Spectrum of quality of life impairment in hypothyroidism

Temperature Differences Between Controlled Primary Hypothyroidism and Healthy Patients: An Exploratory Study

Introduction

Hypothyroidism is conventionally treated with replacement therapy through levothyroxine (LT4). Despite the improvement in symptoms, cold intolerance persists in some patients. The present study aims to determine whether there is a difference in temperature perception and skin temperature between patients with primary controlled hypothyroidism (PCH) and a group of healthy controls matched for body mass index and age. Secondarily we aimed to determine difference in quality of life.

Methodology

Skin temperature measurements were performed in both groups, both in the central and peripheral regions of the body. In addition, subjects were asked about their perception of temperature in a temperature-controlled room; anthropometric measurements were taken, their quality of life was assessed using the ThyPRO-39, and a thyroid hormone profile was performed.

Results

Eleven patients in the PCH group and 30 patients in the control group were studied. It was found that the group with PCH presented a significantly lower palmar temperature than the control group [mean (SD) of 32.05 (1.79) vs 33.10 (1.30) oC, P = .046]. A mediation model showed a direct effect. Temperature perception was equal between groups. The median (interquartile range) of ThyPRO was 8 (5.2) points in the control group vs 21.8 (13.5) in the group of controlled hypothyroidism, P < .001.

Discussion

These results suggest that, despite LT4 treatment, patients continue to present abnormalities in thermogenesis-related thermogenesis, and this may be due to a lack of hormonal adaptation to environmental changes and physiological demands, leading to lower body temperatures and increased sensitivity to cold.

The Impact of Hypothyroidism on the Quality of Life of Adults in Riyadh, Saudi Arabia

Background and objective Hypothyroidism is extremely common and associated with far-reaching health consequences. The negative effects of hypothyroidism on patients' quality of life (QoL) are well-documented. It is said to be common in the countries of the Arabian Gulf, although it is often misdiagnosed and treated in an inconsistent manner. Hence, understanding how an illness like this affects a patient's life might help us enhance their QoL and get us closer to the healthcare transformation goals of Saudi Arabia's Vision 2030. Methodology This cross-sectional study was conducted in Riyadh, Saudi Arabia, between June 2022 and February 2023. A convenience non-probability sampling method was used. The WHO Quality of Life (WHOQOL)-BREF questionnaire in Arabic was used to compile the data. Data were collected using a standardized form, refined using Google Forms, and then documented in an Excel spreadsheet. The descriptive statistics were shown as means and standard deviations (SD). To assess the numerical data, a t-test was used, while the chi-square test was employed to examine the relationship between the qualitative factors. Results A total of 394 adults from the general population with hypothyroidism were surveyed, including 105 men and 289 women. Of them, 151 (38.3%) patients had not sought therapy for their hypothyroidism, while 243 (61.7%) patients had. When asked about the QoL, a significant segment (37.6%) of patients reported that it was high, and 29.7% reported being totally satisfied with their health. The WHOQOL-BREF domain scores revealed that environmental health had the highest value (24.04 ±4.62), followed by physical health (22.24 ±3.23), and then psychological health (18.08 ±2.82), and the lowest scores were reported for the rate of QoL and satisfaction with health (2.64 ±1.36 and 2.80 ±1.68), respectively. Each domain of the WHOQOL-BREF had its own set of variables that differed from one another in a statistically significant manner (p<0.001). Conclusions  Based on our findings, we recommend expert physician monitoring and implementing educational programs as well as placing a greater emphasis on patients' QoL in the management of hypothyroidism.

Thyroid disease-specific quality of life questionnaires - A systematic review

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.

Role of Levothyroxine/Liothyronine Combinations in Treating Hypothyroidism

Diverse causes potentially underlie decreased quality of life in biochemically euthyroid patients treated for hypothyroidism with levothyroxine. Once these contributing factors are addressed, if symptoms persist, there may be benefit to personalized use of combination therapy adding liothyronine. This approach should be carefully monitored: avoiding overtreatment and ensuring that therapy is only continued if it improves patient-reported quality of life. Most randomized clinical trials have not shown benefits, perhaps because of not targeting the most symptomatic patients. Sustained-release liothyronine preparations may soon be available for optimally designed studies assessing whether combination therapy provides superior therapy for hypothyroidism in select patients.

Hypothyroidism

Hypothyroidism is the common clinical condition of thyroid hormone deficiency and, if left untreated, can lead to serious adverse health effects on multiple organ systems, with the cardiovascular system as the most robustly studied target. Overt primary hypothyroidism is defined as elevated thyroid-stimulating hormone (TSH) concentration in combination with free thyroxine (fT₄) concentration below the reference range. Subclinical hypothyroidism, commonly considered an early sign of thyroid failure, is defined by elevated TSH concentrations but fT₄ concentrations within the reference range. Hypothyroidism is classified as primary, central or peripheral based on pathology in the thyroid, the pituitary or hypothalamus, or peripheral tissue, respectively. Acquired primary hypothyroidism is the most prevalent form and can be caused by severe iodine deficiency but is more frequently caused by chronic autoimmune thyroiditis in iodine-replete areas. The onset of hypothyroidism is insidious in most cases and symptoms may present relatively late in the disease process. There is a large variation in clinical presentation and the presence of hypothyroid symptoms, especially in pregnancy and in children. Levothyroxine (LT4) is the mainstay of treatment and is one of the most commonly prescribed drugs worldwide. After normalization of TSH and fT₄ concentrations, a considerable proportion of patients treated with LT4 continue to have persistent complaints, compromising quality of life. Further research is needed regarding the appropriateness of currently applied reference ranges and treatment thresholds, particularly in pregnancy, and the potential benefit of LT4/liothyronine combination therapy for thyroid-related symptom relief, patient satisfaction and long-term adverse effects.

Primary hypothyroidism and quality of life

In the 1970s, treatment with thyroid extract was superseded by levothyroxine, a synthetic L form of tetraiodothyronine. Since then, no major innovation has emerged for the treatment of hypothyroidism. The biochemical definition of subclinical hypothyroidism is a matter of debate. Indiscriminate screening for hypothyroidism has led to overdiagnosis and treatment initiation at lower serum levels of thyroid-stimulating hormone (TSH) than previously. Adverse health effects have been documented in individuals with hypothyroidism or hyperthyroidism, and these adverse effects can affect health-related quality of life (QOL). Levothyroxine substitution improves, but does not always normalize, QOL, especially for individuals with mild hypothyroidism. However, neither studies combining levothyroxine and liothyronine (the synthetic form of tri-iodothyronine) nor the use of desiccated thyroid extract have shown robust improvements in patient satisfaction. Future studies should focus not only on a better understanding of an individual's TSH set point (the innate narrow physiological range of serum concentration of TSH in an individual, before the onset of hypothyroidism) and alternative thyroid hormone combinations and formulations, but also on autoimmunity and comorbidities unrelated to hypothyroidism as drivers of patient dissatisfaction. Attention to the long-term health consequences of hypothyroidism, beyond QOL, and the risks of overtreatment is imperative.

