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De Mingo Dominguez ML, Guadalix Iglesias S, Martin-Arriscado Arroba C, López Alvarez B, Martínez Diaz-Guerra G, Martinez-Pueyo JI, Ferrero Herrero E, Hawkins Carranza F. Low trabecular bone score in postmenopausal women with differentiated thyroid carcinoma after long-term TSH suppressive therapy. Endocrine 2018; 62:166-173. [PMID: 30014437 DOI: 10.1007/s12020-018-1671-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 07/01/2018] [Indexed: 12/31/2022]
Abstract
UNLABELLED The effect of thyroid suppression therapy (TST) on trabecular bone scores (TBS) and bone mineral density (BMD) in thyroidectomized women with differentiated thyroid carcinoma (DTC) on long-term follow-up is presently not conclusive. PATIENTS AND METHODS We carried out a study in 61 premenopausal and 84 postmenopausal Caucasian women with DTC. Serum biochemistry, bone markers, TBS, BMD, and bone fractures were evaluated 1-3 months post surgery and after a median follow-up of 10 years. RESULTS In the final study, patients belonged to Group I Premenopausal (n = 14) who remained in this status; Group II Premenopausal who became postmenopausal (n = 47); Group III patients who were and continued as postmenopausal (n = 84). Baseline premenopausal patients had a normal TBS mean value of 1.39 ± 0.14 significantly higher than that found in postmenopausal 1.31 ± 0.12 (p = 001). In the final study, premenopausal patients continued to have a normal TBS of 1.46 ± 0.08 compared to the significantly lower value of postmenopausal patients 1.25 ± 0.11 (p = 0.0009). Lumbar BMD (L-BMD) loss after the long-term study was significant in Group II (0.99 g/cm2 ± 0.13 vs. 0.91 ± 0.12 g/cm2, p < 0.0001) and there was a slight, but not significant, bone loss in Group I (1.00 ± 0.12 vs. 0.98 ± 0.11, p = 0.1936) and in Group III (0.86 ± 0.12 vs. 0.84 ± 0.15, p = 0.1924) compared with baseline values. CONCLUSION Longer-term suppression therapy in female patients with DTC did not increase significantly the risk of bone loss, although we found in postmenopausal patients deterioration of bone microarchitecture. TBS study should be considered in the evaluation of postmenopausal DTC patients on long-term DTC for the evaluation of the risk of fractures.
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Affiliation(s)
| | - Sonsoles Guadalix Iglesias
- Service of Endocrinology, University Hospital 12 de Octubre, Faculty of Medicine, University Complutense, Madrid, Spain
| | | | | | | | | | - Eduardo Ferrero Herrero
- Endocrine Surgical Unit, University Hospital 12 de Octubre, Complutense University, Madrid, Spain
| | - Federico Hawkins Carranza
- Service of Endocrinology, University Hospital 12 de Octubre, Faculty of Medicine, University Complutense, Madrid, Spain.
- Research Institute i+12, University Hospital 12 de Octubre, Madrid, Spain.
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Haymart MR, Esfandiari NH, Stang MT, Sosa JA. Controversies in the Management of Low-Risk Differentiated Thyroid Cancer. Endocr Rev 2017; 38. [PMID: 28633444 PMCID: PMC5546880 DOI: 10.1210/er.2017-00067] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Controversy exists over optimal management of low-risk differentiated thyroid cancer. This controversy occurs in all aspects of management, including surgery, use of radioactive iodine for remnant ablation, thyroid hormone supplementation, and long-term surveillance. Limited and conflicting data, treatment paradigm shifts, and differences in physician perceptions contribute to the controversy. This lack of physician consensus results in wide variation in patient care, with some patients at risk for over- or undertreatment. To reduce patient harm and unnecessary worry, there is a need to design and implement studies to address current knowledge gaps.
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Affiliation(s)
- Megan R Haymart
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109
| | - Nazanene H Esfandiari
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109
| | - Michael T Stang
- Division of Endocrine Surgery, Department of Surgery, Duke University, Durham, North Carolina 27710
| | - Julia Ann Sosa
- Division of Endocrine Surgery, Department of Surgery, Duke University, Durham, North Carolina 27710
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Papaleontiou M, Hawley ST, Haymart MR. Effect of Thyrotropin Suppression Therapy on Bone in Thyroid Cancer Patients. Oncologist 2016; 21:165-71. [PMID: 26659220 PMCID: PMC4746080 DOI: 10.1634/theoncologist.2015-0179] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 09/28/2015] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The thyroid cancer incidence is rising. Despite current guidelines, controversy exists regarding the degree and duration of thyrotropin suppression therapy. Also, its potential skeletal effects remain a concern to physicians caring for thyroid cancer patients. We conducted a review of published data to evaluate existing studies focusing on the skeletal effects of thyrotropin suppression therapy in thyroid cancer patients. MATERIALS AND METHODS A systematic search of the PubMed, Ovid/Medline, and Cochrane Central Register of Controlled Trials databases was conducted. The retained studies were evaluated for methodological quality, and the study populations were categorized into premenopausal women, postmenopausal women, and men. RESULTS Twenty-five pertinent studies were included. Seven studies were longitudinal and 18 were cross-sectional. Of the 25 included studies, 13 were assigned an excellent methodological quality score. Three of 5 longitudinal studies and 3 of 13 cross-sectional studies reported decreased bone mineral density (BMD) in premenopausal women; 2 of 4 longitudinal studies and 5 of 13 cross-sectional studies reported decreased BMD in postmenopausal women. The remaining studies showed no effect on BMD. The only longitudinal study of men showed bone mass loss; however, cross-sectional studies of men did not demonstrate a similar effect. CONCLUSION Studies to date have yielded conflicting results on the skeletal effects of thyrotropin suppression therapy and a knowledge gap remains, especially for older adults and men. Existing data should be cautiously interpreted because of the variable quality and heterogeneity. Identifying groups at risk of adverse effects from thyrotropin suppression therapy will be instrumental to providing focused and tailored thyroid cancer treatment. IMPLICATIONS FOR PRACTICE The standard treatment for thyroid cancer includes total thyroidectomy with or without radioactive iodine ablation, often followed by thyrotropin suppression therapy. Despite current guidelines, controversy exists regarding the degree and duration of thyrotropin suppression therapy, and discordant results have been reported on its adverse effects on bone. The present review provides physicians with existing data on the skeletal effects of thyrotropin suppression therapy, highlighting the need for further research to identify the groups at risk of adverse skeletal effects. This knowledge will aid in developing tailored thyroid cancer treatment.
