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Padoan A, Clerico A, Zaninotto M, Trenti T, Tozzoli R, Aloe R, Alfano A, Rizzardi S, Dittadi R, Migliardi M, Bagnasco M, Plebani M. Percentile transformation and recalibration functions allow harmonization of thyroid-stimulating hormone (TSH) immunoassay results. Clin Chem Lab Med 2021; 58:1663-1672. [PMID: 31927515 DOI: 10.1515/cclm-2019-1167] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 12/09/2019] [Indexed: 01/22/2023]
Abstract
Background The comparability of thyroid-stimulating hormone (TSH) results cannot be easily obtained using SI-traceable reference measurement procedures (RPMs) or reference materials, whilst harmonization is more feasible. The aim of this study was to identify and validate a new approach for the harmonization of TSH results. Methods Percentile normalization was applied to 125,419 TSH results, obtained from seven laboratories using three immunoassays (Access 3rd IS Thyrotropin, Beckman Coulter Diagnostics; Architect System, Abbott Diagnostics and Elecsys, Roche Diagnostics). Recalibration equations (RCAL) were derived by robust regressions using bootstrapped distribution. Two datasets, the first of 119 EQAs, the second of 610, 638 and 639 results from Access, Architect and Elecsys TSH results, respectively, were used to validate RCAL. A dataset of 142,821 TSH values was used to derive reference intervals (RIs) after applying RCAL. Results Access, Abbott and Elecsys TSH distributions were significantly different (p < 0.001). RCAL intercepts and slopes were -0.003 and 0.984 for Access, 0.032 and 1.041 for Architect, -0.031 and 1.003 for Elecsys, respectively. Validation using EQAs showed that before and after RCAL, the coefficients of variation (CVs) or among-assay results decreased from 10.72% to 8.16%. The second validation dataset was used to test RCALs. The median of between-assay differences ranged from -0.0053 to 0.1955 mIU/L of TSH. Elecsys recalibrated to Access (and vice-versa) showed non-significant difference. TSH RI after RCAL resulted in 0.37-5.11 mIU/L overall, 0.49-4.96 mIU/L for females and 0.40-4.92 mIU/L for males. A significant difference across age classes was identified. Conclusions Percentile normalization and robust regression are valuable tools for deriving RCALs and harmonizing TSH values.
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Affiliation(s)
- Andrea Padoan
- Department of Medicine (DIMED), University of Padova, via Giustiniani 2, 35128, Padova, Italy.,Department of Laboratory Medicine, University-Hospital of Padova, via Giustiniani 2, 35128, Padova, Italy
| | - Aldo Clerico
- Laboratory of Cardiovascular Endocrinology and Cell Biology, Department of Laboratory Medicine, Fondazione CNR-Regione Toscana Gabriele Monasterio, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Martina Zaninotto
- Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy
| | - Tommaso Trenti
- Dipartimento di Medicina di Laboratorio e Anatomia Patologica, Azienda Ospedaliera Universitaria e USL di Modena, Modena, Italy
| | - Renato Tozzoli
- Clinical Pathology Laboratory, Department of Laboratory Medicine, Azienda per l'Assistenza Sanitaria n.5, Pordenone Hospital, Pordenone, Italy
| | - Rosalia Aloe
- Dipartimento di Biochimica ad Elevata Automazione, Dipartimento Diagnostico, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Antonio Alfano
- Clinical Pathology, Hospital ASL TO4, Ciriè, Turin, Italy
| | - Sara Rizzardi
- Laboratorio Analisi Aziendale (SC), Azienda Socio-Sanitaria Territoriale di Cremona, Istituti Ospitalieri, Cremona, Italy
| | - Ruggero Dittadi
- U.O.C. Laboratorio Analisi, Ospedale dell'Angelo, AULSS3 Serenissima, Mestre, Venezia, Italy
| | - Marco Migliardi
- S.C. Laboratorio Analisi, A.O. Ordine Mauriziano di Torino, Turin, Italy
| | | | - Mario Plebani
- Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy.,Department of Medicine (DIMED), University of Padova, Padova, Italy
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Huang C, Wu Y, Chen L, Yuan Z, Yang S, Liu C. Establishment of assay method- and trimester-specific reference intervals for thyroid hormones during pregnancy in Chengdu, China. J Clin Lab Anal 2021; 35:e23763. [PMID: 33942380 PMCID: PMC8128292 DOI: 10.1002/jcla.23763] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 03/04/2021] [Accepted: 03/08/2021] [Indexed: 12/30/2022] Open
Abstract
