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Letter to the Editor EJE
Treatment options for subclinical hypothyroidism
Rudolf Hoermann1 , John E M Midgley2 , Rolf Larisch 1 and Johannes W Dietrich3,4
1 Department for Nuclear Medicine, Klinikum Lüdenscheid, Paulmannshöherstr. 14, 58515 Lüdenscheid, Germany.
2 North Lakes Clinical, 20 Wheatley Avenue, Ilkley LS29 8PT, UK
3 Medical Department I, Endocrinology and Diabetology, Bergmannsheil University Hospitals, Ruhr University of Bochum, Buerkle-de-la-Camp-Platz 1, D-44789 Bochum, Germany
4 Ruhr Center for Rare Diseases (CeSER), Ruhr University of Bochum and Witten/Herdecke University, Alexandrinenstr. 5, D-44791 Bochum, Germany
Short Title: Subclinical hypothyroidism
We read with great interest the current debate on the controversial issues that have long surrounded the treatment of subclinical hypothyroidism (1). The fact that the two discussants disagreed so strongly in their approach to a prevalent problem, routinely faced by clinicians around the globe, may indicate severe shortcomings in the current approach. Although this controversy has started many year ago, it remains unresolved. Unlike in many other diseases, thyroid diagnosis has evolved through definition by exclusive reliance on a single biochemical measure, as opposed to symptomatic presentation of the disease.
In our opinion, the problem begins with the term and very definition of “subclinical hypothyroidism”. What is subclinical hypothyroidism? Is it a true disease or a mere laboratory constellation? According to current guidelines, the diagnosis of subclinical hypothyroidism is made when a confirmed TSH measurement has been obtained that exceeds the upper reference range of the pituitary hormone while the concentrations of thyroid hormones still remain within their reference range (2). Adding to the confusion, therapeutic targets have been separated from diagnostic criteria of the disease by recent guidelines (2). LT4 substitution has been recommended to be withheld in patients with diagnosed subclinical hypothyroidism unless their TSH concentration exceeds a much higher threshold (of 10 mIU/L or even up to 20 mIU/L) than he diagnostic threshold (of approx. 4 mIU/L) (2,3). This disease understanding has left clinicians with a conundrum to explain to many patients why they suffer from a disease, yet would not require any therapeutic intervention. This may be particularly difficult to accept for patients presenting with symptoms which are in their opinion suggestive of a thyroid condition,
Perhaps, it is time to consider a different approach, potentially more satisfying to clinicians. As implied in the original term “subclinical” the new strategy should re-focus on the clinical manifestation rather than the biochemistry. In recent year, the over-reliance on a TSHcentred diagnostic strategy has been strongly challenged (4,5). The apparent deficiencies of this approach and its lack of diagnostic specificity and reliability have been reviewed elsewhere (6). The problem is deeply rooted in the guiding principles of HPT regulation (7).
In patients with subclinical hypothyroidism due to autoimmune thyroiditis and sufficient intact thyroid tissue, thyroid regulation importantly includes, in addition to the classical feedback of circulating thyroid hormones onto pituitary TSH secretion, the feedforward control of TSH over preferential thyroidal triiodothyronine (T3) secretion (8). The system is designed to take pro-active action in anticipation rather than reactive to the event of a shortage of thyroid hormone supply to the body. The manifestation of a clinical disease is determined either by the success or failure of the central attempt at compensation. Measurement of a slightly elevated TSH in subclinical hypothyroidism, cannot reliably discriminate between the two outcomes. It must therefore be regarded as an ambiguous signal, unless all thyroid hormones and clinical endpoints are taken into account.
Subclinical hypothyroidism, as a laboratory constellation, has been implicated to increase the risk of cardiovascular mortality (9). This conclusion may also be premature, because slightly elevated TSH levels together with "normal" thyroid hormone concentrations may not necessarily indicate early thyroid failure (10). Alternatively, this may reflect an increase in the homeostatic set point of the hypothalamus-pituitary-thyroid axis (10). Set point adjustments frequently occur in association with chronic psychosocial stress or allostati
load type 2 (10). The latter, in turn, is a well-recognized cardiovascular risk factor. The high individual variability in the expression of the hypothalamic-pituitary-thyroid set point is further augmented by genetic traits.
