Get Permission Kant, Barnwal, Yadav, Tendulkar, and Bairwa: Subclinical hypothyroidism in community perspective: Treat or not to treat?


Introduction

Subclinical hypothyroidism (SCH)is defined as the value of thyroid-stimulating hormone between 4.5-10mIU/L in the setting of normal fT4 and fT3. There is much controversy regarding the treatment of this condition. Physiological conditions affect the thyroid function test, and hence it is crucial to interpret the test results in light of a particular physiological state.Aging is associated with an increase in TSH concentration, and it has been sometimes considered as a harbinger of long life, at least in Ashkenazi Jew.1, 2 This increase is accounted for by multiple factors such as higher TSH set point, reduced bioactivity, TSH resistance, etc. rather than representing an occult thyroid disorder.3 The cardiovascular system is mostly affected by rising TSH concentration; sub clinical hypothyroidism is an established risk factor in adults and older people, especially less than 65 years of age, as evidenced by a meta-analysis of 15 studies. All these studies included a TSH value of less than 10mIU/L.4 The prevalence of subclinical hypothyroidism varies between 5-15% and shows higher prevalence as the age advances.5 In community-based studies, the prevalence of subclinical hypothyroidism was also observed nearly 4.4% in males and 7.5–8.5 in females.5, 6 Prevalence of subclinical hypothyroidism increases in females with advancing age, and it is more commonly associatedwith elderly females as 7–18% compared to males as 2–15% 7, 8 In a community study in Riyadh, the prevalence of subclinical hypothyroidism was also found to be 10% in visiting patients at primary health centers.9 Primary health care focuses on a comprehensive approach to individuals, families, and communities' physical, mental, and social health needs. A majority of a person's health needs can be covered through primary health care, including prevention, treatment, rehabilitation, and palliative care.10 Thyroid function test is the most commonly requested laboratory investigation in a community setting.3 Treatment for subclinical hypothyroidism is under debate for more than two decades with varying opinions. The main focus of treatment, of course, is aimed at one of the following criteria:

  1. Correction of lipid abnormality

  2. Progression to overt hypothyroidism

  3. Pregnancy and other medical conditions

Correction of lipid abnormality

There exists a plethora of evidence both in favor and against lipid abnormality in subclinical hypothyroidism. The notion of correcting lipid abnormality by treatment with levothyroxine supplementation and thereby reducing cardiovascular morbidity and mortality has strong proponents and opponents. Observational studies by Canaris et al. have shown a mean elevation in total cholesterol, low-density lipoprotein cholesterol (LDL-C), and mean triglyceride level (TG) by approximately 8 and 6 mg% for HDL-C and LDL-C that was significant as against TG, which was not significantly elevated in patients with SCH, 11 these findings are not supported by other researchers like Vierhapper et al.12 and Bell et al.13 who observed no difference in lipid concentrations of SCH and euthyroid patients. NHANES III database also did not find any change in lipid values when adjusted for age, sex, lipid-lowering agents, and SCH.14 However, a population-based survey in 2799 caucasian subjects had conflicting observations and showed total cholesterol elevation by approximately 9 mg/dl.15 The concentration of apolipoprotein B (Apo B), a significant constituent of LDL-C and VLDL-C, has been seen to be elevated in SCH substantially.16

Treatment with levothyroxine (LT4) is as variable as lipid abnormality in SCH Apo B, which is found in atherogenic lipids is significantly lowered after treatment with LT4.17, 18 Study by Razvi et al. In a randomized placebo-controlled trial demonstrated a significant reduction in TC, LDL-C in 100 SCH patients without having much effect of other lipid molecules including Apo B.19 A recent Cochrane review has however refuted the claim of the beneficial impact of LT4 replacement on lipid parameters except for TC.20

Progression to overt hypothyroidism

Subclinical hypothyroidism can progress to overt hypothyroidism (OH); the estimated rate at which SCH moves to OH is dependent on various factors like age and antithyroid peroxidase antibody status. Approximately 33-55%of patients with SCH will develop OH over ten years, with an average rate of 2-6% per year.20, 21 Females who are anti-TPO antibody positive have a higher chance of developing it against those who are negative for anti-TPO. The initial level of TSH is also an essential determinant of progression to OH.22 2. Coronary Heart Disease Subclinical hypothyroidism has association with a higher risk of coronary heart disease and heart failure.23 Patients in whom TSH is below 7 mIU/l has almost the same risk as euthyroid subjects.24 Patients with TSH higher than 10 have had higher odds of developing heart failure.25 Coronary heart disease, heart failure, and atrial fibrillation are more common in patients younger than 65 as opposed to more than 65 years of age, it portends that SCH has a protective role in preventing elderly from this group of diseases. All causes of mortality and deaths due to CHD were higher in both prospective26 and retrospective studies in patients younger than 65years of age.27 Razvi et al., in a retrospective cohort study, reported that the treatment of SCH in the age group 40-70years was associated with reduced all caused mortality and CHD; there was, however, no difference when age was more than 70 years.27 In a Cochrane review, SCH was found to be associated with surrogate markers of CHD like hypertension, echocardiographic findings, lipid abnormality,endothelial dysfunction; these findings improved with treatment.20

Pregnancy and Other Medical Conditions

Pregnancy and SCH

The diagnostic criteria for SCH in pregnancy are different from the non-pregnant status as the features of non-pregnancy. That of SCH is often challenging to differentiate on clinical grounds. American thyroid association and endocrine society have given a trimester-specific range of TSH. The first, second, and third trimester values are 0.1-2.5 mIU/l, 0.2-3mIU/l, and 0.3-3.5mIU/l, respectively.28 SCH in pregnancy has an impact on maternal and fetal outcomes. Casey et al. observed that the prevalence of preterm delivery and abruptio placentae was higher with SCH in 2500 pregnant subjects.29 In a prospective study by Negro et al., miscarriage was also more in the SCH group than euthyroid subjects.30 Fetal outcomes were also affected by maternal thyroid status; children born to SCH females more frequently required intensive care unit admissions.31 Negro et al. in an RCT showed beneficial effects on the maternal and fetal outcomes when SCH was treated both in assisted reproductive technique and non-assisted reproductive pregnancies.30 Currently, treatment is advocated in those who are anti-TPO antibody positive. The data is highly inconclusive so far as infertility is concerned. Some studies have, however, found a positive correlation between the higher prevalence of infertility and SCH. This association was mainly found in ovulatory disorders and not in other disorders like tubal factors, etc.32

Neuropsychiatric symptoms

Subclinical hypothyroidism is associated with reduced quality of life, mood, and treatment failure in depressed patients.33 This association was seen at a higher TSH level of more than 10 mIU/l. ACochrane review has convincingly proven that there is hardly any benefit of treating subclinical hypothyroidism as mood and quality of life is concerned in patients' SCH patients with lower TSH values.

Children and Adolescents

It is found that children with SCH do not usually progress to overt hypothyroidism. Lazer et al., in a retrospective study, found that only those children whose initial TSH was higher than 7.5mI U/l had a higher propensity for OH. It was more common in females, especially around the pubertal age group.34 American thyroid association does not recommend treatment for children with TSH between 5-10 mI U/l.35

Risks with treatment

Treatment of SCH is associated with risk of thyrotoxicosis; some patients felt worse with levothyroxine supplementation in a placebo control study by Cooper et al. 36 Nystrom et al.37 and Flynn RW et al.38 also reported tachyarrhythmia's and angina pectoris and supplementation is also associated with low bone mass.

Conclusion

Treatment for subclinical hypothyroidism is under debate for more than two decades with varying opinions. Of course, treatment's primary focus is aimed at one of the criteria as correction of lipid abnormality, progression to overt hypothyroidism and pregnancy, and other medical conditions.A plethora of evidence exists both in favor and against lipid abnormality in subclinical hypothyroidism. Subclinical hypothyroidism can advance to overt hypothyroidism, and also it is associated with a higher risk of coronary heart disease and heart failure. The diagnostic criteria for SCH in pregnancy are challenging from the non-pregnant status. Even in depressed patients, subclinical hypothyroidism is also associated with reduced quality of life, mood, and treatment failure.As thyroid function test is the most commonly requested laboratory investigations in primary health care settings. However, insufficient data on subclinical hypothyroidism forced medical professionals to screen identified cases and initiate treatment of such conditions in the primary health care setting.

Source of Funding

None.

Conflict of Interest

None

References

1 

M I Surks J G Hollowell Age-specific distribution of serum thyrotropin and antithyroid antibodies in the US population: implications for the prevalence of subclinical hypothyroidismJ Clin Endocrinol Metab2007921245758210.1210/jc.2007-1499

2 

A P Bremner P Feddema P J Leedman S J Brown J P Beilby E M Lim Age-related changes in thyroid function: a longitudinal study of a community-based cohortJ Clin Endocrinol Metab201297515546210.1210/jc.2011-3020

3 

O Koulouri C Moran D Halsall K Chatterjee M Gurnell Pitfalls in the measurement and interpretation of thyroid function testsBest Pract Res Clin Endocrinol Metab201327674576210.1016/j.beem.2013.10.003

4 

S Razvi A Shakoor M Vanderpump J U Weaver S H S Pearce The Influence of Age on the Relationship between Subclinical Hypothyroidism and Ischemic Heart Disease: A MetaanalysisJ Clin Endocrinol Metab20089382998300710.1210/jc.2008-0167

5 

J Wilson G Junger Principles, and practice of screening for disease. Geneva: World Health Organization1968https://apps.who.int/iris/handle/10665/37650

6 

C A Spencer J S LoPresti A Patel R B Guttler A Eigen D Shen Applications of a New Chemiluminometric Thyrotropin Assay to Subnormal Measurement*J Clin Endocrinol Metab19907024536010.1210/jcem-70-2-453

7 

A R Ayala L Wartofsky Minimally Symptomatic (Subclinical) HypothyroidismEndocrinologist199771445010.1097/00019616-199707010-00007

