA, but are difficult to be diagnosed due to their different types. CH is the most common type of thyroid disorder, which requires aggressive L-T4 supplementation during the preoperative period. The primary disease of the thyroid gland is easily missed when NFPA is combined with primary hypothyroidism or primary hyperthyroidism, and the thyroid function test results require to be analyzed carefully for continued treatment for thyroid disease after resection of the NFPA.
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Affiliation(s)
- Xu Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Mingchu Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Xiaohai Liu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Jiantao Liang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Hongchuan Guo
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Ge Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
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24
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Mascarenhas M, Jeve Y, Polanski L, Sharpe A, Yasmin E, Bhandari HM. Management of recurrent implantation failure: British Fertility Society policy and practice guideline. HUM FERTIL 2022; 25:813-837. [PMID: 33820476 DOI: 10.1080/14647273.2021.1905886] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Recurrent implantation failure (RIF) is defined as the absence of a positive pregnancy test after three consecutive transfers of good quality embryos. There remains significant variation in clinical practice in the management of RIF. This British Fertility Society (BFS) Policy and Practice guideline analyses the evidence for investigations and therapies that are employed in RIF and provides recommendations for clinical practice and for further research. Evidence for investigations of sperm and egg quality, uterine and adnexal factors, immunological factors and thrombophilia, endocrine conditions and genetic factors and for associated therapies have been evaluated. This guideline has been devised to assist reproductive medicine specialists and patients in making shared decisions concerning management of RIF. Finally, suggestions for research towards improving understanding and management of RIF have also been provided.
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Affiliation(s)
- Mariano Mascarenhas
- Leeds Fertility, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Glasgow Centre for Reproductive Medicine, The Fertility Partnership, Glasgow, UK
| | - Yadava Jeve
- Birmingham Women's Fertility Centre, Birmingham Women's Hospital, Birmingham, UK
| | - Lukasz Polanski
- Assisted Conception Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Abigail Sharpe
- Leeds Fertility, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ephia Yasmin
- Department of Women's Health, University College London Hospitals, London, UK
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25
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Gottwald-Hostalek U, Razvi S. Getting the levothyroxine (LT4) dose right for adults with hypothyroidism: opportunities and challenges in the use of modern LT4 preparations. Curr Med Res Opin 2022; 38:1865-1870. [PMID: 35484983 DOI: 10.1080/03007995.2022.2071059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Lifelong treatment with levothyroxine (LT4) is the mainstay of management for individuals with hypothyroidism. Many hypothyroid patients start LT4 treatment at a low dose (e.g. 25-50 µg), especially the elderly, those with residual thyroid function, those with low body weight, and those with significant (especially cardiac) comorbidities. Almost half of patients on LT4 replacement therapy demonstrate either under- or over-treatment. Many LT4 preparations have relatively large intervals between tablet strengths at the lower end of their dose ranges (providing 25 µg, 50 µg, and 75 µg tablets), which may represent a barrier to achieving the optimum maintenance treatment for some patients. The availability of intermediate tablet strengths of LT4 in the 25-75 µg range may facilitate precise and effective dose titration of LT4 and may also enable convenient maintenance regimens based on a single LT4 tablet daily, to support adherence to therapy.
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Affiliation(s)
| | - Salman Razvi
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK
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26
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Mansfield BS, Bhana S, Raal FJ. Dyslipidemia in South African patients with hypothyroidism. J Clin Transl Endocrinol 2022; 29:100302. [PMID: 35898802 PMCID: PMC9309410 DOI: 10.1016/j.jcte.2022.100302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/21/2022] [Accepted: 07/05/2022] [Indexed: 11/28/2022] Open
Affiliation(s)
- Brett S. Mansfield
- Division of Endocrinology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Corresponding author at: Division of Endocrinology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa.
| | - Sindeep Bhana
- Division of Endocrinology, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Frederick J. Raal
- Division of Endocrinology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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27
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Abstract
Abuse of androgens and erythropoietin has led to hormones being the most effective and frequent class of ergogenic substances prohibited in elite sports by the World Anti-Doping Agency (WADA). At present, thyroid hormone (TH) abuse is not prohibited, but its prevalence among elite athletes and nonprohibited status remains controversial. A corollary of prohibiting hormones for elite sports is that endocrinologists must be aware of a professional athlete's risk of disqualification for using prohibited hormones and/or to certify Therapeutic Use Exemptions, which allow individual athletes to use prohibited substances for valid medical indications. This narrative review considers the status of TH within the framework of the WADA Code criteria for prohibiting substances, which requires meeting 2 of 3 equally important criteria of potential performance enhancement, harmfulness to health, and violation of the spirit of sport. In considering the valid clinical uses of TH, the prevalence of TH use among young adults, the reason why some athletes seek to use TH, and the pathophysiology of sought-after and adverse effects of TH abuse, together with the challenges of detecting TH abuse, it can be concluded that, on the basis of present data, prohibition of TH in elite sport is neither justified nor feasible.
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Affiliation(s)
- Matti L Gild
- Faculty of Medicine and Health, University of Sydney, Sydney 2006, Australia
- Department of Diabetes and Endocrinology, Royal North Shore Hospital, Sydney 2065, Australia
- Cancer Genetics, Kolling Institute of Medical Research, St Leonards 2065, Australia
| | - Mark Stuart
- Division of Medicine, Centre for Metabolism and Inflammation, University College London, WC1E 6BT, UK
- International Testing Agency Lausanne, Lausanne 1007, Switzerland
| | - Roderick J Clifton-Bligh
- Faculty of Medicine and Health, University of Sydney, Sydney 2006, Australia
- Department of Diabetes and Endocrinology, Royal North Shore Hospital, Sydney 2065, Australia
- Cancer Genetics, Kolling Institute of Medical Research, St Leonards 2065, Australia
| | | | - David J Handelsman
- Correspondence: Professor David Handelsman, ANZAC Research Institute, Department of Andrology, Concord Hospital, Sydney, New South Wales, Australia.
