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Ravensberg J, Poortvliet RKE, Du Puy R, Rodondi N, Blum M, Kearney P, McCarthy VJC, Quinn T, Dekkers O, Jukema W, Mooijaart S, Gussekloo J. Patient-Reported Satisfaction with Thyroid Hormone Replacement Therapy for Subclinical Hypothyroidism in Older Adults: A Pooled Analysis of Individual Participant Data from Two Randomized Controlled Trials. Thyroid 2024; 34:702-712. [PMID: 38661527 DOI: 10.1089/thy.2023.0624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
Background: The benefit of levothyroxine treatment of subclinical hypothyroidism (SCH) is subject to debate. This study compared treatment satisfaction between older adults with SCH using levothyroxine or placebo. Methods: We analyzed pooled individual participant data from two randomized, double-blind, placebo-controlled trials investigating the effects of levothyroxine treatment in older adults with SCH. Community-dwelling participants aged ≥65 years, with SCH (persistent thyrotropin levels 4.60-19.99 mIU/L for >3 months and normal free T4 level), were included. Intervention dose titration until thyrotropin levels normalized, with a mock dose adjustment of placebo. Treatment satisfaction was determined during the final study visit using the Treatment Satisfaction Questionnaire for Medication (TSQM), encompassing perceived effectiveness, side effects, convenience, and global satisfaction, along with the participants' desire to continue study medication after the trial. Results: We included 536 participants. At baseline, the median (interquartile range [IQR]) age was 74.9 (69.7-81.4) years, and 292 (55%) were women. The median (IQR) thyrotropin levels were 5.80 (5.10-7.00) mIU/L at baseline in both groups; at final visit, 4.97 (3.90-6.35) mIU/L in the placebo and 3.24 (2.49-4.41) mIU/L in the levothyroxine group. After treatment, the groups did not differ significantly in global satisfaction (mean difference [CI] -1.1 [-4.5 to 2.1], p = 0.48), nor in any other domain of treatment satisfaction. These results held true regardless of baseline thyrotropin levels or symptom burden. No major differences were found in the numbers of participants who wished to continue medication after the trial (levothyroxine 35% vs. placebo 27%), did not wish to continue (levothyroxine 27% vs. placebo 30%), or did not know (levothyroxine 37% vs. placebo 42%) (p = 0.14). In a subpopulation with high symptom burden from hypothyroid symptoms at baseline, those using levothyroxine more often desired to continue the medication after the trial than those using placebo (mean difference [CI]: -21.1% [-35.6% to -6.5%]). Conclusion: These pooled data from two RCTs showed no major differences in treatment satisfaction between older adults receiving levothyroxine or placebo. This finding has important implications for decision-making regarding initiating levothyroxine treatment for SCH. Our findings generally support refraining from routinely prescribing levothyroxine in older adults with SCH.
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Affiliation(s)
- Janneke Ravensberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
- LUMC Center for Medicine for Older People, Leiden University Medical Center, Leiden, Netherlands
| | - Rosalinde K E Poortvliet
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
- LUMC Center for Medicine for Older People, Leiden University Medical Center, Leiden, Netherlands
| | - Robert Du Puy
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Manuel Blum
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | | | - Vera J C McCarthy
- School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Terry Quinn
- The Academic Section of Geriatric Medicine, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom
| | - Olaf Dekkers
- Department of Endocrinology and Metabolic Disorders, Leiden University Medical Center, Leiden, Netherlands
| | - Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
- Netherlands Heart Institute, Utrecht, Netherlands
| | - Simon Mooijaart
- LUMC Center for Medicine for Older People, Leiden University Medical Center, Leiden, Netherlands
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
- LUMC Center for Medicine for Older People, Leiden University Medical Center, Leiden, Netherlands
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Holley M, Razvi S, Farooq MS, Dew R, Maxwell I, Wilkes S. Cardiovascular and bone health outcomes in older people with subclinical hypothyroidism treated with levothyroxine: a systematic review and meta-analysis. Syst Rev 2024; 13:123. [PMID: 38720372 PMCID: PMC11077844 DOI: 10.1186/s13643-024-02548-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 04/29/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Thyroid dysfunction is common in older people, with females at higher risk. Evidence suggests that thyroid-stimulating hormone (TSH) levels naturally increase with age. However, as uniform serum TSH reference ranges are applied across the adult lifespan, subclinical hypothyroidism (SCH) diagnosis is more likely in older people, with some individuals also being commenced treatment with levothyroxine (LT4). It is unclear whether LT4 treatment in older people with SCH is associated with adverse cardiovascular or bone health outcomes. METHODS A systematic review and meta-analysis were performed to synthesise previous studies evaluating cardiovascular and bone health outcomes in older people with SCH, comparing LT4 treatment with no treatment. PubMed, Embase, Cochrane Library, MEDLINE, and Web of Science databases were searched from inception until March 13, 2023, and studies that evaluated cardiovascular and bone health events in people with SCH over 50 years old were selected. RESULTS Six articles that recruited 3853 participants were found, ranging from 185 to 1642 participants, with the proportion of females ranging from 45 to 80%. The paucity of data resulted in analysis for those aged over 65 years only. Additionally, a study with 12,212 participants aged 18 years and older was identified; however, only data relevant to patients aged 65 years and older were considered for inclusion in the systematic review. Of these 7 studies, 4 assessed cardiovascular outcomes, 1 assessed bone health outcomes, and 2 assessed both. A meta-analysis of cardiovascular outcomes revealed a pooled hazard ratio of 0.89 (95% CI 0.71-1.12), indicating no significant difference in cardiovascular risk between older individuals with SCH treated with LT4 compared to those without treatment. Due to overlapping sub-studies, meta-analysis for bone health outcomes was not possible. CONCLUSIONS This systematic review and meta-analysis found no significant association between LT4 use and cardiovascular and bone health outcomes in SCH participants over 65 years. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42022308006.
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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
| | - Mohammed Saif Farooq
- School of Medicine, Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, 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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3
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Attanasio R, Žarković M, Papini E, Nagy EV, Negro R, Perros P, Akarsu E, Alevizaki M, Ayvaz G, Bednarczuk T, Beleslin BN, Berta E, Bodor M, Borissova AM, Boyanov M, Buffet C, Burlacu MC, Ćirić J, Díez JJ, Dobnig H, Fadeyev V, Field BCT, Fliers E, Führer-Sakel D, Galofré JC, Hakala T, Jiskra J, Kopp PA, Krebs M, Kršek M, Kužma M, Lantz M, Lazúrová I, Leenhardt L, Luchytskiy V, Marques Puga F, McGowan A, Metso S, Moran C, Morgunova T, Niculescu DA, Perić B, Planck T, Poiana C, Robenshtok E, Rosselet PO, Ruchala M, Ryom Riis K, Shepelkevich A, Tronko MD, Unuane D, Vardarli I, Visser WE, Vryonidou A, Younes YR, Hegedüs L. Patients' Persistent Symptoms, Clinician Demographics, and Geo-Economic Factors Are Associated with Choice of Therapy for Hypothyroidism by European Thyroid Specialists: The "THESIS" Collaboration. Thyroid 2024; 34:429-441. [PMID: 38368541 DOI: 10.1089/thy.2023.0580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2024]
Abstract
Background: Hypothyroidism is common, however, aspects of its treatment remain controversial. Our survey aimed at documenting treatment choices of European thyroid specialists and exploring how patients' persistent symptoms, clinician demographics, and geo-economic factors relate to treatment choices. Methods: Seventeen thousand two hundred forty-seven thyroid specialists from 28 countries were invited to participate in an online questionnaire survey. The survey included respondent demographic data and treatment choices for hypothyroid patients with persistent symptoms. Geo-economic data for each country were included in the analyses. Results: The response rate was 32.9% (6058 respondents out of 17,247 invitees). Levothyroxine (LT4) was the initial treatment preferred by the majority (98.3%). Persistent symptoms despite normal serum thyrotropin (TSH) while receiving LT4 treatment were reported to affect up to 10.0% of patients by 75.4% of respondents, while 28.4% reported an increasing such trend in the past 5 years. The principal explanations offered for patients' persistent symptoms were psychosocial factors (77.1%), comorbidities (69.2%), and unrealistic patient expectations (61.0%). Combination treatment with LT4+liothyronine (LT3) was chosen by 40.0% of respondents for patients who complained of persistent symptoms despite a normal TSH. This option was selected more frequently by female thyroid specialists, with high-volume practice, working in countries with high gross national income per capita. Conclusions: The perception of patients' dissatisfaction reported by physicians seems lower than that described by hypothyroid patients in previous surveys. LT4+LT3 treatment is used frequently by thyroid specialists in Europe for persistent hypothyroid-like symptoms even if they generally attribute such symptoms to nonendocrine causes and despite the evidence of nonsuperiority of the combined over the LT4 therapy. Pressure by dissatisfied patients on their physicians for LT3-containing treatments is a likely explanation. The association of the therapeutic choices with the clinician demographic characteristics and geo-economic factors in Europe is a novel information and requires further investigation.
