TSH is either a faulty indicator of treatment or if not, patients are often incorrectly treated by T4 (a logical challenge)

[diogenes]

This paper is useful in indicating how long it takes to recover TSH levels after start of treatment for hypothyroidism, and that a considerable proportion of patients were, according to TSH normalisation or not, were incorrectly treated. Of course, we know TSH normalisation on T4 only isn't a good measure of treatment adequacy, but nevertheless it does show a) TSH rise delay and b) based on this, signs of incorrect treatment. It does however, show the intellectual contortions that such studies make to try to reconcile the irreconcilable.

Excli Journal

21:104-116

DOI: 10.17179/excli2021-4291

Julie Lindgård Nielsen, Jesper Karmisholt, Inge Bülow Pedersen, Allan Carlé

Suboptimal Thyroid Hormone Replacement Is Associated With Worse Hospital Outcomes

Abstract

The aim of this study is to evaluate the adequacy of treatment, and to identify factors influencing treatment of hypothyroidism. Patients newly diagnosed with overt hypothyroidism (n=345) were identified via a register linked to a laboratory database. In selected periods with staff available, 165 patients were invited, and 113 (68.5 %) accepted participating in a comprehensive program including blood tests and completion of questionnaires. We performed a longitudinal follow-up on thyroid function tests 10 years after the diagnosis. Time to reach a serum TSH level of 0.2-10 mU/L (termed as clinically acceptable) and biochemical normalization (TSH: 0.2-5.0 mU/L), respectively, were analyzed using Kaplan Meier survival analysis. Predictors for longer duration to reach the normal TSH range were identified using cox proportional hazards regression. Only 67.7 % of the patients were in the euthyroid range on the long term after diagnosis of overt hypothyroidism (2 years: 59.4 %; 10 years: 67.7 %). Median time to the first normal TSH was 8.9 months (95 % CI: 7.6-10.2 months). The factors associated with longer duration until normalization of TSH after multivariate analysis were age (HR 0.79 per 10 years; 95 % CI: 0.66-0.94; P = <0.01), smoking (HR 0.47; 95 % CI: 0.26-0.83; P = <0.01), serum TSH at diagnosis (HR 0.96 per 10 mU/L; 95 % CI: 0.93-0.99; P = 0.02) and BMI (HR 0.96 per kg/m2; 95 % CI: 0.91-0.99; P = 0.03). A considerable number of hypothyroid patients remained inadequately treated. When treating hypothyroid patients, special attention should be addressed to those patients who never or lately obtain euthyroid status.

[jimh111]

I think you have mixed up the title and DOI / abstract text.

This is the paper with the above text ncbi.nlm.nih.gov/pmc/articl... .

The paper "Suboptimal Thyroid Hormone Replacement Is Associated With Worse Hospital Outcomes" is behind a paywall doi.org/10.1210/clinem/dgac215 . It's no surprise that undertreament is associated with worse outcomes.

[Jumbelina in reply to jimh111]

The correlation of longer hospital stays etc. to high TSH is startling

[humanbean]

Time to reach a serum TSH level of 0.2-10 mU/L (termed as clinically acceptable) and biochemical normalization (TSH: 0.2-5.0 mU/L)

I think it is absolutely shocking that a TSH up to 10 is "clinically acceptable". And saying that a TSH up to 5 is "biochemical normalisation" is also absolutely shocking.

I would always term the upper levels of these (10 and 5 respectively) as medical torture if doctors think they don't need treating, and definitely not normal.

[BB001 in reply to humanbean]

I was just about to write the same thing about it being totally unacceptable that they say the following:serum TSH level of 0.2-10 mU/L (termed as clinically acceptable) and biochemical normalization (TSH: 0.2-5.0 mU/L)

I'm sure the euthyroid population don't have TSH anywhere near that high. Isn't TSH = 2-3 nearer the 'normal' level (from memory so might be incorrect).

[shaws in reply to BB001]

Before I diagnosed myself, GP phoned to tell me that all my results were 'fine' and I had no problems.

Even though my TSH was 100 he had no clue to what the numbers meant.

[jimh111 in reply to shaws]

Just to clarify. I'm liking the fact you posted this information - not that your TSH was 100!

[Lulu2607 in reply to shaws]

Terrible. GP knowledge often lets them down and erodes confidence in them. My Dr kept doing full blood tests for over a year ( not thyroid), telling me all was well (I definitely wasn't) until a near breakdown prompted a look at thyroid by which point TSH was 160 and I was virtually a zombie. Why isn't thyroid routinely checked with FBC checks?

[BB001 in reply to shaws]

But the blood test results even say 'abnormal' how could your GP not know something was wrong?

[TSH110 in reply to BB001]

1.8 I think but if you e no thyroid function it needs to be below 1 and even below 0.5 or less

[humanbean in reply to BB001]

The most common level for TSH (aka the Mode) according to the graph on this link :

healthunlocked.com/thyroidu...

is at 1.25 rather than than 2 - 3.

And for the table for Males and Females at different ages shows the highest TSH for men aged 80+ at 1.8. The 97.5% levels were higher at 3.8 for both men and women.

So, why do people with thyroid disease have to wait until TSH is between 5 and 10, or even more?

[BB001 in reply to humanbean]

This just reinforces my point. I thought a normal TSH of 2-3 was bad enough, but finding out it's 1.25, it just doesn't make sense that they make people wait until they're at TSH of 5+ (or even 10). Adjectives that spring to mind are: cruel, sadistic, and negligent.

[Lulu2607 in reply to BB001]

I agree too, seems like a lot of us may have picked up on those figures.

[TSH110 in reply to humanbean]

My thoughts exactly this is the tip of the bad treatment iceberg

[jimh111]

Another case of peer review being useless. The study measured the time to get TSH within its reference interval, it did not assess adequate treatment.

When TSH is very high or very low the pituitary can take time to respond. Normally the pituitary responds rapidly in response to alterations in hormone levels. In this study we see TSH fell below 10.0 after a median time of 4.3 months but took 8.3 months to fall below 5.0. This is a clear sign of dithering on the part of the doctors. I've noticed that the mental slowness that comes with hypothyroidism often refers to the doctor as well. The authors have the gall to cite 'compliance' as a potential reason for poor response to treatment.

[TSH110 in reply to jimh111]

That’s my journey but maybe 7 months to get to 10 - dither sums it up

[humanbean in reply to jimh111]

Your last sentence seems to have an extra "not" in it.

[jimh111 in reply to humanbean]

Don't know how it got there, removed it, thanks.

[Localhero]

Only 67.7 % of the patients were in the euthyroid range on the long term after diagnosis of overt hypothyroidism (2 years: 59.4 %; 10 years: 67.7 %).

This was pretty shocking to me. So only two thirds were “euthyroid” 10 years after diagnosis?

Also, I’m sure by being “in the euthyroid range” they assume people to be well when we know that is often far from true.