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Affiliation(s)
- Maria Papaleontiou
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Sarah T Hawley
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Megan R Haymart
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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4
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Lee MY, Park JH, Bae KS, Jee YG, Ko AN, Han YJ, Shin JY, Lim JS, Chung CH, Kang SJ. Bone mineral density and bone turnover markers in patients on long-term suppressive levothyroxine therapy for differentiated thyroid cancer. Ann Surg Treat Res 2014; 86:55-60. [PMID: 24761409 PMCID: PMC3994597 DOI: 10.4174/astr.2014.86.2.55] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 09/25/2013] [Accepted: 10/02/2013] [Indexed: 12/21/2022] Open
Abstract
Purpose Current management for patients with differentiated thyroid cancer includes near total thyroidectomy and radioactive iodine therapy followed by administration of supraphysiological doses of levothyroxine (L-T4). Although hyperthyroidism is a well known risk factor for osteoporosis, the effects of L-T4 treatment on bone mineral density (BMD) in patients with thyroid cancer do not appear to be as significant as with endogenous hyperthyroidism. In this study, we evaluated the impact of long-term suppressive therapy with L-T4 on BMD and bone turn over markers in Korean female patients receiving L-T4 suppressive therapy. Methods We enrolled 94 female subjects (mean age, 50.84 ± 11.43 years) receiving L-T4 after total or near total thyroidectomy and radioactive iodine therapy for thyroid cancer (mean follow-up period, 12.17 ± 4.27 years). The subjects were divided into three groups by thyroid stimulating hormone (TSH) level (group 1 with TSH level ≤0.001 µIU/mL, group 2 with TSH level between 0.001 and 0.17 µIU/mL, group 3 with TSH level >0.17 µIU/mL) and four groups by quartile of free T4 level. L-T4 dosage, BMD (examined by dual-energy x-ray absorptiometry), and bone turnover markers were evaluated according to TSH and free T4 levels. Results No significant decrease was detected in BMD or bone turnover markers according to TSH level or free T4 level. Also, the prevalence of osteoporosis and osteopenia was not different among groups. Conclusion Long-term L-T4 suppressive therapy after thyroid cancer management did not affect bone density or increase the prevalence of osteoporosis even though TSH levels were supraphysiologically suppressed.
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Affiliation(s)
- Mi Young Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jae Hyun Park
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Keum Seok Bae
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yong Gwan Jee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - An Na Ko
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yong Jea Han
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jang Yel Shin
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jung Soo Lim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Choon Hee Chung
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea. ; Institute of Life-Long Health, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seong Joon Kang
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
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[Potential risks of the adverse effects of thyrotropin suppression in differentiated thyroid carcinoma]. ACTA ACUST UNITED AC 2011; 58:75-83. [PMID: 21247815 DOI: 10.1016/j.endonu.2010.09.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Revised: 09/14/2010] [Accepted: 09/21/2010] [Indexed: 11/23/2022]
Abstract
In patients with differentiated thyroid carcinoma, long-term inhibition of thyrotropin (TSH) secretion through levothyroxine administration is required when there is evidence of persistent or recurrent disease. In these cases, levothyroxine doses should be monitored to achieve the objectives of inhibiting TSH and avoiding clinical hyperthyroidism. The possibility that suppressive therapy may produce deleterious effects is still controversial, mainly in elderly patients. There are many studies on the potential harmful effects of suppressive therapy on various organs and systems with discrepant results. However, there is no scientific evidence that the clinical impact of these effects is significant.
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Abstract
Subclinical thyroid disease (SCTD) is defined as serum free T(4) and free T(3) levels within their respective reference ranges in the presence of abnormal serum TSH levels. SCTD is being diagnosed more frequently in clinical practice in young and middle-aged people as well as in the elderly. However, the clinical significance of subclinical thyroid dysfunction is much debated. Subclinical hyper- and hypothyroidism can have repercussions on the cardiovascular system and bone, as well as on other organs and systems. However, the treatment and management of SCTD and population screening are controversial despite the potential risk of progression to overt disease, and there is no consensus on the thyroid hormone and thyrotropin cutoff values at which treatment should be contemplated. Opinions differ regarding tissue effects, symptoms, signs, and cardiovascular risk. Here, we critically review the data on the prevalence and progression of SCTD, its tissue effects, and its prognostic implications. We also examine the mechanisms underlying tissue alterations in SCTD and the effects of replacement therapy on progression and tissue parameters. Lastly, we address the issue of the need to treat slight thyroid hormone deficiency or excess in relation to the patient's age.
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Affiliation(s)
- Bernadette Biondi
- Department of Clinical and Molecular Endocrinology and Oncology, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy.
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7
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Abstract
This article provides a summary of the numerous interactions between the thyroid gland and the skeleton, in the normal state, in disorders of thyroid function and as a result of thyroid malignancy. It recaps the current understanding of bone growth and development in the endochondral growth plate and the normal mechanisms of mature bone remodeling. The actions of thyroid hormones on these processes are described, and the clinical impact of thyroid disorders and their treatments on the bone are summarized. Finally, our current understanding of the physiology of bone metastases from thyroid cancer is covered.
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Affiliation(s)
- Jason A Wexler
- Division of Endocrinology, MedStar Diabetes and Research Institute, Washington Hospital Center, 110 Irving Street, NW, Room 2A38A, Washington, DC 20010, USA.