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Affiliation(s)
- Roberto Attanasio
- Scientific Committee Associazione Medici Endocrinologi, Milan, Italy
| | - Miloš Žarković
- Clinic of Endocrinology, Diabetes and Diseases of Metabolism, Thyroid Department, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Enrico Papini
- Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy
| | - Endre Vezekenyi Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Roberto Negro
- Division of Endocrinology, Ospedale Fazzi, Lecce, Italy
| | - Petros Perros
- Institute of Translational and Clinical Research, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ersin Akarsu
- Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Maria Alevizaki
- Endocrine Unit and Diabetes Centre, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Göksun Ayvaz
- Department of Endocrinology and Metabolism, Koru Ankara Hospital, Çankaya, Turkey
| | - Tomasz Bednarczuk
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Biljana Nedeljković Beleslin
- Clinic of Endocrinology, Diabetes and Diseases of Metabolism, Thyroid Department, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Eszter Berta
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Miklos Bodor
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Anna Maria Borissova
- Clinic of Endocrinology and Metabolism, University Hospital "Sofiamed," Medical Faculty, Sofia University "Saint Kliment Ohridski," Sofia, Bulgaria
| | - Mihail Boyanov
- Clinic of Endocrinology and Metabolism, University Hospital "Alexandrovska," Sofia, Bulgaria
- Department of Internal Medicine, Medical University Sofia, Sofia, Bulgaria
| | - Camille Buffet
- GRC n 16, GRC Thyroid Tumors, Thyroid Disease and Endocrine Tumor Department, APHP, Hôpital Pitié-Salpêtriére, Sorbonne Universitè, Paris, France
| | - Maria-Cristina Burlacu
- Department of Endocrinology Diabetology and Nutrition, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Jasmina Ćirić
- Clinic of Endocrinology, Diabetes and Diseases of Metabolism, Thyroid Department, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Juan J Díez
- Department of Endocrinology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana, Calle Manuel de Falla, Madrid, Spain
- Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Harald Dobnig
- Thyroid and Osteoporosis Praxis, Kumberg, Austria
- Thyroid Practice for Radiofrequency Ablation, Vienna, Austria
| | - Valentin Fadeyev
- Department of Endocrinology No. 1, N.V. Sklifosovsky Institute of Clinical Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Benjamin C T Field
- Section of Clinical Medicine, Faculty of Health & Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Eric Fliers
- Department of Endocrinology & Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Dagmar Führer-Sakel
- Department of Endocrinology, Diabetes and Metabolism, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Juan Carlos Galofré
- Department of Endocrinology, Clínica Universidad de Navarra, Pamplona, Spain
- Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Tommi Hakala
- Department of Surgery, Tampere University Hospital, Tampere, Finland
| | - Jan Jiskra
- 3rd Department of Medicine, 1st Faculty of Medicine, Charles University, General University Hospital, Prague, Czech Republic
| | - Peter A Kopp
- Division of Endocrinology, Diabetes and Metabolism, University of Lausanne, Lausanne, Switzerland
| | - Michael Krebs
- Division of Endocrinology and Metabolism, Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Michal Kršek
- 3rd Department of Medicine, 1st Faculty of Medicine, Charles University, General University Hospital, Prague, Czech Republic
| | - Martin Kužma
- 5th Department of Internal Medicine, Medical Faculty of Comenius University and University Hospital, Bratislava, Slovakia
| | - Mikael Lantz
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
| | - Ivica Lazúrová
- 1st Department of Internal Medicine of the Medical Faculty, P.J. Šafárik University Košice, Košice, Slovakia
| | - Laurence Leenhardt
- GRC n 16, GRC Thyroid Tumors, Thyroid Disease and Endocrine Tumor Department, APHP, Hôpital Pitié-Salpêtriére, Sorbonne Universitè, Paris, France
| | - Vitaliy Luchytskiy
- Department of Reproductive Endocrinology, Institute of Endocrinology and Metabolism named after V.P. Komissarenko, National Academy of Medical Science of Ukraine, Kyiv, Ukraine
| | - Francisca Marques Puga
- Endocrinology, Diabetes and Metabolism Service, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Anne McGowan
- Robert Graves Institute, Tallaght University Hospital, Dublin, Ireland
| | - Saara Metso
- Department of Endocrinology, Tampere University Hospital, Tampere, Finland
| | - Carla Moran
- Diabetes & Endocrinology Section, Beacon Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Tatyana Morgunova
- Department of Endocrinology No. 1, N.V. Sklifosovsky Institute of Clinical Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Dan Alexandru Niculescu
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Božidar Perić
- Department of Endocrinology, Diabetes and Metabolic Diseases "Mladen Sekso," University Hospital Center "Sisters of Mercy," Zagreb, Croatia
| | - Tereza Planck
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
| | - Catalina Poiana
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Eyal Robenshtok
- Thyroid Cancer Service, Endocrinology and Metabolism Institute, Beilinson Hospital and Davidoff Cancer Center, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Petah Tikva, Israel
| | | | - Marek Ruchala
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznań, Poland
| | - Kamilla Ryom Riis
- Department of Endocrinology, Odense University Hospital, Odense C, Denmark
| | - Alla Shepelkevich
- Department of Endocrinology, Belarusian State Medical University, Minsk, Republic of Belarus
| | - Mykola D Tronko
- V.P. Komisarenko Institute of Endocrinology and Metabolism of Academy of Medical Sciences of Ukraine, Kyiv, Ukraine
| | - David Unuane
- Department of Internal Medicine, Endocrine Unit, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Irfan Vardarli
- Department of Medicine I, Klinikum Vest GmbH, Knappschaftskrankenhaus Recklinghausen, Academic Teaching Hospital, Ruhr-University Bochum, Recklinghausen, Germany
- Division of Endocrinology and Diabetes, 5th Medical Department, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - W Edward Visser
- Rotterdam Thyroid Center, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Andromachi Vryonidou
- Department of Endocrinology and Diabetes Centre, Hellenic Red Cross Hospital, Athens, Greece
| | | | - Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, Odense C, Denmark
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Tamargo J, Villacastín J, Caballero R, Delpón E. Drug-induced atrial fibrillation. A narrative review of a forgotten adverse effect. Pharmacol Res 2024; 200:107077. [PMID: 38244650 DOI: 10.1016/j.phrs.2024.107077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/22/2023] [Accepted: 01/12/2024] [Indexed: 01/22/2024]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with an increased morbidity and mortality. There is clinical evidence that an increasing number of cardiovascular and non-cardiovascular drugs, mainly anticancer drugs, can induce AF either in patients with or without pre-existing cardiac disorders, but drug-induced AF (DIAF) has not received the attention that it might deserve. In many cases DIAF is asymptomatic and paroxysmal and patients recover sinus rhythm spontaneously, but sometimes, DIAF persists, and it is necessary to perform a cardioversion. Furthermore, DIAF is not mentioned in clinical guidelines on the treatment of AF. The risk of DIAF increases in elderly and in patients treated with polypharmacy and with risk factors and comorbidities that commonly coexist with AF. This is the case of cancer patients. Under these circumstances ascribing causality of DIAF to a given drug often represents a clinical challenge. We review the incidence, the pathophysiological mechanisms, risk factors, clinical relevance, and treatment of DIAF. Because of the limited information presently available, further research is needed to obtain a deeper insight into DIAF. Meanwhile, it is important that clinicians are aware of the problem that DIAF represents, recognize which drugs may cause DIAF, and consider the possibility that a drug may be responsible for a new-onset AF episode.
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Affiliation(s)
- Juan Tamargo
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón, CIBERCV, 28040 Madrid, Spain
| | - Julián Villacastín
- Hospital Clínico San Carlos, CardioRed1, Universidad Complutense de Madrid, CIBERCV, 28040 Madrid, Spain
| | - Ricardo Caballero
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón, CIBERCV, 28040 Madrid, Spain.
| | - Eva Delpón
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón, CIBERCV, 28040 Madrid, Spain
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5
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Žarković M, Attanasio R, Nagy EV, Negro R, Papini E, Perros P, Cohen CA, Akarsu E, Alevizaki M, Ayvaz G, Bednarczuk T, Berta E, Bodor M, Borissova AM, Boyanov M, Buffet C, Burlacu MC, Ćirić J, Díez JJ, Dobnig H, Fadeyev V, Field BCT, Fliers E, Frølich JS, Führer D, Galofré JC, Hakala T, Jiskra J, Kopp P, Krebs M, Kršek M, Kužma M, Lantz M, Lazúrová I, Leenhardt L, Luchytskiy V, McGowan A, Melo M, Metso S, Moran C, Morgunova T, Mykola T, Beleslin BN, Niculescu DA, Perić B, Planck T, Poiana C, Puga FM, Robenshtok E, Rosselet P, Ruchala M, Riis KR, Shepelkevich A, Unuane D, Vardarli I, Visser WE, Vrionidou A, Younes YR, Yurenya E, Hegedüs L. Characteristics of specialists treating hypothyroid patients: the "THESIS" collaborative. Front Endocrinol (Lausanne) 2023; 14:1225202. [PMID: 38027187 PMCID: PMC10660282 DOI: 10.3389/fendo.2023.1225202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Thyroid specialists influence how hypothyroid patients are treated, including patients managed in primary care. Given that physician characteristics influence patient care, this study aimed to explore thyroid specialist profiles and associations with geo-economic factors. Methods Thyroid specialists from 28 countries were invited to respond to a questionnaire, Treatment of Hypothyroidism in Europe by Specialists: an International Survey (THESIS). Geographic regions were defined according to the United Nations Statistics Division. The national economic status was estimated using World Bank data on the gross national income per capita (GNI per capita). Results 5,695 valid responses were received (response rate 33·0%). The mean age was 49 years, and 65·0% were female. The proportion of female respondents was lowest in Northern (45·6%) and highest in Eastern Europe (77·2%) (p <0·001). Respondent work volume, university affiliation and private practice differed significantly between countries (p<0·001). Age and GNI per capita were correlated inversely with the proportion of female respondents (p<0·01). GNI per capita was inversely related to the proportion of respondents working exclusively in private practice (p<0·011) and the proportion of respondents who treated >100 patients annually (p<0·01). Discussion THESIS has demonstrated differences in characteristics of thyroid specialists at national and regional levels, strongly associated with GNI per capita. Hypothyroid patients in middle-income countries are more likely to encounter female thyroid specialists working in private practice, with a high workload, compared to high-income countries. Whether these differences influence the quality of care and patient satisfaction is unknown, but merits further study.
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Affiliation(s)
- Miloš Žarković
- University of Belgrade Faculty of Medicine, Internal Medicine, Belgrade, Serbia
- Clinic of Endocrinology, Diabetes and Diseases of Metabolism, Thyroid Department, Belgrade, Serbia
| | - Roberto Attanasio
- Associazione Medici Endocrinologi, Scientific Committee, Milan, Italy
| | - Endre V. Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Roberto Negro
- Ospedale Vito Fazzi, Department of Endocrinology, Lecce, Italy
| | - Enrico Papini
- Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Albano Laziale, Roma, Italy
| | - Petros Perros
- Institute of Translational and Clinical Research, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | | | - Ersin Akarsu
- Department of Internal Medicine, Division of Endocrinology, Faculty of Medicine, Gaziantep University, Gaziantep, Türkiye
| | - Maria Alevizaki
- Endocrine Unit and Diabetes Centre, Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens Faculty of Medicine, Athens, Greece
| | - Göksun Ayvaz
- Department of Endocrinology and Metabolism, Koru Ankara Hospital, Ankara, Türkiye
| | - Tomasz Bednarczuk
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Eszter Berta
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Miklos Bodor
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Anna Maria Borissova
- Sofia University Saint Kliment Ohridski, Medical Faculty, Clinic of Endocrinology and Metabolism, University Hospital “Sofiamed”, Sofia, Bulgaria
| | - Mihail Boyanov
- University Hospital Alexandrovska, Clinic of Endocrinology and Metabolism, Medical University-Sofia, Internal Medicine, Sofia, Bulgaria
| | - Camille Buffet
- GRC n 16, GRC Thyroid Tumors, Thyroid Disease and Endocrine Tumor Department, AP-HP, Hôpital Pitié Salpêtrière, Sorbonne University, Paris, France
| | - Maria-Cristina Burlacu
- Department of Endocrinology and Nutrition, Cliniques Universitaires St-Luc, Université Catholique De Louvain, Brussels, Belgium
| | - Jasmina Ćirić
- University of Belgrade Faculty of Medicine, Internal Medicine, Belgrade, Serbia
- Clinic of Endocrinology, Diabetes and Diseases of Metabolism, Thyroid Department, Belgrade, Serbia
| | - Juan J. Díez
- Department of Endocrinology, Hospital Universitario Puerta De Hierro Majadahonda, Madrid, Spain
- Instituto De Investigación Sanitaria Puerta De Hierro Segovia De Arana, Majadahonda, Madrid, Spain
- Department of Medicine, Universidad Autónoma De Madrid, Madrid, Spain
| | - Harald Dobnig
