Thyroid hormones treatment for subclinical hypothyroidism: a clinical practice guideline (2019) G E Bekkering et. al

1. G E Bekkering, guideline expert, methodologist1 2,
2. T Agoritsas, doctor in general internal medicine, expert in shared decision making research3 4,
3. L Lytvyn, patient partnership expert, methodologist4,
4. A F Heen, general internist5,
5. M Feller, general practitioner6 7,
6. E Moutzouri, doctor in general internal medicine6 7,
7. H Abdulazeem, patient partner8,
8. B Aertgeerts, general practitioner1 2,
9. D Beecher, patient partner9,
10. J P Brito, endocrinologist10,
11. P D Farhoumand, doctor in general internal medicine11,
12. N Singh Ospina, endocrinologist12,
13. N Rodondi, doctor in general internal medicine6 7,
14. M van Driel, general practitioner13,
15. E Wallace, general practitioner14,
16. M Snel, endocrinologist15,
17. P M Okwen, general practitioner16,
18. R Siemieniuk, doctor in general internal medicine17,
19. P O Vandvik, doctor in general internal medicine18 19 20,
20. T Kuijpers, guideline expert, methodologist21,
21. M Vermandere, general practitioner1

Abstract
Clinical question What are the benefits and harms of thyroid hormones for adults with subclinical hypothyroidism (SCH)? This guideline was triggered by a recent systematic review of randomised controlled trials, which could alter practice.

Current practice Current guidelines tend to recommend thyroid hormones for adults with thyroid stimulating hormone (TSH) levels >10 mIU/L and for people with lower TSH values who are young, symptomatic, or have specific indications for prescribing.

Recommendation The guideline panel issues a strong recommendation against thyroid hormones in adults with SCH (elevated TSH levels and normal free T4 (thyroxine) levels). It does not apply to women who are trying to become pregnant or patients with TSH >20 mIU/L. It may not apply to patients with severe symptoms or young adults (such as those ≤30 years old).

https://www.bmj.com/content/365/bmj.l2006

 

Got the link from here:

PHYSICIAN'S FIRST WATCH for May 15, 2019
David G. Fairchild, MD, MPH, Editor-in-Chief
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Experts: Don't Treat Subclinical Hypothyroidism
By Amy Orciari Herman
Edited by
- David G. Fairchild, MD, MPH, and
- Lorenzo Di Francesco, MD, FACP, FHM

Adults with subclinical hypothyroidism should not be treated with thyroid hormones, according to a new guideline from The BMJ's Rapid Recommendations panel.

The recommendation, characterized as "strong," applies to those with elevated thyroid-stimulating hormone levels (but still below 20 mIU/L) plus normal thyroxine levels noted on two or more consecutive tests. Patients may or may not have mild-to-moderate symptoms.

The recommendation was driven by data from a 2018 meta-analysis, plus a large 2017 trial of treatment in elders (see NEJM Journal Watch coverage at links below). The panel concluded that there are "no important benefits from treatment," while the possibility of treatment harms -- including a potentially higher mortality risk -- could not be excluded.

The guideline does not apply to women who are attempting a pregnancy. Additionally, it may not apply to those with severe symptoms or adults aged 30 and younger.

Link(s):
The BMJ Rapid Recommendations article (Free) http://response.jwatch.org/t?ctl=56B1A:5FF9B588B7CB016C668C4566E8FDB96AD2B71D9A95FA21D3&
Background: NEJM Journal Watch General Medicine & NEJM Journal Watch Psychiatry coverage of 2018 meta-analysis (Your NEJM Journal Watch registration required) http://response.jwatch.org/t?ctl=56B1B:5FF9B588B7CB016C668C4566E8FDB96AD2B71D9A95FA21D3&
Background: NEJM Journal Watch General Medicine coverage of 2017 trial in elders (Your NEJM Journal Watch registration required) http://response.jwatch.org/t?ctl=56B1C:5FF9B588B7CB016C668C4566E8FDB96AD2B71D9A95FA21D3&

 

I have some questions about this new guidance.

First, I'm in Canada - if living in the Canadian wilds makes a difference for thyroid treatment.

Looking at a lab requisition, the reference range for TSH is 0.10 - 5.00 mU/L (milliunits per litre), as opposed to the measurement noted in the article mIU/L. Both of these might mean the same thing.

My understanding is when the TSH is over 5, and there are symptoms of hypothyroidism, then treatment follows. But to wait until a person's TSH is over 10 is puzzling to say the least. I once had a medication switch to a different thyroid drug, and became quite symptomatic at a TSH of 7ish.

