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Dirks NF, den Elzen WPJ, Hillebrand JJ, Jansen HI, Boekel ET, Brinkman J, Buijs MM, Demir AY, Dijkstra IM, Endenburg SC, Engbers P, Gootjes J, Janssen MJW, Kniest-de Jong WHA, Kok MB, Kamphuis S, Kruit A, Michielsen E, Wolthuis A, Boelen A, Heijboer AC. Should we depend on reference intervals from manufacturer package inserts? Comparing TSH and FT4 reference intervals from four manufacturers with results from modern indirect methods and the direct method. Clin Chem Lab Med 2024; 62:1352-1361. [PMID: 38205847 DOI: 10.1515/cclm-2023-1237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 12/30/2023] [Indexed: 01/12/2024]
Abstract
OBJECTIVES Correct interpretation of thyroid function tests relies on correct reference intervals (RIs) for thyroid-stimulating hormone (TSH) and free thyroxine (FT4). ISO15189 mandates periodic verification of RIs, but laboratories struggle with cost-effective approaches. We investigated whether indirect methods (utilizing historical laboratory data) could replace the direct approach (utilizing healthy reference individuals) and compared results with manufacturer-provided RIs for TSH and FT4. METHODS We collected historical data (2008-2022) from 13 Dutch laboratories to re-establish RIs by employing indirect methods, TMC (for TSH) and refineR (for FT4). Laboratories used common automated platforms (Roche, Abbott, Beckman or Siemens). Indirect RIs (IRIs) were determined per laboratory per year and clustered per manufacturer (>1.000.000 data points per manufacturer). Direct RIs (DRIs) were established in 125 healthy individuals per platform. RESULTS TSH IRIs remained robust over the years for all manufacturers. FT4 IRIs proved robust for three manufacturers (Roche, Beckman and Siemens), but the IRI upper reference limit (URL) of Abbott showed a decrease of 2 pmol/L from 2015. Comparison of the IRIs and DRIs for TSH and FT4 showed close agreement using adequate age-stratification. Manufacturer-provided RIs, notably Abbott, Roche and Beckman exhibited inappropriate URLs (overall difference of 0.5-1.0 µIU/mL) for TSH. For FT4, the URLs provided by Roche, Abbott and Siemens were overestimated by 1.5-3.5 pmol/L. CONCLUSIONS These results underscore the importance of RI verification as manufacturer-provided RIs are often incorrect and RIs may not be robust. Indirect methods offer cost-effective alternatives for laboratory-specific or platform-specific verification of RIs.
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Affiliation(s)
- Niek F Dirks
- Endocrine Laboratory, Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Atalmedial Diagnostic Centers, Amsterdam, The Netherlands
- Department of Clinical Chemistry, Hematology & Immunology, Northwest Clinics, Alkmaar, The Netherlands
| | - Wendy P J den Elzen
- Laboratory Specialized Diagnostics & Research, Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Jacquelien J Hillebrand
- Endocrine Laboratory, Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, The Netherlands
| | - Heleen I Jansen
- Endocrine Laboratory, Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, The Netherlands
- Endocrine Laboratory, Department of Laboratory Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Edwin Ten Boekel
- Department of Clinical Chemistry, Hematology & Immunology, Northwest Clinics, Alkmaar, The Netherlands
| | - Jacoline Brinkman
- Department of Clinical Chemistry, St. Jansdal Hospital, Harderwijk, The Netherlands
| | | | - Ayse Y Demir
- Laboratory for Clinical Chemistry and Hematology, Meander Medical Center, Amersfoort, The Netherlands
| | - Ineke M Dijkstra
- Clinical Chemistry, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Silvia C Endenburg
- Department of Clinical Chemistry and Hematology, Dicoon, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Paula Engbers
- Department of Clinical Chemistry, Treant Care Group, Hoogeveen, The Netherlands
| | | | - Marcel J W Janssen
- Laboratory of Clinical Chemistry and Hematology, VieCuri Medical Center, Venlo, The Netherlands
| | | | - Maarten B Kok
- Saltro Diagnostic Center, Unilabs Netherlands, Utrecht, The Netherlands