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Cáncer de tiroides, levotiroxina y masa ósea. La evidencia, la experiencia y tres preguntas. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/s1575-0922(07)71441-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Mazokopakis EE, Starakis IK, Papadomanolaki MG, Batistakis AG, Papadakis JA. Changes of bone mineral density in pre-menopausal women with differentiated thyroid cancer receiving L-thyroxine suppressive therapy. Curr Med Res Opin 2006; 22:1369-73. [PMID: 16834835 DOI: 10.1185/030079906x115612] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE We studied the effect of levothyroxine (L-T(4)) suppressive therapy on bone mineral density (BMD) in pre-menopausal women with total thyroidectomy and radioactive iodine ((131)I) ablation therapy post-operatively for differentiated thyroid cancer (DTC). PATIENTS AND METHODS We prospectively studied 26 athyroid pre-menopausal women (median age 39 years, range 28-48 years) receiving suppressive L-T(4) therapy postoperatively for 48 months. BMD was measured by dual energy X-ray absorptiometry (DEXA) at the femoral neck, femoral trochanter and Ward's triangle, before (basal) and during (12th and 48th month) the follow-up period. None of the women gave a medical history that could possibly affect bone metabolism. Patients were free of thyroid cancer in clinical and laboratory examinations at the time of the study. Paired t-test was used for comparisons among BMD measurements during the suppressive therapy. RESULTS There were statistically significant decreases of BMD at all measured regions during (12th and 48th month) L-T(4) suppressive therapy. The overall decreases in BMD at the femoral neck, femoral trochanter and Ward's triangle were 7.5%, 10.9% and 3.4%, respectively, at the end of the follow-up period. The coefficient of variation (CV) of all BMD measurements was around 10%, showing a rather homogenous group of patients. Our patients had a statistically significant decrease in their body mass index (BMI) and weight at the end of the follow-up period. However, there was no significant correlation between the decrease in BMI and BMD. Patients did not experience significant adverse effects from L-T(4) suppressive therapy during the study. CONCLUSION L-T(4) suppressive therapy for at least 1 year in pre-menopausal women with DTC causes a reduction in BMD of the femoral neck, femoral trochanter and Ward's triangle.
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Affiliation(s)
- Elias E Mazokopakis
- Department of Internal Medicine, University Hospital of Heraklion, Crete, Greece.
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10
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Heijckmann AC, Huijberts MSP, Geusens P, de Vries J, Menheere PPCA, Wolffenbuttel BHR. Hip bone mineral density, bone turnover and risk of fracture in patients on long-term suppressive L-thyroxine therapy for differentiated thyroid carcinoma. Eur J Endocrinol 2005; 153:23-9. [PMID: 15994742 DOI: 10.1530/eje.1.01933] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Untreated hyperthyroidism and treatment with high doses of thyroid hormone are associated with osteoporosis. However, their effect on bone turnover, their contribution to bone mineral density (BMD) in the context of other clinical risk factors for osteoporosis and the prevalence of vertebral fractures is not well documented. DESIGN Cross-sectional study. METHODS We studied 59 patients receiving L-thyroxine suppressive therapy for differentiated thyroid carcinoma (DTC). BMD of the hip was measured by dual X-ray absorptiometry (DXA) and lateral DXA pictures of the lumbar and thoracic vertebrae were performed. Bone resorption was measured by C-telopeptides of type I collagen (ICTP) and bone formation by procollagen type I N-propeptide (PINP). Clinical risk factors for osteoporosis were evaluated using a questionnaire. RESULTS Z-scores of BMD were similar as the NHANES (National Health and Nutrition Examination Survey) III reference group in women and men, also after long-term (> 10 years) suppression therapy. Patients in the lowest and highest quartile of BMD showed significant differences in the presence of clinical risk factors. ICTP levels were significantly higher than in age-matched controls, PINP levels were not different. We found four patients with a prevalent vertebral fracture. CONCLUSIONS We conclude that patients with well-differentiated thyroid carcinoma are not at increased risk of developing low bone mass nor have a higher prevalence of vertebral fracture at least when treated with relatively low doses of L-thyroxine.
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Affiliation(s)
- A Caroline Heijckmann
- Department of Internal Medicine, Division of Endocrinology, University Hospital Maastricht, Maastricht, The Netherlands.
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Abstract
During the past several years, studies have suggested that exogenous thyroid hormone may adversely affect bone. In order to address this contention and to put the issue in perspective for clinicians who treat patients with thyroid hormone replacement, the available literature was reviewed, and the various study populations were characterized. Age, gender, and menopausal status of the patient are important factors, as are the indication for thyroid hormone replacement and the extent, duration, and severity of prior hyperthyroidism. Reliable measures of bone mineral density, particularly dual-energy x-ray, absorptiometry have become available, providing a more accurate reflection of this parameter in patients receiving thyroxine therapy in comparison with control subjects. The bulk of evidence indicates that long-term thyroxine therapy is safe if the dose is carefully monitored. Treatment with thyroxine does not produce clinically significant bone disease.
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Biondi B, Palmieri EA, Klain M, Schlumberger M, Filetti S, Lombardi G. Subclinical hyperthyroidism: clinical features and treatment options. Eur J Endocrinol 2005; 152:1-9. [PMID: 15762182 DOI: 10.1530/eje.1.01809] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Subclinical hyperthyroidism appears to be a common disorder. It may be caused by exogenous or endogenous factors: excessive TSH suppressive therapy with L-thyroxine (L-T4) for benign thyroid nodular disease, differentiated thyroid cancer, or hormone over-replacement in patients with hypothyroidism are the most frequent causes. Consistent evidence indicates that 'subclinical' hyperthyroidism reduces the quality of life, affecting both the psycho and somatic components of well-being, and produces relevant signs and symptoms of excessive thyroid hormone action, often mimicking adrenergic overactivity. Subclinical hyperthyroidism exerts many significant effects on the cardiovascular system; it is usually associated with a higher heart rate and a higher risk of supraventricular arrhythmias, and with an increased left ventricular mass, often accompanied by an impaired diastolic function and sometimes by a reduced systolic performance on effort and decreased exercise tolerance. It is well known that these abnormalities usually precede the onset of a more severe cardiovascular disease, thus potentially contributing to the increased cardiovascular morbidity and mortality observed in these patients. In addition, it is becoming increasingly apparent that subclinical hyperthyroidism may accelerate the development of osteoporosis and hence increased bone vulnerability to trauma, particularly in postmenopausal women with a pre-existing predisposition. Subclinical hyperthyroidism and its related clinical manifestations are reversible and may be prevented by timely treatment.
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Affiliation(s)
- Bernadette Biondi
- Department of Clinical and Molecular Endocrinology and Oncology, University of Naples Federico II, 80131 Naples, Italy.
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Affiliation(s)
- Elaine Murphy
- Molecular Endocrinology Group, 5th Floor MRC Clinical Sciences Centre, Faculty of Medicine, Imperial College London, London, UK
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Affiliation(s)
- Mark Vanderpump
- Department of Endocrinology, Royal Free Hospital NHS Trust, Pond Street, London NW3 2QG, UK.
