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An international panel of experts has concluded that patients with subclinical hypothyroidism should not be routinely offered thyroid hormone replacement therapy.
In the recommendations published online this week in the BMJ, the expert panel writes “for adults with subclinical hypothyroidism, thyroid hormones consistently demonstrate no clinically relevant benefits for quality of life or thyroid-related symptoms, including depressive symptoms, fatigue, and body mass index (BMI).”
The guidance, based on findings from a systematic review and meta-analysis of 21 trials with 2192 participants published in November (JAMA. 2018;320:1349-1359) represents a “strong recommendation” against prescribing thyroid hormones (primarily levothyroxine LT4) in adults with subclinical hypothyroidism.
Subclinical hypothyroidism is defined as elevated thyroid stimulating hormone (TSH) levels when free T4 (thyroxine) levels are normal.
- Subclinical hypothyroidism is known to affect around 5% of the adult population and 10-15% of the elderly.
- About 90% of patients with subclinical hypothyroidism have TSH levels of 4-10 mlU/L, but a slight increase may be normal in older people.
- Symptoms when present include fatigue, muscle cramps, sensitivity to cold, sluggish thinking and depression; as per the expert panel, 20-25% of people with normal thyroid levels report one or two of these symptoms.
- In the majority of cases, the issue resolves itself. About 62% of people with TSH levels of 4-10 mlU/L have normalization of thyroid levels within 5 years without any treatment, states the report. The risk of overt hypothyroidism emerging from the subclinical forms of the condition ranges between 2% and 5% per year.
- Observational data suggest an association between subclinical hypothyroidism and an increased risk of coronary heart disease, the associations have not been seen with TSH levels of 5-10 mIU/L.
Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA