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Abstract
OPINION STATEMENT There are 34 studies in almost 2 million participants that have reported on the association between proton pump inhibitor (PPI) therapy and risk of fracture. There is substantial variation between the results of each study but systematic reviews of the data suggest overall there is an association between PPI therapy and risk of fracture. The magnitude of the association is modest and is most likely due to confounding factors as patients prescribed PPI therapy tend to be more frail with more risk factors for fractures than those not given these drugs. There is no clear dose-response relationship and there is no association between PPI therapy and risk of fracture in those at highest risk. Finally, there is no clear mechanism through which PPI therapy increases the risk of fracture, as recent randomized trials show no impact of PPI therapy on calcium absorption and there is no association between PPI therapy and risk of osteoporosis. We therefore feel there is insufficient evidence to change PPI prescribing habits based on risk of fracture. Similarly, we do not recommend bone mineral density investigations for patients taking PPI therapy other than would be normally indicated. There is no evidence to support prescription of calcium and/or vitamin D in patients simply because they are taking PPI therapy. As with all medications, we only recommend prescribing PPI therapy when there is a clear indication that benefit will outweigh risk and at the lowest effective dose. Patients should be regularly assessed as to whether acid suppression is still required.
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Affiliation(s)
- Grigorios I Leontiadis
- Division of Gastroenterology, Department of Medicine, McMaster University, 1280 Main Street West, Health Sciences Center, area 3V3, Hamilton, Ontario, L8S 4K1, Canada,
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Abrahamsen B, Jørgensen HL, Laulund AS, Nybo M, Brix TH, Hegedüs L. Low serum thyrotropin level and duration of suppression as a predictor of major osteoporotic fractures-the OPENTHYRO register cohort. J Bone Miner Res 2014; 29:2040-50. [PMID: 24723381 DOI: 10.1002/jbmr.2244] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 03/21/2014] [Accepted: 03/25/2014] [Indexed: 11/06/2022]
Abstract
The relationship between thyrotoxicosis and osteoporotic fractures remains controversial, particularly in men. Register-based cohort study including all patients with a serum thyrotropin (TSH) measurement in the region of Funen 1996-2010. All TSH determinations were done in the same lab, which served all hospitals and General Practice (GP) practices in the region. Persons with raised TSH or a history of thyroid/pituitary disease or use of thyroid medications were excluded. The study population consisted of 222,138 (96%) persons with normal and 9217 (4%) with low TSH (<0.3 mIU/L). A single low TSH at baseline was associated with increased risk of hip fractures (adj HR 1.16, 95% CI 1.07-1.26, p < 0.001) but not major osteoporotic fractures (MOF, adj HR 1.06, 95% CI 0.99-1.12, p = 0.058) over a median follow-up of 7.5 years. When men were analyzed separately, results did not reach statistical significance. We found a significant association between duration of thyrotoxicosis and fracture. For each 6 months in which the mean TSH value was decreased (<0.3 mIU/L), hip fracture risk increased by a factor 1.07 (adj HR, 95% CI 1.04-1.10, p < 0.001) and MOF by 1.05 (adj HR, 95% CI 1.03-1.07, p < 0.001). Overt thyrotoxicosis was associated with an increased risk of hip fractures but not MOF. In euthyroid patients, the risk of fractures increased significantly with each SD unit of TSH decrease: Hip fracture (HR 1.45, 95% CI 1.22-1.71, p < 0.001) and MOF (HR 1.32, 95% CI 1.19-1.46, p < 0.001). In a population-based cohort, a single, first measurement of decreased TSH in patients without known thyroid disease was associated with an increased long-term risk of hip fracture, which remained significant in women but not in men after adjusting for confounders. Moreover, the risk of both hip fracture and MOF increased exponentially by the length of time during which TSH had remained low.