- Thyroid Endocrinology, Osteoporosis Institute Dobnig, Graz, Austria
| | - Valentin Fadeyev
- Department of Endocrinology No. 1, N.V. Sklifosovsky Institute of Clinical Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Benjamin C. T. Field
- University of Surrey Faculty of Health and Medical Sciences, Section of Clinical Medicine, Prague, United Kingdom
| | - Eric Fliers
- Department of Endocrinology & Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | | | - Dagmar Führer
- University Hospital Essen, Department of Endocrinology, Diabetes and Metabolism, University-Duisburg-Essen, Essen, Germany
| | - Juan Carlos Galofré
- Departmento De Endocrinologia e Nutrición, Clínica Universidad De Navarra, Pamplona, Spain
| | - Tommi Hakala
- Department of Surgery, Tampere University Hospital, Tampere, Finland
| | - Jan Jiskra
- 3rd Department of Medicine, 1st Faculty of Medicine, Charles University, General University Hospital, Prague, Czechia
| | - Peter Kopp
- Division of Endocrinology, Diabetology and Metabolism, University of Lausanne, Lausanne, Switzerland
| | - Michael Krebs
- Department of Medicine III, Division of Endocrinology, Medical University of Vienna, Vienna, Austria
| | - Michal Kršek
- 3rd Department of Medicine, 1st Faculty of Medicine, Charles University, General University Hospital, Prague, Czechia
| | - Martin Kužma
- 5th Department of Internal Medicine, Medical Faculty of Commenius University and University Hospital, Bratislava, Slovakia
| | - Mikael Lantz
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
| | - Ivica Lazúrová
- P. J. Šafárik University Košice, 1st Department of Internal Medicine of the Medical Faculty, Košice, Slovakia
| | - Laurence Leenhardt
- Hopital Pitie-Salpetriere, Thyroid and Endocrine Tumors Unit, Institut of Endocrinology, Sorbonne University, Paris, France
| | - Vitaliy Luchytskiy
- Department of Reproductive Endocrinogy, Institute of Endocrinology and Metabolism named after V.P. Komissarenko, National Academy of Medical Science of Ukraine, Kyiv, Ukraine
| | - Anne McGowan
- Robert Graves Institute, Tallaght University Hospital, Dublin, Ireland
| | - Miguel Melo
- Department of Endocrinology, Diabetes and Metabolism, Medical Faculty, University of Coimbra, Coimbra, Portugal
| | - Saara Metso
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Carla Moran
- Diabetes & Endocrinology Section, Beacon Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Tatyana Morgunova
- Department of Endocrinology No. 1, N.V. Sklifosovsky Institute of Clinical Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Tronko Mykola
- Institute of Endocrinology and Metabolism named after V.P. Komissarenko, National Academy of Medical Science of Ukraine, Kyiv, Ukraine
| | - Biljana Nedeljković Beleslin
- University of Belgrade Faculty of Medicine, Internal Medicine, Belgrade, Serbia
- Clinic of Endocrinology, Diabetes and Diseases of Metabolism, Thyroid Department, Belgrade, Serbia
| | - Dan Alexandru Niculescu
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Božidar Perić
- Department of Endocrinology, Diabetes and Metabolic Diseases “Mladen Sekso”, University Hospital Center “Sisters of Mercy”, Zagreb, Croatia
| | - Tereza Planck
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
| | - Catalina Poiana
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Francisca Marques Puga
- Endocrinology, Diabetes and Metabolism Service, Porto Hospital and University Centre, Porto, Portugal
| | - Eyal Robenshtok
- Endocrinology Institute, Rabin Medical Center, Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | | | - Marek Ruchala
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Kamilla Ryom Riis
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Alla Shepelkevich
- Department of Endocrinology, Belarusian State Medical University, Minsk, Belarus
| | - David Unuane
- Department of Internal Medicine, Endocrine Unit, UZ Brussel, Vrije Universiteit Brussel, Brussel, Belgium
| | - Irfan Vardarli
- Department of Medicine I, Klinikum Vest GmbH, Knappschaftskrankenhaus Recklinghausen, Recklinghausen, Germany
- 5th Medical Department, Division of Endocrinology and Diabetes, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - W. Edward Visser
- Rotterdam Thyroid Center, Department of Internal Medicine, Erasmus MC, Rotterdam, Netherlands
| | - Andromachi Vrionidou
- Department of Endocrinology and Diabetes Centre, Hellenic Red Cross Hospital, Athens, Greece
| | - Younes R. Younes
- East Surrey Hospital, Surrey & Sussex Healthcare NHS Trust, Redhill, Surrey, United Kingdom
| | | | - Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
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6
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Xie Y, Wang Z, Chen Z. Analysis of Subclinical Thyroid Dysfunction and Metabolic Abnormality in 28568 Healthy People. Int J Endocrinol 2023; 2023:5216945. [PMID: 37876378 PMCID: PMC10593554 DOI: 10.1155/2023/5216945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 07/26/2023] [Accepted: 09/29/2023] [Indexed: 10/26/2023] Open
Abstract
We analyzed the detection rates of metabolic syndrome (MetS) and subclinical thyroid dysfunction, including subclinical hyperthyroidism (SCHyper) and subclinical hypothyroidism (SCH), in healthy people, as well as their relationship. Clinical data were collected from 28,568 healthy individuals who underwent physical examinations. The detection rates of SCHyper, SCH, and MetS, as well as in different genders and ages, were analyzed. The detection rate of SCHyper and SCH in females was significantly higher than that in males (P < 0.001), but that of MetS in males was significantly higher than that in females (P < 0.001). In each age group, the detection rate of SCH in females was higher than that in males (P < 0.001). The detection rate of SCH was significantly different in different age groups (P < 0.001). The detection rates of hyperlipidemia (P < 0.001), obesity (P = 0.004), hypertension (P = 0.009), and hyperglycemia (P < 0.001) in the female SCH group were significantly higher than those in the normal group. The detection rates of hyperlipidemia (P = 0.006), obesity (P = 0.04), and hypertension (P = 0.04) in the male SCH group were higher than those in the normal group. The males with SCHyper were more prone to hyperlipidemia (P = 0.02) and obesity (P = 0.03). In addition, the female SCHyper group was not significantly different from the normal group (P > 0.05). Conclusively, the detection rate of SCHyper and SCH in females is higher than that in males, which increases with age. Attention should be paid to subclinical thyroid dysfunction in elderly people, especially females. Early individualized screening and early intervention should be carried out for people with abnormal metabolism.
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Affiliation(s)
- Yan Xie
- Health Management Centre, The First Affiliated Hospital of Army Medical University, Chongqing 400038, China
| | - Zhixue Wang
- Department of Clinical Laboratory, Bishan Hospital of Chongqing Medical University (Bishan Hospital of Chongqing), Chongqing 402760, China
| | - Zongtao Chen
- Health Management Centre, The First Affiliated Hospital of Army Medical University, Chongqing 400038, China
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7
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Tee SA, Tsatlidis V, Razvi S. The GLP-1 receptor agonist exenatide reduces serum TSH by its effect on body weight in people with type 2 diabetes. Clin Endocrinol (Oxf) 2023; 99:401-408. [PMID: 36843143 DOI: 10.1111/cen.14901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/22/2023] [Accepted: 02/24/2023] [Indexed: 02/28/2023]
Abstract
OBJECTIVE Glucagon-like peptide-1 receptor agonist (GLP-1 RA) therapy in patients with type 2 diabetes and obesity leads to a significant reduction in serum thyrotropin (TSH) levels but it is unclear whether this is related to weight loss and improvement in sensitivity to thyroid hormones (TH). DESIGN, PATIENTS AND MEASUREMENTS We prospectively analysed clinical and biochemical data in patients with type 2 diabetes and obesity who were commenced on the GLP-1 RA exenatide and followed them for 12 months. We assessed the relationship between changes in body weight and serum TSH and resistance to TH indices. RESULTS In 112 patients (mean age: 53.5 years, 43.8% female, mean body mass index: 39.8 kg/m2 ), 12 months of exenatide treatment was associated with a mean (95% CI) percent body weight loss of 6.5% (5.0%-8.1%) and change in serum TSH of -0.25 mU/L (-0.43 to -0.06). There was a significant negative and nonlinear relationship between change in serum TSH and percent body weight loss: -0.25 mU/L with 5%, -0.4 mU/L with 10% and -0.5 mU/L with 15%, respectively, whereas a rise in serum TSH of 0.5 mU/L was associated with 5% weight gain. There were no changes observed in serum FT4 levels with weight loss but a significant reduction in resistance to TH indices was noted. CONCLUSIONS Exenatide therapy reduces serum TSH levels and improves central sensitivity to TH action over 12 months via its effect on weight loss. The effectiveness of weight loss strategies, rather than TH replacement, should be investigated in individuals with obesity and mildly raised serum TSH levels.
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Affiliation(s)
- Su Ann Tee
- Department of Endocrinology, Gateshead Health NHS Foundation Trust, Gateshead, UK
| | - Vasileios Tsatlidis
- Department of Endocrinology, Gateshead Health NHS Foundation Trust, Gateshead, UK
| | - Salman Razvi
- Department of Endocrinology, Gateshead Health NHS Foundation Trust, Gateshead, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
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8
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Trovato M, Valenti A. Medical Applications of Molecular Biotechnologies in the Context of Hashimoto's Thyroiditis. Diagnostics (Basel) 2023; 13:2114. [PMID: 37371008 DOI: 10.3390/diagnostics13122114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
Hashimoto's thyroiditis (HT) is a gender autoimmune disease that is manifested by chronic inflammation of the thyroid. Clinical trial studies (CTSs) use molecular biotechnologies (MB) to approach HT appearance. The aims of this study were to analyze the applications of MB in CTSs carried out in HT populations (HT-CTSs). Further, to evaluate the role of MB in the context of the hygiene hypothesis (HH). From 75 HT-CTSs found at clinicaltrials.gov web place, forty-five were considered for this investigation. Finally, six HT-CTSs were reported as molecular HT-CTSs (mHT-CTSs) because these were planning to utilize MB. Two of mHT-CTSs were programmed on the French population to isolate DNA viral sequences. Blood, urine, and thyroid tissue biospecimens were analyzed to pick out the parvo and polyoma viruses. Two mHT-CTSs carried out in China aimed to identify oral and fecal microbiotas by measuring PCR sequencing of the 16S rRNA gene. Two mHT-CTSs were programmed in the USA and Greece, respectively, for interception of DNA polymorphisms to associate with genetic susceptibility to HT. In conclusion, MB are mainly employed in HT-CTSs for infective pathogenesis and genetic fingerprinting of HT. Furthermore, MB do not provide evidence of HH; however, they are useful for providing direct evidence of the presence of viruses.
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Affiliation(s)
- Maria Trovato
- Department of Clinical and Experimental Medicine, University Hospital, 98125 Messina, Italy
| | - Andrea Valenti
- Department of Clinical and Experimental Medicine, University Hospital, 98125 Messina, Italy
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9
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Ravensberg AJ, Poortvliet RKE, Du Puy RS, Dekkers OM, Mooijaart SP, Gussekloo J. Effects of discontinuation of levothyroxine treatment in older adults: protocol for a self-controlled trial. BMJ Open 2023; 13:e070741. [PMID: 37185193 PMCID: PMC10151847 DOI: 10.1136/bmjopen-2022-070741] [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] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Many older persons use the thyroid hormone levothyroxine which is often continued for life. Scientifically, there is much uncertainty whether simple continuation is the optimal approach. First, the physical need for levothyroxine can decrease with age thereby posing a higher risk of overtreatment and adverse effects. Second, large trials in subclinical hypothyroidism have shown no benefit for the use of levothyroxine. Interestingly, guidelines do not address re-evaluation of the indication. This self-controlled trial aims to determine the effects of discontinuation of levothyroxine treatment in older adults. METHODS AND ANALYSIS Participants are community-dwelling subjects aged ≥60 years using levothyroxine continuously at a stable dosage of ≤150 µg and a level of thyroid-stimulating hormone (TSH) <10 mU/L. After a control period of 12 weeks, levothyroxine treatment is discontinued gradually using a stepwise approach with regular monitoring of thyroid function guided by their GP. The primary outcome is the proportion of participants withdrawn from levothyroxine while maintaining a free T4 level within the reference range and a TSH level <10 mU/L, 52 weeks after the start of discontinuation. Secondary outcomes are compared with the control period (self-controlled) and include among others, the effects on thyroid-specific and general health-related quality of life. Furthermore, patients' attitudes towards deprescribing and regret regarding discontinuing levothyroxine treatment will be recorded. A total of 513 participants will be recruited to estimate the expected proportion of 50% with a 95% CI ranging from 45% to 55%. ETHICS AND DISSEMINATION Approval was obtained from the institutional Medical Ethics Committee. The Older People Advisory Board Health and Well-being has reviewed the research proposal and their comments were used for improvement. In line with the funding policies of the grant organisation funding this study, the study results will be proactively disseminated to the general public and key public health stakeholders. TRIAL REGISTRATION NUMBER NL7978; NCT05821881.
