New Publication “Hypothyroidism”

[DJR1]

Just caught this on X, published in the Lancet this week. Very disappointed at some of the statements made particularly in reference to treatment of older age groups and risks related to osteoporosis etc with below reference range TSH. Something to be aware of if you are discussing your hypothyroid issues with clinical personnel. I would be interested to know others thoughts on this.

sciencedirect.com/science/a...

[DJR1]

I’ve just realised the full text is only available in the link Pete Taylor has posted on X formerly Twitter. I will see if I can work round this.

Maybe this one

authors.elsevier.com/c/1jtE...

Update: yes this link works

[helvella Administrator in reply to DJR1]

Thanks, DJR1.

[jimh111]

As usual endocrine disruption which causes peripheral resistance to thyroid hormone with normal TFTs is ignored.We also get the usual nonsense, signs and symptoms have poor correlation with TSH so sings and symptoms are not relevant! Methinks the studies show TSH has minimal relevance.

[Rapunzel]

Usual frothing over this. I was hoping to see that the researchers got a bung from Abbott, but not that I can find. I would like to know

* Where did the stats come from re this load of tush '10% are still symptomatic' (following levo monotherapy)

* The suggestion that levo is a 'satisfactory treatment'

* Whom to treat' is incomplete, hanging mid-sentence

* Who was consulted in the statement that lio/desiccated thyroid treatment was 'found of no clear benefit'

Major concern - medics read this load of ill-informed, medic-centric nuts; all it does is reinforce incorrectly held views that levo is king and all other medication to alleviate symptoms is snake oil.

Right now I am just so very grateful that I have the means and the knowledge to go my own way. For the latter - Thanks, TUK and this forum.

Walk in my moccasins for a day on levo. You'd need a time machine, obvs. Then tell me my thyroid-S and lio don't work. Jog on, f*ckwits.

[DJR1 in reply to Rapunzel]

My thoughts exactly on the content. What worries me is the coverage this receives by releasing the paper on X. This will reach a very wide audience easily, people who don’t normally spend extra time seeking out research papers. It is a very effective way of reaching the GP community and others who make decisions about our treatment. My GP is a devotee of higher TSH levels and papers like this reinforce his mantra.

[Zephyrbear in reply to Rapunzel]

What a pity that we, as those being on the receiving end of this 🐂💩 can’t leave comments on their pathetically arrogant notions, isn’t it?

Perhaps if we, as patients, could leave some feedback on these articles instead of the jolly backslapping that passes for reaction from their peers, they might just take some notice… especially as some of us are more than capable of expressing ourselves in terminology they would understand.

[Rapunzel]

My GP is a devotee of higher TSH levels and papers like this reinforce his mantra.

Does he have a thyroid issue? Thought not 🤬🤬🤬🤬🤬

[caledoniancat]

The publication describes itself as a 'seminar', so not even a critical review of research let alone a systematic review or meta analyses of research. It's hardly worth the paper it is written on; unfortunately, many medics may not recognise that.

[Ktlc]

interesting. My TSH levels were considered suppressed in my last blood test so the request to reduce my Levo has been made.

I note from this forum many of you disagree with using TSH as a marker and that ‘suppressed’ TSH is not a problem for cardiovascular disease or osteoporosis (which is what the endo told me regarding reducing my Levo). Can you point me in the direction of information regarding why you think this? Is there other research I can read? I do listen to a lot of podcasts who say the same thing, but I don’t understand why it’s at odds with the clinical research

I have been back on 50mg and again feeling pretty tired so I’d like to be able to have a decent conversation with my endo, which lucky for me I’m usually able to do.

I have bloods booked again for next week but these will as usual probably be TSH and a fight for FT4 and FT3

K

[DJR1 in reply to Ktlc]

Have a read of this one regarding low/suppressed TSH

academic.oup.com/jcem/artic...