Given the inherent ambiguity arising from TSH being a controlling parameter, its nonergodic behaviour and complex relationship with both thyroid hormones and clinical endpoints results obtained in clinical studies require careful consideration of their design, statistical analysis (risk of collider stratification bias) and interpretation (risk of confounding between set point elevation and thyroid failure). Consequently, we suggest that a disease defining role should be assigned to thyroid hormones, derived structural thyroid parameters (estimated functional thyroid capacity, set point reconstruction) and markers of tissue response to develop a clinically useful algorithm to be verified in clinical trials.
Recent advances in our understanding of system regulation may help put the role of TSH into a better clinical perspective. The debate should encourage further efforts to address unresolved issues and find a more clinically inclusive definition for subclinical thyroid disease, more deserving of this name.
References
1. Peeters RP, Brito JP 2020 Subclinical hypothyroidism: To treat or not to treat. Eur J Endocrinol 83: D15-D24. doi:10.1530/EJE-20-0621
2. Jonklaas J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, Cooper DS, Kim BW, Peeters RP, Rosenthal MS, Sawka AM 2014 Guidelines for the treatment of hypothyroidism: Prepared by the American Thyroid Association task force on thyroid hormone replacement. Thyroid 24: 1670-1751. doi:10.1089/thy.2014.0028
3. Bekkering GE, Agoritsas T, Lytvyn L, Heen AF, Feller M, Moutzouri E, Abdulazeem H, Aertgeerts B, Beecher D, Brito JP, Farhoumand PD, Singh Ospina N, Rodondi N, Van Driel M, Wallace E, Snel M, Okwen PM, Siemieniuk R, Vandvik PO, Kuijpers T, Vermandere M 2019 Thyroid hormones treatment for subclinical hypothyroidism: A clinical practice guideline. BMJ 365: l2006. doi:10.1136/bmj.l2006
4. Chaker L, Korevaar TIM, Rizopoulos D, Collet TH, Völzke H, Hofman A, Rodondi N, Cappola AR, Peeters RP, Franco OH 2017 Defining optimal health range for thyroid function based on the risk of cardiovascular disease. J Clin Endocrinol Metab. 102: 2853-2861. doi:10.1210/jc.2017-00410
5. Fitzgerald SP, Bean NG, Falhammar H, Tuke J 2020 Clinical parameters are more likely to be associated with thyroid hormone levels than with thyrotropin levels: A systematic review and meta-analysis. Thyroid doi:10.1089/thy.2019.0535
6. Hoermann R, Midgley JEM, Larisch R, Dietrich JW 2017 Recent advances in thyroid hormone regulation: Toward a new paradigm for optimal diagnosis and treatment. Front Endocrinol (Lausanne). 8: 364. doi:10.3389/fendo.2017.0036
7. Hoermann R, Midgley JEM, Larisch R, Dietrich JW 2015 Homeostatic control of the thyroid-pituitary axis: Perspectives for diagnosis and treatment. Front Endocrinol (Lausanne). 6: 177. doi:10.3389/fendo.2015.00177
8. Hoermann R, Pekker MJ, Midgley JEM, Larisch R, Dietrich JW 2020 Triiodothyronine secretion in early thyroid failure: The adaptive response of central feedforward control. Eur J Clin Invest. 50: e13192. doi:10.1111/eci.13192
9. Inoue K, Ritz B, Brent GA, Ebrahimi R, Rhee CM, Leung AM. 2020 Association of subclinical hypothyroidism and cardiovascular disease with mortality. JAMA Network Open 3: e1920745. doi:10.1001/jamanetworkopen.2019.20745
10. Dietrich JW, Hoermann R, Midgley JE, Bergen F, Müller P 2020 The two faces of Janus: Why thyrotropin as a cardiovascular risk factor may be an ambiguous target. Front Endocrinol. 11: 829. doi:10.3389/fendo.2020.542710