| | - Stephan Kamphuis
- Eurofins Clinical Diagnostics, Gelre Hospitals, Apeldoorn, The Netherlands
| | - Adrian Kruit
- Medical Laboratory, Nij Smellinghe Hospital, Drachten, The Netherlands
| | | | - Albert Wolthuis
- Stichting Certe Medische Diagnostiek en Advies, Groningen, The Netherlands
| | - Anita Boelen
- Endocrine Laboratory, Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| | - Annemieke C Heijboer
- Endocrine Laboratory, Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
- Endocrine Laboratory, Department of Laboratory Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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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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Trimboli P, Piticchio T, Dadda Z, Stramazzo I, Gamarra E, Ruinelli L, Virili C. Analysis of dose-TSH response effect of levothyroxine soft-gel formulation. Front Endocrinol (Lausanne) 2024; 15:1340204. [PMID: 38449850 PMCID: PMC10915021 DOI: 10.3389/fendo.2024.1340204] [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: 11/17/2023] [Accepted: 01/30/2024] [Indexed: 03/08/2024] Open
Abstract
Background Hypothyroidism is treated with daily levothyroxine (LT4). In recent years, soft gel caps of LT4 (LT4-C) have been commercialized, and their performance has been optimized. Since guidelines recommend dose LT4 according to the tablet preparation efficacy, the present study was undertaken to obtain data about the daily requirement, normalized per body weight, of LT4-C. Methods Patients undergoing LT4-C after total thyroidectomy and radioiodine treatment for differentiated thyroid carcinoma were selected. There was no specific indication of suppression of TSH (i.e., <0.5 or <0.1 mIU/L). Patients were required to maintain a stable LT4 dose during the study period. Patients with interfering factors were excluded from this study. Results Thirty patients were enrolled (18 females and 12 males; median age, 50 years; median body weight, 71 kg; median LT4-C dose, 1.71 µg/kg/day). The analysis of patient age did not reveal any differences. The LT4-C dose correlated with free-T4 p = 0.03), but not with TSH (p = 0.42) and free-T3 (p = 0.13). TSH was <1.0 mIU/L in 90% of the cases. The LT4-C dose-TSH response effect was analysed by probit regression model: the probability to achieve TSH <1.0 mIU/l was 99% with a dose of 1.84 (95%CI 1.57-2.12) µg/kg/day, 75% with a dose of 1.38 µg/kg/day (95%CI 1.17-1.59), and 50% with a dose of 1.20 (95%CI 0.96-1.43). At ROC curve analysis, the most accurate cut-off of LT4-C dose to achieve TSH <1.0 mIU/l was 1.53 ug/kg/day with 70% sensitivity and 100% specificity. Conclusions Athyreotic patients can be initially treated with an LT4-C dose lower than previously stated. Therefore, further prospective studies are warranted.
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Affiliation(s)
- Pierpaolo Trimboli
- Servizio di Endocrinologia e Diabetologia, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Facoltà di Scienze Biomediche, Università della Svizzera Italiana, Lugano, Switzerland
| | - Tommaso Piticchio
- Servizio di Endocrinologia e Diabetologia, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Endocrinology Section, Department of Clinical and Experimental Medicine, Garibaldi Nesima Hospital, University of Catania, Catania, Italy
| | - Zeno Dadda
- Facoltà di Scienze Biomediche, Università della Svizzera Italiana, Lugano, Switzerland
| | - Ilaria Stramazzo
- Endocrinology Section, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Elena Gamarra
- Servizio di Endocrinologia e Diabetologia, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Lorenzo Ruinelli
- Servizio di Endocrinologia e Diabetologia, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Team Data Science and Research, Area ICT, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Clinical Trial Unit, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Camilla Virili
- Endocrinology Section, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
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