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Larisch R, Midgley JEM, Dietrich JW, Hoermann R. Effect of Radioiodine Treatment on Quality of Life in Patients with Subclinical Hyperthyroidism: A Prospective Controlled Study. Nuklearmedizin 2024; 63:176-187. [PMID: 38262472 DOI: 10.1055/a-2240-8087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
Radioiodine treatment (RIT) has a high success rate in both the treatment of hyperthyroidism and improving the quality of life (QoL) of symptomatic patients. In asymptomatic patients with subclinical hyperthyroidism thyroid related QoL outcomes are less well known. METHODS Study aim was to evaluate thyroid-related QoL in patients with subclinical hyperthyroidism mostly due to toxic nodular goitre undergoing RIT, compared to a control group of euthyroid subjects. Study design was monocentric, prospective, controlled. Fifty control subjects were enrolled and 51 RIT patients. Most subjects were examined at least twice at an interval of 6 months, with visits immediately before and 6 months after treatment in the RIT group. QoL was estimated with the ThyPRO questionnaire, using its composite scale as primary outcome. Treatment effect was the mean adjusted difference (MAD) between groups over time, using repeated? measures mixed? effects models. RESULTS TSH concentrations were lower in the RIT group prior to treatment and recovered thereafter slightly above the level of the control group. Correspondingly, QoL improved significantly after 6 months from a worse level in the RIT group, compared to controls (MAD -10.3 [95% CI -14.9, -5.7], p<0.001). QoL improvements were strong for general items, but less pronounced for the hyperthyroid domain. Compared to controls, thyroid volume, thyroid functional capacity (SPINA-GT) and deiodinase activity (SPINA-GD) were significantly reduced in the RIT group. CONCLUSION Patients with subclinical hyperthyroidism improve both biochemically and in their QoL after RIT, compared to controls. QoL assessment should have a wider role in clinical practice to complement biochemical tests and help with treatment decisions.
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Affiliation(s)
- Rolf Larisch
- Clinic of Nuclear Medicine, Klinikum Lüdenscheid, Lüdenscheid, Germany
| | - John E M Midgley
- North Lakes Clinical, Ilkley LS29 8PT, United Kingdom of Great Britain and Northern Ireland
| | - Johannes W Dietrich
- Medical Hospital I, Endocrinology and Diabetes Department, Ruhr University of Bochum, Bochum, Germany
- Ruhr Center for Rare Diseases (CeSER), Bochum, Germany
| | - Rudolf Hoermann
- Clinic of Nuclear Medicine, Klinikum Lüdenscheid, Lüdenscheid, Germany
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Schnedl WJ, Michaelis S, Mangge H, Enko D. One sip of water with LT-4 supplementation-a key to euthyroidism in Hashimoto's thyroiditis. Endocrine 2024:10.1007/s12020-024-03829-w. [PMID: 38635065 DOI: 10.1007/s12020-024-03829-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 04/09/2024] [Indexed: 04/19/2024]
Abstract
PURPOSE Recommended pharmacotherapy for hypothyroidism in Hashimoto's thyroiditis (HT) is oral supplementation with levothyroxine (LT-4). However, serum thyrotropin (TSH) levels within normal range are not consistently achieved with LT-4 medication. PATIENTS AND METHODS We report on 35 HT patients with LT-4 therapy in this retrospective evaluation. In general, we recommend that a maximum of two sips of water, which would then amount to < 50 mL, be ingested at the same time as LT-4. We report on follow up examinations measuring TSH and antibodies against thyroid peroxidase (TPOAb) after 6 months to five years. RESULTS After median time of 643 days (range 98-1825) we found in 35 HT patients a statistical significant reduction of serum TSH (p < 0.001) and TPOAb (p = 0.006). The patients median body weight was 71 kg (range 48-98) and a daily LT-4 dosage was used with median 69.1 µg (range 25-150). This results in a daily LT-4 dose of median 1.01 µg/kg bodyweight (range 0.3-2.3). CONCLUSIONS The reduction of water ingestion to a maximum of two sips, which is <50 mL, combined with LT-4 supplementation helps to achieve euthyroidism in HT. In addition, it reduces the L-T4 medication dosage needed to lower TSH serum levels and decreases TPO antibodies in HT.
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Affiliation(s)
- Wolfgang J Schnedl
- Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, A-8036, Graz, Austria.
