Edited by: Peter PA Smyth, UCD, Dublin · Published by: Merck KGaA, Darmstadt, Germany 1 | 2012 Angel of the North When people approach Tyneside either via car or train they are greeted by the welcoming wide-open arms of The Angel of the North as it comes into view. The Angel of the North is one of England’s 12 official icons. It stands over 65 feet, higher than four double-decker buses. Its wingspan stretches 175 feet almost the length of a jumbo jets wings. Adrian S Lock, flickr Practical Approach to Management of subclinical hypothyroidism Simon HS Pearce & Salman Razvi Disclaimer This scientific publication is published by and with financial support from Merck KGaA, Darmstadt, Germany subject to the requirement that article(s) published are of a scientific nature. The views expressed by the author(s) do not necessarily reflect the views, ideas or policy of Merck KGaA. This publication is provided for general reference only and is intended solely for healthcare professionals. As a result of ongoing medical advances and developments, the information in this material may not always be completely up to date and, for this reason, such information is provided on an "as is" and "as available" basis. Merck KGaA makes no warranties, representations or gives any undertakings either express or implied about any content of this publication. It may refer to pharmaceutical products, therapeutics or indications not registered or approved in a given c ountry. Please always refer to the full prescribing information applicable in your country for any pharmaceutical product. Registration conditions, warnings and precautions for pharmaceutical products differ from country to country. Copyright in this publication is expressly owned by Merck KGaA and/or its Affiliates (except for any third party content which has been identified as such). All rights reserved. Production Date: August 2012 Thyroid International 1 2012 Practical Approach to Management of subclinical hypothyroidism Simon HS Pearce1,2, Salman Razvi1,3 1. Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK 2. Endocrine Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK 3. Department of Endocrinology, Gateshead Health NHS Foundation Trust, Gateshead, UK Address for Correspondence: Prof. Simon Pearce, Institute of Genetic Medicine, Newcastle University, International Centre for Life, Central Parkway, Newcastle upon Tyne, NE1 3BZ, UK. Email: [email protected] Tel. 44-191-241-8674 Fax. 44-191-241-8666 2 Thyroid International 1 2012 Simon Pearce, MB,BS; MD; FRCP Professor of Endocrinology, Newcastle University, UK. Honorary Consultant Physician, Royal Victoria Infirmary, Newcastle upon Tyne, UK. Salman Razvi, MB,BS; MD; FRCP Consultant Endocrinologist, Gateshead Hospitals NHS Foundation Trust, UK. Honorary Senior Lecturer, Newcastle University, UK Simon Pearce qualified in Medicine MB,BS 1st class honours from Newcastle University. Following internal medicine training, he undertook postgraduate training in endocrinology at the Royal Postgraduate Medical School, Hammersmith, London (MD degree awarded with distinction); Brigham & Women’s Hospital, Boston, USA; and latterly in Newcastle, UK. He was appointed as Senior Lecturer in Endocrinology in 2001 at Newcastle University, and promoted to Professor in 2007, affiliated to the Institute of Genetic Medicine. The main themes of his research programme are in regenerative medicine approaches to adrenal failure, genetics of autoimmune endocrine disease and long-term management of thyroid diseases. Salman Razvi completed MB,BS in 1996 from AP University of Health Sciences, India prior to commencing postgraduate training in the UK. In 2006, he was awarded MD with commendation (Newcastle University) for his thesis on effects of levothyroxine on vascular, endothelial and quality of life markers in subclinical hypothyroidism. He currently practices as a Consultant Endocrinologist with a special interest in thyroid diseases and research interests include cardiovascular effects of thyroid disease, long-term outcomes of thyroid diseases and effects of aging on thyroid function. Thyroid International Editor-in-Chief: Peter PA Smyth, UCD, Dublin This is the title of a publication series published by and with financial support from Merck KGaA, Darmstadt, Germany. The Editor-in-Chief is publishing papers from renowned international thyroid experts in order to pass on the extensive experience which the authors possess in their field to a wide range of physicians d ealing with the diagnosis and therapy of thyroid dis eases. Please refer to the full disclaimer on the inside front cover. Responsible at M erck KGaA, Darmstadt, Germany: Gernot Beroset Photo: Angle of the North, Newcastle by Adrian S Lock/flickr Thyroid International · 1–2012 erck KGaA, Darmstadt, Germany, D-64271 Darmstadt M ISSN 0946-5464 H t Thyr idology ETA’s journal on hot and controversial topics Free access: www.hotthyroidology.com Practical Approach to Management of subclinical hypothyroidism Practical Approach to Management