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Affiliation(s)
- Bo Abrahamsen
- Odense Patient data Explorative Network, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark; Research Centre for Ageing and Osteoporosis, Department of Medicine M, Glostrup Hospital, Copenhagen, Denmark
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Leader A, Ayzenfeld RH, Lishner M, Cohen E, Segev D, Hermoni D. Thyrotropin levels within the lower normal range are associated with an increased risk of hip fractures in euthyroid women, but not men, over the age of 65 years. J Clin Endocrinol Metab 2014; 99:2665-73. [PMID: 24885627 DOI: 10.1210/jc.2013-2474] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
CONTEXT The contemporary literature on the relationship between serum TSH levels and osteoporotic fractures in euthyroid individuals is limited by conflicting results and analyses conducted on a small number of fractures. OBJECTIVE Our objective was to examine the association between the normal range of variation of TSH and the incidence of hip fractures in male and female euthyroid patients aged 65 years or older. DESIGN AND SETTING We performed a population-based historical prospective cohort study within the Clalit Health Services population. PARTICIPANTS Clalit Health Services members aged ≥65 years with at least 1 TSH measurement during the year 2004. We excluded patients with preexisting hip fracture, thyroid disease, malignancy, or chronic kidney disease. OUTCOME MEASURES The primary outcome was hip fracture, and the secondary outcome was any other osteoporotic fracture. STATISTICAL ANALYSIS Adjusted odds ratios comparing episodes of each outcome across 3 TSH groups (low, 0.35-1.6 mIU/L; intermediate, 1.7-2.9 mIU/L; high, 3-4.2 mIU/L) were generated using logistic regression models. RESULTS The 14 325 included participants suffered from 514 hip fractures (mean follow-up, 102 ± 3 months). Women, but not men, in the lowest TSH group had a higher incidence of hip fractures (odds ratio = 1.28, 95% confidence interval = 1.03-1.59, P = .029) when compared with the intermediate group, after multivariate adjustment for age, comorbidities, and use of drugs affecting bone metabolism. There was no difference in hip fracture incidence between intermediate- and high-TSH groups. No association was found between TSH levels and other osteoporotic fractures. CONCLUSIONS TSH levels within the lower normal range are associated with an increased risk of hip fractures in euthyroid women, but not men, aged 65 years and more.
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Affiliation(s)
- Avi Leader
- Departments of Internal Medicine A (A.L., R.H.A., M.L.), and Geriatric Medicine (R.H.A.), Meir Medical Center, Kfar-Saba 44281, Israel; Sackler Faculty of Medicine (A.L., R.H.A., M.L., D.H.), Tel-Aviv University, Tel-Aviv, Israel; and Department of Family Medicine (D.H.) in the Sharon-Shomron District (E.C., D.S.), Clalit Health Services, Israel
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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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Mazziotti G, Mormando M, Cristiano A, Bianchi A, Porcelli T, Giampietro A, Maffezzoni F, Serra V, De Marinis L, Giustina A. Association between l-thyroxine treatment, GH deficiency, and radiological vertebral fractures in patients with adult-onset hypopituitarism. Eur J Endocrinol 2014; 170:893-9. [PMID: 24836549 DOI: 10.1530/eje-14-0097] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE In this study, we aimed at evaluating the association between radiological vertebral fractures and levo-thyroxine (l-T4) replacement doses in adult patients with hypopituitarism. DESIGN Cross-sectional study. METHODS We studied 74 adult hypopituitary patients (males, 43; females, 31; mean age, 57 years; and range, 23-79) with central hypothyroidism treated with l-T4 (median daily dose: 1.1 μg/kg). All patients also had severe GH deficiency (GHD) and 38 of them were replaced with recombinant GH. Vertebral fractures were assessed by a quantitative morphometric analysis performed on thoracic and lumbar spine lateral X-ray. RESULTS Radiological vertebral fractures were found in 23 patients (31.1%) in association with untreated GHD (P=0.02), higher serum free T4 levels (P=0.03), a higher daily dose of l-T4 (P=0.005), and a longer duration of hypopituitarism (P=0.05). When GHD was treated, the prevalence of vertebral fractures was more frequent (P=0.03) in patients receiving high l-T4 doses (third tertile: >1.35 μg/kg per day) as compared with patients who were treated with lower drug doses (first tertile: <0.93 μg/kg per day). Such a difference was not observed in patients with untreated GHD who showed a higher prevalence of vertebral fractures regardless of l-T4 daily doses. Multivariate analysis showed that untreated GHD (odds ratio: 4.27, 95% CI 1.27-14.33; P=0.01) and the daily dose of l-T4 (odds ratio: 4.01, 95% CI 1.16-14.39; P=0.03) maintained a significant and independent association with vertebral fractures in patients with central hypothyroidism. CONCLUSIONS Our data suggest for the first time that a relative overtreatment with l-T4 may influence the fracture risk in some patients with hypopituitarism.