- General Internal Medicine Practice, Dr. Theodor Körnerstrasse 19b, A-8600, Bruck, Austria.
| | - Simon Michaelis
- Institute of Clinical Chemistry and Laboratory Medicine, Hospital Hochsteiermark, Vordernberger Straße 42, A-8700, Leoben, Austria
| | - Harald Mangge
- Clinical Institute of Medical and Chemical Laboratory Diagnosis, Medical University of Graz, Auenbruggerplatz 30, A-8036, Graz, Austria
| | - Dietmar Enko
- Institute of Clinical Chemistry and Laboratory Medicine, Hospital Hochsteiermark, Vordernberger Straße 42, A-8700, Leoben, Austria
- Clinical Institute of Medical and Chemical Laboratory Diagnosis, Medical University of Graz, Auenbruggerplatz 30, A-8036, Graz, Austria
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Fitzgerald SP, Falhammar H, Hoermann R. Re: "Thyroid Stimulating Hormone and Thyroid Hormones (Triiodothyronine and Thyroxine): An American Thyroid Association-Commissioned Review of Current Clinical and Laboratory Status" by Van Uytfanghe et al. Thyroid 2024; 34:274-275. [PMID: 37885212 DOI: 10.1089/thy.2023.0496] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Affiliation(s)
- Stephen P Fitzgerald
- Department of General Medicine, and The Royal Adelaide Hospital, Adelaide, South Australia
- Department of Endocrinology, The Royal Adelaide Hospital, Adelaide, South Australia
- Discipline of Medicine, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Henrik Falhammar
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Rudolf Hoermann
- Department of General Medicine, Gastroenterology and Endocrinology, Klinikum Lüdenscheid, Lüdenscheid, Germany
- Yandina, Australia
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Holley M, Razvi S, Dew R, Maxwell I, Wilkes S. Assessing the cardiovascular effects of levothyroxine use in an ageing United Kingdom population (ACEL-UK) protocol: a cohort and target trial emulation study. Thyroid Res 2023; 16:43. [PMID: 37953303 PMCID: PMC10641939 DOI: 10.1186/s13044-023-00186-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/16/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND Subclinical hypothyroidism is diagnosed when serum thyroid stimulating hormone levels are higher whilst free thyroxine levels remain within their respective reference ranges. These reference ranges are uniformly applied in all adults, despite serum thyroid stimulating hormone levels naturally increasing with age. Research has found that mildly elevated thyroid stimulating hormone levels may be associated with some benefits in ageing patients, including reduced mortality and better cardiorespiratory fitness. Levothyroxine is typically prescribed to patients with hypothyroidism, but no conclusive evidence exists on whether levothyroxine therapy is beneficial or detrimental in older subclinical hypothyroid patients. Despite this, prescriptions for levothyroxine are increasing year-on-year. This study aims to determine if receiving levothyroxine affects the cardiovascular and bone health outcomes of subclinical patients in primary care aged 50 years and over. METHODS This project includes a retrospective cohort analysis and a target trial emulation study using electronic patient records collected between 2006 and 2021 and recorded in The Health Improvement Network database. The primary outcome of this study is to compare the cardiovascular outcomes of subclinical hypothyroid patients aged over 50 years treated with levothyroxine compared to those untreated. Secondary outcomes are bone health and all-cause mortality outcomes. Descriptive and inferential statistics will both be employed to analyse the data. Secondary analysis will explore confounding factors, including age, sex, smoking status, body mass index, co-morbidities, and levothyroxine dosage. DISCUSSION There needs to be a greater understanding of the potential risks of the current treatment for older patients with subclinical hypothyroidism in a primary care setting. We will investigate the clinical importance of this issue and whether older subclinical hypothyroid patients have poorer outcomes when treated. Clarifying this concern may help address the healthcare resource implications of ageing patients being misclassified as having mild hypothyroidism, as these patients are more likely to repeat their blood tests. This could reduce prescription wastage and improve patient outcomes and quality of life in the ageing population. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Mia Holley
- School of Medicine, Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK.
