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Uslar V, Becker C, Weyhe D, Tabriz N. Thyroid disease‐specific quality of life questionnaires ‐ A systematic review. Endocrinol Diabetes Metab 2022; 5:e357. [PMID: 35856310 PMCID: PMC9471597 DOI: 10.1002/edm2.357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/03/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Thyroid diseases are very common and rarely life‐threatening. One of the main therapeutic goals is an improvement in quality of life, making it important to measure in clinical and research settings. The aim of this systematic review is to provide an overview of the currently available thyroid‐specific quality of life questionnaires with regard to their validation quality in order to make recommendations for clinical use with a special focus on German questionnaires. Methods A systematic literature search was performed in Pubmed, Google Scholar and the Cochrane Library. A total of 904 studies were identified. After excluding duplicates, non‐English‐ or German‐language texts, full texts that were not freely available and studies with irrelevant content, 64 studies reporting on 16 different questionnaires were included in the analysis. Results Four questionnaires concerned benign thyroid diseases (ThyPRO, ThyPRO‐39, Thy‐R‐HRQoL and Thy‐D‐QOL), six malignant thyroid diseases (THYCA‐QoL, ThyCa‐HRLQOL, EORTC‐Thy34, MADSI‐Thy, QOL‐Thyroid and ThyCAT), and six endocrine orbitopathy (GO‐QOL, GO‐QLS, TED‐QOL, STED‐QOL, TAO‐QoL and Ox‐TED). Only five questionnaires were at least developed, if not validated, in German, and five were developed in more than two languages. Conclusions ThyPRO and the ThyPRO‐39 are the best‐evaluated questionnaires for benign thyroid diseases. Alternatively, in hypothyroid patients, the adequately validated Thy‐D‐QoL can be used. For malignant thyroid diseases, the choice should be made individually, as all six questionnaires (THYCA‐QoL, ThyCA‐HRQOL, EORTC‐Thy34, MDASI‐Thy, QOL‐Thyroid and ThyCAT) have different strengths and weaknesses. The GO‐QOL is the best‐validated questionnaire in endocrine orbitopathy. However, the TED‐QOL is also suitable as a short‐screening questionnaire for these patients.
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Affiliation(s)
- Verena Uslar
- University Hospital for Visceral Surgery Carl von Ossietzky University Oldenburg Oldenburg Germany
| | - Caroline Becker
- University Hospital for Visceral Surgery Carl von Ossietzky University Oldenburg Oldenburg Germany
| | - Dirk Weyhe
- University Hospital for Visceral Surgery Carl von Ossietzky University Oldenburg Oldenburg Germany
| | - Navid Tabriz
- University Hospital for Visceral Surgery Carl von Ossietzky University Oldenburg Oldenburg Germany
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2
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Ross DS. Treating hypothyroidism is not always easy: When to treat subclinical hypothyroidism, TSH goals in the elderly, and alternatives to levothyroxine monotherapy. J Intern Med 2022; 291:128-140. [PMID: 34766382 DOI: 10.1111/joim.13410] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The majority of patients with hypothyroidism feel better when levothyroxine treatment restores thyroid-stimulating hormone (TSH) concentrations to normal. Increasingly, a significant minority of patients remain symptomatic and are dissatisfied with their treatment. Overzealous treatment of symptomatic patients with subclinical hypothyroidism may contribute to dissatisfaction among hypothyroidism patients, as potential hypothyroid symptoms in patients with minimal hypothyroidism rarely respond to treatment. Thyroid hormone prescriptions have increased by 30% in the United States in the last decade. The diagnosis of subclinical hypothyroidism should be confirmed by repeat thyroid function tests ideally obtained at least 2 months later, as 62% of elevated TSH levels may revert to normal spontaneously. Generally, treatment is not necessary unless the TSH exceeds 7.0-10 mIU/L. In double-blinded randomized controlled trials, treatment does not improve symptoms or cognitive function if the TSH is less than 10 mIU/L. While cardiovascular events may be reduced in patients under age 65 with subclinical hypothyroidism who are treated with levothyroxine, treatment may be harmful in elderly patients with subclinical hypothyroidism. TSH goals are age dependent, with a 97.5 percentile (upper limit of normal) of 3.6 mIU/L for patients under age 40, and 7.5 mIU/L for patients over age 80. In some hypothyroid patients who are dissatisfied with treatment, especially those with a polymorphism in type 2 deiodinase, combined treatment with levothyroxine and liothyronine may be preferred.
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Affiliation(s)
- Douglas S Ross
- Endocrine Division, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts, USA
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Shakir MKM, Brooks DI, McAninch EA, Fonseca TL, Mai VQ, Bianco AC, Hoang TD. Comparative Effectiveness of Levothyroxine, Desiccated Thyroid Extract, and Levothyroxine+Liothyronine in Hypothyroidism. J Clin Endocrinol Metab 2021; 106:e4400-e4413. [PMID: 34185829 PMCID: PMC8530721 DOI: 10.1210/clinem/dgab478] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Studies comparing levothyroxine (LT4) therapy with LT4 + liothyronine (LT3) or desiccated thyroid extract (DTE) did not detect consistent superiority of either treatment. Here, we investigated these therapies, focusing on the whole group of LT4-treated hypothyroid patients, while also exploring the most symptomatic patients. METHODOLOGY Prospective, randomized, double-blind, crossover study of 75 hypothyroid patients randomly allocated to 1 of 3 treatment arms, LT4, LT4 + LT3, and DTE, for 22 weeks. The primary outcomes were posttreatment scores on the 36-point thyroid symptom questionnaire (TSQ-36), 12-point quality of life general health questionnaire (GHQ-12), the Wechsler memory scale-version IV (VMS-IV), and the Beck Depression Inventory (BDI). Secondary endpoints included treatment preference, biochemical and metabolic parameters, etiology of hypothyroidism, and Thr92Ala-DIO2 gene polymorphism. Analyses were performed with a linear mixed model using subject as a random factor and group as a fixed effect. RESULTS Serum TSH remained within reference range across all treatment arms. There were no differences for primary and secondary outcomes, except for a minor increase in heart rate caused by DTE. Treatment preference was not different and there were no interferences of the etiology of hypothyroidism or Thr92Ala-DIO2 gene polymorphism in the outcomes. Subgroup analyses of the 1/3 most symptomatic patients on LT4 revealed strong preference for treatment containing T3, which improved performance on TSQ-36, GHQ-12, BDI, and visual memory index (VMS-IV component). CONCLUSIONS As a group, outcomes were similar among hypothyroid patients taking DTE vs LT4 + T3 vs LT4. However, those patients that were most symptomatic on LT4 preferred and responded positively to therapy with LT4 + LT3 or DTE.
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Affiliation(s)
- Mohamed K M Shakir
- Walter Reed National Military Medical Center, Bethesda, MD 20889-5600, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Daniel I Brooks
- Walter Reed National Military Medical Center, Bethesda, MD 20889-5600, USA
| | - Elizabeth A McAninch
- Division of Endocrinology and Metabolism, Rush University Medical Center, Chicago, IL 60612, USA
| | - Tatiana L Fonseca
- Section of Adult and Pediatric Endocrinology, University of Chicago, Chicago, IL 60637, USA
| | - Vinh Q Mai
- Walter Reed National Military Medical Center, Bethesda, MD 20889-5600, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Antonio C Bianco
- Section of Adult and Pediatric Endocrinology, University of Chicago, Chicago, IL 60637, USA
| | - Thanh D Hoang
- Walter Reed National Military Medical Center, Bethesda, MD 20889-5600, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Carlé A, Karmisholt JS, Knudsen N, Perrild H, Thuesen BH, Ovesen L, Rasmussen LB, Pedersen IB. Does Subclinical Hypothyroidism Add Any Symptoms? Evidence from a Danish Population-Based Study. Am J Med 2021; 134:1115-1126.e1. [PMID: 33872585 DOI: 10.1016/j.amjmed.2021.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 01/31/2021] [Accepted: 03/02/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Few studies have scrutinized the spectrum of symptoms in subclinical hypothyroidism. METHODS From 3 Danish Investigation on Iodine Intake and Thyroid Diseases (DanThyr) cross-sectional surveys performed in the period 1997 to 2005, a total of 8903 subjects participated in a comprehensive investigation including blood samples and questionnaires on previous diseases, smoking habits, alcohol intake, and education. From the 3 surveys we included patients with subclinical hypothyroidism (n = 376) and euthyroid controls (n = 7619). We explored to what extent patients with subclinical hypothyroidism reported 13 previously identified hypothyroidism-associated symptoms (tiredness, dry skin, mood lability, constipation, palpitations, restlessness, shortness of breath, wheezing, globus sensation, difficulty swallowing, hair loss, dizziness/vertigo, and anterior neck pain). In various uni- and multivariate regression models we searched for circumstances predicting why some patients have more complaints than others. RESULTS Subclinically hypothyroid patients did not report higher hypothyroidism score [(median, interquartile range), 2 (0-4) vs 2 (0-4), P = .25] compared with euthyroid controls. Within the group of subclinical hypothyroid patients, comorbidity had the highest impact on symptoms (tiredness, shortness of breath, wheezing; all P < .001); TSH level had no impact on symptom score; and younger age was accompanied by higher mental burden (tiredness, P < .001; mood lability, P < .001; restlessness, P = .012), whereas shortness of breath was associated with high body mass index (P < .001) and smoking (P = .007). CONCLUSION Patients with a thyroid function test suggesting subclinical hypothyroidism do not experience thyroid disease-related symptoms more often than euthyroid subjects. In subclinical hypothyroidism, clinicians should focus on concomitant diseases rather than expecting symptomatic relief following levothyroxine substitution.
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Affiliation(s)
- Allan Carlé
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Institute, Aalborg University, Denmark.
| | - Jesper Scott Karmisholt
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Institute, Aalborg University, Denmark
| | - Nils Knudsen
- Department of Endocrinology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Hans Perrild
- Department of Endocrinology, Bispebjerg University Hospital, Copenhagen, Denmark
| | | | - Lars Ovesen
- Department of Internal Medicine, Slagelse Hospital, Slagelse, Denmark
| | - Lone Banke Rasmussen
- Department of Endocrinology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Inge Bülow Pedersen
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Institute, Aalborg University, Denmark
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Ejaz M, Kumar P, Thakur M, Bachani P, Naz S, Lal K, Shahid W, Shahid S, Jahangir M, Rizwan A. Comparison of Lipid Profile in Patients With and Without Subclinical Hypothyroidism. Cureus 2021; 13:e17301. [PMID: 34567859 PMCID: PMC8451506 DOI: 10.7759/cureus.17301] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2021] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Thyroid hormone affects lipid metabolism. Various studies have shown a contradictory relationship between lipid profile (LP) and subclinical hypothyroidism (SCH). Currently, there is a scarcity of regional data on the relationship between LP and SCH. METHODS This longitudinal study was conducted in the internal medicine and cardiology units of a tertiary care hospital in Pakistan from September 2019 to March 2021. A total of 900 participants, of either gender and between the ages of 40 to 70 years, were enrolled in the study. Blood samples were sent to the laboratory to determine lipid and thyroid parameters. Participants were divided into two groups based on the presence of SCH. RESULTS In our study, 179 (19.8%) participants had SCH. Total cholesterol (TC) and low-density lipoprotein (LDL) was significantly higher in participants with SCH compared to participants without SCH (228.41 ± 35.21 mg/dL vs. 171.21 ± 30.21 mg/dL; p-value: <0.00001) and (131.65 ± 28.22 mg/dL vs. 89.26 ± 18.52 mg/dL; p-value: <0.0001), respectively. CONCLUSION In conclusion, this study found an increased incidence of dyslipidemias in patients with SCH. It is associated with elevated TC and LDL levels, which are risk factors for cardiovascular disease and mortality.