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Affiliation(s)
- G Mazziotti
- Chair of EndocrinologyUniversity of Brescia, A.O. Spedali Civili di Brescia, 25123 Brescia, ItalyPituitary UnitDepartment of Endocrinology, Catholic University of Rome, 00168 Rome, Italy
| | - M Mormando
- Chair of EndocrinologyUniversity of Brescia, A.O. Spedali Civili di Brescia, 25123 Brescia, ItalyPituitary UnitDepartment of Endocrinology, Catholic University of Rome, 00168 Rome, Italy
| | - A Cristiano
- Chair of EndocrinologyUniversity of Brescia, A.O. Spedali Civili di Brescia, 25123 Brescia, ItalyPituitary UnitDepartment of Endocrinology, Catholic University of Rome, 00168 Rome, Italy
| | - A Bianchi
- Chair of EndocrinologyUniversity of Brescia, A.O. Spedali Civili di Brescia, 25123 Brescia, ItalyPituitary UnitDepartment of Endocrinology, Catholic University of Rome, 00168 Rome, Italy
| | - T Porcelli
- Chair of EndocrinologyUniversity of Brescia, A.O. Spedali Civili di Brescia, 25123 Brescia, ItalyPituitary UnitDepartment of Endocrinology, Catholic University of Rome, 00168 Rome, Italy
| | - A Giampietro
- Chair of EndocrinologyUniversity of Brescia, A.O. Spedali Civili di Brescia, 25123 Brescia, ItalyPituitary UnitDepartment of Endocrinology, Catholic University of Rome, 00168 Rome, Italy
| | - F Maffezzoni
- Chair of EndocrinologyUniversity of Brescia, A.O. Spedali Civili di Brescia, 25123 Brescia, ItalyPituitary UnitDepartment of Endocrinology, Catholic University of Rome, 00168 Rome, Italy
| | - V Serra
- Chair of EndocrinologyUniversity of Brescia, A.O. Spedali Civili di Brescia, 25123 Brescia, ItalyPituitary UnitDepartment of Endocrinology, Catholic University of Rome, 00168 Rome, Italy
| | - L De Marinis
- Chair of EndocrinologyUniversity of Brescia, A.O. Spedali Civili di Brescia, 25123 Brescia, ItalyPituitary UnitDepartment of Endocrinology, Catholic University of Rome, 00168 Rome, Italy
| | - A Giustina
- Chair of EndocrinologyUniversity of Brescia, A.O. Spedali Civili di Brescia, 25123 Brescia, ItalyPituitary UnitDepartment of Endocrinology, Catholic University of Rome, 00168 Rome, Italy
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Abstract
Thyroid hormone deficiency can have important repercussions. Treatment with thyroid hormone in replacement doses is essential in patients with hypothyroidism. In this review, we critically discuss the thyroid hormone formulations that are available and approaches to correct replacement therapy with thyroid hormone in primary and central hypothyroidism in different periods of life such as pregnancy, birth, infancy, childhood, and adolescence as well as in adult patients, the elderly, and in patients with comorbidities. Despite the frequent and long term use of l-T4, several studies have documented frequent under- and overtreatment during replacement therapy in hypothyroid patients. We assess the factors determining l-T4 requirements (sex, age, gender, menstrual status, body weight, and lean body mass), the major causes of failure to achieve optimal serum TSH levels in undertreated patients (poor patient compliance, timing of l-T4 administration, interferences with absorption, gastrointestinal diseases, and drugs), and the adverse consequences of unintentional TSH suppression in overtreated patients. Opinions differ regarding the treatment of mild thyroid hormone deficiency, and we examine the recent evidence favoring treatment of this condition. New data suggesting that combined therapy with T3 and T4 could be indicated in some patients with hypothyroidism are assessed, and the indications for TSH suppression with l-T4 in patients with euthyroid multinodular goiter and in those with differentiated thyroid cancer are reviewed. Lastly, we address the potential use of thyroid hormones or their analogs in obese patients and in severe cardiac diseases, dyslipidemia, and nonthyroidal illnesses.
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Affiliation(s)
- Bernadette Biondi
- Department of Clinical Medicine and Surgery (B.B.), University of Naples Federico II, 80131 Naples, Italy; and Washington Hospital Center (L.W.), Washington, D.C. 20010
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Stott DJ, Bauer DC, Ford I, Kearney P, Gussekloo J, Quinn TJ, Rodondi N, Smit J, Westerdorp R. The Dilemma of Treating Subclinical Hypothyroidism: Risk that Current Guidelines Do More Harm than Good. Eur Thyroid J 2014; 3:137-8. [PMID: 25114879 PMCID: PMC4109501 DOI: 10.1159/000360621] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 02/14/2014] [Indexed: 11/19/2022] Open
Affiliation(s)
- David J. Stott
- University of Glasgow, Glasgow, UK
- *David J. Stott, Academic Section of Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow G31 2ER (UK), E-Mail
| | | | - Ian Ford
- University of Glasgow, Glasgow, UK
| | | | | | | | | | - Jan Smit
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Rudi Westerdorp
- Leyden Academy on Vitality and Ageing, Leiden, The Netherlands
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58
