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Nassar M, Hassan A, Ramadan S, Desouki MT, Hassan MA, Chaudhuri A. Evaluating the effectiveness of combined T4 and T3 therapy or desiccated thyroid versus T4 monotherapy in hypothyroidism: a systematic review and meta-analysis. BMC Endocr Disord 2024; 24:90. [PMID: 38877429 PMCID: PMC11177353 DOI: 10.1186/s12902-024-01612-6] [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: 02/07/2024] [Accepted: 05/24/2024] [Indexed: 06/16/2024] Open
Abstract
BACKGROUND Persistent symptoms in hypothyroid patients despite normalized TSH levels suggest the need for alternative treatments. This study aims to evaluate the effectiveness of combined T4 and T3 therapy or desiccated thyroid (DTE) compared to T4 monotherapy, with a focus on thyroid profile, lipid profile, and quality of life metrics. METHODS We conducted a systematic review in Embase, Medline/PubMed, and Web of Science up to 11/23/2023. We used the following keywords: "Armour Thyroid," OR "Thyroid extract," OR "Natural desiccated thyroid," OR "Nature-Throid," "desiccated thyroid," OR "np thyroid," OR "Synthroid," OR "levothyroxine," OR "Liothyronine," "Cytomel," OR "Thyroid USP," OR "Unithroid." AND "hypothyroidism. " We only included RCTs and excluded non-RCT, case-control studies, and non-English articles. RESULTS From 6,394 identified records, 16 studies qualified after screening and eligibility checks. We included two studies on desiccated thyroid and 15 studies on combined therapy. In this meta-analysis, combination therapy with T4 + T3 revealed significantly lower Free T4 levels (mean difference (MD): -0.34; 95% CI: -0.47, -0.20), Total T4 levels (mean difference: -2.20; 95% CI: -3.03, -1.37), and GHQ-28 scores (MD: -2.89; 95% CI: -3.16, -2.63), compared to T4 monotherapy. Total T3 levels were significantly higher in combined therapy (MD: 29.82; 95% CI: 22.40, 37.25). The analyses demonstrated moderate to high heterogeneity. There was no significant difference in Heart Rate, SHBG, TSH, Lipid profile, TSQ-36, and BDI Score. Subjects on DTE had significantly higher serum Total T3 levels (MD: 50.90; 95% CI: 42.39, 59.42) and significantly lower serum Total T4 (MD: -3.11; 95% CI: -3.64, -2.58) and Free T4 levels (MD: -0.50; 95% CI: -0.57, -0.43) compared to T4 monotherapy. Moreover, DTE treatment showed modestly higher TSH levels (MD: 0.49; 95% CI: 0.17, 0.80). The analyses indicated low heterogeneity. There was no significant difference in Heart Rate, SHBG, Lipid profile, TSQ-36, GHQ-28, and BDI Score. CONCLUSIONS Our study revealed that combined therapy and DTE lead to higher T3 and lower T4 levels, compared to T4 monotherapy in hypothyroidism. However, no significant effects on heart rate, lipid profile, or quality of life were noted. Given the heterogeneity of results, personalized treatment approaches are recommended.
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Affiliation(s)
- Mahmoud Nassar
- Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
- Jacobs School of Medicine and Biomedical Sciences, University of Buffalo, Buffalo, NY, USA
| | - Ahmed Hassan
- Department of Cardiology, Suez Medical Complex, Suez, Egypt.
| | | | | | - Malak A Hassan
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ajay Chaudhuri
- Jacobs School of Medicine and Biomedical Sciences, University of Buffalo, Buffalo, NY, USA
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Salloum-Asfar S, Shin KC, Taha RZ, Khattak S, Park Y, Abdulla SA. The Potential Role of Thyroid Hormone Therapy in Neural Progenitor Cell Differentiation and Its Impact on Neurodevelopmental Disorders. Mol Neurobiol 2024; 61:3330-3342. [PMID: 37991699 PMCID: PMC11087352 DOI: 10.1007/s12035-023-03751-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/28/2023] [Indexed: 11/23/2023]
Abstract
Thyroid hormone (T3) plays a vital role in brain development and its dysregulation can impact behavior, nervous system function, and cognitive development. Large case-cohort studies have associated abnormal maternal T3 during early pregnancy to epilepsy, autism, and attention deficit hyperactivity disorder (ADHD) in children. Recent experimental findings have also shown T3's influence on the fate of neural precursor cells and raise the question of its convergence with embryonic neural progenitors. Our objective was to investigate how T3 treatment affects neuronal development and functionality at the cellular level. In vitro experiments using neural precursor cells (NPCs) measured cell growth and numbers after exposure to varying T3 concentrations. Time points included week 0 (W0) representing NPCs treated with 100 nM T3 for 5 days, and differentiated cortical neurons assessed at weeks 3 (W3), 6 (W6), and 8 (W8). Techniques such as single-cell calcium imaging and whole-cell patch clamp were utilized to evaluate neuronal activity and function. IHC staining detected mature neuron markers, and RNA sequencing enabled molecular profiling. W6 and W8 neurons exhibited higher action potential frequencies, with W6 showing increased peak amplitudes and shortened inter-spike intervals by 50%, indicating enhanced activity. Transcriptomic analysis revealed that W6 T3-treated neurons formed a distinct cluster, suggesting accelerated maturation. Comparison with the whole transcriptome further unveiled a correlation between W6 neurons treated with T3 and neuronal regulatory elements associated with autism and ADHD. These findings provide insights into T3's impact on neuronal development and potential mechanisms of T3 dysregulation and neurodevelopmental disorders.
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Affiliation(s)
- Salam Salloum-Asfar
- Neurological Disorders Research Center, Qatar Biomedical Research Institute, Hamad Bin Khalifa University, Qatar Foundation, Doha, Qatar.
| | - Kyung Chul Shin
- Neurological Disorders Research Center, Qatar Biomedical Research Institute, Hamad Bin Khalifa University, Qatar Foundation, Doha, Qatar
| | - Rowaida Z Taha
- Neurological Disorders Research Center, Qatar Biomedical Research Institute, Hamad Bin Khalifa University, Qatar Foundation, Doha, Qatar
| | - Shahryar Khattak
- BESE and KAUST Smart-Health Initiative (KSHI), King Abdullah University of Science and Technology (KAUST), Thuwal, Saudi Arabia
| | - Yongsoo Park
- Neurological Disorders Research Center, Qatar Biomedical Research Institute, Hamad Bin Khalifa University, Qatar Foundation, Doha, Qatar
| | - Sara A Abdulla
- Neurological Disorders Research Center, Qatar Biomedical Research Institute, Hamad Bin Khalifa University, Qatar Foundation, Doha, Qatar.
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Penna GC, Salas-Lucia F, Ribeiro MO, Bianco AC. Gene polymorphisms and thyroid hormone signaling: implication for the treatment of hypothyroidism. Endocrine 2024; 84:309-319. [PMID: 37740833 PMCID: PMC10959761 DOI: 10.1007/s12020-023-03528-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/07/2023] [Indexed: 09/25/2023]
Abstract
INTRODUCTION Mutations and single nucleotide polymorphisms (SNPs) in the genes encoding the network of proteins involved in thyroid hormone signaling (TH) may have implications for the effectiveness of the treatment of hypothyroidism with LT4. It is conceivable that loss-of-function mutations or SNPs impair the ability of LT4 to be activated to T3, reach its targets, and ultimately resolve symptoms of hypothyroidism. Some of these patients do benefit from therapy containing LT4 and LT3. METHODS Here, we reviewed the PubMed and examined gene mutations and SNPs in the TH cellular transporters, deiodinases, and TH receptors, along with their impact on TH signaling, and potential clinical implications. RESULTS In some mechanisms, such as the Thr92Ala-DIO2 SNP, there is a compelling rationale for reduced T4 to T3 activation that limits the effectiveness of LT4 to restore euthyroidism. In other mechanisms, a potential case can be made but more studies with a larger number of individuals are needed. DISCUSSION/CONCLUSION Understanding the clinical impact of the genetic makeup of LT4-treated patients may help in the preemptive identification of those individuals that would benefit from therapy containing LT3.
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Affiliation(s)
- Gustavo C Penna
- Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, University of Chicago, Chicago, IL, USA
| | - Federico Salas-Lucia
- Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, University of Chicago, Chicago, IL, USA
| | - Miriam O Ribeiro
- Developmental Disorders Program, Center for Biological Sciences and Health, Mackenzie Presbyterian University, Sao Paulo, SP, Brazil
| | - Antonio C Bianco
- Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, University of Chicago, Chicago, IL, USA.
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Hadi ZM, Alidrisi HA, Mansour AA. Triiodothyronine/Thyroxine Ratio as a Marker of Clinical Response to Levothyroxine Replacement in Patients With Hypothyroidism. Cureus 2024; 16:e58370. [PMID: 38756268 PMCID: PMC11097253 DOI: 10.7759/cureus.58370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Hypothyroidism is one of the most common endocrine disorders with a simple therapy, that is levothyroxine (LT4). A normal thyroid-stimulating hormone (TSH) measurement is used as a marker of optimal replacement. But, many patients still have symptoms. Triiodothyronine (T3), thyroxine (T4), and their ratio may correlate with clinical improvement. The study aims to assess the T3/T4 ratio as a marker of clinical response in patients with hypothyroidism. Method: A cross-sectional study was conducted from June to November 2022 at Faiha Specialized Diabetes, Endocrine, and Metabolism Center, in Basrah, southern Iraq. We included 48 adult patients with primary hypothyroidism on LT4 treatment only and TSH within the target reference range for at least within the last six months. Each patient was subjected to a questionnaire that was designed to capture hypothyroidism-related complaints in the form of a five-point Likert scale. Biochemical assessments were done with the measurement of TSH, T3, and T4. RESULTS Despite having a normal TSH level, nearly all the patients had persistent and varying severity of clinical complaints of hypothyroidism. Tiredness, hair problems, weight gain, and cold intolerance were the most severely persistent symptoms. Patients with scores of two and more for weight gain, cold intolerance, and skin problems had significantly lower T3/T4 ratios (P = 0.04, 0.002, and 0.02, respectively), while in the remaining clinical symptoms, the T3/T4 ratio did not differ significantly. CONCLUSION A low T3/T4 ratio was significantly associated with resistant symptoms of hypothyroidism and may be used as a marker for treatment efficacy with TSH rather than TSH value alone.
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Affiliation(s)
- Zaid M Hadi
- Medicine, Faiha Specialized Diabetes, Endocrine, and Metabolism Center, Basrah, IRQ
| | - Haider A Alidrisi
- Diabetes and Endocrinology, Faiha Specialized Diabetes, Endocrine, and Metabolism Center, Basrah, IRQ
- Diabetes and Endocrinology, University of Basrah, College of Medicine, Basrah, IRQ
| | - Abbas A Mansour
- Diabetes and Endocrinology, Faiha Specialized Diabetes, Endocrine, and Metabolism Center, Basrah, IRQ
- Diabetes and Endocrinology, University of Basrah, College of Medicine, Basrah, IRQ
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Molewijk E, Fliers E, Dreijerink K, van Dooren A, Heerdink R. Quality of life, daily functioning, and symptoms in hypothyroid patients on thyroid replacement therapy: A Dutch survey. J Clin Transl Endocrinol 2024; 35:100330. [PMID: 38357535 PMCID: PMC10864335 DOI: 10.1016/j.jcte.2024.100330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/25/2024] [Accepted: 01/30/2024] [Indexed: 02/16/2024] Open
Abstract
Objective To explore the nature and extent of possible residual complaints among Dutch hypothyroid patients using thyroid replacement therapy, we initiated a comprehensive study measuring health-related quality of life (QoL), daily functioning, and hypothyroidism-associated symptoms in patients and control persons. Methods An online survey measuring thyroid-specific QoL (ThyPRO), daily functioning, and hypothyroidism-associated symptoms (ThySHI) was distributed among treated hypothyroid patients and control individuals. The advertising text was formulated in an open-ended manner. Patients also provided their most recent thyroid blood values and their thyroid medication. Results There was a large-sized impairment of QoL (Cohen's d = 1.04, +93 % ThyPRO score) in hypothyroid patients on thyroid replacement therapy (n = 1195) as compared to controls (n = 236). Daily functioning was significantly reduced i.e., general health (-38 %), problems with vigorous- (+64 %) and moderate activities (+77 %). Almost 80 % of patients reported having complaints despite thyroid medication and in-range thyroid blood values, with 75 % expressing a desire for improved treatment options for hypothyroidism (total n = 1194). Hypothyroid patients experienced 2.8 times more intense hypothyroidism-associated symptoms than controls (n = 865, n = 203 resp). Patients' median reported serum concentrations were: TSH 0.90 mU/L, FT4 17.0 pmol/L, and FT3 2.67 pmol/L, with 52 % having low T3 levels (<3.1 pmol/L). The QoL was not found to be related to age, sex, BMI, menopausal status, stress, serum thyroid parameters, the origin and duration of hypothyroidism, the type of thyroid medication, or the LT4 dose used. Conclusions Our study revealed major reductions in quality of life and daily functioning, and nearly three times more intense hypothyroidism-associated symptoms in treated hypothyroid patients as compared to controls, despite treatment and largely in-range serum TSH/FT4 concentrations. The QoL was not associated with serum thyroid parameters. We recommend future research into the origin of persisting complaints and the development of improved treatment modalities for hypothyroidism.
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Affiliation(s)
- Ellen Molewijk
- University of Applied Sciences Utrecht, Utrecht, the Netherlands
| | - Eric Fliers
- Amsterdam University Medical Centers, Location Academic Medical Center Amsterdam, Department of Endocrinology and Metabolism, Amsterdam Gastroenterology, Endocrinology & Metabolism, the Netherlands
| | - Koen Dreijerink
- Amsterdam University Medical Centers, Location VU University, Department of Endocrinology and Metabolism, Amsterdam Gastroenterology, Endocrinology & Metabolism, the Netherlands
| | - Ad van Dooren
- University of Applied Sciences Utrecht, Utrecht, the Netherlands
| | - Rob Heerdink
- University of Applied Sciences Utrecht, Utrecht, the Netherlands
- Utrecht Institute for Pharmaceutical Sciences, Utrecht, the Netherlands
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Tian X, Yin Z, Li Z, Wang Z, Xing Z, Liu C, Wang L, Wang C, Zhang J, Dong L. Regeneration of Thyroid Glands in the Spleen Restores Homeostasis in Thyroidectomy Mice. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2024; 11:e2305913. [PMID: 38059822 PMCID: PMC10853707 DOI: 10.1002/advs.202305913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/20/2023] [Indexed: 12/08/2023]
Abstract
Surgical removal of the thyroid gland (TG) for treating thyroid disorders leaves the patients on lifelong hormone replacement that partially compensates the physiological needs, but regenerating TG is challenging. Here, an approach is reported to regenerate TG within the spleen for fully restoring the thyroid's functions in mice, by transplanting thyroid tissue blocks to the spleen. Within 48 h, the transplanted tissue efficiently revascularizes, forming thyroid follicles similar to the native gland after 4 weeks. Structurally, the ectopically generated thyroid integrates with the surrounding splenic tissue while maintaining its integrity, separate from the lymphatic tissue. Functionally, it fully restores the native functions of the TG in hormone regulation in response to physiological stimuli, outperforming the established method of oral levothyroxine therapy in maintaining systemic homeostasis. The study demonstrates the full restoration of thyroid functions post-thyroidectomy by intrasplenic TG regeneration, providing fresh insights for designing novel therapies for thyroid-related disorders.
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Affiliation(s)
- Xue‐Jiao Tian
- State Key Laboratory of Pharmaceutical BiotechnologySchool of Life SciencesNanjing UniversityNanjingJiangsu210023China
| | - Zhi‐Jie Yin
- State Key Laboratory of Pharmaceutical BiotechnologySchool of Life SciencesNanjing UniversityNanjingJiangsu210023China
| | - Zhen‐Jiang Li
- State Key Laboratory of Pharmaceutical BiotechnologySchool of Life SciencesNanjing UniversityNanjingJiangsu210023China
| | - Zhen‐Zhen Wang
- State Key Laboratory of Pharmaceutical BiotechnologySchool of Life SciencesNanjing UniversityNanjingJiangsu210023China
| | - Zhen Xing
- State Key Laboratory of Pharmaceutical BiotechnologySchool of Life SciencesNanjing UniversityNanjingJiangsu210023China
- NJU Xishan Institute of Applied BiotechnologyXishan DistrictWuxiJiangsu214101China
| | - Chun‐Yan Liu
- State Key Laboratory of Pharmaceutical BiotechnologySchool of Life SciencesNanjing UniversityNanjingJiangsu210023China
| | - Lin‐Tao Wang
- State Key Laboratory of Pharmaceutical BiotechnologySchool of Life SciencesNanjing UniversityNanjingJiangsu210023China
| | - Chun‐Ming Wang
- State Key Laboratory of Quality Research in Chinese MedicineInstitute of Chinese Medical SciencesUniversity of MacauTaipaMacau SAR999078China
| | - Jun‐Feng Zhang
- State Key Laboratory of Pharmaceutical BiotechnologySchool of Life SciencesNanjing UniversityNanjingJiangsu210023China
| | - Lei Dong
- State Key Laboratory of Pharmaceutical BiotechnologySchool of Life SciencesNanjing UniversityNanjingJiangsu210023China
- NJU Xishan Institute of Applied BiotechnologyXishan DistrictWuxiJiangsu214101China
- National Resource Center for Mutant MiceNanjing210023China
- Chemistry and Biomedicine Innovative CenterNanjing UniversityNanjingJiangsu210023China
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Hidalgo J, Vallejo BA, Soto Jacome C, Ayala IN, Cordova S, Duran M, Golembiewski E, Toro-Tobon D, Brito JP. Real Practice Assessment of Persistent Symptoms After Initiation of Levothyroxine. Endocr Pract 2024; 30:95-100. [PMID: 37913925 DOI: 10.1016/j.eprac.2023.10.132] [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: 08/24/2023] [Revised: 10/19/2023] [Accepted: 10/27/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE Levothyroxine (LT4) is the standard treatment for hypothyroidism. However, certain patients experience persistent symptoms even after achieving euthyroid status with LT4 therapy. We aimed to determine the frequency of persistent or new symptoms in patients with hypothyroidism after initiating LT4. METHODS This retrospective study included patients with hypothyroidism who started on LT4 between January 2017 and December 2019 at Mayo Clinic in Rochester, Minnesota, USA. Five hundred patient charts were randomly selected for review. Patients with at least 1 documented follow-up encounter after LT4 initiation were evaluated for ≤3 follow-up visits regarding their biochemical status and symptoms. RESULTS We included 356 patients, a majority of whom were female (66.6%), white (92.3%), and obese (71.9%), with an average age of 59.5 years. At the baseline visit, approximately one-half of the patients (177/356, 47.7%) reported hypothyroid symptoms, with fatigue being the most common symptom. During the follow-up periods, we observed that 17.8% (28/157), 17.9% (19/106), and 19.3% (11/57) of patients had normal thyroid stimulating hormone (TSH) values but persistent symptoms, while 12.3% (19/156), 19.9% (16/107), and 8.9% (5/56) had normal TSH values but new symptoms. Overall, during each respective follow-up period, 26.7% (42/157), 27.3% (29/106), and 28% (16/57) of patients experienced persistent or new symptoms alongside normal TSH values, with fatigue being the most constant symptom. CONCLUSION Our findings indicate that approximately 1 in every 4 patients with hypothyroidism receiving LT4 therapy and achieving normal TSH levels experience persistent or new hypothyroid symptoms. The cause of these symptoms remains unclear, emphasizing the need for a better understanding of their underlying causes and the development of effective management strategies.
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Affiliation(s)
- Jessica Hidalgo
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, Minnesota
| | | | - Cristian Soto Jacome
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Ivan N Ayala
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Sandra Cordova
- Department of Cardiology, Mayo Clinic, Rochester, Minnesota
| | - Mayra Duran
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth Golembiewski
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - David Toro-Tobon
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Juan P Brito
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, Minnesota; Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
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Abstract
Levothyroxine (LT4) is effective for most patients with hypothyroidism. However, a minority of the patients remain symptomatic despite the normalization of serum thyrotropin levels. Randomized clinical trials including all types of patients with hypothyroidism revealed that combination levothyroxine and liothyronine (LT4+LT3) therapy is safe and is the preferred choice of patients versus LT4 alone. Many patients who do not fully benefit from LT4 experience improved quality of life and cognition after switching to LT4+LT3. For these patients, new slow-release LT3 formulations that provide stable serum T3 levels are being tested. In addition, progress in regenerative technology has led to the development of human thyroid organoids that restore euthyroidism after being transplanted into hypothyroid mice. Finally, there is a new understanding that, under certain conditions, T3 signaling may be compromised in a tissue-specific fashion while systemic thyroid function is preserved. This is seen, for example, in patients with metabolic (dysfunction)-associated fatty liver disease, for whom liver-selective T3-like molecules have been utilized successfully in clinical trials.
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Affiliation(s)
- Antonio C Bianco
- Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, University of Chicago School of Medicine, Chicago, Illinois, USA;
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Bapputty R, Sapa H, Masaru M, Gubitosi-Klug RA. Diabetes Modulates Iodothyronine Deiodinase 2 Expression in the Mouse Retina: A Role for Thyroid Hormone in the Pathogenesis of Diabetic Retinopathy. Invest Ophthalmol Vis Sci 2023; 64:3. [PMID: 38038617 PMCID: PMC10697172 DOI: 10.1167/iovs.64.15.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 11/09/2023] [Indexed: 12/02/2023] Open
Abstract
Purpose Clinical investigations associate hypothyroidism with an increased risk for microvascular complications, yet the mechanism by which thyroid hormone regulates the development of diabetic retinopathy is not clearly understood. We investigated the role of iodothyronine deiodinase 2 (DIO2) in the pathogenesis of diabetic retinopathy. Methods Retinas from streptozotocin-induced diabetic and nondiabetic mice were evaluated by RNA sequencing, RT-PCR, and immunostaining. Media and cell lysates from mouse retinal microvascular endothelial cells and retinal astrocytes exposed to physiologic (5 mM) and high glucose (25 mM) containing media were assessed by liquid chromatography-tandem mass spectrometry to measure tetraiodothyronine (T4) and tri-iodothyronine (T3) concentrations and by Western blot analysis to determine the relationship of T4/T3 to oxidative stress and inflammatory mediators. Cell death was determined by Trypan Blue exclusion assay. Results At 12 weeks of diabetes duration, retinas from diabetic mice compared with nondiabetic mice demonstrated a significant decrease in Dio2 transcripts and Dio2 gene and protein (P < 0.05) expression. When cultured in the presence of high glucose, both mouse retinal astrocytes and microvascular endothelial cells demonstrated a significant reduction of DIO2 protein compared with cells cultured in physiologic glucose. High glucose inhibited generation of T3, leading to a significantly increased T4/T3 (P < 0.0079). Supplementation of cells with T3, but not T4, prevented the high glucose-induced rise in endothelial nitric oxide synthase, intercellular cell adhesion molecule 1, and endothelial cell death (P < 0.0079). Conclusions Decreased intraretinal T3 owing to diabetes-induced loss of DIO2 may lead to dysfunction and death of cells in the retina, thereby contributing to the pathogenesis of early diabetic retinopathy.
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Affiliation(s)
- Reena Bapputty
- Department of Pediatrics, Case Western Reserve University School of Medicine/Rainbow Babies and Children's Hospital, Cleveland, Ohio, United States
| | - Hima Sapa
- Department of Nephrology and Hypertension, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
| | - Miyagi Masaru
- Department of Pharmacology, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
| | - Rose A. Gubitosi-Klug
- Department of Pediatrics, Case Western Reserve University School of Medicine/Rainbow Babies and Children's Hospital, Cleveland, Ohio, United States
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Caron P. Key data from the 2022 European Thyroid Association congress: Treatment of primary hypothyroidism: Levothyroxine alone or a combination of levothyroxine and liothyronine? ANNALES D'ENDOCRINOLOGIE 2023; 84:751-753. [PMID: 37285954 DOI: 10.1016/j.ando.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 05/22/2023] [Indexed: 06/09/2023]
Affiliation(s)
- Philippe Caron
- Department of Endocrinology and Metabolic Diseases, Cardiovascular and Metabolic Unit, CHU Larrey, 24, chemin de Pouvourville, TSA 30030, 31059 Toulouse cedex, France.
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Premawardhana LD, Taylor PN, Okosieme OE, Adlan MA, Obuobie EK, Dayan CM. Designing a combined liothyronine (LT3), L- thyroxine (LT4) trial in symptomatic hypothyroid subjects on LT4 - the importance of patient selection, choice of LT3 and trial design. Front Endocrinol (Lausanne) 2023; 14:1282608. [PMID: 38034018 PMCID: PMC10687631 DOI: 10.3389/fendo.2023.1282608] [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: 08/24/2023] [Accepted: 10/23/2023] [Indexed: 12/02/2023] Open
Abstract
Approximately 10%-15% of subjects with hypothyroidism on L-thyroxine (LT4) alone have persistent symptoms affecting their quality of life (QoL). Although the cause is unclear, there is evidence that "tissue T3 lack" may be responsible. If so, combining liothyronine (LT3) with LT4 would be helpful. However, randomized controlled trials (RCT), have not established greater efficacy for the LT3 + LT4 combination in these subjects than for LT4 alone. While the trial design may have been responsible, the use of unphysiological, short-acting LT3 preparations and non-thyroid-specific patient-reported outcome measures (PROMs) may have contributed. We recommend attention to the following aspects of trial design for future RCTs of LT3 + LT4 compared to LT4 alone: (a) Subject selection-(i) measurable symptoms (disadvantages should be recognized); (ii) using a validated thyroid specific PROM such as ThyPRO39 or the Composite scale derived from it; (iii) those taking over 1.2 μg/day or 100 μg/day (for pragmatic reasons) of LT4 defining a population likely without intrinsic thyroid activity who depend on exogenous LT4; (iv) recruiting a preponderance of subjects with autoimmune thyroiditis increasing generalisability; and (v) those with a high symptom load with a greater response to combination therapy e.g. those with the deiodinase 2 polymorphism. (b) The use of physiological LT3 preparations producing pharmacokinetic similarities to T3 profiles in unaffected subjects: two long-acting LT3 preparations are currently available and must be tested in phase 2b/3 RCTs. (c) The superiority of a crossover design in limiting numbers and costs while maintaining statistical power and ensuring that all subjects experienced the investigative medication.
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Affiliation(s)
- Lakdasa D. Premawardhana
- Thyroid Research Group, Division of Infection and Immunity, Cardiff University School of Medicine, Heath Park, Cardiff, United Kingdom
| | - Peter Nicholas Taylor
- Thyroid Research Group, Division of Infection and Immunity, Cardiff University School of Medicine, Heath Park, Cardiff, United Kingdom
| | - Onyebuchi E. Okosieme
- Thyroid Research Group, Division of Infection and Immunity, Cardiff University School of Medicine, Heath Park, Cardiff, United Kingdom
| | - Mohamed A. Adlan
- Section of Endocrinology, Ysbyty Ystrad Fawr and Royal Gwent Hospitals, Aneurin Bevan University Health Board, Newport, United Kingdom
| | - Emmanuel K. Obuobie
- Section of Endocrinology, Ysbyty Ystrad Fawr and Royal Gwent Hospitals, Aneurin Bevan University Health Board, Newport, United Kingdom
| | - Colin Mark Dayan
- Thyroid Research Group, Division of Infection and Immunity, Cardiff University School of Medicine, Heath Park, Cardiff, United Kingdom
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Nikanorova AA, Barashkov NA, Pshennikova VG, Teryutin FM, Nakhodkin SS, Solovyev AV, Romanov GP, Burtseva TE, Fedorova SA. A Systematic Review and Meta-Analysis of Free Triiodothyronine (FT3) Levels in Humans Depending on Seasonal Air Temperature Changes: Is the Variation in FT3 Levels Related to Nonshivering Thermogenesis? Int J Mol Sci 2023; 24:14052. [PMID: 37762355 PMCID: PMC10531421 DOI: 10.3390/ijms241814052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/08/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023] Open
Abstract
Thyroid hormones play a crucial role in regulating normal development, growth, and metabolic function. However, the controversy surrounding seasonal changes in free triiodothyronine (FT3) levels remains unresolved. Therefore, the aim of this study was to conduct a systematic review and meta-analysis of variations in FT3 levels in relation to seasonal air temperatures in the context of current knowledge about its role in nonshivering thermogenesis. Ten eligible articles with a total of 336,755 participants were included in the meta-analysis. The studies were categorized into two groups based on the air temperature: "Cold winter", where the winter temperature fell below 0 °C, and "Warm winter", where the winter temperature was above 0 °C. The analysis revealed that in cold regions, FT3 levels decreased in winter compared to summer (I2 = 57%, p < 0.001), whereas in warm regions, FT3 levels increased during winter (I2 = 28%, p < 0.001). These findings suggest that seasonal variations in FT3 levels are likely to be influenced by the winter temperature. Considering the important role of the FT3 in the nonshivering thermogenesis process, we assume that this observed pattern is probably related to the differences in use of thyroid hormones in the brown adipose tissue during adaptive thermogenesis, which may depend on intensity of cold exposure.
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Affiliation(s)
- Alena A. Nikanorova
- Yakut Science Centre of Complex Medical Problems, Yaroslavskogo 6/3, 677000 Yakutsk, Russia; (A.A.N.); (V.G.P.); (F.M.T.); (T.E.B.); (S.A.F.)
| | - Nikolay A. Barashkov
- Yakut Science Centre of Complex Medical Problems, Yaroslavskogo 6/3, 677000 Yakutsk, Russia; (A.A.N.); (V.G.P.); (F.M.T.); (T.E.B.); (S.A.F.)
| | - Vera G. Pshennikova
- Yakut Science Centre of Complex Medical Problems, Yaroslavskogo 6/3, 677000 Yakutsk, Russia; (A.A.N.); (V.G.P.); (F.M.T.); (T.E.B.); (S.A.F.)
| | - Fedor M. Teryutin
- Yakut Science Centre of Complex Medical Problems, Yaroslavskogo 6/3, 677000 Yakutsk, Russia; (A.A.N.); (V.G.P.); (F.M.T.); (T.E.B.); (S.A.F.)
| | - Sergey S. Nakhodkin
- M.K. Ammosov North-Eastern Federal University, Kulakovskogo 46, 677013 Yakutsk, Russia; (S.S.N.); (A.V.S.); (G.P.R.)
| | - Aisen V. Solovyev
- M.K. Ammosov North-Eastern Federal University, Kulakovskogo 46, 677013 Yakutsk, Russia; (S.S.N.); (A.V.S.); (G.P.R.)
| | - Georgii P. Romanov
- M.K. Ammosov North-Eastern Federal University, Kulakovskogo 46, 677013 Yakutsk, Russia; (S.S.N.); (A.V.S.); (G.P.R.)
| | - Tatiana E. Burtseva
- Yakut Science Centre of Complex Medical Problems, Yaroslavskogo 6/3, 677000 Yakutsk, Russia; (A.A.N.); (V.G.P.); (F.M.T.); (T.E.B.); (S.A.F.)
- M.K. Ammosov North-Eastern Federal University, Kulakovskogo 46, 677013 Yakutsk, Russia; (S.S.N.); (A.V.S.); (G.P.R.)
| | - Sardana A. Fedorova
- Yakut Science Centre of Complex Medical Problems, Yaroslavskogo 6/3, 677000 Yakutsk, Russia; (A.A.N.); (V.G.P.); (F.M.T.); (T.E.B.); (S.A.F.)
- M.K. Ammosov North-Eastern Federal University, Kulakovskogo 46, 677013 Yakutsk, Russia; (S.S.N.); (A.V.S.); (G.P.R.)
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Casula S, Ettleson MD, Bianco AC. Are We Restoring Thyroid Hormone Signaling in Levothyroxine-Treated Patients With Residual Symptoms of Hypothyroidism? Endocr Pract 2023; 29:581-588. [PMID: 37419565 PMCID: PMC11221272 DOI: 10.1016/j.eprac.2023.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 07/09/2023]
Abstract
INTRODUCTION Levothyroxine (LT4) at doses that maintain the serum thyroid-stimulating hormone levels within the normal range constitutes the standard of care for the treatment of hypothyroidism. After a few months, this eliminates the signs and symptoms of overt hypothyroidism in the majority of patients, owing to the endogenous activation of thyroxine to triiodothyronine, the biologically active thyroid hormone. Still, a small percentage of the patients (10%-20%) exhibit residual symptoms, despite having normal serum thyroid-stimulating hormone levels. These symptoms include cognitive, mood, and metabolic deficits, with a significant impairment in psychological well-being and quality of life. OBJECTIVE To provide a summary of progress in the approach of patients with hypothyroidism that exhibit residual symptoms despite treatment. METHODS We reviewed the current literature and here we focused on the mechanisms leading to a deficiency of T3 in some LT4-treated patients, the role of residual thyroid tissue and the rationale for combination therapy with LT4 + liothyronine (LT3). RESULTS A score of clinical trials comparing therapy with LT4 versus LT4 + LT3 concluded that both are safe and equally effective (neither is superior); however, these trials failed to recruit a sufficiently large number of patients with residual symptoms. New clinical trials that considered LT4-treated symptomatic patients revealed that such patients benefit from and prefer therapy containing LT4 + LT3; desiccated thyroid extract has also been used with similar results. A practical approach to patients with residual symptoms and on initiation of combination therapy with LT4 + LT3 is provided. CONCLUSION A recent joint statement of the American, British, and European Thyroid Associations recommends that a trial with combination therapy be offered to patients with hypothyroidism that do not fully benefit from therapy with LT4.
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Affiliation(s)
- Sabina Casula
- Department of Endocrinology, Miami Veterans Affairs Healthcare System, Miami, Florida
| | - Matthew D Ettleson
- Section of Adult and Pediatric Endocrinology and Metabolism, University of Chicago, Chicago, Illinois
| | - Antonio C Bianco
- Section of Adult and Pediatric Endocrinology and Metabolism, University of Chicago, Chicago, Illinois.
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14
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Deng Y, Han Y, Gao S, Dong W, Yu Y. The Physiological Functions and Polymorphisms of Type II Deiodinase. Endocrinol Metab (Seoul) 2023; 38:190-202. [PMID: 37150515 PMCID: PMC10164501 DOI: 10.3803/enm.2022.1599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 02/21/2023] [Indexed: 05/09/2023] Open
Abstract
Type II deiodinase (DIO2) is thought to provide triiodothyronine (T3) to the nucleus to meet intracellular needs by deiodinating the prohormone thyroxine. DIO2 is expressed widely in many tissues and plays an important role in a variety of physiological processes, such as controlling T3 content in developing tissues (e.g., bone, muscles, and skin) and the adult brain, and regulating adaptive thermogenesis in brown adipose tissue (BAT). However, the identification and cloning of DIO2 have been challenging. In recent years, several clinical investigations have focused on the Thr92Ala polymorphism, which is closely correlated with clinical syndromes such as type 2 diabetes, obesity, hypertension, and osteoarthritis. Thr92Ala-DIO2 was also found to be related to bone and neurodegenerative diseases and tumors. However, relatively few reviews have synthesized research on individual deiodinases, especially DIO2, in the past 5 years. This review summarizes current knowledge regarding the physiological functions of DIO2 in thyroid hormone signaling and adaptive thermogenesis in BAT and the brain, as well as the associations between Thr92Ala-DIO2 and bone and neurodegenerative diseases and tumors. This discussion is expected to provide insights into the physiological functions of DIO2 and the clinical syndromes associated with Thr92Ala-DIO2.
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Affiliation(s)
- Yan Deng
- Department of Histology and Embryology, School of Basic Medical Sciences, Southwest Medical University, China
| | - Yi Han
- Department of Histology and Embryology, School of Basic Medical Sciences, Southwest Medical University, China
| | - Sheng Gao
- Key Laboratory of Medical Electrophysiology of Ministry of Education and Medical Electrophysiological Key Laboratory of Sichuan Province, Institute of Cardiovascular Research, Southwest Medical University, Luzhou, China
| | - Wei Dong
- Key Laboratory of Medical Electrophysiology of Ministry of Education and Medical Electrophysiological Key Laboratory of Sichuan Province, Institute of Cardiovascular Research, Southwest Medical University, Luzhou, China
| | - Yang Yu
- Department of Histology and Embryology, School of Basic Medical Sciences, Southwest Medical University, China
- Key Laboratory of Medical Electrophysiology of Ministry of Education and Medical Electrophysiological Key Laboratory of Sichuan Province, Institute of Cardiovascular Research, Southwest Medical University, Luzhou, China
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15
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Mazeto GMFDS, Sgarbi JA, Ramos HE, Villagelin DGP, Nogueira CR, Vaisman M, Graf H, Carvalho GAD. Approach to adult patients with primary hypothyroidism in some special situations: a position statement from the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism (SBEM). ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2022; 66:871-882. [PMID: 36394484 PMCID: PMC10118754 DOI: 10.20945/2359-3997000000545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Primary hypothyroidism is a common disorder in clinical practice. The management of most cases of hypothyroidism is usually straightforward, but the best approach in some special situations may raise questions among physicians. This position statement was prepared by experts from the Brazilian Society of Endocrinology and Metabolism to guide the management of three special situations, namely, hypothyroidism in the elderly, subclinical hypothyroidism in patients with heart disease, and difficult-to-control hypothyroidism. The authors prepared the present statement after conducting a search on the databases MEDLINE/PubMed, LILACS, and SciELO and selecting articles with the best evidence quality addressing the selected situations. The statement presents information about the current approach to patients in these special situations.
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Jonklaas J. Restoration of euthyroidism with levothyroxine: implications of etiology of hypothyroidism and the degree of residual endogenous thyroid function. Front Endocrinol (Lausanne) 2022; 13:934003. [PMID: 35966075 PMCID: PMC9363917 DOI: 10.3389/fendo.2022.934003] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 05/01/2022] [Accepted: 06/27/2022] [Indexed: 01/13/2023] Open
Abstract
There are many thyroid-related factors that combine with non-thyroid-related factors in order to affect the patient response to treatment of hypothyroidism, in terms of their satisfaction with therapy. Some of the thyroid-derived factors include the etiology of the hypothyroidism and the amount of residual thyroid function that the patient retains. These two factors may be intertwined and affected by a third influence, the presence of thyroid peroxidase antibodies. The downstream consequences of the interactions between these three factors may influence both free thyroxine and free triiodothyronine levels, TSH concentrations, and various thyroid biomarkers. Evidence of the widespread importance of thyroid hormones can be inferred from the multiple genes that are regulated, with their regulation affecting multiple serum biomarkers. Thyroid biomarkers may extend from various well-known serum markers such as lipids and sex hormone-binding globulin to serum levels of thyroid hormone metabolites. Moreover, the interplay between thyroid hormones and biomarkers and their relative ratios may be different depending on the hypothyroidism etiology and degree of residual thyroid function. The ultimate significance of these relationships and their effect on determining patient-reported outcomes, quality of life, and patient satisfaction is, as yet, poorly understood. However, identification of better biomarkers of thyroid function would advance the field. These biomarkers could be studied and correlated with patient-reported outcomes in future prospective studies comparing the impact of various thyroid hormone therapies.
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Affiliation(s)
- Jacqueline Jonklaas
- Division of Endocrinology, Georgetown University, Washington, DC, United States
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Deligiorgi MV, Trafalis DT. The Clinical Relevance of Hypothyroidism in Patients with Solid Non-Thyroid Cancer: A Tantalizing Conundrum. J Clin Med 2022; 11:jcm11123417. [PMID: 35743483 PMCID: PMC9224934 DOI: 10.3390/jcm11123417] [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] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/06/2022] [Accepted: 06/08/2022] [Indexed: 02/06/2023] Open
Abstract
Hypothyroidism in patients with solid non-thyroid cancer is a tantalizing entity, integrating an intriguing thyroid hormones (THs)–cancer association with the complexity of hypothyroidism itself. The present narrative review provides a comprehensive overview of the clinical relevance of hypothyroidism in solid non-thyroid cancer. Hypothyroidism in patients with solid non-thyroid cancer is reminiscent of hypothyroidism in the general population, yet also poses distinct challenges due to the dual role of THs in cancer: promoting versus inhibitory. Close collaboration between oncologists and endocrinologists will enable the prompt and personalized diagnosis and treatment of hypothyroidism in patients with solid non-thyroid cancer. Clinical data indicate that hypothyroidism is a predictor of a decreased or increased risk of solid non-thyroid cancer and is a prognostic factor of favorable or unfavorable prognosis in solid non-thyroid cancer. However, the impact of hypothyroidism with respect to the risk and/or prognosis of solid non-thyroid cancer is not a consistent finding. To harness hypothyroidism, or THs replacement, as a personalized anticancer strategy for solid non-thyroid cancer, four prerequisites need to be fulfilled, namely: (i) deciphering the dual THs actions in cancer; (ii) identifying interventions in THs status and developing agents that block tumor-promoting THs actions and/or mimic anticancer THs actions; (iii) appropriate patient selection; and (iv) counteracting current methodological limitations.
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18
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Thorkildsen MS, Mohus RM, Åsvold BO, Skei NV, Nilsen TIL, Solligård E, Damås JK, Gustad LT. Thyroid function and risk of bloodstream infections: Results from the Norwegian prospective population-based HUNT Study. Clin Endocrinol (Oxf) 2022; 96:896-906. [PMID: 34951039 DOI: 10.1111/cen.14658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 10/14/2021] [Accepted: 12/05/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Previous studies on thyroid function and risk of infection is conflicting and often stem from intensive care cohorts were nonthyroidal illness syndrome (NTIS) may be present. The objective of this study was to identify the risk of bloodstream infections (BSI) and BSI-related mortality with thyroid-stimulating hormone (TSH) levels within the reference range in a general population. DESIGN Prospective follow-up. PARTICIPANTS The HUNT2 (1995-97) included 34,619 participants with information on TSH levels. MEASUREMENTS Hazard ratios (HRs) with 95% confidence interval (CI) confirmed BSIs and BSI-related mortality until 2011. RESULTS During a median follow-up of 14.5 years, 1179 experienced at least one episode of BSI and 208 died within 30 days after a BSI. TSH levels within the reference range of 0.5-4.5 mU/L were not associated with the risk of first-time BSI, with an HR of 0.97 (95% CI: 0.90-1.04) per mU/L. Stratified by baseline age < or ≥65 years, TSH was inversely associated with the risk of BSI (HR: 0.88; 95% CI: 0.78-1.00 per mU/L) in the youngest age group only. Persons with any baseline thyroid disease had a 30% risk and the hyperthyroid subgroup a 57%, and hypothyroidism a 20% increased risk of BSI. TSH levels were not clearly associated with BSI mortality, but the HRs were imprecise due to few BSI-related deaths. CONCLUSION There was some evidence of a weak inverse association between TSH levels and the risk of BSI in persons below 65 years of age. The increased risk seen in persons with thyroid illness is probably explained by confounding by concurrent ill health.
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Affiliation(s)
- Marianne S Thorkildsen
- Gemini Center for Sepsis Research at Institute of Circulation and Medical Imaging, NTNU, Trondheim, Norway
| | - Randi M Mohus
- Gemini Center for Sepsis Research at Institute of Circulation and Medical Imaging, NTNU, Trondheim, Norway
- Clinic of Anesthesia and Intensive Care, St. Olavs Hospital, Trondheim, Norway
| | - Bjørn O Åsvold
- Department of Public Health and Nursing, K.G. Jebsen Center for Genetic Epidemiology, NTNU, Trondheim, Norway
- Department of Endocrinology, Clinic of Medicine, St. Olavs Hospital, Trondheim, Norway
- Department of Public Health and Nursing, HUNT Research Centre , NTNU, Levanger, Norway
| | - Nina V Skei
- Gemini Center for Sepsis Research at Institute of Circulation and Medical Imaging, NTNU, Trondheim, Norway
- Department of Anesthesia and Intensive Care, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
| | - Tom I L Nilsen
- Clinic of Anesthesia and Intensive Care, St. Olavs Hospital, Trondheim, Norway
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Erik Solligård
- Gemini Center for Sepsis Research at Institute of Circulation and Medical Imaging, NTNU, Trondheim, Norway
- Clinic of Anesthesia and Intensive Care, St. Olavs Hospital, Trondheim, Norway
| | - Jan K Damås
- Gemini Center for Sepsis Research at Institute of Circulation and Medical Imaging, NTNU, Trondheim, Norway
- Centre of Molecular Inflammation Research, NTNU, Trondheim, Norway
- Department of Clinical and Molecular Medicine, NTNU, Trondheim, Norway
- Department of Infectious Diseases, St. Olavs Hospital, Trondheim, Norway
| | - Lise T Gustad
- Gemini Center for Sepsis Research at Institute of Circulation and Medical Imaging, NTNU, Trondheim, Norway
- Clinic of Medicine and Rehabilitation, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
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Abstract
Hypothyroidism is the common clinical condition of thyroid hormone deficiency and, if left untreated, can lead to serious adverse health effects on multiple organ systems, with the cardiovascular system as the most robustly studied target. Overt primary hypothyroidism is defined as elevated thyroid-stimulating hormone (TSH) concentration in combination with free thyroxine (fT4) concentration below the reference range. Subclinical hypothyroidism, commonly considered an early sign of thyroid failure, is defined by elevated TSH concentrations but fT4 concentrations within the reference range. Hypothyroidism is classified as primary, central or peripheral based on pathology in the thyroid, the pituitary or hypothalamus, or peripheral tissue, respectively. Acquired primary hypothyroidism is the most prevalent form and can be caused by severe iodine deficiency but is more frequently caused by chronic autoimmune thyroiditis in iodine-replete areas. The onset of hypothyroidism is insidious in most cases and symptoms may present relatively late in the disease process. There is a large variation in clinical presentation and the presence of hypothyroid symptoms, especially in pregnancy and in children. Levothyroxine (LT4) is the mainstay of treatment and is one of the most commonly prescribed drugs worldwide. After normalization of TSH and fT4 concentrations, a considerable proportion of patients treated with LT4 continue to have persistent complaints, compromising quality of life. Further research is needed regarding the appropriateness of currently applied reference ranges and treatment thresholds, particularly in pregnancy, and the potential benefit of LT4/liothyronine combination therapy for thyroid-related symptom relief, patient satisfaction and long-term adverse effects.
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20
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Perros P, Hegedus L. Enhanced Well-Being Associated with Thyrotoxicosis: A Neglected Effect of Thyroid Hormones? Int J Endocrinol Metab 2022; 20:e127230. [PMID: 35993034 PMCID: PMC9375936 DOI: 10.5812/ijem-127230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 05/14/2022] [Accepted: 05/15/2022] [Indexed: 11/29/2022] Open
Abstract
CONTEXT Thyrotoxicosis may be associated with a better sense of well-being than in the euthyroid state, though this is not widely recognised. EVIDENCE ACQUISITION A comprehensive literature search in PubMed and Google Scholar, was performed to identify studies investigating factors influencing well-being, mood, and psychological features associated with elevated thyroid hormones. RESULTS Enhanced well-being associated with thyrotoxicosis has been described, although the evidence is observational and anecdotal. CONCLUSIONS Enhanced well-being associated with thyrotoxicosis is probably experienced in a minority of patients and may explain why some seek overtreatment with thyroid hormones and report significant improvement on larger than physiological thyroid hormone replacement regimens. It may also explain why some patients with hyperthyroidism (usually due to Graves' disease) are reluctant to adhere to anti-thyroid medication.
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Affiliation(s)
- Petros Perros
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
- Corresponding Author: Department of Endocrinology, Royal Victoria Infirmary, Newcastle Upon Tyne, UK.
| | - Laszlo Hegedus
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
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Ettleson MD, Raine A, Batistuzzo A, Batista SP, McAninch E, Teixeira MCT, Jonklaas J, Laiteerapong N, Ribeiro MO, Bianco AC. Brain Fog in Hypothyroidism: Understanding the Patient's Perspective. Endocr Pract 2022; 28:257-264. [PMID: 34890786 PMCID: PMC8901556 DOI: 10.1016/j.eprac.2021.12.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/20/2021] [Accepted: 12/02/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Patient-centered studies have shown that several patients on thyroid hormone replacement therapy for hypothyroidism exhibit persistent symptoms, including "brain fog." Here, we aimed to determine which of these specific symptoms are associated with brain fog, identify patient-reported factors that modify these symptoms, and identify patient concerns related to brain fog not included in thyroid-specific questionnaires. METHODS A survey on brain fog symptoms adapted from thyroid-specific patient-reported outcome was distributed online. Textual data analysis was performed to identify common areas of concern from open-ended survey responses. RESULTS A total of 5170 participants reporting brain fog while being treated for hypothyroidism were included in the analysis. Of these, 2409 (46.6%) participants reported symptom onset prior to the diagnosis of hypothyroidism, and 4096 (79.2%) participants experienced brain fog symptoms frequently. Of the symptoms listed, participants associated fatigue and forgetfulness most frequently with brain fog. More rest was the most common factor provided for improving symptoms. The textual data analysis identified areas of concern that are not often included in thyroid-specific quality of life questionnaires, including a focus on the diagnosis of hypothyroidism, the types and doses of medications, and the patient-doctor relationship. CONCLUSION Brain fog in patients treated for hypothyroidism was associated most frequently with fatigue and cognitive symptoms. Several additional areas of patient concern were found to be associated with brain fog, which are not typically addressed in thyroid-specific questionnaires.
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Affiliation(s)
- Matthew D. Ettleson
- University of Chicago, Section of Endocrinology, Diabetes, and Metabolism, Chicago, Illinois,Address correspondence to Dr Matthew D. Ettleson, University of Chicago, Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, 5841 S. Maryland Ave. MC1027, Chicago, IL 60637. (M.D. Ettleson)
| | - Ava Raine
- Carleton College, Northfield, Minnesota
| | - Alice Batistuzzo
- Developmental Disorders Program, Center for Biological Sciences and Health, Mackenzie Presbyterian University, Sao Paulo SP, Brazil
| | - Samuel P. Batista
- Developmental Disorders Program, Center for Biological Sciences and Health, Mackenzie Presbyterian University, Sao Paulo SP, Brazil
| | - Elizabeth McAninch
- Stanford University Medical Center, Division of Endocrinolgoy, Gerontology, and Metabolism, Stanford Hospital, Stanford, California
| | - Maria Cristina T.V. Teixeira
- Developmental Disorders Program, Center for Biological Sciences and Health, Mackenzie Presbyterian University, Sao Paulo SP, Brazil
| | - Jacqueline Jonklaas
- Georgetown University Medical Center, Division of Endocrinology, Washington, DC
| | - Neda Laiteerapong
- University of Chicago, Section of General Internal Medicine, Chicago, Illinois
| | - Miriam O. Ribeiro
- Developmental Disorders Program, Center for Biological Sciences and Health, Mackenzie Presbyterian University, Sao Paulo SP, Brazil
| | - Antonio C. Bianco
- University of Chicago, Section of Endocrinology, Diabetes, and Metabolism, Chicago, Illinois
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22
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Maki Y, Horiuchi K, Okamoto T. Fatigue and quality of life among thyroid cancer survivors without persistent or recurrent disease. Endocr Connect 2022; 11:EC-21-0506.R1. [PMID: 35107083 PMCID: PMC8942325 DOI: 10.1530/ec-21-0506] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/02/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Cancer-related fatigue is one of the most important issues for patients, but research on this topic is sparse. This study aimed to determine the prevalence of fatigue in postoperative patients with papillary thyroid carcinoma (PTC) and to identify the clinical features associated with fatigue. METHODS We conducted a cross-sectional study on 292 thyroid cancer survivors. Fatigue and quality of life were the study outcomes, measured using the Cancer Fatigue Scale (CFS) and the SF-36 version 2.0. Furthermore, correlations of demographic characteristics and hormonal data with the CFS scores were assessed by univariable and multivariable analyses. RESULTS The prevalence of fatigue was 41.8% (95% CI: 36.1, 47.5). The CFS score was significantly correlated with the free T3 level (Pearson's r = -0.123, 95% CI: -0.234, -0.008). Multiple regression analysis revealed that the free T3 level and having a job were significant predictors of the CFS score, with unstandardized regression coefficients of -2.52 (95% CI: -4.94, -0.09) and 2.85 (95% CI: 0.49, 5.20), respectively. The median Z-scores were negative for General Health (-0.28) and Vitality (-0.15) subscales of the SF-36. The CFS score was a significant predictor of summary scores of the SF-36. The free T3 level was significantly associated with the physical component summary score with an unstandardized coefficient of 3.20 (95% CI: 0.77, 5.63). CONCLUSIONS Fatigue was prevalent and associated with poor quality of life among PTC survivors. Thyroid functional status, particularly the level of free T3, may be worth to be considered in alleviating the burden.
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Affiliation(s)
- Yukari Maki
- Department of Pediatric Surgery, Tokyo Women’s Medical University, Shinjuku-ku, Tokyo, Japan
| | - Kiyomi Horiuchi
- Department of Endocrine Surgery, Tokyo Women’s Medical University, Shinjuku-ku, Tokyo, Japan
- Correspondence should be addressed to K Horiuchi:
| | - Takahiro Okamoto
- Department of Endocrine Surgery, Tokyo Women’s Medical University, Shinjuku-ku, Tokyo, Japan
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Ito H, Fukuda K, Ashida K, Nagayama A, Sako T, Mizuochi K, Kabashima M, Yoshinobu S, Iwata S, Hasuzawa N, Hayashi S, Akashi T, Nomura M. Case Report: Myxedema Coma Caused by Immunoglobulin A Vasculitis in a Patient With Severe Hypothyroidism. Front Immunol 2022; 13:838739. [PMID: 35251034 PMCID: PMC8895252 DOI: 10.3389/fimmu.2022.838739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 01/24/2022] [Indexed: 11/16/2022] Open
Abstract
Myxedema coma is a critical disorder with high mortality rates. Disruption of the compensatory mechanism for severe and long-term hypothyroidism by various causes leads to critical conditions, including hypothermia, respiratory failure, circulatory failure, and central nervous system dysfunction. Infectious diseases, stroke, myocardial infarction, sedative drugs, and cold exposure are considered the main triggers for myxedema coma. A 59-year-old Japanese woman presented with bilateral painful purpura on her lower legs. She was diagnosed with coexisting immunoglobulin A (IgA) vasculitis and severe IgA vasculitis with nephritis and was consequently treated with intravenous methylprednisolone (125 mg/day). However, she rapidly developed multiple organ failure due to the exacerbation of severe hypothyroidism, i.e., myxedema. Her condition improved significantly following oral administration of prednisolone along with thyroxine. There was a delayed increase in the serum free triiodothyronine level, while the serum free thyroxine level was quickly restored to normal. Rapid deterioration of the patient’s condition after admission led us to diagnose her as having myxedema coma triggered by IgA vasculitis. Hence, clinicians should be aware of the risks of dynamic exacerbations in patients with hypothyroidism. Furthermore, our study suggested that combination therapy with thyroxine and liothyronine might prove effective for patients with myxedema coma, especially for those who require high-dose glucocorticoid administration.
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Affiliation(s)
- Hiroshi Ito
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
- Department of Diabetology, Shimada Hospital, Ogori, Japan
| | - Kenzo Fukuda
- Department of Diabetology, Shimada Hospital, Ogori, Japan
- Department of Intensive Care Medicine, Imamura Hospital, Tosu, Japan
| | - Kenji Ashida
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
- Department of Diabetology, Shimada Hospital, Ogori, Japan
- *Correspondence: Kenji Ashida ,
| | - Ayako Nagayama
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Tomoki Sako
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Kouichiro Mizuochi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Masaharu Kabashima
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Satoko Yoshinobu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Shimpei Iwata
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Nao Hasuzawa
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Sumika Hayashi
- Department of Diabetology, Shimada Hospital, Ogori, Japan
| | | | - Masatoshi Nomura
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
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Ashraf H, Heydari M, Shams M, Zarshenas MM, Tavakoli A, Sayadi M. Efficacy of Ginger Supplementation in Relieving Persistent Hypothyroid Symptoms in Patients with Controlled Primary Hypothyroidism: A Pilot Randomized, Double-Blind, Placebo-Controlled Clinical Trial. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2022; 2022:5456855. [PMID: 35096113 PMCID: PMC8794674 DOI: 10.1155/2022/5456855] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 12/31/2021] [Accepted: 01/04/2022] [Indexed: 11/17/2022]
Abstract
Primary hypothyroidism is a common disease. Some patients have persistent symptoms despite normal serum thyroid-stimulating hormone (TSH) levels. Ginger is reported to be beneficial in relieving similar symptoms. Our aim was to evaluate the efficacy of ginger supplementation in relieving persistent symptoms in these patients. In this randomized, double-blind, placebo-controlled clinical trial, 60 hypothyroid patients aged 20-60 years with normal serum TSH concentrations were randomly allocated to two equal parallel study groups of ginger (500 mg twice a day) or placebo for 30 days. Hypothyroid symptoms were evaluated as the primary outcome using the Thyroid Symptom Rating Questionnaire (ThySRQ) before and after the intervention. Anthropometric measures and laboratory indices including TSH, triglyceride (TG), total cholesterol (TChol), and fasting blood sugar (FBS) were considered as secondary outcomes. A significant lower mean total ThySRQ score (8.63 ± 5.47 vs. 15.76 ± 6.09, P < 0.001) was observed in the ginger group compared to the control group. Ginger led to significant improvements in the mean scores of the weight gain, cold intolerance, constipation, dry skin, appetite, memory loss, concentration disturbance, and feeling giddy or dizzy domains (P < 0.001). However, no significant improvements were observed in hair loss, nail fragility, hearing, hoarseness, speech, and depression or feeling down (P > 0.05). Ginger supplementation also led to a significant decrease in body weight, body mass index, waist circumference, serum TSH, FBS, TG, and TChol levels compared to the placebo. In summary according to preliminary results of this study, ginger supplementation can help relieve persistent hypothyroid symptoms. Also, it may have beneficial effects in terms of weight reduction and regulation of the FBS and lipid profile in hypothyroid patients.
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Affiliation(s)
- Hamide Ashraf
- Department of Persian Medicine, School of Medicine, Shiraz University of Medical Science, Shiraz, Iran
- Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mojtaba Heydari
- Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mesbah Shams
- Endocrinology and Metabolism Research Center, Shiraz University of Medical Science, Shiraz, Iran
| | - Mohammad Mehdi Zarshenas
- Medicinal Plants Processing Research Center, School of Pharmacy, Shiraz University of Medical Science, Shiraz, Iran
- Department of Phytopharmaceuticals (Traditional Pharmacy), School of Pharmacy, Shiraz University of Medical Science, Shiraz, Iran
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Tavakoli
- Department of Persian Medicine, School of Medicine, Shiraz University of Medical Science, Shiraz, Iran
- Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehrab Sayadi
- Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Cui Z, Ding X, Bian N, Chang X, Wang J, An Y, Liu J, Wang G. Relatively Lower FT3 Levels Are Associated with Impaired Quality of Life in Levothyroxine-Treated Patients with Hashimoto Thyroiditis. Int J Endocrinol 2022; 2022:1918674. [PMID: 35311029 PMCID: PMC8926544 DOI: 10.1155/2022/1918674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 01/31/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Patients with Hashimoto thyroiditis (HT) frequently have some complaints despite achieving euthyroidism after levothyroxine (LT4) treatment. This study aimed to investigate the relevant factors affecting the quality of life (QoL) in euthyroid HT patients after LT4 treatment. METHODS In this case-control study, 133 participants with HT were included. They were divided into two groups: 64 euthyroid HT subjects (control group) and 69 HT patients were rendered euthyroid by LT4 treatment (well-controlled group). QoL was measured with the Thyroid-Related Patient-Reported Outcome (ThyPRO-39) questionnaire. RESULTS Both study groups were well matched with respect to gender, age, BMI, euthyroidism, and thyroid antibodies (TPOAb and TGAb). Compared with the control group, the well-controlled group had lower FT3 (P < 0.01) levels. Of note, QoL was impaired on all scales in the well-controlled group. Moreover, ThyPRO-39 scores among the well-controlled group were significantly higher (worse) than the control group in all scales. Regarding the composite scale, its score was related to FT3 (r = -0.176, P=0.043) but not to FT4 and TSH levels. Further logistic regression analysis revealed FT3 was significantly associated with elevated composite QoL [0.128 (0.029-0.577), P < 0.01] after adjustment of potential confounders. CONCLUSION Relatively lower FT3 concentrations, even within the normal reference range, were related to impaired QoL in HT patients treated with LT4. This finding supports the great value of FT3 in clinical decision-making on dose adequacy.
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Affiliation(s)
- Zhijun Cui
- Department of Endocrinology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Xiaoyu Ding
- Department of Endocrinology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Nannan Bian
- Department of Endocrinology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Xiaona Chang
- Department of Endocrinology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Jiaxuan Wang
- Department of Endocrinology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Yu An
- Department of Endocrinology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Jia Liu
- Department of Endocrinology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Guang Wang
- Department of Endocrinology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
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Ettleson MD, Papaleontiou M. Evaluating health outcomes in the treatment of hypothyroidism. Front Endocrinol (Lausanne) 2022; 13:1026262. [PMID: 36329885 PMCID: PMC9623066 DOI: 10.3389/fendo.2022.1026262] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 08/23/2022] [Accepted: 10/04/2022] [Indexed: 11/13/2022] Open
Abstract
Clinical hypothyroidism is defined by the inadequate production of thyroid hormone from the thyroid gland to maintain normal organ system functions. For nearly all patients with clinical hypothyroidism, lifelong treatment with thyroid hormone replacement is required. The primary goal of treatment is to provide the appropriate daily dose of thyroid hormone to restore normal thyroid function for each individual patient. In current clinical practice, normalization of thyrotropin (TSH) level is the primary measure of effectiveness of treatment, however the use of a single biomarker to define adequate thyroid hormone replacement is being reevaluated. The assessment of clinical health outcomes and patient-reported outcomes (PROs), often within the context of intensity of treatment as defined by thyroid function tests (i.e., undertreatment, appropriate treatment, or overtreatment), may play a role in evaluating the effectiveness of treatment. The purpose of this narrative review is to summarize the prominent health outcomes literature in patients with treated hypothyroidism. To date, overall mortality, cardiovascular morbidity and mortality, bone health and cognitive function have been evaluated as endpoints in clinical outcomes studies in patients with treated hypothyroidism. More recent investigations have sought to establish the relationships between these end results and thyroid function during the treatment course. In addition to clinical event outcomes, patient-reported quality of life (QoL) has also been considered in the assessment of adequacy of hypothyroidism treatment. From a health care quality perspective, treatment of hypothyroidism should be evaluated not just on its effectiveness for the individual patients but also to the extent to which patients of different sociodemographic groups are treated equally. Ultimately, more research is needed to explore differences in health outcomes between different sociodemographic groups with hypothyroidism. Future prospective studies of treated hypothyroidism that integrate biochemical testing, PROs, and end result clinical outcomes could provide a more complete picture into the effectiveness of treatment of hypothyroidism.
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Affiliation(s)
- Matthew D. Ettleson
- Section of Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, IL, United States
- *Correspondence: Matthew D. Ettleson,
| | - Maria Papaleontiou
- Division of Metabolism, Endocrinology and Diabetes and Institute of Gerontology, University of Michigan, Ann Arbor, MI, United States
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Amich I, Anguita E, Escribano-Serrat S, Alvarez C, Rodríguez-Muñoz D, García V, Bello R, Peña-Pedrosa JA, Martínez-Micaelo N, Amigó N, Ortiz P, Torrejón MJ, Boscá L, Martín-Sánchez J, Aranda A, Alemany S. Free triiodothyronine levels and age influences the metabolic profile and COVID-19 severity parameters in euthyroid and levothyroxine-treated patients. Front Endocrinol (Lausanne) 2022; 13:1025032. [PMID: 36440226 PMCID: PMC9682171 DOI: 10.3389/fendo.2022.1025032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 10/06/2022] [Indexed: 11/11/2022] Open
Abstract
Metabolic reprogramming is required to fight infections and thyroid hormones are key regulators of metabolism. We have analyzed in hospitalized COVID-19 patients: 40 euthyroid and 39 levothyroxine (LT4)-treated patients in the ward and 29 euthyroid and 9 LT4-treated patients in the intensive care unit (ICU), the baseline characteristics, laboratory data, thyroid-stimulating hormone (TSH), free thyroxine (FT4), free triiodothyronine (FT3), the FT3/FT4 ratio, 11 antiviral cytokines and 74 metabolomic parameters. No evidence for significant differences between euthyroid and LT4-treated patients were found in the biochemical, metabolomic and cytokines parameters analyzed. Only TSH (p=0.009) and ferritin (p=0.031) showed significant differences between euthyroid and LT4-treated patients in the ward, and TSH (p=0.044) and FT4 (p=0.012) in the ICU. Accordingly, severity and mortality were similar in euthyroid and LT4-treated patients. On the other hand, FT3 was negatively related to age (p=0.012), independently of sex and body mass index in hospitalized COVID-19 patients. Patients with low FT3 and older age showed a worse prognosis and higher levels of the COVID-19 severity markers IL-6 and IL-10 than patients with high FT3. IL-6 negatively correlated with FT3 (p=0.023) independently of age, body mass index and sex, whereas IL-10 positively associated with age (p=0.035) independently of FT3, body mass index and sex. A metabolomic cluster of 6 parameters defined low FT3 ward patients. Two parameters, esterified cholesterol (p=4.1x10-4) and small HDL particles (p=6.0x10-5) correlated with FT3 independently of age, body mass index and sex, whereas 3-hydroxybutyrate (p=0.010), acetone (p=0.076), creatinine (p=0.017) and high-density-lipoprotein (HDL) diameter (p=8.3x10-3) were associated to FT3 and also to age, with p-values of 0.030, 0.026, 0.017 and 8.3x10-3, respectively. In conclusion, no significant differences in FT3, cytokines, and metabolomic profile, or in severity and outcome of COVID-19, were found during hospitalization between euthyroid patients and hypothyroid patients treated with LT4. In addition, FT3 and age negatively correlate in COVID-19 patients and parameters that predict poor prognosis were associated with low FT3, and/or with age. A metabolomic cluster indicative of a high ketogenic profile defines non-critical hospitalized patients with low FT3 levels.
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Affiliation(s)
- Inés Amich
- Department of Emergency, Hospital Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Eduardo Anguita
- Department of Hematology, Hospital Clínico San Carlos, Instituto de Medicina de Laboratorio (IML), Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
- Department of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain
| | - Silvia Escribano-Serrat
- Department of Hematology, Hospital Clínico San Carlos, Instituto de Medicina de Laboratorio (IML), Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
| | - Cristina Alvarez
- Clinical Analysis Laboratory, IML, IdISSC, Hospital Clínico San Carlos, Madrid, Spain
| | - Diego Rodríguez-Muñoz
- Department of Metabolism and Cell Signaling, Instituto de Investigaciones Biomédicas “Alberto Sols”, CSIC-UAM, Madrid, Spain
| | - Verónica García
- Hospital Pharmacy, IdISSC, Hospital Clínico San Carlos, Madrid, Spain
| | - Rocío Bello
- Hospital Pharmacy, IdISSC, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Neus Martínez-Micaelo
- Biosfer Teslab, Department of Basic Medical Sciences, Institut d'Investigació Sanitària Pere Virgili (IISPV), Reus, Spain
| | - Nuria Amigó
- Biosfer Teslab, Department of Basic Medical Sciences, Institut d'Investigació Sanitària Pere Virgili (IISPV), Reus, Spain
- Centro de Investigación Biomédicas en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Pablo Ortiz
- Department of Metabolism and Cell Signaling, Instituto de Investigaciones Biomédicas “Alberto Sols”, CSIC-UAM, Madrid, Spain
| | - María José Torrejón
- Clinical Analysis Laboratory, IML, IdISSC, Hospital Clínico San Carlos, Madrid, Spain
| | - Lisardo Boscá
- Department of Metabolism and Cell Signaling, Instituto de Investigaciones Biomédicas “Alberto Sols”, CSIC-UAM, Madrid, Spain
- Centro de Investigación Biomédicas en enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Javier Martín-Sánchez
- Department of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain
- Department of Emergency, IdISSC, Hospital Clínico San Carlos, Madrid, Spain
| | - Ana Aranda
- Department of Endocrine and Nervous System Pathophysiology, Instituto de Investigaciones Biomédicas “Alberto Sols”, CSIC-UAM, Centro de Investigación Biomédicas en Red de Cáncer (CIBERONC), Madrid, Spain
- Centro de Investigación Biomédicas de Cáncer (CIBERONC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- *Correspondence: Ana Aranda, ; Susana Alemany,
| | - Susana Alemany
- Department of Metabolism and Cell Signaling, Instituto de Investigaciones Biomédicas “Alberto Sols”, CSIC-UAM, Madrid, Spain
- *Correspondence: Ana Aranda, ; Susana Alemany,
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Prete A, Matrone A, Gambale C, Bottici V, Cappagli V, Romei C, Torregrossa L, Valerio L, Minaldi E, Campopiano MC, Lorusso L, Agate L, Molinaro E, Viola D, Ramone T, Mulè C, Ciampi R, Basolo F, Elisei R. Active Surveillance in RET Gene Carriers Belonging to Families with Multiple Endocrine Neoplasia. Cancers (Basel) 2021; 13:cancers13215554. [PMID: 34771717 PMCID: PMC8583610 DOI: 10.3390/cancers13215554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/02/2021] [Accepted: 11/04/2021] [Indexed: 12/18/2022] Open
Abstract
Simple Summary MEN2 has a very high penetrance for the development of medullary thyroid cancer. However, intra- and inter-familial variabilities have been described. Accordingly, in this precision medicine era, a personalized approach should be adopted in subjects harboring RET mutations. In these subjects, we showed that thyroid surgery could be safely timed according to basal and stimulated calcitonin, especially in children who can reach adulthood, avoiding the risks of thyroid surgery and decreasing the period of a long-life hypothyroidism treatment. Abstract Multiple Endocrine Neoplasia 2 (MEN2) is a hereditary cancer syndrome for developing medullary thyroid cancer (MTC) due to germline mutations of RET gene. Subjects harboring a germline RET mutation without any clinical signs of MTC are defined as gene carriers (GCs), for whom guidelines propose a prophylactic thyroid surgery. We evaluate if active surveillance of GCs, pursuing early thyroid surgery, can be safely proposed and if it allows safely delaying thyroid surgery in children until adolescence/adulthood. We prospectively followed 189 GCs with moderate or high risk germline RET mutation. Surgery was planned in case of: elevated basal calcitonin (bCT) and/or stimulated CT (sCT); surgery preference of subjects (or parents, if subject less than 18 years old); other reasons for thyroid surgery. Accordingly, at RET screening, we sub-grouped GCs in subjects who promptly were submitted to thyroid surgery (Group A, n = 67) and who were not (Group B, n = 122). Group B was further sub-grouped in subjects who were submitted to surgery during their active surveillance (Group B1, n = 22) and who are still in follow-up (Group B2, n = 100). Group A subjects presented significantly more advanced age, bCT and sCT compared to Group B. Mutation RETV804M was the most common variant in both groups but it was significantly less frequent in Group A than B. Analyzing age, bCT, sCT and genetic landscape, Group B1 subjects differed from Group B2 only for sCT at last evaluation. Group A subjects presented more frequently MTC foci than Group B1. Moreover, Group A MTCs presented more aggressive features (size, T and N) than Group B1. Accordingly, at the end of follow-up, all Group B1 subjects presented clinical remission, while 6 and 12 Group A MTC patients had structural and biochemical persistent disease, respectively. Thank to active surveillance, only 13/63 subjects younger than 18 years at RET screening have been operated on during childhood and/or adolescence. In Group B1, three patients, while actively surveilled, had the possibility to reach the age of 18 (or older) and two patients the age of 15, before being submitted to thyroid surgery. In Group B2, 12 patients become older than 18 years and 17 older than 15 years. In conclusion, we demonstrated that an active surveillance pursuing an early thyroid surgery could be safely recommended in GCs. This patient-centered approach permits postponing thyroid surgery in children until their adolescence/adulthood. At the same time, we confirmed that genetic screening allows finding hidden MTC cases that otherwise would be diagnosed much later.
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Affiliation(s)
- Alessandro Prete
- Endocrine Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (A.P.); (A.M.); (C.G.); (V.B.); (V.C.); (C.R.); (L.V.); (E.M.); (M.C.C.); (L.L.); (L.A.); (E.M.); (D.V.); (T.R.); (C.M.); (R.C.)
| | - Antonio Matrone
- Endocrine Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (A.P.); (A.M.); (C.G.); (V.B.); (V.C.); (C.R.); (L.V.); (E.M.); (M.C.C.); (L.L.); (L.A.); (E.M.); (D.V.); (T.R.); (C.M.); (R.C.)
| | - Carla Gambale
- Endocrine Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (A.P.); (A.M.); (C.G.); (V.B.); (V.C.); (C.R.); (L.V.); (E.M.); (M.C.C.); (L.L.); (L.A.); (E.M.); (D.V.); (T.R.); (C.M.); (R.C.)
| | - Valeria Bottici
- Endocrine Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (A.P.); (A.M.); (C.G.); (V.B.); (V.C.); (C.R.); (L.V.); (E.M.); (M.C.C.); (L.L.); (L.A.); (E.M.); (D.V.); (T.R.); (C.M.); (R.C.)
| | - Virginia Cappagli
- Endocrine Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (A.P.); (A.M.); (C.G.); (V.B.); (V.C.); (C.R.); (L.V.); (E.M.); (M.C.C.); (L.L.); (L.A.); (E.M.); (D.V.); (T.R.); (C.M.); (R.C.)
| | - Cristina Romei
- Endocrine Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (A.P.); (A.M.); (C.G.); (V.B.); (V.C.); (C.R.); (L.V.); (E.M.); (M.C.C.); (L.L.); (L.A.); (E.M.); (D.V.); (T.R.); (C.M.); (R.C.)
| | - Liborio Torregrossa
- Pathology Unit, Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, 56124 Pisa, Italy; (L.T.); (F.B.)
| | - Laura Valerio
- Endocrine Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (A.P.); (A.M.); (C.G.); (V.B.); (V.C.); (C.R.); (L.V.); (E.M.); (M.C.C.); (L.L.); (L.A.); (E.M.); (D.V.); (T.R.); (C.M.); (R.C.)
| | - Elisa Minaldi
- Endocrine Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (A.P.); (A.M.); (C.G.); (V.B.); (V.C.); (C.R.); (L.V.); (E.M.); (M.C.C.); (L.L.); (L.A.); (E.M.); (D.V.); (T.R.); (C.M.); (R.C.)
| | - Maria Cristina Campopiano
- Endocrine Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (A.P.); (A.M.); (C.G.); (V.B.); (V.C.); (C.R.); (L.V.); (E.M.); (M.C.C.); (L.L.); (L.A.); (E.M.); (D.V.); (T.R.); (C.M.); (R.C.)
| | - Loredana Lorusso
- Endocrine Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (A.P.); (A.M.); (C.G.); (V.B.); (V.C.); (C.R.); (L.V.); (E.M.); (M.C.C.); (L.L.); (L.A.); (E.M.); (D.V.); (T.R.); (C.M.); (R.C.)
| | - Laura Agate
- Endocrine Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (A.P.); (A.M.); (C.G.); (V.B.); (V.C.); (C.R.); (L.V.); (E.M.); (M.C.C.); (L.L.); (L.A.); (E.M.); (D.V.); (T.R.); (C.M.); (R.C.)
| | - Eleonora Molinaro
- Endocrine Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (A.P.); (A.M.); (C.G.); (V.B.); (V.C.); (C.R.); (L.V.); (E.M.); (M.C.C.); (L.L.); (L.A.); (E.M.); (D.V.); (T.R.); (C.M.); (R.C.)
| | - David Viola
- Endocrine Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (A.P.); (A.M.); (C.G.); (V.B.); (V.C.); (C.R.); (L.V.); (E.M.); (M.C.C.); (L.L.); (L.A.); (E.M.); (D.V.); (T.R.); (C.M.); (R.C.)
| | - Teresa Ramone
- Endocrine Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (A.P.); (A.M.); (C.G.); (V.B.); (V.C.); (C.R.); (L.V.); (E.M.); (M.C.C.); (L.L.); (L.A.); (E.M.); (D.V.); (T.R.); (C.M.); (R.C.)
| | - Chiara Mulè
- Endocrine Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (A.P.); (A.M.); (C.G.); (V.B.); (V.C.); (C.R.); (L.V.); (E.M.); (M.C.C.); (L.L.); (L.A.); (E.M.); (D.V.); (T.R.); (C.M.); (R.C.)
| | - Raffaele Ciampi
- Endocrine Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (A.P.); (A.M.); (C.G.); (V.B.); (V.C.); (C.R.); (L.V.); (E.M.); (M.C.C.); (L.L.); (L.A.); (E.M.); (D.V.); (T.R.); (C.M.); (R.C.)
| | - Fulvio Basolo
- Pathology Unit, Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, 56124 Pisa, Italy; (L.T.); (F.B.)
| | - Rossella Elisei
- Endocrine Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (A.P.); (A.M.); (C.G.); (V.B.); (V.C.); (C.R.); (L.V.); (E.M.); (M.C.C.); (L.L.); (L.A.); (E.M.); (D.V.); (T.R.); (C.M.); (R.C.)
- Correspondence: ; Tel.: +39-050-544-723; Fax: +39-050-578-772
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Shakir MKM, Brooks DI, McAninch EA, Fonseca TL, Mai VQ, Bianco AC, Hoang TD. Comparative Effectiveness of Levothyroxine, Desiccated Thyroid Extract, and Levothyroxine+Liothyronine in Hypothyroidism. J Clin Endocrinol Metab 2021; 106:e4400-e4413. [PMID: 34185829 PMCID: PMC8530721 DOI: 10.1210/clinem/dgab478] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Studies comparing levothyroxine (LT4) therapy with LT4 + liothyronine (LT3) or desiccated thyroid extract (DTE) did not detect consistent superiority of either treatment. Here, we investigated these therapies, focusing on the whole group of LT4-treated hypothyroid patients, while also exploring the most symptomatic patients. METHODOLOGY Prospective, randomized, double-blind, crossover study of 75 hypothyroid patients randomly allocated to 1 of 3 treatment arms, LT4, LT4 + LT3, and DTE, for 22 weeks. The primary outcomes were posttreatment scores on the 36-point thyroid symptom questionnaire (TSQ-36), 12-point quality of life general health questionnaire (GHQ-12), the Wechsler memory scale-version IV (VMS-IV), and the Beck Depression Inventory (BDI). Secondary endpoints included treatment preference, biochemical and metabolic parameters, etiology of hypothyroidism, and Thr92Ala-DIO2 gene polymorphism. Analyses were performed with a linear mixed model using subject as a random factor and group as a fixed effect. RESULTS Serum TSH remained within reference range across all treatment arms. There were no differences for primary and secondary outcomes, except for a minor increase in heart rate caused by DTE. Treatment preference was not different and there were no interferences of the etiology of hypothyroidism or Thr92Ala-DIO2 gene polymorphism in the outcomes. Subgroup analyses of the 1/3 most symptomatic patients on LT4 revealed strong preference for treatment containing T3, which improved performance on TSQ-36, GHQ-12, BDI, and visual memory index (VMS-IV component). CONCLUSIONS As a group, outcomes were similar among hypothyroid patients taking DTE vs LT4 + T3 vs LT4. However, those patients that were most symptomatic on LT4 preferred and responded positively to therapy with LT4 + LT3 or DTE.
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Affiliation(s)
- Mohamed K M Shakir
- Walter Reed National Military Medical Center, Bethesda, MD 20889-5600, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Daniel I Brooks
- Walter Reed National Military Medical Center, Bethesda, MD 20889-5600, USA
| | - Elizabeth A McAninch
- Division of Endocrinology and Metabolism, Rush University Medical Center, Chicago, IL 60612, USA
| | - Tatiana L Fonseca
- Section of Adult and Pediatric Endocrinology, University of Chicago, Chicago, IL 60637, USA
| | - Vinh Q Mai
- Walter Reed National Military Medical Center, Bethesda, MD 20889-5600, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Antonio C Bianco
- Section of Adult and Pediatric Endocrinology, University of Chicago, Chicago, IL 60637, USA
| | - Thanh D Hoang
- Walter Reed National Military Medical Center, Bethesda, MD 20889-5600, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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30
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Physical Activity in Women With Hypothyroidism on Thyroid Hormone Therapy: Associated Factors and Perceived Barriers and Benefits. J Phys Act Health 2021; 18:1383-1392. [PMID: 34627125 DOI: 10.1123/jpah.2021-0230] [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: 04/04/2021] [Revised: 06/05/2021] [Accepted: 07/26/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The purpose of this study was to analyze factors associated with physical activity (PA) and to identify perceived barriers and benefits of PA among patients with hypothyroidism on thyroid hormone therapy. METHODS This survey-based cross-sectional study was conducted among members of the Dutch thyroid patient organization. Self-reported data on respondents' PA levels and demographic, clinical, and physical health variables were collected. Moreover, perceived barriers and benefits to PA were identified. Respondents were categorized as physically active when meeting the recommended Dutch PA guidelines and physically inactive otherwise. To compare physically active and inactive respondents, potential confounders were entered into univariate analyses. Factors showing significant correlations (P < .20) were added to a multivariate model to determine the associated factors of PA. RESULTS About 1724 female respondents (mean age 53.0 [11.6] y) were included; 16.1% reported meeting the PA recommendations. Multivariate analysis showed that factors associated with PA included levothyroxine/liothyronine therapy, comorbidities, self-perceived physical fitness, and diminished physical endurance. Overall, physically related barriers to PA were rated highest. CONCLUSIONS The vast majority of treated hypothyroid respondents are physically inactive and experience long-term exercise intolerance. Considering the health implications of physical inactivity, promotion of regular PA is of key importance in this population.
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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: 11] [Impact Index Per Article: 3.7] [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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32
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Hernandez A. Toward Epigenetic Profiling of Thyroid Hormone Status. J Clin Endocrinol Metab 2021; 106:e2444-e2446. [PMID: 33693780 DOI: 10.1210/clinem/dgab141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Arturo Hernandez
- Maine Medical Center Research Institute, MaineHealth, Scarborough, ME, USA
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
- Graduate School of Biomedical Sciences and Engineering, University of Maine, Orono, ME, USA
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Thyroid Hormone Replacement in Total Thyroidectomized Patients: Symptomatic and Metabolic Effects of Levothyroxine Monotherapy. JOURNAL OF BASIC AND CLINICAL HEALTH SCIENCES 2021. [DOI: 10.30621/jbachs.916680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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What Is the Quality of Life in Patients Treated with Levothyroxine for Hypothyroidism and How Are We Measuring It? A Critical, Narrative Review. J Clin Med 2021; 10:jcm10071386. [PMID: 33808358 PMCID: PMC8037475 DOI: 10.3390/jcm10071386] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 12/14/2022] Open
Abstract
Thyroid hormone replacement therapy (THRT, generally using oral levothyroxine (LT4)) is a safe, effective means of treating hypothyroidism. However, a proportion of LT4-treated patients with biochemically normal thyroid function tests complain of persistent symptoms that impact their health-related quality of life (QoL). The objectives of this critical, narrative review of the literature were to identify studies of QoL in LT4-treated patients with hypothyroidism, examine the instruments used to measure QoL, determine whether normal QoL is restored by THRT, and identify factors associated with QoL. The PubMed database was searched from 1 January 2000 to 31 December 2020. A total of 809 publications were screened, 129 full-text articles were retrieved, and 58 were analyzed. The studies of overt hypothyroidism evidenced an improvement in psychological and emotional well-being after three to six months of THRT with LT4, although contrasting results were found for patients with subclinical hypothyroidism. Combination treatment with LT4 and liothyronine was not generally associated with better QoL. In hypothyroidism, QoL appears to be influenced by a number of physiological, behavioral, cognitive and/or lifestyle factors that are not strictly related to thyroid hormone levels.
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Jonklaas J, Bianco AC, Cappola AR, Celi FS, Fliers E, Heuer H, McAninch EA, Moeller LC, Nygaard B, Sawka AM, Watt T, Dayan CM. Evidence-Based Use of Levothyroxine/Liothyronine Combinations in Treating Hypothyroidism: A Consensus Document. Eur Thyroid J 2021; 10:10-38. [PMID: 33777817 PMCID: PMC7983670 DOI: 10.1159/000512970] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 11/11/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Fourteen clinical trials have not shown a consistent benefit of combination therapy with levothyroxine (LT4) and liothyronine (LT3). Despite the publication of these trials, combination therapy is widely used and patients reporting benefit continue to generate patient and physician interest in this area. Recent scientific developments may provide insight into this inconsistency and guide future studies. METHODS The American Thyroid Association (ATA), British Thyroid Association (BTA), and European Thyroid Association (ETA) held a joint conference on November 3, 2019 (live-streamed between Chicago and London) to review new basic science and clinical evidence regarding combination therapy with presentations and input from 12 content experts. After the presentations, the material was synthesized and used to develop Summary Statements of the current state of knowledge. After review and revision of the material and Summary Statements, there was agreement that there was equipoise for a new clinical trial of combination therapy. Consensus Statements encapsulating the implications of the material discussed with respect to the design of future clinical trials of LT4/LT3 combination therapy were generated. Authors voted upon the Consensus Statements. Iterative changes were made in several rounds of voting and after comments from ATA/BTA/ETA members. RESULTS Of 34 Consensus Statements available for voting, 28 received at least 75% agreement, with 13 receiving 100% agreement. Those with 100% agreement included studies being powered to study the effect of deiodinase and thyroid hormone transporter polymorphisms on study outcomes, inclusion of patients dissatisfied with their current therapy and requiring at least 1.2 µg/kg of LT4 daily, use of twice daily LT3 or preferably a slow-release preparation if available, use of patient-reported outcomes as a primary outcome (measured by a tool with both relevant content validity and responsiveness) and patient preference as a secondary outcome, and utilization of a randomized placebo-controlled adequately powered double-blinded parallel design. The remaining statements are presented as potential additional considerations. DISCUSSION This article summarizes the areas discussed and presents Consensus Statements to guide development of future clinical trials of LT4/LT3 combination therapy. The results of such redesigned trials are expected to be of benefit to patients and of value to inform future thyroid hormone replacement clinical practice guidelines treatment recommendations.
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Affiliation(s)
- Jacqueline Jonklaas
- Division of Endocrinology, Georgetown University, Washington, District of Columbia, USA
- *Jacqueline Jonklaas, Division of Endocrinology, Georgetown University, 4000 Reservoir Road, NW, Washington, DC 20007 (USA),
| | - Antonio C. Bianco
- Section of Adult and Pediatric Endocrinology and Metabolism, University of Chicago, Chicago, Illinois, USA
| | - Anne R. Cappola
- Division of Endocrinology, Diabetes, and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francesco S. Celi
- Division of Endocrinology, Diabetes and Metabolism, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Eric Fliers
- Department of Endocrinology and Metabolism, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Heike Heuer
- Department of Endocrinology, Diabetes and Metabolism, University Duisburg-Essen, Essen, Germany
| | | | - Lars C. Moeller
- Department of Endocrinology, Diabetes and Metabolism, University Duisburg-Essen, Essen, Germany
| | - Birte Nygaard
- Center for Endocrinology and Metabolism, Department of Internal Medicine, Herlev and Gentofte Hospitals, Herlev, Denmark
| | - Anna M. Sawka
- Division of Endocrinology, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Torquil Watt
- Department of Endocrinology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Colin M. Dayan
- Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, United Kingdom
- **Colin M. Dayan, Thyroid Research Group, School of Medicine, Cardiff University, C2 Link, Heath Park, Cardiff CF14 4XN (UK),
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36
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Jonklaas J, Bianco AC, Cappola AR, Celi FS, Fliers E, Heuer H, McAninch EA, Moeller LC, Nygaard B, Sawka AM, Watt T, Dayan CM. Evidence-Based Use of Levothyroxine/Liothyronine Combinations in Treating Hypothyroidism: A Consensus Document. Thyroid 2021; 31:156-182. [PMID: 33276704 PMCID: PMC8035928 DOI: 10.1089/thy.2020.0720] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: Fourteen clinical trials have not shown a consistent benefit of combination therapy with levothyroxine (LT4) and liothyronine (LT3). Despite the publication of these trials, combination therapy is widely used and patients reporting benefit continue to generate patient and physician interest in this area. Recent scientific developments may provide insight into this inconsistency and guide future studies. Methods: The American Thyroid Association (ATA), British Thyroid Association (BTA), and European Thyroid Association (ETA) held a joint conference on November 3, 2019 (live-streamed between Chicago and London) to review new basic science and clinical evidence regarding combination therapy with presentations and input from 12 content experts. After the presentations, the material was synthesized and used to develop Summary Statements of the current state of knowledge. After review and revision of the material and Summary Statements, there was agreement that there was equipoise for a new clinical trial of combination therapy. Consensus Statements encapsulating the implications of the material discussed with respect to the design of future clinical trials of LT4/LT3 combination therapy were generated. Authors voted upon the Consensus Statements. Iterative changes were made in several rounds of voting and after comments from ATA/BTA/ETA members. Results: Of 34 Consensus Statements available for voting, 28 received at least 75% agreement, with 13 receiving 100% agreement. Those with 100% agreement included studies being powered to study the effect of deiodinase and thyroid hormone transporter polymorphisms on study outcomes, inclusion of patients dissatisfied with their current therapy and requiring at least 1.2 μg/kg of LT4 daily, use of twice daily LT3 or preferably a slow-release preparation if available, use of patient-reported outcomes as a primary outcome (measured by a tool with both relevant content validity and responsiveness) and patient preference as a secondary outcome, and utilization of a randomized placebo-controlled adequately powered double-blinded parallel design. The remaining statements are presented as potential additional considerations. Discussion: This article summarizes the areas discussed and presents Consensus Statements to guide development of future clinical trials of LT4/LT3 combination therapy. The results of such redesigned trials are expected to be of benefit to patients and of value to inform future thyroid hormone replacement clinical practice guidelines treatment recommendations.
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Affiliation(s)
- Jacqueline Jonklaas
- Division of Endocrinology, Georgetown University, Washington, District of Columbia, USA
- Address correspondence to: Jacqueline Jonklaas, MD, PhD, Division of Endocrinology, Georgetown University, 4000 Reservoir Road, NW, Washington, DC 20007, USA
| | - Antonio C. Bianco
- Section of Adult and Pediatric Endocrinology and Metabolism, University of Chicago, Chicago, Illinois, USA
| | - Anne R. Cappola
- Division of Endocrinology, Diabetes, and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francesco S. Celi
- Division of Endocrinology, Diabetes and Metabolism, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Eric Fliers
- Department of Endocrinology and Metabolism, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Center, Netherlands
| | - Heike Heuer
- Department of Endocrinology, Diabetes and Metabolism, University Duisburg-Essen, Essen, Germany
| | | | - Lars C. Moeller
- Department of Endocrinology, Diabetes and Metabolism, University Duisburg-Essen, Essen, Germany
| | - Birte Nygaard
- Center for Endocrinology and Metabolism, Department Internal Medicine, Herlev and Gentofte Hospitals, Herlev, Denmark
| | - Anna M. Sawka
- Division of Endocrinology, University Health Network and University of Toronto, Toronto, Canada
| | - Torquil Watt
- Department of Endocrinology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Colin M. Dayan
- Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, United Kingdom
- Address correspondence to: Colin M. Dayan, MD, PhD, Thyroid Research Group, School of Medicine, Cardiff University, C2 Link, Heath Park, Cardiff CF14 4XN, UK
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