of subclinical hypothyroidism Abstract Subclinical hypothyroidism is a common finding when laboratory thyroid function testing is requested, but its management is not straightforward. Learned guidelines based on a systematic literature review that were published in 2004, concluded that the benefits of treating such patients with L-thyroxine remain unproven. Symptomatic benefits of L-thyroxine treatment are marginal and inconsistent between different studies. However, several large epidemiological studies have shown an association between subclinical hypothyroidism and risk of vascular events. No randomized controlled trials of L-thyroxine in subclinical hypothyroid patients have examined long-term vascular disease outcome or mortality. Nevertheless, information from several studies of surrogate vascular markers and from an observational study of real-life primary care practice suggest no harmful effects of L-thyroxine therapy. Indeed, the latter study was consistent with some benefit, particularly in young to middle-aged individuals with SCH. The various recent strands of evidence are discussed in this article to inform the current optimal management of the patient with subclinical hypothyroidism. Introduction Subclinical hypothyroidism (SCH) is defined by an elevation of the serum TSH above the reference range, with circulating free thyroid hormone concentrations that are within the reference range.1 It is a common problem in clinical practice, with a population prevalence of between 2 and 10 %, which increases in an age-related fashion.2,3 More than three quarters of individuals with SCH have serum TSH concentrations between 5 and 10 mU/l. Although, treatment of the mild thyroid failure of SCH with L-thyroxine would seem to be a logical approach to management, only small number of individuals with SCH have symptoms that are typical of hypothyroidism.4-6 Although some randomized trials of SCH have shown significant improvements in tiredness and other symptoms during L-thyroxine therapy,7,8 several other studies have failed to demonstrate improvement in such symptoms or health-related quality of life.9-12 3 4 Thyroid International 1 2012 What is the evidence for adverse vascular outcomes of SCH? More than 40 years ago, an association between borderline hypothyroidism and adverse vascular events was first suggested by UK and Belgian investigators.13,14 Another early study showed a strong association between mild hypothyroidism and angiographically demonstrated coronary artery disease.15 However, after several years of limited interest, it was the Rotterdam Heart study,16 which showed a doubling of heart attacks and atheromatous vascular calcification in SCH women compared to euthyroid participants, that re-ignited this area of investigation. In this study, SCH contributed as much to the risk of ischaemic heart disease (IHD) in these community-dwelling women as did diabetes mellitus (14 % of the aetiological fraction), which was close to the impact of cigarette use (15 %).16 Since then, there have been several other cross-sectional studies,2,17-21 as well as longitudinal studies that have assessed this relationship.16-25 A 20-year follow-up of 2779 participants in the Whickham study did not originally reveal an association between autoimmune thyroid disease and cardiovascular disease.22 However, a recent reanalysis of this dataset, using a definition of SCH based on TSH measurement, rather than on the presence of autoimmune thyroiditis (excluding antibody-positive euthyroid patients) did confirm an adverse effect of SCH on cardiovascular event rate and mortality.26 An increase in cardiovascular disease, comprising either prevalent heart disease or incident IHD events has also been found in several other well-powered cohort and longitudinal studies.17,18 Interestingly, Rodondi found no difference in prevalent IHD in SCH patients over 70 years old compared to euthyroid subjects, but during 4 years of follow up congestive heart failure was commoner in the SCH group with serum TSH > 7.0 mU/l.19 In contrast, a longitudinal study of 1,191 people aged more than 60 years from Birmingham, UK, showed no increased risk of CV disease in the group with baseline serum TSH > 5.0 mU/l during 10-years follow-up.23 Similarly, the prevalence of cardiovascular disease was not increased in SCH patients in a cross-sectional survey of 3,233 North American people over 65 years old.21 Furthermore, a longitudinal study of Dutch 85 year olds found that a raised serum TSH appeared to be modestly protective from cardiovascular events at older ages.24 Thus, several large studies have made conflicting findings concerning the relationship between SCH and vascular disease. These differences are quite likely to be due to the different population samples studied (inclusion or exclusion of subjects with history of thyroid disease, previous CV events) as well as variations in the definition of IHD, length of follow-up and whether patients subsequently treated with L-thyroxine were excluded. In order