2013 ETA Guideline: Management of Subclinical Hypothyroidism

Levothyroxine therapy in thyroidectomized patients: ongoing challenges and controversies

This mini-review provides an update on the challenges and controversies surrounding levothyroxine therapy in thyroidectomized patients, following an extensive review on dosing strategies and available formulations. Despite efforts to establish an ideal dosage adjustment method, achieving optimal thyroid hormone replacement remains complex due to interindividual variations in the hypothalamic-pituitary-thyroid axis and the pharmacokinetic and pharmacodynamic limitations of exogenous levothyroxine. Additionally, this review highlights the importance of evaluating the risk-benefit ratio of levothyroxine therapy, particularly in the setting of TSH suppression, focusing on its effects on quality of life, bone metabolism, and cardiac rhythm. Levothyroxine-induced subclinical hyperthyroidism may contribute to an increased risk of atrial fibrillation and alterations in bone mineral density, with implications that remain a subject of debate. Given the incomplete replication of endogenous thyroid hormone action by levothyroxine monotherapy, a tailored therapeutic approach is crucial. Despite ongoing research, the optimal management of thyroidectomized patients continues to be an open issue.

Transarterial chemoembolization combined with tyrosine kinase inhibitors and/or immune checkpoint inhibitors induced hypothyroidism is associated with improved overall survival in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) treatments, including transarterial chemoembolization (TACE) and systemic therapies (tyrosine kinase inhibitors [TKIs]/immune checkpoint inhibitors [ICIs]) are linked to hypothyroidism. This study aims to elucidate the clinical significance of treatment-induced hypothyroidism within a real-world cohort. We enrolled 130 HCC patients with baseline thyroid function measurements, and stratified into two cohorts: TACE monotherapy (n = 50) or TACE combined with TKIs/ICIs (n = 80). Primary subclinical or obvious hypothyroidism patients have a serum thyroid-stimulating hormone (TSH) value exceeding the upper limit of the normal range (> 4.94 uIU/L) while thyroid free tetraiodothyronine levels are normal or low. Overall survival (OS) was evaluated via Kaplan-Meier and Cox proportional models. Mortality rate in the whole study population was 25% (13/52) in patients with hypothyroidism vs. 48.7% (38/78) in patients without hypothyroidism (P = 0.007). When using TACE combining TKIs and ICIs, the mortality rate of patients with hypothyroidism were less than that of patients without hypothyroidism (16% [4/25] vs. 50% [8/16], respectively; P = 0.02). For entire cohort, the median OS cutoff in patients with hypothyroidism reached 37.5 months, and median OS was 23.33 months in patients without hypothyroidism (P = 0.015). For patients treated with TACE combined with TKIs + ICIs, the median OS cutoff in patients with hypothyroidism was not reached. But it was longer than those without hypothyroidism where median OS was 22.54 months (P = 0.005). In univariate and multivariate analysis, cancer-specific mortality correlated with some factors including sex, drinking, and hypothyroidism in the whole population as well as subgroups received TACE only or combination. In all patients, after adjustment for confounding factors, drinking showed an increased risk of HCC mortality (HR: 1.94, 95% CI: 1.04-3.61, P = 0.038) versus nondrinkers. Additionally, smoking and higher Child-Pugh score marginally associated with HCC mortality at significance levels of P = 0.042 and P = 0.041, respectively. TACE combination therapy exhibited lower risk on HCC specific mortality than those treated by TACE monotherapy group (HR: 0.45, 95% CI: 0.26-0.82, P = 0.009) among all patients receiving these therapies. Hypothyroidism was inversely related to HCC mortality among the TACE combination patients' group (HR: 0.30, 95% CI: 0.13-0.68, P = 0.04). The result becomes more pronounced in HCCs also administered by TKIs and ICIs (HR: 0.14, 95% CI: 0.03-0.60, P = 0.009). Treatment-induced hypothyroidism is prevalent among HCC patients receiving TACE combined with TKIs/ICIs and is associated with improved survival, potentially reflecting immune activation. Further multinational studies are warranted to validate these observations across diverse ethnic populations and treatment protocols.

Is subclinical hypothyroidism associated with cardiovascular disease in the elderly?

Subclinical hypothyroidism (SCH) is diagnosed when thyroid function tests show that the serum thyrotropin (TSH) level is elevated and the serum free thyroxine (FT4) level is normal. SCH is mainly caused by Hashimoto's thyroiditis, the prevalence of which increases with aging. Recently, it has been revealed that SCH is associated with risk factors for cardiovascular diseases (CVDs), including atherosclerosis, dyslipidemia and hypertension, leading to cardiovascular morbidity and mortality. However, there are still controversies regarding the diagnosis and treatment of SCH in elderly patients. In this review, we present recent evidence regarding the relationship between SCH and CVD and treatment recommendations for SCH, especially in elderly patients. Studies have shown that SCH is associated with CVD and all-cause mortality. Patients aged less than 65 years showed significant associations of SCH with CVD risk and all-cause mortality, whereas patients aged 65 or older did not show such associations. It was shown that levothyroxine therapy was associated with lower all-cause mortality and cardiovascular mortality in younger SCH patients (<65-70 years) but not in SCH patients aged 65-70 years or older. In elderly SCH patients, levothyroxine treatment should be considered individually according to the patient's age, serum TSH level, hypothyroid symptoms, CVD risk and other comorbidities. To further elucidate the impact of SCH on CVD in elderly patients, studies should be conducted using age-specific reference ranges of results of thyroid function tests, focusing on elderly patients, specific serum TSH levels, thyroid antibody status and cardiovascular risk factors.

Incidence and risk factors for early thyroxin supplementation therapy after hemithyroidectomy for benign conditions in Europe. A Eurocrine® registry-based study

The incidence and risk factors of hypothyroidism after hemithyroidectomy (HT) remain poorly defined. Regarding its management, national or local policies may influence on early (first visit) prescription of replacement therapy (EPRT). Our aim was to identify factors influencing and explaining different prescription patterns across European countries. We conducted a retrospective, multicenter study using the Eurocrine® database, focusing on patients undergoing HT for histologically-proven benign conditions. Analyzed variables included the country where surgery was performed, as well as epidemiological, clinical, surgical and pathological data. The dependent variable was EPRT, assessed 30-45 days after surgery. Associations between qualitative variables and the likelihood of receiving EPRT were tested using Chi-square or Fisher's exact tests. A multivariate logistic regression model was developed to identify independent predictors. 14,484 patients undergoing HT between 2015 and 2022 were included. Median age was 52 years, and 11,345 (78.3%) were female. The most common indication for surgery was excluding malignancy in 7873 cases (54.3%). Overall, 4653 patients (32.1%) received EPRT, with significant variability among countries, ranging from 3 to 95%. Independent risk factors for EPRT included female sex, older age, malignancy and thyrotoxicosis as surgical indications, Bethesda III cytology, thyroiditis on histology, and the country where HT was performed. One-third of European patients undergoing HT for confirmed benign conditions required EPRT. That prescription was more likely among older patients, those with suspected malignancy or thyrotoxicosis as surgical indications, suspicious cytology, and thyroiditis on histology. Additionally, the country where surgery was done played a significant role.

Hashimoto's thyroiditis- What's in a name?

Hashimoto's thyroiditis (HT) is the most common autoimmune endocrine disease worldwide with an annual incidence of 0.3-1.5 per 1000 people and a prevalence of 8% of the general population. At least nine terms appear in the literature denoting HT, which are used as synonyms or are terms describing disorders closely related to HT. Moreover, the definitions of HT vary, and the role of several parameters in making a diagnosis remains unclear. Furthermore, the term "thyroiditis" is often used among experts to describe the triphasic evolution in thyroid status (thyrotoxicosis, hypothyroidism, and euthyroidism) that can occur not only after some forms of HT but also in other causes of thyroid inflammation. The present work proposes novel approaches for the nomenclature problems. Firstly, we should abandon the eponym "Hashimoto" in keeping with recent trends. The void left can be replaced by the terms "autoimmune thyroiditis" or "autoimmune thyroid disease", which are already in use. In communicating among ourselves and with patients, it is imperative and good practice to provide, whenever possible, context to these terms by specifying whether they apply to thyroid status, presence or absence of goiter, thyroid autoantibodies, imaging, cytology/histology, epidemiology, or etiology. Secondly, the considerable potential harm associated with treating euthyroid people with thyroid hormones could be curtailed by avoiding testing for thyroid autoantibodies or performing thyroid imaging in asymptomatic euthyroid patients following the current guidelines and by discouraging the use of the word "disease" when the evidence is based only on results of investigations, such as positive antibodies, or imaging.

Progression of Subclinical Hypothyroidism in a Mexican Public Hospital Population: A Retrospective Cohort Study

BACKGROUND AND AIM

Treatment of subclinical hypothyroidism (SCH) is controversial. The uncertainty of the levels of thyroid-stimulating hormone (TSH) that warrant treatment and the risk of progression to overt hypothyroidism may lead to overtreatment. This study aimed to assess the persistence of SCH and its short-term progression to overt hypothyroidism in patients referred to an outpatient endocrinology clinic in Southern Tamaulipas, Mexico, and to identify predictive factors for progression to overt hypothyroidism.

METHODS

This analytic, observational, and retrospective study analyzed records from 1100 patients at a Mexican public hospital between 2018 and 2019. Exclusion criteria included prior hypothyroidism, levothyroxine use, pregnancy, TSH ≥10.0 mIU/L, age <18 years, and non-completion of follow-up. A final sample of 222 patients with SCH (defined as TSH >4.2 and <10.0 mIU/L, with normal T4 levels) was followed for three months, assessing the regression, persistence, and progression of TSH levels. Statistical analyses included a chi-squared test and Student's t-test. Statistical significance was set at alpha=0.05.