Optimal Thyroid Hormone Replacement

Hypothyroidism is a common endocrinopathy, and levothyroxine is frequently prescribed. Despite the basic tenets of initiating and adjusting levothyroxine being agreed on, there are many nuances and complexities to consistently maintaining euthyroidism. Understanding the impact of patient weight and residual thyroid function on initial levothyroxine dosage and consideration of age, comorbidities, thyrotropin goal, life stage, and quality of life as levothyroxine is adjusted can be challenging and continually evolving. Because levothyroxine is a lifelong medication, it is important to avoid risks from periods of overtreatment or undertreatment. For the subset of patients not restored to baseline health with levothyroxine, causes arising from all aspects of the patient's life (coexistent medical conditions, stressors, lifestyle, psychosocial factors) should be broadly considered. If such factors do not appear to be contributing, and biochemical euthyroidism has been successfully maintained, there may be benefit to a trial of combination therapy with levothyroxine and liothyronine. This is not supported by the majority of randomized clinical trials, but may be supported by other studies providing lower-quality evidence and by animal studies. Given this discrepancy, it is important that any trial of combination therapy be continued only as long as a patient benefit is being enjoyed. Monitoring for adverse effects, particularly in older or frail individuals, is necessary and combination therapy should not be used during pregnancy. A sustained-release liothyronine preparation has completed phase 1 testing and may soon be available for better designed and powered studies assessing whether combination therapy provides superior therapy for hypothyroidism.

Comparative Effectiveness of Levothyroxine, Desiccated Thyroid Extract, and Levothyroxine+Liothyronine in Hypothyroidism

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.

What Is the Quality of Life in Patients Treated with Levothyroxine for Hypothyroidism and How Are We Measuring It? A Critical, Narrative Review

Thyroid hormone replacement therapy (THRT, generally using oral levothyroxine (LT4)) is a safe, effective means of treating hypothyroidism. However, a proportion of LT4-treated patients with biochemically normal thyroid function tests complain of persistent symptoms that impact their health-related quality of life (QoL). The objectives of this critical, narrative review of the literature were to identify studies of QoL in LT4-treated patients with hypothyroidism, examine the instruments used to measure QoL, determine whether normal QoL is restored by THRT, and identify factors associated with QoL. The PubMed database was searched from 1 January 2000 to 31 December 2020. A total of 809 publications were screened, 129 full-text articles were retrieved, and 58 were analyzed. The studies of overt hypothyroidism evidenced an improvement in psychological and emotional well-being after three to six months of THRT with LT4, although contrasting results were found for patients with subclinical hypothyroidism. Combination treatment with LT4 and liothyronine was not generally associated with better QoL. In hypothyroidism, QoL appears to be influenced by a number of physiological, behavioral, cognitive and/or lifestyle factors that are not strictly related to thyroid hormone levels.

Evidence-Based Use of Levothyroxine/Liothyronine Combinations in Treating Hypothyroidism: A Consensus Document

BACKGROUND

Fourteen clinical trials have not shown a consistent benefit of combination therapy with levothyroxine (LT4) and liothyronine (LT3). Despite the publication of these trials, combination therapy is widely used and patients reporting benefit continue to generate patient and physician interest in this area. Recent scientific developments may provide insight into this inconsistency and guide future studies.

METHODS

The American Thyroid Association (ATA), British Thyroid Association (BTA), and European Thyroid Association (ETA) held a joint conference on November 3, 2019 (live-streamed between Chicago and London) to review new basic science and clinical evidence regarding combination therapy with presentations and input from 12 content experts. After the presentations, the material was synthesized and used to develop Summary Statements of the current state of knowledge. After review and revision of the material and Summary Statements, there was agreement that there was equipoise for a new clinical trial of combination therapy. Consensus Statements encapsulating the implications of the material discussed with respect to the design of future clinical trials of LT4/LT3 combination therapy were generated. Authors voted upon the Consensus Statements. Iterative changes were made in several rounds of voting and after comments from ATA/BTA/ETA members.

RESULTS

Of 34 Consensus Statements available for voting, 28 received at least 75% agreement, with 13 receiving 100% agreement. Those with 100% agreement included studies being powered to study the effect of deiodinase and thyroid hormone transporter polymorphisms on study outcomes, inclusion of patients dissatisfied with their current therapy and requiring at least 1.2 µg/kg of LT4 daily, use of twice daily LT3 or preferably a slow-release preparation if available, use of patient-reported outcomes as a primary outcome (measured by a tool with both relevant content validity and responsiveness) and patient preference as a secondary outcome, and utilization of a randomized placebo-controlled adequately powered double-blinded parallel design. The remaining statements are presented as potential additional considerations.

DISCUSSION

This article summarizes the areas discussed and presents Consensus Statements to guide development of future clinical trials of LT4/LT3 combination therapy. The results of such redesigned trials are expected to be of benefit to patients and of value to inform future thyroid hormone replacement clinical practice guidelines treatment recommendations.

Evidence-Based Use of Levothyroxine/Liothyronine Combinations in Treating Hypothyroidism: A Consensus Document

Background: Fourteen clinical trials have not shown a consistent benefit of combination therapy with levothyroxine (LT4) and liothyronine (LT3). Despite the publication of these trials, combination therapy is widely used and patients reporting benefit continue to generate patient and physician interest in this area. Recent scientific developments may provide insight into this inconsistency and guide future studies. Methods: The American Thyroid Association (ATA), British Thyroid Association (BTA), and European Thyroid Association (ETA) held a joint conference on November 3, 2019 (live-streamed between Chicago and London) to review new basic science and clinical evidence regarding combination therapy with presentations and input from 12 content experts. After the presentations, the material was synthesized and used to develop Summary Statements of the current state of knowledge. After review and revision of the material and Summary Statements, there was agreement that there was equipoise for a new clinical trial of combination therapy. Consensus Statements encapsulating the implications of the material discussed with respect to the design of future clinical trials of LT4/LT3 combination therapy were generated. Authors voted upon the Consensus Statements. Iterative changes were made in several rounds of voting and after comments from ATA/BTA/ETA members. Results: Of 34 Consensus Statements available for voting, 28 received at least 75% agreement, with 13 receiving 100% agreement. Those with 100% agreement included studies being powered to study the effect of deiodinase and thyroid hormone transporter polymorphisms on study outcomes, inclusion of patients dissatisfied with their current therapy and requiring at least 1.2 μg/kg of LT4 daily, use of twice daily LT3 or preferably a slow-release preparation if available, use of patient-reported outcomes as a primary outcome (measured by a tool with both relevant content validity and responsiveness) and patient preference as a secondary outcome, and utilization of a randomized placebo-controlled adequately powered double-blinded parallel design. The remaining statements are presented as potential additional considerations. Discussion: This article summarizes the areas discussed and presents Consensus Statements to guide development of future clinical trials of LT4/LT3 combination therapy. The results of such redesigned trials are expected to be of benefit to patients and of value to inform future thyroid hormone replacement clinical practice guidelines treatment recommendations.

Combination Therapy for Hypothyroidism: Rationale, Therapeutic Goals, and Design

Hypothyroidism is a common condition with a wide spectrum of etiologies and clinical manifestations. While the majority of patients affected by hypothyroidism respond well to levothyroxine, some patients do not and complain of symptoms despite adequate replacement. There is evidence in experimental models of hypothyroidism that levothyroxine alone may not be able to deliver an adequate amount of T3 to all the tissues targeted by the hormonal action, while liothyronine/levothyroxine combination therapy can. The results of clinical studies directed to assess the effectiveness of liothyronine/levothyroxine combination therapy on the amelioration of hypothyroid symptoms have been disappointing. Most of the trials have been short and underpowered, with several shortcomings in the study design. There is consensus that an adequately powered clinical trial should be developed to prove or disprove the efficacy and effectiveness of therapies other than LT4 alone for the treatment of hypothyroidism, and to assess which group of patients would benefit from them. Here we present some considerations on the technical aspects and necessary tradeoffs in designing such a study with a particular focus on study population selection, choice of endpoints, and study drugs formulation and regimen.