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28
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Abstract
CONTEXT Many patients with hypothyroidism receive suboptimal treatment that may affect hospital outcomes. OBJECTIVE This work aimed to identify differences in hospital outcomes between patients with and without hypothyroidism. METHODS A retrospective cohort study, using the propensity score-based fine stratification method to balance covariates, was conducted using a large, US-based, commercial claims database from January 1, 2008 to December 31, 2015. Participants included patients aged 64 years and younger who had a thyrotropin (TSH) level collected before a hospital admission. Covariates included age, sex, US region, type of admission, year of admission, and comorbidities. Exposure included clinical hypothyroidism, which was divided into 4 subgroups based on prehospitalization TSH level: low (TSH < 0.40 mIU/L), normal (TSH 0.40-4.50 mIU/L), intermediate (TSH 4.51-10.00 mIU/L), and high (TSH > 10.00 mIU/L). MAIN OUTCOME MEASURES INCLUDED length of stay (LOS), in-hospital mortality, and readmission outcomes. RESULTS A total of 43 478 patients were included in the final study population, of whom 8873 had a diagnosis of hypothyroidism. Those with a high prehospitalization TSH level had an LOS that was 1.2 days longer (95% CI, 1.1-1.3; P = .003), a 49% higher risk of 30-day readmission (relative risk [RR] 1.49; 95% CI, 1.20-1.85; P < .001), and a 43% higher rate of 90-day readmission (RR 1.43; 95% CI, 1.21-1.67; P < .001) compared to balanced controls. Patients with normal TSH levels exhibited decreased risk of in-hospital mortality (RR 0.46; 95% CI, 0.27-0.79; P = .004) and 90-day readmission (RR 0.92; 95% CI, 0.85-0.99; P = .02). CONCLUSION The results suggest suboptimal treatment of hypothyroidism is associated with worse hospital outcomes, including longer LOS and higher rate of readmission.
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Affiliation(s)
- Matthew D Ettleson
- Correspondence: Matthew D. Ettleson, MD, Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, University of Chicago, 5841 S Maryland Ave, MC1027, Chicago, IL 60637, USA.
| | - Antonio C Bianco
- Section of Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, Illinois 60637, USA
| | - Wen Wan
- Section of General Internal Medicine, University of Chicago, Chicago, Illinois 60637, USA
| | - Neda Laiteerapong
- Section of General Internal Medicine, University of Chicago, Chicago, Illinois 60637, USA
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29
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Abstract
Diverse causes potentially underlie decreased quality of life in biochemically euthyroid patients treated for hypothyroidism with levothyroxine. Once these contributing factors are addressed, if symptoms persist, there may be benefit to personalized use of combination therapy adding liothyronine. This approach should be carefully monitored: avoiding overtreatment and ensuring that therapy is only continued if it improves patient-reported quality of life. Most randomized clinical trials have not shown benefits, perhaps because of not targeting the most symptomatic patients. Sustained-release liothyronine preparations may soon be available for optimally designed studies assessing whether combination therapy provides superior therapy for hypothyroidism in select patients.
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Affiliation(s)
- Jacqueline Jonklaas
- Division of Endocrinology, Georgetown University, Washington, DC 20007, USA.
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30
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Abstract
Hypothyroidism is the common clinical condition of thyroid hormone deficiency and, if left untreated, can lead to serious adverse health effects on multiple organ systems, with the cardiovascular system as the most robustly studied target. Overt primary hypothyroidism is defined as elevated thyroid-stimulating hormone (TSH) concentration in combination with free thyroxine (fT4) concentration below the reference range. Subclinical hypothyroidism, commonly considered an early sign of thyroid failure, is defined by elevated TSH concentrations but fT4 concentrations within the reference range. Hypothyroidism is classified as primary, central or peripheral based on pathology in the thyroid, the pituitary or hypothalamus, or peripheral tissue, respectively. Acquired primary hypothyroidism is the most prevalent form and can be caused by severe iodine deficiency but is more frequently caused by chronic autoimmune thyroiditis in iodine-replete areas. The onset of hypothyroidism is insidious in most cases and symptoms may present relatively late in the disease process. There is a large variation in clinical presentation and the presence of hypothyroid symptoms, especially in pregnancy and in children. Levothyroxine (LT4) is the mainstay of treatment and is one of the most commonly prescribed drugs worldwide. After normalization of TSH and fT4 concentrations, a considerable proportion of patients treated with LT4 continue to have persistent complaints, compromising quality of life. Further research is needed regarding the appropriateness of currently applied reference ranges and treatment thresholds, particularly in pregnancy, and the potential benefit of LT4/liothyronine combination therapy for thyroid-related symptom relief, patient satisfaction and long-term adverse effects.
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31
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Salvatore D, Porcelli T, Ettleson MD, Bianco AC. The relevance of T 3 in the management of hypothyroidism. Lancet Diabetes Endocrinol 2022; 10:366-372. [PMID: 35240052 PMCID: PMC9987447 DOI: 10.1016/s2213-8587(22)00004-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/24/2021] [Accepted: 12/17/2021] [Indexed: 12/23/2022]
Abstract
Levothyroxine monotherapy has been the standard of care for treatment of hypothyroidism for more than 40 years. However, patients treated with levothyroxine have relatively lower serum tri-iodothyronine (T3) concentrations than the general population, and symptoms of hypothyroidism persist for some patients despite normalisation of thyroid-stimulating hormone (TSH) concentrations. The understanding that maintenance of normal T3 concentrations is the priority for the thyroid axis has redirected the clinical focus to serum T3 concentrations in patients with hypothyroidism. This Personal View explores whether it is currently feasible to identify patients who could be considered for liothyronine supplementation in combination with levothyroxine. Genetic profiling stands out as a potential future tool to identify patients who do not respond well to levothyroxine due to suboptimal peripheral thyroxine (T4) activation. Moreover, new slow-release liothyronine preparations are being developed to be trialled in these symptomatic patients, in an attempt to restore T3 concentrations and provide conclusive results for the use of T4 plus T3 combination therapy.