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Affiliation(s)
- Mishal Ejaz
- Internal Medicine, Ziauddin University, Karachi, PAK
| | - Pardeep Kumar
- Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | | | - Parkash Bachani
- Internal Medicine, Liaquat University of Medical and Health Sciences, Jamshoro, PAK
| | - Sidra Naz
- Internal Medicine, University of Health Sciences, Lahore, PAK
| | - Kirshan Lal
- Internal Medicine, Ghulam Muhammad Mahar Medical College, Sukkur, PAK
| | - Wajeeha Shahid
- Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | - Simra Shahid
- Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | - Maha Jahangir
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Amber Rizwan
- Family Medicine, Jinnah Post Graduate Medical Center, Karachi, PAK
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Leng O, Razvi S. Treatment of subclinical hypothyroidism: assessing when treatment is likely to be beneficial. Expert Rev Endocrinol Metab 2021; 16:73-86. [PMID: 32216473 DOI: 10.1080/17446651.2020.1738924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 03/03/2020] [Indexed: 12/14/2022]
Abstract
Introduction: Subclinical hypothyroidism (SCH) is a common condition diagnosed in up to 16% of the population. SCH is diagnosed when serum TSH is high and circulating thyroid hormones are within the reference range. SCH is considered to be a mild form of thyroid failure by some due to the log-linear relationship between TSH and thyroid hormones. Nevertheless, it is unclear whether the treatment of SCH with thyroid hormones is beneficial, and hence, it is not surprising that expert opinions and recommendations from societies differ in their opinions on how best to manage SCH.Areas covered: This article reviews the currently available evidence pertaining to SCH and provides recommendations as to when treatment of SCH should be considered. An electronic search of PubMed from 1970 to 2019 was performed and systematically reviewed studies assessing the effects of treatment in SCH. The main areas that are considered are the effects of treatment on symptoms and quality of life, and important clinical consequences including psychocognitive outcomes and cardiovascular events.Expert opinion: Treatment of SCH with thyroid hormones is debated and the current literature in this area lacks clarity. We provide an evidence-based recommendation for when treatment of SCH with thyroid hormones should be considered.
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Affiliation(s)
- Owain Leng
- Department of Endocrinology, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Salman Razvi
- Department of Endocrinology, Gateshead Health NHS Foundation Trust, Gateshead, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
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Abdulateef DS, Mahwi TO. Assessment of subclinical hypothyroidism for a clinical score and thyroid peroxidase antibody: a comparison with euthyroidism grouped by different thyroid-stimulating hormone levels. ASIAN BIOMED 2019. [DOI: 10.1515/abm-2019-0045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Subclinical hypothyroidism (SCH) might have many symptoms of hypothyroidism. The controversy appears to lower the level of thyroid-stimulating hormone (TSH) and group subjects with TSH of more than 3 or even 2.5 mIU/L as SCH subjects.
Objectives
To assess SCH subjects both clinically using Zulewski clinical score and biochemically and to evaluate whether the euthyroid subjects with high-normal TSH (HNT) have any clinical symptom or subnormal biochemical finding.
Methods
A prospective cross-sectional study of 233 subjects, 67 with SCH and 166 euthyroidism, was conducted. Euthyroid subjects were divided according to the level of TSH as HNT (>2.5 mIU/L) and low-normal TSH (0.5–2.5 mIU/L). The subjects were examined for clinical feature including Zulewski clinical score and biochemical evaluations including thyroid peroxidase antibody (TPO-Ab) titer. The comparisons between groups were assessed using independent sample t test, and correlations between variables were evaluated using Pearson correlation.
Results
A significantly higher clinical score and higher frequencies of symptoms were found in the SCH group compared to the euthyroid group. The most frequent symptom was fatigue. Euthyroid subjects with HNT were found to have higher TPO-Ab titers than those with low-normal TSH, P < 0.05. The Zulewski clinical score was positively correlated with TSH and TPO-Ab titer but negatively correlated with the FT4 level, P < 0.05.
Conclusions
Zulewski clinical score is higher in SCH subjects compared to euthyroid subjects and can aid in assessing SCH subjects. A significant correlation exists between Zulewski clinical score and each of the TSH, FT4, and TPO-Ab titer levels. The frequency of TPO-Ab positivity is high in SCH. Additionally, euthyroid with higher TSH levels has higher level of TPO-Ab titer but not higher clinical score.
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Affiliation(s)
- Darya S. Abdulateef
- Department of Physiology, College of Medicine, University of Sulaimani , Sulaimani 46001 , Kurdistan , Iraq
| | - Taha O. Mahwi
- Department of Medicine, College of Medicine, University of Sulaimani , Sulaimani 46001 , Kurdistan , Iraq
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8
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Patterson CJ. Four Potentially Practice-Changing Articles From 2018. J Am Med Dir Assoc 2019; 20:294-297. [DOI: 10.1016/j.jamda.2019.01.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 01/17/2019] [Indexed: 11/29/2022]
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Vacante M, Biondi A, Basile F, Ciuni R, Luca S, Di Saverio S, Buscemi C, Vicari ESD, Borzì AM. Hypothyroidism as a Predictor of Surgical Outcomes in the Elderly. Front Endocrinol (Lausanne) 2019; 10:258. [PMID: 31068905 PMCID: PMC6491643 DOI: 10.3389/fendo.2019.00258] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 04/04/2019] [Indexed: 12/30/2022] Open
Abstract
There is a high prevalence of hypothyroidism in the elderly population, mainly among women. The most important cause is autoimmune thyroiditis, but also iodine deficiency, radioiodine ablation, and surgery may be responsible for hypothyroidism in elderly hospitalized patients. Thyroid-related symptoms are sometimes comparable to physiological manifestations of the aging process, and hypothyroidism may be related with many symptoms which can be present in critical patients, such as cognitive impairment, cardiovascular, gastrointestinal, and hematological alterations, and eventually myxedema coma which is a severe and life-threatening condition in older adults. Adequate thyroid hormone levels are required to achieve optimal outcomes from any kind of surgical intervention. However, only few randomized clinical trials investigated the association between non-thyroidal illness (or low-T3 syndrome), and adverse surgical outcomes, so far. The goal of this review is to discuss the role of thyroid function as a predictor of surgical outcomes in the elderly.
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Affiliation(s)
- Marco Vacante
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Antonio Biondi
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Francesco Basile
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Roberto Ciuni
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Salvatore Luca
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Salomone Di Saverio
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Carola Buscemi
- Department of Clinical and Experimental Medicine, Specialization School in Geriatrics, University of Catania, Catania, Italy
| | - Enzo Saretto Dante Vicari
- Department of Clinical and Experimental Medicine, Specialization School in Geriatrics, University of Catania, Catania, Italy
| | - Antonio Maria Borzì
- Department of Clinical and Experimental Medicine, Specialization School in Geriatrics, University of Catania, Catania, Italy
- *Correspondence: Antonio Maria Borzì
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Feller M, Snel M, Moutzouri E, Bauer DC, de Montmollin M, Aujesky D, Ford I, Gussekloo J, Kearney PM, Mooijaart S, Quinn T, Stott D, Westendorp R, Rodondi N, Dekkers OM. Association of Thyroid Hormone Therapy With Quality of Life and Thyroid-Related Symptoms in Patients With Subclinical Hypothyroidism: A Systematic Review and Meta-analysis. JAMA 2018; 320:1349-1359. [PMID: 30285179 PMCID: PMC6233842 DOI: 10.1001/jama.2018.13770] [Citation(s) in RCA: 150] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE The benefit of thyroid hormone therapy for subclinical hypothyroidism is uncertain. New evidence from recent large randomized clinical trials warrants an update of previous meta-analyses. OBJECTIVE To conduct a meta-analysis of the association of thyroid hormone therapy with quality of life and thyroid-related symptoms in adults with subclinical hypothyroidism. DATA SOURCES PubMed, EMBASE, ClinicalTrials.gov, Web of Science, Cochrane Library, CENTRAL, Emcare, and Academic Search Premier from inception until July 4, 2018. STUDY SELECTION Randomized clinical trials that compared thyroid hormone therapy with placebo or no therapy in nonpregnant adults with subclinical hypothyroidism were eligible. Two reviewers independently evaluated eligibility based on titles and abstracts of all retrieved studies. Studies not excluded in this first step were independently assessed for inclusion after full-text evaluation by 2 reviewers. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted data, assessed risk of bias (Cochrane risk-of-bias tool), and evaluated the quality of evidence (GRADE tool). For synthesis, differences in clinical scores were transformed (eg, quality of life) into standardized mean differences (SMDs; positive values indicate benefit of thyroid hormone therapy; 0.2, 0.5, and 0.8 correspond to small, moderate, and large effects, respectively). Random-effects models for meta-analyses were applied. MAIN OUTCOMES AND MEASURES General quality of life and thyroid-related symptoms after a minimum follow-up of 3 months. RESULTS Overall, 21 of 3088 initially identified publications met the inclusion criteria, with 2192 adults randomized. After treatment (range, 3-18 months), thyroid hormone therapy was associated with lowering the mean thyrotropin value into the normal reference range compared with placebo (range, 0.5-3.7 mIU/L vs 4.6 to 14.7 mIU/L) but was not associated with benefit regarding general quality of life (n = 796; SMD, -0.11; 95% CI, -0.25 to 0.03; I2=66.7%) or thyroid-related symptoms (n = 858; SMD, 0.01; 95% CI, -0.12 to 0.14; I2=0.0%). Overall, risk of bias was low and the quality of evidence assessed with the GRADE tool was judged moderate to high. CONCLUSIONS AND RELEVANCE Among nonpregnant adults with subclinical hypothyroidism, the use of thyroid hormone therapy was not associated with improvements in general quality of life or thyroid-related symptoms. These findings do not support the routine use of thyroid hormone therapy in adults with subclinical hypothyroidism.
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Affiliation(s)
- Martin Feller
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care, University of Bern, Bern, Switzerland
- Departement of Endocrinology/General Internal Medicine, Leiden University Center, Leiden, the Netherlands
| | - Marieke Snel
- Departement of Endocrinology/General Internal Medicine, Leiden University Center, Leiden, the Netherlands
| | - Elisavet Moutzouri
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care, University of Bern, Bern, Switzerland
| | - Douglas C. Bauer
- Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco
| | - Maria de Montmollin
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care, University of Bern, Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ian Ford
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland
| | - Jacobijn Gussekloo
- Departement of Endocrinology/General Internal Medicine, Leiden University Center, Leiden, the Netherlands
- Department of Public Health and Primary Care, Leiden University Center, Leiden, the Netherlands
| | | | - Simon Mooijaart
- Departement of Endocrinology/General Internal Medicine, Leiden University Center, Leiden, the Netherlands
- Institute for Evidence-based Medicine in Old Age, Leiden University Center, Leiden, the Netherlands
| | - Terry Quinn
- Institute of Cardiovascular Medicine, University of Glasgow, Glasgow, Scotland
| | - David Stott
- Institute of Cardiovascular Medicine, University of Glasgow, Glasgow, Scotland
| | - Rudi Westendorp
- Department of Public Health and Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care, University of Bern, Bern, Switzerland
| | - Olaf M. Dekkers
- Departement of Endocrinology/General Internal Medicine, Leiden University Center, Leiden, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, the Netherlands
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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12
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Dąbrowska AK, Spano F, Derler S, Adlhart C, Spencer ND, Rossi RM. The relationship between skin function, barrier properties, and body-dependent factors. Skin Res Technol 2017; 24:165-174. [PMID: 29057509 DOI: 10.1111/srt.12424] [Citation(s) in RCA: 169] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Skin is a multilayer interface between the body and the environment, responsible for many important functions, such as temperature regulation, water transport, sensation, and protection from external triggers. OBJECTIVES This paper provides an overview of principal factors that influence human skin and describes the diversity of skin characteristics, its causes and possible consequences. It also discusses limitations in the barrier function of the skin, describing mechanisms of absorption. METHODS There are a number of in vivo investigations focusing on the diversity of human skin characteristics with reference to barrier properties and body-dependent factors. RESULTS Skin properties vary among individuals of different age, gender, ethnicity, and skin types. In addition, skin characteristics differ depending on the body site and can be influenced by the body-mass index and lifestyle. Although one of the main functions of the skin is to act as a barrier, absorption of some substances remains possible. CONCLUSIONS Various factors can alter human skin properties, which can be reflected in skin function and the quality of everyday life. Skin properties and function are strongly interlinked.
