Thyroid disease in older patients. Diagnosis and treatment

Clinical practice guidelines for the management of hypothyroidism

INTRODUCTION

Hypothyroidism has long been known for its effects on different organ systems, leading to hypometabolism. However, subclinical hypothyroidism, its most prevalent form, has been recently related to cardiovascular risk and also to maternal-fetal complications in pregnant women.

OBJECTIVES

In these clinical practice guidelines, several aspects of this field have been discussed with the clear objectives of helping physicians treat patients with hypothyroidism, and of sharing some of our Latin American-based clinical experience.

MATERIALS AND METHODS

The Latin American Thyroid Society commissioned a Task Force on Hypothyroidism to develop evidence-based clinical guidelines on hypothyroidism. A systematic review of the available literature, focused on the primary databases of MedLine/PubMed and Lilacs/SciELO was performed. Filters to assess methodological quality were applied to select the best quality studies. The strength of recommendation on a scale from A-D was based on the Oxford Centre for Evidence--based Medicine, Levels of Evidence 2009, allowing an unbiased opinion devoid of subjective viewpoints. The areas of interest for the studies comprised diagnosis, screening, treatment and a special section for hypothyroidism in pregnancy.

RESULTS

Several questions based on diagnosis, screening, treatment of hypothyroidism in adult population and specifically in pregnant women were posed. Twenty six recommendations were created based on the answers to these questions. Despite the fact that evidence in some areas of hypothyroidism, such as therapy, is lacking, out of 279 references, 73% were Grade A and B, 8% Grade C and 19% Grade D.

CONCLUSIONS

These evidence-based clinical guidelines on hypothyroidism will provide unified criteria for management of hypothyroidism throughout Latin America. Although most of the studies referred to are from all over the world, the point of view of thyroidologists from Latin America is also given.

The effect of fasting and refeeding on thyroid follicule structure and thyroid hormone levels in young and old rats

In order to assess morphological and functional plasticity of the thyroid gland in aging the effects of fasting and refeeding on the thyroid morphology and thyroid hormone serum levels were compared with morphometry and RIA in young and old rats. Young (4 months) and old (24 months) male Wistar rats were fasted for 40 h and sampled, or fasted and fed thereafter for 4 or 24 h. In control (fed) old animals the thyroid follicules were larger, the follicular epithelium was smaller and colloid resorption was smaller than in young rats. 'Thyroid activation index' (epithelial volume/colloid volume ratio) was almost twice lower in the thyroids of control old rats. As the result of fasting, height, surface area and volume of epithelial follicular cells decreased in the thyroids of fasted young rats but not in old ones. On the contrary, in thyroids of fasted old rats the dimensions of epithelial cells did not change and thyroid colloid resorption was increased. After 24 h of refeeding, thyroid morphology in both young and old rats did not differ significantly as compared with control animals. Upon fasting, serum levels of thyroxine (T4) and triiodothyronine (T3) decreased by 28 and 38% in young and by 35 and 46% in old rats, respectively. However, T4 and T3 serum concentrations did not differ significantly between age groups in both fed and fasted states. During refeeding the increase in serum thyroxine concentration was delayed in old rats as compared with young ones. The results of morphological, morphometric and hormonal investigations indicate the existence of age-related changes in the structure and function of thyroid follicular cells.

Mitochondrial biogenesis and healthy aging

Aging is associated with an overall loss of function at the level of the whole organism that has origins in cellular deterioration. Most cellular components, including mitochondria, require continuous recycling and regeneration throughout the lifespan. Mitochondria are particularly susceptive to damage over time as they are the major bioenergetic machinery and source of oxidative stress in cells. Effective control of mitochondrial biogenesis and turnover, therefore, becomes critical for the maintenance of energy production, the prevention of endogenous oxidative stress and the promotion of healthy aging. Multiple endogenous and exogenous factors regulate mitochondrial biogenesis through the peroxisome proliferator-activated receptor gamma coactivator-1alpha (PGC-1alpha). Activators of PGC-1alpha include nitric oxide, CREB and AMPK. Calorie restriction (CR) and resveratrol, a proposed CR mimetic, also increase mitochondrial biogenesis through activation of PGC-1alpha. Moderate exercise also mimics CR by inducing mitochondrial biogenesis. Negative regulators of PGC-1alpha such as RIP140 and 160MBP suppress mitochondrial biogenesis. Another mechanism involved in mitochondrial maintenance is mitochondrial fission/fusion and this process also involves an increasing number of regulatory proteins. Dysfunction of either biogenesis or fission/fusion of mitochondria is associated with diseases of the neuromuscular system and aging, and a greater understanding of the regulation of these processes should help us to ultimately control the aging process.