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Affiliation(s)
- Domenico Salvatore
- Department of Public Health, University of Naples Federico II, Naples, Italy.
| | - Tommaso Porcelli
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Matthew D Ettleson
- Section of Adult and Pediatric Endocrinology and Metabolism, University of Chicago, Chicago, Illinois, IL, USA
| | - Antonio C Bianco
- Section of Adult and Pediatric Endocrinology and Metabolism, University of Chicago, Chicago, Illinois, IL, USA
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32
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Abstract
In the 1970s, treatment with thyroid extract was superseded by levothyroxine, a synthetic L form of tetraiodothyronine. Since then, no major innovation has emerged for the treatment of hypothyroidism. The biochemical definition of subclinical hypothyroidism is a matter of debate. Indiscriminate screening for hypothyroidism has led to overdiagnosis and treatment initiation at lower serum levels of thyroid-stimulating hormone (TSH) than previously. Adverse health effects have been documented in individuals with hypothyroidism or hyperthyroidism, and these adverse effects can affect health-related quality of life (QOL). Levothyroxine substitution improves, but does not always normalize, QOL, especially for individuals with mild hypothyroidism. However, neither studies combining levothyroxine and liothyronine (the synthetic form of tri-iodothyronine) nor the use of desiccated thyroid extract have shown robust improvements in patient satisfaction. Future studies should focus not only on a better understanding of an individual's TSH set point (the innate narrow physiological range of serum concentration of TSH in an individual, before the onset of hypothyroidism) and alternative thyroid hormone combinations and formulations, but also on autoimmunity and comorbidities unrelated to hypothyroidism as drivers of patient dissatisfaction. Attention to the long-term health consequences of hypothyroidism, beyond QOL, and the risks of overtreatment is imperative.
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Affiliation(s)
- Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, Odense, Denmark.
| | - Antonio C Bianco
- Section of Adult and Paediatric Endocrinology, Diabetes & Metabolism, Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Simon H Pearce
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Anthony P Weetman
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Petros Perros
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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33
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Abstract
Nonalcoholic fatty liver disease (NAFLD) can develop in lean individuals. Despite a better metabolic profile, the risk of disease progression to hepatic inflammation, fibrosis, and decompensated cirrhosis in the lean is similar to that in obesity-related NAFLD and lean individuals may experience more severe hepatic consequences and higher mortality relative to those with a higher body mass index (BMI). In the absence of early symptoms and abnormal laboratory findings, lean individuals are not likely to be screened for NAFLD or related comorbidities; however, given the progressive nature of the disease and the increased risk of morbidity and mortality, a clearer understanding of the natural history of NAFLD in lean individuals, as well as efforts to raise awareness of the potential health risks of NAFLD in lean individuals, are warranted. In this review, we summarize available data on NAFLD prevalence, clinical characteristics, outcomes, and mortality in lean individuals and discuss factors that may contribute to the development of NAFLD in this population, including links between dietary and genetic factors, menopausal status, and ethnicity. We also highlight the need for greater representation of lean individuals in NAFLD-related clinical trials, as well as more studies to better characterize lean NAFLD, develop improved screening algorithms, and determine specific treatment strategies based on underlying etiology.
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Affiliation(s)
- Johanna K. DiStefano
- Diabetes and Fibrotic Disease Research Unit, Translational Genomics Research Institute, Phoenix, USA
| | - Glenn S. Gerhard
- Lewis Katz School of Medicine, Temple University School of Medicine, Philadelphia, PA 19140 USA
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Abstract
Hypothyroidism is a common endocrinopathy, and levothyroxine is frequently prescribed. Despite the basic tenets of initiating and adjusting levothyroxine being agreed on, there are many nuances and complexities to consistently maintaining euthyroidism. Understanding the impact of patient weight and residual thyroid function on initial levothyroxine dosage and consideration of age, comorbidities, thyrotropin goal, life stage, and quality of life as levothyroxine is adjusted can be challenging and continually evolving. Because levothyroxine is a lifelong medication, it is important to avoid risks from periods of overtreatment or undertreatment. For the subset of patients not restored to baseline health with levothyroxine, causes arising from all aspects of the patient's life (coexistent medical conditions, stressors, lifestyle, psychosocial factors) should be broadly considered. If such factors do not appear to be contributing, and biochemical euthyroidism has been successfully maintained, there may be benefit to a trial of combination therapy with levothyroxine and liothyronine. This is not supported by the majority of randomized clinical trials, but may be supported by other studies providing lower-quality evidence and by animal studies. Given this discrepancy, it is important that any trial of combination therapy be continued only as long as a patient benefit is being enjoyed. Monitoring for adverse effects, particularly in older or frail individuals, is necessary and combination therapy should not be used during pregnancy. A sustained-release liothyronine preparation has completed phase 1 testing and may soon be available for better designed and powered studies assessing whether combination therapy provides superior therapy for hypothyroidism.
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Hegazy W, Abdel-Moneim A, Abdel-Rehiem ES, Salah M, Abdul-Hamid M. The protective effect of hesperidin on the liver of hypothyroid rats mediated by nuclear factor erythroid 2-related factor 2-dependent activation of heme oxygenase 1. J Mol Histol 2022; 53:543-560. [DOI: 10.1007/s10735-022-10066-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/08/2022] [Indexed: 10/19/2022]
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Moncayo R, Moncayo H. Practical Guidelines for Diagnosing and Treating Thyroid Disease Based on the WOMED Metabolic Model of Disease Focusing on Glycolysis and Coenzyme Q10 Deficiency—A Clinical Alternative to the 2021 Retired Clinical Practice Guidelines of the Endocrine Society. Diagnostics (Basel) 2022; 12:diagnostics12010107. [PMID: 35054274 PMCID: PMC8774471 DOI: 10.3390/diagnostics12010107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 12/30/2021] [Accepted: 01/03/2022] [Indexed: 11/16/2022] Open
Abstract
This review aims to provide a functional, metabolic view of the pathogenesis of benign thyroid disease. Here, we summarize the features of our previous publications on the “WOMED model of benign thyroid disease”. As of 2021, the current state of art indicates that the basic alteration in benign thyroid disease is a metabolic switch to glycolysis, which can be recognized using 3D-power Doppler ultrasound. A specific perfusion pattern showing enlarged vessels can be found using this technology. This switch originates from an altered function of Complex I due to acquired coenzyme Q10 deficiency, which leads to a glycolytic state of metabolism together with increased angiogenesis. Implementing a combined supplementation strategy that includes magnesium, selenium, and CoQ10, the morphological and perfusion changes of the thyroid can be reverted, i.e., the metabolic state returns to oxidative phosphorylation. Normalization of iron levels when ferritin is lower than 50 ng/mL is also imperative. We propose that a modern investigation of probable thyroid disease requires the use of 3D-power Doppler sonography to recognize the true metabolic situation of the gland. Blood levels of magnesium, selenium, CoQ10, and ferritin should be monitored. Thyroid function tests are complementary so that hypo- or hyperthyroidism can be recognized. Single TSH determinations do not reflect the glycolytic state.
