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Hidalgo J, Lincango EP, Cordova-Madera S, Ruiz-Arellanos K, Wenczenovicz C, Ponce O, Álvarez-Villalobos N, Rao A, Singh Ospina NM, Maraka S, Acosta GJ, Brito JP. Interventions to improve symptomatology in patients with hypothyroidism and persistent symptoms: A systematic review. Endocrine 2024:10.1007/s12020-024-03816-1. [PMID: 38622434 DOI: 10.1007/s12020-024-03816-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 03/29/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Levothyroxine (LT4) monotherapy is the standard treatment for hypothyroidism; however, 10-15% of patients have persistent hypothyroid symptoms despite normalizing thyroid hormone levels with LT4. This study aims to summarize the best available evidence on interventions to improve symptomatology in patients with hypothyroidism and persistent symptoms. METHODS A systematic search was conducted in March 2022 for randomized controlled trials and observational studies on interventions for adult patients with persistent hypothyroid symptoms despite biochemical euthyroidism on thyroid hormone replacement. RESULTS A total of 277 articles were reviewed and seven fulfilled the inclusion criteria. 455 participants were included. Most intervention participants were female (78.6%) with a mean age of 47.5 (±2.8) years. Five clinical trials evaluating ginger (vs. starch), L-carnitine (vs. placebo), combination LT4 and liothyronine (LT3) (vs. LT4 or placebo), and surgery for patients with serum antithyroid peroxidase (TPO Ab) titers greater than 1000 IU/ml (vs. LT4) found inconsistent improvement in hypothyroidism related symptoms and general health. The two clinical trials with the largest improvement in fatigue scores were the use of ginger and surgery. One observational study comparing thyroidectomy vs observation found no significant difference on general health. Lastly, another observational study evaluating combination LT4/LT3 (vs. LT4 monotherapy) found improvement in fatigue and quality of life. There were 31 (12%) adverse events in the intervention group and 18 (10.8%) in the comparator group. CONCLUSIONS There is no high-quality evidence supporting any intervention for persistent symptoms in hypothyroidism. Available evidence, limited by the risk of bias, inconsistency, and heterogeneity, suggests that some persistent symptoms, particularly fatigue, could improve with ginger and thyroidectomy.
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Affiliation(s)
- Jessica Hidalgo
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, MN, USA
- Rutgers Health Community Medical Center, Internal Medicine, Toms River, NJ, USA
| | - Eddy P Lincango
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, MN, USA
- CaTaLiNA Research Initiative (Cancer de tiroides en Latinoamerica), Quito, Ecuador
- University of Central Florida, Department of Surgery, Orlando, FL, USA
| | - Sandra Cordova-Madera
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Kim Ruiz-Arellanos
- Facultad de Medicina Alberto Hurtado, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Camila Wenczenovicz
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, MN, USA
| | - Oscar Ponce
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, MN, USA
- Frimley Park Hospital, Frimley Health NHS Foundation Trust, Camberley, UK
| | | | - Arbaaz Rao
- Rutgers Health Community Medical Center, Internal Medicine, Toms River, NJ, USA
| | - Naykky M Singh Ospina
- Division of Endocrinology, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Spyridoula Maraka
- Division of Endocrinology and Metabolism, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Endocrine Section, Medicine Service, Central Arkansas Veterans Healthcare System, Little Rock, AR, USA
| | - Gonzalo J Acosta
- Division of Endocrinology, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Juan P Brito
- Division of Diabetes, Endocrinology, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
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Ayala IN, Soto Jacome C, Toro-Tobon D, Golembiewski E, Garcia-Bautista A, Hidalgo J, Cordova-Madera S, Al Anbari R, Sohn R J, Singh Ospina N, Maraka S, Joseph M, Brito JP. Appropriateness of Levothyroxine Prescription: A Multicenter Retrospective Study. J Clin Endocrinol Metab 2024; 109:e765-e772. [PMID: 37656124 PMCID: PMC10795923 DOI: 10.1210/clinem/dgad517] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/17/2023] [Accepted: 08/29/2023] [Indexed: 09/02/2023]
Abstract