A Cross-Sectional Study to Assess the Prevalence of Adult Thyroid Dysfunction Disorders in Jordan

Background: Insufficient production of thyroid hormones results in hypothyroidism, while overproduction results in hyperthyroidism. These are common adult disorders, with hypothyroidism more common in the elderly. Jordan has had past problems with dietary iodine deficiency but there are no published studies assessing the population prevalence of these disorders in the Arab Middle East. Methods: A cross-sectional study was conducted in three representative areas of Jordan. There were 7085 participants with a mean age of 40.8 years. Participants completed a questionnaire and had blood taken for thyroid analysis. Results:Hypothyroidism: The prevalence of any hypothyroidism (already diagnosed and/or identified by blood testing) was 17.2% in females and 9.1% in males. Undiagnosed prevalence was 8% and 6.2% for females and males, respectively. The prevalence of subclinical hypothyroidism, defined as high serum thyrotropin (TSH) and normal serum-free thyroxine (fT4), was 5.98% among females and 4.40% among males. The prevalence of overt hypothyroidism, defined as high TSH and low fT4, was 2.00% among females and 1.80% among males. Only 53.5% (55.3% for females, 42.1% males) of those previously diagnosed with hypothyroidism had TSH levels within the appropriate range. Hyperthyroidism: The prevalence of any hyperthyroidism (already diagnosed and/or identified by blood testing) was 1.8% in females and 2.27% in males. The undiagnosed prevalence was 1.4% and 2.1% for females and males, respectively. The prevalence of subclinical hyperthyroidism (low TSH and normal fT4) was 1.20% and 1.80% among males and females accordingly. The prevalence of overt hyperthyroidism (low TSH and high fT4) was 0.2% among females and 0.3% among males. About 85.7% (83.3% for females, 100% males) of those previously diagnosed with hyperthyroidism had TSH levels within the appropriate range. Conclusions: The results of this study reveal that the total prevalence of thyroid dysfunction among adult females and males in Jordan is very high compared with international statistics, particularly in the rates of undiagnosed cases. This indicates the need for further assessment of the value of screening for adult hypothyroidism in Jordan.

Treatment of adult Graves' disease

Treatment strategy in Graves' disease firstly requires recovery of euthyroid status by antithyroid therapy. Treatment modalities, precautions, advantages and side-effects are to be discussed with the patient. No particular treatment modality has demonstrated superiority. Pregnancy or pregnancy project affects choice of treatment and monitoring. Graves' orbitopathy is liable to be aggravated by iodine-131 treatment and requires pre-treatment assessment. Iodine-131 treatment aims at achieving hypothyroidism. Thyroid surgery for Graves' disease should preferably be performed by an expert team. In case of recurrence of hyperthyroidism, the various treatment options should be discussed with the patient. Empiric treatment of thyroid dermopathy uses local corticosteroids in occlusive dressing.

Impairment of Health-related Quality of Life among Indian Patients with Hypothyroidism

CONTEXT

Health-related quality of life (HRQL) is an important outcome measure for various diseases, although there are sparse data regarding HRQL among Indian patients with hypothyroidism.

AIMS

This study aimed to assess HRQL among Indian patients with hypothyroidism using the SF-36 questionnaire.

METHODS

This cross-sectional study evaluated 244 consecutive patients with hypothyroidism who were treated at the Vydehi Institute of Medical Sciences and Research Centre in Bengaluru. All patients were >18 years old and visited the outpatient department for endocrine treatment. Perceived health status was evaluated using the SF-36 questionnaire. The patients' data were compared to data from 250 age-matched and sex-matched healthy controls.

RESULTS

Compared to the healthy controls, the patients with hypothyroidism had significantly lower scores for six of the eight SF-36 scales. No significant intergroup differences were observed in the "role emotional" and "social functioning" dimensions.

INTERPRETATION AND CONCLUSIONS

Hypothyroidism was associated with reduced HRQL among Indian patients. These patients generally experienced greater reductions in physical dimensions, compared to social and emotional dimensions.

Treatment of hypothyroidism with levothyroxine plus liothyronine: a randomized, double-blind, crossover study

OBJECTIVE

To compare the effects of a unique fixed combination levothyroxine/liothyronine (LT4/LT3) therapy in patients with primary hypothyroidism.

SUBJECTS AND METHODS

This is a randomized, double-blind, crossover study. Adults with primary hypothyroidism (n = 32, age 42.6 ± 13.3, 30 females) on stable doses of LT4 for ≥ 6 months (125 or 150 μg/day) were randomized to continue LT4 treatment (G1) or to start LT4/LT3 therapy (75/15 μg/day; G2). After 8 weeks, participants switched treatments for 8 more weeks. Thyroid function, lipid profile, plasma glucose, body weight, electrocardiogram, vital signs, and quality of life (QoL) were evaluated at weeks 0, 8 and 16.

RESULTS

Free T4 levels were significantly lower while on LT4/LT3 (G1: 1.07 ± 0.29 vs. 1.65 ± 0.46; G2: 0.97 ± 0.26 vs. 1.63 ± 0.43 ng/dL; P < 0.001). TSH and T3 levels were not affected by type of therapy. More patients on LT4/LT3 had T3 levels above the upper limit (15% vs. 3%). The combination therapy led to an increase in heart rate, with no significant changes in electrocardiogram or arterial blood pressure. Lipid profile, body weight and QoL remained unchanged.

CONCLUSIONS

The combination therapy yielded significantly lower free T4 levels, with no changes in TSH or T3 levels. More patients on LT4/T3 had elevated T3 levels, with no significant alterations in the evaluated outcomes. No clear clinical benefit of the studied formulation could be observed. Future trials need to evaluate different formulations and the impact of the combined therapy in select populations with genetic polymorphisms.

Risks and safety of combination therapy for hypothyroidism

INTRODUCTION

Hypothyroidism is currently a condition that can be treated, but not cured. Although levothyroxine reverses stigmata of hypothyroidism in most individuals, some patients feel dissatisfied with 'monotherapy', and this has stimulated interest in 'combination therapy' with both levothyroxine and liothyronine.

AREAS COVERED

A search of PubMed was conducted using terms including hypothyroidism, treatment, benefits, risks, and safety. Based on the articles identified, the body of evidence regarding the efficacy of traditional levothyroxine is reviewed. Concerns with levothyroxine therapy including impaired quality of life in treated patients, thyroxine-predominant hormone ratios, and inadvertent iatrogenic thyroid disease are discussed. The trials of combination therapy performed since 1999 were reviewed. The heterogeneity of these trials, both in terms of design and results, is discussed. The potential for new trials to determine whether combination therapy can reverse the dissatisfaction associated with monotherapy, while avoiding non-physiologic hormone ratios, inadvertent thyrotoxicosis, and unacceptable side effects is discussed. Expert commentary: Research regarding which therapy fully reverses hypothyroidism at a tissue and cellular level is ongoing. The field would be advanced by the development of an extended release preparation of liothyronine. In the future regeneration of functional thyroid follicles from stem cells may offer hope for curing hypothyroidism.

Quality of life, clinical outcomes and safety of early prophylactic levothyroxine administration in patients with Graves' hyperthyroidism undergoing radioiodine therapy: a randomized controlled study

OBJECTIVE

While radioiodine therapy is commonly used for treating Graves' disease, a prolonged and clinical hypothyroidism may result in disabling symptoms leading to deterioration of quality of life (QoL) of patients. Introducing levothyroxine (LT4) treatment in the early post-therapeutic period may be an interesting approach to limit this phenomenon.

