Hot Topic in Endocrinology 1

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Published on February 18, 2009

Author: ashrafalabasiry

Source: authorstream.com

Hot Topics in Endocrinology I : Hot Topics in Endocrinology I Dr Hussam Abu-seido Consultant Family Medicine Saad Specialist Hospital Hypothyroidism : Hypothyroidism This was reviewed in the BMJ (BMJ2008:337;a801) together with clinical uncertainties’ paper about whether we should treat sub-clinical hypothyroidism (BMJ2008:337;a834) Hypothyroidism : Hypothyroidism Although considered a simple condition to manage, studies show that between 40-80% are over or under-treated. Therefore the review of evidence produces some useful learning points Hypothyroidism (Diagnosis) : Hypothyroidism (Diagnosis) The presenting symptoms all known The review talks of ‘exhaustion’ and ‘somnolence’ rather than just tiredness TSH levels show about a 30% diurnal variation, including in mild hypothyroidism, and this can give the impression of fluctuating disease Hypothyroidism (Diagnosis) : Hypothyroidism (Diagnosis) Antibodies to thyroid peroxidase (formerly called microsomal) or thyroglobulin are detected in 90% and 70% respectively of patients with autoimmune thyroid disease Hypothyroidism (Diagnosis) : Hypothyroidism (Diagnosis) Overt Hypothyroidism: Symptomatic hypothyroidism with a TSH>10 and a reduced serum free or total Thyroxin Subclinical or Mild hypothyroidism: TSH 5-10 and normal thyroxin levels Hypothyroidism (management) : Hypothyroidism (management) Overt Hypothyroidism ?Confirm TSH on second sample ?Start treatment and advise that it will be life long ?The carrot is that patients will feel better, although it may take several months for symptoms to resolve Hypothyroidism (management) : Hypothyroidism (management) Overt Hypothyroidism ?Any associated dyslipidemia and increased vascular risk will be reversed ?Levothyroxine alone is the treatment of choice ?Current evidence showing no advantage of combination treatment with liothyronine Hypothyroidism (management) : Hypothyroidism (management) Overt Hypothyroidism Levothyroxine is commonly titrated upwards, but RCT evidence shows this approach is not necessary for most patients ?Start full daily dose of 1.6 mcg/kg body weight which will render most patients euthyroid ?Exceptions are patients over 60 and with IHD. Hypothyroid induced bradycardia may mask asymptomatic coronary artery disease, so caution needed, start with low dose (12.5-25mcg) and increase every 3 to 6 weeks until euthyroid Hypothyroidism (management) : Hypothyroidism (management) Subclinical or mild hypothyroidism There is lack of evidence of whether we should treat such patients or not, exception is pregnancy or when trying to conceive when mild hypothyroidism should always be treated Hypothyroidism (management) : Hypothyroidism (management) Subclinical or mild hypothyroidism The risk of progression to overt hypothyroidism is relatively small (5% pa in asymptomatic patients with antibodies, 2% without antibodies) ?Recent meta-analysis show these patients have increased CVD risk, but another recent meta-analysis fails to show that thyroxine reduces this risk ?In patients over 85 subclinical hypothyroidism is associated with longevity Hypothyroidism (management) : Hypothyroidism (management) Subclinical or mild hypothyroidism The paper advises that we repeat the test complete with antibodies ?if patients have symptoms, a therapeutic trial of thyroxine for up to 6 months is reasonable, up to 50% of these patients then feel better and in these it is reasonable to continue otherwise the drug should be stopped ?if patients do not have symptoms but do have antibodies, treatment is not recommended but yearly surveillance is recommended (every 3 years of antibodies absent) Hypothyroidism (management) : Hypothyroidism (management) What about patients with symptoms of hypothyroidism but normal TFTs? The review quotes a small but well done RCT showing that levothyroxine does not improve symptoms in these patients Hypothyroidism (management) : Hypothyroidism (management) The aims of treatment is simple ?Make the patient feel better ?Level of TSH in lower half of reference range (0.4-2.5) Hypothyroidism (management) : Hypothyroidism (management) How should we monitor treatment? ?TSH should be measured 8-12 weeks after starting treatment and dose adjustment. Once stable annual is sufficient. ?Older people may need dose reduction as body mass and thyroxine clearance declines Hypothyroidism (management) : Hypothyroidism (management) How should we monitor treatment? ?Fully suppressed level(<0.1) should always be avoided. Studies show an association with osteoporosis and atrial fibrillation ?Partially suppressed (0.1-0.4) may be acceptable in a younger person who remains symptomatic on a lower dose. In older people over 60 even these levels have been shown to be associated with osteoporosis and should trigger a 25mcg reduction in dose Hypothyroidism (management) : Hypothyroidism (management) How should we monitor treatment? ?If patient has persistent symptoms an increase of 25mcg daily, or on alternate days, is reasonable ?Recent RCT shows that titrating the dose upwards, often leading to suppression of TSH, does not improve well-being Hypothyroidism (management) : Hypothyroidism (management) How should we monitor treatment? A persistently high TSH suggests non-concordance. ?If patient miss a dose, advise to take a double dose the next day. One small RCT has shown that taking a weekly dose (7X the daily dose) is safe, and can be suggested in carefully selected cases. ?Less commonly it may be caused by drugs that decrease absorption, such as calcium or ferrous salts, or induce thyroxine metabolism such as AEDs. ?Coeliac and Autoimmune gastritis are associated conditions and should be excluded if malabsorption is suggested Hypothyroidism (management) : Hypothyroidism (management) How should we monitor treatment? The patient does not feel well despite normalised TSH level ?Consider other causes (biological, psychological, or social) ?If patient feels clearly worse after starting levothyroxine, Addisons should be considered ?Other autoimmune conditions (coeliac, pernicious anemia and diabetes) should be considered. ?If the TSH is above 1.5 the authors suggest a trial dose increase of 25mcg, or change to nocturnal dosing which may improve absorption Hypothyroidism (management) : Hypothyroidism (management) When starting treatment, titrate dose only if over 60 or IHD. Otherwise start full dose Do not treat biochemical subclinical hypothyroidism, but trial of treatment is reasonable if symptomatic Fully suppressed levels of TSH should always be avoided. Aim for 0.4 to 2.5

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