Hyperthyroidism.

Thyrotoxicosis is a general term for excess circulating and tissue thyroid hormone levels, whereas hyperthyroidism specifically denotes disorders involving a hyperactive thyroid gland (Graves disease, toxic multinodular goiter, toxic adenoma). Diagnosis and determination of the cause rely on clinical evaluation, laboratory tests, and imaging studies. Hyperthyroidism is treated with antithyroid drugs, radioactive iodine ablation, or thyroidectomy. Other types of thyrotoxicosis are monitored and treated with ß-blockers to control symptoms given that most of these conditions resolve spontaneously.

Hypothyroidism.

Hypothyroidism is a common condition in which the thyroid gland provides insufficient amounts of thyroid hormone for the needs of peripheral tissues. The most common cause in adults is chronic lymphocytic thyroiditis (Hashimoto thyroiditis), but there are many other causes. Because most of the clinical features of hypothyroidism are nonspecific, the diagnosis requires laboratory testing. Serum thyroid-stimulating hormone (TSH) measurement is the best diagnostic test; an elevated TSH level almost always signals primary hypothyroidism. Serum free thyroxine levels may be below the reference range (overt hypothyroidism) or within the reference range (subclinical hypothyroidism). All patients with overt hypothyroidism should be treated, but those with subclinical hypothyroidism do not always benefit from treatment, especially elderly patients and those with baseline TSH levels below 10 mU/L. Oral L-thyroxine is the treatment of choice because of its well-demonstrated efficacy, safety, and ease of use. Therapy goals are symptom relief and maintenance of serum TSH levels within the reference range. Myxedema coma is a life-threatening form of decompensated hypothyroidism that must be treated with aggressive L-thyroxine replacement and other supportive measures in the inpatient setting.

Increased Risk of Radioiodine Treatment Failure Associated with Graves Disease Refractory to Methimazole.

OBJECTIVE: Iodine 131 (I-131) radioactive iodine (RAI) therapy has been the preferred treatment for Graves disease in the United States; however, trends show a shift toward antithyroid drug (ATD) therapy as first-line therapy. Consequently, this would favor RAI as second-line therapy, presumably for ATD refractory disease. Outcomes of RAI treatment after first-line ATD therapy are unclear. The purpose of this study was to investigate treatment failure rates and potential risk factors for treatment failure, including ATD use prior to RAI treatment. METHODS: A retrospective case control study of Graves disease patients (n = 200) after I-131 RAI therapy was conducted. Treatment failure was defined as recurrence or persistence of hyperthyroidism in the follow-up time after therapy (mean 2.3 years). Multivariable regression models were used to evaluate potential risk factors associated with treatment failure. RESULTS: RAI treatment failure rate was 16.5%. A majority of patients (70.5%) used ATD prior to RAI therapy, predominantly methimazole (MMI) (91.9%), and approximately two-thirds of patients used MMI for >3 months prior to RAI therapy. Use of ATD prior to RAI therapy (P = .003) and higher 6-hour I-123 thyroid uptake prior to I-131 RAI therapy (P<.001) were associated with treatment failure. MMI use >3 months was also associated with treatment failure (P = .002). CONCLUSION: More patients may be presenting for RAI therapy after failing first-line ATD therapy. MMI use >3 months was associated with RAI treatment failure. Further studies are needed to investigate the association between long-term first-line ATD use and RAI treatment failure.

Low awareness of nonalcoholic fatty liver disease among patients at high metabolic risk.