METHODS

A multicenter, prospective, open-label randomized controlled trial enrolled 94 patients with Graves' hyperthyroidism randomly assigned to the experimental group (n=46) (group A: early prophylactic LT4 treatment) or the control group (n=48) (group B: standard follow-up). The primary endpoint was the 6-month QoL. The secondary endpoints were other QoL scores such as Graves' ophthalmopathy (GO) outcomes, thyroid function tests and safety.

RESULTS

The primary endpoint at 6 months was achieved: the mental composite score (MCS) of Short Form 36 (SF-36) was significantly higher in group A compared to group B (P=0.009). Four other dimension scores of the SF-36 and four dimension scores of the thyroid-specific patient-reported outcome (ThyPRO) significantly differed between the two groups, indicating better QoL in group A. After adjustment for variables, the early LT4 administration strategy was found as an independent factor for only two scores of SF-36: the MCS and the general health (GH) score. There were no differences in GO, final thyroid status and changes in the anti-TSH receptor antibodies (TRAbs) levels between the two groups. No adverse cardiovascular event was reported.

CONCLUSION

Early LT4 administration post-radioactive iodine (RAI) could represent a safe potential benefit for patients with regard to QoL. The optimal strategy taking into account administered RAI activities and LT4 treatment dosage and timing remains to be determined.

A systematic review of quality of thyroid-specific health-related quality-of-life instruments recommends ThyPRO for patients with benign thyroid diseases

OBJECTIVES

To appraise the measurement properties of thyroid-specific health-related quality-of-life (HRQOL) instruments and to provide recommendations on the choice of HRQOL instruments.

STUDY DESIGN AND SETTING

Systematic review of English-language literature published between 1993 and 2015 identified psychometric studies involving patients with thyroid disease through a search of Pubmed, Web of Science, Embase, and OVID MEDLINE. HRQOL instruments were graded on methodological quality and overall levels of evidence using a COSMIN checklist.

RESULTS

After a review of 742 original studies, 23 studies reporting 14 standardized HRQOL instruments targeted for Graves' ophthalmopathy (n = 4), hypothyroidism (n = 3), thyroid cancer (n = 2), other thyroid disease (n = 3), and nonthyroid tumor sites (n = 2) were identified. Hypothesis testing was evaluated most frequently. The 84-item thyroid-specific patient-reported outcome measure (ThyPRO) and 16-item Graves' ophthalmopathy-specific Quality-of-Life (GO-QOL) instruments were the most extensively evaluated instrument. The highest number of positive ratings in overall level of psychometric evidence was found in ThyPRO, GO-QOL, and 11-item Thyroid Treatment Satisfaction Questionnaire (ThyTSQ) instruments.

CONCLUSION

The ThyPRO is recommended for the assessment of HRQOL in patients with benign thyroid diseases while measurement properties of GO-QOL and ThyTSQ are satisfactory in measuring HRQOL of patients with Graves' ophthalmopathy and hypothyroidism, respectively.

Treated Autoimmune Thyroid Disease Is Associated with a Decreased Quality of Life among Young Persons with Type 1 Diabetes

Type 1 diabetes (T1D) in children and adolescents is relatively often accompanied by other immunopathological diseases, autoimmune thyroid disease (AITD) or celiac disease (CD). Our aim was to assess whether these conditions are associated with changes in the health-related quality of life (HRQOL) in pediatric patients with T1D. In a cross-sectional study we identified eligible 332 patients with T1D aged 8-18 years, of whom 248 (75%) together with their parents responded to the PedsQL Generic and Diabetes Modules. Compared to 143 patients without thyroid autoantibodies, 40 patients with a thyroxine-treated AITD scored lower in the overall generic HRQOL (P = 0.014), as well as in the overall diabetes-specific HRQOL (P = 0.013). After adjustment for age, gender, duration of diabetes, type of diabetes treatment, and diabetes control, this association remained statistically significant for the generic HRQOL (P = 0.023). Celiac disease was not associated with a change in the generic or diabetes-specific HRQOL (P = 0.07  and  P = 0.63, resp.). Parental scores showed no association with AITD or celiac disease, except a marginally significant decrease in the overall generic HRQOL (P = 0.039) in the T1D + AITD compared to T1D group. Our study indicates that, in pediatric patients with T1D, concomitant thyroxine-treated AITD is associated with lower quality of life.

Thyroid-specific questions on work ability showed known-groups validity among Danes with thyroid diseases

Purpose

We aimed to identify the best approach to work ability assessment in patients with thyroid disease by evaluating the factor structure, measurement equivalence, known-groups validity, and predictive validity of a broad set of work ability items.

Methods

Based on the literature and interviews with thyroid patients, 24 work ability items were selected from previous questionnaires, revised, or developed anew. Items were tested among 632 patients with thyroid disease (non-toxic goiter, toxic nodular goiter, Graves’ disease (with or without orbitopathy), autoimmune hypothyroidism, and other thyroid diseases), 391 of which had participated in a study 5 years previously. Responses to select items were compared to general population data. We used confirmatory factor analyses for categorical data, logistic regression analyses and tests of differential item function, and head-to-head comparisons of relative validity in distinguishing known groups.

Results

Although all work ability items loaded on a common factor, the optimal factor solution included five factors: role physical, role emotional, thyroid-specific limitations, work limitations (without disease attribution), and work performance. The scale on thyroid-specific limitations showed the most power in distinguishing clinical groups and time since diagnosis. A global single item proved useful for comparisons with the general population, and a thyroid-specific item predicted labor market exclusion within the next 5 years (OR 5.0, 95 % CI 2.7–9.1).

Conclusions

Items on work limitations with attribution to thyroid disease were most effective in detecting impact on work ability and showed good predictive validity. Generic work ability items remain useful for general population comparisons.

Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement

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.

Hypothyroidism is a predictor of disability pension and loss of labor market income: a Danish register-based study

BACKGROUND

Hypothyroidism is associated with an increased somatic and psychiatric disease burden. Whether there are any socioeconomic consequences of hypothyroidism, such as early retirement or loss of income, remains unclarified.

AIM

Our aim was to examine, compared with a matched control group, the risk of receiving disability pension (before the age of 60) and the effect on labor market income in patients diagnosed with hypothyroidism.

METHODS

This was an observational register-based cohort study. By record linkage between different Danish health registers, 1745 hypothyroid singletons diagnosed before the age of 60 were each matched with 4 non-hypothyroid controls and followed for a mean of 5 (range 1-31) years. Additionally, we included 277 same-sex twin pairs discordant for hypothyroidism. The risk of disability pension was evaluated by the Cox regression analysis. Changes in labor market income progression over 5 years were evaluated using a difference in difference model.

RESULTS

With a hazard ratio of 2.24 (95% confidence interval = 1.73-2.89), individuals diagnosed with hypothyroidism had a significantly increased risk of disability pension. This remained significant when adjusting for educational level and comorbidity (hazard ratio = 1.89; 95% confidence interval = 1.42-2.51). In an analysis of labor market income, 2 years before compared with 2 years after the diagnosis of hypothyroidism, the hypothyroid individuals had on average a €1605 poorer increase than their euthyroid controls (P < .001). Essentially similar results were found in the twin population.

CONCLUSION

A diagnosis of hypothyroidism before the age of 60 is associated with loss of labor market income and an 89% increased risk of receiving a disability pension.

Increased risk of long-term sickness absence, lower rate of return to work, and higher risk of unemployment and disability pensioning for thyroid patients: a Danish register-based cohort study

CONTEXT

Little is known about how thyroid diseases affect work ability.

OBJECTIVE

The objective of this study was to evaluate the risk of work disability for patients with thyroid disease compared with the general population.