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Abstract
PURPOSE The purpose of this study was to investigate the success outcomes of implants and prosthodontic treatment placed in patients with a previous history of hypothyroidism that was being controlled with medications. MATERIALS AND METHODS Twenty-seven female patients with a medically confirmed history of primary hypothyroid disease who were on replacement medications at the time of implant surgery were selected as the study group. They were matched with 29 control patients by age, gender, location (jaw and zone) of implants, type of prosthesis, and dental status of the opposing arch. Additional factors studied were medical history, medications, smoking habits, and bone quality and quantity. RESULTS There was no statistical difference in the number of implant failures between the two groups (p = .781). The hypothyroid patients had more soft tissue complications (p = .018) following stage 1 surgery. More bone loss around implants in the hypothyroid patients was recorded after year 1 of loading when compared with loss in their matched controls (p = .017). CONCLUSIONS This study suggests that medically controlled hypothyroid female patients treated with dental implants are not at higher risk of implant failure when compared with matched controls, and that a history of controlled hypothyroidism does not appear to be a contraindication for implant therapy with endosseous implants.
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Van Den Eeden SK, Barzilay JI, Ettinger B, Minkoff J. Thyroid hormone use and the risk of hip fracture in women > or = 65 years: a case-control study. J Womens Health (Larchmt) 2003; 12:27-31. [PMID: 12639366 DOI: 10.1089/154099903321154112] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There is controversy about whether thyroid hormone therapy may lead to osteoporosis, and less is known about the clinically more important end point of whether its use increases fracture risk. METHODS We used a case-control study to examine the association between thyroid hormone use and hip fractures among older women in a large managed care organization in Northern California. The subjects were 501 women > or =65 years of age who were hospitalized for hip fractures and 533 age-matched controls without hip fractures. RESULTS No difference in the ever use or duration of use of exogenous thyroid hormone was found between cases and controls (odds ratio [OR] 1.1, 95% confidence interval [CI] 0.8,1.6). Hip fracture was associated with evidence of visual impairment, prior use of steroids, and number of falls. CONCLUSIONS In women > or =65 years, an independent effect of thyroid hormone use on the risk of hip fracture was not found. This finding is reassuring, given the large number of women on thyroid hormone therapy today.
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Affiliation(s)
- Stephen K Van Den Eeden
- Division of Research, Kaiser Permanente, Northern California, Oakland, California 94612, USA.
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Vestergaard P, Mosekilde L. Fractures in patients with hyperthyroidism and hypothyroidism: a nationwide follow-up study in 16,249 patients. Thyroid 2002; 12:411-9. [PMID: 12097203 DOI: 10.1089/105072502760043503] [Citation(s) in RCA: 160] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AIM To study fracture risk in patients with hyperthyroidism and hypothyroidism. SUBJECTS AND METHODS All patients with hyperthyroidism or autoimmune hypothyroidism diagnosed for the first time between 1983 and 1996 in Denmark were identified through the National Patient Discharge Register. Each patient was compared with three age- and gender-matched controls randomly selected from the general population. Fracture occurrence before and after diagnosis was compared between patients and controls. RESULTS 11,776 patients with hyperthyroidism (6301 patients with diffuse toxic goiter, mean age, 52.1 +/- 18.6 years, and 5475 with nodular toxic goiter, mean age, 60.4 +/- 15.9 years), and 4473 patients with hypothyroidism (mean age, 66.1 +/- 17.3) were identified. In patients with hyperthyroidism, fracture risk was only significantly increased around the time of diagnosis (incidence rate ratio [IRR] between 1.26 and 2.29), but decreased to normal levels after diagnosis. Surgical treatment of hyperthyroidism was associated with a decreased fracture risk after diagnosis (RR = 0.66, 95% confidence interval [CI]: 0.55-0.78). In hypothyroidism, fracture risk was significantly increased both before and after diagnosis with a peak around the time of diagnosis (IRR between 2.17 and 2.35). CONCLUSIONS Fracture risk is increased in hyperthyroidism and hypothyroidism. Thyroid surgery seems associated with a decreased fracture risk in hyperthyroid patients.
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Affiliation(s)
- Peter Vestergaard
- Department of Endocrinology and Metabolism C, Aahus Amtssygehus, Aarhus University Hospital, Denmark.
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Quan ML, Pasieka JL, Rorstad O. Bone mineral density in well-differentiated thyroid cancer patients treated with suppressive thyroxine: a systematic overview of the literature. J Surg Oncol 2002; 79:62-9; discussion 69-70. [PMID: 11754378 DOI: 10.1002/jso.10043] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The effects of subclinical hyperthyroidism on bone mineral density (BMD) induced by suppressive thyroxine therapy in patients with well-differentiated thyroid cancer (WDTC) remains unclear. An overview of the current literature was undertaken to evaluate studies to date. METHODS A systematic medline search yielded a total of 11 studies appropriate for review which included premenopausal women, postmenopausal women, and men on suppressive thyroxine post thyroidectomy for WDTC. Main outcome measures were bone mineral density and bone turnover markers. CONCLUSIONS Although studies were limited by small numbers and varying degrees of control for confounding variables, results suggested no significant change in bone mineral density for premenopausal women or men. Findings for postmenopausal women remain unclear with two of the best controlled studies reporting opposing results. Further studies for this population are recommended to help guide clinical practice.
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Affiliation(s)
- May Lynn Quan
- Department of Surgery, Division of General Surgery, University of Calgary, Calgary, Alberta, Canada
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Vestergaard P, Weeke J, Hoeck HC, Nielsen HK, Rungby J, Rejnmark L, Laurberg P, Mosekilde L. Fractures in patients with primary idiopathic hypothyroidism. Thyroid 2000; 10:335-40. [PMID: 10807062 DOI: 10.1089/thy.2000.10.335] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
AIM To study fracture risk and risk factors for fractures in patients with primary idiopathic hypothyroidism (ICD 10: E03.9). DESIGN Historical follow-up. MATERIAL AND METHODS A self-administered questionnaire was issued to 628 patients with primary idiopathic levothyroxine-substituted hypothyroidism. A total of 412 (65.6%) responded and of these, 408 could be analyzed. The 408 respondents were age- (+/- 5 years) and gender-matched with 408 normal controls randomly selected from the background population who responded to the same questionnaire. RESULTS Overall fracture risk was increased in patients compared to controls (relative risk: RR = 1.6, 95% CI: 1.0-2.5). However, the increase was temporary and limited to the period within the first 2 years after the diagnosis of hypothyroidism (RR = 3.1, 95% CI: 1.4-7.0). Before the diagnosis and more than 2 years after the diagnosis, the fracture risk in patients did not deviate from that of the controls. The increase in fracture risk was only significant in the age group above 50 years (RR = 1.8, 95% CI: 1-3.2), and was limited to the forearms (RR = 3.0, 95% CI: 1.4-6.3 for the entire patient population). CONCLUSIONS There was a temporary increase in fracture risk within the first 2 years after diagnosis of primary idiopathic hypothyroidism. The fracture risk was mainly increased in the age group above 50 years, and the increased risk was limited to the forearms.