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Ettleson MD, Papaleontiou M. Evaluating health outcomes in the treatment of hypothyroidism. Front Endocrinol (Lausanne) 2022; 13:1026262. [PMID: 36329885 PMCID: PMC9623066 DOI: 10.3389/fendo.2022.1026262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/04/2022] [Indexed: 11/13/2022] Open
Abstract
Clinical hypothyroidism is defined by the inadequate production of thyroid hormone from the thyroid gland to maintain normal organ system functions. For nearly all patients with clinical hypothyroidism, lifelong treatment with thyroid hormone replacement is required. The primary goal of treatment is to provide the appropriate daily dose of thyroid hormone to restore normal thyroid function for each individual patient. In current clinical practice, normalization of thyrotropin (TSH) level is the primary measure of effectiveness of treatment, however the use of a single biomarker to define adequate thyroid hormone replacement is being reevaluated. The assessment of clinical health outcomes and patient-reported outcomes (PROs), often within the context of intensity of treatment as defined by thyroid function tests (i.e., undertreatment, appropriate treatment, or overtreatment), may play a role in evaluating the effectiveness of treatment. The purpose of this narrative review is to summarize the prominent health outcomes literature in patients with treated hypothyroidism. To date, overall mortality, cardiovascular morbidity and mortality, bone health and cognitive function have been evaluated as endpoints in clinical outcomes studies in patients with treated hypothyroidism. More recent investigations have sought to establish the relationships between these end results and thyroid function during the treatment course. In addition to clinical event outcomes, patient-reported quality of life (QoL) has also been considered in the assessment of adequacy of hypothyroidism treatment. From a health care quality perspective, treatment of hypothyroidism should be evaluated not just on its effectiveness for the individual patients but also to the extent to which patients of different sociodemographic groups are treated equally. Ultimately, more research is needed to explore differences in health outcomes between different sociodemographic groups with hypothyroidism. Future prospective studies of treated hypothyroidism that integrate biochemical testing, PROs, and end result clinical outcomes could provide a more complete picture into the effectiveness of treatment of hypothyroidism.
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Affiliation(s)
- Matthew D. Ettleson
- Section of Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, IL, United States
- *Correspondence: Matthew D. Ettleson,
| | - Maria Papaleontiou
- Division of Metabolism, Endocrinology and Diabetes and Institute of Gerontology, University of Michigan, Ann Arbor, MI, United States
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Kahaly GJ, Gottwald-Hostalek U. Use of levothyroxine in the management of hypothyroidism: A historical perspective. Front Endocrinol (Lausanne) 2022; 13:1054983. [PMID: 36407302 PMCID: PMC9666762 DOI: 10.3389/fendo.2022.1054983] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 10/10/2022] [Indexed: 11/07/2022] Open
Abstract
The thyroid operates within a complex system of homeostatic regulation, where the level of thyrotropin (TSH) influences the rate of secretion of the principal thyroid hormones, thyroxine (T4) and triiodothyronine (T3). The devastating consequences of untreated thyroid dysfunction have been evident for centuries. Indeed, sources from antiquity described goitre and cretinism, two of the clinical sequelae of untreated overt thyroid disease. It was not until the first part of the 19th century that goitre and cretinism were first associated with iodine status; however, the endocrine function of the thyroid was not clearly identified until the early part of the 20th century. Three principal innovations in the 20th century supported the use of levothyroxine (LT4) replacement therapy for the management of hypothyroidism: a practical technique for the synthesis of LT4 suitable to support pharmaceutical use (late 1940s), the discovery that LT4 is converted to the active thyroid hormone, T3, in the peripheral tissues (1970), and the development of robust and sensitive assay methodology for measuring thyroid hormones in the blood (1960 onwards). Synthetic LT4, titrated to bring the level of TSH within a predefined "normal" reference range, is now established as the mainstay of treatment for hypothyroidism, and provides adequate restoration of thyroid hormone function for most people with this condition. Future research will explore further the nuances of the hypothalamic-pituitary-thyroid axis, and the place, if any, for T3 within the management of thyroid dysfunction.
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Affiliation(s)
- George J. Kahaly
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
- *Correspondence: George J. Kahaly,
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Zhao C, Wang Y, Xiao L, Li L. Effect of Levothyroxine on Older Patients With Subclinical Hypothyroidism: A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne) 2022; 13:913749. [PMID: 35909574 PMCID: PMC9329610 DOI: 10.3389/fendo.2022.913749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/23/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Subclinical hypothyroidism (SCH) is usually treated with levothyroxine, but there is controversy as to whether SCH should be treated, especially for older patients. The aim of the systematic review and meta-analysis was to evaluate whether levothyroxine has a beneficial or harmful effect on older patients with SCH. METHODS Databases including PubMed, Embase, Cochrane Library, Web of Science, Wanfang, Weipu and China National Knowledge Infrastructure were searched from inception until December 21, 2021. Subjects must be diagnosed with SCH, and older than or equal to 60 years of age. Interventions should be thyroid hormone therapy (e.g. levothyroxine). The literature was independently screened by 2 researchers. Statistical analysis was performed using RevMan5.3 software. RESULTS A total of 13 articles were included. Meta-analysis results showed that in older SCH patients, levothyroxine can significantly reduce cholesterol (TC) (p < 0.00001), triglyceride (TG) (p < 0.00001), low-density lipoprotein cholesterol (LDL-C) (p = 0.03) and apolipoprotein B (ApoB) (p < 0.00001). In addition, levothyroxine had no significant effect on bone mineral density, fatigue, hypothyroidism symptoms, quality of life, BMI, cognitive function, depression, blood pressure, etc. in older SCH patients, and also did not significantly increase the incidence of adverse events. CONCLUSIONS Among older SCH patients, levothyroxine treatment may reduce TC, TG, LDL-C, and ApoB.
