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Bekkering GE, Agoritsas T, Lytvyn L, Heen AF, Feller M, Moutzouri E, Abdulazeem H, Aertgeerts B, Beecher D, Brito JP, Farhoumand PD, Singh Ospina N, Rodondi N, van Driel M, Wallace E, Snel M, Okwen PM, Siemieniuk R, Vandvik PO, Kuijpers T, Vermandere M. Thyroid hormones treatment for subclinical hypothyroidism: a clinical practice guideline. BMJ 2019; 365:l2006. [PMID: 31088853 DOI: 10.1136/bmj.l2006] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
CLINICAL QUESTION What are the benefits and harms of thyroid hormones for adults with subclinical hypothyroidism (SCH)? This guideline was triggered by a recent systematic review of randomised controlled trials, which could alter practice. CURRENT PRACTICE Current guidelines tend to recommend thyroid hormones for adults with thyroid stimulating hormone (TSH) levels >10 mIU/L and for people with lower TSH values who are young, symptomatic, or have specific indications for prescribing. RECOMMENDATION The guideline panel issues a strong recommendation against thyroid hormones in adults with SCH (elevated TSH levels and normal free T4 (thyroxine) levels). It does not apply to women who are trying to become pregnant or patients with TSH >20 mIU/L. It may not apply to patients with severe symptoms or young adults (such as those ≤30 years old). HOW THIS GUIDELINE WAS CREATED A guideline panel including patients, clinicians, and methodologists produced this recommendation in adherence with standards for trustworthy guidelines using the GRADE approach. THE EVIDENCE The systematic review included 21 trials with 2192 participants. For adults with SCH, thyroid hormones consistently demonstrate no clinically relevant benefits for quality of life or thyroid related symptoms, including depressive symptoms, fatigue, and body mass index (moderate to high quality evidence). Thyroid hormones may have little or no effect on cardiovascular events or mortality (low quality evidence), but harms were measured in only one trial with few events at two years' follow-up. UNDERSTANDING THE RECOMMENDATION The panel concluded that almost all adults with SCH would not benefit from treatment with thyroid hormones. Other factors in the strong recommendation include the burden of lifelong management and uncertainty on potential harms. Instead, clinicians should monitor the progression or resolution of the thyroid dysfunction in these adults. Recommendations are made actionable for clinicians and their patients through visual overviews. These provide the relative and absolute benefits and harms of thyroid hormones in multilayered evidence summaries and decision aids available in MAGIC (https://app.magicapp.org/) to support shared decisions and adaptation of this guideline.
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Affiliation(s)
- G E Bekkering
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Belgium
- Belgian Centre for Evidence-Based Medicine, Cochrane Belgium
| | - T Agoritsas
- Division of General Internal Medicine and Division of Clinical Epidemiology, University
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - L Lytvyn
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - A F Heen
- Department of Medicine, Innlandet Hospital Trust-division, Gjøvik, Norway
| | - M Feller
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - E Moutzouri
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - B Aertgeerts
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Belgium
- Belgian Centre for Evidence-Based Medicine, Cochrane Belgium
| | | | - J P Brito
- Knowledge and Evaluation Research Unit in Endocrinology (KER_Endo), Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - P D Farhoumand
- Division General Internal Medicine, University Hospitals of Geneva, 1205 Geneva, Switzerland
| | - N Singh Ospina
- Department of Medicine, Division of Endocrinology, University of Florida, Gainesville, Florida, USA
| | - N Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - M van Driel
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane Qld 4029, Australia
| | - E Wallace
- HRB Centre for Primary Care Research and Department of General Practice, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - M Snel
- Department of Endocrinology/General Internal Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - P M Okwen
- Effective Basic Services (eBASE), Bamenda, Cameroon
| | - R Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - P O Vandvik
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Medicine, Innlandet Hospital Trust-division, Gjøvik, Norway
- Norwegian Institute of Public Health, Oslo, Norway
| | - T Kuijpers
- Dutch College of General Practitioners, Utrecht, Netherlands
| | - M Vermandere
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Belgium
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