to further clarify whether SCH is detrimental overall to cardiovascular health, several authors have performed meta-analyses.27-32 Overall, these metaanalyses signal that SCH is associated with cardiovascular disease (Table 1). Two studies that investigated this showed a significant excess of IHD or IHD events Table 1 Summary of meta-analysis results relating subclinical hypothyroidism, cardiovascular events and mortality Author Number Cardiovascular events* Cardiovascular mortality All cause mortality Singh 2008 (27) 13,267 1.53 (1.31–1.79) 1.28 (1.02–1.60) 1.12 (0.99-1.26) Ochs 2008 (28) 14,449 1.20 (0.97-1.49) 1.18 (0.98-1.42) 1.12 (0.99 to 1.26) Haentjens 2008 (29) 14,619 NI NI 1.22 (0.95-1.57) Razvi 2008 (30) 29,022 1.23 (1.02– 1.48) 1.09 (0.84 –1.41) NI Rodondi 2010 (31) 55,287 1.18 (0.99- 1.42) 1.14 (0.99- 1.32) 1.09 (0.96-1.24) Thvilum 2012 (32) 35,740 NI NI 1.17 (1.00-1.37) Studies with significant results are shown in blue. *Relative risks with 5-95% confidence intervals are shown for each meta-analysis. NI = Not investigated. Practical Approach to Management of subclinical hypothyroidism in SCH cohorts, with a further two studies showing a suggestive trend. However, the link between excess cardiovascular and/or all cause mortality is less consistent, being found in the most recent meta-analysis containing the largest dataset,32 but not in all previous studies (summarised in table 1). These meta-analyses also give some important clues to the demographics of the patients who might be most at risk. Razvi and coworkers investigated whether age is an important determinant of vascular risk in SCH.30 In studies that enlisted populations over the age of 65 years, there was no excess in incident vascular events or vascular mortality in SCH compared to euthyroid subjects (p = 0.83 & 0.44, respectively); whereas these complications were significantly associated with SCH in younger patient cohorts (p = 0.0003 & 0.02, respectively).30 This phe- nomenon was confirmed with an individual-level data meta-analysis, showing that the adverse affects of SCH on vascular events and mortality was attenuated at older ages.31 Similarly, this study was able to confirm that cardiovascular event rates are proportionate to the elevation in serum TSH concentration: patients with serum TSH between 4.5–6.9 mU/l had no increase in cardiovascular mortality (relative risk [RR] 1.09 [0.911.30]), but this became significant in patients with TSH levels over 7.0 mU/l (RR 1.42 [1.03–1.95]).31 Thus, both age and degree of serum TSH elevation seem to be important clinical variables that predict poor vascular disease outcomes in SCH patients. What remains unknown is whether intervention in younger people with higher serum TSH levels will be beneficial. What are the mechanisms linking vascular disease and SCH? Thus far, there has been no randomised controlled trial (RCT) that has investigated the effect of L-thyroxine on CV disease incidence. However, a number of L-thyroxine intervention studies have looked at various surrogate cardiovascular risk factors in SCH patients. Most consistently, many studies have shown a beneficial effect of L-thyroxine on cardiac function (including systolic and diastolic function) in SCH patients.33-38, reviewed 39 Similarly, a few trials that studied endothelial dysfunction found that L-thyroxine had a beneficial effect.7,40 Circulating endothelial progenitor cells (EPC), an emerging marker of vascular risk, have been shown to be reduced in number in SCH.41 Furthermore, treatment with L-thyroxine improved EPC numbers to healthy values.41 Meta-analysis of several cohort studies shows an average increase in systolic blood pressure of about 2 mmHg in SCH, with diastolic blood pressure being 0.75 mmHg raised in SCH individuals.42 However, blood pressure has not shown significant changes during L-thyroxine intervention.7 Similarly, the effect of L-thyroxine on serum lipids in SCH appears variable.43,44 A meta-analysis has shown that the reduction in total cholesterol ranges from 0.2 to 0.4 mmol/L and LDL cholesterol by 0.26 mmol/L.44 There was no alteration in serum HDL cholesterol or triglycerides. Reductions in plasma factor VIII and von Willebrand factor have also been noted in SCH and improved following L-thyroxine treatment.45 Thus several mechanisms, either acting singly or in combination could account for the adverse vascular risk found in SCH. Results of analysis of real-life practice Although an RCT of L-thyroxine intervention in SCH with cardiovascular outcomes as an endpoint is underway (the ‘TRUST study’),46 it is likely to be more than 5 years before the results are reported. Thus, we currently face a relative vacuum of evidence regarding the long-term outcomes of people with SCH during L-thyroxine treatment. One of the commonly raised criticisms of a strategy of treating people with SCH, is that up to 50 % of people taking L-thyroxine will have poorly controlled thyroid function as judged by serum TSH.4,47,48 It is possible that there may be significant