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Affiliation(s)
- A K Dąbrowska
- Laboratory for Biomimetic Membranes and Textiles, Empa, Swiss Federal Laboratories for Materials Science and Technology, St. Gallen, Switzerland.,Laboratory for Surface Science and Technology, Department of Materials, ETH Zürich, Zürich, Switzerland
| | - F Spano
- Laboratory for Biomimetic Membranes and Textiles, Empa, Swiss Federal Laboratories for Materials Science and Technology, St. Gallen, Switzerland
| | - S Derler
- Laboratory for Biomimetic Membranes and Textiles, Empa, Swiss Federal Laboratories for Materials Science and Technology, St. Gallen, Switzerland
| | - C Adlhart
- Institute of Chemistry and Biotechnology, Zurich University of Applied Sciences, ZHAW, Wädenswil, Switzerland
| | - N D Spencer
- Laboratory for Surface Science and Technology, Department of Materials, ETH Zürich, Zürich, Switzerland
| | - R M Rossi
- Laboratory for Biomimetic Membranes and Textiles, Empa, Swiss Federal Laboratories for Materials Science and Technology, St. Gallen, Switzerland
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Zhao T, Chen B, Zhou Y, Wang X, Zhang Y, Wang H, Shan Z. Effect of levothyroxine on the progression of carotid intima-media thickness in subclinical hypothyroidism patients: a meta-analysis. BMJ Open 2017; 7:e016053. [PMID: 29061604 PMCID: PMC5665330 DOI: 10.1136/bmjopen-2017-016053] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Subclinical hypothyroidism (SCH) has been associated with increased carotid intima-media thickness (C-IMT) in recent studies, but the effects of levothyroxine (L-T4) therapy on C-IMT in SCH patients are still controversial. AIM To evaluate the effect of L-T4 therapy on endothelial function as determined by C-IMT in patients with SCH. METHODS BeforeJuly 2016, we searched the PubMed, Embase, Cochrane Library and Google Scholar databases, selecting published randomised controlled trials (RCTs) and self-controlled trials for the meta-analysis. RESULTS Three RCTs with 117 patients were considered appropriate for the meta-analysis. The results of the meta-analysis indicated that L-T4 significantly decreased the development of C-IMT (weighted mean difference (WMD) -0.05 mm, 95% CI -0.08 to -0.01 mm; p=0.025). We also analysed nine studies (self-controlled trials) with 247 patients and extracted the IMT of SCH patients before and after L-T4 treatment. After L-T4 therapy, the pooled estimate of the WMD of decreased C-IMT was -0.04 mm (95% CI -0.07 to -0.02 mm; p=0.05). Subgroup analysis showed that L-T4 therapy was associated with a decrease in C-IMT among patients of mixed genders (WMD -0.03 mm, 95% CI -0.06 to -0.01 mm; p=0.145). L-T4 therapy was associated with a decrease in C-IMT among female patients (WMD -0.07 mm, 95% CI -0.14 to -0.01; p=0.186). Longer treatment (>6 months) also resulted in a significant decrease in C-IMT (WMD -0.05 mm, 95% CI -0.08 to -0.02; p=0.335). CONCLUSION This meta-analysis indicates that L-T4 treatment of SCH patients can reduce C-IMT, possibly as a result of the reduction of total cholesterol, triglyceride, low density lipoprotein, systolic blood pressure, diastolic blood pressure, lipoprotein(a), and flow-mediated dilatation. Decreased C-IMT was observed in SCH patients after long-term (>6 months) L-T4 treatment. RCTs with larger samples are needed to verify these observations.
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Affiliation(s)
- Tong Zhao
- Department of Endocrinology and Metabolism, Institute of Endocrinology, First Affiliated Hospital, Chinese Medical University, Shenyang, Liaoning, China
| | - Baomin Chen
- Department of Liver and Gall Surgery, First Affiliated Hospital, Chinese Medical University, Shenyang, Liaoning, China
| | - Yingying Zhou
- Department of Endocrinology and Metabolism, Institute of Endocrinology, First Affiliated Hospital, Chinese Medical University, Shenyang, Liaoning, China
| | - Xinyi Wang
- Department of Endocrinology and Metabolism, Institute of Endocrinology, First Affiliated Hospital, Chinese Medical University, Shenyang, Liaoning, China
| | - Yuanyuan Zhang
- Department of Endocrinology and Metabolism, Institute of Endocrinology, First Affiliated Hospital, Chinese Medical University, Shenyang, Liaoning, China
| | - Haoyu Wang
- Department of Endocrinology and Metabolism, Institute of Endocrinology, First Affiliated Hospital, Chinese Medical University, Shenyang, Liaoning, China
| | - Zhongyan Shan
- Department of Endocrinology and Metabolism, Institute of Endocrinology, First Affiliated Hospital, Chinese Medical University, Shenyang, Liaoning, China
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Juárez-Cedillo T, Basurto-Acevedo L, Vega-García S, Sánchez-Rodríguez Martha A, Retana-Ugalde R, Juárez-Cedillo E, Gonzalez-Melendez Roberto C, Escobedo-de-la-Peña J. Prevalence of thyroid dysfunction and its impact on cognition in older mexican adults: (SADEM study). J Endocrinol Invest 2017; 40:945-952. [PMID: 28343318 DOI: 10.1007/s40618-017-0654-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 03/07/2017] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Subclinical thyroid dysfunction is a possible risk factor for cognitive impairment in old age, but results are inconsistent. Aim of the present study was to evaluate the prevalence of thyroid dysfunction among older community-dwelling adults and to see whether thyroid function impacts the cognitive status of the elderly. METHODS We included 1750 participants from the Study on Aging and Dementia in Mexico (SADEM). All subjects were evaluated clinically via specific interviews. TSH levels were analyzed by chemiluminescent immunometry assay. We classified participants into five thyroid state groups: (1) normal TSH levels (0.40-4.0 IU/L) were considered euthyroid; (2) Overt hyperthyroidism: TSH <0.3 IU/l and FT4 >23 pmol/l; (3) Overt hypothyroidism: TSH >4.8 IU/l, FT4 <13 pmol/l; (4) Subclinical hyperthyroidism: TSH <0.3 IU/l, FT4: 13-23 pmol/l; (5) Subclinical hypothyroidism: TSH >4.8 IU/l, FT4: 13-23 pmol/l. RESULTS The overall estimated prevalence of thyroid dysfunction in Mexican population was 23.7% (95% CI, 22.66-26.77). Of these, 15.4% older adults were classified as subclinical hypothyroidism, 7.2% overt hypothyroidism, 0.5% subclinical hyperthyroidism, and 0.6% overt hyperthyroidism. The association of thyroid dysfunction with cognitive impairment was most evident in overt hypothyroidism OR = 1.261 (1.185-1.343). CONCLUSIONS The present study demonstrated a high prevalence of thyroid dysfunction in Mexican elderly people living in the community. A relationship between cognitive impairment and the presence of hypothyroidism was also shown, and to a lesser degree in hyperthyroidism.
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Affiliation(s)
- T Juárez-Cedillo
- Unidad de Investigación en Epidemiología Clínica, Hospital General Regional No 1 Carlos McGregor Sánchez Navarro, Gabriel Mancera 222, Colonia Del Valle, Delegación, Benito Juárez, 03100, México, DF, Mexico.
- High Studies (FES) Zaragoza, National Autonomous University of Mexico, Mexico City, Mexico.
| | - L Basurto-Acevedo
- Endocrine Research Unit, National Medical Center, Mexican Institute of Social Security, Mexico City, Mexico
| | - S Vega-García
- Endocrine Research Unit, National Medical Center, Mexican Institute of Social Security, Mexico City, Mexico
| | - A Sánchez-Rodríguez Martha
- Gerontology Research Unit. Faculty of High Studies (FES) Zaragoza, National Autonomous University of Mexico, Mexico City, Mexico
| | - R Retana-Ugalde
- Gerontology Research Unit. Faculty of High Studies (FES) Zaragoza, National Autonomous University of Mexico, Mexico City, Mexico
| | - E Juárez-Cedillo
- Unidad de Investigación en Epidemiología Clínica, Hospital General Regional No 1 Carlos McGregor Sánchez Navarro, Gabriel Mancera 222, Colonia Del Valle, Delegación, Benito Juárez, 03100, México, DF, Mexico
| | | | - J Escobedo-de-la-Peña
- Unidad de Investigación en Epidemiología Clínica, Hospital General Regional No 1 Carlos McGregor Sánchez Navarro, Gabriel Mancera 222, Colonia Del Valle, Delegación, Benito Juárez, 03100, México, DF, Mexico
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Abstract
Subclinical hypothyroidism (SCH) represents a mild or compensated form of primary hypothyroidism. The diagnosis of SCH is controversial, as its symptoms are non-specific and its biochemical diagnosis is arbitrary. The treatment of SCH was examined among non-pregnant adults, pregnant adults and children. In non-pregnant adults, treatment of SCH may prevent its progression to overt hypothyroidism, reduce the occurrence of coronary heart disease, and improve neuropsychiatric and musculoskeletal symptoms associated with hypothyroidism. These benefits are counteracted by cardiovascular, neuropsychiatric and musculoskeletal side effects. SCH is associated with adverse maternal and fetal outcomes that may improve with treatment. Treating SCH in children is safe and may improve growth. Importantly, the evidence in this field is largely from retrospective and prospective studies with design limitations, which precludes a conclusive recommendation for the treatment of SCH.
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Li X, Wang Y, Guan Q, Zhao J, Gao L. The lipid-lowering effect of levothyroxine in patients with subclinical hypothyroidism: A systematic review and meta-analysis of randomized controlled trials. Clin Endocrinol (Oxf) 2017; 87:1-9. [PMID: 28342184 DOI: 10.1111/cen.13338] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Revised: 03/12/2017] [Accepted: 03/12/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Dyslipidaemia is common in patients with subclinical hypothyroidism (SCH). To date, there is no universal agreement regarding the lipid-lowering effect of substitution treatment with L-T4 in patients with SCH. We aimed to clarify the effect by conducting this systematic review and meta-analysis of randomized controlled trials (RCTs). DESIGN We systematically searched PubMed, the Cochrane Library, ClinicalTrials.gov and EMBASE for RCTs comparing substitution treatment to placebo treatment or observation. We focused on the primary outcomes of changes from baseline of total, low-density lipoprotein and high-density lipoprotein cholesterol (TC, LDL-C and HLD-C) and triglycerides. Subgroup analyses were performed, assessing the effect of treatment duration, disease severity and ethnicity on the occurrence of discrepancy. RESULTS Twelve trials, with 940 participants, were eligible for analysis. Compared with the control group, levothyroxine substitution yielded a mean reduction in TC (-0.29 mmol/L, [-0.42 to -0.16]) and LDL-C (-0.22 mmol/L, [-0.36 to -0.09]), with no significant effects on HDL-C (-0.04 mmol/L, [-0.08 to 0.01]) or triglycerides (-0.04 mmol/L, [-0.08 to 0.00]). Trials in which only patients with mild SCH (thyrotropin <10 mIU/L) were enrolled showed equivalent effects. The lowering effects were weaker, but still significant, in long-term treatment (>6 months) compared with short-term treatment (≤6 months) for TC (-0.19 mmol/L [-0.35, -0.03] vs -0.50 mmol/L [-0.68, -0.31], P=.047) and LDL-C (-0.09 mmol/L [-0.16, -0.02] vs -0.46 mmol/L [-0.68, -0.25], P=.006). CONCLUSIONS Levothyroxine treatment has clear benefits on TC and LDL-C in SCH patients, including those with mild SCH.
