A new downloadable paper in Frontiers in Thyroid Endocrinology. It still peddles T4 only as the only option. Polypharmacy means taking other drugs as well as T4.
Overt and Subclinical Hypothyroidism in the Elderly: When to Treat?
•
March 2019
•Frontiers in Endocrinology 10:177
•DOI: 10.3389/fendo.2019.00177
Valeria Calsolaro, Filippo Niccolai, Giuseppe Pasqualetti, Fabio Monzani et al
Abstract
Hypothyroidism is characterized by increased thyrotropin (TSH) levels and reduced free thyroid hormone fractions while, subclinical hypothyroidism (sHT) by elevated serum TSH in the face of normal thyroid hormones. The high frequency of hypothyroidism among the general population in Western Countries made levothyroxine (LT4) one of the 10 most prescribed drugs. However, circulating TSH has been demonstrated to increase with aging, regardless the existence of an actual thyroid disease. Thus, when confronting an increase in circulating TSH levels in the elderly, especially in the oldest old, it is important to carry an appropriate diagnostic path, comprehensive of clinical picture as well as laboratory and imaging techniques. In the current review, we summarize the recommendations for a correct diagnostic workup and therapeutic approach to older people with elevated TSH value, with special attention to the presence of frailty, comorbidities, and poly-therapy. The treatment of choice for hypothyroid patients is hormone replacement with LT4 but, it is important to consider multiple factors before commencing the therapy, from the age dependent TSH increase to the presence of an actual thyroid disease and comorbidities. When treatment is necessary, a tailored therapy should be chosen, considering poly-pharmacy and frailty. A careful follow-up and treatment re-assessment should be always considered to avoid the risk of over-treatment. It is important to stress the need of educating the patient for a correct administration of LT4, particularly when poly-therapy is in place, and the importance of a tailored therapeutic approach and follow-up, to avoid overtreatment.
Written by
diogenes
Remembering
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My understanding is that polypharmacy was a term coined by the Choose Wisely organisation in Canada to introduce a way of making it a palatable term to use in front of patients when the NHS wants to deprescribe certain medicines. Like Liothyronine.
That is interesting. I read that it was introduced here by Big Pharma to doctors, as a way of getting as many elderly people as possible onto their daily ‘box of tricks’, thus massively increasing profits to Big Pharma, all carried out for them by GPs. Of course GPs thought it an excellent idea as it covered all bases of elderly type problems, such as high cholesterol, diabetes etc in one jolly little box with days of the week clearly marked for those poor souls descending into dementia. Sorry if I sound cynical. I shall soon be offered one myself, no doubt.
Strange to see an argument tie itself into knots to carry on depending on TSH. The big question seems to be: Do elderly people just naturally have a higher TSH, without it reflecting low hormone levels and symptoms?
The simple answer to this seems to be to measure freeT4 and freeT3, and enquire about symptoms! But instead TSH must be treated as a mysterious puzzle
Having now properly read the whole paper, at some points I wondered if I would have to eat my words because there was a lot of detail. But there was still no exploration of whether the these high TSHs reflect what we would consider the experience of having thyroid illness (which includes not only the quality of life symptoms we're aware of, but also deterioration organs and tissues). The issue of 'frailness' was returned to a few times as a reason not to treat. I searched for a definition of frail, and found: unexplained weight loss, weakness in grip, self reported exhaustion, slow walking speed and lack of physical activity. All potential hypothyroid symptoms
I found it rather upsetting that for the bulk of the paper the only 'symptom' that is discussed is actual death! I think many on this forum would agree that we'd rather die earlier but have a life where we can go to work, care for our families, pursue hobbies and keep fit, etc, so longevity is a bit of a tangential symptoms to consider and use to leverage logical arguments. The issue of 'frailness' was returned to a few times as a reason not to treat. I searched for a definition of frail, and found: unexplained weight loss, weakness in grip, self reported exhaustion, slow walking speed and lack of physical activity. All potential hypothyroid symptoms
Reading papers like this does sometimes make me wonder if patient groups exist in a parallel universe to medical research. TSH values like 10 are being bandied about as something that may not cause symptoms, whereas in this forum it's rare to see a TSH as high as this. It almost makes me wonder if the mythical figure with a TSH of 10 has a different illness than the one we discuss all day (we also sometimes see people with an exceptionally high TSH picked up by coincidence in other testing, who don't have symptoms, so it's not that strange an idea).
I also took exception to the idea at one point that those who have been fine on thyroid replacement are no longer thyroid patients, and if they pop up later with an extreme TSH caused by other things (maybe like removal of T3 treatment) they are a brand new case. As a person with no thyroid who has never been well on thyroid replacement... Rather horrifying to think I might pop up at different points over the years defined as a different kind of patient
With all the detailed discussion with a lot of technical medical terms, there was a sense of rearranging deck chairs on the Titanic. The big elephant in the room for me was: Why not try just treating these patients in the same way we would younger people who present this way, and see if they feel better! And the larger question of whether they feel terrible is completely ignored.
I felt like exactly the same paper could be written about the whole thyroid patient group, regardless of age, trying to use literature review to establish whether we are impaired and sick with our out of whack thyroid panel results. And I think you'd get similarly wavering conclusions, not sure whether to treat or not. While those of us who have the illness are extremely sure that we're impaired and want treatment. This paper doesn't give us any clue about whether these older patients (some not very old, as the cutoff for discussion seems to be 60) feel the same.
The whole paper feels like it's making an assumption that's started to annoy me - the idea that if lots of people have a certain symptom or sign then it can't be an illness and then can't even cause any problems. I've got a big bee in my bonnet about this, and like to make the comparison with glasses. Well over 50% of people in the Western world use glasses of some form, and we know that eyesight deteriorates with age and as we get older almost everyone will need reading glasses. Nobody pops up and says that because we're inside the normal range we should just manage with the amount of sight we've got. More and more I've started to believe, personally, that the number of people who would benefit from a little top up of thyroid hormone is probably huge. But there's a strange unstated belief in medicine that the number should be arbitrarily kept as small as possible.
I wonder...How do these people define elderly in this context?
Age - the number - can be as misleading/misinterpreted as the numbers In thyroid test results!
Do they actually mean infirm?
It strikes me that carrying out a diagnostic TSH test in the "elderly' is like closing the stable door after the horse has bolted. Far too late!
Yet, they insist on adhering to (their addiction to) TSH testing with what appears to be complete disregard for both FT3 and FT4 tests. It makes no sense.
This "elderly" 73 year old was treated with LT4 for about 20 years during which time my health gradually deteriorated until I could barely function....but, my GP pointed out, my results were normal so I should be well. Instead it must be A, B or C syndrome.
In the end (briefly) I ignored warnings about the dangers of T3, did my own research and am now slowly recovering
It's an oft repeated tale here......and many of us may well be considered elderly but - surprise! - we still have a few functioning grey cells left! More than many (thyroid) medics I might suggest!
Were early diagnostic thyroid tests to be carried out in youth before deterioration began then polypharmacy may be of less significance/necessity amongst the "elderly".
Oh! On the one hand we (the elderly) may be considered as having frailties while on the other, "the need of educating the patient for a correct administration of LT4...." must be stressed. They appear to be tying themselves in knots.
Were this to be the highest standard of current thyroid research then the future does not look bright....
Thankfully it is not!
Sorry, this paper just annoyed me hence today's rant!
Thank you diogenes
Think I must be the among the oldest old! At least I feel it!
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