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Affiliation(s)
- P Vestergaard
- The Osteoporosis Clinic, Aarhus Amtssygehus, Aarhus University Hospital, Denmark.
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20
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Abstract
Many therapeutic regimens in cancer treatment carry the risk of causing or favoring the development of osteoporosis. Therapies in which hypogonadism may occur are most relevant in this respect. Prompt hormone replacement therapy is indicated in these patients. In patients in whom this is undesirable because of a hormone-dependent tumor, the risk of osteoporosis should be assessed by means of osteodensitometry, and prophylactic or therapeutic measures should be instituted if necessary. Early intervention improves outcome because osteoporosis therapy is most effective in preventing deterioration of bone mass. There remains much uncertainty in assessing the risk of combination chemotherapy with regard to the development of osteoporosis. Negative effects on the skeleton have, however, been demonstrated for individual drugs, such as methotrexate and ifosfamide. Negative effects of the tumor itself on bone metabolism may aggravate the degree of osteoporosis. Detailed data and long-term experience to assess the risk are urgently needed in this area and constitute an important research topic for the coming years and decades. This review discusses the most prevalent mechanisms of osteoporosis caused by cancer treatment and outlines therapeutic strategies for the prevention and treatment of therapy-induced bone loss.
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Affiliation(s)
- J Pfeilschifter
- Berufsgenossenschaftliche Kliniken Bergmannsheil, Department of Internal Medicine, University of Bochum, Germany
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21
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Abstract
The development of sensitive assays for thyrotropin (TSH) has led to the discovery that many older patients have abnormal TSH levels without other alterations in serum thyroid hormone levels, conditions termed subclinical hypothyroidism (isolated elevation of TSH levels) and subclinical hyperthyroidism (isolated suppression of TSH levels). Subclinical hypothyroidism occurs in 5% to 10% of elderly subjects, and is especially prevalent in elderly women. Subclinical hyperthyroidism is less common, affecting less than 2% of the elderly population. The causes of subclinical thyroid disease in the elderly are similar to those of thyroid disease in the general population, although medications and iodine-containing compounds may play an increased role. Potential risks of subclinical hypothyroidism in the elderly include progression to overt hypothyroidism, cardiovascular effects, hyperlipidemia, and neurological and neuropsychiatric effects. Potential risks of subclinical hyperthyroidism in the elderly include progression to overt hyperthyroidism, cardiovascular effects (especially atrial fibrillation), and osteoporosis. Decisions to treat elderly subjects with subclinical thyroid disease should be based on a careful assessment of these risks in the individual patient.
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Affiliation(s)
- M H Samuels
- Division of Endocrinology, Diabetes, and Clinical Nutrition, Oregon Health Sciences University, Portland 97201, USA
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22
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Knudsen N, Faber J, Sierbaek-Nielsen A, Vadstrup S, Sørensen HA, Hegedüs L. Thyroid hormone treatment aiming at reduced, but not suppressed, serum thyroid-stimulating hormone levels in nontoxic goitre: effects on bone metabolism amongst premenopausal women. J Intern Med 1998; 243:149-54. [PMID: 9566644 DOI: 10.1046/j.1365-2796.1998.00258.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To study the effects of six months' treatment with either T4 or T3, aiming at reduced but not totally suppressed serum TSH levels, as measured by a third generation TSH assay, on biochemical bone turnover parameters as well as bone mass in patients with nontoxic goitre. DESIGN Prospective randomized study with a matched control group, not blinded. SETTING Two University Hospital Clinics in Copenhagen. SUBJECTS AND INTERVENTION Twenty-four consecutive premenopausal women with moderate sized nontoxic goitre. Fourteen patients randomized to T4 or T3 treatment for six months with monthly titration of the dose, aiming at TSH values between 0.005 and 0.2 mUL(-1). Ten controls. MAIN OUTCOME MEASURES Serum parathyroid hormone (PTH), serum procollagen I C-terminal propeptide (PICP), serum alkaline phosphatase, serum osteocalcin, u-pyridinoline, u-deoxypyridinoline, u-hydroxyproline. Bone mass (BMD) at the lumbar spine and at both femoral necks. RESULTS Serum TSH was generally kept within the desired interval. There was no difference in any marker of bone metabolism between the effects of T4 and T3. Consequently, these groups were combined in order to evaluate the effect of thyroid hormones on the bone and mineral metabolism. Thyroid hormone treatment resulted in increased levels of serum ionized calcium (Ca) (P=0.02), serum alkaline phosphatase (P=0.007), serum-PICP (P=0.003), serum osteocalcin (P=0.02) and urinary excretion of deoxypridinoline (P=0.03) compared to untreated controls. Bone mass did not change. CONCLUSION Six months treatment with either T4 or T3 of premenopausal women with nontoxic goitre, aiming at reduced but not totally suppressed TSH values, resulted in biochemical signs of increased bone turnover, whereas bone mass remained unaltered. No differences were found between the effects of T4 or T3 treatment.