deleterious effects from overtreatment of such patients, 5 Thyroid International 1 2012 in terms of atrial fibrillation, vascular outcomes and bone health. We sought to address this problem using data from about 320,000 participants in the UK General Practice Research Database who had a serum TSH estimation during 2001.49 Of these records, 4,735 individuals over 40 years of age had a serum TSH between 5 and 10 mU/l and their outcome was studied up to 2008, a median period of 7.6 years. Participants were divided by age into those between 40 and 70 years of age, and those over 70 years, and those taking thyroid altering medications and with heart or vascular disease at baseline were excluded. Approximately 50 % of each age-group were treated with L-thyroxine by their primary care physician over the follow up period. Women and people with a higher TSH and lower FT4 measurements were more likely to be treated in each age-group, but there were no other differences at baseline.49 In the younger agegroup, fatal and nonfatal cardiovascular events were about 40 % fewer over time in the L-thyroxine treated group, than in the untreated SCH group, following multivariate analysis (Figure 1). However, this was not the case in the group over 70 years of age. Similarly, all cause mortality was found to be less in the L-thyroxine treated group than in the untreated group for patients between 40 and 70 years, but not in the older patients. Importantly, atrial fibrillation was not more common in patients taking L-thyroxine, even in the older agegroup.49 Although we have scrutinized this dataset carefully for evidence of confounding by indication, including analysis of socioeconomic status, frequency of clinic visits and concurrent medication use, we can find no evidence of bias. Similarly, the findings were robust to multiple sensitivity analyses, including removing patients who had vascular events early on during follow-up. Thus, the data contained within this analysis of real-life practice, coupled with our understanding of the pathophysiological changes in SCH, are reassuring that L-thyroxine treatment of patients less than 70 years old wasn’t harmful. Indeed, these findings are consistent with a modest beneficial effect of L-thyroxine treatment on medium-term vascular outcomes in younger but not older individuals with SCH.49 Figure 1 Multivariate-adjusted cumulative event plots for levothyroxine sodium–treated and untreated individuals with subclinical hypothyroidism for fatal and nonfatal ischemic heart disease. A, Younger patients (P = .02). B, Older patients (P = .56). Multivariate analysis shown is adjusted for age, sex, body mass index, socioeconomic deprivation score, total cholesterol level, index serum thyrotropin level, smoking status, systolic and diastolic blood pressure, history of diabetes mellitus, and levothyroxine use as a time-dependent covariate. Reproduced from citation 49. A B 0.06 0.16 No levothyroxine treatment Levothyroxine treatment 0.14 Cumulative Events 0.05 Cumulative Events 6 0.04 0.03 0.02 0.12 0.10 0.08 0.06 0.04 0.01 0.00 0.02 0 20 40 60 80 100 0.00 0 20 Follow-up, mo Events Participants at risk 58 3035 87 3006 114 2979 40 60 80 100 155 1487 192 1450 Follow-up, mo 138 2955 165 2928 Events Participants at risk 74 1568 117 1525 139 1503 Practical Approach to Management of subclinical hypothyroidism What is the expert view? In order to explore the factors that clinicians take into account in making a decision about treatment of SCH, a debate on this subject was held during the 14th International Thyroid Congress (Paris, September 13th 2010). Three hundred and eighty clinicians (60 % of whom were from Europe) responded electronically to questions about their use of L-thyroxine for several clinical case scenarios.50 For the case of a fifty three year old woman with difficulty losing weight, feelings of exhaustion and lack of mental focus with a serum TSH of 6.8 mU/l and normal circulating free thyroxine concentration, about half of respondents would treat with L-thyroxine (Figure 2). However, if dyslipidaemia (LDL-cholesterol 6.5 mmol/l) was also present, 75 % would then treat with L-thyroxine. Notably, for a more elderly patient (84 years) with identical serum thyroid function only 8 % would treat with L-thyroxine.50 The is significant disparity in clinical practice, even amongst expert thyroidologists. Furthermore, the results are at odds with a postal survey of members of the American Thyroid Association carried out in 2001, in which 95 and 92 % of respondents would treat a patient with a serum TSH of 8.2 mU/l, at the ages of 26 and 71 years, respectively.51 This might reflect differences in the clinical details of the cases, additional information about the risks and benefits of treating SCH that have come to light over the last 10 years, or differences in clinical practice influenced by alternative healthcare re-imbursement models. results of the participants’ opinion are shown in figure 2. The result of this small survey shows that there Figure 2 