CONTEXT Levothyroxine is one of the most prescribed medications in the United States. OBJECTIVE This study explores the appropriateness of levothyroxine prescriptions. METHODS A retrospective multicenter study was conducted on adult patients who were prescribed levothyroxine for the first time between 2017 and 2020 at three academic centers in the United States. We classified each case of levothyroxine initiation into one of three mutually exclusive categories: appropriate (clinically supported), indeterminate (clinically unclear), or nonevidence based (NEB, not clinically supported). RESULTS A total of 977 participants were included. The mean age was 55 years (SD 19), there was female (69%) and White race predominance (84%), and 44% had possible hypothyroid symptoms. Nearly half of the levothyroxine prescriptions were considered NEB (528, 54%), followed by appropriate (307, 31%) and indeterminate (118, 12%). The most common reason for NEB prescription was an index thyrotropin (TSH) value of less than 10 mIU/L without previous TSH or thyroxine values (131/528, 25%), for appropriate prescription, was overt hypothyroidism (163/307, 53%), and for an indeterminate prescription was a nonconfirmed subclinical hypothyroidism with TSH greater than or equal to 10 mIU/L (no confirmatory testing) (51/118, 43%). In multivariable analysis, being female (odds ratio [OR]: 1.3; 95% CI, 1.0-1.7) and prescription by a primary care provider (OR: 1.5; 95% CI, 1.2-2.0) were associated with NEB prescriptions. CONCLUSION There is a considerable proportion of NEB levothyroxine prescriptions. These results call for additional research to replicate these findings and to explore the perspective of those prescribing and receiving levothyroxine.
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Affiliation(s)
- Ivan Nicolas Ayala
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN 55902, USA
| | - Cristian Soto Jacome
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN 55902, USA
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN 55902, USA
| | - David Toro-Tobon
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN 55902, USA
| | - Elizabeth Golembiewski
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN 55902, USA
| | - Andrea Garcia-Bautista
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN 55902, USA
| | - Jessica Hidalgo
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN 55902, USA
| | | | - Raghda Al Anbari
- Division of Endocrinology, Department of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Jessica Sohn R
- Division of Endocrinology, Department of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Naykky Singh Ospina
- Division of Endocrinology, Department of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Spyridoula Maraka
- Division of Endocrinology and Metabolism, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
- Section of Endocrinology, Medicine Service, Central Arkansas Veterans Healthcare System, Little Rock, AR 72205, USA
| | - Marina Joseph
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - Juan P Brito
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN 55902, USA
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN 55902, USA
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Mogollon R, Quintero-Martinez J, Vallejo B, Garcia-Arango M, Cordova-Madera S, Pislaru S, Kane G, Villarraga H. How do cardiovascular risk factors and cardiac remodeling type affect left ventricular global longitudinal strain and right ventricular free wall strain in patients with obesity. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Obesity, defined by the World Health Organization (WHO) as a BMI greater than 30k g/m2, has reached epidemic proportions worldwide, related to approximately 2.8 million deaths/year as of June 2021. WHO sub-classifies obesity based on BMI in Class 1: 30–34.9 kg/m2, Class 2: 35–39.9 kg/m2, and Class 3: ≥40 kg/m2. This state of increased body weight is associated with an increased risk of cardiovascular disease. Cardiac remodeling can be affected by obesity and/or other cardiovascular risk factors (CVRF) as an adaptive physiological response. The remodeling patterns, Normal Geometry (NG), Concentric Remodeling (CR), Concentric Hypertrophy (CH), and Eccentric Hypertrophy, are classified by changes in Relative Wall Thickness (RWT), ≤ or >0.42, and/or Left Ventricular Mass Index (LVMI g/m2), ≤ or >88 for women and ≤ or >102 for men. Left Ventricular Ejection Fraction (LVEF) can remain within normal limits in patients with obesity with multiple CVRF and cardiac remodeling. Left Ventricular Global Longitudinal Strain (LV-GLS) and Right ventricular free wall strain (RV-FWS) can be useful to detect subclinical myocardial dysfunction. The aim of this study was to evaluate if these strain variables are affected in patients with obesity associated to other CVRF in relation to cardiac remodeling type when compared to controls.
