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A Clinical Debate: Subclinical Hypothyroidism

First author, Sina Jasim MD, MPH and co-authors (Bernadette Biondi, MD; Hossein Gharib, MD, MACP, MACE, Hengameh Abdi, MD) published an article titled, “A Clinical Debate: Subclinical Hypothyroidism” in the International Journal of Endocrinology and Metabolism.

Sina Jasim, MD, MPH

Subclinical hypothyroidism (SCH) is a biochemical condition defined by elevated serum thyroid stimulating hormone (TSH) and normal free thyroxine (FT4) and free triiodothyronine (FT3) concentrations.

The authors explore the options for treating a 42 year-old female patient with subclinical hypothyroidism considering her medical history, no family history of thyroid disease and her lab results.

In option 1, Drs. Jasim and Gharib explain their rationale for treating subclinical hypothyroidism for this patient. They cover factors pertaining to lipids and cardiovascular disease (CVD) in SCH; symptoms in SCH; pregnancy and fertility in SCH; and what clinical guidelines are recommended in SCH.

Regarding their decision to treat, the authors stated, “We consider LT4 therapy beneficial in this case considering her age, symptoms, progressive increase of TSH level and positive TPOAb. The possibility of pregnancy is another reason favoring treatment. The potential risk of developing hyperthyroidism due to LT4 over-treatment is avoided by careful follow-up. Of note, untreated patients also require follow-up office visits and laboratory monitoring. Since the degree of thyroid dysfunction is mild, a small dose of LT4 (50 µg) seems adequate to restore normal serum TSH levels. “

In option 2, Dr. Biondi explores reasons when not to treat subclinical hypothyroidism.

After her assessment, Dr. Biondi states, “I am inclined to treat this patient. However, based on the aforementioned debates, I would consider two options: (1) a wait-and-see strategy to evaluate the possibility of a TSH normalization and the potential improvement of symptoms after 2 – 3 months of lifestyle intervention; (2) the use of replacement doses of LT4 after carefully excluding transient conditions of isolated hyperthyrotropinemia or situations that can induce a false diagnosis of SCH.

I would discuss these two possible choices as well as the benefits/risks of LT4 therapy with the patient and take her preference into account.”

A Clinical Debate: Subclinical Hypothyroidism