Background The reference intervals of thyroid hormone will change at different stages of pregnancy because of physiological alterations. On the other hand, the reference intervals of thyroid hormone will also change in different detection systems due to the manufacturer's methodology as well as a different race. The objective of this study was to establish the assay method‐ and trimester‐specific reference intervals for thyroid‐stimulating hormone, free thyroxine and free triiodothyronine for pregnant women in Chengdu. Methods A prospective, population‐based cohort study involved 23,701 reference samples of pregnant women during the three trimesters and 8646 non‐pregnant women with pre‐pregnancy clinical and laboratory tests. The 2.5th and 97.5th percentiles were calculated as the reference intervals for thyroid‐stimulating hormone, free thyroxine and free triiodothyronine at each trimester of pregnant women according to ATA Guidelines. Results The reference interval of thyroid‐stimulating hormone in the 2.5th and 97.5th percentiles has a significant increasing trend from the first trimester, to second trimester and to third trimester, which was 0.08–3.79 mIU/L for the first trimester, and 0.12–3.95 mIU/L for the second trimester and 0.38–4.18 mIU/L for the third trimester, respectively (p < 0.001). However, the reference intervals of free thyroxine and free triiodothyronine in the 2.5th and 97.5th percentiles have significant decreasing trends from the first trimester, to second trimester and to third trimester, which were 11.87–18.83 pmol/L and 3.77–5.50 pmol/L for the first trimester, and 11.22–18.19 pmol/L and 3.60–5.41 pmol/L for the second trimester, and 10.19–17.42 pmol/L and 3.37–4.79 pmol/L for the third trimester, respectively (both p < 0.001). Conclusion It is necessary to establish assay method‐ and trimester‐specific reference intervals for thyroid‐stimulating hormone, free thyroxine, and free triiodothyronine because the reference intervals of these thyroid hormones are significantly different at different stages of pregnancy.
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Affiliation(s)
- Cheng Huang
- Department of Clinical Laboratory, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Ying Wu
- Department of Science and Education, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Linong Chen
- Department of Clinical Laboratory, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Zhiya Yuan
- Department of Clinical Laboratory, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Shuzhe Yang
- Department of Clinical Laboratory, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Chenggui Liu
- Department of Clinical Laboratory, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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Li ZZ, Yu BZ, Wang JL, Yang Q, Ming J, Tang YR. Reference intervals for thyroid-stimulating hormone and thyroid hormones using the access TSH 3rd IS method in China. J Clin Lab Anal 2020; 34:e23197. [PMID: 31912542 PMCID: PMC7246370 DOI: 10.1002/jcla.23197] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/16/2019] [Accepted: 12/18/2019] [Indexed: 11/09/2022] Open
Abstract
Background To calculate the reference intervals for thyroid‐stimulating hormone (TSH) and thyroid hormones using the Access TSH 3rd IS method and evaluate the differences between age and genders in Chinese populations. Methods This study collected 349 serum samples of healthy subjects were from Shengli Oilfield Central Hospital in China. Subjects who tested positive for thyroid peroxidase antibody or thyroglobulin antibody were excluded. Accordingly, 313 subjects were included for establishing reference intervals for the thyroid hormones. The serum concentrations of TSH, total and free thyroxine (TT4 and FT4), and total and free triiodothyronine (TT3 and FT3) were measured using the Access TSH 3rd IS method. The 2.5th and 97.5th percentiles or mean with standard deviation were calculated as the reference interval as appropriate. Results The reference intervals for TSH, FT4, FT3, TT4, and TT3 calculated in present study were 0.61‐4.16 mIU/L, 0.67‐1.11 ng/dL, 2.63‐4.33 pg/mL, 5.56‐11.33 μg/dL, and 0.72‐1.32 ng/mL, respectively. The FT3, TT4, and TT3 levels in males were significantly higher than in females (P < .05), while TSH levels in males were significantly lower than in females (P < .05). The levels of FT3 in subjects with the age of less than 30 years were significantly higher than other groups (P < .05). Conclusion The present study provided a valid basis for the reference intervals for TSH, FT4, FT3, TT4, and TT3 in Chinese populations. In addition, this present study indicated that age and gender should be considered in diagnostic evaluation of thyroid diseases.
