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Newsome SD, Tian F, Shoemaker T, Fitzgerald KC, Cassard SD, Fiol J, Snoops S, Cooper DS, Mammen JSR, Bhargava P, Mowry EM, Calabresi PA. A Phase 1b, Open-Label Study to Evaluate the Safety and Tolerability of the Putative Remyelinating Agent, Liothyronine, in Individuals with MS. Neurotherapeutics 2023; 20:1263-1274. [PMID: 37460763 PMCID: PMC10480368 DOI: 10.1007/s13311-023-01402-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 09/07/2023] Open
Abstract
Thyroid hormones are essential during developmental myelination and may play a direct role in remyelination and repair in the adult central nervous system by promoting the differentiation of oligodendrocyte precursor cells into mature oligodendrocytes. Since tri-iodothyronine (T3) is believed to mediate the majority of important thyroid hormone actions, liothyronine (synthetic T3) has the potential to induce reparative mechanisms and limit neurodegeneration in multiple sclerosis (MS). We completed a phase 1b clinical trial to determine the safety and tolerability of ascending doses of liothyronine in individuals with relapsing and progressive MS. A total of 20 people with MS were enrolled in this single-center trial of oral liothyronine. Eighteen participants completed the 24-week study. Our study cohort included mostly women (11/20), majority relapsing MS (12/20), mean age of 46, and baseline median EDSS of 3.5. Liothyronine was tolerated well without treatment-related severe/serious adverse events or evidence of disease activation/clinical deterioration. The most common adverse events included gastrointestinal distress and abnormal thyroid function tests. No clinical thyrotoxicosis occurred. Importantly, we did not observe a negative impact on secondary clinical outcome measures. The CSF proteomic changes suggest a biological effect of T3 treatment within the CNS. We noted changes primarily in proteins associated with immune cell function and angiogenesis. Liothyronine appeared safe and was well tolerated in people with MS. A larger clinical trial will help assess whether liothyronine can promote oligodendrogenesis and enhance remyelination in vivo, limit axonal degeneration, or improve function.
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Affiliation(s)
- Scott D Newsome
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Baltimore, MD, USA.
| | - Fan Tian
- Department of Mathematics, Tufts University, Medford, USA
| | | | - Kathryn C Fitzgerald
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Baltimore, MD, USA
| | - Sandra D Cassard
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Baltimore, MD, USA
| | - Julie Fiol
- National Multiple Sclerosis Society, New York, NY, USA
| | - Sarah Snoops
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Baltimore, MD, USA
| | - David S Cooper
- Department of Medicine, Division of Endocrinology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer S R Mammen
- Department of Medicine, Division of Endocrinology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pavan Bhargava
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Baltimore, MD, USA
| | - Ellen M Mowry
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Baltimore, MD, USA
| | - Peter A Calabresi
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Baltimore, MD, USA
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Abstract
Older adults are more vulnerable to the negative effects of excess thyroid hormone and may even be protected by lower levels of thyroid hormone. The diagnosis and management of thyroid disease in older adults needs to account for aging-related changes in function and resilliance.
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Affiliation(s)
- Jennifer S R Mammen
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, 5501 Hopkins Bayview Circle, Asthma and Allergy Center, 2A62, Baltimore, MD 21224, USA.
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Mohajer B, Moradi K, Guermazi A, Mammen JSR, Hunter DJ, Roemer FW, Demehri S. Levothyroxine use and longitudinal changes in thigh muscles in at-risk participants for knee osteoarthritis: preliminary analysis from Osteoarthritis Initiative cohort. Arthritis Res Ther 2023; 25:58. [PMID: 37041609 PMCID: PMC10088133 DOI: 10.1186/s13075-023-03012-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 02/14/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND We examined the association between levothyroxine use and longitudinal MRI biomarkers for thigh muscle mass and composition in at-risk participants for knee osteoarthritis (KOA) and their mediatory role in subsequent KOA incidence. METHODS Using the Osteoarthritis Initiative (OAI) data, we included the thighs and corresponding knees of participants at risk but without established radiographic KOA (baseline Kellgren-Lawrence grade (KL) < 2). Levothyroxine users were defined as self-reported use at all annual follow-up visits until the 4th year and were matched with levothyroxine non-users for potential confounders (KOA risk factors, comorbidities, and relevant medications covariates) using 1:2/3 propensity score (PS) matching. Using a previously developed and validated deep learning method for thigh segmentation, we assessed the association between levothyroxine use and 4-year longitudinal changes in muscle mass, including cross-sectional area (CSA) and muscle composition biomarkers including intra-MAT (within-muscle fat), contractile percentage (non-fat muscle CSA/total muscle CSA), and specific force (force per CSA). We further assessed whether levothyroxine use is associated with an 8-year risk of standard KOA radiographic (KL ≥ 2) and symptomatic incidence (incidence of radiographic KOA and pain on most of the days in the past 12 months). Finally, using a mediation analysis, we assessed whether the association between levothyroxine use and KOA incidence is mediated via muscle changes. RESULTS We included 1043 matched thighs/knees (266:777 levothyroxine users:non-users; average ± SD age: 61 ± 9 years, female/male: 4). Levothyroxine use was associated with decreased quadriceps CSAs (mean difference, 95%CI: - 16.06 mm2/year, - 26.70 to - 5.41) but not thigh muscles' composition (e.g., intra-MAT). Levothyroxine use was also associated with an increased 8-year risk of radiographic (hazard ratio (HR), 95%CI: 1.78, 1.15-2.75) and symptomatic KOA incidence (HR, 95%CI: 1.93, 1.19-3.13). Mediation analysis showed that a decrease in quadriceps mass (i.e., CSA) partially mediated the increased risk of KOA incidence associated with levothyroxine use. CONCLUSIONS Our exploratory analyses suggest that levothyroxine use may be associated with loss of quadriceps muscle mass, which may also partially mediate the increased risk of subsequent KOA incidence. Study interpretation should consider underlying thyroid function as a potential confounder or effect modifier. Therefore, future studies are warranted to investigate the underlying thyroid function biomarkers for longitudinal changes in the thigh muscles.
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Affiliation(s)
- Bahram Mohajer
- Musculoskeletal Radiology, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 N Caroline St., JHOC 5165, Baltimore, MD, 21287, USA
| | - Kamyar Moradi
- Tehran University of Medical Sciences, School of Medicine, Tehran, Iran
| | - Ali Guermazi
- Department of Radiology, Chobanian & Avedisian Boston University School of Medicine, Boston, MA, USA
| | - Jennifer S R Mammen
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David J Hunter
- Rheumatology Department, Royal North Shore Hospital, St Leonards, 2065 NSW, Australia
- Sydney Musculoskeletal Health, Arabanoo Precinct, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, 2065 NSW, Australia
| | - Frank W Roemer
- Department of Radiology, Chobanian & Avedisian Boston University School of Medicine, Boston, MA, USA
- Department of Radiology, Universitätsklinikum Erlangen & Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Shadpour Demehri
- Musculoskeletal Radiology, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 N Caroline St., JHOC 5165, Baltimore, MD, 21287, USA.