I've been on thyroid meds for over 4 decades - I think when I was first diagnosed it was the T4 that was tested, not the TSH, but this is back in the mists of time, so I could be misremembering.

Another interesting point in the abstract is that the T4 is measured. T4 isn't routinely measured here. Patients have to pay for this themselves if they want it done. Only TSH is usually tested.

I don't know if these guidelines will be picked up by Canadian medical authorities, but it could mean adding the T4 to testing.

I don't know where T3 levels fit into this. It's the active form. Some physicians have written about a conversion defect - not converting T4 to T3. I do understand this new guideline is mainstream.

I understand health risks re thyroid hormones can include osteoporosis. I can't recall the other potential risks - I believe there are more. This guidance wants physicians to very definitely err on the side of caution, but what about people who have to drag themselves around for perhaps years, feeling worse and worse until they hit the magic number? Are they just given antidepressants and told to exercise?

A thyroid related question: could thyroid hormone supplementation increase PSA levels? I haven't found anything on this, but wondered if anyone had come across this.

 

I think you should pray that the Canadian medical authorities don't pick up this new set of guidelines. They are sadistic in the extreme. I just wonder how many thousands or millions of patients (who are mostly women) are going to have their thyroid medication taken off them as a result.

You might be interested in this Canadian article :

https://thyroidpatients.ca/2019/05/...roidism-guidelines-delay-ineffective-therapy/

 

Thank you @Arnie Pye

Has this been adopted by the UK government? Looks like anyone whose TSH is below 20 might be pulled off thyroid supplementation. That seems radical.
Many, many people, at least thousands could become very debilitated. What purpose does this serve? And, where are the medical voices who say wait a minute - let's examine this study, and these new guidelines?

I've come across people who are symptomatic for years, and finally get thyroid for a subclinical condition, and do much, much better. Are they just supposed to continue suffering, and getting worse because their blood test doesn't measure up?

This is very concerning.

 

Not yet. But I've no doubt it will be implemented here in the not too distant future.

To save money for national healthcare organisations, I suspect. It is also useful for pharma companies because all the symptoms of hypothyroidism can be treated one symptom at a time. It won't make the patients any healthier, but just think of the profits!

They do exist, but in tiny, tiny numbers, and they shout into a void that nobody listens to.

Yes. And they will be told they are ill because they are suffering from mental illness and they just need CBT and GET. Alternatively they will be denied treatment of any kind and will be dismissed as attention-seekers and hypochondriacs. In other words, they will be treated exactly like people with ME/CFS.

 

This guideline if followed as the Canadian article says it might be - the broad brush approach that anyone with a TSH under 20 does not qualify as hypothyroid, and therefore should not receive meds, appears to revamp the entire testing and treatment of hypothyroidism. It seems to go back to square one and reinvent the entire approach to hypothyroidism. I may be misinterpreting the Canadian article; more explanation needed. IMHO if it is the intention that 20 is the new reference range, this magnitude of change needs much more examination than one review group can give it. This just seems over the top.

 

The absurd and utterly sadistic thing about this suggestion that TSH must be > 20 before treating is that the mode (most common value) for TSH for healthy women is around 1.25 i.e. 1/16th of the level at which treatment might be granted in future.

One problem with hypothyroidism is that deterioration is usually slow. So people could be suffering for decades before dying, and thus plausible deniability becomes easy. Whole lives are going to be wasted in misery. And of course, women tend to either become infertile or they miscarry when TSH is too high. And according to the thyroid forum I read there are plenty of untreated women with TSH above the level which makes pregnancy more likely who are being told they are not hypothyroid so they won't be prescribed treatment. It is just too bad that they want to get pregnant. But I am more and more convinced that that is the intention. There are too many people on the planet and the powers-that-be want to thin out the herd.

 

It seems quite an awful situation. I don't what else to say about depriving people of needed medication. This seemingly drastic revamping of the biomarker seems out of sync with the rest of medicine, but my knowledge of this type of thing is limited. On the face of it, it appears very questionable. Are there no other
authorities on this who believe differently?
Medicine is usually conservative, and moves slowly. This significant change seems out of place.

One could maybe predict that thyroid meds will be the new "illegal" drug on the street, if masses of people who need this drug are refused treatment. Some jurisdictions have
a work around, as naturopathic doctors can prescribe some drugs including thyroid meds. Although, not everyone can afford to consult with naturopathic doctors.

I'm with you on this situation, if it plays
out as the Canadian article predicts, it
could spell disaster for many. And, although it seems impossible, the
ME community has had decades of experience being deprived of effective biomedical treatment, so it is not out of the realm of possibiolity that another patient group could be cast adrift.