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Janett-Pellegri C, Wildisen L, Feller M, Del Giovane C, Moutzouri E, Grolimund O, Walter P, Waeber G, Marques-Vidal P, Vollenweider P, Rodondi N. Prevalence and factors associated with chronic use of levothyroxine: A cohort study. PLoS One 2021; 16:e0261160. [PMID: 34928965 PMCID: PMC8687586 DOI: 10.1371/journal.pone.0261160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 11/25/2021] [Indexed: 11/19/2022] Open
Abstract
Importance Levothyroxine prescriptions are rising worldwide. However, there are few data on factors associated with chronic use. Objective To assess the prevalence of chronic levothyroxine use, its rank among other chronic drugs and factors associated with chronic use. To assess the proportion of users outside the therapeutic range of thyroid-stimulating hormone (TSH). Design Cohort study (CoLaus|PsyCoLaus) with recruitment from 2003 to 2006. Follow-ups occurred 5 and 10 years after baseline. Participants A random sample of Lausanne (Switzerland) inhabitants aged 35–75 years. Main outcomes We evaluated the prevalence of chronic levothyroxine use and we then ranked it among the other most used chronic drugs. The ranking was compared to data from health insurance across the country. We assessed the association between each factor and chronic levothyroxine use in multivariable logistic regression models. The proportion of chronic levothyroxine users outside the usual TSH therapeutic range was assessed. Results 4,334 participants were included in the analysis (mean±SD age 62.8±10.4 years, 54.9% women). 166 (3.8%) participants were chronic levothyroxine users. Levothyroxine was the second most prescribed chronic drug after aspirin in the cohort (8.2%) and the third most prescribed when using Swiss-wide insurance data. In multivariable analysis, chronic levothyroxine use was associated with increasing age [odds ratio 1.03, 95% confidence interval 1.01–1.05 per 1-year increase]; female sex [11.87 (5.24–26.89)]; BMI [1.06 (1.02–1.09) per 1-kg/m2 increase]; number of concomitant drugs [1.22 (1.16–1.29) per 1-drug increase]; and family history of thyroid pathologies [2.18 (1.37–3.48)]. Among chronic levothyroxine users with thyroid hormones assessment (n = 157), 42 (27%) were outside the TSH therapeutic range (17% overtreated and 10% undertreated). Conclusions In this population-based study, levothyroxine ranked second among chronic drugs. Age, female sex, BMI, number of drugs and family history of thyroid pathologies were associated with chronic levothyroxine use. More than one in four chronic users were over- or undertreated.
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Affiliation(s)
- Camilla Janett-Pellegri
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Lea Wildisen
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Martin Feller
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Elisavet Moutzouri
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | | | | | - Gérard Waeber
- Department of Medicine, Internal Medicine, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Pedro Marques-Vidal
- Department of Medicine, Internal Medicine, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Peter Vollenweider
- Department of Medicine, Internal Medicine, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- * E-mail:
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Abstract
OBJECTIVE Medicines with limited evidence of effectiveness are prime candidates for disinvestment. However, investment in further research may be preferable to deimplementation, given that the absence of evidence is not evidence of absence, and research can inform formulary decisions. A case in point is liothyronine, which is sometimes prescribed to levothyroxine-treated patients who continue to experience hypothyroid symptoms. It is a putative low value medicine, associated with uncertainties in both clinical and cost-effectiveness. The aim was to assess the cost-effectiveness of liothyronine in this context, and estimate the value of conducting further research. DESIGN Cost utility and value of information analyses. SETTING Primary care within the National Health Service in the UK. PARTICIPANTS Fifty-four levothyroxine-treated patients with persistent symptoms of hypothyroidism. INTERVENTIONS Liothyronine plus levothyroxine versus levothyroxine alone. PRIMARY AND SECONDARY OUTCOME MEASURES Incremental cost per quality-adjusted life year (QALY) gained, and the expected monetary value of sample information. RESULTS 20/54 (37%) of patients who responded to the survey reported severe problems in carrying out usual activities of everyday living and 12/54 (22%) reported severe anxiety or depression symptoms. Mean (SD) utility was 0.53 (0.23). The differences in expected total, 10-year costs and QALYs between a treatment strategy of liothyronine/levothyroxine combination therapy, and levothyroxine alone, was £12 053 and 1.014, respectively. The incremental cost-effectiveness ratio of £11 881 per QALY gained was sensitive to the price of liothyronine. The probability of liothyronine/levothyroxine combination therapy being cost effective at a threshold of £20 000 per QALY was 0.56. The value of reducing uncertainty in the efficacy of treatment was £3.64 m per year in the UK. CONCLUSIONS A definitive clinical trial to confirm clinical effectiveness may be preferable to immediate disinvestment, and would be justified given the value of the information gained far exceeds the cost.
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Affiliation(s)
- Dyfrig A Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, Gwynedd, UK
| | | | | | - Pippa Anderson
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, Gwynedd, UK
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | - Adrian Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
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Gottwald-Hostalek U, Kahaly GJ. Triiodothyronine alongside levothyroxine in the management of hypothyroidism? Curr Med Res Opin 2021; 37:2099-2106. [PMID: 34553643 DOI: 10.1080/03007995.2021.1984219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The current guideline-based management of hypothyroidism recommends monotherapy with levothyroxine (LT4), titrated to maintain the level of thyrotropin within a euthyroid reference range. This has been successful for most people with hypothyroidism, but a substantial minority still report symptoms of hypothyroidism unexplained by a comorbid medical condition. LT4 is essentially a prodrug for triiodothyronine (T3), the thyroid hormone that acts on target tissues in the brain and the periphery. Thyroid hormone replacement with LT4 alone does not restore physiological tissue levels of thyroid hormones, particularly T3. During the last two decades, much interest has focussed on the potential of combinations of LT4 and T3 to provide a superior outcome to LT4 monotherapy for people with hypothyroidism, especially those with residual symptoms despite thyrotropin-optimized LT4. This review seeks to provide an overview of currently available evidence on combination (LT4 + T3) therapy to be used for personalized medicine in patients with hypothyroidism. A number of randomized, controlled trials (RCTs) have failed to demonstrate superiority for the combination therapy approach, largely due to non-physiological T3 doses. However, patients with hypothyroidism are highly heterogeneous in terms of their residual thyroid function, individual set points for optimal thyroid homeostasis and for the presence or absence of polymorphisms in deiodinase enzymes in tissues that activate and deactivate circulating thyroid hormones. Accordingly, these RCTs may have failed to demonstrate benefits of combination therapy in individual hypothyroid phenotypes. The pharmacokinetics of LT4 and T3 also differ, which is a barrier to their co-administration. Future clinical trials using LT4 + T3 tablets better suited for combination therapy will resolve the outstanding research questions relating to the place of LT4 + T3 combination therapy in the management of hypothyroidism.