GOALS: To assess awareness of nonalcoholic fatty liver disease (NAFLD) as a disease entity among individuals with and without metabolic risk factors in an outpatient clinical setting, and to evaluate interest in patient-centered education on NAFLD. BACKGROUND: NAFLD is the most common chronic liver disease in the United States with up to 30% of the adult population affected. Individuals with metabolic risk factors, particularly, insulin resistance, diabetes, and overweight/obesity, have a high prevalence of NAFLD estimated up to 70%, yet little is known about the understanding and perceptions of NAFLD in these high-risk patients. STUDY: A self-administered paper questionnaire was given to 368 adult patients presenting to an outpatient endocrinology clinic from February 2012 to October 2012. RESULTS: A total of 302 surveys were completed for a response rate of 82%. Overall, 18% of all respondents reported awareness of NAFLD. Even among patients with self-reported major risk factors for NAFLD (overweight/obese, insulin resistant, or both overweight/obese and insulin resistant), the rates of awareness of NAFLD were low (19%, 23%, and 24%, respectively). A majority of survey respondents expressed interest in receiving patient-centered education on NAFLD (73%). CONCLUSIONS: Among high metabolic risk individuals there is low awareness of NAFLD. The majority of those surveyed expressed interest in learning about NAFLD. These findings suggest opportunities to raise public awareness of NAFLD, particularly among patients at high metabolic risk, and to provide education to high-risk individuals with the goal of implementing early prevention strategies and optimizing care.

High- and normal-protein diets improve body composition and glucose control in adults with type 2 diabetes: a randomized trial.

OBJECTIVE: Weight loss of ≥10% improves glucose control and may remit type 2 diabetes (T2D). High-protein (HP) diets are commonly used for weight loss, but whether protein sources, especially red meat, impact weight loss-induced T2D management is unknown. This trial compared an HP diet including beef and a normal-protein (NP) diet without red meat for weight loss, body composition changes, and glucose control in individuals with T2D. METHODS: A total of 106 adults (80 female) with T2D consumed an HP (40% protein) diet with ≥4 weekly servings of lean beef or an NP (21% protein) diet excluding red meat during a 52-week weight loss intervention. Body weight, body composition, and cardiometabolic parameters were measured before and after intervention. RESULTS: Weight loss was not different between the HP (-10.2 ± 1.6 kg) and NP (-12.7 ± 4.8 kg, p = 0.336) groups. Both groups reduced fat mass and increased fat-free mass percent. Hemoglobin A1c, glucose, insulin, insulin resistance, blood pressure, and triglycerides improved, with no differences between groups. CONCLUSIONS: The lack of observed effects of dietary protein and red meat consumption on weight loss and improved cardiometabolic health suggests that achieved weight loss, rather than diet composition, should be the principal target of dietary interventions for T2D management.

In the clinic. Hypothyroidism.

The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including PIER (Physicians' Information and Education Resource) and MKSAP (Medical Knowledge and Self Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing division and with assistance of science writers and physician writers. Editorial consultants from PIER and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult www.acponline.org, http://pier.acponline.org, and other resources referenced within each issue of In the Clinic.

Osteoporosis risk in premenopausal women.

Although clinically significant bone loss and fractures in healthy premenopausal women are rare, more women are seeking evaluation for osteoporosis from their health care providers. As pharmacists are in an ideal position to influence the management of premenopausal women with osteoporosis, it is important that pharmacists understand the available data on bone loss, fractures, and risk factors and secondary causes for osteoporosis, as well as when to recommend testing and treatment in premenopausal women. Limited data are available; therefore, we conducted a MEDLINE search of the literature from January 1993-August 2008. Studies evaluating bone loss, fractures, and fracture risk in healthy premenopausal women were targeted and summarized; most recommendations are based on expert opinion. A small but statistically significant loss in bone mineral density of 0.25-1%/year by dual-energy x-ray absorptiometry is seen healthy premenopausal women; the clinical significance of this is unknown. Whereas absolute fracture risk is low, premenopausal fractures appear to increase postmenopausal fracture risk by 1.5-3-fold. Risk factors for low bone density appear to be similar between pre- and postmenopausal women. Bone density screening in healthy premenopausal women is not recommended, but bone mineral density testing is advisable for those who have conditions or who receive drug therapy that may cause secondary bone loss. Lifestyle modification emphasizing bone-healthy habits such as adequate calcium and vitamin D nutrition, regular exercise, limitation of caffeine and alcohol consumption, and avoidance of tobacco are essential to the management of osteoporosis risk. The efficacy and safety of osteoporosis drugs have not been adequately demonstrated in premenopausal women. Therefore, pharmacologic interventions cannot be recommended in young women with low bone mass but may be considered in those having a more significant fracture risk, such as those with a previous low-trauma fracture or an identified secondary cause for bone loss.