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Affiliation(s)
- N Knudsen
- Department of Endocrinology E, Frederiksberg Hospital, Denmark
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23
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Bauer DC, Nevitt MC, Ettinger B, Stone K. Low thyrotropin levels are not associated with bone loss in older women: a prospective study. J Clin Endocrinol Metab 1997; 82:2931-6. [PMID: 9284722 DOI: 10.1210/jcem.82.9.4229] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The relationship between excess thyroid hormone and bone loss is controversial. To determine whether low TSH levels, indicating excessive thyroid hormone, are associated with low bone mass or accelerated bone loss in older women, we performed a prospective cohort study of 458 women over age 65 yr participating in the multicenter Study of Osteoporotic Fractures. Three hundred and twenty-three women were randomly selected from the entire cohort of 9704; an additional 135 randomly selected thyroid hormone users were studied. Medical history, medication use, and calcaneal bone mineral density (BMD) were assessed at the baseline visit. Serum was collected and stored at -190 C. Hip and spine BMD were measured approximately 2 yr later, and follow-up calcaneal and hip BMD measurements were obtained after mean follow-up periods of 5.7 and 3.5 yr, respectively. TSH levels were determined in baseline serum samples using a third generation chemiluminescent assay. After adjustment for age, weight, previous hyperthyroidism, and use of estrogen, bone loss over 4-6 yr was similar in women with low, normal, or high TSH. For example, femoral neck bone loss was -0.3%/yr (95% confidence interval, -0.8%, 0.3%) among women with low TSH (< or = 0.1 mU/L) and -0.5%/yr (95% confidence interval, -0.7%, -0.3%) in those with normal TSH (0.1-5.5 mU/L). There were no statistically significant differences in baseline bone mass of the calcaneus, spine, or femoral neck or trochanteric hip subregions. Baseline total hip BMD was 6% lower (P = 0.01) in women with low TSH. Similar results were obtained in analyses confined to women not taking estrogens. We found no consistent evidence that low TSH, a sensitive biochemical marker of excess thyroid hormone, was associated with low BMD or accelerated bone loss in older ambulatory women.
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Affiliation(s)
- D C Bauer
- Division of General Internal Medicine, University of California, San Francisco 94105, USA
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24
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Nguyen TT, Heath H, Bryant SC, O'Fallon WM, Melton LJ. Fractures after thyroidectomy in men: a population-based cohort study. J Bone Miner Res 1997; 12:1092-9. [PMID: 9200009 DOI: 10.1359/jbmr.1997.12.7.1092] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Bone mass is purportedly reduced by an endogenous or exogenous excess of thyroid hormone or, perhaps, by calcitonin deficiency. Patients who have undergone thyroidectomy could be subject to all of these effects, yet their practical implications in terms of fracture risk are poorly defined. Interpretation is further hampered by the focus on women, where results may be influenced by involutional osteoporosis. Consequently, we assessed the potential for fractures among the 136 Rochester, Minnesota men who underwent thyroidectomy between 1935 and 1979, relative to a group of age-matched control men from the community. With 2194 person-years of follow-up in each group, survival free of any fracture of vertebra, proximal humerus, distal forearm, pelvis, or proximal femur was similar in the two groups (p = 0.23), and the relative risk of any of these fractures for thyroidectomized patients versus their controls was increased only 1.5-fold (95% CI, 0.7-3.2). The difference was entirely accounted for by a statistically significant excess of proximal femur fractures in the men with thyroidectomy. Risk factors for fractures among men with thyroidectomy included greater age at surgery, greater extent of surgery, and the presence of risk factors for secondary osteoporosis. Thus, thyroidectomy, performed mainly for adenoma or goiter, seems to have little overall influence on the risk of age-related fractures in men. However, the association with hip fractures requires further evaluation.
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Affiliation(s)
- T T Nguyen
- Division of Endocrinology and Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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25
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Marcocci C, Golia F, Vignali E, Pinchera A. Skeletal integrity in men chronically treated with suppressive doses of L-thyroxine. J Bone Miner Res 1997; 12:72-7. [PMID: 9240728 DOI: 10.1359/jbmr.1997.12.1.72] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We measured bone mineral density (BMD) (lumbar spine, femoral neck, Ward's triangle, and trochanter) in 34 men given suppressive doses of levothyroxine (L-T4) for a mean of 10.2 years. Indications for treatment were nontoxic goiter (n = 5) or thyroidectomy for differentiated thyroid cancer (n = 6) or nontoxic goiter (n = 3). Patients were followed at our institution and treated with the minimal amount of L-T4 able to suppress thyroid-stimulating hormone (TSH). At the time of evaluation, free T3 was normal in all cases, whereas free T4 was increased in 14 men (41.2%). The mean daily dose of L-T4 was 172 +/- 6 microg, and the cumulative dose of L-T4 was 673 +/- 71 mg. We found no significant difference between patients and age- and weight-matched controls in BMD (g/cm2) at any site of measurement (lumbar spine 1.144 +/- 0.12 vs. 1.168 +/- 0.15; femoral neck 0.979 +/- 0.13 vs. 1.001 +/- 0.13; Ward's triangle 0.854 +/- 0.17 vs. 0.887 +/- 0.15; and trocanther 0.852 +/- 0.13 vs. 0.861 +/- 0.13). BMD was not correlated with the duration of therapy, cumulative or mean daily dose of L-T4, serum levels of free T4, free T3, osteocalcin, and bone alkaline phosphatase. Serum calcium and osteocalcin were slightly but significantly elevated in patients compared with controls, whereas there was no difference in intact parathyroid hormone, bone alkaline phosphatase, and sex hormone-binding globulin (marker of thyroid hormone action). Our data suggest that L-T4 suppressive therapy, if carefully carried out and monitored, using the smallest dose necessary to suppress TSH secretion, has no significant effects on bone metabolism and bone mass in men.
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Affiliation(s)
- C Marcocci
- Isitituto di Endocrinologia, Università di Pisa, Tirrenia-Pisa, Italy
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26
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Grant DJ, McMurdo ME, Mole PA, Paterson CR. Is previous hyperthyroidism still a risk factor for osteoporosis in post-menopausal women? Clin Endocrinol (Oxf) 1995; 43:339-45. [PMID: 7586604 DOI: 10.1111/j.1365-2265.1995.tb02041.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Hyperthyroidism is a risk factor for osteoporosis, but the relative contributions of the episode of hyperthyroidism and thyroxine replacement for subsequent hyperthyroidism remain uncertain. In this study we have measured bone mineral density (BMD) in post-menopausal women with a previous history of hyperthyroidism, comparing those requiring thyroxine therapy with those remaining euthyroid and with an historical local control population. DESIGN Cross-sectional study. PATIENTS One hundred and six post-menopausal women with a previous history of hyperthyroidism. These were divided into four groups: treated with radioiodine, remaining euthyroid (group RU, n = 15); treated with radioiodine, receiving thyroxine for at least 5 years (group RT, n = 46); treated with surgery, remaining euthyroid (group SU, n = 21); treated with surgery, receiving thyroxine for at least 5 years (group ST, n = 24). There were 102 control subjects. MEASUREMENT Forearm bone mineral density at distal and ultradistal sites as measured by single-photon absorptiometry. RESULTS Results were expressed as 'Z-scores' i.e. number of standard deviations from the mean of a 5-year age-band from the local control population. Mean Z-scores at distal and ultradistal sites were as follows: -0.61 and -0.81 in group RU; -0.58 and -0.56 in group RT; -0.27 and -0.30 in group SU; -0.81 and -0.57 in group ST. Patients in groups RU, RT and ST but not SU had significantly lower BMD than controls. CONCLUSION Post-menopausal women with previous hyperthyroidism treated with radioiodine have reduced BMD, whether or not receiving thyroxine. They should be targeted for densitometry and protective therapy with oestrogen should be considered. Those treated with surgery appear to be at less risk; this may be because most are diagnosed and treated whilst premenopausal. Thyroxine may have a deleterious effect in this group; longitudinal studies would provide further clarification.
