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Hypothyroid Guidlines

Jan 26, 2016

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  • ORIGINAL STUDIES, REVIEWS,AND SCHOLARLY DIALOG

    THYROID FUNCTION AND DYSFUNCTION

    Clinical Practice Guidelines for Hypothyroidism in Adults:Cosponsored by the American Association of ClinicalEndocrinologists and the American Thyroid Association

    Jeffrey R. Garber,1,2,* Rhoda H. Cobin,3 Hossein Gharib,4 James V. Hennessey,2 Irwin Klein,5

    Jeffrey I. Mechanick,6 Rachel Pessah-Pollack,6,7 Peter A. Singer,8 and Kenneth A. Woeber9

    for the American Association of Clinical Endocrinologists and American Thyroid AssociationTaskforce on Hypothyroidism in Adults

    Background: Hypothyroidism has multiple etiologies and manifestations. Appropriate treatment requires anaccurate diagnosis and is influenced by coexisting medical conditions. This paper describes evidence-basedclinical guidelines for the clinical management of hypothyroidism in ambulatory patients.Methods: The development of these guidelines was commissioned by the American Association of Clinical En-docrinologists (AACE) in association with American Thyroid Association (ATA). AACE and the ATA assembled atask force of expert clinicians who authored this article. The authors examined relevant literature and took anevidence-based medicine approach that incorporated their knowledge and experience to develop a series ofspecific recommendations and the rationale for these recommendations. The strength of the recommendations andthe quality of evidence supporting each was rated according to the approach outlined in the American Associationof Clinical Endocrinologists Protocol for Standardized Production of Clinical Guidelines2010 update.Results: Topics addressed include the etiology, epidemiology, clinical and laboratory evaluation, management,and consequences of hypothyroidism. Screening, treatment of subclinical hypothyroidism, pregnancy, and areasfor future research are also covered.Conclusions: Fifty-two evidence-based recommendations and subrecommendations were developed to aid inthe care of patients with hypothyroidism and to share what the authors believe is current, rational, and optimalmedical practice for the diagnosis and care of hypothyroidism. A serum thyrotropin is the single best screeningtest for primary thyroid dysfunction for the vast majority of outpatient clinical situations. The standard treat-ment is replacement with L-thyroxine. The decision to treat subclinical hypothyroidism when the serum thy-rotropin is less than 10mIU/L should be tailored to the individual patient.

    By mutual agreement among the authors and the editors of their respective journals, this work is being published jointly in Thyroid andEndocrine Practice.

    *Jeffrey R. Garber, M.D., is Chair of the American Association of Clinical Endocrinologists and American Thyroid Association Taskforce onHypothyroidism in Adults. All authors after the first author are listed in alphabetical order.

    1Endocrine Division, Harvard Vanguard Medical Associates, Boston, Massachusetts.2Division of Endocrinology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.3New Jersey Endocrine and Diabetes Associates, Ridgewood, New Jersey.4Division of Endocrinology, Mayo Clinic, Rochester, Minnesota.5The Thyroid Unit, North Shore University Hospital, Manhassett, New York.6Division of Endocrinology, Mount Sinai Hospital, New York, New York.7Division of Endocrinology, ProHealth Care Associates, Lake Success, New York.8Keck School of Medicine, University of Southern California, Los Angeles, California.9UCSF Medical Center at Mount Zion, San Francisco, California.

    THYROIDVolume 22, Number 12, 2012 Mary Ann Liebert, Inc.DOI: 10.1089/thy.2012.0205

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  • INTRODUCTION

    These updated clinical practice guidelines (CPGs)(13) summarize the recommendations of the authors,acting as a joint American Association of Clinical En-docrinologists (AACE) and American Thyroid Association(ATA) task force for the diagnostic evaluation and treatmentstrategies for adults with hypothyroidism, as mandated by theBoard of Directors of AACE and the ATA.

    The ATA develops CPGs to provide guidance and recom-mendations for particular practice areas concerning thyroiddisease, including thyroid cancer. The guidelines are not in-clusive of all proper approaches or methods, or exclusive ofothers. the guidelines do not establish a standard of care, andspecific outcomes are not guaranteed. Treatment decisionsmustbe made based on the independent judgment of health careproviders and each patients individual circumstances. Aguideline is not intended to take the place of physician judgmentin diagnosing and treatment of particular patients (for detailedinformation regarding ATA guidelines, see the SupplementaryData, available online at www.liebertpub.com/thy).