RESULTS

The study included 181 (81.5%) females with a mean age of 49.7 years (±13.5). After three months, 158 (71.2%) patients regressed to euthyroidism, 47 (21.2%) remained subclinically hypothyroid, and 17 (7.6%) progressed to overt hypothyroidism. The highest progression rate to overt hypothyroidism (16.0%) was observed in patients with initial TSH levels >6.0 to ≤8.0 mIU/L (relative risk: 5.4; 95% confidence interval {CI}: 1.83-16.0, p<0.001). Mean baseline TSH levels were 6.57±1.11 mIU/L (95% CI: 6.00-7.15, p<0.001) in those who progressed to overt hypothyroidism. No association was observed between symptoms and disease progression.

CONCLUSION

Most patients with SCH regressed to an euthyroid state without treatment in the short term, supporting a monitoring-first approach.

Evaluation of the effect of subclinical hypothyroidism on retinal blood flow. OCT angiography study

PURPOSE

To evaluate retinal blood flow and retinal nerve fiber layer (RNFL) thickness in untreated subclinical hypothyroid patients by optical coherence tomography angiography (OCT-A).

METHODS

Forty-four eyes of 44 patients in the subclinical hypothyroidism group (SCHG) and 42 eyes of 42 healthy subjects in the control group (CG) were included in the study. Macular superficial retinal blood flow (SRBF), peripapillary RNFL thickness and optic nerve head cup to disk ratio (C/D) were measured and recorded by OCT angiography and compared between the patient and control groups. Correlation analysis between disease duration and SRBF and RNFL thickness was also performed.

RESULTS

Mean SRBF was 37.23 ± 2.11 in the SCH group and 38.45±1.20 in the control group. Mean SRBF was significantly lower in the SCH group (p=0.003). Mean Peripapillary RNFL thickness was 98.18±7.77 in the SCH group and 100.07 ± 7.71 in control group. Peripapillary RNFL thickness was not significantly different between groups (p=0.290). There was no significant difference in mean C/D between the groups (p=0.708). Correlation analysis showed a moderate negative correlation between duration of disease diagnosis and SRBF in the SCH group (p<0.001, r=-0.564). There was also a weak to moderate negative correlation between disease duration and RNFL thickness in SCH group (p=0.002, r=-0.489).

CONCLUSIONS

A reduction in SRBF was observed in patients with subclinical hypothyroidism. Additionally, a negative correlation was identified between disease duration and RNFL thickness. Patients with subclinical hypothyroidism should be monitored for potential retinal vascular disease and the development of normotensive glaucoma.

Prevalence of subclinical hypothyroidism in polycystic ovary syndrome and its impact on insulin resistance: a systematic review and meta-analysis

BACKGROUND

Although recent studies indicate a high prevalence of subclinical hypothyroidism (SCH) in women with polycystic ovary syndrome (PCOS), the reported prevalence rates vary widely. Therefore, we conducted this study to estimate the pooled prevalence of SCH among women with PCOS. Additionally, emerging evidence suggests that SCH may negatively impact insulin resistance in PCOS. Thus, we examined its effect on insulin resistance indices as our secondary objective.

METHODS

We searched PubMed, Web of Science, Scopus, and Embase from their inception to February 25, 2024. Observational studies reporting the prevalence of SCH among women with PCOS were included. Joanna Briggs Institute's (JBI) critical appraisal checklist for prevalence studies was adopted for the risk of bias assessment. The random-effects model was employed to estimate the pooled prevalence with its 95% confidence intervals (CI). The weighted mean difference (WMD) was used to compare the insulin resistance indices between PCOS patients with and without SCH.

RESULTS

Twenty-nine studies comprising 5765 women with PCOS were included. The meta-analysis demonstrated that 19.7% (95% CI: 16.1%; 23.5%) of women with PCOS have SCH. PCOS patients with SCH had significantly higher HOMA-IR (WMD = 0.78, 95% CI: 0.34; 1.22) and fasting insulin (WMD = 2.38, 95% CI: 0.34; 4.42) levels than those without SCH. Differences in fasting plasma glucose and 2-hour postprandial glucose did not reach statistical significance.

CONCLUSION

This systematic review and meta-analysis found that approximately 20% of women with PCOS have SCH. This underscores the need for regular thyroid function testing in these patients. The prevalence of SCH is influenced by the TSH cut-off used for diagnosis, highlighting the need for establishing a standardized TSH cut-off value. Furthermore, SCH significantly elevates the HOMA-IR index and fasting insulin levels, highlighting its potential impact on insulin resistance. Whether these metabolic changes are clinically important and put these individuals at higher risk of developing type 2 diabetes mellitus and cardiovascular disease requires further investigation.

SYSTEMATIC REVIEW REGISTRATION NUMBER IN PROSPERO

CRD42024510798.

CLINICAL TRIAL NUMBER

Not applicable.

Evaluation of a laboratory reflex testing protocol to detect hypopituitarism in primary care presenting as hypothyroxinaemia

BackgroundThyroid function tests (TFTs) are routinely requested by general practitioners (GPs) in the clinical biochemistry laboratory. Hypothyroxinaemia (low fT4) accompanied by TSH within the reference interval (RI) is a discordant pattern which is seen commonly in non-thyroidal illness and also as result of medications. Hypopituitarism is a lot rarer, but a serious condition the laboratory does not want to miss.MethodsAll thyroid hormone samples from primary care meeting the discordant case definition under investigation [fT4<10 pmol/L and TSH within RI (0.3-4.2 mU/L)] had partial anterior pituitary profiles [PAPP (cortisol, oestradiol/testosterone, prolactin, gonadotrophins)] added as reflex tests and results interpreted by a chemical pathologist. From January to June 2023, we conducted structured interviews with the requesting GPs, and, where indicated, requested repeat samples for full anterior pituitary profile [FAPP (PAPP, growth hormone (GH) and insulin-like growth factor 1 (IGF-1)]. We also reviewed the laboratory records of patients with previously known hypopituitarism to determine their fT4 and TSH values at diagnosis.ResultsOver the 6 months 41,487 GP TFTs were requested; 54 (0.13%) fitted the discordant case definition and had PAPP reflexed. 13 FAPPs were requested. We identified 3 cases of hypopituitarism. The number of additional tests required to diagnose 1 case of hypopituitarism was 129. In 74% of reflex-tested cases, there was a plausible explanation for the TFT pattern (medications, known thyroid dysfunction, non-thyroidal illness, pregnancy).ConclusionThis study highlights the importance of medical liaison and early intervention in a biochemistry laboratory in identifying cases of unsuspected hypopituitarism.

PEG Precipitation to Detect Macro-TSH in Clinical Practice: A Systematic Review

Macro-thyroid-stimulating hormone (macro-TSH) is a complex formed by monomeric TSH with anti-TSH antibodies, causing falsely elevated TSH levels and potential misdiagnosis of hypothyroidism. Identification of macro-TSH is essential for proper treatment and patient follow-up. Its diagnostic gold standard is gel filtration chromatography (GFC), which is very expensive, time-consuming, and rarely available. Polyethylene glycol (PEG) precipitation is more accessible and inexpensive. The aim of the study was to review evidence on PEG precipitation for the detection of macro-TSH to standardize its application in clinical practice.

METHODS

According to PRISMA guidelines, we conducted up to August 2024 a comprehensive search of PubMed and Scopus databases, using terms related to macro-TSH and PEG precipitation.

RESULTS

We included 23 studies with 4476 subjects, encompassing 10 observational studies and 13 case series/reports. All studies showed a low risk of bias. They were conducted in tertiary centres and included newborns to elderly subjects. The most of evidence about the procedure has been achieved with PEG concentrations of 12.5%. The PEG-precipitable TSH of the macro-TSH cases was always higher than 75% ranging on average from 81% to 90%. No-macro-TSH cases (controls) showed a PEG-precipitable TSH percentage ranging from 44.1% to 61.8%.

CONCLUSIONS

PEG precipitation can be taken into account as a useful diagnostic tool for macro-TSH. However, it is necessary to perform PEG precipitation in cases with a highly suspicious clinical picture and at the same time perform all available ancillary tests. PEG-precipitable TSH > 75% can be considered a reliable diagnostic threshold for macro-TSH cases.

The Association Between Thyrotropin and Clinically Relevant Depression: A Retrospective Cross-Sectional Study

Introduction: Thyroid dysfunction and mood disorders are chronic health conditions with a significant impact on quality of life. This study aimed to investigate the association between thyrotropin (TSH) and clinically relevant depression (CRD) in patients with and without mood disorders, in a population-based sample. Methods: This retrospective cross-sectional study included all consecutive adults (≥18 years) who had TSH and completed the Patient Health Questionnaire (PHQ-9) within 6 months of the index visit, between October 2016 and May 2021, at the University of Utah Health. Data on demographics, hypothyroidism diagnoses, TSH, thyroid hormone replacement (THR), PHQ-9, antidepressant (AD) medications, and mood disorder diagnoses (using the International Classification of Diseases, 10th Revision, Clinical Modification codes; Major depressive disorder single episode-F32, recurrent-F33, persistent mood disorder-F34, bipolar disorder-F30+F31, and mood disorder not otherwise specified-F39) were extracted electronically. CRD was defined as PHQ-9 ≥ 10. t-Test and chi-square test were used to compare continuous and categorical variables, respectively. Logistic regression models were formulated to evaluate the association between TSH and CRD, after adjusting for covariates. Results: The cohort included 33,138 patients, mean age 42.41 ± 16.10 years, 80.67% Caucasian, 69.10% females, and mean PHQ-9 score 10.11 ± 6.94. A total of 45.23% (n = 14,989) patients had a diagnosis of mood disorders, and 49.70% had CRD. Patients with mood disorders were more likely to be female, Caucasian, non-Hispanic/Latino, on AD, had hypothyroidism diagnoses, on thyroid medications, had higher mean PHQ-9 scores, and had CRD. TSH level was associated with an increased odds of CRD (odds ratio [OR] = 1.01, confidence interval [CI], 1.01-1.02, p < 0.009) after adjusting for age, sex, body mass index, Charlson Comorbidity Index, and use of THR and AD. Both the low TSH and high TSH groups showed increased odds of CRD, with respective ORs of 1.19 (CI: 1.04-1.37) and 1.26 (CI: 1.13-1.40). Conclusions: Thyroid dysfunction is associated with an increase in the odds of depression. Future longitudinal cohort studies are recommended to investigate the association between thyroid function and incident depression.