53 or 84 year old female, TSH 6.8 mU/L Percent 90 80 92% Treat with LT4 80 Do not treat 75% 70 70 60 50 40 60 49% 50 51% 40 30 30 25 % 20 20 10 0 90 Percent 10 8% 53 yo, no dyslipidaemia (n =344) 53 yo, dyslipidaemia (n = 363) Voting of 380 thyroidologists attending the ITC (from Pearce et al.50) 84 yo, no goitre (n=377) 0 7 8 Thyroid International 1 2012 Practical Approach to Management of subclinical hypothyroidism When faced with a patient with an elevated serum TSH hypothyroidism it is reasonable to consider a therapeuconcentration, what should the clinician do? Firstly the tic trial of L-thyroxine. This is particularly the case in TSH should be repeated, along with serum free thyroxindividuals with higher serum TSH levels, with a ine and thyroid peroxidase auto- Box 1 Treat subclinical hypothyroidism threshold of around 7.0 mU/l antibodies. In up to 50 % of cases being reasonable. A trial of close with levothyroxine TSH will normalise on repeat to a full replacement dose (75 or Treat at all ages if: testing.52 Many cases of SCH will 100 µg daily L-thyroxine) for 3 • TSH >10.0 mU/l be asymptomatic, but the typical or 4 months should be per• Pregnancy or pre-pregnancy symptoms of hypothyroidism formed, with a review of sympshould be sought. In particular, toms at the end of the trial.55 If Consider treatment, if: patients with SCH may complain symptoms are improved, then it • Symptoms or signs of hypothyroidism of generalized fatigue, and menis reasonable to continue • Age less than 70 yrs tal befuddlement and forgetfulL-thyroxine lifelong, adjusting • TSH >7.0 mU/l ness. An examination of the carthe dose to aim for a serum TSH • Goitre diovascular system and thyroid is concentration in the lower half • High vascular risk including worthwhile, as a significant goiof the reference interval.55 If Ischaemic heart disease ter would be a factor favoring symptoms are not improved, Diabetes treatment. Pregnancy or a plan then TSH monitoring should be Dyslipidaemia for pregnancy in the near future undertaken. The interval of are unequivocal indications for monitoring should reflect the 53,54 L-thyroxine treatment, so this should be identified risk of deterioration to overt hypothyroidism or a early (Box 1). Similarly, patients with a serum TSH > 10.0 mU/l should generally receive treatment. In contrast, patients with a TSH between 5 and 10 mU/l over the age of 70 may be unlikely to benefit from treatment,24,25,49 and a monitoring strategy should generally be implemented. In younger patients, in the absence of goiter or pregnancy, if the patient has symptoms of serum TSH > 10.0, and this is determined by the autoantibody status. For individuals with positive thyroid peroxidase antibodies, the risk of progression to overt disease is around 4.5 % annually, so annual TSH monitoring is reasonable.56 For those with negative antibodies, the risk is around 2 % so 2 or 3 yearly monitoring is sufficient.56 Summary Despite the persisting lack of the level 1 evidence from an RCT of L-thyroxine in SCH, the last 4 years have brought several advances in knowledge about the vascular risks of mild hypothyroidism, and what might be expected during its treatment. In particular, the differential effects of age and serum TSH on vascular risk, and the safety of L-thyroxine treatment in a large cohort observing the outcome of real-life practice are now understood. These advances should allow the clinician to target L-thyroxine therapy for appropriate patients with SCH with a greater degree of confidence than ever before. Practical Approach to Management of subclinical hypothyroidism References 1.Evered DC, Ormston BJ, Smith PA, Hall R, Bird T. Grades of Hypothyroidism. Br Med J 1973; 5854: 657–662. 2. Tunbridge WM, Evered DC, Hall R, Appleton D, Brewis M, Clark F, Evans JG, Young E, Bird T, Smith PA. The spectrum of thyroid disease in a community: the Whickham survey. Clin Endocrinol 1977; 7: 481-93. 3. Hollowell JG, Staehling NW, Flanders WD, Hannon WH, Gunter EW, Spencer CA, Braverman LE. Serum TSH, T(4), and thyroid antibodies in the United States population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III). J Clin Endocrinol Metab 2002; 87: 489-99. 4. Canaris GJ, Manowitz NR, Mayor G, Ridgway EC. The Colorado thyroid disease prevalence study. Arch Intern Med 2000; 160: 526-34. 5.Razvi S, Ingoe LE, McMillan CV, Weaver JU. Health status in patients with sub-clinical hypothyroidism. Eur J Endocrinol 2005; 152:713-7. 6. Reuters VS, Teixeira Pde F, Vigário PS, Almeida CP, Buescu A, Ferreira MM, de Castro CL, Gold J, Vaisman M. Functional capacity and muscular abnormalities in subclinical hypothyroidism. Am J Med Sci 2009; 338:259-63. 7. Razvi S, Ingoe L, Keeka G, Oates C, McMillan C, Weaver JU 2007 The beneficial effect of L-thyroxine on cardiovascular risk factors, endothelial function and quality of life in subclinical hypothyroidism: randomized, crossover trial. J Clin Endocrinol Metab 2007; 92:1715–1723 8. Meier C, Staub JJ, Roth CB, Guglielmetti M, Kunz M, Miserez AR, Drewe J, Huber P, Herzog R, Müller B. TSH-controlled L-thyroxine therapy reduces cholesterol levels and clinical symptoms in subclinical hypothyroidism: a double blind, placebo-controlled trial (Basel Thyroid Study). J Clin Endocrinol Metab 2001; 86: 4860-6. 