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Affiliation(s)
- A Janneke Ravensberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
| | - Rosalinde K E Poortvliet
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
- University Network for the Care Sector Zuid-Holland, Leiden University Medical Center, Leiden, Netherlands
| | - Robert S Du Puy
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
| | - Olaf M Dekkers
- Endocrinology and Metabolic Disorders, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
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10
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Montagna C, Zangelidis A. Labour market implications of thyroid dysfunctions. ECONOMICS AND HUMAN BIOLOGY 2023; 50:101247. [PMID: 37148629 DOI: 10.1016/j.ehb.2023.101247] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 03/17/2023] [Accepted: 04/19/2023] [Indexed: 05/08/2023]
Abstract
This paper aims to shed some light on the labour market implications of thyroid disease. Undetected hypothyroidism has adverse effects on wages for female workers,thus widening the existing gender wage gap. However, once female individuals are diagnosed (and therefore assumed to be treated) with hypothyroidism, they experience wage gains and have a higher employment probability. In relation to other labour market outcomes, thyroid disease does not appear to play a significant role on individuals' labour force participation decision and their working hours. Results suggest that productivity gains may drive the improvement in wages.
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Affiliation(s)
- Catia Montagna
- Economics, Centre for Labour Market Research, Business School, University of Aberdeen, Aberdeen, AB24 3QY, Scotland, UK
| | - Alexandros Zangelidis
- Economics, Centre for Labour Market Research, Business School, University of Aberdeen, Aberdeen, AB24 3QY, Scotland, UK.
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11
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Taylor PN, Lansdown A, Witczak J, Khan R, Rees A, Dayan CM, Okosieme O. Age-related variation in thyroid function - a narrative review highlighting important implications for research and clinical practice. Thyroid Res 2023; 16:7. [PMID: 37009883 PMCID: PMC10069079 DOI: 10.1186/s13044-023-00149-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 02/05/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Thyroid hormones are key determinants of health and well-being. Normal thyroid function is defined according to the standard 95% confidence interval of the disease-free population. Such standard laboratory reference intervals are widely applied in research and clinical practice, irrespective of age. However, thyroid hormones vary with age and current reference intervals may not be appropriate across all age groups. In this review, we summarize the recent literature on age-related variation in thyroid function and discuss important implications of such variation for research and clinical practice. MAIN TEXT There is now substantial evidence that normal thyroid status changes with age throughout the course of life. Thyroid stimulating hormone (TSH) concentrations are higher at the extremes of life and show a U-shaped longitudinal trend in iodine sufficient Caucasian populations. Free triiodothyronine (FT3) levels fall with age and appear to play a role in pubertal development, during which it shows a strong relationship with fat mass. Furthermore, the aging process exerts differential effects on the health consequences of thyroid hormone variations. Older individuals with declining thyroid function appear to have survival advantages compared to individuals with normal or high-normal thyroid function. In contrast younger or middle-aged individuals with low-normal thyroid function suffer an increased risk of adverse cardiovascular and metabolic outcomes while those with high-normal function have adverse bone outcomes including osteoporosis and fractures. CONCLUSION Thyroid hormone reference intervals have differential effects across age groups. Current reference ranges could potentially lead to inappropriate treatment in older individuals but on the other hand could result in missed opportunities for risk factor modification in the younger and middle-aged groups. Further studies are now needed to determine the validity of age-appropriate reference intervals and to understand the impact of thyroid hormone variations in younger individuals.
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Affiliation(s)
- Peter N Taylor
- Thyroid Research Group Institute of Molecular and Experimental Medicine, C2 link corridor, UHW, Cardiff University School of Medicine, Heath Park, Cardiff, UK.
- Department of Endocrinology, University Hospital of Wales, Cardiff, UK.
| | - Andrew Lansdown
- Department of Endocrinology, University Hospital of Wales, Cardiff, UK
| | - Justyna Witczak
- Department of Endocrinology, University Hospital of Wales, Cardiff, UK
| | - Rahim Khan
- Department of Endocrinology, University Hospital of Wales, Cardiff, UK
| | - Aled Rees
- Thyroid Research Group Institute of Molecular and Experimental Medicine, C2 link corridor, UHW, Cardiff University School of Medicine, Heath Park, Cardiff, UK
- Department of Endocrinology, University Hospital of Wales, Cardiff, UK
- Neuroscience and Mental Health Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Colin M Dayan
- Thyroid Research Group Institute of Molecular and Experimental Medicine, C2 link corridor, UHW, Cardiff University School of Medicine, Heath Park, Cardiff, UK
| | - Onyebuchi Okosieme
- Thyroid Research Group Institute of Molecular and Experimental Medicine, C2 link corridor, UHW, Cardiff University School of Medicine, Heath Park, Cardiff, UK
- Diabetes Department, Prince Charles Hospital, Cwm Taf Morgannwg University Health Board, Merthyr Tydfil, UK
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12
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Razvi S, Jabbar A, Addison C, Vernazza J, Syed A, Soran H, Leng O. Variation in the reference range limits of thyroid function tests and association with the prevalence of levothyroxine treatment. Eur J Endocrinol 2023; 188:7031057. [PMID: 36751726 DOI: 10.1093/ejendo/lvad016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/11/2023] [Accepted: 01/30/2023] [Indexed: 02/09/2023]
Abstract
Many individuals with marginally abnormal thyroid function test (TFT) results may be treated and it is unknown if the limits of the thyrotropin (TSH) and free thyroxine (FT4) reference intervals reported alongside the laboratory results are associated with the prevalence of levothyroxine treatment. We obtained information regarding reported TFT reference intervals from UK National Health Service (NHS) laboratories and evaluated its relationship with the prevalence of levothyroxine treatment for corresponding health areas for 2014. The upper limit of serum TSH was significantly, linearly, independently, and negatively associated with prevalent levothyroxine treatment: -0.54% (95% CI, -0.68% to -0.40%). The lower limit of serum FT4 was significantly and independently associated with the prevalence of levothyroxine treatment in a non-linear (J-shaped) manner with an increase being noted from a FT4 level of ≈9.5 pmol/L onwards. We conclude that minor changes in the reference range limits for serum TSH and FT4 are associated with levothyroxine treatment.
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Affiliation(s)
- Salman Razvi
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Avais Jabbar
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Caroline Addison
- South of Tyne Laboratories, Gateshead Health NHS Foundation Trust, Gateshead, United Kingdom
| | - Jonathan Vernazza
- South of Tyne Laboratories, Gateshead Health NHS Foundation Trust, Gateshead, United Kingdom
| | - Akheel Syed
- Department of Diabetes and Endocrinology, Salford Care Organisation, Salford, United Kingdom
| | - Handrean Soran
- Department of Diabetes, Endocrinology and Metabolism, Manchester University Hospital, Manchester, United Kingdom
| | - Owain Leng
- Department of Diabetes and Endocrinology, Northumbria Healthcare NHS Foundation Trust, North Tyneside, United Kingdom
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13
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Lyko C, Blum MR, Abolhassani N, Stuber MJ, Del Giovane C, Feller M, Moutzouri E, Oberle J, Jungo KT, Collet TH, den Elzen WPJ, Poortvliet RKE, Du Puy RS, Dekkers OM, Trompet S, Jukema JW, Aujesky D, Quinn T, Westendorp R, Kearney PM, Gussekloo J, Van Heemst D, Mooijaart SP, Bauer DC, Rodondi N. Thyroid antibodies and levothyroxine effects in subclinical hypothyroidism: A pooled analysis of two randomized controlled trials. J Intern Med 2022; 292:892-903. [PMID: 35894851 PMCID: PMC9796496 DOI: 10.1111/joim.13544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Antithyroid antibodies increase the likelihood of developing overt hypothyroidism, but their clinical utility remains unclear. No large randomized controlled trial (RCT) has assessed whether older adults with subclinical hypothyroidism (SHypo) caused by autoimmune thyroid disease derive more benefits from levothyroxine treatment (LT4). OBJECTIVE To determine whether older adults with SHypo and positive antibodies derive more clinical benefits from LT4 than those with negative antibodies. METHODS We pooled individual participant data from two RCTs, Thyroid Hormone Replacement for Untreated Older Adults with Subclinical Hypothyroidism and IEMO 80+. Participants with persistent SHypo were randomly assigned to receive LT4 or placebo. We compared the effects of LT4 versus placebo in participants with and without anti-thyroid peroxidase (TPO) at baseline. The two primary outcomes were 1-year change in Hypothyroid Symptoms and Tiredness scores on the Thyroid-Related Quality-of-Life Patient-Reported Outcome Questionnaire. RESULTS Among 660 participants (54% women) ≥65 years, 188 (28.5%) had positive anti-TPO. LT4 versus placebo on Hypothyroid Symptoms lead to an adjusted between-group difference of -2.07 (95% confidence interval: -6.04 to 1.90) for positive antibodies versus 0.89 (-1.76 to 3.54) for negative antibodies (p for interaction = 0.31). Similarly, there was no treatment effect modification by baseline antibody status for Tiredness scores-adjusted between-group difference 1.75 (-3.60 to 7.09) for positive antibodies versus 1.14 (-1.90 to 4.19) for negative antibodies (p for interaction = 0.98). Positive anti-TPO were not associated with better quality of life, improvement in handgrip strength, or fewer cardiovascular outcomes with levothyroxine treatment. CONCLUSIONS Among older adults with SHypo, positive antithyroid antibodies are not associated with more benefits on clinical outcomes with LT4.