Comprehensive view of suicide: A neuro-immune-endocrine approach

Suicide is defined as the act of a person attempting to take their own life by causing death. Suicide is a complex phenomenon that is influenced by a multitude of factors, including psychosocial, cultural, and religious aspects, as well as genetic, biochemical, and environmental factors. From a biochemical perspective, it is crucial to consider the communication between the endocrine, immune, and nervous systems when studying the etiology of suicide. Several pathologies involve the bidirectional communication between the peripheral activity and the central nervous system by the action of molecules such as cytokines, hormones, and neurotransmitters. These humoral signals, when present in optimal quantities, are responsible for maintaining physiological homeostasis, including mood states. Stress elevates the cortisol and proinflammatory cytokines levels and alter neurotransmitters balance, thereby increasing the risk of developing a psychiatric disorder and subsequently the risk of suicidal behavior. This review provides an integrative perspective about the neurochemical, immunological, and endocrinological disturbances associated with suicidal behavior, with a particular focus on those alterations that may serve as potential risk markers and/or indicators of the state preceding such a tragic act.

Thyrotropin reference interval in older adults

It is estimated that by the year 2050, 16% of the world's population will be 65 years old and above. As the global aging population continues to grow, there is an increasing focus on thyroid disorders among older individuals. Thyrotropin is widely used in diagnosing subclinical thyroid diseases due to its high sensitivity as an indicator of changes in thyroid function. However, thyrotropin levels change with age, and different reference intervals have been proposed in various studies. The variation in thyrotropin ranges among older adults is probably caused by the heterogeneity of the studied population. This review aims to provide an overview of the existing literature on thyrotropin reference intervals in older adults and their distinction as adaptive or pathologic. Recent research indicates that older individuals may have slightly elevated levels of thyrotropin and higher upper limits of reference intervals. Therefore, a higher thyrotropin threshold for diagnosing and treating subclinical hypothyroidism in the elderly seems reasonable.

Prevalence of abnormal thyroid hormone levels in acute new-onset atrial fibrillation

Introduction

Known risk factors for new-onset atrial fibrillation/flutter (NOAF) include thyrotoxicosis and subclinical hypothyroidism. While prior research has predominantly explored the link between thyrotoxicosis and NOAF, the presence of subclinical hypothyroidism among patients presenting with acute NOAF in the emergency department (ED) remains an underexplored area of inquiry. This study aimed to assess the prevalence of undiagnosed thyrotoxicosis and subclinical hypothyroidism in patients with acute NOAF diagnosed in the ED.

Methods

This registry-based cohort study was conducted in the ED at Vrinnevi Hospital in Sweden during the years 2018, 2020, and 2022, with a 1-year follow-up period. Patients ≥18 years diagnosed with NOAF in the ED, with no ongoing thyroid hormone substitution or previous documented thyroid abnormality within the past 2 years, were included. The primary outcome was the diagnosis of thyrotoxicosis or subclinical hypothyroidism either in the ED or during a 1-year follow-up period.

Results

486 patients with NOAF were included in the study (43.6% females). 329 (67.7%) underwent thyroid function testing in the ED or by the end of the 1-year follow-up. In total, 16 (4.9%) patients presented with subclinical hypothyroidism while 4 (1.2%) patients presented with clinical or subclinical thyrotoxicosis.

Discussion

This study found that subclinical hypothyroidism was more prevalent (4.9%) than thyrotoxicosis (1.2%) among patients presenting with acute NOAF. These findings contrast with previous research that has predominantly linked thyrotoxicosis with acute NOAF, suggesting the need for further studies including both subclinical hypothyroidism and thyrotoxicosis in patients with NOAF.

Therapeutic efficacy and patient compliance of levothyroxine liquid and softgel formulations taken with meals: a systematic review

PURPOSE

Levothyroxine (L-T4) is the drug of choice for treating primary hypothyroidism. L-T4 tablets should be taken at least 30 min before breakfast. Several studies have suggested that serum thyroid profile is not affected by concomitant intake of liquid/softgel L-T4 with meals. Our aim is to review the evidence on therapeutic efficacy and patient compliance with the liquid and softgel formulation of L-T4 taken with meals, also compared with the standard tablet therapy regimen, in hypothyroid patients.

METHODS

We performed a systematic review of literature by searching PubMed, Embase, and Cochrane Library databases. PRISMA guidelines were applied, and the risk of bias of the included studies was assessed using the RoB 2 and ROBINS tools. The methodological quality was assessed following the GRADE criteria.

RESULTS

We included 13 studies, accounting for a total of 1697 patients. The timing of liquid L-T4 intake from breakfast did not affect the therapeutic efficacy of the treatment. No significant differences in the absorption of liquid L-T4 were found when administered together with different foods, beverages, drugs, or other supplements. TSH levels are not influenced by taking softgel L-T4 at breakfast; the efficacy of softgel and liquid formulation is similar when they are taken with a meal, but superior to that of tablet formulation. Shifting from L-T4 tablets taken 30 min before breakfast to liquid/softgel formulation taken with the meal improved medication adherence and perceived quality of life of patients.

CONCLUSION

Liquid and softgel formulation of L-T4 can be taken at breakfast or close to meals, without losing therapeutic efficacy. These formulations could also improve patient compliance and quality of life compared to L-T4 tablet therapy taken 30 min before breakfast.

Type 2 Diabetes, Obesity and Their Relation to the Risks of Thyroid Cancer

OBJECTIVE

patients with type 2 diabetes (T2DM) and obesity are generally known to have increased risk of various types of cancer, though studies addressing associations between T2DM/obesity and thyroid cancer are inconclusive. The aim of our study was to evaluate the risk of thyroid cancer focusing on diabetic patients under conditions of euthyroid status. A retrospective study in 184 patients was performed. Three cohorts were established according to tumor histology: malignant (M), benign (B) and low-risk carcinoma (MB). Fisher's exact test and Kruskal-Wallis one-way ANOVA of ranks were used for statistical analysis. The M (39.1 %), B (57.6 %) and MB (3.3 %) cohorts had comparable age (p=0.4), BMI (p=0.452), glycaemia (p=0.834), Hb1AC (p=0.157) and HOMA-IR (p=0.235). T2DM patients had larger thyroid gland volumes (28.8 vs 17.6 mL;p=0.001) compared to the cohort with normal glucose tolerance. Compared to women, men had more frequently present distal metastases (p=0.017), minimally invasive disease (p=0.027), more advanced staging (p=0.01) and positive pathogenic mutations in the TERT gene (p=0.009);these results were also significant for the diabetic male cohort (p=0.026). Type 2 diabetes and obesity are not risk factors for thyroid cancer, but a subgroup of males seems to have thyroid cancers of poorer prognosis. In general, diabetic patients with insulin resistance and hyperinsulinemia are also prone to have a goiter.

KEY WORDS

Thyroid cancer, Type 2 diabetes, Obesity, Thyroid nodule, Insulin resistance.

Prevalence and Risk Factors for Atherosclerotic Cardiovascular Disease in 7704 Individuals: An Analysis from the Greek Registry for the Prevalence of Familial Hypercholesterolemia (GRegistry-FH)

The intention of this study was to profile the cohort from the Greek Registry for the prevalence of Familial Hypercholesterolemia (GRegistry-FH) by estimating the prevalence of coronary artery disease (CAD), myocardial infarction (MI), stroke, dyslipidemia, arterial hypertension, diabetes mellitus (DM), pre-DM, smoking, abnormal thyroid function (ATF), and lipid values. The GRegistry-FH is a prospective study involving door-to-door interviews conducted by trained interviewers. Overall, 7704 individuals aged ≥18 years, randomly selected from all the regions of Greece, participated. The prevalence of atherosclerotic cardiovascular disease (ASCVD) was 13.9% (CAD 6%, MI 3.2%, stroke 4.7%). Treated hypercholesterolemia was present in 20.1%, arterial hypertension in 24%, and DM in 11.3% individuals (25.5% had pre-DM). The prevalence of smoking was 37.9% (29% current) and the prevalence of ATF was 13.1% (hypothyroidism 11.3%). A family history of ASCVD was reported by 60.5% (CAD 32.2%, stroke 28.3%). The mean (SD) lipid values in mg/dL were as follows: total cholesterol of 201.8 (41.5), low-density lipoprotein cholesterol of 126.3 (30.1), high-density lipoprotein cholesterol of 51.9 (12.5), and triglycerides of 135.9 (64.7). The GRegistry-FH highlights the significant prevalence of ASCVD and its risk factors among Greek adults, indicating a pressing need for early detection and management strategies to mitigate ASCVD burden. This nationwide registry serves as a crucial tool for guiding public health policies and personalized preventive measures (NCT03140605).

Turner Syndrome and the Thyroid Function-A Systematic and Critical Review

Turner syndrome (TS) is associated with thyroid disorders. Since the rate of thyroid disease among patients with this syndrome is significantly higher as compared to the general population, it seems vital to explore this particular area. This systematic and critical review was performed to evaluate thyroid function and autoimmunity in patients with Turner syndrome. Four databases were searched: PubMed, Scopus, Google Scholar, and Cochrane Library from the onset of the study to July 2024. Two independent researchers manually searched databases for the following keywords: "Turner syndrome", "anti-TPO", "anti-Tg", "autoimmune thyroid disorders", "TSH", and "hypothyroidism", which were entered into the search engine in isolation, as well as in combinations. Criteria incorporating information on thyroid-stimulating hormone (TSH), triiodothyronine (total-TT3), and thyroxine (free and total-fT4, TT4) concentrations among patients and control groups were also included. Thyroid diseases are common in patients with Turner syndrome. Women with TS present both higher TSH levels and positive thyroid antibodies concentrations. Typical thyroid ultrasound heterogeneity with a hypogenic or mixed echopattern was also observed. As a result, it is essential to monitor thyroid hormone levels in this group, in order to detect hypothyroidism earlier and initiate appropriate replacement therapy. Thyroid diseases in women with TS may remain underdiagnosed for a number of years, due to the lack of screening. Therefore, the authors suggest a thyroid screening regimen for TS patients, which allows for early detection of the disease and implementation of treatment.