Differential effect of retinoic acid and triiodothyronine on the age-related hypo-expression of neurogranin in rat

Given the important role of retinoids and thyroid hormone for optimal brain functioning and the tenuous relationship between retinoic acid (RA) and triiodothyronine (T3) signalings, we compared the effects of RA or T3 administrations on RA and T3 nuclear receptors (RAR, RXR and TR) and on their target genes, neuromodulin (GAP43) and neurogranin (RC3) in 24-month-old rats. Quantitative real time PCR and western blot analysis allowed us to verify that retinoid and thyroid signalings and GAP43 and RC3 expression are affected by age. By in situ hybridization we observed a decreased expression of RC3 in hippocampus, striatum and cerebral cortex. RARbeta, RXRbeta/gamma and GAP43 were up-regulated by RA as well as T3 treatment. The abundance of TRalpha/beta mRNA and RC3 expression were only increased by T3 administration in the whole brain. This up-regulator effect of T3 on RC3 was only observed in the striatum. During aging, T3 become a limiting factor alone able to correct the age-related concomitant hypo-activation of retinoid and thyroid signalings and alterations of synaptic plasticity.

Aging affects the retinoic acid and the triiodothyronine nuclear receptor mRNA expression in human peripheral blood mononuclear cells

BACKGROUND

Inadequate retinoid status has often been described as occurring with aging. Moreover, subclinical hypothyroid status has also been evoked in the elderly. Several studies performed in animals have described the crucial incidence of age-related hypo-functioning of retinoid and thyroid signalling pathways, particularly in the brain.

OBJECTIVE

The aim of the present study was to clarify whether aging modifies retinoid and thyroid signalling in humans.

METHODS

Using real-time RT-PCR the relative amount of mRNA of the retinoid (RARalpha, RARgamma and RXRalpha) and thyroid (TRalpha and TRbeta) nuclear receptors in peripheral blood mononuclear cells (PBMC) of young (24-57 years old, n = 22) compared with elderly (69-90 years old, n = 24) healthy subjects was quantitated. Classical plasma parameters used to characterize the retinoid and thyroid status - retinol (ROH), retinol-binding protein (RBP), free triiodothyronine (FT3) and thyroxine (FT4), thyroid-stimulating hormone (TSH) and transthyretin (TTR) - were also assessed.

RESULTS

RARgamma expression was significantly decreased in elderly versus young subjects while no modification of the retinoid-related plasma parameters ROH and RBP were emphasized by aging. Concerning thyroid criteria, the elderly exhibited an increase in TSH concentration (+39%) without significant modifications of FT3 and FT4, which indicated an age-related sub-clinical hypothyroidism. Concurrently, the amount of TR mRNA (alpha as well as beta subtypes) was significantly decreased in the elderly.

CONCLUSION

These data constitute the first evidence of an age-related hypo-activation of the retinoid and thyroid nuclear pathways in PBMC. Further study of the possible association between the expression of the retinoid and thyroid nuclear receptors and age-related cognitive alterations in humans would be interesting.

Hypothyroidism in patients older than 55 years: an analysis of the etiology and assessment of the effectiveness of therapy

BACKGROUND

Several epidemiological studies on the prevalence of hypothyroidism in the elderly have been reported; however, extensive series of elderly patients with thyroid dysfunction have not been studied. Our aim has been to assess the relative frequency of the diverse causes of hypothyroidism in a group of patients older than 55 years and the adequacy of control of thyroid function attained by levothyroxine therapy.

METHODS

We performed a descriptive, observational, cross-sectional study in the setting of a hospital endocrinology clinic. From a total of 1581 patients older than 55 who were complaining of a thyroid disorder, we studied a group of 655 patients with hypothyroidism. There were 559 women (85.3%, age 65.01 +/- 7.90 years) and 96 men (14.7%, 65.36 +/- 8.39 years). In every patient, we collected etiology, presence of goiter, time of evolution from diagnosis and from therapy prescription, previous and present treatments, current thyroid functional status (free thyroxine and thyrotropin concentration), adequacy of disease control, and thyroid autoimmune status.