DESIGN, SETTING, AND PARTICIPANTS

In a longitudinal register study, outpatients (n = 862) with nontoxic goiter, hyperthyroidism, Graves' orbitopathy (GO), autoimmune hypothyroidism, or other thyroid diseases and their matched controls (n = 7043) were observed in the years 1994-2011 in Danish national registers of social benefits, health, and work characteristics. Cox regression analyses estimated adjusted hazard ratios (HRs) for the first year after diagnosis and subsequent years.

MAIN OUTCOME MEASURES

Transitions between work, long-term sickness absence, unemployment, and disability pension were measured.

RESULTS

Patients differed significantly from the general population with regard to sickness absence, disability pension, return from sickness absence, and unemployment. In the first year after diagnosis, higher risks of sickness absence was seen for GO (HR 6.94) and other hyperthyroid patients (HR 2.08), who also had lower probability of returning from sickness absence (HR 0.62) and higher risk of disability pension (HR 4.15). Patients with autoimmune hypothyroidism showed a lower probability of returning from sickness absence (HR 0.62). In subsequent years, GO patients had significantly higher risk of sickness absence (HR 2.08), lower probability of return from sickness absence (HR 0.51), and unemployment (HR 0.52) and a higher risk of disability pension (HR 4.40). Hyperthyroid patients also had difficulties returning from sickness absence (HR 0.71).

CONCLUSIONS

Thyroid patients' risk of work disability is most pronounced in the first year after diagnosis and attenuates in subsequent years. GO patients have the highest risk of work disability.

Cardiovascular risk and quality of life in elderly people with mild thyroid hormone deficiency

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.

Desiccated thyroid extract compared with levothyroxine in the treatment of hypothyroidism: a randomized, double-blind, crossover study

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.

Is there a relationship between fatigue perception and the serum levels of thyrotropin and free thyroxine in euthyroid subjects?

BACKGROUND

Thyrotoxicosis and hypothyroidism are associated with fatigue. Here we studied euthyroid subjects to determine if there was a relationship between serum thyrotropin (TSH), free thyroxine (FT(4)) and thyroperoxidase antibodies and fatigue.

METHODS

A total of 5897 participants of the Nijmegen Biomedical Study received a questionnaire and serum TSH (normal range 0.4-4.0 mIU/L) and FT(4) (normal range 8-22 pmol/L) were measured. Fatigue was evaluated by the RAND-36 and the shortened fatigue questionnaire (SFQ).

RESULTS

Euthyroid subjects with a serum TSH level of 0.4-1.0 mIU/L had a lower RAND-36 vitality score (65.2 vs. 66.8; regression coefficient (RC) -1.6 [95% confidence interval (CI) -2.6 to -0.5]; p=0.005) and a higher SFQ score (11.7 vs. 11.0; RC 0.6 [CI 0.2-1.0]; p=0.004) than those with a TSH of 1.0-2.0 mIU/L. Those with a serum FT(4) of 18.5-22 pmol/L reported fatigue more often (52.5% vs. 33.3%; relative risk (RR) 1.4 [CI 1.0-1.9]; p=0.03), had a lower RAND-36 vitality score (61.7 vs. 66.6; RC -4.4 [CI -8.1 to -0.6]; p=0.02) and a higher SFQ score (13.2 vs. 11.0; RC 1.9 [CI 0.4-3.3]; p=0.01) than subjects with a FT(4) level of 11.5-15 pmol/L. In comparison to euthyroid subjects without known thyroid disease, euthyroid subjects with previously known thyroid disease reported fatigue more often (52.3% vs. 34.0%; RR 1.3 [CI 1.0-1.5]; p=0.025), had a lower RAND-36 vitality score (61.4 vs. 66.3; RC -2.9 [CI -5.3 to -0.6]; p=0.015) and a higher SFQ score (13.7 vs. 11.1; RC 1.4 [CI 0.5-2.3]; p=0.002).

CONCLUSION

In euthyroid individuals without a history of thyroid disease, there is a modest relationship between thyroid function and fatigue with subjects having an apparently higher production of T(4) experiencing more fatigue. Subjects with a history of thyroid disease, but with normal TSH and FT(4) concentrations, experience more fatigue than the general population. The reasons for this are unclear, but subtle abnormalities in the dynamics of thyroid hormone secretion should be considered.

Effects of subclinical hypothyroidism treatment on psychiatric symptoms, muscular complaints, and quality of life

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.

Thyroid peroxidase antibody positivity is associated with symptomatic distress in patients with Hashimoto's thyroiditis

Previous studies suggest impairments of physical, mental, and psychic well-being in patients with Hashimoto's thyroiditis (HT), but these impairments have been shown to be independent of thyroid dysfunction. In 64 euthyroid patients with HT, symptomatic distress was assessed with the Symptom Checklist-90-Revised (SCL-90-R), a 90-item multidimensional self-report symptom inventory using a 5-point rating scale. In a subgroup of patients, endocrine testing 3 years prior to the current investigation was available. Anti-thyroid peroxidase antibodies (TPO-Abs) were associated with the three SCL-90-R global indices Global Severity Index (GSI), Positive Symptom Distress Index (PSDI), and Positive Symptom Total (PST) as well as with somatization and obsessive-compulsive symptoms after adjustment for age, gender, and thyroid function as assessed by TSH levels (all p<0.05). HT patients positive for TPO-Abs showed poorer results in the three SCL-90-R global indices as well as in the three domains: somatization, obsessive-compulsive symptoms, and depression (all p≤0.02), though the aforementioned associations did not withstand sequential Bonferroni correction for multiple testing. In contrast, TPO-Abs positivity, defined as TPO-Abs >100 IU/l, significantly predicted poorer psychosocial well-being in all of the three SCL-90-R global indices after three years, even after correction (all p≤0.02). In conclusion, high TPO-Abs are associated with poor physical and psychological well-being and appear to predict future health perception in HT patients.

Five-year longitudinal evaluation of quality of life in a cohort of patients with differentiated thyroid carcinoma

Differentiated thyroid carcinoma (DTC) generally has a favorable outcome. Thyroid disease, treatments, stress, and comorbidity can compromise health-related quality of life (QoL) and indirectly weigh upon the outcome. From 2004 to 2008, we evaluated QoL longitudinally in 128 DTC subjects. During scheduled examinations, subjects were asked to undergo a semi-structured psychiatric interview and five rated inventories. The same examination was conducted in 219 subjects after surgery for benign thyroid pathology. Low scores represent a better QoL. DTC and control subjects were similar in terms of age, male/female ratio, concomitant psychopharmacological treatments, and frequency of psychiatric diseases. In DTC subjects, Billewicz scale (BS) scores showed an increasing trend over time, especially among females. The ad hoc thyroid questionnaire (TQ) scores were similar in both groups and did not change over time, but at the end of the study ad hoc TQ and BS were significantly related. Ad hoc TQ scores were also related to age on entry to the study. In both male and female DTC subjects, Hamilton's tests for anxiety (HAM-A), but not for depression (HAM-D), showed an improving trend. At the end of the study, HAM-A and HAM-D scores were comparable to those of the control group. HAM-A and HAM-D were both positively correlated with the stage of cancer and the time between diagnosis and treatment. Only HAM-D correlated with age on entry to the study. Kellner symptom questionnaire (KSQ) item scores were higher in DTC subjects than in controls. The change over time in the items including anxiety, somatization, depression, and hostility was significant. Somatization and hostility were more significantly reduced in DTC females than in DTC males. Hostility scores were significantly lower in DTC subjects than in controls at the end of the study. Somatization and depression were significantly related to staging on diagnosis and age on entry to the study. Our study confirms a wide variation of illness perception in DTC subjects, which is generally unrelated to the favorable clinical follow-up of the disease. Psychological evaluation during long-term follow-up improved QoL scores, which reached the same levels noted in subjects with a history of thyroid surgery for benign thyroid pathology. Our data indicate that special attention should be paid to QoL in older DTC subjects and those with more severe staging on diagnosis.