The Role of Physical Exercise as a Therapeutic Tool to Improve Lipedema: A Consensus Statement from the Italian Society of Motor and Sports Sciences (Società Italiana di Scienze Motorie e Sportive, SISMeS) and the Italian Society of Phlebology (Società Italiana di Flebologia, SIF)

PURPOSE OF REVIEW

This consensus statement from the Italian Society of Motor and Sports Sciences (Società Italiana di Scienze Motorie e Sportive, SISMeS) and the Italian Society of Phlebology (Società Italiana di Flebologia, SIF) provides the official view on the role of exercise as a non-pharmacological approach in lipedema. In detail, this consensus statement SISMeS - SIF aims to provide a comprehensive overview of lipedema, focusing, in particular, on the role played by physical exercise (PE) in the management of its clinical features.

RECENT FINDINGS

Lipedema is a chronic disease characterized by abnormal fat accumulation. It is often misdiagnosed as obesity, despite presenting distinct pathological mechanisms. Indeed, recent evidence has reported differences in adipose tissue histology, metabolomic profiles, and gene polymorphisms associated with this condition, adding new pieces to the complex puzzle of lipedema pathophysiology. Although by definition lipedema is a condition resistant to diet and PE, the latter emerges for its key role in the management of lipedema, contributing to multiple benefits, including improvements in mitochondrial function, lymphatic drainage, and reduction of inflammation. Various types of exercise, such as aquatic exercises and strength training, have been shown to alleviate symptoms and improve the quality of life of patients with lipedema. However, standardized guidelines for PE prescription and long-term management of patients with lipedema are lacking, highlighting the need for recommendations and further research in this area in order to optimise therapeutic strategies.

The impact of thyroid disorder on cardiovascular disease: Unraveling the connection and implications for patient care

The thyroid gland is responsible for metabolism, as well as cardiac function and the peripheral vascular system. Thyroid dysfunctions are associated with an increase in the risk of cardiovascular diseases, including heart failure and coronary heart disease atrial fibrillation, by impairing heart contractility, stroke volume, heart rate, peripheral vascular resistance, and electrical activity. Thyroid dysfunctions also alter several cardiovascular risk factors, such as atherosclerosis, hypertension, and dyslipidemia, as well as causing stroke, which is associated with atrial fibrillation. An antiarrhythmic drug, amiodarone, may also induce both thyrotoxicosis and hypothyroidism, so its use requires serial thyroid function testing. Every CVD patient is recommended to be screened and treated for any possible thyroid dysfunction to reduce the patient's mortality and morbidity.

Role of Thyrotropin-Releasing Hormone Stimulation Test and Autoantibody in 952 Subjects with Subclinical Hypothyroidism

Context

Subclinical hypothyroidism (SCH) is characterized by elevated thyroid-stimulating hormone (TSH) levels and normal free thyroxine (fT4) levels. In upper normal TSH levels, thyrotropin-releasing hormone (TRH) stimulation test proved to be useful in identifying an exaggerated TSH response.

Objective

We aimed to evaluate the incidence and predictive ability of basal TSH, anti-thyroid peroxidase antibodies (TPOAb), and anti-thyroglobulin antibodies (TgAb) for exaggerated TRH stimulation test in SCH.

Methods

A total of 952 subjects with SCH (TSH 4.01-10.00 mIU/L) found during health checkups were evaluated for TSH response to TRH stimulation testing and autoantibodies. Exaggerated TSH response was defined as ΔTSH (peak serum TSH level after TRH injection minus basal TSH level) of > 25.00 mIU/L.

Results

The prevalence of exaggerated TSH responses in SCH was 66% (n = 633). The proportion of exaggerated TSH response tended to increase as basal TSH levels increased (P for trend <.001). Also, the proportion of positive TPOAb or TgAb tended to increase as basal TSH levels increased (P for trend <.05). Analysis of predictive ability of basal TSH, positive TPOAb, or TgAb for exaggerated TRH stimulation test revealed that positive TPOAb or TgAb showed high specificity (> 90%) for positive TRH stimulation test but low sensitivity. Basal TSH showed low sensitivity and specificity.

Conclusion

Two-thirds of SCH showed exaggerated TRH stimulation test. Positive TPOAb or TgAb showed high specificity (> 90%) for positive TRH stimulation test but basal serum TSH levels showed low predictability. The TRH stimulation test may be a valuable guide to identify SCH patients with hypothyroid state.

Euthyroid sick syndrome predicts the risk of ischemic stroke-associated pneumonia in the acute stage of ischemic stroke: a nested case-control study

Objective

Ischemic stroke-associated pneumonia (iSAP) affects about 10% of acute ischemic stroke patients during hospitalization. Current prediction scales for iSAP are insufficient. Identifying early biomarkers for stroke-associated pneumonia is crucial for improving patient outcomes. This study aimed to investigate the predictive value of euthyroid sick syndrome (ESS) for iSAP in acute-stage of ischemic stroke patients.

Methods

We studied 1767 acute ischemic stroke patients within one week of symptom onset, categorizing them into an infection group (iSAP, n=376) and control group (control, n=1391). COX regression analysis was used to identify the potential risk and protected factors. Kaplan-Meier time-event curves and Log-Rank tests were performed to differentiate infection time in patients with ESS or normal T3 group.

Results

The iSAP group had higher rates of risk factors like older age, atrial fibrillation, COPD, and ESS, along with elevated levels of WBC, CRP,and FT4 levels (all P < 0.001). Conversely, iSAP patients had lower GCS scores, eGFR, TSH, T3, FT3 (all P < 0.001) and T4 levels (P = 0.005) upon admission. No significant differences were observed in sex, smoking history, hypertension, diabetes, or LDL-C levels (P > 0.05). COX regression analysis identified age, KWST scores, leukocyte count, CRP, and ESS (all P < 0.001) as significantly correlated with iSAP. ROC analysis revealed ESS as a predictor with sensitivity of 35.64% and specificity of 87.92% for SAP prediction, like atrial fibrillation and higher than COPD and eGFR.

Conclusion

ESS at admission predicts a higher risk of stroke-associated pneumonia in acute-stage of ischemic stroke.

Occupational Physical Activity and Regular Exercise Are Inversely Correlated with Thyroid Function in Patients with Hashimoto's Thyroiditis

OBJECTIVE

We evaluated correlations of occupational physical activity (OPA) and recreational exercise (RE), respectively, with thyroid function in patients with Hashimoto's thyroiditis (HT).

METHODS

We included 438 individuals with clinically diagnosed HT. Information on OPA and RE were collected through a self-report questionnaire. We assessed correlations between clinical phenotypes (TSH, T3, T4, fT4, TgAb, TPOAb, thyroid volume, vitamin D) and physical activities (OPA and RE) in all HT patients (ALL) and in two severity-based subgroups of patients (MILD and OVERT).

RESULTS

The main novel findings are significant correlations between increase in OPA and (i) a decrease in fT4 (OVERT, r = -0.265, p = 0.0002 and ALL, r = -0.138, p = 0.006); (ii) an increase in TSH (ALL, r = 0.124, p = 0.014 and OVERT, r = 0.183, p = 0.013) and (iii) an increase in TPOAb antibodies (ALL, r = 0.101, p = 0.045). In contrast, we observed correlations between increase in RE and: (i) a decrease in TSH (OVERT, r = -0.238, p = 0.001); (ii) a decrease in TgAb antibodies (OVERT, r = -0.194, p = 0.01) and (iii) an increase in vitamin D levels (ALL, r = 0.146, p = 0.005 and OVERT, r = 0.173, p = 0.023).

CONCLUSIONS

Our results suggest that, unlike RE, OPA correlates with decreased thyroid function and increased thyroid autoimmunity. Our study proposes that the PA health paradox also applies for the thyroid health.

Age-Specific Reference Intervals for Thyroid-Stimulating Hormones and Free Thyroxine to Optimize Diagnosis of Thyroid Disease

Background: Thyroid-stimulating hormone (TSH) and subsequent free thyroxine (FT4) concentrations outside the reference interval (RI) are used to diagnose thyroid diseases. Most laboratories do not provide age-specific RIs for TSH and FT4 beyond childhood, although TSH concentrations vary with age. Therefore, we aimed to establish TSH and FT4 age-specific RIs throughout life and aimed to determine whether using these RIs would result in reclassification of thyroid disease diagnoses in adults. Methods: This multicenter retrospective cross-sectional study used big data to determine indirect RIs for TSH and FT4. These RIs were determined by TMC and refineR-analysis, respectively, using four different immunoassay platforms (Roche, Abbott, Siemens, and Beckman Coulter). Retrospective data (2008-2022) from 13 Dutch laboratories for general practitioners and local hospitals were used. RIs were evaluated per manufacturer. Age groups were established from 2 to 20 years by 2-year categories and decade categories between 20 and 100 years. Results: We included totally 7.6 million TSH and 2.2 million FT4 requests. TSH upper reference limits (URLs) and FT4 lower reference limits were higher in early childhood and decreased toward adulthood. In adulthood, TSH URLs increased from 60 years in men, and from 50 years in women, while FT4 URLs increased from 70 years onward. Using adult age-specific RIs resulted in a decrease in diagnoses of subclinical and overt hypothyroidism in women above 50 and men above 60 years in our Roche dataset. Conclusion: This study stressed the known importance of using age-specific RIs for TSH and FT4 in children. This study also showed the clinical relevance of using age-specific RIs for TSH in adulthood to reduce diagnoses of subclinical hypothyroidism in older persons. Therefore, implementation of adult TSH age-specific RIs should be strongly considered. Data are less uniform regarding FT4 age-specific RIs and more research should be performed before implementing these in clinical practice.

Effect of different initiation timing of levothyroxine on pregnancy outcomes and development of offspring in women with gestational subclinical hypothyroidism

Objective

To explore the impact of levothyroxine (L-T4) administration at different time points on pregnancy outcomes and offspring development in patients with subclinical hypothyroidism (SCH).

Methods

In this retrospective study, medical records of 107 patients with SCH treated in Huzhou Nanxun District People's Hospital from February 2021 to March 2023 were retrospectively reviewed. Of them, 55 patients received treatment before eight gestational weeks (Early group), and 52 patients received treatment after eight gestational weeks (Mid group). Levels of thyroid function indicators, occurrence of adverse pregnancy outcomes, occurrence of adverse reactions, and development of offspring before and after the treatment were compared.

Results

After the treatment, the thyroid function indicators in both groups improved compared to before treatment, and the improvement in the Early group was significantly better than that in the Mid group (P<0.05). The incidence of adverse pregnancy outcomes in the early group (5.45%) was lower than that in the mid group (19.23%) (P<0.05). There was no significant difference in the incidence of adverse reactions between the groups (P>0.05). The scores of fine motor, gross motor, language, personal-social behavior, and adaptability in offspring of patients the Early group were higher than those of the mid group (P<0.05).

Conclusions

Early administration of L-T4 is safe and can effectively improve thyroid function in SCH patients, reduce adverse pregnancy outcomes, and ensure growth and development of offspring.

Thyroid function effect on cardiac structure, cardiac function, and disease risk: Evidence of causal associations in European ancestry

BACKGROUND

Thyroid hormones play a crucial role in cardiovascular physiology. Subclinical thyroid dysfunction has been associated with adverse cardiovascular outcomes, but evidence is mixed regarding causality.

OBJECTIVE

The purpose of this study was to investigate the potential causal relationships of thyroid-stimulating hormone (TSH), free thyroxine, hypothyroidism, and hyperthyroidism with cardiovascular outcomes, including atrial fibrillation (AF), coronary artery disease, myocardial infarction, heart failure, and ischemic stroke, as well as their effect on cardiac structure and function assessed by cardiac magnetic resonance imaging.

METHODS

A comprehensive 2-sample Mendelian randomization analysis was performed using summary data from large-scale meta-analyses of European ancestry individuals.

RESULTS

Genetically determined lower TSH levels (odds ratio 0.928; 95% confidence interval 0.884-0.974; P = .003) and genetic risk of hyperthyroidism (odds ratio 1.049; 95% confidence interval 1.016-1.083; P = .003) were associated with increased AF risk. These associations remained significant even after adjusting for cardiovascular risk factors. Colocalization and multivariable Mendelian randomization revealed height as a key mediator between TSH/hyperthyroidism and AF. These findings were further corroborated in the independent FinnGen cohort. However, no clear evidence was found for relationships between thyroid function and other cardiovascular outcomes and cardiac structure and function.

CONCLUSION

Our study shows that reduced TSH levels and hyperthyroidism heighten AF risk, with height serving as an important mediator in these associations. The primary focus of thyroid management in cardiovascular health should be on preventing and treating arrhythmias, particularly AF. Our research highlights the importance of routine screening and timely treatment of thyroid dysfunction to optimize the prevention and management of arrhythmias.

Efficacy of Thyroid Hormone Replacement Therapy in Nasopharyngeal Carcinoma Patients with Radiation-Induced Subclinical Hypothyroidism

AIMS

Hypothyroidism is a common side effect of radiotherapy for nasopharyngeal carcinoma. However, the impact of thyroid hormone replacement therapy on patients with radiation-induced subclinical hypothyroidism has not been extensively explored. This study aimed to analyze the efficacy of thyroid hormone replacement therapy in nasopharyngeal carcinoma patients with subclinical hypothyroidism.

METHODS

Patients diagnosed with nasopharyngeal carcinoma who developed subclinical hypothyroidism after definitive radiotherapy between September 2019 and December 2020 were selected for inclusion in this study. Prior to thyroid hormone replacement therapy and after maintaining euthyroidism for 6-12 months through thyroid hormone replacement therapy, assessments using the SF36 Brief Health Status Scale and the Hypothyroidism-related Symptom Questionnaire were conducted via trained questionnaires. Lipid profiles were assessed at baseline and after 6-12 months of thyroid hormone replacement therapy. Statistical analyses were performed using matched samples T-test or Mann-Whitney U test.

RESULTS

The median follow-up period was 14.5 months. The median score of hypothyroid symptoms was 5.5 out of 19 points, with the most common symptoms being chills (65.0%), fatigue (50.0%), weight gain (45.0%), and limb numbness (40.0%). Thyroid hormone replacement therapy did not significantly improve the quality of life, hypothyroidism-related symptoms, or blood lipid profile in patients. However, there was an observed downward trend in serum cholesterol levels following treatment (P=0.052).

CONCLUSION

Thyroid hormone replacement therapy did not have a significant impact on alleviating hypothyroid symptoms, improving quality of life, or enhancing lipid profiles in patients with radiation-induced subclinical hypothyroidism. Nevertheless, a potential decrease in serum cholesterol levels was noted after thyroid hormone replacement therapy.

Age-specific thyrotropin references decrease over-diagnosis of hypothyroidism in elderly patients in iodine-excessive areas

OBJECTIVE

Acute or chronic exposure to excess iodine has detrimental effects on thyroid physiology; therefore, this study aimed to determine the prevalence of overt hypothyroidism (OH) and subclinical hypothyroidism (SCH) in an elderly population residing in geographical areas with chronic exposure to excess iodine intake and to analyse contributing risk factors.

DESIGN

This cross-sectional study was conducted from 2016 to 2017 in areas of Jiangsu Province that have documented chronic exposure to high iodine intake.

PATIENTS

We enroled 2559 adult participants using a multistage, stratified sampling method.

MEASUREMENTS

Urinary iodine concentration (UIC), serum thyroid-stimulating hormone (TSH) level and other relevant parameters were measured. Demographic information was recorded using a standardized questionnaire. The age-specific TSH references were determined by the National Academy of Clinical Biochemistry guidelines. Univariate and multivariate logistic regression analyses were performed to identify risk factors for hypothyroidism in the study population.

RESULTS

The median UIC of participants was 307.3 µg/L (interquartile range: 200.7, 469.8 μg/L). The prevalence of OH in subjects ≥70 years using laboratory reference ranges was 2.37%; however, it decreased to 1.78% with the use of an age-specific reference range. Similarly, the prevalence of SCH also declined drastically from 29.59% to 2.96% with the application of an age-specific reference range. In both univariate and multivariate models, advanced age, female gender and high UIC were identified as risk factors for hypothyroidism.

CONCLUSIONS

Usage of age-specific TSH reference ranges led to a significantly lower prevalence of OH and SCH in the study population, thus preventing unnecessary over-diagnosis and over-treatment.

Evaluation of the etiology of subclinical hypothyroidism in children

OBJECTIVES

Subclinical hypothyroidism (SH) is defined by normal free triiodothyronine (fT3) and free thyroxine (fT4) levels, elevated thyroid-stimulating hormone levels, and the absence of overt clinical signs of hypothyroidism. The natural course of SH is influenced by the underlying etiology. The purpose of this study was to evaluate the etiologic causes of SH.

METHODS

A total of 135 patients aged 1-18 years, diagnosed with SH by at least two analytical measurements, were included in the study. The anthropometric measurements, demographic characteristics, and laboratory findings of the patients were determined. A comparison was conducted between patients with Hashimoto's thyroiditis and patients with non-autoimmune etiology.

RESULTS

The median age was 9.7 (6.5) years, and 82 of the 135 patients were female. The most prevalent etiology was idiopathic, affecting 39 (28.9 %) patients. This was followed by obesity, which was identified in 21 (15.6 %) patients. Hashimoto's thyroiditis was the third most common cause, accounting for 18 (13.3 %) patients. In patients with Hashimoto's disease, fT4 levels were significantly lower, and the rate of initiation of LT4 treatment was higher than in patients with other etiologies. A heterozygous variation in the TSH receptor (TSHR) gene was detected in six patients.

CONCLUSIONS

In our study, idiopathic cases were the most frequently identified in the etiology of SH. It is important to determine whether there is autoimmune thyroiditis. In cases of idiopathic SH, it is recommended to perform TSHR gene analysis, particularly in the presence of positive family history and newborn screening results. This approach will help elucidate the underlying etiology.

Hypothyroidism

Hypothyroidism, the deficiency of thyroid hormone, is a common condition worldwide. It affects almost all body systems and has a wide variety of clinical presentations from being asymptomatic to, in rare cases, life threatening. The classic symptoms of hypothyroidism include fatigue, lethargy, weight gain, and cold intolerance; however, these symptoms are non-specific and the diagnosis is typically made on biochemical grounds through serum thyroid function tests. The most common cause of hypothyroidism is chronic autoimmune thyroiditis (Hashimoto's thyroiditis), although other causes, including drugs (such as amiodarone, lithium, and immune checkpoint inhibitors), radioactive-iodine treatment, and thyroid surgery, are frequent. Historically, severe iodine deficiency was the most common cause. Reference ranges for thyroid function tests are based on fixed percentiles of the population distribution, but there is increasing awareness of the need for more individualised reference intervals based on key factors such as age, sex, and special circumstances such as pregnancy. Levothyroxine monotherapy is the standard treatment for hypothyroidism; it is safe and inexpensive, restores thyroid function tests to within the reference range, and improves symptoms in the majority of patients. However, 10% of patients have persistent symptoms of ill health despite normalisation of thyroid function tests biochemically and a substantial proportion of patients on levothyroxine have thyroid-stimulating hormone concentrations outside the reference range. Ongoing symptoms despite levothyroxine treatment has led to some patients using liothyronine or desiccated thyroid extract. Taken together, these factors have led to intense debate around the treatment thresholds and treatment strategies for hypothyroidism. In this Seminar, we review the epidemiology, genetic determinants, causes, and presentation of hypothyroidism; highlight key considerations and controversies in its diagnosis and management; and provide future directions for research.