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Canadian Association of Gastroenterology position statement: hip fracture and proton pump inhibitor therapy-a 2013 update. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2014; 27:593-5. [PMID: 24251323 DOI: 10.1155/2013/321379] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Ko YJ, Kim JY, Lee J, Song HJ, Kim JY, Choi NK, Park BJ. Levothyroxine dose and fracture risk according to the osteoporosis status in elderly women. J Prev Med Public Health 2014; 47:36-46. [PMID: 24570805 PMCID: PMC3930806 DOI: 10.3961/jpmph.2014.47.1.36] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Accepted: 11/26/2013] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To evaluate the association between fracture risk and levothyroxine use in elderly women with hypothyroidism, according to previous osteoporosis history. METHODS We conducted a cohort study from the Korean Health Insurance Review and Assessment Service claims database from January 2005 to June 2006. The study population comprised women aged ≥65 years who had been diagnosed with hypothyroidism and prescribed levothyroxine monotherapy. We excluded patients who met any of the following criteria: previous fracture history, hyperthyroidism, thyroid cancer, or pituitary disorder; low levothyroxine adherence; or a follow-up period <90 days. We categorized the daily levothyroxine doses into 4 groups: ≤50 µg/d, 51 to 100 µg/d, 101 to 150 µg/d, and >150 µg/d. The hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated with the Cox proportional hazard model, and subgroup analyses were performed according to the osteoporosis history and osteoporosis-specific drug prescription status. RESULTS Among 11 155 cohort participants, 35.6% had previous histories of osteoporosis. The adjusted HR of fracture for the >150 µg/d group, compared with the 51 to 100 µg/d group, was 1.56 (95% CI, 1.03 to 2.37) in osteoporosis subgroup. In the highly probable osteoporosis subgroup, restricted to patients who were concurrently prescribed osteoporosis-specific drugs, the adjusted HR of fracture for the >150 µg/d group, compared with the 51 to 100 µg/d group, was 1.93 (95% CI, 1.14 to 3.26). CONCLUSIONS While further studies are needed, physicians should be concerned about potential levothyroxine overtreatment in elderly osteoporosis patients.
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Affiliation(s)
- Young-Jin Ko
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Young Kim
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Joongyub Lee
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Korea
| | - Hong-Ji Song
- Department of Family Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Ju-Young Kim
- Department of Family Medicine, Health Promotion Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Nam-Kyong Choi
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Korea
| | - Byung-Joo Park
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea. ; Korea Institute of Drug Safety and Risk Management, Seoul, Korea
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Rochon PA, Gruneir A, Wu W, Gill SS, Bronskill SE, Seitz DP, Bell CM, Fischer HD, Stephenson AL, Wang X, Gershon AS, Anderson GM. Demographic Characteristics and Healthcare Use of Centenarians: A Population-Based Cohort Study. J Am Geriatr Soc 2014; 62:86-93. [DOI: 10.1111/jgs.12613] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Paula A. Rochon
- Women's College Research Institute; Women's College Hospital; Toronto Ontario Canada
- Department of Medicine; University of Toronto; Toronto Ontario Canada
- Institute of Health Policy, Management and Evaluation; University of Toronto; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Andrea Gruneir
- Women's College Research Institute; Women's College Hospital; Toronto Ontario Canada
- Institute of Health Policy, Management and Evaluation; University of Toronto; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Wei Wu
- Women's College Research Institute; Women's College Hospital; Toronto Ontario Canada
| | - Sudeep S. Gill
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
- St. Mary's of the Lake Hospital; Kingston Ontario Canada
- Department of Medicine; Queen's University; Kingston Ontario Canada
| | - Susan E. Bronskill
- Institute of Health Policy, Management and Evaluation; University of Toronto; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Dallas P. Seitz
- Department of Psychiatry; Queen's University; Kingston Ontario Canada
| | - Chaim M. Bell
- Department of Medicine; University of Toronto; Toronto Ontario Canada
- Institute of Health Policy, Management and Evaluation; University of Toronto; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
- Mount Sinai Hospital; Toronto Ontario Canada
| | - Hadas D. Fischer
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Anne L. Stephenson
- Department of Medicine; University of Toronto; Toronto Ontario Canada
- Keenan Research Centre; Li Ka Shing Knowledge Institute; St. Michael's Hospital; Toronto Ontario Canada
| | - Xuesong Wang
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Andrea S. Gershon
- Department of Medicine; University of Toronto; Toronto Ontario Canada
- Institute of Health Policy, Management and Evaluation; University of Toronto; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
- Sunnybrook Health Sciences Centre; Toronto Ontario Canada
| | - Geoffrey M. Anderson
- Women's College Research Institute; Women's College Hospital; Toronto Ontario Canada
- Institute of Health Policy, Management and Evaluation; University of Toronto; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
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62
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Abstract
The pituitary gland has a role in puberty, reproduction, stress-adaptive responses, sodium and water balance, uterine contractions, lactation, thyroid function, growth, body composition and skin pigmentation. Ageing is marked by initially subtle erosion of physiological signalling mechanisms, resulting in lower incremental secretory-burst amplitude, more disorderly patterns of pituitary hormone release and blunted 24 h rhythmic secretion. Almost all pituitary hormones are altered by ageing in humans, often in a manner dependent on sex, body composition, stress, comorbidity, intercurrent illness, medication use, physical frailty, caloric intake, immune status, level of exercise, and neurocognitive decline. The aim of this article is to critically discuss the mechanisms mediating clinical facets of changes in the hypothalamic-pituitary axis during ageing, and the extent to which confounding factors operate to obscure ageing-related effects.