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Mammen JSR, Cooper DS. TSH Receptor Antibody Testing in Early Pregnancy. J Clin Endocrinol Metab 2022; 107:e4324-e4325. [PMID: 35973059 DOI: 10.1210/clinem/dgac490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Jennifer S R Mammen
- Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
| | - David S Cooper
- Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
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Abbey EJ, McGready J, Oh E, Simonsick EM, Mammen JSR. Thyroid hormone use and overuse in dementia: Results from the Health, Aging and Body Composition Study. J Am Geriatr Soc 2022; 70:3308-3311. [PMID: 35866295 PMCID: PMC9669113 DOI: 10.1111/jgs.17961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/14/2022] [Accepted: 06/22/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Enoch J Abbey
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - John McGready
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Esther Oh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Jennifer S R Mammen
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Abbey EJ, McGready J, Sokoll LJ, Simonsick EM, Mammen JSR. Free Thyroxine Distinguishes Subclinical Hypothyroidism From Other Aging-Related Changes in Those With Isolated Elevated Thyrotropin. Front Endocrinol (Lausanne) 2022; 13:858332. [PMID: 35311240 PMCID: PMC8931280 DOI: 10.3389/fendo.2022.858332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/11/2022] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Although a finding of isolated elevated thyrotropin (TSH) often leads to treatment with thyroid hormone, it is not specific to a diagnosis of subclinical hypothyroidism, particularly in older adults. We have previously used longitudinal assessment of TSH and free thyroxine (FT4) to distinguish primary and secondary changes in the hypothalamic-pituitary-thyroid (HPT) axis, an approach which is impractical for clinical diagnosis. OBJECTIVE Identify contemporaneous clinical tests and criteria that predict the longitudinally-derived HPT axis phenotype in those with isolated elevated TSH. METHODS Using data from Baltimore Longitudinal Study of Aging, participants with over three years of follow up not on thyroid hormone replacement, with a TSH above the reference range and an in-range FT4 at the current visit, and at least 1% per year increase in TSH (mean 6.9% annual increase; n=72), we examined correlations between various clinical factors and the change in FT4 across the phenotypic range from emerging hypothyroidism, with falling FT4, to adaptive stress-response, with rising FT4. RESULTS Current FT4 level, but not TSH, Free T3, anti-TPO antibody status, age or sex, was significantly associated with phenotype, determined by the annual rate of change in FT4 in those with elevated and rising TSH, both as a continuous variable (β=0.07 per ng/dL increase in FT4; p<0.001) and in quartiles (p<0.001). We estimated a threshold for FT4 of less than 0.89 ng/dL (11.45 pmol/L; the 24th percentile of the reference range), as predictive of a phenotype in the first quartile, consistent with subclinical hypothyroidism, while a FT3:FT4 ratio below 2.77 predicted a phenotype in the fourth quartile, more consistent with adaptive stress-response. CONCLUSIONS In those with isolated elevated TSH, a FT4 in the lowest quartile of the reference range differentiates those with developing hypothyroidism from other HPT-axis aging changes.
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Affiliation(s)
- Enoch J. Abbey
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
- *Correspondence: Enoch J. Abbey,
| | - John McGready
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Lori J. Sokoll
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Eleanor M. Simonsick
- National Institute of Aging, National Institute of Health (NIH), Baltimore, MD, United States
| | - Jennifer S. R. Mammen
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
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Abbey EJ, Mammen JSR, Soghoian SE, Cadorette MAF, Ariyo P. In-hospital Mortality and the Predictive Ability of the Modified Early Warning Score in Ghana: Single-Center, Retrospective Study. JMIRx Med 2021; 2:e24645. [PMID: 37725551 PMCID: PMC10414437 DOI: 10.2196/24645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 04/09/2021] [Accepted: 05/09/2021] [Indexed: 09/21/2023]
Abstract
BACKGROUND The modified early warning score (MEWS) is an objective measure of illness severity that promotes early recognition of clinical deterioration in critically ill patients. Its primary use is to facilitate faster intervention or increase the level of care. Despite its adoption in some African countries, MEWS is not standard of care in Ghana. In order to facilitate the use of such a tool, we assessed whether MEWS, or a combination of the more limited data that are routinely collected in current clinical practice, can be used predict to mortality among critically ill inpatients at the Korle-Bu Teaching Hospital in Accra, Ghana. OBJECTIVE The aim of this study was to identify the predictive ability of MEWS for medical inpatients at risk of mortality and its comparability to a measure combining routinely measured physiologic parameters (limited MEWS [LMEWS]). METHODS We conducted a retrospective study of medical inpatients, aged ≥13 years and admitted to the Korle-Bu Teaching Hospital from January 2017 to March 2019. Routine vital signs at 48 hours post admission were coded to obtain LMEWS values. The level of consciousness was imputed from medical records and combined with LMEWS to obtain the full MEWS value. A predictive model comparing mortality among patients with a significant MEWS value or LMEWS ≥4 versus a nonsignificant MEWS value or LMEWS <4 was designed using multiple logistic regression and internally validated for predictive accuracy, using the receiver operating characteristic (ROC) curve. RESULTS A total of 112 patients were included in the study. The adjusted odds of death comparing patients with a significant MEWS to patients with a nonsignificant MEWS was 6.33 (95% CI 1.96-20.48). Similarly, the adjusted odds of death comparing patients with a significant versus nonsignificant LMEWS value was 8.22 (95% CI 2.45-27.56). The ROC curve for each analysis had a C-statistic of 0.83 and 0.84, respectively. CONCLUSIONS LMEWS is a good predictor of mortality and comparable to MEWS. Adoption of LMEWS can be implemented now using currently available data to identify medical inpatients at risk of death in order to improve care.
