Management of Primary Hypothyroidism Statement by the British Thyroid Association Executive Committee

[helvella]

Any comments?

Clin Endocrinol (Oxf). 2015 May 23. doi: 10.1111/cen.12824. [Epub ahead of print]

Management of Primary Hypothyroidism Statement by the British Thyroid Association Executive Committee.

Okosieme O1, Gilbert J2, Abraham P3, Boelaert K4, Dayan C5, Gurnell M6, Leese G7, McCabe C8, Perros P9, Smith V8, Williams G10, Vanderpump M11.

Author information

1Prince Charles Hospital, Medicine, Merthyr Tydfil, United Kingdom.

2King's College Hospital, Endocrinology, Denmark Hill, London, United Kingdom.

3Aberdeen Royal Infirmary, Endocrinology, Foresterhill, Aberdeen, United Kingdom.

4University of Birmingham, Division of Medical Sciences, Birmingham, West Midlands, United Kingdom.

5Cardiff University, Centre for Endocrine and Diabetes Sciences, Cardiff, United Kingdom.

6Institute of Metabolic Science, Addenbrooke's Hospital, Endocrinology, Hills Road, Cambridge, United Kingdom.

7University of Dundee, Medical Research Institute, Dundee, United Kingdom.

8University of Birmingham, College of Medical and Dental Sciences, Birmingham, United Kingdom.

9Royal Victoria Infirmary, Endocrinology, Newcastle, United Kingdom.

10Imperial College London, Molecular Endocrinology Group, Department of Medicine, Hammersmith Campus, Du Cane Road, London, United Kingdom.

11Royal Free Hampstead NHS Trust, Endocrinology, Pond Street, London, United Kingdom.

Abstract

Primary hypothyroidism is an insidious condition with a significant morbidity and often subtle and non-specific symptoms and clinical signs [1, 2]. The earliest biochemical abnormality is an increase in serum thyroid-stimulating hormone (thyrotrophin) (TSH) concentration associated with normal serum free thyroxine (T4) and triiodothyronine (T3) concentrations (subclinical hypothyroidism), followed by a decrease in serum free T4 concentration, at which stage most patients have symptoms and benefit from treatment (overt hypothyroidism) [1-3]. In the UK, the prevalence of spontaneous hypothyroidism is between 1% and 2%, and it is more common in older women and ten times more common in women than in men [4, 5]. The cause is either chronic autoimmune disease (atrophic autoimmune thyroiditis or goitrous autoimmune thyroiditis (Hashimoto's thyroiditis)) or destructive treatment for hyperthyroidism with either radioiodine or surgery which may account for up to one-third of cases of hypothyroidism in the community [6]. Less frequent causes include surgery and radioiodine ablation for benign nodular thyroid disease and thyroid cancer, external beam irradiation of malignant tumours of the head and neck and drugs including lithium, amiodarone and interferon [1]. Congenital hypothyroidism affects about one newborn in 3,500-4,000 births [7]. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

PMID: 26010808 [PubMed - as supplied by publisher]

ncbi.nlm.nih.gov/pubmed/260...

The full paper is available here:

onlinelibrary.wiley.com/doi...

At a cost of $6 to read it for 48 hours, $15 to access it in the cloud, or $38 for a PDF.

[ Update ]

On this page:

onlinelibrary.wiley.com/doi...

... there is a Click for preview. You might be able to see a little more than the abstract above.

In a response below, Clutter points out a patient access option which is £2.27.

[HIFL]

What is the point of paying money to read a paper written by people who don't understand thyroid physiology? The second sentence of the abstract does not apply to many Graves' patients, who typically have a lower TSH than normal folk, even after RAI or thyroidectomy.

[helvella Administrator Thyroid UK in reply to HIFL]

Absolutely true, but I am sure the authors would point out the paper's title which restricts itself to primary hypothyroidism.

The abstract gives no hint whatsoever how anyone might be able to adequately identify primary hypothyroidism to the exclusion of any and all other types in order to apply anything else they say. In fact, no hint of a definition of primary hypothyroidism, merely some examples.

[acunatang in reply to HIFL]

I totally agree with you! The second sentence is rubbish!!! My TSH has always been in normal range but my symptoms sometimes severe!!!

[Clutter]

They're still not accepting that the subtle and non-specific symptoms can precede abnormal biochemistry by years or that many subclinical hypothyroid patients are clinically symptomatic.