9.Cooper DS, Halpern R, Wood LC, Levin AA, Ridgway EC. L-Thyroxine therapy in subclinical hypothyroidism. A doubleblind, placebo-controlled trial. Ann Intern Med 1984; 101: 18-24. 10. Jorde, R., Waterloo, K., Storhaug, H., Nyrnes, A., Sundsfjord, J. & Jenssen, T.G. Neuropsychological function and symptoms in subjects with subclinical hypothyroidism and the effect of thyroxine treatment. J Clin Endocrinol Metab 2006; 91: 145-153. 11.Nyström E, Caidahl K, Fager G, Wikkelsö C, Lundberg PA, Lindstedt G. A double-blind cross-over 12-month study of L-thyroxine treatment of women with 'subclinical' hypothyroidism. Clin Endocrinol (Oxf) 1988; 29: 63-75. 12. Villar HC, Saconato H, Valente O, Atallah AN. Thyroid hormone replacement for subclinical hypothyroidism. Cochrane Database Syst Rev 2007; 3:CD003419. 13. Fowler PBS, Swale J, Andrews H. Hypercholesterolaemia in borderline hypothyroidism: Stage of premyxoedema. Lancet 1970; 2(7671): 488-491. 14.Bastenie PA, Vanhaelst L, Bonnyns M, Neve P, Staquet M. Preclinical hypothyroidism: a risk factor for coronary heart-disease. Lancet 1971;1(7692):203-4. 15. Dean JW, Fowler PBS. Exaggerated responsiveness to thyrotrophin releasing hormone: a risk factor in women with coronary artery disease. Br Med J (Clin Res Ed). 1985; 290: 1555-61. 16. Hak, A.E., Pols, H.A., Visser, T.J., Drexhage, H.A., Hofman, A. & Witteman, J.C. Subclinical hypothyroidism is an independent risk factor for atherosclerosis and myocardial infarction in elderly women: the Rotterdam Study. Ann Intern Med 2000; 132: 270278. 17. Imaizumi, M., Akahoshi, M., Ichimaru, S., Nakashima, E., Hida, A., Soda, M., Usa, T., Ashizawa, K., Yokoyama, N., Maeda, R., Nagataki, S. & Eguchi, K. Risk for ischemic heart disease and allcause mortality in subclinical hypothyroidism. J Clin Endocrinol Metab 2004; 89: 3365-3370. 18. Walsh, J.P., Bremner, A.P., Bulsara, M.K., O'Leary, P., Leedman, P.J., Feddema, P. & Michelangeli, V. Subclinical thyroid dysfunction as a risk factor for cardiovascular disease. Arch Intern Med 2005; 165: 2467-2472. 19.Rodondi, N., Newman, A.B., Vittinghoff, E., de Rekeneire, N., Satterfield, S., Harris, T.B. & Bauer, D.C. Subclinical hypothyroidism and the risk of heart failure, other cardiovascular events, and death. Arch Intern Med 2005; 165: 2460-2466. 20. Cappola AR, Fried LP, Arnold AM, Danese MD, Kuller LH, Burke GL, Tracy RP, Ladenson PW. Thyroid status, cardiovascular risk, and mortality in older adults. JAMA 2006; 295:1033-41. 21. Lindeman RD, Romero LJ, Schade DS, Wayne S, Baumgartner RN, Garry PJ. Impact of subclinical hypothyroidism on serum total homocysteine concentrations, the prevalence of coronary heart disease (CHD), and CHD risk factors in the New Mexico Elder Health Survey. Thyroid 2003; 13:595-600. 22. Vanderpump MP, Tunbridge WM, French JM, Appleton D, Bates D, Clark F, Grimley Evans J, Rodgers H, Tunbridge F, Young ET. The development of ischemic heart disease in relation to autoimmune thyroid disease in a 20-year follow-up study of an English community. Thyroid 1996; 6:155-60. 23. Parle JV, Maisonneuve P, Sheppard MC, Boyle P, Franklyn JA. Prediction of all-cause and cardiovascular mortality in elderly people from one low serum thyrotropin result: a 10-year cohort study. Lancet 2001; 358: 861-865. 24.Gussekloo J, van Exel E, Craen AJM, Meinders AE, Frölich M, Westendorp RGJ. Thyroid status, disability and cognitive function, and survival in old age. JAMA 2004; 292: 2591-2599. 25.Boekholdt SM, Titan SM, Wiersinga WM, et al. Initial thyroid status and cardiovascular risk factors: the EPIC-Norfolk prospective population study. Clin Endocrinol (Oxf) 2010; 72: 404-410. 26. Razvi S, Weaver JU, Vanderpump MP, Pearce SHS. The incidence of ischemic heart disease and mortality in people with subclinical hypothyroidism: re-analysis of the Whickham Survey cohort. J Clin Endocrinol Metab 2010; 95: 1734-40. 27. Singh S, Duggal J, Molnar J, Maldonado F, Barsano CP, Arora R. Impact of subclinical thyroid disorders on coronary heart disease, cardiovascular and all-cause mortality: a meta-analysis. Int J Cardiol 2008; 125: 41-8. 38. Ochs N, Auer R, Bauer DC, Nanchen D, Gussekloo J, Cornuz J, Rodondi N. Meta-analysis: subclinical thyroid dysfunction and the risk for coronary heart disease and mortality. Ann Intern Med 2008; 148: 832-45. 29.Haentjens P, Van Meerhaeghe A, Poppe K, Velkeniers B. Subclinical thyroid dysfunction and mortality: an estimate of relative and absolute excess all-cause mortality based on timeto-event data from cohort studies. Eur J Endocrinol 2008; 159:329-41. 