A patient outreach program between visits improves diabetes care: a pilot study.

OBJECTIVE: Barriers to guideline-based diabetes care include poor patient activation, haphazard clinic appointments, poorly organized medical records and a lack of automated physician decision support. We developed a patient recall intervention to mitigate these barriers and improve diabetes care coordination. We evaluated this intervention in terms of operational feasibility, provider and patient acceptance and effects on process of care measures. METHODS: On the basis of the American Diabetes Association criteria, we identified patients with diabetes in a large internal medicine practice who were due for provider visits; hemoglobin A1c, lipid, microalbumin and serum creatinine laboratories; and retinal examinations. An outreach coordinator contacted patients to summarize this information and schedule recommended services. We assessed patient responsiveness to outreach and used medical chart review to compare diabetes care rendered before and after the intervention. Providers gave feedback about their satisfaction with the program. RESULTS: Over 3 months, 709 patients were overdue for diabetes-related services. Of 415 overdue for provider visits, a total of 125 (30.1%) completed such visits arranged by an outreach coordinator and, of these, 101 (80.8%) completed laboratories at least a day ahead of time. An additional 52 out of 415 patients (12.5%) bypassed the outreach coordinator to self-schedule diabetes visits within a 6-week period after the outreach letter was mailed. Among overdue patients, completion of recommended services and intensity of diabetes care were significantly greater through the outreach program compared with traditional care. Provider attitudes were favorable. CONCLUSIONS: An outreach intervention was associated with improved timeliness and intensity of diabetes care in an outpatient setting. The success of this pilot program in terms of process measures warrants additional evaluation focused on clinical outcomes.

Vitamin D intervention by pharmacists in geriatric outpatients.

OBJECTIVES: To develop a pharmacist-provided educational intervention that instructs participants to consume 1,200 IU vitamin D daily and to evaluate its effect on serum 25-hydroxyvitamin D (vitamin D) concentrations and self-reported daily vitamin D intake in geriatric outpatients with insufficient vitamin D. DESIGN: Randomized controlled trial. SETTING: University-affiliated geriatric clinic, December 2005 to May 2006. PATIENTS: 80 participants aged 65 to 89 years. INTERVENTION: Participants with insufficient vitamin D (12-31 ng/mL) were randomized to receive either the educational intervention (n = 23) or no intervention (n = 22). MAIN OUTCOME MEASURES: Difference in change from baseline to 12 weeks in vitamin D concentrations and self-reported daily vitamin D intake between groups. RESULTS: At 12 weeks, vitamin D concentrations in the educational intervention group (n = 22) increased from a mean (+/- SD) of 23.5 +/- 5.0 to 30.4 +/- 6.3 ng/mL. Vitamin D concentrations in the nonintervention group (n = 21) increased from 22.8 +/- 5.4 to 26.9 +/- 6.2 ng/mL. The difference between the groups at 12 weeks did not reach statistical significance (P = 0.07). However, 12 participants (55%) in the educational intervention group achieved sufficient vitamin D concentrations compared with only 5 participants (24%) in the nonintervention group (P = 0.04). Self-reported daily vitamin D intake increased by a mean of 647 IU/day in the educational intervention group and 67 IU/day in the nonintervention group. The difference in self-reported intake between groups at 12 weeks, controlling for baseline, was significant (P < 0.0001). Serum parathyroid hormone concentrations decreased significantly among those in the intervention group (P = 0.04). CONCLUSION: A pharmacist-developed and -administered vitamin D educational intervention increased the proportion of participants achieving sufficient vitamin D concentrations, increased the self-reported daily vitamin D intake, and lowered serum parathyroid hormone concentrations. However, it did not significantly increase the overall mean serum vitamin D concentration, compared with the control group. A daily recommendation of more than 1,200 IU vitamin D daily is likely necessary to ensure that all geriatric outpatients with insufficient vitamin D concentrations achieve the target of at least 32 ng/mL.

5-alpha-dihydrotestosterone elevations associated with phentermine use.