There is patient access to the pdf for £2.27 but I can't remember my pword and am being flung around screens as I try to get a pword reset.

I'd like to read the full article to see whether they have views on the impact of autoimmune thyroid disease on quality of life.

[galathea]

There are many conditions which can occur in a body. Most of them have a clinical guideline.

If someone presents at the docs with a problem, the dc looks up the correct guideline and the patient is treated and happy. The guidelines are not continually re written ....

Doesn't the fact that a new opinion or guide about hypothyroidism surfaces every few months show that the current thinking is just plain wrong? I haven't paid to read this one, but. I would put money on it, that whatever they suggest won't be the same as we patients would suggest. grrrrr,,, why don't they ask us? I

[RedApple Administrator]

So we pay their salaries through our taxes, and then we have to pay to read their 'statement' about the health condition that causes so much controversy? Is it just me that feels angry about that? £2.27 for patient access may not seem much, but it's the principle rather than the amount. Enough to raise our blood pressure even before we've read it!

[Hidden in reply to RedApple]

Absolutely! Research paid for out of the public purse and we have to pay to read it (even if it is rubbish)? But then after I had an operation, I got a six page 'summary' of the process, with every aspect of the procedure covered by copyright marks (where applicable). Filthy lucre rules!

[RedApple Administrator in reply to Hidden]

This isn't even 'research'. It's a 'statement'.

If we were able to read the whole thing, we'd probably find they say the same thing as always... that there's not enough 'research' to show the benefit of adding T3 blah blah blah.

[humanbean in reply to RedApple]

I rarely, if ever, notice the weasel words they use - like "statement" for example, instead of "guidelines".

They just create something that they hope they can't be taken to court over if they fudge it enough, so they twist the language until it screams.

[Muffy in reply to humanbean]

They use 'statement', as NICE do not have any official guidelines, but of course doctors use it as though it is actually guidelines.

[helvella Administrator Thyroid UK in reply to Muffy]

They use 'statement' like banks. Summing up your worth in numbers with little room for compassion or understanding - is the bottom line plus or minus?

[Lizzy1606]

Dr Onyebuchi Okosieme is a Endo at Prince Charles hospital ,he was mentioned in a article by Jerome Burne Tick box medicine that fails hypothyroid patients.Apparently his interest is thyroid and he does quite a bit of reseach.I did contact the hospital to see if he was doing any with thyroid patients in Wales but there was nothing at the moment.I have thought that maybe we could write to him ,he is also on the committee of the BTA .Just a thought he might listen.

[Eddie83]

No. The earliest sign of impending hypoT is, more often than not, TPO or TgAB antibodies. However if the UK is like the US, most of our doctors don't even test for antibodies so they let autoimmunity continue to stew and do lots of extra damage.

You ought to buy access to the paper and see if you can download it and post it somewhere. Who's going to find out? So far as I'm concerned, charging these kind of rates to access medical papers (esp. those containing the wrong-headed medical establishment view) is an affront to the chronically ill, who are already under enough financial pressure.

[CatSlave in reply to Eddie83]

Off topic but there's actually a dude in the USA who started a network where there is something similar to this. He created a site where folks can repost papers published theyve purchased which were originally published by public bodies in the USA. LOL. Great idea!

[helvella Administrator Thyroid UK in reply to Eddie83]

I entirely agree about the morality of access. However, "they" can find out. Every downloaded PDF is coded, possibly in several ways, some not obvious, so that the publisher can trace any copy back to the original purchase, hence the original purchaser.

[helvella Administrator Thyroid UK]

The earliest biochemical abnormality is an increase in serum thyroid-stimulating hormone (thyrotrophin) (TSH) concentration...

The absolute assertion, repeated ad nauseam, is that TSH reflects thyroid hormone levels. That is, TSH rises because of inadequate thyroid hormone levels. If we accept that, then the rise in TSH is obviously a consequence of lowered thyroid hormone levels: the earliest biochemical abnormality must be lower T4/T3 levels. Of course, the T4/T3 levels might not drop very far at that stage, the T4/T3 might not be measured, but they will have dropped below what that individual needs.

The TSH abnormality is only the earliest in the sense of the earliest that might, if you are lucky, be noticed. And who knows what other biochemical abnormalities might also be found if looked for?