Validity and reliability of the novel thyroid-specific quality of life questionnaire, ThyPRO

BACKGROUND

Appropriate scale validity and internal consistency reliability have recently been documented for the new thyroid-specific quality of life (QoL) patient-reported outcome (PRO) measure for benign thyroid disorders, the ThyPRO. However, before clinical use, clinical validity and test-retest reliability should be evaluated.

AIM

To investigate clinical ('known-groups') validity and test-retest reliability of the Danish version of the ThyPRO.

METHODS

For each of the 13 ThyPRO scales, we defined groups expected to have high versus low scores ('known-groups'). The clinical validity (known-groups validity) was evaluated by whether the ThyPRO scales could detect expected differences in a cross-sectional study of 907 thyroid patients. Test-retest reliability was evaluated by intra-class correlations of two responses to the ThyPRO 2 weeks apart in a subsample of 87 stable patients.

RESULTS

On all 13 ThyPRO scales, we found substantial and significant differences between the groups expected to have high versus low scores. Test-retest reliability was above 0.70 (range 0.77-0.89) for all scales, which is usually considered necessary for comparisons among patient groups, but below 0.90, which is the usual threshold for use in individual patients.

CONCLUSION

We found support for the clinical validity of the new thyroid-specific QoL questionnaire, ThyPRO, and evidence of good test-retest reliability. The questionnaire is now ready for use in clinical studies of patients with thyroid diseases.

Quality of life changes and clinical outcomes in thyroid cancer patients undergoing radioiodine remnant ablation (RRA) with recombinant human TSH (rhTSH): a randomized controlled study

BACKGROUND

Recombinant human TSH (rhTSH) has become the modality of choice for radioiodine remnant ablation (RRA) in low-risk thyroid cancer patients.

AIMS AND METHODS

The aims of the present prospective randomized study were to evaluate the impact of TSH stimulation procedure (hypothyroidism vs. rhTSH) on quality of life (QoL) of thyroid cancer patients undergoing RRA and to evaluate efficacy of both procedures. L-T4 was initiated in both groups after thyroidectomy. After randomization, L-T4 was discontinued in hypothyroid (hypo) group and continued in rhTSH group. A measure of 3.7 GBq of radioiodine was given to both groups. The functional assessment of chronic illness therapy-fatigue (FACIT-F) was administered from the early postoperative period to 9 months. Socio-demographic parameters, anxiety and depression scales were also evaluated (CES-D, BDI and Spielberger state-trait questionnaires). At 9 months, patients underwent an rhTSH stimulation test, diagnostic (131)I whole body scan (dxWBS) and neck ultrasonography.

RESULTS

A total of 74 patients were enrolled for the study. There was a significant decrease in QoL from baseline (t0) to t1 (RRA period) in the hypothyroid group with significant differences in FACIT-F TOI (P < 10(-3)), FACT-G total score (P = 0.005) and FACIT-F total score (P = 0.003). By contrast, QoL was preserved in the rhTSH group. In the multivariate analysis, FACIT-TOI changes were only affected by the modality of TSH stimulation performed for RRA. From 3 to 9 months, changes of QoL scales and subscales were no longer statistically different in both groups of patients. Based on serum rhTSH-stimulated Tg alone (Tg < 0.8 microg/l, BRAHMS Tg Kryptor), no difference in ablation success was observed between rhTSH and hypothyroidism groups, 91.7% and 97.1%, respectively. A higher rate of persistent thyroid remnants was observed in the rhTSH arm, although in most cases uptake was < 0.1% and of no clinical significance.

CONCLUSIONS

rhTSH preserves QoL of patients undergoing RRA with similar rates of ablation success compared to hypothyrodism. However, there is a wide heterogeneity in the clinical impact of hypothyroidism.

Efficacy of combined levothyroxine and liothyronine as compared with levothyroxine monotherapy in primary hypothyroidism: a randomized controlled trial

OBJECTIVES

To examine the efficacy of combination therapy with levothyroxine and liothyronine in improvement of general health, psychological problems, and metabolic status in primary hypothyroidism.

METHODS

Seventy-one patients diagnosed with primary hypothyroidism were randomly allocated into two study groups: the first group received usual dose of levothyroxine and the second group received combination of levothyroxine and liothyronine for at least 4 months. The main outcomes were psychosocial problems (Goldberg's General Health Questionnaire, GHQ-28), bodyweight, heart rate, blood pressure, and serum lipid levels.

RESULTS

In both groups serum thyroid-stimulating hormone levels remained unchanged compared with baseline. Psychosocial scores, body weight, heart rate, blood pressure, and lipid profile in the two groups remained constant. The only exception was a small but significant reduction in anxiety/insomnia in combined treatment group as compared with monotherapy.

CONCLUSIONS

The data do not support the hypothesis that combined therapy improves the well-being and general health of patients.

Evaluation of new measures of the impact of hypothyroidism on quality of life and symptoms: the ThyDQoL and ThySRQ

OBJECTIVES

This article reports the psychometric properties of two new condition-specific questionnaires: 1) the 18-item Underactive Thyroid-Dependent Quality of Life Questionnaire (ThyDQoL) individualized measure of perceived impact of hypothyroidism on quality of life (QoL); and 2) the 15-item Underactive Thyroid Symptom Rating Questionnaire (ThySRQ), in which patients rate symptom bother.

METHODS

A cross-sectional survey was conducted of 110 adults with overt and subclinical hypothyroidism, 103 treated with thyroxine. Patients, the majority of whom (81%) were women, were recruited from primary care (57%) and from hospital clinics (43%). The mean age of patients was 55.1 (SD 14.3) years. Respondents rated personally applicable ThyDQoL life domains for importance and impact of hypothyroidism, and ThySRQ symptom bother.

RESULTS

Completion rates were high (>98%). All 18 ThyDQoL domains were rated as negatively impacted by hypothyroidism and important for QoL. The ThyDQoL had high internal consistency reliability (Cronbach's alpha = 0.949 [N = 97]), factor analysis indicated that applicable domains could be combined into an overall Average Weighted Impact score, for which the sample mean, -3.11 (2.2), showed considerable negative impact of hypothyroidism on QoL (maximum possible range -9 to +3). There is good preliminary evidence to justify shortening the ThyDQoL to 14 domain-specific items. For the ThySRQ Cronbach's alpha was 0.808 (N = 95). Highest symptom bother ratings were for hair problems, weight gain, depression, cold, and tiredness.

CONCLUSIONS

Both the ThyDQoL and ThySRQ are highly acceptable to patients with hypothyroidism and have good internal consistency reliability. Their sensitivity to change now needs to be evaluated in clinical trials.

Thyroid hormone replacement for central hypothyroidism: a randomized controlled trial comparing two doses of thyroxine (T4) with a combination of T4 and triiodothyronine

BACKGROUND

Dosage of T(4) in central hypothyroidism is primarily guided by the free serum T(4) level (fT4). However, the optimum fT4 range is ill defined, and subtle hypothyroidism might be missed using this approach.

OBJECTIVES

Our aim was to investigate the effects of a body weight (bw)-adapted T(4) treatment, alone or in combination with T(3), on metabolism, well-being, and cognitive function in comparison to a regimen leading to normal fT4.