BACKGROUND: A case of 5-alpha-dihydrotestosterone (DHT) elevation associated with phentermine initiation is reported, and possible mechanisms are discussed. There are no published reports of this association in the literature. METHODS: Clinical and laboratory information is described. RESULTS: A 72-year-old male with metastatic prostate cancer taking dutasteride to lower his DHT levels initiated phentermine 15 mg daily for weight loss. His DHT level drawn within 1 week prior to starting phentermine was 9.9 pg/ml. When reporting for follow up 2 weeks later, his DHT level had increased to 114 pg/ml. The DHT level was checked again 2 weeks after that visit, and had increased to 174 pg/ml. At that time, phentermine was discontinued, and 1 week later, the DHT level had decreased to 20.1 pg/ml. Over the next 4 months, the patient's DHT levels were maintained at less than 20 pg/ml. Phentermine 15 mg daily was then reinitiated while his DHT level was 7.5 pg/ml. Two weeks after resuming phentermine, his DHT level had again increased to 196 pg/ml. The patient's phentermine was then discontinued, and around 1 week later, his DHT level had fallen to 5.1 pg/ml. CONCLUSION: A 72-year-old male with metastatic prostate cancer experienced profound increases in DHT upon initiation of phentermine despite continuation of his baseline dutasteride therapy. The etiology of these increases is still unclear.

Does Reverse Triiodothyronine Testing Have Clinical Utility? An Analysis of Practice Variation Based on Order Data from a National Reference Laboratory.

BACKGROUND: Clinical laboratories are under pressure to increase value by improving test utilization. The clinical utility of reverse triiodothyronine (rT3) is controversial. A study was conducted to identify order patterns that might suggest inappropriate utilization of rT3. METHODS: All orders for thyroid tests placed over a period of one year at a national reference laboratory were reviewed. Order patterns by client (hospital) and by provider were analyzed. A Pareto analysis was conducted to determine the percentage of orders placed as a function of the percentage of providers. A systematic review of the indexed literature and an informal review of the web were conducted to identify indications for rT3 testing. RESULTS: There were 402,386 orders for 447,664 thyroid tests, including 91,767 orders for rT3. These orders were placed by 60,733 providers located at 1139 different organizations. Only 20% of providers who ordered thyroid tests placed an order for rT3. Of those who placed an order for rT3, 95% placed two orders or fewer for rT3. One hundred providers (0.1% of the 60,733 providers who placed orders for thyroid tests) accounted for 29.5% of the orders for rT3. Of the 100 providers, 60 with the highest order volumes for rT3 were classified as practitioners of functional medicine. A systematic review of Medline found little evidence to support the high volumes of orders for rT3. A survey of Web sites for functional medicine suggests that rT3 is useful for the diagnosis of rT3 dominance and can be used to direct triiodothyronine replacement therapy. CONCLUSIONS: There is wide practice variation in rT3 testing. A high proportion of tests are ordered by a relatively small proportion of providers. There is little evidence to support high volumes of rT3 testing placed by some practitioners.

Prevalence of vitamin D insufficiency in elderly ambulatory outpatients in Denver, Colorado.

BACKGROUND: Vitamin D insufficiency is common in the elderly. However, previous studies have utilized 25-hydroxvvitamin D (25[OH]D) concentrations as low as <16 ng/mL for defining vitamin D insufficiency. Moreover, most of the studies have been conducted in European patients, in certain geographic areas of the United States, or in institutionalized elderly. OBJECTIVE: The goal of this study was to characterize vitamin D concentrations in ambulatory elderly living in metropolitan Denver, Colorado, utilizing 25(OH)D concentrations <32 ng/mL as the definition for vitamin D insufficiency. METHODS: Ambulatory older adults (aged 65-89 years) with clinic visits during December 2005 and January 2006 were enrolled. Serum concentrations of 25(OH)D, parathyroid hormone (PTH), calcium, phosphorus, creatinine, and albumin were measured; height and weight were also measured. Data regarding dietary and over-the-counter vitamin D intake were collected, as well as information on body mass index, history of osteoporosis, osteoporosis treatment, and history of falls and fractures. RESULTS: Eighty patients (mean [SD] age, 77.8 [5.3] years; age range, 66-89 years) completed the study; there were no dropouts. The majority of patients were white (88%) and female (68%). Fifty-nine (74%) were found to have vitamin D insufficiency. Mean total and over-the-counter vitamin D intake was significantly higher in sufficient (P < 0.01) and insufficient (P < 0.05) patients compared with deficient patients, but dietary intake did not differ significantly between groups. The majority of patients who were vitamin D insufficient consumed more than the recommended 400 to 600 IU/d of vitamin D. Obese patients were found to have significantly lower 25(OH)D concentrations (P < 0.001) and higher PTH concentrations (P = 0.04) than nonobese patients. CONCLUSIONS: Vitamin D insufficiency is prevalent in ambulatory, and especially obese, elderly living in Denver, Colorado, despite vitamin D intake consistent with national recommendations. Dietary intake of vitamin D appeared to be unreliable to prevent insufficiency. Based on our results, along with other published data, we feel that national recommendations for vitamin D intake in the elderly should be increased to at least 800 to 1000 IU/d of over-the-counter supplemental cholecalciferol.