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Affiliation(s)
- Christina Lyko
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Manuel R Blum
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.,Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nazanin Abolhassani
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Mirah J Stuber
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.,Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Martin Feller
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Elisavet Moutzouri
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Jolanda Oberle
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.,Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Katharina T Jungo
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Tinh-Hai Collet
- Service of Endocrinology, Diabetes, Nutrition and Therapeutic Education, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Wendy P J den Elzen
- Atalmedial Diagnostics Centre, Amsterdam, The Netherlands.,Amsterdam UMC, Department of Clinical Chemistry, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Rosalinde K E Poortvliet
- Department of Public Health and Primary Care, Leiden University Medical Center UMC, Leiden, The Netherlands
| | - Robert S Du Puy
- Department of Public Health and Primary Care, Leiden University Medical Center UMC, Leiden, The Netherlands
| | - Olaf M Dekkers
- Department of Endocrinology and Metabolic Disorders, Leiden University Medical Center, Leiden, The Netherlands
| | - Stella Trompet
- Department of Internal Medicine-Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands.,Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.,Netherlands Heart Institute, Utrecht, The Netherlands
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Terry Quinn
- Academic Section of Geriatric Medicine, Institute of Cardiovascular and Medical Sciences University of Glasgow, Glasgow, UK
| | - Rudi Westendorp
- Department of Public Health and, Center for Healthy Ageing, University of Copenhagen, Copenhagen, Denmark
| | - Patricia M Kearney
- Department of Epidemiology and Public Health, University College Cork, Cork, Ireland
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center UMC, Leiden, The Netherlands
| | - Diana Van Heemst
- Department of Internal Medicine-Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Simon P Mooijaart
- Department of Internal Medicine-Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Douglas C Bauer
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.,Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco, USA
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.,Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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14
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Brancato D, Biondi B, Attardo TM, Fierro A, Nizzoli M, Vettor R, Monaco E, Romano R, Ariete V, Usai C, Zagarrì E, Campanini M. Management of Hypothyroidism in Internal Medicine: Patient Profile and Effects of an Educational Programme in the Cluster-Randomized FADOI TIAMO Study. Front Endocrinol (Lausanne) 2022; 13:839300. [PMID: 35769080 PMCID: PMC9235396 DOI: 10.3389/fendo.2022.839300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 04/06/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND AND AIMS There is still limited knowledge regarding the clinical profile and appropriateness of treatment in patients with hypothyroidism hospitalized in Internal Medicine (IM) Departments in Italy. The aim of this study is to evaluate: 1) the characteristics of patients and possible deviations from national and international clinical practice recommendations (CPRs) in evidence-based guidelines (EBGs); 2) the improvement of patient management by means of a standardized educational programme (EP). METHODS A nationwide multicentre study, comprising two replications of a retrospective survey (phases 1 and 3) with an intervening EP (phase 2) in half of the centres and no EP in the other half, was conducted. The EP was based on outreach visits. Centres were assigned to the two arms of the study, labelled the training group (TG) and control group (CG) respectively, by cluster randomization. Four EBGs and 39 CPRs provided the basis on which 22 treatment management indicators were identified (7 referring to the time of hospital admission, 15 to post-admission). RESULTS The 21 participating centres recruited 587 hospitalized patients with hypothyroidism, 421 of which were females (71.7%, mean age 74.1 + 14.4 yrs): 318 in phase 1 and 269 in phase 3. The cause of hypothyroidism was unknown in 282 patients (48%). Evaluation at the time of admission identified satisfactory adherence to CPRs (>50%) for 63.6% of the indicators. In the phase 3, TG centres showed significant improvement vs CG in 4 of the 15 post-admission indicators, while 1 out of 15 was significantly worse. CONCLUSIONS The EP based on outreach visits significantly improved some indicators in the management of patients with hypothyroidism, with specific reference to appropriateness of TSH dosage and levothyroxine (LT4) treatment modality. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, identifier NCT05314790.
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Affiliation(s)
- D. Brancato
- Internal Medicine Department, Ospedale Civile di Partinico, Palermo, Italy
- *Correspondence: D. Brancato,
| | - B. Biondi
- Department of Clinical Medicine and Surgery, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - T. M. Attardo
- Internal Medicine Department, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - A. Fierro
- Formerly at Internal Medicine Department, Pertini Hospital, Rome, Italy
| | - M. Nizzoli
- Department of Endocrinology and Metabolic Diseases, Morgagni - Pierantoni Hospital, Forlì, Italy
| | - R. Vettor
- Department of Medicine, Università degli Studi, Padova, Italy
| | - E. Monaco
- Internal Medicine Department, San Paolo Hospital, Savona, Italy
| | - R. Romano
- Geriatric Department, Azienda Ospedaliera di Rilievo Nazionale e Alta Specializzazione “Garibaldi”, Catania, Italy
| | - V. Ariete
- Internal Medicine Department, Gubbio - Gualdo Tadino Hospital, Perugia, Italy
| | - C. Usai
- Internal Medicine Department, S.S. Annunziata Hospital, Sassari, Italy
| | - E. Zagarrì
- Department of Clinical Research, FADOI Study Center, Milano, Italy
| | - M. Campanini
- Internal Medicine Department, Maggiore della Carità Hospital, Novara, Italy
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Wiersinga WM. T4+T3 Combination Therapy: An Unsolved Problem of Increasing Magnitude and Complexity. Endocrinol Metab (Seoul) 2021; 36:938-951. [PMID: 34587734 PMCID: PMC8566135 DOI: 10.3803/enm.2021.501] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 08/30/2021] [Indexed: 12/29/2022] Open
Abstract
Thyroxine (T4)+triiodothyronine (T3) combination therapy can be considered in case of persistent symptoms despite normal serum thyroid stimulating hormone in levothyroxine (LT4)-treated hypothyroid patients. Combination therapy has gained popularity in the last two decades, especially in countries with a relatively high gross domestic product. The prevalence of persistent symptoms has also increased; most frequent are complaints about energy levels and fatigue (80% to 90%), weight management (70% to 75%), memory (60% to 80%), and mood (40% to 50%). Pathophysiological explanations for persistent problems are unrealistic patient expectations, comorbidities, somatic symptoms, related disorders (Diagnostic and Statistical Manual of Mental Disorders [DSM-5]), autoimmune neuroinflammation, and low tissue T3. There is fair circumstantial evidence for the latter cause (tissue and specifically brain T3 content is normalized by T4+T3, not by T4 alone), but the other causes are viewed as more relevant in current practice. This might be related to the 'hype' that has emerged surrounding T4+T3 therapy. Although more and better-designed trials are needed to validate the efficacy of T4+T3 combination, the management of persistent symptoms should also be directed towards alternative causes. Improving the doctor-patient relationship and including more and better information is crucial. For example, dissatisfaction with the outcomes of T4 treatment for subclinical hypothyroidism can be anticipated as recent trials have demonstrated that LT4 is hardly effective in improving symptoms associated with subclinical hypothyroidism.
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Affiliation(s)
- Wilmar M Wiersinga
- Department of Endocrinology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam, the Netherlands
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16
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Dal Maso L, Panato C, De Paoli A, Mattioli V, Serraino D, Elisei R, Zoppini G, Gobitti C, Borsatti E, Di Felice E, Falcini F, Ferretti S, Francisci S, Giorgi Rossi P, Guzzinati S, Mazzoleni G, Pierannunzio D, Piffer S, Vaccarella S, Vicentini M, Zorzi M, Franceschi S, Fedeli U. Trends in thyroid function testing, neck ultrasound, thyroid fine needle aspiration, and thyroidectomies in North-eastern Italy. J Endocrinol Invest 2021; 44:1679-1688. [PMID: 33460012 PMCID: PMC8285305 DOI: 10.1007/s40618-020-01475-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/24/2020] [Indexed: 11/04/2022]
Abstract
PURPOSE Evidence of an increased diagnostic pressure on thyroid has emerged over the past decades. This study aimed to provide estimates of a wide spectrum of surveillance indicators for thyroid dysfunctions and diseases in Italy. METHODS A population-based study was conducted in North-eastern Italy, including 11.7 million residents (20% of the total Italian population). Prescriptions for TSH testing, neck ultrasound or thyroid fine needle aspiration (FNA), surgical procedures, and drugs for hypo- or hyperthyroidism were extracted from regional health databases. Proportions and rates of selected examinations were calculated from 2010 to 2017, overall and by sex, calendar years, age, and region. RESULTS Between 2010 and 2017 in North-eastern Italy, 24.5% of women and 9.8% of men received at least one TSH test yearly. In 2017, 7.1% of women and 1.5% of men were prescribed drugs for thyroid dysfunction, 94.6% of whom for hypothyroidism. Neck ultrasound examinations were performed yearly in 6.9% of women and 4.6% of men, with a nearly two-fold variation between areas. Thyroid FNA and thyroidectomies were three-fold more frequent in women (394 and 85 per 100,000) than in men (128 and 29 per 100,000) with a marked variation between areas. Both procedures decreased consistently after 2013. CONCLUSIONS The results of this population-based study describe recent variations over time and between surrounding areas of indicators of 'diagnostic pressure' on thyroid in North-eastern Italy. These results emphasize the need to harmonize practices and to reduce some procedures (e.g., neck ultrasound and total thyroidectomies) in certain areas.
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Affiliation(s)
- L Dal Maso
- Cancer Epidemiology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Via Franco Gallini 2, 33081, Aviano, PN, Italy.
| | - C Panato
- Cancer Epidemiology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Via Franco Gallini 2, 33081, Aviano, PN, Italy
| | - A De Paoli
- Epidemiological Department, Azienda Zero, Via J. Avanzo, 35, 35132, Padua, Italy
| | - V Mattioli
- Cancer Epidemiology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Via Franco Gallini 2, 33081, Aviano, PN, Italy
| | - D Serraino
- Cancer Epidemiology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Via Franco Gallini 2, 33081, Aviano, PN, Italy
| | - R Elisei
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - G Zoppini
- Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Hospital Trust of Verona, Verona, Italy
| | - C Gobitti
- Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081, Aviano, Italy
| | - E Borsatti
- Nuclear Medicine Unit, CRO Aviano National Cancer Institute, Via Franco Gallini, 2, 33081, Aviano, Italy
| | - E Di Felice
- Authority for Healthcare and Welfare, Emilia Romagna Regional Health Service, Bologna, Italy
| | - F Falcini
- Romagna Cancer Registry, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), IRCCS, Meldola, Italy
- Azienda Usl della Romagna, Forlì, Italy
| | - S Ferretti
- Ferrara Cancer Registry, University of Ferrara, Azienda USL Ferrara, Ferrara, Italy
| | - S Francisci
- National Centre for Disease Prevention and Health Promotion, National Institute of Health, Rome, Italy
| | - P Giorgi Rossi
- Reggio Emilia Cancer Registry, Epidemiology Unit, AUSL ASMN-IRCCS, Azienda USL di Reggio Emilia, Reggio Emilia, Italy
| | - S Guzzinati
- Epidemiological Department, Azienda Zero, Via J. Avanzo, 35, 35132, Padua, Italy
| | | | - D Pierannunzio
- National Centre for Disease Prevention and Health Promotion, National Institute of Health, Rome, Italy
| | - S Piffer
- Trento Province Cancer Registry, Unit of Clinical Epidemiology, Trento, Italy
| | - S Vaccarella
- Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France
| | - M Vicentini
- Reggio Emilia Cancer Registry, Epidemiology Unit, AUSL ASMN-IRCCS, Azienda USL di Reggio Emilia, Reggio Emilia, Italy
| | - M Zorzi
- Epidemiological Department, Azienda Zero, Via J. Avanzo, 35, 35132, Padua, Italy
| | - S Franceschi
- Cancer Epidemiology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Via Franco Gallini 2, 33081, Aviano, PN, Italy
| | - U Fedeli
- Epidemiological Department, Azienda Zero, Via J. Avanzo, 35, 35132, Padua, Italy.
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Razvi S, Arnott B, Teare D, Hiu S, O'Brien N, Pearce SH. Multinational Survey of Treatment Practices of Clinicians Managing Subclinical Hypothyroidism in Older People in 2019. Eur Thyroid J 2021; 10:330-338. [PMID: 34395305 PMCID: PMC8314758 DOI: 10.1159/000509228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 06/08/2020] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND International societies have recommended that levothyroxine should not routinely be prescribed in older individuals for the management of mild subclinical hypothyroidism (SCH). However, it is unknown whether clinicians managing people with SCH are either aware of or adhere to these guidelines. METHODS A web-based survey of members of several international thyroid associations and general practitioners in North-East England was conducted. Respondents were presented with a vignette of an 80-year-old gentleman with mild persistent SCH experiencing tiredness. Multivariable logistic regression analyses were performed to evaluate predictors of awareness of guidelines and responses to treatment. RESULTS The survey response rate was 21.9% (565/2,583). Only 7.6% of clinicians were unaware of guidelines regarding management of SCH in older people. Twenty percent of clinicians stated that they would treat the older patient with mild SCH, whereas 13% were unsure. Clinicians from North America were more likely to treat the older person with mild SCH than clinicians from elsewhere (OR 2.24 [1.25-3.98]). Likewise, non-endocrinologists were also more likely than endocrinologists to treat the older person with mild SCH (OR 3.26 [1.45-6.47]). CONCLUSION The majority of clinicians are aware of guidelines regarding management of SCH in older individuals. However, a considerable proportion of clinicians would still treat an older person with non-specific symptoms and mild SCH. These guidelines need to be disseminated more widely and more research is required to understand barriers to adherence to international recommendations.
