New Thyroid Guidance Challenged

Nicky Broyd

June 03, 2019

The Society for Endocrinology (SfE) and British Thyroid Association (BTA) have challenged a new clinical practice guideline on managing subclinical hypothyroidism (SCH).

Two weeks ago, as part of the BMJ's rapid recommendations initiative, an international panel of experts issued new guidance in the BMJ that said patients with subclinical hypothyroidism were being overtreated and should not be routinely offered thyroid hormone replacement therapy.

In a statement the SfE and BTA state that for such a strong recommendation the supporting evidence has to be compelling and that is 'simply not the case'.

Between 4 and 20% of adults have subclinical hypothyroidism but around a third of these experience no symptoms.

Evidence Review

The guidance was based on the results of a systematic review of evidence and meta-analysis of 21 trials with 2192 participants. The review included the TRUST trial that found levothyroxine (LT4) treatment showed "no apparent benefits in older persons with subclinical hypothyroidism".

The guidance review panel wrote: "There was high certainty that there is little to no difference in general quality of life, thyroid-related symptoms, depressive symptoms, fatigue, cognitive function, muscle strength, and BMI.

"The results are consistent across these outcomes, which strengthens our confidence that there really is a lack of benefit."

Treatment Threshold 'Too Stringent'

Challenging the guidance, SfE and BTA issued a joint statement saying insufficient evidence has been cited to support practice changes: "Due to over-extrapolation from available data, most of which is from older patients with milder symptoms or from small-scale studies, the conclusions drawn are not justified. SfE and BTA are concerned that these recommendations could influence primary care physicians to dismiss patients with subclinical hypothyroidism, particularly younger ones, which could lead to some missing out on vital treatment if their condition progresses.

"SfE and BTA urge that larger studies, using more sensitive measures and taking factors, such as age and genetics, into consideration are needed before drawing such strong conclusions on the benefits or disadvantages of SCH treatment."

Two experts provided additional insights. Dr Peter Taylor, clinical senior lecturer and consultant endocrinologist at Cardiff University said: "What this detailed summary of the data does show is the urgent need for clinical trials of symptomatic patients with subclinical hypothyroidism especially in younger individuals."

Dr Onyebuchi Okosieme, consultant endocrinologist at Cardiff University School of Medicine said: "It is difficult to justify denying treatment to patients with fairly advanced degrees of subclinical hypothyroidism (TSH levels of 10-20 mU/L), as recommended by these guidelines. Many such patients will have intrinsic thyroid disease and withholding treatment puts them at risk of disease complications."

BMJ 2019. Published online May 14, 2019. Full text.

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