Hypoglycemic effects of tramadol analgesia in hospitalized patients: a case-control study.

BACKGROUND: In outpatient populations, hypoglycemia has been associated with tramadol. We sought to determine the magnitude of risk for hypoglycemia associated with tramadol use in hospitalized patients. METHODS: During a 2-year period of observation, adult inpatients who received ≥1 dose of tramadol were identified and their medical records were reviewed. Patients were included if they had blood or plasma glucose (BG) concentrations measured on at least two occasions within five days after the initial administration of tramadol. A contemporary comparator group of hospitalized oxycodone recipients was similarly reviewed. RESULTS: Tramadol was administered to 2927 patients who met inclusion criteria. Among these, hypoglycemia (BG ≤70 mg/dL) was documented in 22 (46.8%) of 47 patients with type 1 diabetes, 113 (16.8%) of 673 patients with type 2 diabetes, and 103 (4.7%) of 2207 patients who did not have a diabetes mellitus diagnosis. In those without a diabetes diagnosis, the causality association between hypoglycemia and tramadol use was probable in 77 patients (3.5%). By comparison, hypoglycemia was documented in 8 (1.1%) of 716 matched oxycodone recipients without diabetes (p = 0.002). As compared with tramadol recipients who did not develop low BG concentrations, those who experienced tramadol-related hypoglycemia were relatively young (mean age 52.0 versus 59.8 years; p = 0.027) and predominantly female (74.0% versus 59.8%; p = 0.012). CONCLUSIONS: Tramadol use was causally associated with hypoglycemia in hospitalized patients. The proportion of patients without diabetes who developed hypoglycemia was higher among those who received tramadol than among those who received oxycodone. TRIAL REGISTRATION: Colorado Multiple Institutional Review Board Protocol № 15-2215. Registered/approved 8 December 2015.

Management of diabetes mellitus in hospitalized patients: efficiency and effectiveness of sliding-scale insulin therapy.

STUDY OBJECTIVE: To determine the efficiency and effectiveness of current prescribing practices relative to short- and intermediate-acting insulins in the prevention or treatment of acute hyperglycemic episodes in hospitalized patients with diabetes mellitus or hyperglycemia, and to identify clinical findings that influence the effectiveness of insulin therapy in these patients. DESIGN: Retrospective observational study. SETTING: University-affiliated hospital. PATIENTS: Ninety consecutive adult inpatients who had orders placed for as-needed subcutaneous regular or lispro sliding-scale insulin. MEASUREMENTS AND MAIN RESULTS: Medical records were reviewed for patients' clinical characteristics and responses to administered insulin that were recorded during each of the first 5 days of hospitalization in which sliding-scale insulin therapy was used. Despite the immediate or bedside availability of both computerized and manual means to record finger-stick blood glucose levels and insulin injections, uncertainties or missing information related to execution, timing, blood glucose levels, or insulin dose were present in approximately 30% of all anticipated points of care involving insulin. Ten episodes of hypoglycemia in six patients were associated with sliding-scale insulin. Appropriately timed, successive glucose measurements documented a decrement in elevated blood glucose values to within the target range of 90-130 mg/dl after 76 (12%) of 621 sliding-scale insulin injections. Glucose levels remained elevated, and insulin effects were therefore subtherapeutic after 523 injections (84%). Despite blood glucose levels that remained persistently elevated, corresponding adjustments in either the timing or the dose of insulin were made infrequently. Sliding-scale insulin regimens were never adjusted in 73 patients (81%). Through 5 days of therapy, the proportion of patients who attained good glycemic control ranged from 2-10% (mean 6%). The mode of overall glycemic control was poor, with 51-68% of patients in this category on any given day. Overall, treated diabetic and hyperglycemic patients were more likely to be poorly controlled than relatively well controlled. CONCLUSION: Our findings reveal outcomes associated with sliding-scale insulin that are widely variable, often ineffectual, and prone to deficiencies in monitoring, documentation, and prescribing soundness. Efforts to improve glycemic control in hospitalized patients are clearly needed.