DESIGN

This was a placebo-controlled trial (double-blind, crossover).

PATIENTS

A total of 29 patients (age 52 +/- 2 yr; females/males, 8/21) with hypopituitarism, including TSH deficiency, participated in the study.

INTERVENTIONS

Three regimens were compared (5 wk each): "EMPIRICAL-T4," empirical T(4) dosage (1 +/- 0.05 microg/kg bw) leading to normal fT4; BW-ADAPTED-T4 (1.6 microg/kg bw T(4)); and "BW-ADAPTED-T3T4," bw-adapted combination of T(3) and T(4) (ratio of 1:10).

RESULTS

BW-ADAPTED-T4 administration increased mean fT4 concentrations to the upper limit of the normal range (peak levels). Compared with EMPIRICAL-T4, BW-ADAPTED-T4 treatment resulted in a lower body mass index (BMI) (29.0 +/- 0.7 vs. 29.5 +/- 0.7 kg/m(2); P < 0.03), lower total cholesterol (198 +/- 9 vs. 226 +/- 7 mg/dl; P < 0.01), and lower low-density lipoprotein (LDL) cholesterol (116 +/- 5 vs. 135 +/- 7 mg/dl; P < 0.01). BW-ADAPTED-T3T4 treatment was associated with additional beneficial effects on ankle reflex time and working memory but resulted in supraphysiological free serum T(3) (fT(3)) levels.

LIMITATIONS

Long-term side effects may have been missed.

CONCLUSIONS

Using a dose of 1.6 microg/kg bw improved markers commonly associated with central hypothyroidism. This suggests that T(4) dosage based on bw and aiming at fT4 in the upper reference range is superior to titration of T(4) aiming at middle normal fT4 concentrations in those patients.

Which domains of thyroid-related quality of life are most relevant? Patients and clinicians provide complementary perspectives

OBJECTIVE

To identify how thyroid diseases impact the patients' lives and to select the most relevant quality of life (QoL) issues for a thyroid-specific questionnaire.

DESIGN

Fifteen thyroid experts and 80 thyroid outpatients (14 with nontoxic goiter, 12 nodular toxic goiter, 21 Graves' disease, 17 thyroid-associated ophthalmopathy, and 16 primary hypothyroidism) were interviewed.

METHODS

The relevance of 138 thyroid disease-related issues was rated during interviews. For each issue, three relevance measures were obtained: a diagnosis-specific patient rating, a diagnosis-specific expert rating, and a combined overall patient/expert rating. The 75 most relevant issues overall and the 15 most relevant issues in each patient category were selected.

RESULTS

Based on the above, 92 issues were selected, covering a broad range of clinical and QoL domains. Across patient groups, broader QoL domains were most relevant, especially fatigue and emotional susceptibility. However, when focusing on individual patient groups, diagnosis-related physical symptoms were very relevant too. Patients rated issues about psychosocial problems and impact on daily life as more relevant, whereas clinicians focused on thyroid-characteristic issues.

CONCLUSIONS

A broad range of QoL issues and physical symptoms are relevant for thyroid patients, particularly fatigue and emotional susceptibility. Patients and clinicians offer complementary perspectives on relevance.

Reliability and validity of the Korean version of Kidney Disease Quality of Life instrument (KDQOL-SF)

Although the Kidney Disease Quality of Life instrument (KDQOL-SF), which was designed to measure the comprehensive quality of life in patients with end stage renal disease, has been tested and widely administered in many other counties, it has not yet been translated, validated and reported for Korea. The primary purpose of this study was to validate a Korean version of KDQOL-SF and to evaluate its psychometric properties. The study subjects were 164 patients with hemodialysis or continuous ambulatory peritoneal dialysis in university dialysis centers in Korea. In order to investigate the reliability, test-retest reliability and internal consistency reliability were assessed. Both test-retest reliability and internal consistency reliability were found to be high. In order to investigate the construct validation, all the items of the SF-36 scales, an established generic QOL measures, were compared with an overall health rating scale in kidney disease-targeted scale. They found to be highly correlated with each other. Moreover, overall health rating scale was significantly correlated with symptoms/problems, effects of kidney disease, burden of kidney disease, cognitive function (p < 0.001), and quality of social interaction (p < 0.05). These results suggest that the Korean version of KDQOL-SF satisfies its reliability and validity in Korean patients with hemodialysis or continuous ambulatory peritoneal dialysis. This questionnaire provides important and clinically valuable information for understanding the health related quality of life in the Korean patients with dialysis.

Recombinant human thyrotropin-assisted radioiodine therapy for patients with metastatic thyroid cancer who could not elevate endogenous thyrotropin or be withdrawn from thyroxine

The value of recombinant human thyrotropin (rhTSH) as preparation for radioiodine therapy was assessed in 115 patients with metastatic thyroid cancer. Patients who were either unable to elevate endogenous TSH during thyroxine withdrawal, or in whom thyroxine withdrawal was contraindicated for medical reasons were eligible. Their physicians requested rhTSH as part of the Thyrogen Compassionate Use Program. This is a retrospective summary of the nonrandomized uncontrolled experience. We assessed the ability of rhTSH to elevate the serum TSH; to avoid the complications of hypothyroidism; to stimulate radioiodine uptake; and to stimulate the serum thyroglobulin. Disease response and adverse events were also assessed. After rhTSH, the serum TSH levels rose to >or=25mU/L in every patient in whom levels were measured (n = 112). Hypothyroid complications were avoided in 22 of 25 patients who had experienced them in the past, and in 47 of 51 patients who were at high risk for hypothyroid complications. Radioiodine uptake was present on whole-body scans (WBS) in 105 of the 115 patients. Serum thyroglobulin levels were lower than baseline in 73% of patients assessed at 12 months. Cancer-related symptoms were improved in approximately 25%. Two patients had serious adverse events that were thought to be related to rhTSH. rhTSH elevates serum TSH and facilitates radioiodine uptake in patients who cannot produce endogenous TSH or who cannot tolerate hypothyroidism.

A comparison of short-term changes in health-related quality of life in thyroid carcinoma patients undergoing diagnostic evaluation with recombinant human thyrotropin compared with thyroid hormone withdrawal

CONTEXT

Thyroid carcinoma requires lifelong monitoring with serum thyroglobulin, radioactive iodine whole body scanning, and other imaging modalities. Levothyroxine (L-T4) withdrawal for thyroglobulin measurement and whole body scanning increases these tests' sensitivities but causes hypothyroidism. Recombinant human TSH (rhTSH) enables testing without L-T4 withdrawal.

OBJECTIVE

Our objective was to examine the impact of short-term hypothyroidism on the health-related quality of life (HRQOL) of patients after rhTSH vs. L-T4 withdrawal.

DESIGN, SETTING, AND PATIENTS

In this multicenter study, the SF-36 Health Survey was administered to 228 patients at three time points: on L-T4, after rhTSH, and after L-T4 withdrawal.

INTERVENTIONS

INTERVENTIONS included administration of rhTSH on L-T4 and withdrawal from thyroid hormone.

MAIN OUTCOME MEASURES

Mean SF-36 scores were compared during the two interventions and with the U.S. general population and patients with heart failure, depression, and migraine headache.

RESULTS

Patients had SF-36 scores at or above the norm for the general U.S. population in six of eight domains at baseline on L-T4 and in seven of eight domains after rhTSH. Patients' scores declined significantly in all eight domains after L-T4 withdrawal when compared with the other two periods (P < 0.0001). Patients' HRQOL scores while on L-T4 and after rhTSH were at or above those for patients with heart failure, depression, and migraine in all eight domains. After L-T4 withdrawal, patients' HRQOL scores were significantly below congestive heart failure, depression, and migraine headache norms in six, three, and six of the eight domains, respectively.