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Affiliation(s)
- Johannes D Veldhuis
- Endocrine Research Unit, Mayo School of Graduate Medical Education, Center for Translational Science Activities, Mayo Clinic, Rochester, MN 55905, USA.
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63
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Abstract
Osteoporosis is a common disease in the elderly population. The progress of this disease results in the reduction of bone mass and can increase the incidence of fractures. Drugs presently used clinically can block the aggravation of this disease. However, these drugs cannot increase the bone mass and may result in certain side effects. Statins, also known as HMG-CoA (3-hydroxy-3-methylglutaryl-CoA) reductase inhibitors, have been widely prescribed for CVD (cardiovascular disease) for decades. Nonetheless, several studies have demonstrated that statins exert bone anabolic effect and may be helpful for the treatment of osteoporosis. Several experiments have analysed the mechanisms of bone anabolism regulated by statins. In the present paper, we review the mechanisms of promoting osteogenesis, suppressing osteoblast apoptosis and inhibiting osteoclastogenesis.
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Abstract
In many parts of the world, incidence of papillary thyroid cancer is increasing faster than any other malignancy. Most papillary thyroid cancers that are diagnosed are small and are generally regarded as being low risk, with little or no effect on mortality. Papillary thyroid cancer is a clinical challenge because it is difficult to prove benefit from the traditional therapeutic triad for this disorder (ie, total thyroidectomy with or without prophylactic central neck dissection, radioiodine remnant ablation, and suppression of serum thyroid-stimulating hormone with levothyroxine). However, risk of disease recurrence might be reduced by these therapies in a subset of patients with more aggressive disease. In the past decade, professional societies and other groups have established evidence-based clinical practice guidelines for management of papillary thyroid cancer, but these efforts have been made difficult by a paucity of randomised controlled trials. In this review, we summarise epidemiological data for disease incidence, discuss some controversies in disease management, and outline a therapeutic framework founded in the best available medical evidence and existing recommendations from clinical practice guidelines.
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Affiliation(s)
- Donald S A McLeod
- Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
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Vadiveloo T, Donnan PT, Murphy MJ, Leese GP. Age- and gender-specific TSH reference intervals in people with no obvious thyroid disease in Tayside, Scotland: the Thyroid Epidemiology, Audit, and Research Study (TEARS). J Clin Endocrinol Metab 2013; 98:1147-53. [PMID: 23345094 DOI: 10.1210/jc.2012-3191] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of the study was to examine the association of tested TSH with age, gender, and diabetes in a large population-based cohort without evidence of thyroid disease. DESIGN Record-linkage technology was used retrospectively to identify people without evidence of thyroid disease in the general population of Tayside, Scotland, from July 1, 2003, to December 31, 2009. COHORT All Tayside residents who had thyroid function tests performed were identified. Using a unique patient identifier, data linkage enabled a cohort without thyroid disease to be identified by excluding anyone with thyroid or antithyroid prescription, thyroid-related admission or surgery, treatment with radioactive iodine and/or positive thyroid antibodies. Cases below 18 years of age were also excluded. OUTCOME MEASURES We measured TSH distribution among different age groups and by gender. RESULTS We identified the latest TSH measurements in 153127 people from the reference population after applying the exclusion criteria. There was a significant increase in median TSH (1.58 mU/L at 31-40 y to 1.86 mU/L at >90 y; P < .001) and 97.5th centile TSH (3.98 to 5.94 mU/L, respectively) with increasing age. The 2.5th centile decreased with age (0.51 to 0.31 mU/L). Patients with diabetes had marginally higher TSH concentration (1.80 vs 1.70 mU/L; P < .001). CONCLUSION The use of these age-specific reference intervals for TSH, especially in those over 70 years old, would result in the reclassification of many TSH results from "abnormal" to "normal" (within the 95th centile reference interval) and avoid unnecessary treatment.
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Affiliation(s)
- Thenmalar Vadiveloo
- Dundee Epidemiology and Biostatistics Unit, Division of Population Health Sciences, Medical Research Institute, MacKenzie Building, Kirsty Semple Way, University of Dundee, Dundee DD2 4BF, Scotland, United Kingdom.