30. Razvi S, Shakoor A, Weaver JU, Vanderpump M, Pearce SH. The influence of age on ischeamic heart disease and mortality in subclinical hypothyroidism – a meta-analysis. J Clin Endocrinol Metab 2008; 93: 2998-3007 31. Rodondi N, den Elzen WP, Bauer DC, Cappola AR, Razvi S, Walsh JP, Asvold BO, Iervasi G, Imaizumi M, Collet TH, Bremner A, Maisonneuve P, Sgarbi JA, Khaw KT, Vanderpump MP, Newman AB, Cornuz J, Franklyn JA, Westendorp RG, Vittinghoff E, Gussekloo J; Thyroid Studies Collaboration. Subclinical hypothyroidism and the risk of coronary heart disease and mortality. JAMA 2010; 304:1365-74. 9 10 Thyroid International 1 2012 32. Thvilum M, Brandt F, Brix TH, Hegedüs L. A review of the evidence for and against increased mortality in hypothyroidism. Nat Rev Endocrinol 2012 doi: 10.1038/nrendo.2012.29 [Epub ahead of print] 49.Razvi S, Weaver JU, Butler TJ, Pearce SH. Levothyroxine Treatment of Subclinical Hypothyroidism, Fatal and Nonfatal Cardiovascular Events, and Mortality. Arch Intern Med 2012 [Epub ahead of print] PMID: 22529180 33. Forfar JC, Wathen CG, Todd WT, Bell GM, Hannan WJ, Muir AL, Toft AD.Left ventricular performance in subclinical hypothyroidism. Q J Med 1985; 57:857-65. 50. Pearce SH, Vaisman M, Wemeau JL. Management of subclinical hypothyroidism: The thyroidologists’ view. Eur Thyroid J 2012; 1: 45-50. 34. Földes J, Istvánfy M, Halmágyi M, Váradi A, Gara A, Pártos O. Hypothyroidism and the heart. Examination of left ventricular function in subclinical hypothyroidism. Acta Med Hung 1987; 44: 337-47. 51. McDermott MT, Haugen BR, Lezotte DC, Seggelke S, Ridgway EC. Management practices among primary care physicians and thyroid specialists in the care of hypothyroid patients. Thyroid 2001; 11:757-64. 35. Arem R, Rokey R, Kiefe C, Escalante DA, Rodriguez A. Cardiac systolic and diastolic function at rest and exercise in subclinical hypothyroidism: effect of thyroid hormone therapy. Thyroid 1996; 6: 397-402. 52.Meyerovitch J, Rotman-Pikielny P, Sherf M, Battat E, Levy Y, Surks MI. Serum thyrotropin measurements in the community: five-year follow-up in a large network of primary care physicians. Arch Intern Med 2007; 167: 1533-8. 36. Biondi B, Fazio S, Palmieri EA, Carella C, Panza N, Cittadini A, Bonè F, Lombardi G, Saccà L. Left ventricular diastolic dysfunction in patients with subclinical hypothyroidism. J Clin Endocrinol Metab 1999; 84: 2064-7. 53. Negro R, Schwartz A, Gismondi R, Tinelli A, Mangieri T, StagnaroGreen A. Increased pregnancy loss rate in thyroid antibody negative women with TSH levels between 2.5 and 5.0 in the first trimester of pregnancy. J Clin Endocrinol Metab 2010; 95:E44-8. 37. Monzani F, Di Bello V, Caraccio N, Bertini A, Giorgi D, Giusti C, Ferranini E. Effect of L-thyroxine on cardiac function and structure in subclinical hypothyroidism: a double blind, placebocontrolled study. J Clin Endocrinol Metab 2001; 86:1110–1115 54. Stagnaro-Green A, Abalovich M, Alexander E, Azizi F, Mestman J, Negro R, Nixon A, Pearce EN, Soldin OP, Sullivan S, Wiersinga W; American Thyroid Association Taskforce on Thyroid Disease During Pregnancy and Postpartum. Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and postpartum. Thyroid 2011;21:1081125. 38. Yazici M, Gorgulu S, Sertbas Y, Erbilen E, Albayrak S, Yildiz O, Uyan C. Effects of thyroxin therapy on cardiac function in patients with subclinical hypothyroidism: index of myocardial performance in the evaluation of left ventricular function. Int J Cardiol 2004; 95:135-43. 39. Kahaly GJ. Cardiovascular and atherogenic aspects of subclinical hypothyroidism. Thyroid 2000;10:665-79. 40. Taddei S, Caraccio N, Virdis A, Dardano A, Versari D, Ghiadoni L, Salvetti D, Ferranini E, Monzani F. Impaired endotheliumdependent vasodilatation in subclinical hypothyroidism: beneficial effect of L-thyroxine therapy. J Clin Endocrinol Metab 2003; 88:3731–3737. 41. Shakoor SK, Aldibbiat A, Ingoe LE, Campbell SC, Sibal L, Shaw J, Home PD, Razvi S, Weaver JU. Endothelial progenitor cells in subclinical hypothyroidism: the effect of thyroid hormone replacement therapy. J Clin Endocrinol Metab 2010 ; 95: 319-22. 42. Cai Y, Ren Y, Shi J. Blood pressure levels in patients with subclinical thyroid dysfunction: a meta-analysis of cross-sectional data. Hypertens Res 2011; 34: 1098-105. 43. Teixeira PF, Reuters VS, Ferreira MM, Almeida CP, Reis FA, Melo BA, Buescu A, Costa AJ, Vaisman M. Treatment of subclinical hypothyroidism reduces atherogenic lipid levels in a placebo-controlled double-blind clinical trial. Horm Metab Res 2008; 40: 50-5. 44. Danese MD, Ladenson PW, Meinert CL, Powe NR. Clinical review 115: effect of thyroxine therapy on serum lipoproteins in patients with mild thyroid failure: a quantitative review of the literature. J Clin Endocrinol Metab 2000; 85:2993–3001. 45.Gullu S, Sav H, Kamel N. Effects of L-thyroxine treatment on biochemical and hemostasis parameters in patients with hypothyroidism. Eur J Endocrinol 2005; 152:355-61. 46. TRUST study website. www.trustthyroidtrial.com 47.Parle JV, Franklyn JA, Cross KW, Jones SR, Sheppard MC. Thyroxine prescription in the community: serum thyroid stimulating hormone level assays as an indicator of undertreatment or overtreatment. Br J Gen Pract 1993; 43:107-9. 