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Affiliation(s)
- Zhen-Zhen Li
- Department of Clinical Laboratory, Shengli Oilfield Central Hospital, Dongying, China
| | - Ben-Zhang Yu
- Department of Clinical Laboratory, Shengli Oilfield Central Hospital, Dongying, China
| | - Ji-Liang Wang
- Department of Clinical Laboratory, Shengli Oilfield Central Hospital, Dongying, China
| | - Qin Yang
- Department of Clinical Laboratory, Shengli Oilfield Central Hospital, Dongying, China
| | - Jia Ming
- Department of Clinical Laboratory, Shengli Oilfield Central Hospital, Dongying, China
| | - Yu-Rong Tang
- Department of Clinical Laboratory, Shengli Oilfield Central Hospital, Dongying, China
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Creo A, Anderson H, Cannon B, Lteif A, Kumar S, Tebben P, Iqbal AM, Ramakrishna A, Pittock S. Patterns of amiodarone-induced thyroid dysfunction in infants and children. Heart Rhythm 2019; 16:1436-1442. [PMID: 30904484 DOI: 10.1016/j.hrthm.2019.03.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Heart Rhythm Society guidelines recommend obtaining thyroid function tests (TFTs) at amiodarone initiation and every 6 months thereafter in adults, with no specific pediatric recommendations. Untreated hypothyroidism in young children negatively affects brain development and somatic growth, yet the optimal screening frequency for pediatric patients remains unclear, and limited data exist on pediatric amiodarone-induced thyroid dysfunction. OBJECTIVE The purpose of this study was to describe the patterns of amiodarone-induced thyroid dysfunction in pediatric patients. METHODS We established a retrospective cohort of 527 pediatric patients who received amiodarone between 1997 and 2017. We defined amiodarone therapy lasting 3-30 days as "short term" and >30 days as "long term." RESULTS The final cohort (n = 150) consisted of 27 neonates (18%), 25 infants (16%), 27 young children (18%), and 71 children (47%). Of the children in whom TFTs were checked, half (50.8%) developed a thyroid-stimulating hormone (TSH) value above the reference for age. Neonates had the highest median peak TSH values in both short- and long-term groups: 23.5 mIU/L (interquartile range 11.4-63.1) and 28.8 mIU/L (interquartile range 11.4-34.4), respectively. Although concurrent use of inotropic support was significantly associated with lower initial TSH values, no variable related to cardiac illness or type of heart disease was associated with peak TSH values. CONCLUSION Neonates and infants receiving amiodarone had more thyroid dysfunction with greater degrees of TSH elevation than older children. TSH elevations occurred early, even with short-term exposure. Given the concern for brain development and growth in hypothyroid children, our results suggest the need for more rigorous pediatric-specific thyroid monitoring guidelines.
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Affiliation(s)
- Ana Creo
- Division of Pediatric Endocrinology and Metabolism, Mayo Clinic, Rochester, Minnesota
| | - Heather Anderson
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
| | - Bryan Cannon
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
| | - Aida Lteif
- Division of Pediatric Endocrinology and Metabolism, Mayo Clinic, Rochester, Minnesota
| | - Seema Kumar
- Division of Pediatric Endocrinology and Metabolism, Mayo Clinic, Rochester, Minnesota
| | - Peter Tebben
- Division of Pediatric Endocrinology and Metabolism, Mayo Clinic, Rochester, Minnesota; Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, Minnesota
| | - Anoop Mohamed Iqbal
- Division of Pediatric Endocrinology and Metabolism, Mayo Clinic, Rochester, Minnesota
| | - Akhila Ramakrishna
- Division of Pediatric Endocrinology and Metabolism, Mayo Clinic, Rochester, Minnesota
| | - Siobhan Pittock
- Division of Pediatric Endocrinology and Metabolism, Mayo Clinic, Rochester, Minnesota.
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Clerico A, Belloni L, Carrozza C, Correale M, Dittadi R, Dotti C, Fortunato A, Vignati G, Zucchelli GC, Migliardi M. A Black Swan in clinical laboratory practice: the analytical error due to interferences in immunoassay methods. Clin Chem Lab Med 2018; 56:397-402. [PMID: 29220884 DOI: 10.1515/cclm-2017-0881] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 10/22/2017] [Indexed: 12/11/2022]
Abstract
It is well known that the results of immunoassay methods can be affected by specific or non-specific interferences, ranging from 0.4% to 4.0%. The presence of interference may greatly compromise the accuracy of immunoassay analyses causing an error in the measurement, producing false-positive or false-negative results. From a clinical point of view, these analytical errors may have serious implications for patient care because they can cause misdiagnosis or inappropriate treatment. Unfortunately, it is a very difficult task to identify the irregular analytical errors related to immunoassay methods because they are not detectable by normal laboratory quality control procedures, are reproducible within the test system, may be clinically plausible and are relatively rare. The first line of defense against erroneous results is to use in laboratory practice only immunoassay systems with the highest level of robustness against interference. The second line of defense is always taking into account the possibility of interference in immunoassay results. A correct approach should be addressed on identification of samples at high risk of interference. The attainment of this goal requires a critical review of the test result in relation to patient's clinical conditions and literature data, taking into account the analytical characteristics of the immunoassay system. The experts in immunoassay systems should make every effort to find some specific and reliable quality indicators for irregular analytical errors in order to better detect and monitor erroneous immunoassay results due to specific or non-specific interferences.
