alexa Subclinical Thyroid DiseaseClinical Applications
Diabetes & Endocrinology

Diabetes & Endocrinology

Journal of Thyroid Disorders & Therapy

Author(s): Nananda F, Martin I Surks, Gilbert H

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Subclinical hypothyroidism and hyperthyroidism are diagnoses based on laboratory evaluation with few if any clinical signs or symptoms. Subclinical hypothyroidism is defined as an elevation in serum thyroid-stimulating hormone (TSH) above the upper limit of the reference range (0.45-4.5 mIU/L) with normal serum FT4 concentration; subclinical hyperthyroidism is defined as a decrease in serum TSH below the reference range with normal serum FT4 and T3 concentrations. Though these conditions represent the earliest stages of thyroid dysfunction, the benefits of detecting and treating subclinical thyroid disease are not well established. Most persons found to have subclinical thyroid disease will have TSH values between 0.1 and 0.45 mIU/L or between 4.5 and 10 mIU/L, for which the benefits of treatment are not clearly established; treatment may be beneficial in individuals with serum TSH lower than 0.1 mIU/L or higher than 10 mIU/L. This article illustrates approaches to managing patients with subclinical hypothyroidism and hyperthyroidism through 5 case scenarios that apply the principles of evidence-based medicine. Because of the substantial uncertainty concerning the consequences of untreated subclinical hypothyroidism and hyperthyroidism, as well as the benefit of initiating treatment, patient preferences are important in deciding on management of subclinical disease. Subclinical hypothyroidism and hyperthyroidism represent the earliest stages of thyroid dysfunction. Subclinical hypothyroidism is defined as an elevation in serum thyroid-stimulating hormone (TSH) above the upper limit of the reference range (0.45-4.5 mIU/L) with a normal serum free T4 (FT4) concentration; subclinical hyperthyroidism is defined as a decrease in serum TSH concentration below the reference range, with normal serum FT4 and T3 concentrations. Most patients have few if any signs or symptoms of thyroid dysfunction; therefore, it is a diagnosis based on laboratory evaluation. Because the risk for subclinical thyroid dysfunction, particularly subclinical hypothyroidism, increases with age,1 the number of cases should increase as the US population ages. Management of patients with thyroid dysfunction remains controversial because the body of scientific evidence available to guide clinical decisions is limited. Fundamental questions such as whom to screen and when to initiate treatment remain largely unanswered. Based on the available data, withholding treatment for individuals with serum TSH values that are slightly above or below the reference range (4.5-10 or 0.1-0.45 mIU/L) likely poses no harm, and initiating treatment likely poses no clear gains. Individuals with serum TSH concentrations lower than 0.1 or higher than 10 mIU/L are more likely to benefit from treatment, though some uncertainty remains. Subclinical thyroid dysfunction predicts future progression to overt disease; however, TSH levels in some individuals with subclinical hypothyroidism or hyperthyroidism return to the reference range. Initiating treatment for subclinical hypothyroidism does not alter the natural history of the disease but may prevent symptoms and signs of overt disease. In disorders for which the definition of the condition is imprecise and the benefits and risks of treatment are not clearly established, patient preferences play a critical role in treatment decisions. To make informed decisions, patients should understand the benefits and risks of initiating vs withholding treatment, as well as the expense and inconvenience of treatment vs monitoring. Figure 1 and Figure 2 depict simplified clinical algorithms for approaching subclinical hypothyroidism and hyperthyroidism.

This article was published in JAMA and referenced in Journal of Thyroid Disorders & Therapy

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