One sip of water with LT-4 supplementation-a key to euthyroidism in Hashimoto's thyroiditis

PURPOSE

Recommended pharmacotherapy for hypothyroidism in Hashimoto's thyroiditis (HT) is oral supplementation with levothyroxine (LT-4). However, serum thyrotropin (TSH) levels within normal range are not consistently achieved with LT-4 medication.

PATIENTS AND METHODS

We report on 35 HT patients with LT-4 therapy in this retrospective evaluation. In general, we recommend that a maximum of two sips of water, which would then amount to < 50 mL, be ingested at the same time as LT-4. We report on follow up examinations measuring TSH and antibodies against thyroid peroxidase (TPOAb) after 6 months to five years.

RESULTS

After median time of 643 days (range 98-1825) we found in 35 HT patients a statistical significant reduction of serum TSH (p < 0.001) and TPOAb (p = 0.006). The patients median body weight was 71 kg (range 48-98) and a daily LT-4 dosage was used with median 69.1 µg (range 25-150). This results in a daily LT-4 dose of median 1.01 µg/kg bodyweight (range 0.3-2.3).

CONCLUSIONS

The reduction of water ingestion to a maximum of two sips, which is <50 mL, combined with LT-4 supplementation helps to achieve euthyroidism in HT. In addition, it reduces the L-T4 medication dosage needed to lower TSH serum levels and decreases TPO antibodies in HT.

Subclinical hypothyroidism and metabolic syndrome in psychiatric patients: A systematic literature review and meta-analysis

OBJECTIVE

The systematic review evaluated the association of subclinical hypothyroidism (SCH) with metabolic syndrome (MetS) and specific MetS components in people with major psychiatric disorders.

METHODS

A systematic review and meta-analysis was conducted to evaluate the association of SCH with MetS and its components in people with major psychiatric conditions.

RESULTS

Five studies incorporating 24,158 participants met the inclusion criteria. All five studies comprised patients with depression and/or anxiety. Three studies incorporating 3365 participants were suitable for the meta-analysis. The pooled Odds Ratio (OR) of MetS was 3.46 (95% Confidence Interval/CI = 1.39-8.62) in major depressive disorder (MDD) and anxiety disorders patients with concurrent SCH compared to those without SCH. Meta-analysis showed a significant positive association between SCH and high body mass index (OR = 2.58, 95%CI = 1.33-5.01), high fasting plasma glucose (OR = 3.05, 95%CI = 1.79-5.18) and low high-density lipoprotein cholesterol (OR = 2.30, 95%CI = 1.82-2.92).

CONCLUSIONS

These findings suggest a significant positive association between MetS and SCH in people with MDD and anxiety disorders. This review informed the clinical implications of MetS in MDD with comorbid SCH and the importance of early diagnosis and treatment for SCH and MetS in psychiatric patients.

Apalutamide-induced severe hypothyroidism: case series and practice recommendations for thyroid management

The androgen receptor signaling inhibitor apalutamide is used successfully for the treatment of prostate cancer. An increased risk of hypothyroidism, mostly subclinical, has been reported in the SPARTAN and TITAN trials. We present three cases of subacute deterioration of previously known but well-controlled hypothyroidism treated with levothyroxine, occurring shortly after the initiation of treatment with apalutamide, resulting in severe hypothyroidism. These cases highlight the importance of awareness of thyroid dysfunction during treatment with apalutamide, particularly in patients with pre-existing thyroid disease, common in the general population. We provide practice recommendations for thyroid management prior to and during apalutamide treatment as well as after the interruption of this therapy.

Levothyroxine Treatment of Subclinical Hypothyroidism and the Risk of Adverse Cardiovascular Events

Importance: There is uncertainty as to whether treatment of subclinical hypothyroidism (SCH) is associated with cardiovascular outcomes. Objectives: To determine whether levothyroxine replacement therapy decreases the risk of major adverse cardiovascular events (MACE) among individuals with SCH defined as having a thyrotropin (TSH) level between 5 and 10 mU/L. Design: We conducted a population-based cohort study using a prevalent new-user design. Setting: The study utilized data from the United Kingdom Clinical Practice Research Datalink. Participants: We identified a base cohort of individuals aged ≥18 years with incident SCH defined as having at least two TSH levels between 5 and 10 mU/L within one year between 1998 and 2018. We matched 76,946 levothyroxine treated to 76,946 untreated individuals based on age, sex, calendar time, duration of SCH, and time-conditional propensity score. We compared individuals with SCH treated with levothyroxine with individuals with no treatment. Exposure: Levothyroxine treatment versus no treatment. Main Outcome Measures: The primary outcome, MACE, was defined as a composite of nonfatal myocardial infarction, nonfatal ischemic stroke, and cardiovascular-related mortality. Results: The mean age of the study cohort was 62.8 years, and 76.5% were women. During a median follow-up time of 1.6 years (interquartile range: 0.5-4.2), the incidence rate for MACE among individuals treated with levothyroxine was 12.8 per 1000 person-years; confidence interval (CI): 12.2-13.3 and 13.9 per 1000 person-years; CI: 13.4-14.3 among nontreated individuals. Levothyroxine treatment was associated with a small decreased risk of MACE (hazard ratio: 0.88; CI: 0.83-0.93). Conclusions: Levothyroxine treatment of SCH was associated with a small decreased risk of MACE. However, given the observational nature of the study, residual confounding should be considered in the interpretation of this finding.

The evidence base of the 10 most prescribed drugs in England, France, and the United States: a scoping review

OBJECTIVES

To evaluate whether there is evidence of efficacy of the most commonly used medications in their primary indications.

STUDY DESIGN AND SETTING

This scoping review was executed using the Cochrane Library and MEDLINE databases up to May 2023. The 10 most prescribed medications in England, France, and the United States were identified using country-specific public databases. Up to 3 common indications in primary care were defined for each medication, based on a survey of general practitioners. The outcomes were determined by the authors to be patient-important outcomes, with placebo as the comparator. Two investigators independently conducted searches, following a predefined algorithm, to identify randomized controlled trials or meta-analyses of randomized controlled trials assessing the efficacy of these medications for each indication. The risk of bias was assessed using the ROBIS or ROB 2.0 tools.

RESULTS

We identified 21 drugs, covering 56 indications and 114 outcomes. Sixty-seven percent of the evaluated medications demonstrated efficacy for at least one outcome in at least one of the sought indications. Overall, evidence of efficacy was found for 48% of the indications. There was no study evaluating the efficacy of amoxicillin and salbutamol. For other drugs such as phloroglucinol or cholecalciferol, available studies suggested an absence of efficacy in the most common indications.

CONCLUSION

This study underscores the lack of data regarding the level of evidence for the most prescribed medications. Limitations include the choice of outcomes, and the understanding that the absence of evidence is not synonymous with the absence of efficacy.

Frequency and Determinants of Levothyroxine Therapy Initiation for Veterans with Subclinical Hypothyroidism

Background/Objectives: There is evidence of overtreatment in patients with subclinical hypothyroidism (SCH). We aimed to identify the proportion of patients treated for SCH and the determinants of thyroid hormone therapy initiation. Methods: We included a random sample of adult Veterans diagnosed with SCH from 1 January 2016 to 31 December 2018 and conducted univariate and multivariable logistic regression to identify factors associated with levothyroxine initiation. Results: Out of 229 Veterans with SCH [90.0% male, 87.2% White, 99.1% non-Hispanic, median age (interquartile range; IQR) 68 (17) years], 27.5% were treated with levothyroxine. The treated group had a higher proportion of White patients (95.2% vs. 84.2%, p = 0.039), a higher thyrotropin level [median (IQR), 6.98 (2.06) mIU/L vs. 6.14 (1.10) mIU/L, p = 0.0002], a higher proportion of patients with thyrotropin level ≥ 10 mIU/L (11.1% vs. 3.0%, p = 0.021), a lower frequency of confirmatory thyroid testing before initiating levothyroxine (49.2% vs. 97.0%, p < 0.0001), and a similar frequency of thyroid autoimmunity testing (3.2% vs. 0.6%, p = 0.18) compared to the untreated group. In a multivariable logistic regression analysis, White race (OR = 4.50, 95% CI 1.19 to 17.08, p = 0.026) and index thyrotropin level [OR = 1.71, 95% CI 1.24 to 2.35, p = 0.001; for every SD increase (1.6 mIU/L)] were associated with higher odds of treatment. Conclusions: Three in 10 Veterans with SCH received levothyroxine, often based on a single abnormal thyroid test without autoimmunity assessment. White race and higher thyrotropin level were linked to increased odds of starting treatment, indicating potential disparities and the influence of SCH severity on decision-making.