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Affiliation(s)
- Aldo Clerico
- Laboratory of Cardiovascular Endocrinology and Cell Biology, Department of Laboratory Medicine, Fondazione CNR Toscana G. Monasterio, Scuola Superiore Sant'Anna, Via Trieste 41, 56126 Pisa, Italy
| | - Lucia Belloni
- Dipartimento di Medicina di laboratorio, Arcispedale Santa Maria Nuova - IRCCS, Reggio Emilia, Italy
| | - Cinzia Carrozza
- Laboratorio Analisi 1, Fondazione Policlinico Universitario "A. Gemelli", Roma, Italy
| | - Mario Correale
- Clinical Pathology Unit, IRCCS De Bellis, Castellana Grotte, Bari, Italy
| | - Ruggero Dittadi
- Medicina di Laboratorio, Ospedale dell'Angelo ULSS 3 Serenissima, Mestre, Italy
| | - Claudio Dotti
- Dipartimento di Medicina di laboratorio, Arcispedale Santa Maria Nuova - IRCCS, Reggio Emilia, Italy
| | - Antonio Fortunato
- U.O.C. Patologia Clinica, ASUR Marche Area Vasta 5, Ascoli Piceno, Italy
| | | | | | - Marco Migliardi
- S.C. Laboratorio Analisi, A.O. Ordine Mauriziano di Torino, Torino, Italy
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Clerico A, Plebani M. Biotin interference on immunoassay methods: sporadic cases or hidden epidemic? ACTA ACUST UNITED AC 2017; 55:777-779. [DOI: 10.1515/cclm-2017-0070] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Dittadi R, Rizzardi S, Masotti S, Prontera C, Ripoli A, Fortunato A, Alfano A, Carrozza C, Correale M, Gessoni G, Migliardi M, Zucchelli G, Clerico A. Multicenter evaluation of the new immunoassay method for TSH measurement using the automated DxI platform. Clin Chim Acta 2017; 468:105-110. [DOI: 10.1016/j.cca.2017.02.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 02/08/2017] [Accepted: 02/08/2017] [Indexed: 12/17/2022]
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Welsh KJ, Soldin SJ. DIAGNOSIS OF ENDOCRINE DISEASE: How reliable are free thyroid and total T3 hormone assays? Eur J Endocrinol 2016; 175:R255-R263. [PMID: 27737898 PMCID: PMC5113291 DOI: 10.1530/eje-16-0193] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 07/08/2016] [Indexed: 11/08/2022]
Abstract
Hypothyroidism is a very common disorder worldwide, for which the usual treatment is monotherapy with levothyroxine (L-T4). However, a number of patients treated with L-T4 continue to report symptoms of hypothyroidism despite seemingly normal levels of thyroid-stimulating hormone (TSH), free-T3 (FT3) and free-T4 (FT4) measured by immunoassay. This review summarizes the limitations of the immunoassays commonly used to measure thyroid hormone levels and emphasizes the advantages of the role of liquid chromatography-tandem mass spectrometry (LC-MS/MS). Immunoassays for free thyroid hormone are affected by alterations in serum binding proteins that occur in many physiological and disease states. Multiple studies show falsely normal values for T3, FT3 and FT4 by immunoassay that are below the reference interval when measured by (ultrafiltration) LC-MS/MS, a reference method. We suggest evaluation of thyroid hormone levels by ultrafiltration LC-MS/MS for patients who continue to experience hypothyroid symptoms on LT-4. This may help identify the approximately 20% subset of patients who would benefit from addition of T3 to their treatment regimen (combination therapy).
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Affiliation(s)
- Kerry J Welsh
- Clinical Chemistry DivisionDepartment of Laboratory Medicine, National Institutes of Health, Bethesda, Maryland, USA
| | - Steven J Soldin
- Clinical Chemistry DivisionDepartment of Laboratory Medicine, National Institutes of Health, Bethesda, Maryland, USA
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Diederichsen SZ, Darkner S, Chen X, Johannesen A, Pehrson S, Hansen J, Feldt-Rasmussen U, Svendsen JH. Short-term amiodarone treatment for atrial fibrillation after catheter ablation induces a transient thyroid dysfunction: Results from the placebo-controlled, randomized AMIO-CAT trial. Eur J Intern Med 2016; 33:36-41. [PMID: 27129624 DOI: 10.1016/j.ejim.2016.04.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Revised: 04/06/2016] [Accepted: 04/12/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Amiodarone is known to affect the thyroid, but little is known about thyroid recovery after short-term amiodarone treatment. OBJECTIVES We aimed to evaluate the impact of 8weeks of amiodarone treatment on thyroid function in patients with atrial fibrillation (AF) undergoing catheter ablation in a randomised, double-blind clinical trial. METHODS 212 patients referred for AF ablation at two centres were randomized to 8weeks of oral amiodarone or placebo. Thyroid function tests (TSH, thyroid stimulating hormone; T4, thyroxine; T3, triiodothyronine; fT4, free T4; fT3, free T3) were performed at baseline and 1, 3 and 6months. RESULTS Study drug was discontinued due to mild thyroid dysfunction in 1 patient in the placebo vs. 3 in the amiodarone group (p=0.6). In linear mixed models there were significant effects of amiodarone on thyroid function tests, modified by follow-up visit (p<10(-9) for both TSH, T4, T3, fT4 and fT3). The amiodarone group had higher TSH, fT4 and T4 after 1 and 3months compared to placebo, whereas T3 and fT3 were lower. In all cases, the amiodarone-induced thyroid dysfunction was largest at 1month, declining at 3months, and with no differences at 6months, compared to baseline. CONCLUSION We found amiodarone to have a significant impact on thyroid function after only 1month, but with a fast recovery of thyroid function after amiodarone discontinuation. Our study indicates that short-term amiodarone can be considered safe in patients without prior thyroid dysfunction.