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Affiliation(s)
| | - George J Kahaly
- Department of Medicine I, Johannes Gutenberg-University Medical Centre, Mainz, Germany
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Zhang Y, He DH, Jiang SN, Wang HL, Xu XH, Kong LR. Biological variation of thyroid function biomarkers over 24 hours. Clin Chim Acta 2021; 523:519-524. [PMID: 34762936 DOI: 10.1016/j.cca.2021.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 10/29/2021] [Accepted: 11/05/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Thyroid-stimulating hormone (TSH), triiodothyronine (T3), thyroxine (T4), free T3 (FT3), and free T4 (FT4) are used to diagnose thyroid diseases and monitor treatment effects. Reliable biological variation (BV) data is required to ensure accurate clinical decisions. METHODS Blood samples were collected from 31 healthy subjects at 00:00, 04:00, 08:00, 12:00, 16:00, and 20:00; each sample was analyzed twice for TSH, T3, T4, FT3, and FT4. After outlier exclusion, normality assessment, and variance homogeneity, sex-stratified BV, including within-subject (CVI) and between-subject (CVG), was defined using nested ANOVA. RESULTS Concentrations of five biomarkers were significantly different between sexes. The CVI and CVG estimates were 34.54% and 34.43% for TSH, 5.89% and 14.18% for T3, 4.48% and 14.96% for T4, 5.37% and 11.23% for FT3, and 3.57% and 8.03% for FT4, respectively. The individual indexes (IIs) of all the biomarkers (except TSH) were ≤ 0.63. Males had lower CVIs and IIs than females. CONCLUSION CVI estimates of all hormones, except TSH, were lower than those reported on the BV website, showing low IIs and differences between sexes. We provide updated data on the short-term BV of thyroid function biomarkers according to sex and complement BV data of thyroid function biomarkers.
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Affiliation(s)
- Yan Zhang
- Department of Clinical Laboratory, Traditional Chinese Medicine Hospital of Pidu District, Chengdu, China
| | - Da-Hai He
- Department of Clinical Laboratory, Traditional Chinese Medicine Hospital of Pidu District, Chengdu, China
| | - Shun-Ning Jiang
- Department of Clinical Laboratory, Traditional Chinese Medicine Hospital of Pidu District, Chengdu, China
| | - Hua-Li Wang
- Department of Clinical Laboratory, Traditional Chinese Medicine Hospital of Pidu District, Chengdu, China
| | - Xiao-Hua Xu
- Department of Clinical Laboratory, Traditional Chinese Medicine Hospital of Pidu District, Chengdu, China
| | - Li-Rui Kong
- Department of Clinical Laboratory, Traditional Chinese Medicine Hospital of Pidu District, Chengdu, China.
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Gluvic Z, Obradovic M, Stewart AJ, Essack M, Pitt SJ, Samardzic V, Soskic S, Gojobori T, Isenovic ER. Levothyroxine Treatment and the Risk of Cardiac Arrhythmias - Focus on the Patient Submitted to Thyroid Surgery. Front Endocrinol (Lausanne) 2021; 12:758043. [PMID: 34803920 PMCID: PMC8600254 DOI: 10.3389/fendo.2021.758043] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 10/11/2021] [Indexed: 02/05/2023] Open
Abstract
Levothyroxine (LT4) is used to treat frequently encountered endocrinopathies such as thyroid diseases. It is regularly used in clinical (overt) hypothyroidism cases and subclinical (latent) hypothyroidism cases in the last decade. Suppressive LT4 therapy is also part of the medical regimen used to manage thyroid malignancies after a thyroidectomy. LT4 treatment possesses dual effects: substituting new-onset thyroid hormone deficiency and suppressing the local and distant malignancy spreading in cancer. It is the practice to administer LT4 in less-than-high suppressive doses for growth control of thyroid nodules and goiter, even in patients with preserved thyroid function. Despite its approved safety for clinical use, LT4 can sometimes induce side-effects, more often recorded with patients under treatment with LT4 suppressive doses than in unintentionally LT4-overdosed patients. Cardiac arrhythmias and the deterioration of osteoporosis are the most frequently documented side-effects of LT4 therapy. It also lowers the threshold for the onset or aggravation of cardiac arrhythmias for patients with pre-existing heart diseases. To improve the quality of life in LT4-substituted patients, clinicians often prescribe higher doses of LT4 to reach low normal TSH levels to achieve cellular euthyroidism. In such circumstances, the risk of cardiac arrhythmias, particularly atrial fibrillation, increases, and the combined use of LT4 and triiodothyronine further complicates such risk. This review summarizes the relevant available data related to LT4 suppressive treatment and the associated risk of cardiac arrhythmia.
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Affiliation(s)
- Zoran Gluvic
- Clinic for Internal Medicine, Department of Endocrinology and Diabetes, Zemun Clinical Hospital, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Milan Obradovic
- Department of Radiobiology and Molecular Genetics, VINČA Institute of Nuclear Sciences - National Institute of the Republic of Serbia, University of Belgrade, Belgrade, Serbia
| | - Alan J. Stewart
- School of Medicine, University of St Andrews, St Andrews, United Kingdom
| | - Magbubah Essack
- King Abdullah University of Science and Technology (KAUST), Computer, Electrical, and Mathematical Sciences and Engineering (CEMSE) Division, Computational Bioscience Research Center (CBRC), Thuwal, Saudi Arabia
| | - Samantha J. Pitt
- School of Medicine, University of St Andrews, St Andrews, United Kingdom
| | - Vladimir Samardzic
- Clinic for Internal Medicine, Department of Endocrinology and Diabetes, Zemun Clinical Hospital, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Sanja Soskic
- Department of Radiobiology and Molecular Genetics, VINČA Institute of Nuclear Sciences - National Institute of the Republic of Serbia, University of Belgrade, Belgrade, Serbia
| | - Takashi Gojobori
- King Abdullah University of Science and Technology (KAUST), Computer, Electrical, and Mathematical Sciences and Engineering (CEMSE) Division, Computational Bioscience Research Center (CBRC), Thuwal, Saudi Arabia
| | - Esma R. Isenovic
- Department of Radiobiology and Molecular Genetics, VINČA Institute of Nuclear Sciences - National Institute of the Republic of Serbia, University of Belgrade, Belgrade, Serbia
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Leese G, Soto-Pedre E. Time to refresh thinking on the terminology and management of hypothyroidism? Clin Endocrinol (Oxf) 2021; 95:574-575. [PMID: 33990990 DOI: 10.1111/cen.14485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 04/12/2021] [Accepted: 04/14/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Graham Leese
- University of Dundee - Endocrinology, Dundee, UK
| | - Enrique Soto-Pedre
- University of Dundee - Division of Molecular and Clinical Medicine, Dundee, UK