[Ktlc in reply to DJR1]

Thanks so this suggests that a suppressed TSH IS associated with cardiovascular disease and osteoporosis as per the Endo advice. Thx

[mstp in reply to Ktlc]

Read it again. It looks to me as if it says the exact opposite.

[helvella Administrator in reply to mstp]

Conclusions: Patients with a high or suppressed TSH had an increased risk of cardiovascular disease, dysrhythmias, and fractures, but patients with a low but unsuppressed TSH did not. It may be safe for patients treated with T4 to have a low but not suppressed serum TSH concentration.

It all depends on the meaning of "suppressed". In this context:

suppressed TSH (≤0.03 mU/liter)

Whereas I have seen some regard any TSH lower than expected as being suppressed.

This paper says it might be fine to have any TSH down to 0.03 - which is pretty low but not down to undetectable. But even then, they do not appear to make the case that is is lack of TSH which is the cause of any issues.

And they point out that a high TSH (> 4) is also a problem.

[Ktlc in reply to mstp]

I have reread it and I still read it as risk is increased in those with high and suppressed TSH but not risk in patients with low TSH….

Cardiovascular disease, dysrhythmias, and fractures were increased in patients with a high TSH: adjusted hazards ratio, 1.95 (1.73–2.21), 1.80 (1.33–2.44), and 1.83 (1.41–2.37), respectively; and patients with a suppressed TSH: 1.37 (1.17–1.60), 1.6 (1.10–2.33), and 2.02 (1.55–2.62), respectively, when compared to patients with a TSH in the laboratory reference range. Patients with a low TSH did not have an increased risk of any of these outcomes [hazards ratio: 1.1 (0.99–1.123), 1.13 (0.88–1.47), and 1.13 (0.92–1.39), respectively].

[tattybogle in reply to Ktlc]

Ktlc ~ re. low TSH 'risks' ~ you need to bear i mind there is a distinction between 'low but not supressed' and 'supressed '........ this distinction is muddied in a lot of research papers ... or rather it is muddied by those reading/ quoting them.

This post contains the references i collected on the subject , and has links to other posts which contain some useful discussions on the subject of low TSH / Risk vs quality of life : healthunlocked.com/thyroidu... useful-evidence-that-tsh-between-0.04-0.4-has-no-increased-risk-to-patients-on-levothyroxine-updated-new-study-does-show-small-risk

You also need to bear in mind that a low TSH when taking thyroid hormone replacement is not quite the same thing as low TSH without taking thyroid replacement ,,, on levo we tend to end up with relatively higher T4 / relatively lower fT3/ and relatively lower TSH than people with healthy functioning thyroid gland . Much of the research associating various risks with low TSH comes from people who are hyperthyroid (their own thyroid making too much T4/T3, causing low TSH) which should not be directly applied to people on thyroid replacement ... it's not comparing 'like with like'. So when reading research papers to assess these risks for yourself you need to look at the the details of the study very closely ~ ie. which group of people did the data come from etc .

This post contains references showing how TSH is relatively lower in patients taking levo :

healthunlocked.com/thyroidu.... healthunlocked.com/thyroidu....

[Lottyplum in reply to tattybogle]

But as taking T3 (I understand), either on its own or T3/T4 combo, lowers TSH, surely for many on such could have suppressed TSH as the outcome? My TSH has been suppressed for years+I've been taking T4 for 43 yrs (suppressed for at least a decade) and combo T4/T3 for a year. I also understood, in cases like me, my TSH may never rise. Your thoughts?

[tattybogle in reply to Lottyplum]

basically if someone has no alternative but to have supressed TSH in order to get decent quality of life, then so be it .

ideally i think it's worth trying to keep it at least 0.04 IF POSSIBLE, by fine tuning dose as far as possible, but if i've tried a lower dose properly and didn't function well enough , then totally supressed TSH wouldn't worry me unduly .

[Lottyplum in reply to tattybogle]

In 2022 (after moving+new medical centre) dropping my levo dose from 175 to 150 resulted in me ending up in the Surgical assessment unit! Why aren't symptoms addressed as well as TSH? Ive read on the forum of ppl needing over 200mcg of levo to function but as drs don't seem the understand the conversion issues of T4 to T3 ( and that included me until I found this forum), so many of us have suffered, often in silence! I'm of the opinion now that Dr doesn't necessarily know best, esp regarding the endocrine system!!

[helvella Administrator in reply to tattybogle]

There are too many questions about these low end TSH numbers!

Is it the tiny amount of TSH itself that matters?

Or that even such a low level of TSH indicates that the person isn't over-dosed? (That is, over-dosed into toxicity, they could still be over-dosed by other criteria.)

[tattybogle in reply to helvella]

yes . more questions than answers. i reckon TSH is more useful for comparison within the individual , and less so between individuals .

for many yrs i was ok with TSH between 0.05 and 0.1 , and the one time i had overmedicated symptoms on levo, it was 0.016.... so 0.04 as a cut off happened to 'fit' for me for a long time . But someone else would not have any overmedicated symptoms at 0.016... and someone else may feel overmedicated at 0.05

also , 0.04 was purely arbitrary, the Leese study decided to use that as their cut off, but they could have used 0.02 or 0.06 for example , and probably get similar associations with risk.

keeping it 'measurable' allows me a certain level of reassurance i suppose, i can at least see it go up and down in response to subtle changes..... once it's totally supressed you have little idea what your pituitary / hypothalamus 'think' about any minor changes , cos it may take supressed TSH months and months on slightly lower dose to respond at all..... and whilst i take it's 'opinion' with a pinch of salt .. i am still interested in knowing my pituitary's opinion... ( because my own opinion is also a bit untrustworthy at times, so it's useful to have a second opinion on my dose)

but i accept that that is just 'luck' that my TSH happens to remain measurable at a dose that works ... if i was someone else it might end up supressed and i'd have to live with it.

waffle waffle ..lol ... what was the question ? .. where's my coffee ?

[Buttercupsareyellow]

I do agree some biases and not a research article , more review of literature, however:

They do at least highlight some issues (in the section on alternatives to levothyroxine) such as levels of T3 not being as high at a tissue level unless dosing causing elevated T4 given in mono therapy, the higher incidence of statin prescriptions on those on mono therapy regime only compared to general population. They also flag some of the issues of past studies in that those recruited into studies around combined medications haven’t necessarily been those who have reported issues on mono therapy ergo not surprisingly studies (which they also flagged had far too small sample sizes) didn’t pick up potential benefits. They did refer to one study where there was higher satisfaction with NDT. They also advocated for urgent research into use of combination therapy and alternatives to help increase evidence base for best practice TARGETING the groups of patients who aren’t responding to mono therapy……

[arTistapple]

I like Dr Peter Taylor. He is an enthusiastic researcher. The way I read this is, it’s a pitch for further funding. He establishes the common view of hypothyroidism, and at the same time highlights some questions around the parameters.

To me it proves the snail’s pace of attempting change in thyroid treatment. I see the new president of the British Thyroid Foundation is also involved in this research. Both these people ‘practise’ endocrinology and both are known to prescribe T3.

No I think this is a ‘thoughtful’ move to look much more closely at treatment.

I just wish they would get bloody move on.

[TaraJR in reply to arTistapple]

I think you mean president of the British Thyroid Association? British Thyroid Foundation is the 'patient charity', though it is affiliated to the BTA.

Hypothyroidism is the poor relation in medical terms - the powers that be seem to think it's important, so funding for research is very hard to get.

[arTistapple in reply to TaraJR]

Oops.

[TaraJR in reply to arTistapple]

!! It doesn't matter!

[HowNowWhatNow]

comes across as though written by Chat GPT. Nothing substantial.

[jimh111]

Pete Taylor acknowledged my comment on endocrine disruptors and said they need more attention.