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Affiliation(s)
- Søren Zöga Diederichsen
- Department of Cardiology, Section 2013, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Stine Darkner
- Department of Cardiology, Section 2013, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Xu Chen
- Department of Cardiology, Section 2013, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Arne Johannesen
- Department of Cardiology, Gentofte Hospital, Copenhagen University Hospital, Gentofte, Denmark
| | - Steen Pehrson
- Department of Cardiology, Section 2013, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jim Hansen
- Department of Cardiology, Gentofte Hospital, Copenhagen University Hospital, Gentofte, Denmark
| | - Ulla Feldt-Rasmussen
- Department of Medical Endocrinology, Section 2132, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jesper Hastrup Svendsen
- Department of Cardiology, Section 2013, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; The Danish National Research Centre for Cardiac Arrhythmia, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Hudzik B, Zubelewicz-Szkodzinska B. Amiodarone-related thyroid dysfunction. Intern Emerg Med 2014; 9:829-39. [PMID: 25348560 DOI: 10.1007/s11739-014-1140-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 10/10/2014] [Indexed: 11/28/2022]
Abstract
Nowadays, amiodarone is the most commonly used antidysrhythmic drug in clinical practice. It is highly effective in the management of recurrent ventricular dysrhythmias, paroxysmal supraventricular dysrhythmias, including atrial fibrillation and flutter, and in the maintenance of sinus rhythm after electrical cardioversion of atrial fibrillation. Moreover, it has the added benefit of being well tolerated in patients with both normal and impaired left ventricular systolic function. Despite amiodarone's potent antidysrhythmic actions, its use is hampered by numerous adverse effects on various organs, including the thyroid. Adverse effects are becoming more prevalent given the increasing incidence of dysrhythmias and wider amiodarone use. Thus, physicians and patients should both be aware of the potential thyroid-specific sequelae. However, amiodarone is likely to remain a significant problem for endocrinologists as concerns exist over the use of the new alternative antiarrhythmic agent, dronedarone, especially in patients with heart failure and left ventricular dysfunction because of the risk of hepatic injury and increased mortality. The final diagnostic and therapeutic approaches must be discussed among the patient, the general practitioner, the cardiologist, and the endocrinologist.
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Affiliation(s)
- Bartosz Hudzik
- Third Department of Cardiology, Silesian Centre for Heart Disease, Medical University of Silesia, Curie-Sklodowska 9, 41-800, Zabrze, Poland,
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Danzi S, Klein I. Amiodarone-induced thyroid dysfunction. J Intensive Care Med 2013; 30:179-85. [PMID: 24067547 DOI: 10.1177/0885066613503278] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 06/11/2013] [Indexed: 11/16/2022]
Abstract
Amiodarone is an effective medication for the treatment of cardiac arrhythmias. Originally developed for the treatment of angina, it is now the most frequently prescribed antiarrhythmia drug despite the fact that its use is limited because of potential serious side effects including adverse effects on the thyroid gland and thyroid hormones. Although the mechanisms of action of amiodarone on the thyroid gland and thyroid hormone metabolism are poorly understood, the structural similarity of amiodarone to thyroid hormones, including the presence of iodine moieties on the inner benzene ring, may play a role in causing thyroid dysfunction. Amiodarone-induced thyroid dysfunction includes amiodarone-induced thyrotoxicosis (AIT) and amiodarone-induced hypothyroidism (AIH). The AIT develops more commonly in iodine-deficient areas and AIH in iodine-sufficient areas. The AIT type 1 usually occurs in patients with known or previously undiagnosed thyroid dysfunction or goiter. The AIT type 2 usually occurs in normal thyroid glands and results in destruction of thyroid tissue caused by thyroiditis. This is the result of an intrinsic drug effect from the amiodarone itself. Mixed types are not uncommon. Patients with cardiac disease receiving amiodarone treatment should be monitored for signs of thyroid dysfunction, which often manifest as a reappearance of the underlying cardiac disease state. When monitoring patients, initial tests should include the full battery of thyroid function tests, thyroid-stimulating hormone, thyroxine, triiodothyronine, and antithyroid antibodies. Mixed types of AIT can be challenging both to diagnose and treat and therapy differs depending on the type of AIT. Treatment can include thionamides and/or glucocorticoids. The AIH responds favorably to thyroid hormone replacement therapy. Amiodarone is lipophilic and has a long half-life in the body. Therefore, stopping the amiodarone therapy usually has little short-term benefit.