 

There has been a very good Rapid Response to the article in the BMJ given in the first post in this thread :

https://www.bmj.com/content/365/bmj.l2006/rr-6

It's well worth reading.

 

According to the thyroid forum I read some GPs have read the article in the BMJ about only treating when TSH > 20 and are implementing it already. A couple of people have been taken off their Levothyroxine too. It didn't take long to start wrecking people's lives. If the affected people can afford to they will probably have to submerge themselves in the shark infested waters of buying thyroid hormones on the internet. If they can't afford, or are too afraid, to buy their own they will just have to struggle along until they commit suicide, get sectioned, or go into a coma.

 

@Arnie Pye

That is terrible. Can those taken off their meds get new thyroid tests, once the drug is out of their system? My understanding is one's body develops a dependency on this treatment. I'm wondering if their new measures might dip low enough for the new questionable benchmark.

I know it's a question of money, but are there any alternative, or naturopathic doctors who can prescribe thyroid meds for people? Some jurisdictions allow this.

What a desperate situation this may leave some in!

 

If this is the case then the GP(s) haven't read the full recommendations!

See below [bolding mine]

This recommendation may not apply to

• Those with severe symptoms, as few were included in the studies reviewed. However, there is no clear evidence on how to attribute symptoms to SCH reliably, even with severe symptoms
  
  
• Very young adults (such as ≤30 years old). Few of these patients were included in the studies, probably because SCH is so uncommon at younger ages
  
  
• Women at risk of unplanned pregnancy. Clinicians may consider offering thyroid hormones because pregnant women with SCH may be at increased risk of adverse outcomes for mother and baby25
  
  
• Patients who already take thyroid hormones. The evidence presented here looked at the effect of starting medication and only indirectly informs stopping it
  

 

Somehow I doubt it, if the patient's TSH was under 20 when last tested. The doctors who've read that article and who think hypothyroidism is over-treated generally are likely to seize on it as a way of saving money.

As far as I know all mammals, birds, fish and amphibians have a thyroid and need thyroid hormones. Everyone is dependent on thyroid hormones, it isn't just people with hypothyroidism of some form or other. I have read that it takes about 12 years for someone with untreated overt hypothyroidism to die. Before they got that far they would have suffered enormously, and probably become insane. Someone who has their thyroid removed would go into a coma within a few weeks. Saying that bodies develop a dependency on prescribed thyroid hormone minimises their importance and makes hypothyroid people sound like junkies. Another issue for patients is that some doctors have been taught that thyroid hormones are addictive, and they say things to patients who ask for higher doses of Levo or who ask for T3 or NDT that are unforgivable - and they are often said with a snigger: "Cocaine makes people feel better, but we don't prescribe that either."

So doctors, who have T3 flowing through their veins in amounts that keep them healthy deny it to people who have low levels of T3 in their blood.

I don't really think that matters. New clinical practice guidelines have been issued and some GPs and other doctors are pouncing on it with glee because it is convenient to do so. As for the issue of people who are already on thyroid hormones, one of the people who had their prescription taken away was only in the very early stages of treatment, and I doubt that their TSH went over 20 at any stage.

The thing that sticks in my throat is that the modal level of TSH in the healthy population of women is 1.25. By insisting that TSH must be > 20 before treatment it means people must produce 16 times the amount of TSH that a healthy person produces. In some cases patients can produce immense amounts of TSH. But there are plenty of people with very low levels of thyroid hormones who can't produce much TSH at all. It looks as if secondary or central hypothyroidism will vanish from the textbooks and I'm sure that some sufferers will die.

 

NICE are currently developing an official clinical guideline on Thyroid disease.

See:

https://www.nice.org.uk/guidance/indevelopment/gid-ng10074

https://www.nice.org.uk/guidance/gid-ng10074/documents/stakeholder-list-3

 

Yes I know - several of the thyroid charities are stakeholders. The doctors using the BMJ article as bona-fide new guidelines are jumping the gun and appear to be doing so simply out of self-interest.

 

@Arnie Pye

By saying the body becomes dependent on thyroid hormones, I meant that my understanding is the thyroid gland stops producing its own thyroid if there is supplementation, so withdrawing the drug, isn't going to make the thyroid kick back in. I meant that biologically, the body is dependent on the supplementation, not that they are a junkies.

I had that experience myself, as a ND had the idea that after 10 years or so of thyroid meds, maybe I should stop and see if my body actually needed the thyroid prescription. I wound down like a ten day clock. I was very hypothyroid when diagnosed and put on the meds, so that ND's "bright" idea was not so bright after all.

This new protocol in the UK sounds like a nightmare.