48.Okosieme OE, Belludi G, Spittle K, Kadiyala R, Richards J. Adequacy of thyroid hormone replacement in a general population. QJM 2011; 104: 395-401. 55. Vaidya B, Pearce SHS. Management of hypothyroidism in adults. BMJ 2008;337: 284-89. 56. Vanderpump MP, Tunbridge WM, French JM, Appleton D, Bates D, Clark F, Grimley Evans J, Hasan DM, Rodgers H, Tunbridge F, et al. The incidence of thyroid disorders in the community: a twenty-year follow-up of the Whickham Survey. Clin Endocrinol (Oxf) 1995; 43:55-68. Practical Approach to Management of subclinical hypothyroidism 11 12 Thyroid International 1 2012 Former Editions of Thyroid International No 4-2011 D iagnosis and Treatment of Graves’ Disease in Children and Adolescents: Challenges & controversies (Rosalind S. Brown, MD, CM, FRCP (C)) No 3-2011 A View of Diabetes from the Thyroid Corner (Gabriela Brenta, M.D.) No 2-2011 Antithyroid Drugs (Luigi Bartalena) No 1-2011 Guidelines for the Diagnosis and Management of Thyroid Nodules (Mahmood Gharib, Hossein Gharib) No 5-2010 Highlights of the 14th International Thyroid Congress 11th–16th September 2010, Palais des Congrès, Paris (Clara V Alvarez, Stephen W Spaulding, Peter PA Smyth) No 4-2010 The interaction between growth hormone and the thyroid axis (Lucy Ann Behan, Amar Agha) No 3-2010 Transient Hypothyroxinemia of Prematurity: Current State of Knowledge (Nevena Simic, Joanne Rovet) No 2-2010 3-Iodothyronamine (T1AM): A new thyroid hormone? (Barbara D Hettinger, Kathryn G Schuff, Thomas S Scanlan) No 1-2010 R eport on the 34th Annual Meeting of the European Thyroid Association (Clara V Alvarez and Peter PA Smyth) No 5-2009 F actors Affecting Thyroid Hormone Gastrointestinal Absorption (Kenneth D. Burman, M.D.) No 4-2009 Iodine Deficiency Disorders: Silent Pandemic (Fereidoun Azizi) No 3-2009 A merican Thyroid Association: Highlights of the 79th Annual Meeting (Stephen W Spaulding, P.P.A. Smyth) No 2-2009 E pidemiology of Thyroid Dysfunction – Hypothyroidism and Hyperthyroidism (M.P.J. Vanderpump) No 1-2009 R eport on the 33rd Annual Meeting of the European Thyroid Association (L.H. Duntas, P.P.A. Smyth) No 4-2008 T hyroid autoimmunity and female infertility (Kris Poppe, Daniel Glinoer, Brigitte Velkeniers) No 3-2008 N ew reference range for TSH? (Georg Brabant) No 2-2008 A merican Thyroid Association: Highlights of the 78th Annual Meeting (Stephen W Spaulding, Peter PA Smyth) No 1-2008 R eport of the 32th Annual Meeting of the European Thyroid Association (GJ Kahaly, P.P.A. Smyth) (John H Lazarus, Peter PA Smyth) No 1-2007 The story of the ThyroMobil (F. Delange, C.J. Eastman, U. Hostalek, S. Butz, P.P.A. Smyth) No 3-2006 Thyroid Peroxidase – Enzyme and Antigen (Barbara Czarnocka) No 2-2006 Genetics of benign and malignant thyroid tumours (Dagmar Führer) No 1-2006 Highlights of the 13th ITC (Sheue-yann Cheng, Peter PA Smyth) No 4-2005 Thyroid Eye Disease: Current Concepts and the EUGOGO Perspective (Gerasimos E Krassas, Wilmar M Wiersinga) No 3-2005 Clinical Expression of Mutations in the TSH Receptor: TSH-R Disorders (Davide Calebiro, Luca Persani, Paolo Beck-Peccoz) No 2-2005 Transient Hypothyroxinaemia and Preterm Infant Brain Development (Robert Hume, Fiona LR Williams, Theo J Visser) No 1-2005 The Spectrum of Autoimmunity in Thyroid Disease (Anthony P. Weetman) No 5-2004 Postpartum Thyroiditis: An Update (Kuvera E. Premawardhana, John H. Lazarus) No 4-2004 Report of the 29th Annual Meeting of the European Thyroid Association (G. Hennemann) No 3-2004 Autoimmune Thyroiditis And Pregnancy (Alex F. Muller, Arie Berghout) No 2-2004 Report of the 75th Annual Meeting of the American Thyroid Association (G. Hennemann) No 1-2004 Thyroid and Lipids: a Reappraisal (Leonidas H. Duntas) No 5-2003 Use of Recombinant TSH in Thyroid Disease: An Evidence-Based Review (Sara Tolaney M.D., Paul W. Ladenson M.D.) No 4-2003 New Insights for Using Serum Thyroglobulin (Tg) Measurement for Managing Patients with Differentiated Thyroid Carcinomas (C.A. Spencer) No 3-2003 The Significance of Thyroid Antibody Measurement in Clinical Practice (A. Pinchera, M. Marinò, E. Fiore) No 2-2003 Etiology, diagnosis and treatment of Graves’ disease (A.P. Weetman) No 1-2003 Report of the 74th Annual Meeting of the American Thyroid Association (G. Hennemann) No 6-2002 R eport of the 28th Annual Meeting of the European Thyroid Association (G. Hennemann) No 4-2007 T he Thyroid and Twins (Pia Skov Hansen, Thomas Heiberg Brix, Laszlo Hegedüs) No 5-200 2 Iodine Deficiency in Europe anno 2002 (François M. Delange, MD, PhD) No 2-2007 R eport of the 31th Annual Meeting of the European Thyroid Association No 3-200 2 Congenital Hypothyroidism (Delbert A. Fisher) No 3-2007 C linical Aspects of Thyroid Disorders in the Elderly (Valentin Fadeyev) No 4-200 2 Thyroid Imaging in Nuclear Medicine (Dik J. Kwekkeboom, Eric P. Krenning) Thyroid International is also published on the website ThyroLink: www.thyrolink.com (Literature) Merck Serono A division of Merck KGaA Frankfurter Str. 250 64293 Darmstadt Germany W.81089.7
© Copyright 2024