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Affiliation(s)
- Sara Danzi
- Department of Biological Sciences and Geology, Queensborough Community College, Bayside, NY, USA
| | - Irwin Klein
- Department of Medicine, NYU School of Medicine, New York, NY, USA
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Lai ECC, Yang YHK, Lin SJ, Hsieh CY. Use of antiepileptic drugs and risk of hypothyroidism. Pharmacoepidemiol Drug Saf 2013; 22:1071-9. [DOI: 10.1002/pds.3498] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Revised: 07/16/2013] [Accepted: 07/17/2013] [Indexed: 01/03/2023]
Affiliation(s)
- Edward Chia-Cheng Lai
- Institute of Clinical Pharmacy and Pharmaceutical Sciences; National Cheng Kung University; Tainan Taiwan
| | - Yea-Huei Kao Yang
- Institute of Clinical Pharmacy and Pharmaceutical Sciences; National Cheng Kung University; Tainan Taiwan
- Health Outcome Research Center; National Cheng Kung University; Tainan Taiwan
| | - Swu-Jane Lin
- Department of Pharmacy Administration, College of Pharmacy; University of Illinois at Chicago; Chicago IL USA
| | - Cheng-Yang Hsieh
- Institute of Clinical Pharmacy and Pharmaceutical Sciences; National Cheng Kung University; Tainan Taiwan
- Department of Neurology; Tainan Sin-Lau Hospital; Tainan Taiwan
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Abstract
OBJECTIVE To report a case of postnatal, postoperative amiodarone-induced hypothyroidism in an infant with a congenital heart defect. DESIGN Case report and literature review. SETTING Pediatric intensive care unit at a freestanding tertiary care children's hospital. PATIENT At 7 wks of age, a female infant with a congenital heart defect was confirmed to have profound hypothyroidism after amiodarone administration for a postoperative cardiac arrhythmia. INTERVENTIONS Levothyroxine treatment. MEASUREMENTS AND MAIN RESULTS Thyroid function tests were regularly performed to guide levothyroxine dosing. Thyroid hormone replacement was discontinued after the infant had been off amiodarone for 6 mos. CONCLUSIONS Given the potential adverse developmental consequences associated with hypothyroidism during infancy and early childhood, thyroid function tests should be carefully monitored in any infant treated with amiodarone.
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Mikosch P. [Thyroid and treatment with amiodarone diagnosis, therapy and clinical management]. Wien Med Wochenschr 2008; 158:29-35. [PMID: 18286247 DOI: 10.1007/s10354-007-0475-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2007] [Accepted: 08/09/2007] [Indexed: 11/30/2022]
Abstract
Amiodarone is a frequently used antiarrhythmic drug with a high antiarrhythmic potency. However, beside its antiarrhythmic effects Amiodarone also reveals a variety of adverse effects and drug-related complications. The affected organs include the eyes, skin, lungs, nervous system, liver, gastrointestinal tract and the thyroid. The thyroid is one of the most frequently affected organs by Amiodarone. An altered hormone equilibrium always occurs and has to be distinguished from Amiodarone induced hyperthyroidism and hypothyroidism. The differentiation of these states frequently causes problems and may even be a diagnostic and therapeutic challenge in certain cases. The article gives an overview on the interactions between Amiodarone and the thyroid, the diagnostic and therapeutic options and management strategies of patient on Amiodarone therapy in the view of thyroid function.
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Affiliation(s)
- Peter Mikosch
- 2. Medizinische Abteilung, Landeskrankenhaus Klagenfurt, St. Veiterstrasse 47, Klagenfurt, Austria.
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15
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Braithwaite SS. Thyroid Disorders. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50063-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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16
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Abstract
Among the drugs affecting the thyroid gland, no drug has puzzled, and at the same time fascinated, endocrinologists more than amiodarone. Amiodarone is a potent class III anti-arrhythmic drug that also possesses beta-blocking properties. It is very rich in iodine, with a 100-mg tablet containing an amount of iodine that is 250 times the recommended daily iodine requirement. Amiodarone produces characteristic alterations in thyroid function tests in euthyroid patients. Understanding these alterations is crucial in avoiding unnecessary investigations and treatment. Amiodarone-induced thyroid dysfunction occurs because of both its iodine content and the direct toxic effects of the compound on thyroid parenchyma. Amiodarone-induced hyperthyroidism is more common in iodine-deficient regions of the world, whereas amiodarone-induced hypothyroidism is usually seen in iodine-sufficient areas. In contrast to amiodarone-induced hypothyroidism, amiodarone-induced thyrotoxicosis is a difficult condition to diagnose and treat. In this review, we discuss the alterations in thyroid function tests seen in euthyroid subjects, the epidemiology and mechanism of amiodarone-induced thyroid dysfunction, treatment options available, and the consequences of amiodarone use in pregnancy and lactation; and finally, we propose a follow-up strategy in patients taking amiodarone.
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Affiliation(s)
- Shehzad Basaria
- Department of Medicine, Division of Endocrinology, Johns Hopkins University School of Medicine, Bayview Medical Center, Baltimore, Maryland, USA
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17
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Childress RD, Qureshi MN, Kasparova M, Oktaei H, Williams-Cleaves B, Solomon SS. Thyrotoxicosis Presenting as Hypogonadism: A Case of Central Hyperthyroidism. Am J Med Sci 2004; 328:295-8. [PMID: 15545848 DOI: 10.1097/00000441-200411000-00011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Herein, we present a case of central thyrotoxicosis with well-documented serial therapeutic interventions. Thyroid-stimulating hormone (TSH)-secreting pituitary tumors represent a rare cause of hyperthyroidism. It is being diagnosed more frequently with the third-generation TSH assay. Many conditions can produce normal or elevated TSH levels in combination with elevated thyroid hormone levels. The differential diagnosis includes resistance to thyroid hormone (RTH, Refetoff's syndrome), assay interference from anti-T4/T3 and heterophile antibodies, elevated or altered binding proteins, drugs affecting peripheral metabolism, and noncompliance with thyroid replacement therapy. In contrast to RTH, our patient presented had high alpha-subunit-to-TSH molar ratio, failed TSH response to thyrotropin-releasing hormone stimulation, and a large pituitary mass. Normal or high TSH in the presence of elevated T4 or T3 is a fairly common clinical scenario with many etiologic possibilities. This TSH-producing adenoma represents an unusual initial clinical presentation, as hypogonadism appeared before features of thyrotoxicosis were appreciated. This case represents the most modern therapeutic approach to the management of this rare disease. Our patient has done well on octreotide with control of thyrotoxicosis and an additional 30% shrinkage of his tumor mass.
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Affiliation(s)
- R Dale Childress
- University of Tennessee Health Science Center, Division of Endocrinology and Metabolism, Department of Medicine and the Veterans Administration Medical Center (VAMC) Memphis, TN 38104, USA
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18
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Abstract
OBJECTIVE To study the effects of ingestion of two different doses of supplemental kelp on the thyroid function of healthy euthyroid subjects. METHODS We conducted a double-blind prospective clinical trial involving 36 healthy euthyroid subjects, who were randomly assigned to receive placebo (4 alfalfa capsules per day), low-dose kelp (2 kelp capsules and 2 alfalfa capsules per day), or high-dose kelp (4 kelp capsules per day) for 4 weeks. Thyrotropin (thyroid-stimulating hormone or TSH), free thyroxine, and total triiodothyronine were assessed at weeks 0, 4, and 6. Response to thyrotropin-releasing hormone stimulation, urinary iodine excretion, and basal metabolic rate were determined at weeks 0 and 4. RESULTS TSH concentrations did not differ significantly between week 0 and week 4 in the placebo group (P = 0.16) but increased significantly in both the low-dose kelp (P = 0.04) and high-dose kelp (P = 0.002) groups. Free thyroxine concentrations decreased slightly but significantly after 4 weeks of placebo but were unchanged in the low-dose and the high-dose kelp groups. In contrast, total triiodothyronine levels did not differ significantly after 4 weeks of placebo or low-dose kelp therapy but were significantly decreased after high-dose kelp therapy (P = 0.04). Similarly, the thyrotropin-releasing hormone stimulation test showed no significant change in poststimulation TSH after 4 weeks in the placebo or low-dose kelp groups but revealed a significantly increased response after high-dose kelp therapy (P = 0.0002). The 24-hour urinary iodine excretion showed dose-dependent increases in the two kelp study groups. Basal metabolic rate did not change significantly in any study group during the 4-week study period. All thyroid laboratory values returned to baseline 2 weeks after cessation of kelp supplementation, except for TSH in the high-dose kelp group, which was significantly decreased. CONCLUSION Short-term dietary supplementation with kelp significantly increases both basal and poststimulation TSH. These findings corroborate previous studies on the effects of supplemental iodide given to euthyroid subjects for a similar period. Further studies are needed to determine whether long-term kelp supplementation would cause clinically significant thyroid disease.