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Affiliation(s)
- Salman Razvi
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
- *Salman Razvi, Senior Lecturer and Consultant Endocrinologist, Institute of Genetic Medicine, Central Parkway, Newcastle upon Tyne NE1 3BZ (UK),
| | - Bronia Arnott
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Dawn Teare
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Shaun Hiu
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Nicki O'Brien
- Department of Psychology, Northumbria University, Newcastle upon Tyne, United Kingdom
| | - Simon H. Pearce
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
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Leng O, Razvi S. Treatment of subclinical hypothyroidism: assessing when treatment is likely to be beneficial. Expert Rev Endocrinol Metab 2021; 16:73-86. [PMID: 32216473 DOI: 10.1080/17446651.2020.1738924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 03/03/2020] [Indexed: 12/14/2022]
Abstract
Introduction: Subclinical hypothyroidism (SCH) is a common condition diagnosed in up to 16% of the population. SCH is diagnosed when serum TSH is high and circulating thyroid hormones are within the reference range. SCH is considered to be a mild form of thyroid failure by some due to the log-linear relationship between TSH and thyroid hormones. Nevertheless, it is unclear whether the treatment of SCH with thyroid hormones is beneficial, and hence, it is not surprising that expert opinions and recommendations from societies differ in their opinions on how best to manage SCH.Areas covered: This article reviews the currently available evidence pertaining to SCH and provides recommendations as to when treatment of SCH should be considered. An electronic search of PubMed from 1970 to 2019 was performed and systematically reviewed studies assessing the effects of treatment in SCH. The main areas that are considered are the effects of treatment on symptoms and quality of life, and important clinical consequences including psychocognitive outcomes and cardiovascular events.Expert opinion: Treatment of SCH with thyroid hormones is debated and the current literature in this area lacks clarity. We provide an evidence-based recommendation for when treatment of SCH with thyroid hormones should be considered.
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Affiliation(s)
- Owain Leng
- Department of Endocrinology, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Salman Razvi
- Department of Endocrinology, Gateshead Health NHS Foundation Trust, Gateshead, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
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Gong IY, Atzema CL, Lega IC, Austin PC, Na Y, Rochon PA, Lipscombe LL. Levothyroxine dose and risk of atrial fibrillation: A nested case-control study. Am Heart J 2021; 232:47-56. [PMID: 33022231 DOI: 10.1016/j.ahj.2020.09.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 09/24/2020] [Indexed: 12/29/2022]
Abstract
Contemporary data on the effect of levothyroxine dose on the occurrence of atrial fibrillation (AF) are lacking, particularly in the older population. Our objective was to determine the effect of cumulative levothyroxine exposure on risk of AF and ischemic stroke in older adults. METHODS We conducted a population-based observational study using health care databases from Ontario, Canada. We identified adults aged ≥66 years without a history of AF who filled at least 1 levothyroxine prescription between April 1, 2007, and March 31, 2016. Cases were defined as cohort members who had incident AF (emergency room visit or hospitalization) between the date of first levothyroxine prescription and December 31, 2017. Index date was date of AF. Cases were matched with up to 5 controls without AF on the same index date. Secondary outcome was ischemic stroke. Cumulative levothyroxine exposure was estimated based on total milligrams of levothyroxine dispensed in the year prior to index date. Using nested case-control approach, we compared outcomes between older adults who received high (≥0.125 mg/d), medium (0.075-0.125 mg/d), or low (0-0.075 mg/d) cumulative levothyroxine dose. We compared outcomes between current, recent past, and remote past levothyroxine use. RESULTS Of 183,360 older adults treated with levothyroxine (mean age 82 years; 72% women), 30,560 (16.1%) had an episode of AF. Compared to low levothyroxine exposure, high and medium exposure was associated with significantly increased risk of AF after adjustment for covariates (adjusted odds ratio [aOR] 1.29, 95% CI 1.23-1.35; aOR 1.08, 95% CI 1.04-1.11; respectively). No association was observed between levothyroxine exposure and ischemic stroke. Compared with current levothyroxine use, older adults with remote levothyroxine use had lower risks of AF (aOR 0.56, 95% CI 0.52-0.59) and ischemic stroke (aOR 0.61, 95% CI 0.56-0.67). CONCLUSIONS Among older persons treated with levothyroxine, levothyroxine at doses >0.075 mg/d is associated with an increased risk of AF compared to lower exposure.
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Galoppo GH, Tavalieri YE, Schierano-Marotti G, Osti MR, Luque EH, Muñoz-de-Toro MM. Long-term effects of in ovo exposure to an environmentally relevant dose of atrazine on the thyroid gland of Caiman latirostris. ENVIRONMENTAL RESEARCH 2020; 186:109410. [PMID: 32283336 DOI: 10.1016/j.envres.2020.109410] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 03/16/2020] [Accepted: 03/17/2020] [Indexed: 06/11/2023]
Abstract
The increased incidence of human thyroid disorders, particularly in women, suggests that the exposure to endocrine-disrupting compounds (EDCs) together with sex-related factors could play a role in thyroid dysregulation. Since the herbicide atrazine (ATZ) is an environmental EDC suspected to behave as a thyroid disruptor, and Caiman latirostris is a crocodilian species highly sensitive to endocrine disruption that can be exposed to ATZ, this study aimed to describe the histoarchitecture and sexually dimorphic features of the thyroid gland of C. latirostris, and to determine the long-term effects of in ovo exposure to an environmentally relevant dose of ATZ (0.2 ppm) on its thyroid gland and growth. Control caimans showed no sexual dimorphisms. In contrast, ATZ-exposed caimans showed altered embryo growth but an unaltered temporal pattern of development and a sexually dimorphic response in the body condition index growth curves postnatally, which suggests a female-related increase in fat storage. Besides, both male and female exposed caimans showed increases in the size of the thyroid stromal compartment, content of interstitial collagen, and follicular hyperplasia, and decreases in the expression of androgen receptor in the follicular epithelium. ATZ-exposed females, but not males, also showed evidences of thyroid enlargement, colloid depletion, increased follicular epithelial height and increased presence of microfollicular structures. Our results demonstrate that prenatal exposure of caimans to ATZ causes thyroid disruption and that females were more vulnerable to ATZ than males. The effects were organizational and observed long after exposure ended. These findings alert on ATZ side-effects on the growth, metabolism, reproduction and development of non-target exposed organisms, particularly females.
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Affiliation(s)
- Germán Hugo Galoppo
- Instituto de Salud y Ambiente del Litoral (ISAL), Universidad Nacional del Litoral - Consejo Nacional de Investigaciones Científicas y Técnicas, Ciudad Universitaria s/n, 4to piso, CP3000, Santa Fe, Argentina; Cátedra de Patología Humana, Facultad de Bioquímica y Ciencias Biológicas, Universidad Nacional del Litoral, Ciudad Universitaria s/n, 4to piso, CP3000, Santa Fe, Argentina.
| | - Yamil Ezequiel Tavalieri
- Instituto de Salud y Ambiente del Litoral (ISAL), Universidad Nacional del Litoral - Consejo Nacional de Investigaciones Científicas y Técnicas, Ciudad Universitaria s/n, 4to piso, CP3000, Santa Fe, Argentina; Cátedra de Patología Humana, Facultad de Bioquímica y Ciencias Biológicas, Universidad Nacional del Litoral, Ciudad Universitaria s/n, 4to piso, CP3000, Santa Fe, Argentina.
| | - Gonzalo Schierano-Marotti
- Instituto de Salud y Ambiente del Litoral (ISAL), Universidad Nacional del Litoral - Consejo Nacional de Investigaciones Científicas y Técnicas, Ciudad Universitaria s/n, 4to piso, CP3000, Santa Fe, Argentina.
| | - Mario Raúl Osti
- Cátedra de Patología Humana, Facultad de Bioquímica y Ciencias Biológicas, Universidad Nacional del Litoral, Ciudad Universitaria s/n, 4to piso, CP3000, Santa Fe, Argentina.
| | - Enrique Hugo Luque
- Instituto de Salud y Ambiente del Litoral (ISAL), Universidad Nacional del Litoral - Consejo Nacional de Investigaciones Científicas y Técnicas, Ciudad Universitaria s/n, 4to piso, CP3000, Santa Fe, Argentina.
| | - Mónica Milagros Muñoz-de-Toro
- Instituto de Salud y Ambiente del Litoral (ISAL), Universidad Nacional del Litoral - Consejo Nacional de Investigaciones Científicas y Técnicas, Ciudad Universitaria s/n, 4to piso, CP3000, Santa Fe, Argentina; Cátedra de Patología Humana, Facultad de Bioquímica y Ciencias Biológicas, Universidad Nacional del Litoral, Ciudad Universitaria s/n, 4to piso, CP3000, Santa Fe, Argentina.
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To Treat or Not to Treat Subclinical Hypothyroidism, What Is the Evidence? ACTA ACUST UNITED AC 2020; 56:medicina56010040. [PMID: 31963883 PMCID: PMC7022757 DOI: 10.3390/medicina56010040] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 01/13/2020] [Accepted: 01/14/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE levothyroxine prescriptions have increased remarkably during the last decade, and it is most likely to be prescribed in subclinical hypothyroidism. The aim of this review was to present data on when levothyroxine treatment should be initiated, and the effects of treatment in subclinical hypothyroidism on symptoms such as weight, quality of life, vitality, cognition, and cardiovascular disease. We also discuss evidence for different thyroid-hormone medications. In addition, the option to withhold medication when there is uncertain diagnosis or lack of clinical improvement is discussed. METHODS a literature search in PubMed on the term "treatment of subclinical hypothyroidism" in combination with "quality of life", "weight", "cognition", and "cerebrovascular disease". RESULTS current research supports that levothyroxine should be initiated in patients with a thyroid stimulating hormone (TSH) >10 mIU/L. Treatment for hypothyroidism is becoming more frequent. Symptoms related to vitality, weight, and quality of life in subclinical disease often persist with levothyroxine treatment, and other causes should be explored. Patients with cardiovascular-risk factors may benefit from treatment, especially younger patients. Caution is necessary when treating elderly subjects with levothyroxine. CONCLUSION lifelong treatment with levothyroxine should normally only be considered in manifest hypothyroidism. However, in subclinical hypothyroidism with a TSH >10 mIU/L, therapy is indicated. In milder subclinical forms, a wait-and-see strategy is advocated to see if normalization occurs. Subgroups with cardiovascular risk and subclinical hypothyroidism may benefit from levothyroxine therapy.