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Stedman M, Taylor P, Premawardhana L, Okosieme O, Dayan C, Heald AH. Liothyronine and levothyroxine prescribing in England: A comprehensive survey and evaluation. Int J Clin Pract 2021; 75:e14228. [PMID: 33864324 PMCID: PMC9285455 DOI: 10.1111/ijcp.14228] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/28/2021] [Accepted: 04/12/2021] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION The approach to thyroid hormone replacement varies across centres, but the extent and determinants of variation is unclear. We evaluated geographical variation in levothyroxine (LT4) and liothyronine (LT3) prescribing across General Practices in England and analysed the relationship of prescribing patterns to clinical and socioeconomic factors. METHODS Data was downloaded from the NHS monthly General Practice Prescribing Data in England for the period 2011-2020. RESULTS The study covered a population of 19.4 million women over 30 years of age, attending 6,660 GP practices and being provided with 33.7 million prescriptions of LT4 and LT3 at a total cost of £90million/year. Overall, 0.5% of levothyroxine treated patients continue to receive liothyronine. All Clinical Commission Groups (CCGs) in England continue to have at least one liothyronine prescribing practice and 48.5% of English general practices prescribed liothyronine in 2019-2020. Factors strongly influencing more levothyroxine prescribing (model accounted for 62% of variance) were the CCG to which the practice belonged and the proportion of people with diabetes registered on the practice list plus antidepressant prescribing, with socioeconomic disadvantage associated with less levothyroxine prescribing. Whereas factors that were associated with increased levels of liothyronine prescribing (model accounted for 17% of variance), were antidepressant prescribing and % of type 2 diabetes mellitus individuals achieving HbA1c control of 58 mmol/mol or less. Factors that were associated with reduced levels of liothyronine prescribing included smoking and higher obesity rates. CONCLUSION In spite of strenuous attempts to limit prescribing of liothyronine in general practice a significant number of patients continue to receive this therapy, although there is significant geographical variation in the prescribing of this as for levothyroxine, with specific general practice and CCG-related factors influencing prescribing of both levothyroxine and liothyronine across England.
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Affiliation(s)
| | - Peter Taylor
- Thyroid Research GroupSystems Immunity Research InstituteCardiff University School of MedicineCardiffUK
| | - Lakdasa Premawardhana
- Thyroid Research GroupSystems Immunity Research InstituteCardiff University School of MedicineCardiffUK
| | - Onyebuchi Okosieme
- Thyroid Research GroupSystems Immunity Research InstituteCardiff University School of MedicineCardiffUK
| | - Colin Dayan
- Thyroid Research GroupSystems Immunity Research InstituteCardiff University School of MedicineCardiffUK
| | - Adrian H. Heald
- The School of MedicineManchester Academic Health Sciences CentreUniversity of ManchesterManchesterUK
- Department of Endocrinology and DiabetesSalford Royal HospitalSalfordUK
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Kalaria T, Sanders A, Fenn J, Ashby HL, Mohammed P, Buch HN, Ford C, Gama R. The diagnosis and management of subclinical hypothyroidism is assay-dependent- Implications for clinical practice. Clin Endocrinol (Oxf) 2021; 94:1012-1016. [PMID: 33475154 DOI: 10.1111/cen.14423] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/29/2020] [Accepted: 01/03/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE We assessed the commutativity of Roche and Abbott thyroid assays in the diagnosis and management of subclinical hypothyroidism (SCH). The Roche and Abbott thyroid assays are used by approximately 75% of clinical laboratories in the UK. METHOD Consecutive samples received from primary care on patients with SCH who had a raised thyroid-stimulating hormone (TSH) <10 mIU/L and a normal free thyroxine (fT4) from two laboratories using either Roche or Abbott thyroid assays were identified over 10 working days. Following identification, samples were analysed at the other site within 24 hours. Diagnostic and management discordance were studied using the relevant manufacturer-provided reference ranges. RESULTS We identified 93 patients with SCH (53 using the Roche assay). Roche TSH and fT4 results were respectively 40% ± 15% and 16% ± 7% higher (P < .001) compared to Abbott results. Of the 93 patients, 41 (44%) were concordant for SCH on both methods. Of the 53 patients with SCH on the Roche assays, 40 (75.5%) had normal thyroid function and 13 (24.5%) had SCH when analysed using the Abbott assays. Of the 40 patients with SCH on the Abbott assays, 28 (70%) had SCH and 12 (30%) had results indicative for levothyroxine replacement when analysed on the Roche assays. Of these 12 patients, four had TSH > 10 mIU/L, five had low fT4 and three had both. CONCLUSION The diagnosis and management of SCH is strikingly different when using TSH and fT4 assays provided by Abbott Laboratories and Roche Diagnostics. Clinicians and laboratorians should be aware that between-assay differences and variations in reference ranges will directly impact the diagnosis and management of subclinical hypothyroidism.
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Affiliation(s)
- Tejas Kalaria
- Black Country Pathology Services, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Anna Sanders
- Black Country Pathology Services, The Dudley Group NHS Foundation Trust, Dudley, UK
| | - Jonathan Fenn
- Black Country Pathology Services, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Helen L Ashby
- Black Country Pathology Services, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
- Black Country Pathology Services, The Dudley Group NHS Foundation Trust, Dudley, UK
| | - Pervaz Mohammed
- Black Country Pathology Services, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
- Black Country Pathology Services, The Dudley Group NHS Foundation Trust, Dudley, UK
| | - Harit N Buch
- Endocrinology and Diabetes, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Clare Ford
- Black Country Pathology Services, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Rousseau Gama
- Black Country Pathology Services, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
- School of Medicine and Clinical Practice, University of Wolverhampton, Wolverhampton, UK
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Stedman M, Taylor P, Premawardhana L, Okosieme O, Dayan C, Heald AH. Trends in costs and prescribing for liothyronine and levothyroxine in England and wales 2011-2020. Clin Endocrinol (Oxf) 2021; 94:980-989. [PMID: 33411974 DOI: 10.1111/cen.14414] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 12/14/2020] [Accepted: 12/21/2020] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Recent prescribing policies in England and Wales have imposed significant restrictions on liothyronine prescribing in general practice driven by the prohibitive costs and uncertain benefits of liothyronine in the management of hypothyroidism. However, the impact of these policies on liothyronine usage and costs is still unclear. METHODS Data were downloaded from the NHS monthly General Practice Prescribing Data in England and from the Comparative Analysis System for Prescribing Audit (CASPA) in Wales for 2011-2020. Trends over the period in amount and costs of levothyroxine and liothyronine prescribing were analysed. RESULTS The total medication costs per year for England Wales for hypothyroidism rose from £60.8 million to £129.8 million in 2015-16 and have since reduced to £88.4 million. Levothyroxine prescriptions have been growing above the population growth rate at 0.7%/annum in England and 1.1% in Wales. The costs/patient/year for liothyronine rose from £550 to £3000 in 2015-16 and has since fallen to £2500. Use of liothyronine as a percentage of levothyroxine started to fall in 2015-16 at 7%/annum in England and 3% in Wales. Nevertheless, 0.5% of levothyroxine-treated patients continue to receive liothyronine. All Clinical Commission Groups (CCGs) in England continue to have at least one liothyronine prescribing practice and 48.5% of English general practices prescribed liothyronine in 2019-20. CONCLUSION In spite of strenuous attempts to limit prescribing of liothyronine in general practice, a significant number of patients continue to receive this therapy. The price differential of liothyronine vs levothyroxine should be examined again in light of the continuing use of liothyronine.