Novel Management of Insulin Autoimmune Syndrome with Rituximab and Continuous Glucose Monitoring.

CONTEXT: Insulin autoimmune syndrome (IAS), or Hirata's disease, is a rare hypoglycemic disorder characterized by spontaneous hypoglycemia without evidence of exogenous insulin administration, a high serum concentration of total immunoreactive insulin, and the presence of insulin autoantibodies in high titer. The majority of cases occur in the Asian population, and treatment is generally successful with watchful waiting or steroids. CASE DESCRIPTION: We report the case of a 71-year-old Caucasian man with severe hypoglycemia due to IAS that was refractory to a prolonged course of high-dose steroids. Type 1 diabetes prevention trials using rituximab have shown selective suppression of insulin autoantibodies, which are the pathogenic antibodies in IAS, and therefore we provided this therapy. Treatment with two doses of rituximab and daily use of a continuous glucose monitor resulted in disease remission. CONCLUSION: We present the first case where potentially life-threatening hypoglycemia due to IAS was successfully managed with rituximab and a continuous glucose monitor. We conclude that these treatment modalities are effective for the management of severe, refractory IAS.

Cardiovascular Outcomes of New Medications for Type 2 Diabetes.

Cardiovascular (CV) disease remains the leading cause of death in people with diabetes, highlighting the importance of using treatment options that do not increase CV risk or possibly decrease CV outcomes. Since 2008, the Food and Drug Administration has required demonstration of CV safety for all new medications developed for the glycemic management of diabetes. Seven trials have been published that have established CV safety for three DPP-4 inhibitors (alogliptin, saxagliptin, and sitagliptin), three GLP-1 receptor agonists (liraglutide, lixisenatide, and semaglutide), and one sodium-glucose cotransporter-2 inhibitor (empagliflozin). Three of those studies also established superiority with liraglutide, empagliflozin, and semaglutide at reducing the composite primary endpoint of major CV events (CV death, nonfatal myocardial infarction, and nonfatal stroke). In addition, one trial found an increase in heart failure hospitalizations with saxagliptin. The findings of these trials must be compared and contrasted cautiously given the differences in patient populations and trial designs, but together they provide important information that can be used to shape our treatment guideline recommendations and patient-specific treatment decisions.

Lack of diagnosis and treatment of osteoporosis in men and women after hip fracture.

STUDY OBJECTIVE: To determine whether men and women admitted to a university teaching hospital for a low-trauma hip fracture were diagnosed, evaluated, or treated for osteoporosis during admission or for up to 1 year after admission. DESIGN: Retrospective chart review. SETTING: University of Colorado Hospital, Denver, Colorado. PATIENTS: One hundred eighteen patients admitted with a low-trauma hip fracture from January 1993-December 1998. MEASUREMENTS AND MAIN RESULTS: Demographics, medical and social history, prescribed drugs, clinical outcomes, and information regarding the diagnosis, evaluation, and treatment of osteoporosis were abstracted from inpatient medical records for the index hip fracture. Similar data for the first year after the index hip fracture were abstracted from outpatient medical records of patients who had follow-up visits within the hospital system. Mean +/- SD age at the time of fracture was 70 +/- 15 years; 43 patients were men and 75 were women. Eighteen percent of patients had experienced a previous hip fracture, 4% had a history of vertebral fracture, and 6% reported a previous wrist fracture. The diagnosis of osteoporosis was noted in the charts of 14% of the patients at discharge and 26% of patients at follow-up. Only 4% of patients during hospitalization and 9% during follow-up received any evaluative tests for osteoporosis, including bone densitometry. Subsequent fractures occurred in 12.5% of patients. Documented treatment of osteoporosis was uncommon, with approximately 75% of patients receiving no therapy for osteoporosis on discharge or during follow-up. Women were more likely than men to receive a diagnosis of osteoporosis, bone mineral density testing, and osteoporosis drug therapy. CONCLUSION: In patients with hip fractures, osteoporosis is commonly not diagnosed or treated appropriately

