This review from Glasgow (beware Scottish patients) falls plumb into the logical trap of treating the individual patient by the statistics rather than consider them as unique. It shows just how far we have to go to drive some logic into them. Eg not treating patients with TSH 7-10: a statistic imposed on the individual as optimal diagnosis/treatment when at the same individuality is acknowledged re patients suitable for combined therapy. For an individual treatment either works or doesn't and it can only be found by trial and error, dependent on patient response, SO CLASS, SAY AFTER ME: I am treating a patient not a statistic. If the numbers say no, then leave them on one side until we have a grasp of what is happening.
Journal of Internal Medicine
Treating hypothyroidism is not always easy: When to treat subclinical hypothyroidism, TSH goals in the elderly, and alternatives to levothyroxine monotherapy
Douglas S. Ross
First published: 11 November 2021 doi.org/10.1111/joim.13410
The majority of patients with hypothyroidism feel better when levothyroxine treatment restores thyroid-stimulating hormone (TSH) concentrations to normal. Increasingly, a significant minority of patients remain symptomatic and are dissatisfied with their treatment. Overzealous treatment of symptomatic patients with subclinical hypothyroidism may contribute to dissatisfaction among hypothyroidism patients, as potential hypothyroid symptoms in patients with minimal hypothyroidism rarely respond to treatment. Thyroid hormone prescriptions have increased by 30% in the United States in the last decade. The diagnosis of subclinical hypothyroidism should be confirmed by repeat thyroid function tests ideally obtained at least 2 months later, as 62% of elevated TSH levels may revert to normal spontaneously. Generally, treatment is not necessary unless the TSH exceeds 7.0–10 mIU/L. In double-blinded randomized controlled trials, treatment does not improve symptoms or cognitive function if the TSH is less than 10 mIU/L. While cardiovascular events may be reduced in patients under age 65 with subclinical hypothyroidism who are treated with levothyroxine, treatment may be harmful in elderly patients with subclinical hypothyroidism. TSH goals are age dependent, with a 97.5 percentile (upper limit of normal) of 3.6 mIU/L for patients under age 40, and 7.5 mIU/L for patients over age 80. In some hypothyroid patients who are dissatisfied with treatment, especially those with a polymorphism in type 2 deiodinase, combined treatment with levothyroxine and liothyronine may be preferred.