RESULTS

The causes of hypothyroidism were as follows: autoimmune thyroiditis, 308 (47.0%); postoperative hypothyroidism, 175 (26.7%); therapy for previous thyrotoxicosis, 63 (9.6%); thyrotropin deficiency, 15 (2.3%); iodine excess, 6 (0.9%); subacute thyroiditis, 2 (0.3%); and unknown etiology, 86 (13.1%) patients. Most patients with autoimmune thyroiditis were positive for thyroid peroxidase antibodies at the time of the study (94.4%). Mean (+/- SD) age at diagnosis was 61.8 +/- 9.4 years in men and 59.8 +/- 9.7 years in women. Median (range) duration of hypothyroidism was 1.4 (0-18) years in men and 3 (0-45) years in women ( p <.05). Adequacy of therapy was studied in 385 patients treated with replacement doses of levothyroxine. Two hundred and sixty (67.5%) of these subjects attained good control, whereas 125 (32.5%) showed inadequate control of the disease at the time of the study. A model of logistic regression showed that adequacy of therapy was dependent on the duration of therapy, but independent of age, gender, degree of hypothyroidism, etiology, autoimmune status, age at diagnosis, and dose of levothyroxine. A 2-year follow-up study performed in 56 newly diagnosed patients showed that an adequate control of hypothyroidism was attained in 35 (62.5%) patients at 6 months, in 46 (82.1%) patients at 1 year, and in 49 (87.5%) at 2 years of therapy with levothyroxine.

CONCLUSIONS

Autoimmune thyroiditis and postoperative hypothyroidism are the main causes of thyroid hypofunction in patients older than 55 years. The time from starting therapy is the main determinant of the adequacy of control of thyroid hypofunction in this population. With effective therapy and appropriate monitoring, more than 80% of the patients showed adequate control within 1 year of follow-up.

Characteristics of thyroid carcinomas in aging patients

BACKGROUND

To investigate the clinical features of thyroid cancer in aging patients and to present the results of treatment. From this we can provide bases for earlier diagnoses and better treatment of thyroid malignancies in older patients.

MATERIALS AND METHODS

In this study a retrospective analysis was performed with 204 thyroid cancer patients aged 60 years or older (132 women, with a mean age of 68.3 +/- 6.6 years; 72 men, with a mean age of 67.0 +/- 5.3 years).

RESULTS

Of the 204 patients, 142 had well-differentiated thyroid carcinomas (96 papillary thyroid carcinomas, 43 follicular carcinomas, three Hürthle cell carcinomas) and three medullary carcinomas. Sixty-nine (33.8%) of the 204 patients died after treatment. Of these, three patients died of causes not related to thyroid cancer. For well-differentiated thyroid carcinomas, male gender, follicular carcinoma, and a larger tumour size indicated a poor prognosis. Of the 59 non-well-differentiated thyroid carcinomas, 39 were anaplastic thyroid carcinomas, nine metastatic cancers of the thyroid, seven lymphomas, and four squamous cell carcinomas. After treatment, 40 (67.8%) of the 59 patients died. In multivariant analysis of the differences in clinical parameters between aging and younger thyroid cancer patients, the current status, tumour size, follow-up period, sex, and stage at diagnosis were independent factors. From this data the delayed diagnosis of aging patients with thyroid cancer was of note when compared with younger patients.

CONCLUSION

Thyroid cancer in older patients is not a benign clinical disorder. Early diagnosis and urgent aggressive treatment are recommended courses of action for this type of cancer, especially for non-well-differentiated thyroid cancers.