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Affiliation(s)
| | - Peter Taylor
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Lakdasa Premawardhana
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Onyebuchi Okosieme
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Colin Dayan
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Adrian H Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
- Department of Endocrinology and Diabetes, Salford Royal Hospital, Salford, UK
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Guzman-Prado Y, Vita R, Samson O. Concomitant Use of Levothyroxine and Proton Pump Inhibitors in Patients with Primary Hypothyroidism: a Systematic Review. J Gen Intern Med 2021; 36:1726-1733. [PMID: 33469743 PMCID: PMC8175524 DOI: 10.1007/s11606-020-06403-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 12/03/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The aim of this study was to assess the effect of concomitant use of levothyroxine (LT4) and proton pump inhibitors (PPIs) on thyroid-stimulating hormone (TSH) levels in patients with primary hypothyroidism. METHODS A systematic review of interventional and observational studies that compared the TSH levels before and after concomitant use of LT4 and PPI was performed. Articles published in English up to September 1, 2019, were included. PubMed, EMBASE, and Cochrane Library databases. Gray literature was also searched in repositories, websites OpenGrey and Google Scholar, and abstracts of major international congresses. Study quality was assessed with the Newcastle-Ottawa quality assessment scale for observational studies and the Risk Of Bias In Non-randomized Studies - of Interventions (ROBINS-I) tool was used. RESULTS Five thousand twelve discrete articles were identified. Following assessment and application of eligibility criteria, seven studies were included. There was a considerable heterogeneity among the included studies in design, sample size, inclusion and exclusion criteria, treatment regimen, and baseline demographics. Each of the included studies showed an increase in TSH levels following LT4 and PPI consumption, and in the majority of these, the increase was statistically significant. DISCUSSION The concomitant use of LT4 and PPI showed a significant increase in TSH concentration. However, given the small number of studies, further research is needed to clarify the interfering role of PPI on LT4 intestinal absorption. PROSPERO REGISTRATION NUMBER CRD42020047084.
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Affiliation(s)
| | - Roberto Vita
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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Kalaria TR, Sanders A, Ford C, Buch H, Fenn JS, Ashby HL, Mohammed P, Gama RM. Biochemical assessment of adequate levothyroxine replacement in primary hypothyroidism differs with different TSH assays: potential clinical implications. J Clin Pathol 2021; 75:379-382. [PMID: 33990368 DOI: 10.1136/jclinpath-2020-207316] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 02/10/2021] [Accepted: 02/14/2021] [Indexed: 12/11/2022]
Abstract
AIM Thyroid stimulating hormone (TSH) assays provided by Abbott Laboratories and Roche Diagnostics are used by approximately 75% of laboratories in the UK. We assessed the potential impact of Abbott and Roche TSH assay differences on the biochemical assessment of levothyroxine replacement in primary hypothyroidism. METHOD Samples from 100 consecutive primary care patients (83 women, median age 64 years, IQR 51-73 years) with primary hypothyroidism on adequate levothyroxine based on an Abbott Architect TSH in the reference range were analysed for TSH on Roche cobas within 24 hours. The Abbott and Roche TSH results were compared. Over 1 year, TSH results from patients in primary care from the laboratories with Abbott and Roche methods were compared. RESULTS The median (IQR) Roche TSH (2.5 (1.3-3.6) mIU/L) was 30%±10% higher (p<0.001) than Abbott TSH (1.9 (1.1-2.6) mIU/L). Although all Abbott TSH results were in the Abbott specific reference range, 14 patients (14%) had Roche TSH results above the Roche specific reference range. In the 1 year gather, Roche TSH (1.9 (1.3-2.9) mIU/L, n=103 932) results were higher (p<0.001) than Abbott TSH (1.5 (1.0-2.2) mIU/L, n=1 10 544) results. The TSH results were above their assay-specific upper reference limit in 10.7% of Roche results and 4.2% of Abbott results. CONCLUSION Biochemical assessment of levothyroxine replacement may be dependent on the type of TSH assay. Laboratorians and clinicians should be aware that the lack of harmonisation between TSH methods and their assay-specific reference ranges may potentially lead to different patient management decisions. We suggest lot verification in laboratories should include processes to identify cumulative drift in assay performance.
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Affiliation(s)
- Tejas R Kalaria
- Clinical Biochemistry, Black Country Pathology Services, New Cross Hospital, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Anna Sanders
- Clinical Biochemistry, Black Country Pathology Services, Russells Hall Hospital, Royal Wolverhampton Hospitals NHS Trust, Dudley, UK
| | - Clare Ford
- Clinical Biochemistry, Black Country Pathology Services, New Cross Hospital, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Harit Buch
- Endocrinology and Diabetes, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Jonathan Samuel Fenn
- Clinical Biochemistry, Black Country Pathology Services, New Cross Hospital, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Helen L Ashby
- Clinical Biochemistry, Black Country Pathology Services, Russells Hall Hospital, Royal Wolverhampton Hospitals NHS Trust, Dudley, UK
| | - Pervaz Mohammed
- Clinical Biochemistry, Black Country Pathology Services, Russells Hall Hospital, Royal Wolverhampton Hospitals NHS Trust, Dudley, UK
| | - Rousseau Mariano Gama
- Clinical Biochemistry, Black Country Pathology Services, New Cross Hospital, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK.,School of Medicine and Clinical Practice, University of Wolverhampton, Wolverhampton, UK
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