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Affiliation(s)
- Xiang Li
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong, China
| | - Yupeng Wang
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong, China
| | - Qingbo Guan
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong, China
| | - Jiajun Zhao
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong, China
| | - Ling Gao
- Scientific Center, Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong, China
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Pandrc MS, Ristić A, Kostovski V, Stanković M, Antić V, Milin-Lazović J, Ćirić J. The Effect of Early Substitution of Subclinical Hypothyroidism on Biochemical Blood Parameters and the Quality of Life. J Med Biochem 2017; 36:127-136. [PMID: 28680356 PMCID: PMC5471645 DOI: 10.1515/jomb-2017-0007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 01/29/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Subclinical hypothyroidism (SCH) is defined as high TSH and normal thyroxine. Data on the effects of early substitution by levothyroxine on psychophysical health in SCH are still not consistent enough to support its introduction. METHODS Clinical parameters, biochemical data and quality of life (Short Form 36 questionnaire) were measured before the intervention and 3 months after the euthyroid state had been achieved in SCH patients. RESULTS Significant reduction in body weight (p=0.030), systolic and diastolic blood pressure (p=0.024, p=0.019), homocysteine (p<0.001), leukocytes and neutrophils (p=0.011, p=0.001), INR (p=0.049), K levels (p=0.040, p=0.013), HbA1c (p=0.001), fasting insulin (p<0.001) and insulin resistance measured by HOMA index (p<0.001), lipid parameters (total cholesterol (p<0.001), LDL-cholesterol (p<0.001), triglycerides (p=0.007), apoB (p=0.022), Lp(a) (p<0.001), LDL/HDL (p=0.008), LAP (p=0.04) and apoB/apoA1 ratios (p<0.023)), TSH (p<0.001) and tAbs (p<0.001) was recorded. Frequency of fatty liver (20% to 2.9%, p=0.016), hyperlipidemia (85% to 65.7%, p=0.001) and metabolic syndrome (34.3% to 2.9%, p=0.070) significantly decreased. A statistically significant positive association was found between the average dose of levothyroxine and changes in physical functioning (r=0.391, p=0.020), vitality (r=0.393, p=0.020), mental health (r=0.374, p=0.027) and overall dimensions of mental health (r=0.376, p=0.026). With increasing doses of levothyroxine, the previously listed scores of SF 36 grew (r=0.296, p=0.084). CONCLUSIONS Early substitution of SCH improved the many clinical and biochemical parameters related to cardiovascular risk. Quality of life was also improved, and correlated only with thyroxine doses suggesting an indirect relationship between the degree of hypothyroidism and quality of life.
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Affiliation(s)
- Milena S Pandrc
- Department of Internal Medicine, Military Medical Academy, Belgrade, Serbia
| | - Anđelka Ristić
- Department of Urgent Internal Medicine, Military Medical Academy, Belgrade, Serbia
| | - Vanja Kostovski
- Clinic for Thoracic Surgery, Military Medical Academy, Belgrade, Serbia
| | - Marko Stanković
- Primary Medical Centre »Dr Simo Milošević«, Belgrade, Serbia
| | - Vladimir Antić
- Department of Radiology, Military Medical Academy, Belgrade, Serbia
| | - Jelena Milin-Lazović
- Institute for Medical Statistics and Informatics, Clinical Center of Serbia, Belgrade, Serbia
| | - Jasmina Ćirić
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, University of Belgrade School of Medicine, Belgrade, Serbia
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Abreu IM, Lau E, de Sousa Pinto B, Carvalho D. Subclinical hypothyroidism: to treat or not to treat, that is the question! A systematic review with meta-analysis on lipid profile. Endocr Connect 2017; 6:188-199. [PMID: 28249936 PMCID: PMC5428911 DOI: 10.1530/ec-17-0028] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 03/01/2017] [Indexed: 01/07/2023]
Abstract
Previous studies suggested that subclinical hypothyroidism has a detrimental effect on cardiovascular risk factors, and that its effective treatment may have a beneficial impact on overall health. The main purpose of this review and meta-analysis was to assess whether subclinical hypothyroidism treatment is of clinical relevance, based on cardiovascular risk parameters correction. A systemic research of the literature using MEDLINE tool was performed to identify the relevant studies. Only placebo-controlled randomized control trials were included. A quantitative analysis was also performed. This systematic review and meta-analysis of randomized placebo-controlled trials assess the different impact of levothyroxine vs placebo treatment. A significant decrease in serum thyroid-stimulating hormone and total and low-density lipoprotein cholesterol was obtained with levothyroxine therapy (66, 9 and 14%, respectively) and, although modest, this could be significant in terms of reduction of the incidence of coronary artery disease. Other significant results of lipid parameters were not obtained. This systematic review provides a strong evidence-based data in favour of specific changes and beneficial effects of levothyroxine treatment.
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Affiliation(s)
- Isabel M Abreu
- Faculty of MedicineUniversity of Porto, Alameda Professor Hernâni Monteiro, Porto, Portugal
| | - Eva Lau
- Faculty of MedicineUniversity of Porto, Alameda Professor Hernâni Monteiro, Porto, Portugal
- Department of EndocrinologyDiabetes and Metabolism, Centro Hospitalar S. João, Alameda Professor Hernâni Monteiro, Porto, Portugal
- Instituto de Investigação e Inovação em SaúdeUniversidade do Porto, Porto, Portugal
| | | | - Davide Carvalho
- Faculty of MedicineUniversity of Porto, Alameda Professor Hernâni Monteiro, Porto, Portugal
- Department of EndocrinologyDiabetes and Metabolism, Centro Hospitalar S. João, Alameda Professor Hernâni Monteiro, Porto, Portugal
- Instituto de Investigação e Inovação em SaúdeUniversidade do Porto, Porto, Portugal
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19
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Lucy JM, Peterson ME, Randolph JF, Scrivani PV, Rishniw M, Davignon DL, Thompson MS, Scarlett JM. Efficacy of Low-dose (2 millicurie) versus Standard-dose (4 millicurie) Radioiodine Treatment for Cats with Mild-to-Moderate Hyperthyroidism. J Vet Intern Med 2017; 31:326-334. [PMID: 28158908 PMCID: PMC5354058 DOI: 10.1111/jvim.14646] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 09/18/2016] [Accepted: 11/29/2016] [Indexed: 12/02/2022] Open
Abstract
Background Radioiodine (131I) is effective treatment for hyperthyroidism in cats, but optimal dose to restore euthyroidism without inducing hypothyroidism is unclear. Treatment‐induced hypothyroidism can lead to azotemia and reduced duration of survival. Objective To compare efficacy and short‐term outcomes of low‐dose 131I versus higher, standard‐dose 131I as treatment for hyperthyroidism. Animals A total of 189 client‐owned cats undergoing 131I treatment for mild‐to‐moderate hyperthyroidism (serum T4 ≥ 4.0 μg/dL and <13.0 μg/dL). Methods Prospective, nonrandomized, cohort study comparing treatment with either low‐dose (2 mCi, n = 150) or standard‐dose (4 mCi, n = 39) 131I. Serum T4, thyroid‐stimulating hormone (TSH), and creatinine concentrations were measured after 1, 3, and 6 months to determine persistent hyperthyroidism, overt hypothyroidism (low T4, high TSH), subclinical hypothyroidism (normal T4, high TSH), and azotemia. Results There was no significant difference in prevalence of cats with persistent hyperthyroidism between standard‐ and low‐dose treatment groups at 3 (0% versus 5.3%; P = .34) and 6 (0% versus 3.3%; P = .51) months. Overt (18% versus 1%; P = .0005) or subclinical (46% versus 21%; P = .004) hypothyroidism was more common in cats at 6 months after standard‐dose 131I. No difference in incidence of azotemia existed between groups, but cats treated with standard‐dose 131I had higher creatinine concentrations (P < .05) and higher percent rises in creatinine (P < .0001). Conclusions and Clinical Importance Low‐dose 131I is safe and effective for cats with mild‐to‐moderate hyperthyroidism, as evidenced by a cure rate of >95% with reduced frequency of iatrogenic hypothyroidism and azotemia.
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Affiliation(s)
- J M Lucy
- Departments of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY
| | | | - J F Randolph
- Departments of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY
| | - P V Scrivani
- Departments of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY
| | - M Rishniw
- Departments of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY
| | - D L Davignon
- Departments of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY
| | - M S Thompson
- Departments of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY
| | - J M Scarlett
- Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY
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Li X, Meng Z, Jia Q, Ren X. Effect of L-thyroxine treatment versus a placebo on serum lipid levels in patients with sub-clinical hypothyroidism. Biomed Rep 2016; 5:443-449. [PMID: 27699011 DOI: 10.3892/br.2016.745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 08/10/2016] [Indexed: 01/16/2023] Open
Abstract
Sub-clinical hypothyroidism is a common disease and whether L-thyroxine replacement treatment improves serum lipid levels in affected patients remains controversial. Thus, the aim of the present meta-analysis was to assess the effect of L-thyroxine therapy on serum lipid levels in sub-clinical hyperthyroidism. Relevant randomized controlled trials (RCTs) containing continuous data, published until July 2015 were retrieved from the Cochrane Library, PubMed, Medline, Google Scholar and Embase databases and subjected to meta-analysis using Review Manager software version 5.2 (The Nordic Cochrane Centre, Copenhagen, Denmark). Seven RCTs comprising 319 patients were included. The overall methodological quality of the RCTs was good. Statistical analysis revealed that serum low-density lipoprotein-cholesterol (LDL-C) levels were significantly decreased after L-thyroxine treatment [mean difference (MD): -0.23; 95% confidence interval: -0.44, -0.03; P=0.02], while changes of total cholesterol (TC), triglyceride (TG) and high-density lipoprotein-cholesterol (HDL-C) were not significant (MD: -0.18, P=0.09; MD: -0.02, P=0.78; and MD: -0.06, P=0.14, respectively). In conclusion, the meta-analysis performed in the present study revealed that compared with placebo treatment, L-thyroxine significantly improved serum LDL-C levels in patients with sub-clinical hypothyroidism, while not significantly affecting TC, TG and HDL-C levels.
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Affiliation(s)
- Xue Li
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Heping, Tianjin 300052, P.R. China
| | - Zhaowei Meng
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Heping, Tianjin 300052, P.R. China
| | - Qiang Jia
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Heping, Tianjin 300052, P.R. China
| | - Xiaojun Ren
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Heping, Tianjin 300052, P.R. China
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Bonora BM, Fadini GP. Subclinical Hypothyroidism and Metabolic Syndrome: A Common Association by Chance or a Cardiovascular Risk Driver? Metab Syndr Relat Disord 2016; 14:378-380. [PMID: 27551743 DOI: 10.1089/met.2016.29009.bon] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The metabolic syndrome (MS) and subclinical hypothyroidism (SCH) are highly prevalent in the general population. Cross-sectional epidemiological data suggest that a mutual association exists between the two, although the cause-effect relationship remains poorly elucidated. As SCH raises cholesterol, blood pressure, and visceral fat, it is easy to understand why it associates with MS. Rather, the reasons whereby MS patients are at higher risk for SCH are less apparent. Some studies have reported that SCH is itself characterized by high cardiovascular risk. Therefore, the coexistence of SCH and MS may identify subjects at a particularly high risk for future cardiovascular events. Recent data published in Metabolic Syndrome and Related Disorders indicate that carotid intima-media thickness, a marker of initial atherosclerosis and a possible predictor of future events, is higher in patients with both SCH and MS than in the presence of each condition alone. In this Editorial, we discuss the clinical implications of SCH and MS association and the interpretation of such recent findings.
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Affiliation(s)
- Benedetta Maria Bonora
- Department of Medicine, Division of Metabolic Diseases, University of Padova , Padova, Italy
| | - Gian Paolo Fadini
- Department of Medicine, Division of Metabolic Diseases, University of Padova , Padova, Italy
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22
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Duntas L, Krassas G, Mantzou E, Koutras D. Effectiveness of Combined Treatment with L-Thyroxine and Iron Proteinsuccinylate in Patients with Subclinical Hypothyroidism and Manifested Sideropenic Anemia. Nutr Neurosci 2016. [DOI: 10.1080/1028415x.2000.11747340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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23
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Celi FS. A MUCH-NEEDED HISTORIC PERSPECTIVE ON THE THERAPEUTIC USE OF THYROID HORMONES. Endocr Pract 2015. [PMID: 26214106 DOI: 10.4158/ep15875.co] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Levothyroxine Substitution in Patients with Subclinical Hypothyroidism and the Risk of Myocardial Infarction and Mortality. PLoS One 2015; 10:e0129793. [PMID: 26069971 PMCID: PMC4466400 DOI: 10.1371/journal.pone.0129793] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 05/12/2015] [Indexed: 01/07/2023] Open
Abstract
Background Subclinical hypothyroidism is associated with a number of cardiovascular risk factors, yet only limited data exist on long-term outcome of levothyroxine treatment of this condition with respect to hard end-points. The aim of this retrospective cohort study was to determine effects of levothyroxine treatment on myocardial infarction (MI), cardiovascular death and all-cause mortality, in patients with subclinical hypothyroidism. Methods and Results Primary care patients aged 18 years and older that underwent thyroid function tests between 2000 and 2009 were enrolled. Participants were identified by individual-level linkage of nationwide registers. Patients with subclinical hypothyroidism at baseline were included in the study. Exclusion criteria included a history of thyroid disease, related medication or medication affecting thyroid function. The total cohort comprised 628,953 patients of which 12,212 (1.9%) had subclinical hypothyroidism (mean age 55.2 [SD ± 18.8] years; 79.8% female). Within the first six months 2,483 (20.3%) patients claimed a prescription for levothyroxine. During a median follow-up of 5.0 (IQR: 5.2) years, 358 MI’s and 1,566 (12.8%) deaths were observed. Out of these, 766 of the deaths were cardiovascular related. No beneficial effects were found in levothyroxine treated patients on MI (IRR 1.08 [95% CI: 0.81 to 1.44]), cardiovascular death (IRR 1.02 [95% CI: 0.83 to 1.25]) or all-cause mortality (IRR 1.03 [95% CI: 0.90 to 1.19]), except in patients under the age of 65 years (IRR 0.63 [95% CI: 0.40 to 0.99]). Conclusion Levothyroxine substitution in subclinical hypothyroid patients does not indicate an association with lower mortality or decreased risk of MI.
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25
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LeFevre ML. Screening for thyroid dysfunction: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2015; 162:641-50. [PMID: 25798805 DOI: 10.7326/m15-0483] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
DESCRIPTION Update of the 2004 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for thyroid disease. METHODS The USPSTF reviewed the evidence on the benefits and harms of screening for subclinical and "overt" thyroid dysfunction without clinically obvious symptoms, as well as the effects of treatment on intermediate and final health outcomes. POPULATION This recommendation applies to nonpregnant, asymptomatic adults. RECOMMENDATION The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for thyroid dysfunction in nonpregnant, asymptomatic adults. (I statement).
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Rugge JB, Bougatsos C, Chou R. Screening and treatment of thyroid dysfunction: an evidence review for the U.S. Preventive Services Task Force. Ann Intern Med 2015; 162:35-45. [PMID: 25347444 DOI: 10.7326/m14-1456] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In 2004, the U.S. Preventive Services Task Force found insufficient evidence to recommend thyroid screening. PURPOSE To update the 2004 U.S. Preventive Services Task Force review on the benefits and harms of screening and treatment of subclinical and undiagnosed overt hypothyroidism and hyperthyroidism in adults without goiter or thyroid nodules. DATA SOURCES MEDLINE and Cochrane databases through July 2014. STUDY SELECTION Randomized, controlled trials and observational studies of screening and treatment. DATA EXTRACTION One investigator abstracted data, and a second investigator confirmed; 2 investigators independently assessed study quality. DATA SYNTHESIS No study directly assessed benefits and harms of screening versus no screening. For subclinical hypothyroidism (based on thyroid-stimulating hormone levels of 4.1 to 11.0 mIU/L), 1 fair-quality cohort study found that treatment of subclinical hypothyroidism was associated with decreased risk for coronary heart disease events versus no treatment. No study found that treatment was associated with improved quality of life, cognitive function, blood pressure, or body mass index versus no treatment. Effects of treatment versus no treatment showed potential beneficial effects on lipid levels, but effects were inconsistent, not statistically significant in most studies, and of uncertain clinical significance (difference, -0.7 to 0 mmol/L [-28 to 0 mg/dL] for total cholesterol levels and -0.6 to 0.1 mmol/L [-22 to 2 mg/dL] for low-density lipoprotein cholesterol levels). Treatment harms were poorly studied and sparsely reported. Two poor-quality studies evaluated treatment of subclinical hyperthyroidism but examined intermediate outcomes. No study evaluated treatment versus no treatment of screen-detected, undiagnosed overt thyroid dysfunction. LIMITATION English-language articles only, no treatment study performed in the United States, and small trials with short duration that used different dosage protocols. CONCLUSION More research is needed to determine the clinical benefits associated with thyroid screening. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.
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Affiliation(s)
- J. Bruin Rugge
- From Oregon Health & Science University, Portland, Oregon
| | | | - Roger Chou
- From Oregon Health & Science University, Portland, Oregon
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Sun X, Sun Y, Li WC, Chen CY, Chiu YH, Chien HY, Wang Y. Association of thyroid-stimulating hormone and cardiovascular risk factors. Intern Med 2015; 54:2537-44. [PMID: 26466686 DOI: 10.2169/internalmedicine.54.4514] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Thyroid hormone plays an important role in regulating the lipid and glucose metabolism. Previously, much attention has been drawn to define the pathophysiological relationship between thyroid dysfunction and the incidence of cardiovascular diseases (CVDs). While the conditions of overt hypothyroidism and subclinical hypothyroidism were both emphasized, the association between CVD risks and the deregulated circulating thyroid-stimulating hormone (TSH) level remains to be elucidated. Nevertheless, multiple TSH-mediated physiological adaptations, including alteration of the serum lipids, body mass index, blood pressure and insulin sensitivity, have led to the difficulty of clearly examining the association between the TSH level and CVD prevalence. The current review aims to 1) summarize the evidence for the role of thyroid dysfunction and TSH abnormality in CVD pathogenesis and 2) explore the possible underlying molecular mechanisms of TSH-mediated cardiovascular pathology in hopes of providing better therapeutic strategies for the patients with deregulated TSH.
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Affiliation(s)
- Xianglan Sun
- Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong University, China
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Çatlı G, Anık A, Tuhan HÜ, Böber E, Abacı A. The effect of L-thyroxine treatment on hypothyroid symptom scores and lipid profile in children with subclinical hypothyroidism. J Clin Res Pediatr Endocrinol 2014; 6:238-44. [PMID: 25541895 PMCID: PMC4293659 DOI: 10.4274/jcrpe.1594] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To evaluate i) the frequency of typical hypothyroidism symptoms in children with subclinical hypothyroidism (SH), ii) to evaluate the association of SH with lipoproteins and iii) to investigate possible improving effects of L-thyroxine (LT4) treatment on these findings. METHODS Twenty-seven children with SH who had elevated thyroid-stimulating hormone (TSH: >4.94 µIU/L) but normal free T4 levels and healthy euthyroid children of similar age and sex were enrolled in the study. Anthropometric and laboratory (lipid profile and thyroid function tests) measurements were performed at diagnosis and six months after euthyroidism was achieved. All children were also subjected to a questionnaire on hypothyroid symptoms at diagnosis. The SH patients were subjected to the questionnaire also following treatment. Pre-treatment data were compared with those of controls and post-treatment measurements. RESULTS Anthropometric and laboratory parameters of the groups were not statistically different except for higher TSH levels in the SH group. Serum lipoprotein levels and dyslipidemia frequency were similar between the groups. Compared to the controls, hypothyroidism symptom score was significantly higher in the SH group. Six months after euthyroidism was achieved, a significant reduction in the hypothyroid symptom score was obtained in the SH group. Except for significantly higher serum TSH values, no significant differences regarding demographic characteristics, symptom scores and lipid parameters were present between patients with Hashimoto's thyroiditis and the remaining SH patients. CONCLUSION The results of this study showed that in children with SH i) the hypothyroidism symptom score was significantly higher than in euthyroid children, ii) LT4 treatment improved the hypothyroidism symptom score and iii) SH does not seem to be associated with dyslipidemia.
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Affiliation(s)
- Gönül Çatlı
- Dokuz Eylül University Faculty of Medicine, Department of Pediatric Endocrinology, İzmir, Turkey. E-mail:
| | - Ahmet Anık
- Dokuz Eylül University Faculty of Medicine, Department of Pediatric Endocrinology, İzmir, Turkey
| | - Hale Ünver Tuhan
- Dokuz Eylül University Faculty of Medicine, Department of Pediatric Endocrinology, İzmir, Turkey
| | - Ece Böber
- Dokuz Eylül University Faculty of Medicine, Department of Pediatric Endocrinology, İzmir, Turkey
| | - Ayhan Abacı
- Dokuz Eylül University Faculty of Medicine, Department of Pediatric Endocrinology, İzmir, Turkey
,* Address for Correspondence: Dokuz Eylül University Faculty of Medicine, Department of Pediatric Endocrinology, İzmir, Turkey Phone: +90 232 412 6076 E-mail:
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Jonklaas J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, Cooper DS, Kim BW, Peeters RP, Rosenthal MS, Sawka AM. Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid 2014; 24:1670-751. [PMID: 25266247 PMCID: PMC4267409 DOI: 10.1089/thy.2014.0028] [Citation(s) in RCA: 935] [Impact Index Per Article: 93.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND A number of recent advances in our understanding of thyroid physiology may shed light on why some patients feel unwell while taking levothyroxine monotherapy. The purpose of this task force was to review the goals of levothyroxine therapy, the optimal prescription of conventional levothyroxine therapy, the sources of dissatisfaction with levothyroxine therapy, the evidence on treatment alternatives, and the relevant knowledge gaps. We wished to determine whether there are sufficient new data generated by well-designed studies to provide reason to pursue such therapies and change the current standard of care. This document is intended to inform clinical decision-making on thyroid hormone replacement therapy; it is not a replacement for individualized clinical judgment. METHODS Task force members identified 24 questions relevant to the treatment of hypothyroidism. The clinical literature relating to each question was then reviewed. Clinical reviews were supplemented, when relevant, with related mechanistic and bench research literature reviews, performed by our team of translational scientists. Ethics reviews were provided, when relevant, by a bioethicist. The responses to questions were formatted, when possible, in the form of a formal clinical recommendation statement. When responses were not suitable for a formal clinical recommendation, a summary response statement without a formal clinical recommendation was developed. For clinical recommendations, the supporting evidence was appraised, and the strength of each clinical recommendation was assessed, using the American College of Physicians system. The final document was organized so that each topic is introduced with a question, followed by a formal clinical recommendation. Stakeholder input was received at a national meeting, with some subsequent refinement of the clinical questions addressed in the document. Consensus was achieved for all recommendations by the task force. RESULTS We reviewed the following therapeutic categories: (i) levothyroxine therapy, (ii) non-levothyroxine-based thyroid hormone therapies, and (iii) use of thyroid hormone analogs. The second category included thyroid extracts, synthetic combination therapy, triiodothyronine therapy, and compounded thyroid hormones. CONCLUSIONS We concluded that levothyroxine should remain the standard of care for treating hypothyroidism. We found no consistently strong evidence for the superiority of alternative preparations (e.g., levothyroxine-liothyronine combination therapy, or thyroid extract therapy, or others) over monotherapy with levothyroxine, in improving health outcomes. Some examples of future research needs include the development of superior biomarkers of euthyroidism to supplement thyrotropin measurements, mechanistic research on serum triiodothyronine levels (including effects of age and disease status, relationship with tissue concentrations, as well as potential therapeutic targeting), and long-term outcome clinical trials testing combination therapy or thyroid extracts (including subgroup effects). Additional research is also needed to develop thyroid hormone analogs with a favorable benefit to risk profile.