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Negro R, Attanasio R, Nagy EV, Papini E, Perros P, Hegedüs L. Use of Thyroid Hormones in Hypothyroid and Euthyroid Patients; the 2019 Italian Survey. Eur Thyroid J 2020; 9:25-31. [PMID: 32071899 PMCID: PMC7024857 DOI: 10.1159/000502057] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 07/09/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The incidence and prevalence of hypothyroidism are increasing and the threshold for the treatment of hypothyroid as well as individuals without evident thyroid disease with thyroid hormone is declining. OBJECTIVE To investigate endocrinologists' use of thyroid hormones in hypothyroid and euthyroid patients in Italy, a country where different formulations of levothyroxine (LT4; tablet, liquid solution and soft-gel capsule) are available on the market. METHODS Members of the Associazione Medici Endocrinologi (Italian Association of Clinical Endocrinologists) were invited to participate in a web-based survey investigating the topic. RESULTS A total of 797 of 2,028 (39.3%) members completed all the sections of the survey; 98.7% declared that the treatment of choice for hypothyroidism is LT4. A significant minority (37.3%) indicated that LT4 may be considered in infertile euthyroid women seeking pregnancy and harbouring positive thyroperoxidase antibodies (TPOAb) and in goitre increasing in size (18.1%). LT4 + LT3 was considered by 43.2% for LT4-replaced patients and normal TSH, if they reported persistent symptoms. High percentages of respondents chose LT4 in a liquid solution or soft-gel capsules when taken together with other drugs interfering with LT4 absorption (81.8%), in patients with a history of celiac disease, malabsorption, lactose intolerance, intolerance to common excipients (96.6%), or unexplained poor biochemical control of hypothyroidism (74.4%), or in patients not able to adhere to ingesting LT4 fasted and/or separated from food/drink (98.9%). In total, 43.6% of responders would use LT4 in a liquid solution or soft-gel capsules for hypothyroid patients with biochemical euthyroidism on LT4, who had persistent symptoms. CONCLUSIONS The preferred treatment for hypothyroidism is LT4; LT3 + LT4 combination treatment is mainly considered in patients with persistent symptoms. A significant minority would offer LT4 to euthyroid women with positive TPOAb and infertility and to euthyroid patients with progressive simple goitre. Alternative LT4 formulations like liquid solution or soft-gel capsules are largely reserved for specific conditions (interfering drugs, actual or suspected malabsorption, inability to take LT4 in the fasting state, unexplained poor biochemical control of hypothyroidism).
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Affiliation(s)
- Roberto Negro
- Division of Endocrinology, V. Fazzi Hospital, Lecce, Italy
- *Roberto Negro, Division of Endocrinology, V. Fazzi Hospital, Piazza Muratore, IT–73100 Lecce (Italy), E-Mail
| | | | - Endre V. Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Enrico Papini
- Department of Endocrinology and Metabolism, Ospedale Regina Apostolorum, Rome, Italy
| | - Petros Perros
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Laszlo Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
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Jonklaas J, DeSale S. Levothyroxine prescriptions trends may indicate a downtrend in prescribing. Ther Adv Endocrinol Metab 2020; 11:2042018820920551. [PMID: 32489581 PMCID: PMC7238309 DOI: 10.1177/2042018820920551] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 03/27/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND There has been a trend for increased prescribing of levothyroxine (LT4) in many countries, including the United States. Several different factors have been suggested to be the cause of this practice pattern. These factors include increased size of the United States population, more diagnosis of hypothyroidism, more treatment of minimally elevated thyroid-stimulating hormone (TSH) levels, more use of LT4 in older patients, and use of LT4 for treatment of euthyroid patients with non-thyroidal conditions. METHODS The electronic databases of the MedStar Health system operating in the Washington, DC and Maryland areas were interrogated to determine the number of patients who were being prescribed levothyroxine during the time period 2008-2016, the number of prescriptions supplied to these individuals, the associated diagnosis, and whether the prescriptions were new or existing prescriptions. Regression analyses were also performed to determine the prescribing trends during this time period. RESULTS Although the annual number of levothyroxine prescriptions increased during this time period, the percentage of patients in the database receiving levothyroxine for hypothyroidism initially increased and then decreased over time (2.5% to 3.2% to 2.5%). The percentage of prescriptions written for patients who did not appear to carry a diagnosis of hypothyroidism steadily declined (3.5% to 1.0%). Although the percentage of patients with existing prescriptions for hypothyroidism initially increased and then were maintained at steady levels (1.4% to 2.4% to 2.2%), a smaller percentage of patients with existing prescriptions were documented over time when there was no diagnosis of hypothyroidism (1.45% to 0.89%). The percentage of patients with new prescriptions declined over time for all groups. The number of annual 90-day period prescriptions increased over the time for patients with a diagnosis of hypothyroidism, but down-trended starting over the latter part of the time period for those patients without a diagnosis of hypothyroidism. CONCLUSION Taken together, these data suggest that there may be a stabilization, and even a down-trend in levothyroxine prescribing with the MedStar system. The decrease in levothyroxine prescribing appears to be accounted for by less use of levothyroxine without an established diagnosis of hypothyroidism, and less initiation of new prescriptions.
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Affiliation(s)
| | - Sameer DeSale
- Department of Biostatistics and Biomedical
Informatics, MedStar Health Research Institute, Washington, DC, USA
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Razvi S, Ryan V, Ingoe L, Pearce SH, Wilkes S. Age-Related Serum Thyroid-Stimulating Hormone Reference Range in Older Patients Treated with Levothyroxine: A Randomized Controlled Feasibility Trial (SORTED 1). Eur Thyroid J 2020; 9:40-48. [PMID: 32071901 PMCID: PMC7024859 DOI: 10.1159/000504047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 10/11/2019] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Serum thyroid-stimulating hormone (TSH) increases with age but target TSH is similar in younger and older hypothyroid patients on treatment. It is unknown if quality of life (QoL), hypothyroid symptoms and cardiovascular risk factors change in older hypothyroid patients treated to an age-appropriate reference range. OBJECTIVE To assess if a higher target serum TSH of 4.01-8.0 mU/L is feasible in, and acceptable to, older treated hypothyroid patients. METHODS A single-blind (participant) randomised controlled feasibility trial involving 48 hypothyroid patients aged ≥80 years on established and stable levothyroxine (LT4) therapy with serum TSH levels within the standard reference range (0.4-4.0 mU/L) was conducted. Standard (0.4-4.0 mU/L) or higher (4.1-8.0 mU/L) TSH target (standard TSH [ST] or higher TSH [HT] groups) LT4 for 24 weeks was administered. The outcome measures evaluated were thyroid function tests, QoL, hypothyroid symptoms, cardiovascular risk factors and serum marker of bone resorption in participants that completed the trial (n = 21/24 ST group, n = 19/24 HT group). RESULTS At 24 weeks, in the ST and HT groups, respectively, median (interquartile range) serum TSH was 1.25 (0.76-1.72) and 5.50 (4.05-9.12) mU/L, mean (± SD) free thyroxine (FT4) was 19.4 ± 3.5 and 15.9 ± 2.4 pmol/L, and daily LT4 dose was 82.1 ± 26.4 and 59.2 ± 23.9 µg. There was no suggestion of adverse impact of a higher serum TSH in the HT group with regard to any of the outcomes assessed. CONCLUSIONS In hypothyroid patients aged ≥80 years on LT4 therapy for 24 weeks, there was no evidence that a higher target serum TSH was associated with an adverse impact on patient reported outcomes, cardiovascular risk factors or bone resorption marker over 24 weeks. Longer-term trials assessing morbidity and mortality outcomes and health-utility in this age group are feasible and should be performed.
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Affiliation(s)
- Salman Razvi
- Institute of Genetic Medicine, Newcastle University, Newcastle, United Kingdom
- Department of Endocrinology, Gateshead Health NHS Foundation Trust, Gateshead, United Kingdom
- *Dr. Salman Razvi, Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne NE1 4LB (UK), E-Mail
| | - Vicky Ryan
- Institute of Health and Society, Newcastle University, Newcastle, United Kingdom
| | - Lorna Ingoe
- Department of Endocrinology, Gateshead Health NHS Foundation Trust, Gateshead, United Kingdom
- Department of Endocrinology, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, United Kingdom
| | - Simon H. Pearce
- Institute of Genetic Medicine, Newcastle University, Newcastle, United Kingdom
- Department of Endocrinology, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, United Kingdom
| | - Scott Wilkes
- School of Medicine, University of Sunderland, Sunderland, United Kingdom
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Challenges in Interpreting Thyroid Stimulating Hormone Results in the Diagnosis of Thyroid Dysfunction. J Thyroid Res 2019; 2019:4106816. [PMID: 31662841 PMCID: PMC6778876 DOI: 10.1155/2019/4106816] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 09/01/2019] [Indexed: 12/16/2022] Open
Abstract
The pituitary hormone, thyrotropin (TSH), is regarded as the primary biomarker for evaluating thyroid function and is useful in guiding treatment with levothyroxine for patients with hypothyroidism. The amplified response of TSH to slight changes in thyroid hormone levels provides a large and easily measured signal in the routine care setting. Laboratories provide reference ranges with upper and lower cutoffs for TSH to define normal thyroid function. The upper limit of the range, used to diagnose subclinical (mild) hypothyroidism, is itself a matter for debate, with authoritative guidelines recommending treatment to within the lower half of the range. Concomitant diseases, medications, supplements, age, gender, ethnicity, iodine status, time of day, time of year, autoantibodies, heterophilic antibodies, smoking, and other factors influence the level of TSH, or the performance of current TSH assays. The long-term prognostic implications of small deviations of TSH from the reference range are unclear. Correction of TSH to within the reference range does not always bring thyroid and other biomarkers into range and will not always resolve the patient's symptoms. Overt hypothyroidism requires intervention with levothyroxine. It remains important that physicians managing a patient with symptoms suggestive of thyroid disease consider all of the patient's relevant disease, lifestyle, and other factors before intervening on the basis of a marginally raised TSH level alone. Finally, these limitations of TSH testing mitigate against screening the population for the undoubtedly substantial prevalence of undiagnosed thyroid disease, until appropriately designed randomised trials have quantified the benefits and harms from this approach.
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Thayakaran R, Adderley NJ, Sainsbury C, Torlinska B, Boelaert K, Šumilo D, Price M, Thomas GN, Toulis KA, Nirantharakumar K. Thyroid replacement therapy, thyroid stimulating hormone concentrations, and long term health outcomes in patients with hypothyroidism: longitudinal study. BMJ 2019; 366:l4892. [PMID: 31481394 PMCID: PMC6719286 DOI: 10.1136/bmj.l4892] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To explore whether thyroid stimulating hormone (TSH) concentration in patients with a diagnosis of hypothyroidism is associated with increased all cause mortality and a higher risk of cardiovascular disease and fractures. DESIGN Retrospective cohort study. SETTING The Health Improvement Network (THIN), a database of electronic patient records from UK primary care. PARTICIPANTS Adult patients with incident hypothyroidism from 1 January 1995 to 31 December 2017. EXPOSURE TSH concentration in patients with hypothyroidism. MAIN OUTCOME MEASURES Ischaemic heart disease, heart failure, stroke/transient ischaemic attack, atrial fibrillation, any fractures, fragility fractures, and mortality. Longitudinal TSH measurements from diagnosis to outcomes, study end, or loss to follow-up were collected. An extended Cox proportional hazards model with TSH considered as a time varying covariate was fitted for each outcome. RESULTS 162 369 patients with hypothyroidism and 863 072 TSH measurements were included in the analysis. Compared with the reference TSH category (2-2.5 mIU/L), risk of ischaemic heart disease and heart failure increased at high TSH concentrations (>10 mIU/L) (hazard ratio 1.18 (95% confidence interval 1.02 to 1.38; P=0.03) and 1.42 (1.21 to 1.67; P<0.001), respectively). A protective effect for heart failure was seen at low TSH concentrations (hazard ratio 0.79 (0.64 to 0.99; P=0.04) for TSH <0.1 mIU/L and 0.76 (0.62 to 0.92; P=0.006) for 0.1-0.4 mIU/L). Increased mortality was observed in both the lowest and highest TSH categories (hazard ratio 1.18 (1.08 to 1.28; P<0.001), 1.29 (1.22 to 1.36; P<0.001), and 2.21 (2.07 to 2.36; P<0.001) for TSH <0.1 mIU/L, 4-10 mIU/L, and >10 mIU/L. An increase in the risk of fragility fractures was observed in patients in the highest TSH category (>10 mIU/L) (hazard ratio 1.15 (1.01 to 1.31; P=0.03)). CONCLUSIONS In patients with a diagnosis of hypothyroidism, no evidence was found to suggest a clinically meaningful difference in the pattern of long term health outcomes (all cause mortality, atrial fibrillation, ischaemic heart disease, heart failure, stroke/transient ischaemic attack, fractures) when TSH concentrations were within recommended normal limits. Evidence was found for adverse health outcomes when TSH concentration is outside this range, particularly above the upper reference value.