CONCLUSIONS

Short-term hypothyroidism after L-T4 withdrawal is associated with a significant decline in quality of life that is abrogated by rhTSH use.

Three-Week Thyroxine Withdrawal: A Thyroid-Specific Quality of Life Study

OBJECTIVES/HYPOTHESIS

The purpose of this study is to determine the impact of a 3-week T4 withdrawal test on the quality of life (QOL) of patients undergoing investigation for residual/recurrent well-differentiated thyroid cancer.

STUDY DESIGN

Prospective survey study.

METHODS

181 patients with well-differentiated thyroid cancer were surveyed using a thyroid-specific QOL-thyroid survey at three times throughout the study: prior to T4 withdrawal, after the 3-week withdrawal period, and 4 weeks after resuming T3/T4 combination therapy.

RESULTS

A very small, though statistically significant, reduction was observed in the four domains of QOL defined by the QOL-thyroid survey from baseline values to 3 weeks after T4 withdrawal. The maximal difference was 2.04 (fatigue), out of a possible 10 point score, in the physical well-being category.

CONCLUSIONS

The thyroid-specific QOL questionnaire demonstrates a statistically significant though very small and probably not clinically significant reduction in the QOL of thyroid cancer patients undergoing an induced 3-week hypothyroid state. Three-week T4 withdrawal is a simple, cost-effective, and readily available test.

Neuropsychological function and symptoms in subjects with subclinical hypothyroidism and the effect of thyroxine treatment

OBJECTIVE

Our objective was to examine the relation between neuropsychological function and subclinical hypothyroidism (SHT), defined as serum TSH of 3.5-10.0 mIU/liter and normal serum free T4 and free T3 levels, and to study the effect of T4 supplementation.

SUBJECTS

A total of 89 subjects (45 males) with SHT and 154 control subjects (72 males) were recruited from a general health survey (the fifth Tromsø study). Sixty-nine of those with SHT were included in a placebo-controlled, double-blind intervention study with T4 medication for 1 yr.

MAIN OUTCOME MEASURES

We used fourteen tests of cognitive function, Beck Depression Inventory, General Health Questionnaire, and a questionnaire on hypothyroid symptoms.

RESULTS

The mean +/- sd serum TSH in the SHT and control group were 5.57 +/- 1.68 and 1.79 +/- 0.69 mIU/liter, respectively. There were no significant differences in cognitive function and hypothyroid symptoms between the two groups, but those with SHT scored significantly better than the controls on the GHQ-30. At the end of the intervention study, serum TSH in the T4 group (n = 36) and the placebo group (n = 33) were 1.52 +/- 1.51 and 5.42 +/- 1.96 mIU/liter, respectively. T4 substitution had no effect on any of the parameters measured.

CONCLUSION

In subjects with SHT where the serum TSH level is in the 3.5-10.0 mIU/liter range, there is no neuropsychological dysfunction, and compared with healthy controls, there is no difference in symptoms related to hypothyroidism.

Instruments used in measuring symptoms, health status and quality of life in hypothyroidism: a systematic qualitative review

BACKGROUND

Symptoms of hypothyroidism are varied and nonspecific, thereby making clinical diagnosis impossible. Some patients report ongoing symptoms despite treatment. Measuring symptoms, health status and quality of life by using appropriate instruments, in addition to biochemical tests, is therefore vital to quantify disease severity and assess response to treatment. A number of instruments have been used in hypothyroidism, leading to lack of clarity about what exactly is being measured, and the rationale for the inclusion of particular measures is often uncertain.

OBJECTIVES

To evaluate and compare instruments used in hypothyroidism in assessing patient-reported outcomes.

DATA SOURCES AND STUDY SELECTION

All published literature on MEDLINE until March 2005 was searched using the keywords 'hypothyroidism', 'symptoms', 'quality of life' and 'health status'. Articles reporting controlled trials or instrument design and development were analysed to assess the instruments used and to ascertain whether they were measuring the stated outcome.

DATA SYNTHESIS

Available tools to measure symptoms, health status and quality of life in diagnosis and management of hypothyroidism are discussed. We also describe how these tools have been described in published clinical trials along with the advantages and possible pitfalls of each of the commonly used tools.

CONCLUSIONS

Some instruments reviewed have not been suited to the outcome being studied, thereby giving rise to questionable results. This review should be useful for clinicians, researchers and patient-support groups in understanding the principles behind these tools and the results obtained from their use in clinical practice, and in selecting measures for their own use.

Determinants of modality selection among incident US dialysis patients: results from a national study

Few studies have comprehensively addressed the association of social factors and elements of pre-end-stage renal disease (ESRD) care with the selection of dialysis modality. This study examines the relative contribution of demographic, medical, social, pre-ESRD, and geographic factors to modality assignment among new ESRD patients. Data were collected from the Dialysis Mortality and Morbidity Wave 2 Study, a national random sample of 4025 patients in 1996 and 1997. In multivariate analyses, the selection of peritoneal dialysis (PD) over hemodialysis (HD) was significantly associated with younger age, white race, fewer comorbid conditions, and lower serum albumin. Greater use of PD was seen in patients who were employed, married, and living with someone before the start of ESRD and in those who were more autonomous and more accomplished educationally. Patients referred earlier to a nephrologist (> 4 mo versus < or =4 mo) and seen more frequently by a nephrologist (> or =2 visits versus < 2 visits) in the pre-ESRD period had greater PD use. Of the factors listed, 25% of the variability (R(2)) in PD use was explained by demographic (4.1%), comorbid (1.2%), social/pre-ESRD (14.5%), and geographic (5.2%) factors. This study identifies several clinical, social, and pre-ESRD factors with the selection of PD, and it underscores the importance of patient education, autonomy, and a strong social support system in improving rates of PD use in the United States. As pre-ESRD patient care is an important contributor to PD use in the United States, greater efforts should be expended in improving its delivery earlier in the pre-ESRD period.

Does treatment with L-thyroxine influence health status in middle-aged and older adults with subclinical hypothyroidism?

OBJECTIVE

To determine if health-related quality of life (HRQL) in patients of middle age and older with elevated thyroid-stimulating hormone (TSH) and normal total thyroid hormone levels-subclinical hypothyroidism-improves with L-thyroxine replacement therapy.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING

Outpatient clinic.

PATIENTS

Thirty-seven patients with subclinical hypothyroidism, most with symptoms consistent with hypothyroidism, over 55 years of age.

INTERVENTIONS

Placebo or L-thyroxine replacement therapy to achieve normal TSH level.

MEASUREMENTS AND MAIN RESULTS

Disease-specific and general HRQL, cognitive function, bone mineral density, lipid levels. The mean daily dose of L-thyroxine replacement in the active group was 68 +/- 21 micrograms. TSH decreased by 8.6 mIU/L (95% confidence interval [CI] 4.1 to 13.1) and T4 increased by 27.9 nmol/L (95% CI 14.8 to 41.2). There was a statistically significant improvement in a composite psychometric memory score in treated versus control patients; all other outcomes showed similar findings in the two groups. Although confidence intervals for most measures did not exclude an important improvement in HRQL with thyroid replacement, no measure of symptoms or HRQL either showed clinically important trends in favor of treatment, or approached conventional levels of statistical significance.

CONCLUSIONS

In middle-aged and older patients with elevated TSH and normal T4, it may not be harmful to follow biochemical and clinical status even in the presence of nonspecific symptoms potentially associated with hypothyroidism.