The determinants of leptin, angiopoietin like 8, and thyroid hormones levels in Saudi females with type 2 diabetes mellitus: A retrospective study

This study aimed to assess the prevalence of thyroid dysfunction, as measured by hormone levels, in Saudi women with type 2 diabetes mellitus (T2DM). The study will also assess thyroid hormones and leptin, angiopoietin like 8 (ANGPTL8), obesity, and cardiovascular diseases (CVD) in T2D patients. A total of 250 women aged 40 to 60 years with T2DM were retrospectively studied between 2021 and 2022. This research examined medical records for T2DM patients. In this investigation, no T2DM patients had thyroid autoantibodies in their medical records. These patients were chosen for their FT4 and TSH values. All participants were Saudi females with T2DM, aged 54.5 years. Of the 250 participants, 32% had hypothyroidism, 14.8% had hyperthyroidism, and 40.8% (102) had no thyroid disease. Hypothyroidism (7.8 ± 0.67 mmol/L) exhibited greater fasting blood glucose (FBG) levels than hyperthyroidism (7.1 ± 0.64 mmol/L) (P < .05). Hypothyroid and hyperthyroid females had significant differences in high density lipoprotein-cholestrol (HDL-C), triglycerides, triglyceride glucose (TyG) index, body mass index (BMI), waist circumstance (WC), high-sensitivity C-reactive protein (hs-CRP), leptin, ANGPTL8, insulin resistance (IR), and insulin levels (P < .05). Pearson's correlation test showed that T2DM patients' HDL-C levels were favorably but negatively correlated with leptin and ANGPTL8 levels. In hypothyroidism, thyroid stimulation hormone (TSH) is favorably linked with glycated hemoglobin (HbA1c), triglyscride (TG), TyG index, BMI, WC, leptin, ANGPTL8, hs-CRP, and IR. T2DM is linked to thyroid malfunction, notably hypothyroidism, which correlates positively with TSH. TSH variations due to increasing leptin, ANGPTL8, and TyG index may enhance the risk of insulin resistance diseases, such as obesity and CVD, in Saudi females with T2DM.

Nrf2, gp91phox and IL-17 are associated with severity and clinical outcomes of patients with subclinical hypothyroidism: a comparative study

The mechanisms underlying subclinical hypothyroidism (SCH) remain unclear, making timely and accurate differentiation between hypothyroidism and SCH, as well as severity assessment, challenging. This study aimed to investigate the role of NFE2 like bZIP transcription factor 2 (Nrf2), gp91phox, and interleukin-17 (IL-17) in the pathogenesis of SCH. In this prospective comparative study, 105 SCH patients, 105 hypothyroidism patients, and 105 healthy individuals were enrolled from January 2022 to August 2023. SCH patients were categorized into mild-moderate and severe groups based on thyroid-stimulating hormone (TSH) levels. Levels of TSH, free T4 (FT4), free T3 (FT3), thyroglobulin antibodies (TG-Ab), thyroid peroxidase antibodies (TPO-Ab), cholesterol (TC), triglycerides (TG), high-density lipoprotein-cholesterol (HDL-ch), and low-density lipoprotein-cholesterol (LDL-ch) were measured. Nrf2, IL-1β, IL-6, IL-17, and gp91phox levels were tested using ELISA. Nrf2, IL-17 and gp91phox were significantly higher in SCH and hypothyroidism patients compared to the healthy controls, with hypothyroidism patients showing the highest levels. Nrf2 levels were negatively correlated with TSH, TG-Ab and IL-17, but not gp91phox. Nrf2, IL-17 and gp91phox could be used for diagnosis of SCH and severe SCH. Only TG-Ab, IL-17 and gp91phox were independent risk factors for severe SCH. This study demonstrates a negative correlation between serum Nrf2 levels and SCH severity. TG-Ab, IL-17, and gp91phox are independent risk factors, and their associations with SCH pathology suggest their potential roles in the disease mechanism. These findings provide insights into SCH pathogenesis and highlight the need for further research to elucidate their diagnostic or prognostic significance.

The impact of severe nephrotic syndrome on thyroid function, nutrition and coagulation

Background

Nephrotic syndrome (NS) is characterized by urinary loss of proteins, including hormones and their carrier proteins, potentially resulting in endocrine disorders. This study aimed to assess thyroid dysfunction frequency and potential implications in NS.

Methods

In this case-control study, patients with severe NS (serum albumin ≤2.5 g/dl) and controls without proteinuria were evaluated for thyroid, haemostatic and nutritional parameters, including body composition.

Results

A total of 42 nephrotic and 40 non-proteinuric patients were enrolled. The NS group showed higher thyroid-stimulating hormone and lower free hormones, corresponding to a higher frequency of both euthyroid sick syndrome {ESS; 36% versus 5%; odds ratio [OR] 10.6 [95% confidence interval (CI) 2.2-50.0]} and hypothyroidism [31% versus 5%; OR 8.5 (95% CI 1.8-40.7)] compared with the control group. Levothyroxine supplementation was required for 11 NS patients (26% of the NS group). In addition, compared with control individuals, NS patients exhibited lower lean tissue mass and a trend towards hypercoagulability, which was evidenced by higher levels of most coagulation factors and fibrinolysis inhibitors, and reduced endogenous anticoagulants activities. Furthermore, NS patients with ESS presented with a 10.4 kg (95% CI -18.68 to -2.12) lower lean tissue mass. Those with hypothyroidism had significantly reduced activity of coagulation factor X [by -30% (95% CI -47 to -13)] and protein S [by -27% (95% CI -41 to -13)] compared with euthyroid NS individuals.

Conclusions

Thyroid dysfunction is common in severe NS, often necessitating levothyroxine supplementation, which supports routine thyroid workup. A potential link between thyroid, nutritional and coagulation disorders in NS requires further investigation.

Epigenetic impact of hypothyroidism on the functional differentiation of the mammary gland in rats

Mammary gland (MG) lactogenic differentiation involves epigenetic mechanisms. We have previously shown that hypothyroidism (HypoT) alters the MG transcriptome in lactation. However, the role of thyroid hormones (T3 and T4 a. k.a. THs) in epigenetic differentiation of MG is still unknown. We used a model of post-lactating HypoT rats to study in MG: a) Methylation and expression level of Gata3, Elf5, Stat6, Stat5a, Stat5b; b) Expression of Lalba, IL-4Rα and Ncoa1 mRNA; c) Histone H3 acetylation and d) Estrogen and progesterone concentration in serum. HypoT increases the estrogen serum level, decreases the progesterone level, promotes methylation of Stat5a, Stat5b and Stat6, decreasing their mRNA level and of its target genes (Lalba and IL-4Rα) and increases the Ncoa1 mRNA expression and histone H3 acetylation level. Our results proved that HypoT alters the post-lactation MG epigenome and could compromise mammary functional differentiation.

Subclinical hypothyroidism predicts outcome in heart failure: insights from the T.O.S.CA. registry

Subclinical hypothyroidism (SH), defined as increased serum thyroid-stimulating hormone (TSH) with normal free T4 (fT4) levels, is frequently observed in the general population. Prevalence ranges from 0.6% to 1.8% in the adult population, depending on age, sex, and iodine intake. Several studies reported a worse prognosis in patients with heart failure with reduced ejection fraction (HFrEF) and SH, but they considered heterogeneous populations suffering mainly from severe SH. Aim of this study was to evaluate if SH was independently associated with the occurrence of cardiovascular death considering 30 months of follow-up. 277 HFrEF patients enrolled in the prospective, multicenter, observational T.O.S.CA. (Terapia Ormonale Scompenso CArdiaco) registry, were included in this analysis. Patients were divided into two groups according to the presence of SH (serum TSH levels > 4.5 mIU/L with normal fT4 levels). Data regarding clinical status, echocardiography, and survival were analyzed. Twenty-three patients displayed SH (87% mild vs 13% severe), while 254 were euthyroid. No differences were found in terms of age, sex, HF etiology, and left ventricular ejection fraction. When compared with the euthyroid group, SH patients showed higher TSH levels (7.7 ± 4.1 vs 1.6 ± 0.9, p < 0.001), as expected, with comparable levels of fT4 (1.3 ± 0.3 vs 1.3 ± 0.3, p = NS). When corrected for established predictors of poor outcome in HF, the presence of SH resulted to be an independent predictor of cardiovascular mortality (HR: 2.96; 5-95% CI:1.13-7.74; p = 0.03). Since thyroid tests are widely available and inexpensive, they should be performed in HF patients to detect subclinical disorders, evaluate replacement therapy, and improve prognosis.

Towards Personalized TSH Reference Ranges: A Genetic and Population-Based Approach in Three Independent Cohorts

Background: Serum thyroid-stimulating hormone (TSH) measurement is the diagnostic cornerstone for primary thyroid dysfunction. There is high inter-individual but limited intra-individual variation in TSH concentrations, largely due to genetic factors. The currently used wide population-based reference intervals may lead to inappropriate management decisions. Methods: A polygenic score (PGS) including 59 genetic variants was used to calculate genetically determined TSH reference ranges in a thyroid disease-free cohort (n = 6,834). Its effect on reclassification of diagnoses was investigated when compared to using population-based reference ranges. Next, results were validated in a second independent population-based thyroid disease-free cohort (n = 3,800). Potential clinical implications were assessed in a third independent population-based cohort including individuals without thyroid disease (n = 26,321) as well as individuals on levothyroxine (LT4) treatment (n = 1,132). Results: PGS was a much stronger predictor of individual TSH concentrations than FT4 (total variance in TSH concentrations explained 9.2-11.1% vs. 2.4-2.7%, respectively) or any other nongenetic factor (total variance in TSH concentrations explained 0.2-1.8%). Genetically determined TSH reference ranges differed significantly between PGS quartiles in all cohorts, while the differences in FT4 concentrations were absent or only minor. Up to 24.7-30.1% of individuals, previously classified as having subclinical hypo- and hyperthyroidism when using population-based TSH reference ranges, were reclassified as euthyroid when genetically determined TSH reference ranges were applied. Individuals in the higher PGS quartiles had a higher probability of being prescribed LT4 treatment compared to individuals from the lower PGS quartiles (3.3% in Q1 vs. 5.2% in Q4, Pfor trend =1.7 × 10-8). Conclusions: Individual genetic profiles have the potential to personalize TSH reference ranges, with large effects on reclassification of diagnosis and LT4 prescriptions. As the currently used PGS can only predict approximately 10% of inter-individual variation in TSH concentrations, it should be further improved when more genetic variants determining TSH concentrations are identified in future studies.