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Solter D, Solter M. Do we treat hypothyroidism properly? A survey of 2488 patients from University Hospital Center, Zagreb, Croatia. ANNALES D'ENDOCRINOLOGIE 2013; 74:27-9. [PMID: 23337019 DOI: 10.1016/j.ando.2012.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 11/19/2012] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The objective was to examine the effectiveness of levothyroxine treatment in hypothyroid patients in achieving normal thyroid stimulating hormone (TSH), T4 and T3. MATERIAL AND METHODS Results of the treatment of 2448 hypothyroid patients treated with LT4 for at least 12 months between 2006 and 2011 (1920 with spontaneous hypothyroidism and 528 with hypothyroidism following surgery or 131I) are presented. Serum TSH, T4 and T3 were analyzed and referred as normal, increased or decreased. RESULTS Normal TSH was found in 75 and 68% of patients respectively. In subgroups with increased TSH, 15% and 14% of patients showed borderline or only mildly increased TSH (4.1-5.5 mIU/L). T4 (94 and 86%) and T3 (93 and 90% respectively) were normal in the majority of patients from both groups. LT4 over-treatment is observed in only 4 and 6% of patients respectively. CONCLUSION The results are less favorable for the group with hypothyroidism following surgery or (131)I than in spontaneous hypothyroidism, but in about 90% of patients with spontaneous hypothyroidism and 82% with hypothyroidism following surgery or (131)I, the LT4 dose could remain unchanged. It is discussed whether standard LT4 replacement could render normal TSH and thyroid hormone patterns in all hypothyroid patients.
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Affiliation(s)
- Darko Solter
- Department of Otorhinolaryngology, Head and Neck Surgery, Sisters of Mercy University Hospital Center, Vinogradska 29, 10000 Zagreb, Croatia
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Gesing A, Lewiński A, Karbownik-Lewińska M. The thyroid gland and the process of aging; what is new? Thyroid Res 2012; 5:16. [PMID: 23176389 PMCID: PMC3526560 DOI: 10.1186/1756-6614-5-16] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 11/18/2012] [Indexed: 01/07/2023] Open
Abstract
The endocrine system and particular endocrine organs, including the thyroid, undergo important functional changes during aging. The prevalence of thyroid disorders increases with age and numerous morphological and physiological changes of the thyroid gland during the process of aging are well-known. It is to be stressed that the clinical course of thyroid diseases in the elderly differs essentially from that observed in younger individuals, because symptoms are more subtle and are often attributed to normal aging. Subclinical hypo- and hyperthyroidism, as well as thyroid neoplasms, require special attention in elderly subjects. Intriguingly, decreased thyroid function, as well as thyrotropin (TSH) levels - progressively shifting to higher values with age - may contribute to the increased lifespan.This short review focuses on recent findings concerning the alterations in thyroid function during aging, including these which may potentially lead to extended longevity, both in humans and animals.
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Affiliation(s)
- Adam Gesing
- Department of Oncological Endocrinology, Medical University of Lodz, Zeligowski St,, No, 7/9, Lodz, 90-752, Poland.
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Willie MM, Gantsho M. Visit to general practitioners as a proxy for accessing chronic benefits by members of medical schemes, South Africa. Afr J Prim Health Care Fam Med 2012. [PMCID: PMC4565034 DOI: 10.4102/phcfm.v4i1.419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background Objectives Method Results Conclusion
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Affiliation(s)
- Bernard Goichot
- Department of Internal Medicine, Endocrinology, and Nutrition, University Hospital of Strasbourg, Strasbourg, France.
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Biondi B, Wartofsky L. Combination treatment with T4 and T3: toward personalized replacement therapy in hypothyroidism? J Clin Endocrinol Metab 2012; 97:2256-71. [PMID: 22593590 DOI: 10.1210/jc.2011-3399] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
CONTEXT Levothyroxine therapy is the traditional lifelong replacement therapy for hypothyroid patients. Over the last several years, new evidence has led clinicians to evaluate the option of combined T(3) and T(4) treatment to improve the quality of life, cognition, and peripheral parameters of thyroid hormone action in hypothyroidism. The aim of this review is to assess the physiological basis and the results of current studies on this topic. EVIDENCE ACQUISITION We searched Medline for reports published with the following search terms: hypothyroidism, levothyroxine, triiodothyronine, thyroid, guidelines, treatment, deiodinases, clinical symptoms, quality of life, cognition, mood, depression, body weight, heart rate, cholesterol, bone markers, SHBG, and patient preference for combined therapy. The search was restricted to reports published in English since 1970, but some reports published before 1970 were also incorporated. We supplemented the search with records from personal files and references of relevant articles and textbooks. Parameters analyzed included the rationale for combination treatment, the type of patients to be selected, the optimal T(4)/T(3) ratio, and the potential benefits of this therapy on symptoms of hypothyroidism, quality of life, mood, cognition, and peripheral parameters of thyroid hormone action. EVIDENCE SYNTHESIS The outcome of our analysis suggests that it may be time to consider a personalized regimen of thyroid hormone replacement therapy in hypothyroid patients. CONCLUSIONS Further prospective randomized controlled studies are needed to clarify this important issue. Innovative formulations of the thyroid hormones will be required to mimic a more perfect thyroid hormone replacement therapy than is currently available.
