Management Practices Among Primary Care Physicians and Thyroid Specialists in the Care of Hypothyroid Patients

Abstract

Prospective studies are not available to address various issues commonly encountered in the management of hypothyroid patients. We have conducted a case-based mail survey of American Thyroid Association (ATA) members and primary care providers (PCP) regarding hypothyroidism management issues. A majority of ATA members and a minority of PCPs used antithyroid antibody testing in the evaluation of hypothyroidism. Approximately 2/3 of all respondents indicated that they would treat patients with mild thyroid failure when antithyroid antibodies are negative; 77% of PCPs and 95% of ATA members recommended treatment when antibodies are positive. For a young patient with mild thyroid failure, 71% of ATA members would initiate a full levothyroxine (LT4) replacement dose of 1.6 microg/kg per day or slightly lower; PCPs were more likely to start with a low dose and titrate upwards. For a young patient with overt hypothyroidism, 42% of PCPs and 51% of ATA respondents recommended an initial full LT4 replacement dose. The majority of all respondents would start with a low LT4 dose and adjust the dose gradually in an elderly patient, regardless of the severity of thyroid hormone deficiency. More than 40% of ATA respondents chose a target thyrotropin (TSH) range of 0.5-2.0 microU/mL for a young patient while 39% favored a goal of 1.0-4.0 microU/mL for an elderly patient. PCPs more often chose a broader TSH goal of 0.5-5.0 microU/mL. In conclusion, the current practice patterns of PCPs and ATA members that were elicited in this survey differ significantly in regard to the evaluation and management of hypothyroidism.

International variation in GP treatment strategies for subclinical hypothyroidism in older adults: a case-based survey

“…In general, the response rates were higher in countries where the survey was forwarded to GPs affiliated with a research and teaching network. Although the overall response rate in this study was comparable to a case-based survey on subclinical hypothyroidism among primary care physicians in the US, 20 the low response impaired generalisability and prohibited performing a paired analysis. However, sensitivity analyses using only data from the Netherlands, Germany, and Switzerland showed similar results as when using data from all countries.…”

“…These findings are in line with a previous case-based survey among primary care physicians and thyroid specialists in the US in which physicians adopted a more conservative treatment strategy (with lower starting dose) for older patients with mild thyroid failure than for young patients. 20 Although no differences were observed in treatment decision for vital and frail older females, treatment decisions may also depend on various patient, doctor, and healthcare characteristics (for example, age, TSH level, sex of the GP, health insurance, or medication costs). …”

“…In a previous case-based survey in the US, primary care physicians and American Thyroid Association members chose different treatment strategies for patients with thyroid failure. 20 Another study using data from the Birmingham Elderly Thyroid Study (BETS) showed large variation in interpretation of symptoms and thyroid function tests in older individuals, and, consequently, large differences in therapy initiation between GPs in 19 UK practices. 21 In addition, a focus group study among GPs in New Zealand also revealed considerable variability in how GPs defined and managed subclinical hypothyroidism.…”

Timing of Thyroxine Dose Adjustment in Hypothyroid Patients: When are TSH Levels Stable?

“…Previous studies have shown that primary hypothyroidism is associated with changes in kidney function and promotes endothelial dysfunction [20][21][22][23]. Hypothyroidism decreases renal blood flow and creatinine clearance/GFR, as reflected by an increase in creatinine levels.…”

Possible Consequences of Changing of the TSH Reference Ranges

“…Интервал 0,4-2,5 мЕд/л рядом авторов стал рассмат риваться в качестве целевого при заместительной те рапии тироксином (L Т4) [6]. Однако необходимой доказательной базой эти положения пока не подк реплены.…”