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Affiliation(s)
| | - Antonio C. Bianco
- Division of Endocrinology, Rush University Medical Center, Chicago, Illinois
| | - Andrew J. Bauer
- Division of Endocrinology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kenneth D. Burman
- Endocrine Section, Medstar Washington Hospital Center, Washington, DC
| | - Anne R. Cappola
- Division of Endocrinology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Francesco S. Celi
- Division of Endocrinology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - David S. Cooper
- Division of Endocrinology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brian W. Kim
- Division of Endocrinology, Rush University Medical Center, Chicago, Illinois
| | - Robin P. Peeters
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - M. Sara Rosenthal
- Program for Bioethics, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Anna M. Sawka
- Division of Endocrinology, University Health Network and University of Toronto, Toronto, Ontario, Canada
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Brenta G, Vaisman M, Sgarbi JA, Bergoglio LM, Andrada NCD, Bravo PP, Orlandi AM, Graf H. Clinical practice guidelines for the management of hypothyroidism. ACTA ACUST UNITED AC 2014; 57:265-91. [PMID: 23828433 DOI: 10.1590/s0004-27302013000400003] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Accepted: 04/01/2013] [Indexed: 01/07/2023]
Abstract
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.
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Carter Y, Sippel RS, Chen H. Hypothyroidism after a cancer diagnosis: etiology, diagnosis, complications, and management. Oncologist 2014; 19:34-43. [PMID: 24309982 PMCID: PMC3903058 DOI: 10.1634/theoncologist.2013-0237] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 09/12/2013] [Indexed: 01/18/2023] Open
Abstract
Hypothyroidism is a common disease that is easily treated in the majority of cases, when readily diagnosed; however, presentation of an aggregate of its symptoms is often clinically overlooked or attributed to another disease and can potentially be lethal. Already prevalent in older women, its occurrence in younger patients is rising as a result of radiation therapy, radioactive iodine therapy, and newer antineoplastic agents used to manage various malignancies. The presence of nonspecific constitutional symptoms and neuropsychiatric complaints in cancer patients can be attributed to a myriad of other diagnoses and therapies. Thyroid dysfunction can be easily overlooked in cancer patients because of the complexity of cancer's clinical picture, particularly in the pediatric population. Underdiagnosis can have important consequences for the management of both hypothyroidism and the malignancy. At minimum, quality of life is adversely affected. Untreated hypothyroidism can lead to heart failure, psychosis, and coma and can reduce the effectiveness of potentially life-saving cancer therapies, whereas iatrogenic causes can provoke atrial fibrillation and osteoporosis. Consequently, the diagnosis and treatment of hypothyroidism in cancer patients are pertinent. We summarize the history, epidemiology, pathophysiology, clinical diagnosis, and management of hypothyroidism in cancer patients.
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Affiliation(s)
- Yvette Carter
- Section of Endocrine Surgery, University of Wisconsin, Madison, Wisconsin, USA
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Tognini S, Pasqualetti G, Calsolaro V, Polini A, Caraccio N, Monzani F. Cardiovascular risk and quality of life in elderly people with mild thyroid hormone deficiency. Front Endocrinol (Lausanne) 2014; 5:153. [PMID: 25339939 PMCID: PMC4188129 DOI: 10.3389/fendo.2014.00153] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 09/12/2014] [Indexed: 01/06/2023] Open
Abstract
Subclinical hypothyroidism (sHT) is a common condition in the general population, the prevalence increases with age, especially in women. An association between sHT and increased coronary heart disease (CHD) and heart failure (HF) risk and mortality has been described. However, this association is far to be established in older people (>65 years), especially in the oldest old (>85 years). Individuals with sHT may experience symptoms that resemble those observed in the overt form of the disease, leading to an impaired quality of life (QoL). Although very old people are frequently frail and potentially more susceptible to the effects of a disease, few studies were designed to assess the effect of sHT on QoL in this subset of population. Interestingly, the serum TSH concentration curve of general population has a skewed distribution with a "tail" toward higher values, which is amplified with aging. Thus, the diagnosis of sHT and the interpretation of its potential effects on CV function and QoL in older people may be a challenge for the clinician. Giving these premises, we reviewed the English scientific literature available on National Library of Medicine (www.pubmed.com) since 1980 regarding hypothyroidism, sHT, elderly, cardiovascular risk, CHD or HF events and mortality, health-related QoL, and LT4 therapy. Consistent results among large prospective cohort studies suggest an age-independent relationship between sHT and HF progression, while an impact of sHT on CHD events and mortality is essentially reported in young adults (aged below 65-70 years) with long-lasting disease. Scanty data are available on QoL of older people with sHT (>65 years) and, generally, no significant alterations are described.
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Affiliation(s)
- Sara Tognini
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giuseppe Pasqualetti
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Valeria Calsolaro
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Antonio Polini
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Nadia Caraccio
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Fabio Monzani
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- *Correspondence: Fabio Monzani, Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Via Paradisa, Pisa 56100, Italy e-mail:
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Pearce SHS, Brabant G, Duntas LH, Monzani F, Peeters RP, Razvi S, Wemeau JL. 2013 ETA Guideline: Management of Subclinical Hypothyroidism. Eur Thyroid J 2013; 2:215-28. [PMID: 24783053 PMCID: PMC3923601 DOI: 10.1159/000356507] [Citation(s) in RCA: 418] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 10/07/2013] [Indexed: 01/08/2023] Open
Abstract
Subclinical hypothyroidism (SCH) should be considered in two categories according to the elevation in serum thyroid-stimulating hormone (TSH) level: mildly increased TSH levels (4.0-10.0 mU/l) and more severely increased TSH value (>10 mU/l). An initially raised serum TSH, with FT4 within reference range, should be investigated with a repeat measurement of both serum TSH and FT4, along with thyroid peroxidase antibodies, preferably after a 2- to 3-month interval. Even in the absence of symptoms, replacement therapy with L-thyroxine is recommended for younger patients (<65-70 years) with serum TSH >10 mU/l. In younger SCH patients (serum TSH <10 mU/l) with symptoms suggestive of hypothyroidism, a trial of L-thyroxine replacement therapy should be considered. For such patients who have been started on L-thyroxine for symptoms attributed to SCH, response to treatment should be reviewed 3 or 4 months after a serum TSH within reference range is reached. If there is no improvement in symptoms, L-thyroxine therapy should generally be stopped. Age-specific local reference ranges for serum TSH should be considered in order to establish a diagnosis of SCH in older people. The oldest old subjects (>80-85 years) with elevated serum TSH ≤10 mU/l should be carefully followed with a wait-and-see strategy, generally avoiding hormonal treatment. If the decision is to treat SCH, then oral L-thyroxine, administered daily, is the treatment of choice. The serum TSH should be re-checked 2 months after starting L-thyroxine therapy, and dosage adjustments made accordingly. The aim for most adults should be to reach a stable serum TSH in the lower half of the reference range (0.4-2.5 mU/l). Once patients with SCH are commenced on L-thyroxine treatment, then serum TSH should be monitored at least annually thereafter.
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Affiliation(s)
- Simon H S Pearce
- Institute of Genetic Medicine, Newcastle University, UK ; Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Georg Brabant
- Medizinische Klinik I, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Leonidas H Duntas
- Endocrine Unit, Evgenidion Hospital, University of Athens, Athens, Greece
| | - Fabio Monzani
- Department of Clinical and Experimental Medicine, Università di Pisa, Pisa, Italy
| | - Robin P Peeters
- Rotterdam Thyroid Center, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Salman Razvi
- Institute of Genetic Medicine, Newcastle University, UK ; Queen Elizabeth Hospital, Gateshead, UK
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Park WR, Oh TK, Jeon HJ. Prospective observation of 5-year clinical course of subclinical hypothyroidism in korean population. J Korean Med Sci 2013; 28:1622-6. [PMID: 24265525 PMCID: PMC3835504 DOI: 10.3346/jkms.2013.28.11.1622] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 09/11/2013] [Indexed: 11/20/2022] Open
Abstract
Subclinical hypothyroidism (SCH) is a common clinical condition, whereas it's natural course has not been identified distinctly. We evaluated the natural history of 169 SCH patients over 5-yr and the prognostic factors including thyroid autoantibodies and thyroid ultrasonographic (USG) findings related to develop overt hypothyroidism. After 5 yr, 47.3% of patients showed normalization of TSH, while 36.7% of patients remained persistence of high level of TSH, and overt hypothyroidism developed in 11.2% of patients. There were painless thyroiditis (2.9%) and hyperthyroidism (1.7%) during 5 yr follow-up. The thyroid nodule was seen in 48.6% of patients. Most of patients had 1 to 2 nodules whereas only 3% of patients with thyroid nodule had more than 6 nodules. Overt hypothyroidism patients had more heterogenous echogenecity in USG compared to patients with normalization or persistent SCH (76.5% vs 50.0% vs 35.0%, P = 0.048) and higher prevalence positive anti-thyroid peroxidase (anti-TPO Ab) and anti-thyroglobulin antibody (anti-Tg Ab) and titer of anti-TPO Ab than other two groups. The cut off values for prediction of overt hypothyroidism were TSH > 7.45 µIU/mL, free T4 < 1.09 ng/dL and Anti-TPO Ab > 560 IU/mL. SCH has various courses and initial TSH, free T4, presence of thyroid autoantibody, titer of thyroid autoantibody; and thyroid USG findings can serve as a prognostic factor for progression of overt hypothyroidism. These parameters suggest consideration to initiate thyroid hormone treatment in SCH.
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Affiliation(s)
- Woo Ri Park
- Department of Internal Medicine, Chungbuk National University School of Medicine, Cheongju, Korea
| | - Tae Keun Oh
- Department of Internal Medicine, Chungbuk National University School of Medicine, Cheongju, Korea
| | - Hyun Jeong Jeon
- Department of Internal Medicine, Chungbuk National University School of Medicine, Cheongju, Korea
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Maor E, Kivity S, Kopel E, Segev S, Sidi Y, Goldenberg I, Olchovsky D. Differences in heart rate profile during exercise among subjects with subclinical thyroid disease. Thyroid 2013; 23:1226-32. [PMID: 23777550 DOI: 10.1089/thy.2013.0043] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Clinical thyroid disease is associated with changes in the cardiovascular system, including changes in heart rate during exercise. However, data on the relation between subclinical thyroid disease (SCTD) and heart rate during exercise are limited. METHODS We investigated 3799 apparently healthy subjects who were evaluated in the Institute for Preventive Medicine at the Sheba Medical Center. All subjects answered standard health questionnaires; were examined by a physician; completed routine blood tests including thyrotropin, free triiodothyronine, and free thyroxine levels; and underwent a treadmill exercise according to the Bruce protocol. Subjects with known thyroid disease or those who were taking thyroid-related drugs were excluded from the analysis. Heart rate profile was compared between patients with subclinical hypothyroidism (SCHypoT), patients with normal thyroid function, and patients with subclinical hyperthyroidism (SCHyperT) using propensity score matching. RESULTS Seventy patients had SCHyperT and 273 had SCHypoT. Compared with age- and sex-matched normal subjects, SCHyperT subjects had a higher resting heart rate (83±17 vs. 76±12 beats per minute [bpm], p=0.006), a significantly higher recovery heart rate (94±12 vs. 90±12 bpm, p=0.045), and a significantly lower heart rate reserve (80±20 vs. 87±18 bpm, p=0.006). Subjects with SCHypoT showed a trend toward a lower resting heart rate (75±13 vs. 77±15 bpm, p=0.09) and had a significantly lower recovery heart rate (88±12 vs. 90±13 bpm, p=0.035). There was no significant difference in exercise duration or blood pressure between subjects with SCTD and their matched normal controls. CONCLUSIONS Subjects with SCTD have a significantly different heart rate profile during rest, exercise, and recovery.
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Affiliation(s)
- Elad Maor
- 1 Leviev Heart Institute, Chaim Sheba Medical Center , Tel Hashomer, Israel
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Feldman AZ, Shrestha RT, Hennessey JV. Neuropsychiatric manifestations of thyroid disease. Endocrinol Metab Clin North Am 2013; 42:453-76. [PMID: 24011880 DOI: 10.1016/j.ecl.2013.05.005] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The interface between thyroid hormone action and neuropsychiatric function is intricate, and several mechanisms of thyroid hormone uptake into brain tissues, hormone activation, and influences on neurotransmitter generation have been identified. Symptoms of hypothyroidism are nonspecific, whereas those attributed to thyrotoxicosis may be more characteristic. Neuropsychiatric manifestations triggered by thyroid dysfunction likely respond well to reestablishment of the euthyroid state, although some patients have persistent complaints. The addition of LT3 to ongoing LT4 replacement has yet to be definitively shown to be advantageous. Treatment of euthyroid depression with LT3 in addition to antidepressant therapy lacks convincing evidence of superior outcomes.
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Affiliation(s)
- Anna Z Feldman
- Division of Endocrinology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Gryzmish 6, Boston, MA 02215, USA
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Pasqualetti G, Tognini S, Polini A, Caraccio N, Monzani F. Is subclinical hypothyroidism a cardiovascular risk factor in the elderly? J Clin Endocrinol Metab 2013; 98:2256-66. [PMID: 23559085 DOI: 10.1210/jc.2012-3818] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
CONTEXT The negative impact of subclinical hypothyroidism (sHT) on cardiovascular risk, widely recognized in young adults (aged <55-60 y), is still debated in the elderly (>65 y), especially in the oldest olds (>80 y). EVIDENCE ACQUISITION We searched Medline for reports published with the following search terms: "hypothyroidism," "subclinical hypothyroidism," "ageing," "elderly," "L-thyroxin," "thyroid," "guidelines," "treatment," "quality of life," "cardiovascular risk," "heart failure," "coronary heart disease" (CHD), "atherosclerosis," and "endothelial dysfunction." We limited our search to reports in English published after 1980, although we incorporated some reports published before 1980. We supplemented the search with records from personal files, textbooks, and relevant articles. Analyzed parameters included the epidemiology of thyroid failure, the effect of thyroid hormone on the aging process, cardiovascular function, and CHD risk factors. We also included the potential benefits of L-T4 therapy on the quality of life, cardiovascular events, and survival. EVIDENCE SYNTHESIS TSH levels increase with age, even in older people without thyroid disease. Most longitudinal studies show an increased risk for CHD events and mortality in sHT participants. This increase is less evident in the elderly, mainly in cases of serum TSH values above 10 mIU/L. Lower mortality rate in a cohort of the oldest olds (>85 y) has been reported. CONCLUSIONS sHT in older people should be not regarded as a unique condition, and moderately old patients (aged <70-75 y) could be considered clinically similar to the adult population, albeit with a higher optimal TSH target value. Conversely, the oldest old subjects should be carefully followed with a wait-and-see strategy, generally avoiding hormonal treatment. The decision to treat elderly people is still an unresolved clinical challenge--first, due to a lack of appropriately powered randomized controlled trials of L-T4 in sHT patients, examining cardiovascular hard endpoints in various classes of age; and second, because of the negative effects of possible overtreatment.
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Affiliation(s)
- Giuseppe Pasqualetti
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56126 Pisa, Italy
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Hoang TD, Olsen CH, Mai VQ, Clyde PW, Shakir MKM. Desiccated thyroid extract compared with levothyroxine in the treatment of hypothyroidism: a randomized, double-blind, crossover study. J Clin Endocrinol Metab 2013; 98:1982-90. [PMID: 23539727 DOI: 10.1210/jc.2012-4107] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Patients previously treated with desiccated thyroid extract (DTE), when being switched to levothyroxine (L-T₄), occasionally did not feel as well despite adequate dosing based on serum TSH levels. OBJECTIVE Our objective was to investigate the effectiveness of DTE compared with L-T₄ in hypothyroid patients. DESIGN AND SETTING We conducted a randomized, double-blind, crossover study at a tertiary care center. PATIENTS Patients (n = 70, age 18-65 years) diagnosed with primary hypothyroidism on a stable dose of L-T₄ for 6 months were included in the study. INTERVENTION Patients were randomized to either DTE or L-T₄ for 16 weeks and then crossed over for the same duration. OUTCOME MEASURES Biochemical and neurocognitive tests at baseline and at the end of each treatment period were evaluated. RESULTS There were no differences in symptoms and neurocognitive measurements between the 2 therapies. Patients lost 3 lb on DTE treatment (172.9 ± 36.4 lb vs 175.7 ± 37.7 lb, P < .001). At the end of the study, 34 patients (48.6%) preferred DTE, 13 (18.6%) preferred L-T₄, and 23 (32.9%) had no preference. In the subgroup analyses, those patients who preferred DTE lost 4 lb during the DTE treatment, and their subjective symptoms were significantly better while taking DTE as measured by the general health questionnaire-12 and thyroid symptom questionnaire (P < .001 for both). Five variables were predictors of preference for DTE. CONCLUSION DTE therapy did not result in a significant improvement in quality of life; however, DTE caused modest weight loss and nearly half (48.6%) of the study patients expressed preference for DTE over L-T₄. DTE therapy may be relevant for some hypothyroid patients.
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Affiliation(s)
- Thanh D Hoang
- Department of Endocrinology, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, Maryland 20889-5600, USA
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Canaris GJ, Tape TG, Wigton RS. Thyroid disease awareness is associated with high rates of identifying subjects with previously undiagnosed thyroid dysfunction. BMC Public Health 2013; 13:351. [PMID: 23590562 PMCID: PMC3643833 DOI: 10.1186/1471-2458-13-351] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Accepted: 04/03/2013] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Conventional screening for hypothyroidism is controversial. Although hypothyroidism is underdiagnosed, many organizations do not recommend screening, citing low disease prevalence in unselected populations. We studied attendees at a thyroid health fair, hypothesizing that certain patient characteristics would enhance the yield of testing. METHODS We carried out an observational study of participants at a Michigan health fair that focused on thyroid disease. We collected patient-reported symptoms and demographics by questionnaire, and correlated these with the TSH values obtained through the health fair. RESULTS 794 of 858 health fair attendees participated. Most were women, and over 40% reported a family history of thyroid disease. We identified 97 (12.2%) participants with previously unknown thyroid dysfunction. No symptom or combination of symptoms discriminated between hypothyroid and euthyroid individuals. Hypothyroid and euthyroid participants in the health fair reported each symptom with a similar prevalence (p > 0.01), a prevalence which was very high. In fact, when compared with a previously published case-control study that reported symptoms, the euthyroid health fair participants reported a higher symptom prevalence (range 3.9% to 66.3%, mean 31.5%), than the euthyroid individuals from the case-control study (range 2% to 54%, mean 17.4%). CONCLUSIONS A high proportion of previously undiagnosed thyroid disease was identified at this health fair. We initially hypothesized symptoms would distinguish between thyroid function states. However, this was not the case in this health fair screening population. The prevalence of reported symptoms was similar and high in both euthyroid and hypothyroid participants. Because attendees were self-selected, it is possible that this health fair that focused on thyroid disease attracted participants specifically concerned about thyroid health. Despite the lack of symptom discrimination, the much higher prevalence of hypothyroidism in this study (12%) compared with the general population (<2%) suggests that screening may be appropriate and effective in certain circumstances such as thyroid health fairs.
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Affiliation(s)
- Gay J Canaris
- University of Nebraska Medical Center, College of Medicine, Omaha, NE, USA
| | - Thomas G Tape
- University of Nebraska Medical Center, College of Medicine, Omaha, NE, USA
| | - Robert S Wigton
- University of Nebraska Medical Center, College of Medicine, Omaha, NE, USA
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Sgarbi JA, Teixeira PFS, Maciel LMZ, Mazeto GMFS, Vaisman M, Montenegro Junior RM, Ward LS. Consenso brasileiro para a abordagem clínica e tratamento do hipotireoidismo subclínico em adultos: recomendações do Departamento de Tireoide da Sociedade Brasileira de Endocrinologia e Metabologia. ACTA ACUST UNITED AC 2013; 57:166-83. [DOI: 10.1590/s0004-27302013000300003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 03/05/2013] [Indexed: 03/20/2023]
Abstract
INTRODUÇÃO: O hipotireoidismo subclínico (HSC), definido por concentrações elevadas do TSH em face de níveis normais dos hormônios tireoidianos, tem elevada prevalência no Brasil, particularmente entre mulheres e idosos. Embora um número crescente de estudos venha associando o HSC com maior risco de doença arterial coronariana e de mortalidade, não há ensaio clínico randomizado sobre o benefício do tratamento com levotiroxina na redução dos riscos e o tratamento permanece controverso. OBJETIVO: Este consenso, patrocinado pelo Departamento de Tireoide da Sociedade Brasileira de Endocrinologia e Metabologia e desenvolvido por especialistas brasileiros com vasta experiência clínica em tireoide, apresenta recomendações baseadas em evidências para uma abordagem clínica do paciente com HSC no Brasil. MATERIAIS E MÉTODOS: Após estruturação das questões clínicas, a busca das evidências disponíveis na literatura foi realizada inicialmente na base de dados do MedLine-PubMed e posteriormente nas bases Embase e SciELO - Lilacs. A força da evidência, avaliada pelo sistema de classificação de Oxford, foi estabelecida a partir do desenho de estudo utilizado, considerando-se a melhor evidência disponível para cada questão e a experiência brasileira. RESULTADOS: Os temas abordados foram definição e diagnóstico, história natural, significado clínico, tratamento e gestação, que resultaram em 29 recomendações para a abordagem clínica do paciente adulto com HSC. CONCLUSÃO: O tratamento com levotiroxina foi recomendado para todos os pacientes com HSC persistente com níveis séricos do TSH > 10 mU/L e para alguns subgrupos especiais de pacientes.
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Abstract
Aging is associated with a host of alterations in thyroid gland structure and function. Some of these changes have favorable effects on longevity, whereas others are maladaptive and contribute to a decline in health and quality of life. An area of particular controversy is the diagnosis and management of subclinical hypothyroidism in the elderly. The clinical diagnosis of hypothyroidism in the elderly is difficult, because many signs and symptoms associated with hypothyroidism are commonly present in euthyroid elderly individuals. The biochemical profile of subclinical hypothyroidism includes normal serum levels of thyroid hormones with mildly elevated serum thyrotropin concentrations in the range of 4.5 to 10 mIU/L. In this article, the epidemiology of subclinical hypothyroidism in the elderly is reviewed, the potential advantages of mild hypothyroidism in people over the age of 75 years are discussed, and some guidelines for screening and management of this common thyroid dysfunction are suggested.
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Joffe RT, Pearce EN, Hennessey JV, Ryan JJ, Stern RA. Subclinical hypothyroidism, mood, and cognition in older adults: a review. Int J Geriatr Psychiatry 2013; 28:111-8. [PMID: 22410877 PMCID: PMC3488161 DOI: 10.1002/gps.3796] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Accepted: 02/06/2012] [Indexed: 11/12/2022]
Abstract
OBJECTIVES To perform a critical review of the literature on the mood and cognitive changes associated with subclinical hypothyroidism (SCH), with an emphasis on older adults. To evaluate these data against the Consensus Statement on the management of SCH from the American Association of Clinical Endocrinologists, the American Thyroid Association, and The Endocrine Society. METHOD A comprehensive literature review. RESULTS Subclinical hypothyroidism may be associated with an increased risk of mood and cognitive dysfunction, although the strength of this association and the efficacy of replacement hormone therapy require further investigation. CONCLUSION It remains unclear whether SCH leads to significant mood and cognitive impairments in most older patients. More research is required to determine the nature and extent of this association and whether thyroid hormone replacement therapy is appropriate and effective in treating SCH-associated neurobehavioral impairments.
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Affiliation(s)
- Russell T Joffe
- Department of Psychiatry, Staten Island University Hospital, Staten Island, NY 10305, USA.
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Abstract
INTRODUCTION Subclinical thyroid disease is a common finding on testing of thyroid function and its management remains controversial. SOURCE OF DATA Epidemiological data from large population studies from USA and Europe. AREAS OF AGREEMENT There is an increased risk of progression to overt hypothyroidism or hyperthyroidism. The treatment of mild thyroid failure is of importance in optimizing pregnancy outcome. AREAS OF CONTROVERSY Diagnostic criteria differ and there is variation between management guidelines. The difference was found in long-term clinical outcomes between endogenous and exogenous subclinical hyperthyroidism. GROWING POINTS Meta-analyses have provided epidemiological data in cardiovascular mortality and morbidity in subclinical thyroid disease. Increased use of echocardiography and bone markers in identifying those who benefit from intervention. AREAS TIMELY FOR DEVELOPING RESEARCH A randomized controlled trial to identify those subjects identified from screening programmes that benefit from intervention in terms of morbidity and mortality.
