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Subclinical hypothyroidism guideline recommends against treatment
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A panel of researchers strongly advised against the use of thyroid hormones to treat adults with subclinical hypothyroidism in a recent BMJ Rapid Recommendations guide published in The BMJ.
Based on a systematic review of 21 studies that included 2,192 participants, the panel found high evidence of “no important difference” in quality of life, thyroid-related symptoms, fatigue/tiredness or depressive symptoms after 1 year between thyroid hormone treatment and no treatment in adults aged at least 65 years with subclinical hypothyroidism, which was defined as having a measure of thyroid-stimulating hormone between 4 mIU/L and 10 mIU/L and normal free thyroxine levels.
The evidence was less conclusive for adults younger than 65 years with subclinical hypothyroidism, although there was at least moderate support that hormone therapy had little beneficial effect compared with no treatment on quality of life, thyroid-related symptoms, fatigue/tiredness and depressive symptoms after 1 year.
Although little difference was found between treating with thyroid hormones or no treatment, there were the potential for negative effects from treatment with thyroid hormones. Evidence from the review showed a wide variability in potential mortality outcomes as well as an increased burden when taking thyroid hormones due to daily treatment that requires careful scheduling around meals and the potential development of hyperthyroidism due to overdosing, according to the panel.
The researchers further wrote although a TSH level of more than 10 mIU/L is currently used as a cutoff for thyroid hormone therapy, such variance in these measures is common and these measures “may revert to normal without treatment.”
The recommendation was not meant to apply to all adults. The researchers excluded women attempting pregancy and adults with a TSH measure of more than 20 mIU/L. They also noted that those younger than 30 years and those with greater symptom severity may not be subject to this recommendation due to a paucity of data from these populations in the review.
Despite this recommendation, the Society for Endocrinology and the British Thyroid Association issued a joint statement expressing their concerns. The two associations took issue with what they considered a small sample of trials, particularly noting that many of the participants were older than 65 years, leaving little evidence for younger adults. In addition, they questioned the TSH threshold the recommendation provides for treatment and encourage further larger-scale trials with more varied populations to better influence practical guidelines.
“A particular concern about the strong conclusion and high TSH threshold for intervention in this meta-analysis is that primary care physicians may now dismiss patients with subclinical hypothyroidism rather than institute ongoing surveillance, potentially resulting in some patients with progression of hypothyroidism being deprived of treatment,” the statement said. “Given how common subclinical hypothyroidism is throughout the world and the persistent concerns patients have regarding its treatment, it is disappointing that current available evidence on therapeutic intervention is so limited.” – by Phil Neuffer
Disclosures: The researchers report no relevant financial disclosures.
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