Organ injury and its management in heart failure: Liver, kidney, and thyroid gland dysfunction

Heart failure is hemodynamically characterized as congestion and/or end-organ hypoperfusion, and is associated with increased morbidity and mortality. Underlying pathophysiology, such as neuro-hormonal activation, exacerbates heart failure and leads to functional deterioration of other organs. We have been conducting clinical research to study the pathophysiology of heart failure and discover prognostic factors. In this review article, we report the results and implications of our clinical research on heart failure.

The association between TSH and thyroid hormones in the normal or subclinical dysfunction range with left ventricular diastolic dysfunction

Thyroid hormones modulate the cardiovascular system. However, the effects of subclinical thyroid dysfunction and euthyroidism on cardiac function remain unclear. We investigated the association between left ventricular (LV) diastolic dysfunction and subclinical thyroid dysfunction or thyroid hormones within the reference range. This cross-sectional study included 26,289 participants (22,197 euthyroid, 3,671 with subclinical hypothyroidism, and 421 with subclinical thyrotoxicosis) who underwent regular health check-ups in the Republic of Korea. Individuals with thyroid stimulating hormone (TSH) levels > 4.2 µIU/mL and normal free thyroxine (FT4, 0.78-1.85 ng/dL) and triiodothyronine (T3, 76-190 ng/dL) levels were defined as having subclinical hypothyroidism. Individuals with serum TSH levels < 0.4 µIU/mL and normal FT4 and T3 levels were defined as having subclinical thyrotoxicosis. The cardiac structure and function were evaluated using echocardiography. LV diastolic dysfunction with normal ejection fraction (EF) was defined as follows: EF of > 50% and (a) E/e' ratio > 15, or (b) E/e' ratio of 8-15 and left atrial volume index ≥ 34 mL/m2. Subclinical hypothyroidism was significantly associated with cardiac indices regarding LV diastolic dysfunction. The odds of having LV diastolic dysfunction was also increased in participants with subclinical hypothyroidism (adjusted odds ratio [AOR] 1.36, 95% confidence interval [CI], 1.01-1.89) compared to euthyroid participants. Subclinical thyrotoxicosis was not associated with LV diastolic dysfunction. Among the thyroid hormones, only serum T3 was significantly and inversely associated with LV diastolic dysfunction even within the normal range. Subclinical hypothyroidism was significantly associated with LV diastolic dysfunction, whereas subclinical thyrotoxicosis was not. Serum T3 is a relatively important contributor to LV diastolic dysfunction compared to TSH or FT4.

Clearing the Skepticism about Subclinical Hypothyroidism: Is It Beneficial to Treat Patients with Thyroid-Stimulating Hormone >4.5 and <10 mIU/L?

Subclinical hypothyroidism (SCH) is a heterogeneous clinical condition ranging from asymptomatic to wide variety of clinical manifestations, which are often nonspecific. Being a common laboratory finding, clinicians often face the dilemma of whether to treat or not. Threshold of 10 mIU/L of thyroid-stimulating hormone (TSH) is often used as a cutoff limit to offer treatment. However, still, debate remains on whether to treat less than 10 mIU/L considering special clinical conditions like pregnancy. Whether SCH exists, is screening needed in asymptomatic individuals, is treating asymptomatic cases beneficial or harmful and what threshold level of TSH to be considered for treatment are all potential questions that need to be answered.

EMAS position statement: Thyroid disease and menopause

INTRODUCTION

Thyroid diseases are common in women in their late reproductive years; therefore, thyroid disease and menopause may co-exist. Both conditions may present with a wide range of symptoms, leading to diagnostic challenges and delayed diagnosis. Aim To construct the first European Menopause and Andropause Society (EMAS) statement on thyroid diseases and menopause.

MATERIALS AND METHODS

Literature review and consensus of expert opinion (EMAS executive board members/experts on menopause and thyroid disease).

SUMMARY RECOMMENDATIONS

This position paper highlights the diagnostic and therapeutic dilemmas in managing women with thyroid disease during the menopausal transition, aiming to increase healthcare professionals' awareness of thyroid disorders and menopause-related symptoms. Clinical decisions regarding the treatment of both conditions should be made with caution and attention to the specific characteristics of this age group while adopting a personalized patient approach. The latter must include the family history, involvement of the woman in the decision-making, and respect for her preferences, to achieve overall well-being.

Multifaceted physiological and therapeutical impact of curcumin on hormone-related endocrine dysfunctions: A comprehensive review

Over the past five decades, Curcumin (Cur), derived from turmeric (Curcuma longa), has gained considerable attention for its potential therapeutic applications. Synthesizing insights from clinical trials conducted over the last 25 years, this review delves into diseases where Cur has demonstrated promise, offering a nuanced understanding of its pharmacokinetics, safety, and effectiveness. Focusing on specific examples, the impact of Cur on various human diseases is explored. Endocrine glands and associated signaling pathways are highlighted, elucidating how Cur influences cellular signaling. The article underscores molecular mechanisms such as hormone level alteration, receptor interaction, cytokine and adipokine expression inhibition, antioxidant enzyme activity, and modulation of transcription factors. Cur showcases diverse protective mechanisms against inflammation and oxidative damage by suppressing antiapoptotic genes and impeding tumor promotion. This comprehensive overview emphasizes the potential of Cur as a natural agent for countering aging and degenerative diseases, calling for further dedicated research in this realm.

Liothyronine (LT3) prescribing in England: Are cost constraints inhibiting guideline implementation?

BACKGROUND

Primary hypothyroidism affects about 3% of the general population in Europe. In most cases people with hypothyroidism are treated with levothyroxine. In the context of the 2023 British Thyroid Association guidance and the 2020 Competitions and Marketing Authority (CMA) ruling, we examined prescribing data for levothyroxine, Natural desiccated thyroid (NDT) and liothyronine by dose, regarding changes over the years 2016-2022.

DESIGN

Monthly primary care prescribing data for each British National Formulary code were analysed for levothyroxine, liothyronine and NDT.

PATIENTS AND MEASUREMENTS

The rolling 12-month total/average of cost or prescribing volume was used to identify the moment of change. Results included number of prescriptions, the actual costs, and the cost/prescription/mcg of drug.

RESULTS

Liothyronine: In 2016 94% of the total 74,500 prescriptions were of the 20 mcg dose. In 2020 the percentage prescribed in the 5 mcg and 10 mcg doses started to increase so that by 2022 each reached nearly 27% of total liothyronine prescribing. The average cost/prescription in 2016 of 20 mcg was £404/prescription and this fell by 80% to £101 in 2022; while the 10 mcg cost of £348/prescription fell by only 35% to £255 and the 5 mcg cost of £355/prescription fell by 38% to £242/prescription. The total prescriptions of liothyronine in 2016 were 74,605, falling by 30% up to 2019 when they started to grow again - most recently at 60,990-15% lower than the 2016 figure, with the result that total costs fell by 70% to £9 m/year.

CONCLUSIONS

Liothyronine costs fell after the CMA ruling but remain orders of magnitude higher than for levothyroxine. The remaining 0.2% of patients with liothyronine treated hypothyroidism are still absorbing 16% of medication costs. The lower liothyronine 5cmg and 10 mcg doses as recommended by BTA are 240% the costs of the 20 mcg dose. Thus, following latest BTA guidance which recommends the lower liothyronine doses still incurs substantial additional costs vs the prescribing liothyronine in the no longer recommended treatment regime. High drug price continues to impact clinical decisions, potentially limiting liothyronine therapy availability to a considerable number of patients who could benefit from this treatment.

Nutritional and exercise interventions to improve conception in women suffering from obesity and distinct nosological entities

Infertility among women, particularly those living with obesity, presents a multifaceted challenge with implications for reproductive health worldwide. Lifestyle interventions, mainly focusing on weight loss, have emerged as promising strategies to improve fertility outcomes in this population. This review aims to explore the effectiveness of various lifestyle interventions, encompassing dietary modifications and exercise regimens, in enhancing fertility outcomes among women with obesity and associated conditions such as polycystic ovary syndrome, congenital adrenal hyperplasia, type 2 diabetes mellitus, premenopause, hypothyroidism and eating disorders. Methodology of study search encompass a broad spectrum, ranging from interventions targeting weight management through slow or rapid weight loss to dietary approaches emphasizing whole food groups, specific nutrients, and dietary patterns like low-carbohydrate or ketogenic diets, as well as the Mediterranean diet. By synthesizing existing findings and recommendations, this review contributes to the understanding of lifestyle interventions in addressing infertility, with an emphasis on the population of women of reproductive age with excess weight and known or unknown infertility issues, while promoting their integration into clinical practice to optimize reproductive health and overall well-being.

Risks of Iodine Excess

Iodine is a micronutrient that is required for thyroid hormone synthesis. The iodide cycle in thyroid hormone synthesis consists of a series of transport, oxidation, organification, and binding/coupling steps in thyroid follicular cells. Common sources of iodine include the consumption of an iodine-rich diet or iodine fortified foods, the administration of amiodarone, iodine-containing supplements, or iodinated contrast media, and other miscellaneous sources. Methods to assess population iodine status include the measurement of urinary iodine concentrations, blood thyroglobulin levels, prevalence of elevated neonatal TSH levels, and thyroid volume. Although excessive iodine intake or exposure is generally well tolerated, an acute iodine load may result in thyroid dysfunction (hypothyroidism or hyperthyroidism) in certain susceptible individuals due to the failure to escape from the Wolff-Chaikoff effect and to the Jod-Basedow phenomenon, respectively. In this review, we discuss the associations between excessive iodine intake or exposure, with particular focus on iodinated contrast media as a common source of excess iodine in healthcare settings, and risks of incident thyroid dysfunction. We also summarize the risks of iodine excess in vulnerable populations and review current guidelines regarding the screening and monitoring of iodinated contrast-induced thyroid dysfunction. Finally, we discuss the long-term potential nonthyroidal health risks associated with iodine excess and suggest the need for more data to define safe upper limits for iodine intake, particularly in high-risk populations.