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Affiliation(s)
- D J Grant
- University of Dundee, Ninewells Hospital and Medical School, UK
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27
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Müller CG, Bayley TA, Harrison JE, Tsang R. Possible limited bone loss with suppressive thyroxine therapy is unlikely to have clinical relevance. Thyroid 1995; 5:81-7. [PMID: 7647577 DOI: 10.1089/thy.1995.5.81] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
To determine the effect of suppressive doses of thyroxine (T4) on bone mass, we studied 50 women on suppressive doses of T4 for 3-27 years (mean of 11 years). Twenty-five had nontoxic goiter and 25 had well-differentiated thyroid carcinoma. Fifty controls were matched for age, menopausal status, and body mass index. Bone mineral density (BMD) was measured in the lumbar spine (LS), femoral neck (FN), trunk (TK), and extremities (EXT) by dual-energy X-ray absorptiometry (DXA). In addition, the trunk area was measured by neutron activation analysis and recorded as a calcium bone index (CaBI). Twenty-one patients were restudied with DXA measurements at a mean of 1.5 +/- 0.5 (1 SD) years. The total population of 50 patients showed no difference in bone mass from controls. In patients with nontoxic goiter, there was no evidence of any loss in bone mass. Cancer patients showed insignificant reductions of 2-5% in BMD of LS, FN, and TK and a significant 5% reduction in BMD of EXT, compared to controls, and a 12% reduction in CaBI compared to goiter patients. Cancer patients had a slightly higher (p < 0.001) mean daily dose of T4 than goiter patients (0.23 vs 0.15 mg/day) but had a similar degree of TSH suppression. BMD and CaBI values did not correlate with free T4 index) with the daily T4 dose, accumulative dose, or with duration of T4 therapy. There were no significant changes in bone mass in either goiter or cancer patients restudied after a mean of 1.5 years.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- C G Müller
- Department of Medicine University of Toronto, St. Joseph's Health Centre, Princess Margaret Hospital, Canada
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28
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Abstract
OBJECTIVE To investigate the prevalence of thyroid illness - especially hyperthyroidism - and exposure to thyroid hormones in patients with hip fracture. DESIGN A case-control study. SETTING Two surgical/orthopaedic hospital units and 22 facilities for the aged in a moderately iodine-deficient region of Germany. SUBJECTS A total of 116 postmenopausal females with hip fracture and 402 postmenopausal female controls. MAIN OUTCOME MEASURES Hip fracture; thyroid disease confirmed by measurement of serum thyrotropin, total and free thyroxine and triiodothyronine; history of thyroid disease and thyroid medication obtained by a questionnaire. RESULTS Of the hip fracture patients 4.3% had overt untreated hyperthyroidism, and 6.9% gave a history of past hyperthyroidism (total, 11.2%). The corresponding figures for the controls were 2.0 and 2.7%, respectively (total, 4.7%). 7.8% of the cases had been exposed to levo-thyroxine for 3-29 years, compared to 11.2% of the controls. The odds ratio for hyperthyroidism (present and past) was 2.5 (1.2-5.3, 95% confidence interval), and the odds ratio for levo-thyroxine exposure was 0.67 (0.32-1.41) in the hip fracture patients. CONCLUSIONS Hyperthyroidism is found 2.5-fold more often in hip fracture patients than in controls. Hence, hyperthyroidism appears to be a significant risk factor for hip fracture and should be investigated by clinical and, when necessary, laboratory means in hip fracture patients. In contrast, no increased risk for hip fracture could be detected after exposure to levothyroxine.
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Affiliation(s)
- B Wejda
- Department of Clinical Endocrinology, Medizinische Klinik und Poliklinik, University of Essen, Germany
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29
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Fujiyama K, Kiriyama T, Ito M, Kimura H, Ashizawa K, Tsuruta M, Nagayama Y, Villadolid MC, Yokoyama N, Nagataki S. Suppressive doses of thyroxine do not accelerate age-related bone loss in late postmenopausal women. Thyroid 1995; 5:13-7. [PMID: 7787427 DOI: 10.1089/thy.1995.5.13] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
To examine whether suppressive doses of thyroxine have any adverse effects on bone, we evaluated various bone metabolic markers (lectin-precipitated alkaline phosphatase, osteocalcin, carboxyl-terminal region of type I collagen propeptide, tartrate-resistant alkaline phosphatase, and urinary excretion of hydroxyproline and pyridinium crosslinks), incidence of vertebral deformity, total body and regional (lumbar spine and radius) bone mineral densities (BMDs), and rates of bone loss in 24 late postmenopausal (more than 5 years after menopause) women who were treated with levothyroxine (L-T4) after total thyroidectomy for differentiated carcinoma. Depending on the clinical records, including serum TSH levels measured by immunoradiometric assay, these patients were divided into two groups. One group of patients was given suppressive doses of L-T4 (TSH < 0.1 mU/L, n = 12) and the other group was given nonsuppressive doses of L-T4 (TSH > 0.1 mU/L, n = 12). There was no difference in bone metabolic markers and incidence of vertebral deformity between the groups. In patients with TSH suppression, Z-scores of BMDs calculated from age-matched healthy women (n = 179, aged 55 to 80) were nearly in the zero range of values (0.077 at total body, 0.228 at lumbar spine, and -0.117 at trabecular region of lumbar spine). The rate of bone loss in TSH-suppressed patients (-0.849 +/- 0.605%/year) was not significantly different from that of nonsuppressed patients (-0.669 +/- 0.659). These prospective and cross-sectional data suggest that long-term levothyroxine therapy using suppressive doses has no significant adverse effects on bone.