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Affiliation(s)
- Enoch Joseph Abbey
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Jennifer S R Mammen
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Samara E Soghoian
- Department of Emergency Medicine, New York University Grossman School of Medicine, New York University Langone Health, New York, NY, United States
| | - Maureen A F Cadorette
- Occupational and Environmental Health, Department of Environmental Health and Engineering, Johns Hopkins School of Public Health, Baltimore, MD, United States
| | - Promise Ariyo
- Division of Adult Critical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
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Affiliation(s)
- Jennifer S R Mammen
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Anne R Cappola
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Associate Editor, JAMA
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Abbey EJ, McGready J, Ferrucci L, Simonsick EM, Mammen JSR. Thyroid Hormone Supplementation and All-Cause Mortality in Community-Dwelling Older Adults: Results from the Baltimore Longitudinal Study of Aging. J Am Geriatr Soc 2021; 69:1283-1290. [PMID: 33418603 DOI: 10.1111/jgs.17015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 12/14/2020] [Accepted: 12/17/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Although elevated thyrotropin (TSH) is common in older adults, controversy exists over what degree of elevation should be treated with thyroid hormone supplements. Isolated, elevated TSH in this population can be consistent with aging-related adaptations rather than indicative of primary thyroid disease, raising the possibility that thyroid hormone replacement may be harmful. OBJECTIVES Determine the association between all-cause mortality and levothyroxine use among older adults. DESIGN Longitudinal observational study. SETTING Baltimore Longitudinal Study of Aging. PARTICIPANTS One thousand two hundred and fifty eight community dwelling adult participants aged 65+ with an average of 9 years of follow up. MEASUREMENTS Thyroid and pituitary hormone levels and thyroid hormone supplementation were determined at each visit. Incident rate ratios (IRR) for all-cause mortality were calculated using time-dependent Poisson regression models to accommodate the varying start times. To isolate the effects of hormone replacement from its effects on TSH, the association between treatment and all-cause mortality was analyzed in participants with stable thyroid function status throughout follow-up (N = 638). RESULTS Thyroid hormone supplementation was not associated with a significant increase all-cause mortality in the subsequent year in the fully adjusted model (IRR = 1.40, 95% confidence interval (CI) = 0.93-2.12). In a stratified analysis of euthyroid participants, thyroid hormone use was associated with significantly greater mortality, with an adjusted IRR = 1.81 (95% CI = 1.10-2.98). CONCLUSION The increased mortality associated with thyroid hormone use among the subclass of euthyroid community dwelling older adults is consistent with a model in which TSH elevation can result from a variety of underlying pathophysiologic processes, not all of which should be treated with thyroid hormone supplementation. Clinicians should consider overall clinical status when interpreting an isolated elevated TSH in older adults.
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Affiliation(s)
- Enoch J Abbey
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - John McGready
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Luigi Ferrucci
- National Institute of Aging, NIH, Baltimore, Maryland, USA
| | | | - Jennifer S R Mammen
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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