Thyroid Peroxidase and Thyroglobulin Expression in Normal Human Thyroid Glands

The objective of the present study was to investigate thyroid peroxidase (TPO) and thyroglobulin (Tg) expression in normal thyroid tissue. Thirty-eight normal thyroids from fetuses(1) children, adults, and elderly subjects were evaluated. TPO and Tg expression was determined by analyzing at least 200 cells/specimen. A value of 80% was considered to be the threshold for TPO positivity. In terms of age, TPO expression occurs in fetuses along with follicle differentiation and is absent in solid follicles. TPO staining was cytoplasmic, and was more intense in the apical membrane in tissue from fetuses, children, and young adults. A perinuclear rang was found in tissue from older adults and from the elderly subjects. There was concomitant TPO and Tg expression in all groups studied. Tg expression was observed in all normal thyroids from all age groups. Tg expression was extremely variable (10-100% of the cells) and fainter than TPO expression.

A risk assessment perspective on the neurobehavioral toxicity of endocrine disruptors

Agents that alter the functional properties of endocrine systems pervade the environment. Their full implications for public health and ecological integrity, however, may not be captured by labels such as "disruptor" because their actions ramify in so many directions. The process by which we describe and evaluate such actions, risk assessment, is also the means by which society judges their significance. It determines the allocation of resources to their investigation and, potentially, control. A full, formal, risk assessment endeavor, in the detail applied to cancer evaluation, still awaits application to endocrine disruptors, however. It will not be as transparent a process because, unlike the conventional risk model based on carcinogens, identification of a chemical as an endocrine disruptor, as is true of neurobehavioral toxicants in general, will not trigger a virtually automatic sequence of policy steps. The primary distinction between cancer and endocrine disruptors and neurotoxicants is the plethora of possible endpoints by which toxicity can be expressed. Cancer is a unitary index. Adverse consequences flowing from exposure to endocrine disruptors can take an almost infinite variety of forms, including neurobehavioral outcomes. In their most troubling manifestations, these emerge as disorders of early development. They can range from deviant patterns of male copulatory behavior to impaired cognitive function. Each of these indices, in turn, exhibits multiple dimensions. Moreover, some aftermaths, as with cancer, might emerge only after long latencies. Different stages of the life cycle following developmental exposure will manifest different outcomes as a consequence. Some adverse effects may arise for the first time in advanced age because it is a period of declining compensatory margins. These multiple facets of neurobehavioral toxicity, and, by extension, their coupling to endocrine disruptors, imply a risk assessment process that corresponds, in many ways, to the global views adopted by ecotoxicologists.

Aging decreases retinoic acid and triiodothyronine nuclear expression in rat liver: exogenous retinol and retinoic acid differentially modulate this decreased expression

The expression of nuclear receptors of retinoic acid (RAR) and triiodothyronine (TR) was analyzed in the liver of rats aged 2.5 (young), 6 (adult) and 24 (aged) months. In aged rats, decreased binding properties, binding capacity (Cmax) and affinity (Ka), of nuclear receptors were observed. This resulted, at least in part, from decreased transcription of receptor genes in that the amount of their mRNA also decreased. Moreover, the activity of malic enzyme (ME) and tissue transglutaminase (tTG), whose genes are TR and RAR responsive, respectively, was reduced in aged rats. These results are in agreement with the decreased binding capacity of these receptors. An inducer-related increase of RAR and TR expression was observed 24 h after a single dose of retinoic acid administration (5 mg/kg), while retinol administration (retinyl palmitate, 13 mg/kg) was without incidence on nuclear receptor expression in aged rats.

Age-related decreases in mRNA for brain nuclear receptors and target genes are reversed by retinoic acid treatment

Ageing is accompanied by certain problems resulting from changes of hormonal status, in particular thyroid hormone (T3) status and vitamin A status. Since retinoic acid (RA), the active metabolite of vitamin A, and T3 play physiological roles in the adult brain, the effect of ageing on the amounts of mRNA for retinoic acid (RAR and RXR) and triiodothyronine (TR) nuclear receptors were studied. Also, the expression of RA and T3 target genes, tissue transglutaminase (tTG) and neurogranin (RC3), was measured in the whole brain and in the hippocampus of mice. Relative to young (3 months) mice, aged (22 months) mice exhibited lower amounts of RAR, RXR and TR mRNA concomitantly with a lower expression of tTG and RC3. RA administration to old mice (24 h before sacrifice) was able to restore the amount of mRNA of nuclear receptors and of RC3. It is hypothesized that a decrease in the cellular action of RA and T3 could play a role, via a decrease in the expression of RC3, in the alteration of synaptic plasticity occurring in aged mice.