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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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Austin PC, Anderson GM, Cigsar C, Gruneir A. Comparing the cohort design and the nested case-control design in the presence of both time-invariant and time-dependent treatment and competing risks: bias and precision. Pharmacoepidemiol Drug Saf 2012; 21:714-724. [PMID: 22653805 PMCID: PMC3471986 DOI: 10.1002/pds.3299] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 04/18/2012] [Accepted: 04/28/2012] [Indexed: 11/21/2022]
Abstract
Purpose Observational studies using electronic administrative healthcare databases are often used to estimate the effects of treatments and exposures. Traditionally, a cohort design has been used to estimate these effects, but increasingly, studies are using a nested case–control (NCC) design. The relative statistical efficiency of these two designs has not been examined in detail. Methods We used Monte Carlo simulations to compare these two designs in terms of the bias and precision of effect estimates. We examined three different settings: (A) treatment occurred at baseline, and there was a single outcome of interest; (B) treatment was time varying, and there was a single outcome; and C treatment occurred at baseline, and there was a secondary event that competed with the primary event of interest. Comparisons were made of percentage bias, length of 95% confidence interval, and mean squared error (MSE) as a combined measure of bias and precision. Results In Setting A, bias was similar between designs, but the cohort design was more precise and had a lower MSE in all scenarios. In Settings B and C, the cohort design was more precise and had a lower MSE in all scenarios. In both Settings B and C, the NCC design tended to result in estimates with greater bias compared with the cohort design. Conclusions We conclude that in a range of settings and scenarios, the cohort design is superior in terms of precision and MSE. Copyright © 2012 John Wiley & Sons, Ltd.
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Affiliation(s)
- Peter C Austin
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Institute of Health Management, Policy and Evaluation, University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Reyes García R, Jódar Gimeno E, García Martín A, Romero Muñoz M, Gómez Sáez JM, Luque Fernández I, Varsavsky M, Guadalix Iglesias S, Cano Rodriguez I, Ballesteros Pomar MD, Vidal Casariego A, Rozas Moreno P, Cortés Berdonces M, Fernández García D, Calleja Canelas A, Palma Moya M, Martínez Díaz-Guerra G, Jimenez Moleón JJ, Muñoz Torres M. [Clinical practice guidelines for evaluation and treatment of osteoporosis associated to endocrine and nutritional conditions. Bone Metabolism Working Group of the Spanish Society of Endocrinology]. ACTA ACUST UNITED AC 2012; 59:174-96. [PMID: 22321561 DOI: 10.1016/j.endonu.2012.01.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Accepted: 01/10/2012] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To provide practical recommendations for evaluation and treatment of osteoporosis associated to endocrine diseases and nutritional conditions. PARTICIPANTS Members of the Bone Metabolism Working Group of the Spanish Society of Endocrinology, a methodologist, and a documentalist. METHODS Recommendations were formulated according to the GRADE system (Grading of Recommendations, Assessment, Development, and Evaluation) to describe both the strength of recommendations and the quality of evidence. A systematic search was made in MEDLINE (Pubmed), using the following terms associated to the name of each condition: AND "osteoporosis", "fractures", "bone mineral density", and "treatment". Papers in English with publication date before 18 October 2011 were included. Current evidence for each disease was reviewed by two group members, and doubts related to the review process or development of recommendations were resolved by the methodologist. Finally, recommendations were discussed in a meeting of the Working Group. CONCLUSIONS The document provides evidence-based practical recommendations for evaluation and management of endocrine and nutritional diseases associated to low bone mass or an increased risk of fracture. For each disease, the associated risk of low bone mass and fragility fractures is given, recommendations for bone mass assessment are provided, and treatment options that have shown to be effective for increasing bone mass and/or to decreasing fragility fractures are listed.
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Thorpe CT, Lassila HC, O'Neil CK, Thorpe JM, Hanlon JT, Maher RL. Reconsideration of key articles regarding medication-related problems in older adults from 2011. THE AMERICAN JOURNAL OF GERIATRIC PHARMACOTHERAPY 2012; 10:2-13. [PMID: 22330099 PMCID: PMC3378666 DOI: 10.1016/j.amjopharm.2012.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Accepted: 01/04/2012] [Indexed: 05/31/2023]
Affiliation(s)
- Carolyn T Thorpe
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Abstract
All forms of thyroid diseases are much more frequently observed in women than men, although the reasons are still not completely elucidated.Hyperthyroidism is defined by elevated circulating free thyroid hormones. The prevalence is about 2 % in women and 0.2 % in men. The most frequent causes are various forms of thyroid autonomy in elderly women and Graves' disease, which occurs mostly in younger women.Hypothyroidism is defined by a lack of thyroid hormones. It is a common endocrine disorder caused by autoimmune thyroiditis (Hashimoto thyroiditis), iodine deficiency or following surgery or radioiodine therapy. Thyroxine requirements depend on fat-free mass and are, therefore, somewhat higher in males who are more often undersubstituted. In pregnancy lower TSH-reference ranges have to be considered and thyroid function should be monitored throughout pregnancy to avoid harm to the foetus caused by maternal thyroid dysfunctions. If overtreated women more often feature fractures, whereas males more often develop atrial fibrillation.