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Affiliation(s)
- Rasiah Thayakaran
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- Joint first authors
| | - Nicola J Adderley
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- Joint first authors
| | - Christopher Sainsbury
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Barbara Torlinska
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Kristien Boelaert
- Institute of Metabolism and Systems Research, Edgbaston, Birmingham B15 2TT, UK
- Institute of Translational Medicine, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Edgbaston, Birmingham B15 2TT, UK
| | - Dana Šumilo
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Malcolm Price
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - G Neil Thomas
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Konstantinos A Toulis
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- Department of Endocrinology, 424 General Army Training Hospital, Thessaloniki, Greece
| | - Krishnarajah Nirantharakumar
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Edgbaston, Birmingham B15 2TT, UK
- Health Data Research UK Midlands, Institute of Translational Medicine, Edgbaston, Birmingham B15 2TH, UK
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Hoermann R, Midgley JEM, Larisch R, Dietrich JW. Individualised requirements for optimum treatment of hypothyroidism: complex needs, limited options. Drugs Context 2019; 8:212597. [PMID: 31516533 PMCID: PMC6726361 DOI: 10.7573/dic.212597] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 07/09/2019] [Accepted: 07/15/2019] [Indexed: 12/21/2022] Open
Abstract
Levothyroxine (LT4) therapy has a long history, a well-defined pharmacological profile and a favourable safety record in the alleviation of hypothyroidism. However, questions remain in defining the threshold for the requirement of treatment in patients with subclinical hypothyroidism, assessing the dose adequacy of the drug, and selecting the best treatment mode (LT4 monotherapy versus liothyronine [LT3]/LT4 combinations) for subpopulations with persisting complaints. Supplied as a prodrug, LT4 is enzymatically converted into the biologically more active thyroid hormone, triiodothyronine (T3). Importantly, tetraiodothyronine (T4) to T3 conversion efficiency may be impaired in patients receiving LT4, resulting in a loss of thyroid-stimulating hormone (TSH)-mediated feed-forward control of T3, alteration of the interlocking equilibria between serum concentrations of TSH, free thyroxine (FT4), and free triiodothyonine (FT3), and a decrease in FT3 to FT4 ratios. This downgrades the value of the TSH reference system derived in thyroid health for guiding the replacement dose in the treatment situation. Individualised conditionally defined setpoints may therefore provide appropriate biochemical targets to be clinically tested, together with a stronger focus on clinical presentation and future endpoint markers of tissue thyroid state. This cautionary note encompasses the use of aggregated statistical data from clinical trials which are not safely applicable to the individual level of patient care under these circumstances.
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Affiliation(s)
- Rudolf Hoermann
- Department for Nuclear Medicine, Klinikum Lüdenscheid, Paulmannshöherstr. 14, 58515 Lüdenscheid, Germany
| | | | - Rolf Larisch
- Department for Nuclear Medicine, Klinikum Lüdenscheid, Paulmannshöherstr. 14, 58515 Lüdenscheid, Germany
| | - Johannes W Dietrich
- Medical Department I, Endocrinology and Diabetology, Bergmannsheil University Hospitals, Ruhr University of Bochum, Buerkle-de-la-Camp-Platz 1, 44789 Bochum, Germany.,Ruhr Center for Rare Diseases (CeSER), Ruhr University of Bochum and Witten/Herdecke University, Alexandrinenstr. 5, 44791 Bochum, Germany
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Jonklaas J, Razvi S. Reference intervals in the diagnosis of thyroid dysfunction: treating patients not numbers. Lancet Diabetes Endocrinol 2019; 7:473-483. [PMID: 30797750 DOI: 10.1016/s2213-8587(18)30371-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 12/05/2018] [Accepted: 12/12/2018] [Indexed: 12/20/2022]
Abstract
Although assigning a diagnosis of thyroid dysfunction appears quite simple, this is often not the case. Issues that make it unclear whether thyroid function is normal include transient changes in thyroid parameters, inter-individual and intra-individual differences in thyroid parameters, age-related differences, and ethnic variations. In addition, a statistically calculated distribution of thyroid analytes does not necessarily coincide with intervals or cutoffs that have predictive value for beneficial or adverse health outcomes. Based on current clincial trial data, it is unclear which individuals with mild thyroid-stimulating hormone elevations will benefit from levothyroxine treatment. For example, only a small number of patients with thyroid-stimulating hormone values of more than 10 mIU/L have been studied in a randomised manner. Even if therapy is initiated for abnormal thyroid function, not all treated individuals are maintained at the desired treatment target, and therefore might still be at risk. The consequence of this is that each patient's thyroid function needs to be assessed on an individual basis with the entire clinical picture in mind. Monitoring also needs to be vigilant, and the targets for treatment reassessed continually.
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Affiliation(s)
| | - Salman Razvi
- Department of Endocrinology, University of Newcastle, Newcastle, UK
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Abstract
BACKGROUND Both overt hypothyroidism as well as minor elevations of serum thyrotropin (TSH) levels associated with thyroid hormones within their respective reference ranges (termed subclinical hypothyroidism) are relatively common in older individuals. There is growing evidence that treatment of subclinical hypothyroidism may not be beneficial, particularly in an older person. These findings are relevant at a time when treatment with thyroid hormones is increasing and more than 10-15% of people aged over 80 years are prescribed levothyroxine replacement therapy. MAIN BODY The prevalence of hypothyroidism increases with age. However, the reference range for TSH also rises with age, as the population distribution of TSH concentration progressively rises with age. Furthermore, there is evidence to suggest that minor TSH elevations are not associated with important outcomes such as impaired quality of life, symptoms, cognition, cardiovascular events and mortality in older individuals. There is also evidence that treatment of mild subclinical hypothyroidism may not benefit quality of life and/or symptoms in older people. It is unknown whether treatment targets should be reset depending on the age of the patient. It is likely that some older patients with non-specific symptoms and incidental mild subclinical hypothyroidism may be treated with thyroid hormones and could potentially be harmed as a result. This article reviews the current literature pertaining to hypothyroidism with a special emphasis on the older individual and assesses the risk/benefit impact of contemporary management on outcomes in this age group. CONCLUSIONS Current evidence suggests that threshold for treating mild subclinical hypothyroidism in older people should be high. It is reasonable to aim for a higher TSH target in treated older hypothyroid patients as their thyroid hormone requirements may be lower. In addition, age-appropriate TSH reference ranges should be considered in the diagnostic pathway of identifying individuals at risk of developing hypothyroidism. Appropriately designed and powered randomised controlled trials are required to confirm risk/benefit of treatment of subclinical hypothyroidism in older people. Until the results of such RCTs are available to guide clinical management international guidelines should be followed that advocate a conservative policy in the management of mild subclinical hypothyroidism in older individuals.
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Affiliation(s)
- Owain Leng
- Department of Endocrinology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE1 4LP UK
| | - Salman Razvi
- Department of Endocrinology, Gateshead Health NHS Foundation Trust, Queen Elizabeth Hospital, Gateshead, Gateshead, NE9 6SX UK
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, NE1 3BZ UK
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Hoermann R, Midgley JEM, Larisch R, Dietrich JW. Functional and Symptomatic Individuality in the Response to Levothyroxine Treatment. Front Endocrinol (Lausanne) 2019; 10:664. [PMID: 31616383 PMCID: PMC6775211 DOI: 10.3389/fendo.2019.00664] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 09/13/2019] [Indexed: 12/12/2022] Open
Abstract
Background: For significant numbers of patients dissatisfied on standard levothyroxine (LT4) treatment for hypothyroidism, patient-specific responses to T4 could play a significant role. Aim: To assess response heterogeneity to LT4 treatment, identifying confounders and hidden clusters within a patient panel, we performed a secondary analysis using data from a prospective cross-sectional and retrospective longitudinal study. Methods: Multivariate and multivariable linear models adjusted for covariates (gender, age, and BMI) were stratified by disease-specific treatment indication. During follow-up, pooled observations were compared from the same patient presenting either with or without self-reported symptoms. Statistical analysis was extended to multilevel models to derive intra-class correlation coefficients and reliability measures during follow-up. Results: Equilibria between TSH, FT4, and FT3 serum concentrations in 342 patients were examined by treatment indication (benign goiter, autoimmune thyroiditis, thyroid carcinoma), consequently displaying complex interactive response patterns. Seventy-seven patients treated with LT4 and monitored for thyroid carcinoma presented, in association with changes in LT4 dose, either with hypothyroid symptoms or symptom-free. Significant biochemical differences appeared between the different presentations. Leveled trajectories by subject to relief from hypothyroid symptoms differed significantly, indicating distinct responses, and denying a single shared outcome. These were formally defined by a high coefficient of the intraclass correlation (ICC1, exceeding 0.60 in all thyroid parameters) during follow-up on multiple visits at the same LT4 dose, when lacking symptoms. The intra-personal clusters were clearly differentiated from random variability by random group resampling. Symptomatic change in these patients was strongly associated with serum FT3, but not with FT4 or TSH concentrations. In 25 patients transitioning from asymptomatic to symptomatically hyperthyroid, FT3 concentrations remained within the reference limits, whilst at the same time marked biochemical differences were apparent between the presentations. Conclusions: Considerable intra-individual clustering occurred in the biochemical and symptomatic responses to LT4 treatment, implying statistically multileveled response groups. Unmasking individual differences in the averaged treatment response hereby highlights clinically distinguishable subgroups within an indiscriminate patient panel. This, through well-designed larger clinical trials will better target the different therapeutic needs of individual patients.
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Affiliation(s)
- Rudolf Hoermann
- Department for Nuclear Medicine, Klinikum Lüdenscheid, Lüdenscheid, Germany
- *Correspondence: Rudolf Hoermann
| | | | - Rolf Larisch
- Department for Nuclear Medicine, Klinikum Lüdenscheid, Lüdenscheid, Germany
| | - Johannes W. Dietrich
- Medical Department I, Endocrinology and Diabetology, Bergmannsheil University Hospitals, Ruhr University of Bochum, Bochum, Germany
- Ruhr Center for Rare Diseases (CeSER), Ruhr University of Bochum and Witten/Herdecke University, Bochum, Germany
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