    The AACE Medical Guidelines for Clinical Practice aresystematically developed statements to assist health careprofessionals in medical decision making for specific clinicalconditions. Most of their content is based on literature re-views. In areas of uncertainty, professional judgment is ap-plied (for detailed information regarding AACE guidelines,see the Supplementary Data).

    These guidelines are a document that reflects the currentstate of the field and are intended to provide a working doc-ument for guideline updates since rapid changes in this fieldare expected in the future. We encourage medical profession-als to use this information in conjunction with their bestclinical judgment. The presented recommendations may notbe appropriate in all situations. Any decision by practitioners

    to apply these guidelines must be made in light of local re-sources and individual patient circumstances.

    The guidelines presented here principally address themanagement of ambulatory patients with biochemicallyconfirmed primary hypothyroidism whose thyroid status hasbeen stable for at least several weeks. They do not deal withmyxedema coma. The interested reader is directed to the othersources for this information (4). The organization of theguidelines is presented in Table 1.

    Serum thyrotropin (TSH) is the single best screening test forprimary thyroid dysfunction for the vast majority of outpatientclinical situations, but it is not sufficient for assessing hospital-ized patients or when central hypothyroidism is either presentor suspected. The standard treatment is replacement withL-thyroxine which must be tailored to the individual patient.The therapy and diagnosis of subclinical hypothyroidism,which often remains undetected, is discussed. L-triiodothyro-nine in combination with L-thyroxine for treating hypo-thyroidism, thyroid hormone for conditions other thanhypothyroidism, and nutraceuticals are considered.

    METHODS

    This CPG adheres to the 2010 AACE Protocol for Stan-dardized Production of Clinical Practice Guidelines publishedin Endocrine Practice (5). This updated protocol describes amore transparent methodology of rating the clinical evidenceand synthesizing recommendation grades. The protocol alsostipulates a rigorous multilevel review process.

    The process was begun by developing an outline for re-viewing the principal clinical aspects of hypothyroidism.Computerized and manual searches of the medical literatureand various databases, primarily including Medline, werebased on specific section titles, thereby avoiding inclusion ofunnecessary detail and exclusion of important studies.

    Table 1. Organization of Clinical Practice Guidelines for Hypothyroidism in Adults

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    Introduction 1201Methods 1201Objectives 1204Guidelines for CPGs 1204Levels of scientific substantiation and recommendation grades (transparency) 1204Summary of recommendation grades 1205

    Topics Relating to Hypothyroidism 1205Epidemiology 1205Primary and secondary etiologies of hypothyroidism 1206Disorders associated with hypothyroidism 1207Signs and symptoms of hypothyroidism 1207Measurement of T4 and T3 1207Pitfalls encountered when interpreting serum TSH levels 1208Other diagnostic tests for hypothyroidism 1209Screening and aggressive case finding for hypothyroidism 1209When to treat hypothyroidism 1210L-thyroxine treatment of hypothyroidism 1210Therapeutic endpoints in the treatment of hypothyroidism 1213When to consult an endocrinologist 1214Concurrent conditions of special significance in hypothyroid patients 1214Hypothyroidism during pregnancy 1214Diabetes mellitus 1215Infertility 1215

    (continued)

    PRACTICE GUIDELINES FOR HYPOTHYROIDISM IN ADULTS 1201

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  • Table 1. (Continued)

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    Obesity 1215Patients with normal thyroid tests 1215Depression 1215Nonthyroidal illness 1215

    Dietary supplements and nutraceuticals in the treatment of hypothyroidism 1216Overlap of symptoms in euthyroid and hypothyroid patients 1216Excess iodine intake and hypothyroidism 1216Desiccated thyroid 12163,5,3-Triiodothyroacetic acid 1217Thyroid-enhancing preparations 1217Thyromimetic preparations 1217Selenium 1217

    Questions and Guideline Recommendations 1217Q1 When should anti-thyroid antibodies be measured? 1217R1 TPOAb measurements and subclinical hypothyroidism 1217R2 TPOAb measurements and nodular thyroid disease 1217R3 TPOAb measurements and recurrent miscarriage 1217R4 TSHRAb measurements in women with Graves disease

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