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Affiliation(s)
- Clifford D Clark
- Department of Internal Medicine, Division of Endocrinology and Metabolism, University of New Mexico Health Sciences Center, Albuquerque, New Mexico 87131, USA
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19
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Abstract
Amiodarone is a benzofuranic-derivative iodine-rich drug widely used for the treatment of tachyarrhythmias and, to a lesser extent, of ischemic heart disease. It often causes changes in thyroid function tests (typically an increase in serum T(4) and rT(3), and a decrease in serum T(3), concentrations), mainly related to the inhibition of 5'-deiodinase activity, resulting in a decrease in the generation of T(3) from T(4) and a decrease in the clearance of rT(3). In 14-18% of amiodarone-treated patients, there is overt thyroid dysfunction, either amiodarone-induced thyrotoxicosis (AIT) or amiodarone-induced hypothyroidism (AIH). Both AIT and AIH may develop either in apparently normal thyroid glands or in glands with preexisting, clinically silent abnormalities. Preexisting Hashimoto's thyroiditis is a definite risk factor for the occurrence of AIH. The pathogenesis of iodine-induced AIH is related to a failure to escape from the acute Wolff-Chaikoff effect due to defects in thyroid hormonogenesis, and, in patients with positive thyroid autoantibody tests, to concomitant Hashimoto's thyroiditis. AIT is primarily related to excess iodine-induced thyroid hormone synthesis in an abnormal thyroid gland (type I AIT) or to amiodarone-related destructive thyroiditis (type II AIT), but mixed forms frequently exist. Treatment of AIH consists of L-T(4) replacement while continuing amiodarone therapy; alternatively, if feasible, amiodarone can be discontinued, especially in the absence of thyroid abnormalities, and the natural course toward euthyroidism can be accelerated by a short course of potassium perchlorate treatment. In type I AIT the main medical treatment consists of the simultaneous administration of thionamides and potassium perchlorate, while in type II AIT, glucocorticoids are the most useful therapeutic option. Mixed forms are best treated with a combination of thionamides, potassium perchlorate, and glucocorticoids. Radioiodine therapy is usually not feasible due to the low thyroidal radioiodine uptake, while thyroidectomy can be performed in cases resistant to medical therapy, with a slightly increased surgical risk.
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Affiliation(s)
- E Martino
- Dipartimento di Endocrinologia e Metabolismo, University of Pisa, Ospedale de Cisanello, via Paradisa, 2, 56124 Pisa, Italy.
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20
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Abstract
Although amiodarone is regarded as a highly effective anti-arrhythmic agent, its use may lead to alterations in thyroid gland function and/or thyroid hormone metabolism, partly because of its rich iodine content. Patients treated with amiodarone may manifest altered thyroid hormone profile without thyroid dysfunction, or they may present with clinically significant amiodarone-induced hypothyroidism or amiodarone-induced thyrotoxicosis. The former results from the inability of the thyroid to escape from the Wolff-Chaikoff effect. It prevails in areas with high dietary iodine intake, and it is readily managed by discontinuation of amiodarone or thyroid hormone replacement. Amiodarone-induced thyrotoxicosis occurs more frequently in areas with low iodine intake; it may arise from iodine-induced excessive thyroid hormone synthesis (type I) or destructive thyroiditis with release of preformed hormones (type II). Type I should be treated with thionamides alone or in combination with potassium perchlorate, whereas type II benefits from treatment with glucocorticoids. Surgery may be a feasible option for patients who require long-term amiodarone treatment.
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Affiliation(s)
- K C Loh
- Endocrine Unit, Department of Medicine, Tan Tock Seng Hospital, Singapore 308433
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Claxton S, Sinha SN, Donovan S, Greenaway TM, Hoffman L, Loughhead M, Burgess JR. Refractory amiodarone-associated thyrotoxicosis: an indication for thyroidectomy. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 2000; 70:174-8. [PMID: 10765898 DOI: 10.1046/j.1440-1622.2000.01780.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Tasmania is an area of endemic iodine deficiency. Amiodarone is a class III anti-arrhythmic drug that is widely used for the management of ventricular and supraventricular tachydysrhythmias. Individuals from areas of endemic iodine deficiency appear more likely to manifest hyperthyroidism following amiodarone therapy, whereas hypothyroidism is a more frequent complication in iodine-replete communities. METHODS Cases series. The clinical and biochemical response to medical and surgical management of five consecutive Tasmanian patients presenting with severe type-II amiodarone-associated thyrotoxicosis was reviewed. RESULTS Five patients were identified. Combinations of antithyroid therapy including propylthiouracil, lithium carbonate, dexamethasone and cholestyramine were used. Thyroidectomy was required in two cases (40%) due to severe unremitting thyrotoxicosis despite combined drug regimens. Anaesthesia and total thyroidectomy were undertaken without complication despite the presence of severe hyperthyroidism at the time of surgery. In both cases thyroid histopathology demonstrated degenerative and destructive follicular lesions with multinuclear cell infiltrate and focal fibrosis. CONCLUSION Amiodarone-associated thyrotoxicosis may be severe and refractory to medical therapy. Despite the potential risks of anaesthesia associated with uncontrolled thyrotoxicosis, thyroidectomy should be considered in the setting of life-threatening thyrotoxicosis.
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Affiliation(s)
- S Claxton
- Department of Diabetes and Endocrine Services, Royal Hobart Hospital, Tasmania, Australia
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