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Affiliation(s)
- Alois Gessl
- Department of Internal Medicine III, Medical University Of Vienna, Vienna, Austria
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Chakera AJ, Pearce SHS, Vaidya B. Treatment for primary hypothyroidism: current approaches and future possibilities. DRUG DESIGN DEVELOPMENT AND THERAPY 2011; 6:1-11. [PMID: 22291465 PMCID: PMC3267517 DOI: 10.2147/dddt.s12894] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Primary hypothyroidism is the most common endocrine disease. Although the diagnosis and treatment of hypothyroidism is often considered simple, there are large numbers of people with this condition who are suboptimally treated. Even in those people with hypothyroidism who are biochemically euthyroid on levothyroxine replacement there is a significant proportion who report poorer quality of life. This review explores the historical and current treatment options for hypothyroidism, reasons for and potential solutions to suboptimal treatment, and future possibilities in the treatment of hypothyroidism.
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Affiliation(s)
- Ali J Chakera
- Department of Endocrinology, Royal Devon and Exeter Hospital and Peninsula Medical School, Exeter, UK
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Ward LS. [Levothyroxine and the problem of interchangeability of drugs with narrow therapeutic index]. ACTA ACUST UNITED AC 2011; 55:429-34. [PMID: 22147090 DOI: 10.1590/s0004-27302011000700001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Accepted: 10/03/2011] [Indexed: 11/22/2022]
Abstract
The exchange of a prescribed drug by other similar, by generic products and even by custom products has become common practice in our country, often ignoring basic tenets of bioequivalence, interchangeability, stability and characteristics of the pharmaceutical compounds. In the case of drugs of narrow therapeutic index, such as levothyroxine, these problems are intensified, putting the effectiveness of treatment and patient health at serious risk. We review the pertinent legislation, emphasizing the characteristics of levothyroxine and adverse effects that limit the interchangeability of the compound.
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Affiliation(s)
- Laura Sterian Ward
- Departamento de Tireoide da Sociedade Brasileira de Endocrinologia e Metabologia, Universidade Estadual de Campinas, SP, Brasil.
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Okosieme OE. Thyroid hormone replacement: current status and challenges. Expert Opin Pharmacother 2011; 12:2315-28. [DOI: 10.1517/14656566.2011.600307] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Mitrou P, Raptis SA, Dimitriadis G. Thyroid disease in older people. Maturitas 2011; 70:5-9. [PMID: 21719219 DOI: 10.1016/j.maturitas.2011.05.016] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 05/27/2011] [Indexed: 01/07/2023]
Abstract
Several changes in thyroid hormone secretion, metabolism, and action occur with the increase in age. Aging is often associated with a decrease in serum thyroid stimulating hormone and T3 levels, whereas serum free T4 levels usually remain unchanged. The prevalence of thyroid dysfunction is higher in the elderly as compared to the younger population. In elderly individuals the non-specific clinical manifestations of thyroid hormone excess or deprivation can cause confusion in the clinical setup; while some of the symptoms of thyroid disease are similar to those in younger patients, it is not uncommon for both hyperthyroidism and hypothyroidism to be manifested in subtle ways in older patients, often mimicking symptoms of aging or masquerading as diseases of the cardiovascular, gastrointestinal, or nervous system. In addition, diagnosis of thyroid disorders is commonly complicated, due to chronic, non-thyroidal illness or medication therapy. Early diagnosis and treatment of overt thyroid disorders is crucial, since these disorders are associated with increased morbidity and mortality in the elderly, usually due to common coexistent diseases such as diminished cardiovascular reserve. Treatment of subclinical thyroid disease should also be considered, based on a combination of age, symptoms and risk factors in the individual patients. In addition, both prevalence and aggressiveness of thyroid cancer increase with age. This review summarizes the changes of thyroid function, as well as the clinical manifestations and treatment of thyroid disorders with advancing age.
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Affiliation(s)
- Panayota Mitrou
- Hellenic National Center for Research, Prevention and Treatment of Diabetes Mellitus and its Complications (HNDC), Athens, Greece
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Haugen T. Levotyroksin gir økt risiko for fraktur hos eldre. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2011. [DOI: 10.4045/tidsskr.11.0692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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