| | - Salman Razvi
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Rosie Dew
- School of Medicine, Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK
| | - Ian Maxwell
- School of Medicine, Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK
| | - Scott Wilkes
- School of Medicine, Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK
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Fitzgerald SP, Falhammar H. Redefinition of Successful Treatment of Patients With Hypothyroidism. Is TSH the Best Biomarker of Euthyroidism? Front Endocrinol (Lausanne) 2022; 13:920854. [PMID: 35784560 PMCID: PMC9243528 DOI: 10.3389/fendo.2022.920854] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 05/10/2022] [Indexed: 12/14/2022] Open
Abstract
In recent years evidence has accumulated supporting a revised view of the nature of euthyroidism and the biomarkers of thyroid function. Within the normal range, variations in thyroid hormone levels are associated with variations in clinical parameters and outcomes. There are therefore no readily identified individually specific optimum levels of thyroid hormones for any individual. Levels around the middle of the normal population range may best reflect euthyroidism. These levels may have evolutionary advantages on the basis that adverse outcomes often increase with divergence from such levels, and physiological processes tend to minimise such inter-individual and intra-individual divergence. In populations of predominantly untreated individuals, levels of thyroid hormones and in particular levels of free thyroxine (FT4) correlate more often with clinical parameters than do levels of thyrotropin (TSH). Levels of thyroid hormones may therefore be regarded as the best available biomarkers of euthyroidism and dysthyroidism. It follows that 'subclinical hypothyroidism' (normal FT4/raised TSH levels), rather than being an accurate marker of peripheral tissue hypothyroidism is more a marker of decreased thyroid reserve and prognosis. The recent evidence suggests that treatment of hypothyroxinemia, regardless of the TSH level, and monitoring therapy using FT4 and/or triiodothyronine levels, depending on the replacement regime, may result in more successful treatment of hypothyroidism than relying on thyrotropin levels for patient selection and subsequent treatment monitoring. The equivalents of mid-range levels of thyroid hormones (especially FT4), adjusted by individual comorbidity concerns, may be rational general replacement targets. These implications of the new evidence may create opportunities for novel trials of thyroid replacement therapy.
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Affiliation(s)
- Stephen P. Fitzgerald
- The Departments of General Medicine and Endocrinology, The Royal Adelaide Hospital, Adelaide, SA, Australia
- School of Medicine, The University of Adelaide, Adelaide, SA, Australia
| | - Henrik Falhammar
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Menzies School of Health Research and Royal Darwin Hospital, Tiwi, NT, Australia
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Fitzgerald SP, Bean NG, Fitzgerald SP, Falhammar H. The application of new concepts of the assessment of the thyroid state to pregnant women. Front Endocrinol (Lausanne) 2022; 13:987397. [PMID: 36051398 PMCID: PMC9424676 DOI: 10.3389/fendo.2022.987397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 07/25/2022] [Indexed: 11/25/2022] Open
Abstract
Recently proposed concepts regarding the nature and assessment of the thyroid state have provided a model more consistent with empiric evidence. It now appears likely that there are no such entities as thyroid set points and individual euthyroidism. Rather than there being discrete thyroid states, peripheral organ parameters are associated with thyroid function in a continuous manner. Thyroid hormone levels and, in particular, levels of free thyroxine now appear to be superior to thyrotropin levels as indicators of the thyroid state. Complicating the assessment of the correlations of the thyroid state with pregnancy outcomes are the contribution of the placenta to maternal thyroid function, fetal thyroid development, the multiple potential pathways to any particular outcome, the likely presence of small critical periods of time, the differing genetics of fetal and maternal tissues, and the unreliability of thyroid hormone assays. Nevertheless, there is no apparent reason for there to be a change in pregnancy to the basic principles of thyroid hormone action. The relationships between mild abnormalities of the thyroid state and pregnancy outcomes and the value of treating such mild abnormalities remain uncertain and controversial. The evidence suggests that further investigation of these clinical questions might better be based on thyroid hormone, particularly free thyroxine, levels. In the investigation of borderline low thyroid states, the categories of subclinical hypothyroidism and isolated hypothyroxinemia might both be abandoned with attention being directed to low free thyroxine levels regardless of the thyroid-stimulating hormone (TSH) levels. For these changes to occur, there would ideally be improvements in the assays for free thyroxine in pregnancy. The evidence suggests that, just as in the non-pregnant situation, pregnancy guidelines based on thyrotropin levels may need revision.
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Affiliation(s)
- Stephen P. Fitzgerald
- The Departments of General Medicine and Endocrinology, The Royal Adelaide Hospital, Adelaide, SA, Australia
- School of Medicine, The University of Adelaide, Adelaide, SA, Australia
- *Correspondence: Stephen P. Fitzgerald,
| | - Nigel G. Bean
- Adjunct Professor, School of Mathematical Science, University of Adelaide, Adelaide, SA, Australia
| | - Samuel P. Fitzgerald
- Department of Obstetrics and Gynaecology, The Townsville Hospital, Townsville, QLD, Australia
- School of Medicine, University of Queensland, St Lucia, QLD, Australia
| | - Henrik Falhammar
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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