Clinical comparison of whole-body radioiodine scan and serum thyroglobulin after stimulation with recombinant human thyrotropin.

Sensitive monitoring for thyroid cancer recurrence or persistence includes whole-body radioiodine scanning (WBS) and measurement of serum thyroglobulin (Tg) after endogenous or exogenous thyrotropin (TSH) stimulation. We reviewed our experience using recombinant human thyrotropin (rhTSH) in 83 patients to compare the clinical relevance of a positive WBS and/or Tg. Ten patients had a positive WBS; eight of these patients had activity limited to the thyroid bed. rhTSH-stimulated Tg was 2 ng/mL or more in 25 and 5 ng/mL or more in 13 patients. Of the patients with a negative WBS, 11 of 20 patients with a Tg 2 ng/mL or more and 7 of 9 patients with a Tg 5 ng/mL or more received therapy or further evaluation based on the Tg alone. Conversely, only 1 of 5 patients with a serum Tg less than 2 ng/mL received therapy or further evaluation based on a positive WBS alone. Three of the patients who did not receive therapy or further evaluation, had subsequent negative WBS 10-12 months later, suggesting lack of clinically significant disease. Twenty patients had a negative WBS and serum Tg 2 ng/mL or more. Eleven of 20 patients had a Tg less than 5 ng/mL and 4 of these patients had further evaluation with a neck ultrasound. One patient had a biopsy-proven recurrence (rhTSH-stimulated Tg 4 ng/mL). Subsequent evaluations (> or = 6 months later) have been negative for 8 patients. Of the nine patients with a Tg 5 ng/mL or more and a negative WBS, 7 had further evaluation and 6 of 7 had identified disease. In summary, rhTSH-stimulated WBS and Tg are complementary, but Tg is a more sensitive indicator of disease recurrence or persistence. In our practice, an rhTSH-stimulated Tg greater than 4-5 ng/mL often resulted in further evaluation, while a Tg less than 4 ng/mL rarely resulted in further immediate evaluation.

The management of subclinical hyperthyroidism by thyroid specialists.

Subclinical hyperthyroidism is a relatively common condition for which prospectively derived evidenced-based management guidelines do not exist. We have conducted a case-based mail survey to solicit opinions from members of the American Thyroid Association (ATA) about various issues that arise in the management of patients with this disorder. The survey was completed and returned by 185 of 300 (62%) of the original survey recipients. Four hypothetical cases varying in age, thyrotropin (TSH) level and underlying etiology were presented. The majority of respondents recommended further evaluation of all cases, most commonly choosing a radioactive iodine uptake (42%-71%), thyroid scan (39%-68%) and antithyroid (TPO/Tg) antibodies (49%-55%) as the additional tests to be ordered. The large majority (84%) recommended observation rather than active treatment for a young patient with a low but detectable serum TSH level. A small majority also recommended observation alone for a young woman with an undetectable serum TSH level (58%) and for an older woman with a low but detectable serum TSH value (63%). However, the majority (66%) favored treating an older woman with an undetectable serum TSH. When treatment was advised in the patients with subclinical hyperthyroidism, the respondents strongly favored anti-thyroid drugs when the etiology was Graves' disease and radioactive iodine when the etiology was toxic nodular thyroid disease. In the absence of adequate evidence-based guidelines, it is hoped that this survey of expert opinions may provide useful guidance for physicians providing care for patients with subclinical hyperthyroidism.