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Affiliation(s)
- K Fujiyama
- First Department of Internal Medicine, Nagasaki University School of Medicine, Japan
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30
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Abstract
The availability of sensitive thyrotropin assays allows effective biochemical monitoring of both replacement and suppressive therapy with thyroxine. Whatever target organ is examined, there is tissue thyrotoxicosis if the serum thyrotropin concentration is low, even if the serum triiodothyronine and thyroxine concentrations are normal. Although suppression of thyrotropin secretion is recommended in the treatment of patients with thyroid carcinoma, the aim of thyroxine-replacement therapy in patients with primary hypothyroidism should be to maintain the serum thyrotropin concentration in the normal range. The most convincing argument for the treatment of subclinical hypothyroidism is progression to overt hypothyroidism at a rate of 5 to 20 percent per year.
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Affiliation(s)
- A D Toft
- Royal Infirmary, Edinburgh, Scotland
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31
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Duncan WE, Chang A, Solomon B, Wartofsky L. Influence of clinical characteristics and parameters associated with thyroid hormone therapy on the bone mineral density of women treated with thyroid hormone. Thyroid 1994; 4:183-90. [PMID: 7920001 DOI: 10.1089/thy.1994.4.183] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Reports of reduced bone mineral density (BMD) in patients receiving long-term replacement and suppression therapy with L-thyroxine have generated considerable interest and controversy. A substantial literature has evolved, with interpretation of conflicting results obscured by a variety of confounding factors. We examined the BMD measurements of 202 white women who were taking thyroid hormone to determine the contribution to BMD of a number of clinical characteristics and parameters associated with thyroid hormone therapy. Measurements of BMD (N = 335 over 2.6 +/- 1.6 years) of the spine (L2-L4) were performed in 195 subjects. The BMD of three sites of the hip was measured (N = 247 over 1.8 +/- 1.1 years) in 157 subjects. The BMD of the proximal radius was also measured (N = 172 over 1.8 +/- 1.2 years) in 124 subjects. Increasing age and a history of previous thyrotoxicosis had a deleterious effect on spine BMD. Body mass index (BMI) was positively correlated with spine BMD. Dose of thyroid hormone, duration of therapy, type of underlying thyroid disease, history of thyroidectomy, or serum-free thyroxine index did not influence either the initial BMD or the change in spine BMD over time. In the hip, age correlated with a decrease, and BMI with an increase in BMD. A history of previous thyrotoxicosis was associated with a decrease in hip BMD at all three sites (0.05 < p < 0.10). No other clinical parameters significantly influenced either the initial BMD or the change in hip BMD over time. Increasing age and dose of thyroid hormone, and a prior history of thyrotoxicosis had a deleterious effect on the BMD at the proximal radius. In summary, thyroid hormone therapy was not associated with a significant effect on BMD of the spine or hip, but a decreased BMD of the proximal radius was related to both previous thyrotoxicosis and to dose of thyroid hormone.
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Affiliation(s)
- W E Duncan
- Department of Medicine, Walter Reed Army Medical Center, Washington, D.C
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32
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Abstract
Clinically symptomatic osteoporosis and fractures from thyrotoxicosis have been rare since the availability of antithyroid drugs and radioiodine for the treatment of hyperthyroidism. However, the widespread use of bone density measurements and sensitive TSH assays in the past decade has demonstrated that women taking levothyroxine with subclinical hyperthyroidism have reduced bone density. Cortical bone is affected more than trabecular bone, and postmenopausal women are at a greater risk than premenopausal women. However, it is uncertain whether subclinical hyperthyroidism is associated with an increased risk of fracture. Hypothyroidism is associated with an increase in cortical bone width. The initiation of levothyroxine treatment in hypothyroid women results in a reduction in cortical bone width to levels seen in euthyroid controls after 6-12 months. There is no reduction in bone density when women with subclinical hypothyroidism are treated with levothyroxine for a year. A single study showing reduced bone density in patients receiving chronic levothyroxine replacement therapy requires confirmation and raises an important question: Does levothyroxine replacement therapy, which results in higher serum thyroxine concentrations than those seen in euthyroid controls, accurately mimic physiology?
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Affiliation(s)
- D S Ross
- Thyroid Unit, Massachusetts General Hospital, Boston
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33
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35
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Campos-Pastor MM, Muñoz-Torres M, Escobar-Jiménez F, Ruiz de Almodóvar M, Jódar Gimeno E. Bone mass in females with different thyroid disorders: influence of menopausal status. BONE AND MINERAL 1993; 21:1-8. [PMID: 8324416 DOI: 10.1016/s0169-6009(08)80115-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The aim of this study was to evaluate the effect of thyroid functional state on cortical and trabecular bone mineral density (BMD) (g/cm2) in premenopausal and postmenopausal women. Control subjects were used as a reference population to calculate Z-scores from patient data. In patients with active hyperthyroidism, BMD was reduced in lumbar spine (LS; P < 0.01), femoral neck (FN; P < 0.01) and Ward triangle (WT; P < 0.0001) in comparison with reference standards. In premenopausal women treated in the past for hyperthyroidism or treated at the time of study with L-thyroxine in non-TSH-suppressive doses, there was no significant decrease in BMD. In postmenopausal women with hyperthyroidism in remission, we found a significant decrease in BMD in LS (P < 0.01), FN (P < 0.05) and WT (P < 0.0001). In postmenopausal women treated with L-thyroxine (L-T4), there was a significant decrease in BMD in LS (P < 0.01) and WT (P < 0.01). There was a significant negative correlation between the cumulative dose of L-T4 and BMD in FN (r = -0.688, P < 0.05) and WT (r = -0.657, P < 0.05) in postmenopausal women. Our findings suggest that the deleterious effects of thyroid hormones on BMD are accentuated in areas consisting predominantly of trabecular bone, e.g., the LS and WT. Postmenopausal women subjected to excess thyroid hormone represent a population at greater risk for osteoporosis.
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Affiliation(s)
- M M Campos-Pastor
- Servicio de Endocrinología, Hospital Universitario de Granada, Spain
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