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ATA/AACE update treatment of hypothyroidism in adults
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QUEBEC CITY — The American Association of Clinical Endocrinologists and the American Thyroid Association have updated the clinical practice recommendations for hypothyroidism in adults for the first time in a decade.
“It was time to update the guidelines,” Jeffrey Garber, MD, Endocrine Today Editorial Board member and chair of the AACE/ATA task force, said in an interview. “Hypothyroidism arguably isn’t a rapidly changing field, but there is certainly an ever-expanding literature.”
Important updates
The document, which represents the first joint effort by AACE and the ATA to develop guidelines for the diagnosis and management of hypothyroidism, contains 52 evidence-based clinical recommendations besides a discussion of the etiology and epidemiology of the condition.
Jeffrey Garber
One important recommendation addresses diagnosis, with the task force stating that measuring serum thyroid-stimulating hormone is the “single best screening test for primary thyroid dysfunction for the vast majority of outpatient situations.” Nevertheless, it remains insufficient for evaluating hospitalized patients or when central hypothyroidism is present or suspected, the task force states. Additionally, the guidelines recommend against universal screening for hypothyroidism in women who are pregnant or planning to become pregnant because of limitations in the scientific evidence demonstrating its benefits.
The task force also establishes parameters for treatment. Patients with primary hypothyroidism and TSH levels >10 mIU/L should be treated, according to the guidelines, although clinicians should individualize treatment for patients with TSH levels ranging from 4.5 mIU/L to 10 mIU/L. One exception, however, includes pregnant women, as studies associate hypothyroidism with an increased rate of pregnancy loss and stillbirth in those with thyroid antibody negative women with TSH values between 2.5 mIU/L and 5 mIU/L.
The guidelines also recommend treatment with levothyroxine (LT4), noting that data have failed to confirm the benefits of combination LT4 and levotriiodothyronine (LT3) therapy. Further, Garber said they argue against using combination LT4 and LT3 therapies in pregnancy because these treatments lower maternal LT4 levels, which may have a negative impact on fetal neurological development.
The task force does not endorse the use of desiccated thyroid hormone, and the guidelines discuss nutraceuticals and other over-the-counter products marketed for “thyroid support” or to promote “thyroid health.” The recommendations state that, currently, clinical data showing the safety and efficacy of these products are lacking and, therefore, do not support their use. Clinicians should counsel their patients regarding these alternative treatments, Garber said.
The guidelines highlight when patients should see endocrinologists. Although most physicians can diagnose and treat the condition, the task force said, an endocrinologist should be consulted when children and infants, pregnant patients and women planning conception, and those with heart disease or other endocrine diseases such as adrenal and pituitary disorders are affected.
“We also go into areas of future research, including cardiovascular effects of hypothyroidism, [LT3] monotherapy, which we’re not currently endorsing, thyroid hormone analogues and universal screening for hypothyroidism in pregnancy,” Garber said.
Strength of the guidelines
Although the recommendations themselves are important, Garber said consideration of the grading system and analysis of the evidence’s strength is necessary as well.
“Reading the recommendations is key, but if you’re going to read them, understand the strengths of the evidence, the strengths of the grade and do look at the text,” he said. “Spend some time reading the exposition; don’t just read the recommendations at the bottom line. We think the strength of this particular guideline is that it’s transparent, and we explain the reasoning behind each recommendation.”
The new guidelines presentaly appear online in Thyroid and Endocrine Practice, and were presented at the American Thyroid Association 82nd Annual Meeting. – by Samantha Costa and Melissa Foster
For more information:
Garber J. ATA/AACE hypothyroidism guidelines session. Presented at: the American Thyroid Association Annual Meeting; Sept. 19-23, 2012; Quebec City.
Garber J. Thyroid. 2012;doi:10.1089/thy.2012.0205.
Disclosure: Jeffrey I. Mechanick, MD reports that he has received speaker and program development honoraria from Abbott Nutrition. Garber and other task force members report no relevant financial disclosures.
Perspective
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Elizabeth N. Pearce, MD, MSc
The most important thing about the guidelines is simply that they exist — having a set of hypothyroidism guidelines is a huge accomplishment. We haven’t had a new ATA guideline for hypothyroidism for over a decade, and the last AACE hypothyroidism guidelines were published in 2002. There has been a large amount of new literature since then, and there are many controversial areas where it should prove helpful to providers to have clear-cut recommendations.
The screening for and treatment of subclinical hypothyroidism is one of the greatest gray areas in terms of clinical management of hypothyroidism. These guidelines recommend treatment for TSH levels >10 mIU/L, and for all subclinically hypothyroid women who are pregnant or planning a pregnancy. They advocate individualizing treatment decisions for adults with subclinical hypothyroidism when the TSH is <10 mIU/L. There is also a clear recommendation for treatment with T4 (rather than T4/T3 combinations).
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