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Affiliation(s)
- Anukul Garg
- Department of Endocrinology, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, UK
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Reuters VS, Almeida CDP, Teixeira PDFDS, Vigário PDS, Ferreira MM, Castro CLND, Brasil MA, Costa AJLD, Buescu A, Vaisman M. Effects of subclinical hypothyroidism treatment on psychiatric symptoms, muscular complaints, and quality of life. ACTA ACUST UNITED AC 2012; 56:128-36. [PMID: 22584566 DOI: 10.1590/s0004-27302012000200006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2011] [Accepted: 02/23/2012] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To evaluate the impact of subclinical hypothyroidism (sHT) treatment on health-related quality of life (QoL), psychiatric symptoms, clinical score, and muscle function. MATERIALS AND METHODS In this randomized double-blind study, patients were assigned either to treatment (n = 35) or placebo (n = 36). Clinical and psychiatric symptoms were assessed by the Zulewski, Hamilton and Beck scales. QoL was assessed by the SF-36 questionnaire. Assessments of quadriceps (QS) and inspiratory muscle (IS) strength were performed by a chair dynamometer and a manuvacuometer. RESULTS Treatment improved IS (+11.5 ± 17.2; p = 0.041), as did QoL domains "Pain" and "Role Physical" (+19.7 ± 15.2, 0.039 and +22.1 ± 47.5, p = 0.054; respectively). Clinical and psychiatric symptoms showed similar responses to both interventions. CONCLUSIONS sHT treatment improved IS and physical aspects of QoL, despite no impact in other muscle parameters. Clinical score, psychiatric symptoms, and SF-36 domains, based on mental dimensions of QoL may be more susceptible to "placebo effect" in patients with sHT.
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Abstract
Subclinical thyroid dysfunction (STD) represents a condition of slight thyroid hormone excess or deficiency, which may be associated with important adverse effects. This review will focus on the natural history, diagnosis and management of subclinical thyroid dysfunction. Since STD is only detected as a thyroid stimulating hormone (TSH) abnormality, it is essential to exclude transient causes of abnormal serum TSH before treating this disorder. Treatment of subclinical hyperthyroidism (SHyper) is recommended in elderly patients with undetectable serum TSH for the increased risk of atrial fibrillation, osteoporosis and bone fractures and for the higher risk of progression to overt disease. Treatment of subclinical hypothyroidism should be considered in patients with serum TSH above 10 mU/L for the increased risk of progression to overt hypothyroidism and the increased risk of coronary heart disease and heart failure events, which have been documented in patients with TSH increase above 10 mU/L. About 75% of patients with STD have mild dysfunction. The mild form of STD (low but detectable serum TSH in SHyper and mild increased serum TSH between 5 and 9 mU/L in SHypo is associated with a minor risk of disease progression to overt dysfunction. The best treatment for STD remains controversial. Treatment of the mild form of STD should be considered after evaluating the patients' age, the adverse risk factors, the potential beneficial effects of treating this disorder and any underlying co-morbidities. Mild SHypo should be treated in infertile and pregnant women.
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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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Shin DH, Lee MJ, Kim SJ, Oh HJ, Kim HR, Han JH, Koo HM, Doh FM, Park JT, Han SH, Yoo TH, Kang SW. Preservation of renal function by thyroid hormone replacement therapy in chronic kidney disease patients with subclinical hypothyroidism. J Clin Endocrinol Metab 2012; 97:2732-40. [PMID: 22723335 DOI: 10.1210/jc.2012-1663] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Subclinical hypothyroidism is not a rare condition, but the use of thyroid hormone to treat subclinical hypothyroidism is an issue of debate. OBJECTIVE This study was undertaken to investigate the impact of thyroid hormone therapy on the changes in estimated glomerular filtration rate (eGFR) in subclinical hypothyroidism patients with stage 2-4 chronic kidney disease. PATIENTS A total of 309 patients were included in the final analysis. MAIN OUTCOME MEASURE The changes in eGFR over time were compared between patients with and without thyroid hormone replacement therapy using a linear mixed model. Kaplan-Meier curves were constructed to determine the effect of thyroid hormone on renal outcome, a reduction of eGFR by 50%, or end-stage renal disease. The independent prognostic value of subclinical hypothyroidism treatment for renal outcome was ascertained by multivariate Cox regression analysis. RESULTS Among the 309 patients, 180 (58.3%) took thyroid hormone (treatment group), whereas 129 (41.7%) did not (nontreatment group). During the mean follow-up duration of 34.8 ± 24.3 months, the overall rate of decline in eGFR was significantly greater in the nontreatment group compared to the treatment group (-5.93 ± 1.65 vs. -2.11 ± 1.12 ml/min/yr/1.73 m(2); P = 0.04). Moreover, a linear mixed model revealed that there was a significant difference in the rates of eGFR decline over time between the two groups (P < 0.01). Kaplan-Meier analysis also showed that renal event-free survival was significantly lower in the nontreatment group (P < 0.01). In multivariate Cox regression analysis, thyroid hormone replacement therapy was found to be an independent predictor of renal outcome (hazard ratio, 0.28; 95% CI, 0.12-0.68; P = 0.01). CONCLUSION Thyroid hormone therapy not only preserved renal function better, but was also an independent predictor of renal outcome in chronic kidney disease patients with subclinical hypothyroidism.
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Affiliation(s)
- Dong Ho Shin
- Department of Internal Medicine, College of Medicine, Yonsei University, Seoul 120-752, Korea
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Why are GPs treating subclinical hypothyroidism? Case note review and GP survey. Prim Health Care Res Dev 2012; 14:175-84. [PMID: 23174158 DOI: 10.1017/s1463423612000230] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Subclinical hypothyroidism (SCHo) is a common biochemical diagnosis in older age. Evidence of impact is inconclusive and guidelines are inconsistent. With increasing numbers of thyroid function tests (TFTs) performed, GPs frequently have to make management decisions regarding this diagnosis. However, little is known about how SCHo is currently being managed in primary care. AIM To explore management of SCHo in primary care and GP reported rationale for treatment of SCHo in older individuals. DESIGN Descriptive study using retrospective case note review and GP survey. SETTING Nineteen General Practices, Central England, UK. METHODS Follow-up of a large cohort with subsequent detailed review of individuals for whom therapy had been initiated following diagnosis of SCHo. Data on practice policies, and rationale behind treatment were collected via GP questionnaire. RESULTS Forty-two individuals were treated following identification of SCHo. Factors regarded as supporting instigation of therapy recorded by practitioners included symptoms, a positive antithyroid antibody test and history of radioiodine therapy. In all, 55% were registered at 3/19 practices suggesting significant between practice variation. Reasons for testing included chronic disease check-up (n = 14), presenting 'thyroid symptoms' (n = 5) and presenting other symptoms (n = 9). Reasons for therapy initiation were only recorded in 26 cases and included presence of symptoms, persistently high or increasing serum thyroid stimulating hormone concentration and patient request. Only 2/15 GPs reported having practice guidelines on management. CONCLUSION Results suggest that GPs are uncertain how to interpret symptoms and TFT results in older individuals. There is considerable variation in management of SCHo between GPs with some GPs treating patients outside of all guideline recommendations.
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Subclinical hypothyroidism is associated with increased risk for all-cause and cardiovascular mortality in adults. J Am Coll Cardiol 2012; 60:730-7. [PMID: 22726629 DOI: 10.1016/j.jacc.2012.03.047] [Citation(s) in RCA: 127] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Revised: 02/28/2012] [Accepted: 03/19/2012] [Indexed: 01/07/2023]
Abstract
OBJECTIVES This study sought to evaluate the relationship between subclinical hypothyroidism (SCH) and all-cause and cardiovascular disease (CVD) mortality. BACKGROUND SCH may increase the risks of hypercholesterolemia and atherosclerosis. The associations between SCH and all-cause or CVD mortality are uncertain, on the basis of the results of previous studies. METHODS A baseline cohort of 115,746 participants without a history of thyroid disease, ≥20 years of age, was recruited in Taiwan. SCH was defined as a serum thyroid-stimulating hormone (TSH) level of 5.0 to 19.96 mIU/l with normal total thyroxine concentrations. Euthyroidism was defined as a serum TSH level of 0.47 to 4.9 mIU/l. Cox proportional hazards regression analysis was used to estimate the relative risks (RRs) of death from all-cause and CVD for adults with SCH during a 10-year follow-up period. RESULTS There were 3,669 deaths during the follow-up period; 680 deaths were due to CVD. Compared with subjects with euthyroidism, after adjustment for age, sex, body mass index, diabetes, hypertension, dyslipidemia, smoking, alcohol consumption, betel nut chewing, physical activity, income, and education level, the RRs (95% confidence interval) of deaths from all-cause and CVD among subjects with SCH were 1.30 (1.02 to 1.66), and 1.68 (1.02 to 2.76), respectively. CONCLUSIONS Adult Taiwanese with SCH had an increased risk for all-cause mortality and CVD death.
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Abstract
Thyroid disorders are highly prevalent, occurring most frequently in aging women. Thyroid-associated symptoms are very similar to symptoms of the aging process; thus, improved methods for diagnosing overt and subclinical hypothyroidism in elderly people are crucial. Thyrotropin measurement is considered to be the main test for detecting hypothyroidism. Combined evaluations of thyroid stimulating hormone (TSH) and free-thyroxine can detect overt hypothyroidism (high TSH with low free-thyroxine levels) and subclinical hypothyroidism (high TSH with normal free-thyroxine levels). It is difficult to confirm the diagnosis of thyroid diseases based only on symptoms, but presence of symptoms could be an indicator of who should be evaluated for thyroid function. The most important reasons to treat overt hypothyroidism are to relieve symptoms and avoid progression to myxedema. Overt hypothyroidism is classically treated using L-thyroxine; elderly patients require a low initial dose that is increased every 4 to 6 weeks until normalization of TSH levels. After stabilization, TSH levels are monitored yearly. There is no doubt about the indication for treatment of overt hypothyroidism, but indications for treatment of subclinical disease are controversial. Although treatment of subclinical hypothyroidism may result in lipid profile improvement, there is no evidence that this improvement is associated with decreased cardiovascular or all-cause mortality in elderly patients. In patients with a high risk of progression from subclinical to overt disease, close monitoring of thyroid function could be the best option.
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Affiliation(s)
- Isabela M Bensenor
- Division of Internal Medicine, Hospital Universitário, University of São Paulo, São Paulo, Brazil.
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Pearce SH, Vaisman M, Wemeau JL. Management of subclinical hypothyroidism: the thyroidologists' view. Eur Thyroid J 2012; 1:45-50. [PMID: 24782997 PMCID: PMC3821451 DOI: 10.1159/000335964] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 11/22/2011] [Indexed: 01/07/2023] Open
Abstract
Subclinical hypothyroidism is a common finding when serum thyrotropin and thyroid hormones are measured, but the benefits of treating such patients with levothyroxine remain unproven. During the 14th International Thyroid Congress, a debate and discussion relating to three different clinical case scenarios of subclinical hypothyroidism was held. The audience consisted predominantly of members of the European Thyroid Association. Participants (n = 380) voted using an electronic system to express their opinion about the treatment of the 3 cases. For a 53-year-old woman with fatigue and difficulty losing weight, who has a serum TSH of 6.8 mU/l, 49% would treat with levothyroxine. Whereas, for an 84-year-old woman with a serum TSH of 6.8 mU/l, only 8% of participants would treat with levothyroxine. In contrast, for a 39-year-old woman who is trying to become pregnant, with a serum TSH of 4.5 mU/l and strongly positive thyroid peroxidase antibodies, 95% of respondents would treat with levothyroxine. This article details the clinical case scenarios and the results of the thyroidologists' opinions on treatment. It forms a snapshot of the range of accepted clinical practice in this common condition.
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Affiliation(s)
- Simon H.S. Pearce
- Institute of Genetic Medicine, Newcastle University and Endocrine Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Mario Vaisman
- Department of Endocrinology, Faculdade de Medicina, UFRJ, Rio de Janeiro, Brazil
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