Methods
2859 patients with BMI ≥30 kg/m2 and 2616 normal-weight controls (BMI between 18.5 and 24.9 kg/m2), with normal and abnormal cardiac geometry, and normal ejection fraction by echocardiography performed between 01/01/2008 and 12/31/2018, were compared. Obesity was classified based on the World Health Organization. CVRF included were Hypertension (HTN), Diabetes Mellitus (DM), Dyslipidemia, history of Vascular Event (myocardial infarction and/or stroke), and Obstructive sleep apnea (OSA).
Results
BMI, cardiac geometry, CVRF, and the number of comorbidities independently affected GLS and RV-FWS (Figure 1 and Figure 2). LV-GLS and RV-FWS values [mean (SD)] in obesity classes 1, 2, and 3 were −19 (2.9), −18.9 (2.9), −18.7 (2.9) & −24.2 (5.2), −23.8 (6.2), −24.5 (5.9), respectively. In the control group LV-GLS and RV-FWS values [mean (SD)] were −20.1 (3.0) & −27 (5.6), respectively. CH was associated with the greatest decrease in LV-GLS and RV-FWS in males and females, regardless of BMI (Figure 2). LV-GLS values [mean (SD)] associated to CH for obesity class 1, 2, and 3, and controls in females were −18.4 (3.4), −18 (3.1) −17.6 (3.6), and −17.8 (4), respectively, and for obesity class 1, 2, and 3, and controls in males were −16.1 (3.5), 16.5 (3.2), −14.4 (2.7), and −16.6 (4.7), respectively (Figure 1).
Conclusion
Obesity associated to CVRF and CH have the lowest values of GLS in patients with normal ejection fraction. These values were exceedingly below average compared to other groups. These parameters should be used as reference values for this population.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- R Mogollon
- Mayo Clinic Hospital-Rochester , Rochester , United States of America
| | | | - B Vallejo
- Mayo Clinic Hospital-Rochester , Rochester , United States of America
| | - M Garcia-Arango
- Mayo Clinic Hospital-Rochester , Rochester , United States of America
| | - S Cordova-Madera
- Mayo Clinic Hospital-Rochester , Rochester , United States of America
| | - S Pislaru
- Mayo Clinic Hospital-Rochester , Rochester , United States of America
| | - G Kane
- Mayo Clinic Hospital-Rochester , Rochester , United States of America
| | - H Villarraga
- Mayo Clinic Hospital-Rochester , Rochester , United States of America
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Mogollon R, Jadav RS, Badawy M, Garcia-Arango M, Quintero-Martinez JA, Cordova-Madera S, Dichak AL, Pislaru SV, Pellikka PA, Kane GC, Villarraga HR. VARIABILITY OF LEFT VENTRICULAR GLOBAL LONGITUDINAL STRAIN AND RIGHT VENTRICULAR FREE WALL STRAIN IN PATIENTS WITH OBESITY AND CARDIOVASCULAR RISK FACTORS. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02273-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Garcia-Arango M, Larsen C, Mogollon R, Quintero-Martinez JA, Cordova-Madera S, Cerhan JR, Haddad TC, Nkomo VT, Thompson CA, Villarraga HR. RADIATION-INDUCED VALVULAR HEART DISEASE IN A COMMUNITY BASED EPIDEMIOLOGICAL STUDY WITH A FOLLOW-UP RANGE OF UP TO 21 YEARS. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02888-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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