8 

G J Canaris N R Manowitz G Mayor E C Ridgway The Colorado Thyroid Disease Prevalence StudyArch Intern Med200016045263410.1001/archinte.160.4.526

9 

E A Eidan S U Rahman S A Qahtani A A Farhan I Abdulmajeed Prevalence of subclinical hypothyroidism in adults visiting primary health-care setting in RiyadhJ Community Hosp Intern Med Perspect20188111510.1080/20009666.2017.1422672

11 

G J Canaris N R Manowitz G Mayor E C Ridgway The Colorado Thyroid Disease Prevalence StudyJAMA Arch Intern Med200016045263410.1001/archinte.160.4.526

12 

H Vierhapper A Nardi P Grösser W Raber A Gessl Low-Density Lipoprotein Cholesterol in Subclinical HypothyroidismThyroid20001011981410.1089/thy.2000.10.981

13 

R J Bell L R Woll S L Davison D J Topliss S Donath S R Davis Well-being, health-related quality of life and cardiovascular disease risk profile in women with subclinical thyroid disease ? a community-based studyClin Endocrinol20076645485610.1111/j.1365-2265.2007.02771.x

14 

A M Perak H Ning B K Kit Trends in Levels of Lipids and Apolipoprotein B in US Youths Aged 6 to 19 YearsJAMA19993211895190510.1001/jama.2019.4984

15 

A M Kanaya F Harris S Volpato E J P Stable T Harris D C Bauer Association between thyroid dysfunction and total cholesterol level in an older biracial population: the health, aging and body composition studyArch Intern Med20028162773910.1001/archinte.162.7.773

16 

F Monzani N Caraccio M Kozàkowà A Dardano F Vittone A Virdis Effect of Levothyroxine Replacement on Lipid Profile and Intima-Media Thickness in Subclinical Hypothyroidism: A Double-Blind, Placebo- Controlled StudyJ Clin Endocrinol Metab2004895209910610.1210/jc.2003-031669

17 

M Ito T Arishima T Kudo E Nishihara H Ohye S Kubota Effect of levothyroxine replacement on non-high-density lipoprotein cholesterol in hypothyroid patientsJ Clin Endocrinol Metab20019226081910.1210/jc.2006-1605

18 

A Pérez J M Cubero N Sucunza E Ortega R Arcelús J R Espinosa Emerging cardiovascular risk factors in subclinical hypothyroidism: Lack of change after restoration of euthyroidismMetabolism200453111512510.1016/j.metabol.2004.05.016

19 

S Razvi L Ingoe G Keeka C Oates C McMillan J U Weaver The Beneficial Effect ofl-Thyroxine on Cardiovascular Risk Factors, Endothelial Function, and Quality of Life in Subclinical Hypothyroidism: Randomized, Crossover TrialJ Clin Endocrinol Metab200792517152310.1210/jc.2006-1869

20 

H C C E Villar H Saconato O Valente Á N Atallah Thyroid hormone replacement for subclinical hypothyroidismCochrane Database Syst Rev20073CD003419.10.1002/14651858.cd003419.pub2

21 

U M Kabadi Subclinical hypothyroidism': natural course of the syndrome during a prolonged follow-up study. Archives of internal medicineArch Intern Med199315389576110.1001/archinte.153.8.957

22 

J Meyerovitch Serum Thyrotropin Measurements in the CommunityArch Intern Med2007167141533810.1001/archinte.167.14.1533

23 

C Mcquade M Skugor D M Brennan B Hoar C Stevenson B J Hoogwerf Hypothyroidism and moderate subclinical hypothyroidism are associated with increased all-cause mortality independent of coronary heart disease risk factors: a PreCIS database studyThyroid20012188374310.1089/thy.2010.0298

24 

N Rodondi W P J Elzen D C Bauer A R Cappola S Razvi J P Walsh Jacques Cornuz Subclinical Hypothyroidism and the Risk of Coronary Heart Disease and MortalityJAMA20103041213657410.1001/jama.2010.1361

25 

N Rodondi D C Bauer A R Cappola J Cornuz J Robbins L P Fried Subclinical Thyroid Dysfunction, Cardiac Function, and the Risk of Heart FailureJ Am Coll Cardiol200852141152910.1016/j.jacc.2008.07.009

26 

C Mcquade M Skugor D M Brennan B Hoar C Stevenson B J Hoogwerf Hypothyroidism and moderate subclinical hypothyroidism are associated with increased all-cause mortality independent of coronary heart disease risk factors: a PreCIS database studyThyroid20012188374310.1089/thy.2010.0298

27 

S Razvi J U Weaver T J Butler S H Pearce Levothyroxine treatment of subclinical hypothyroidism, fatal and nonfatal cardiovascular events, and mortalityArch Intern Med201217210811710.1001/archinternmed.2012.1159

28 

L De Groot M Abalovich E K Alexander Management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society clinical practice guidelineJ Clin Endocrinol Metab201297825436510.1210/jc.2011-2803

29 

B M Casey J S Dashe C E Wells D D Mcintire W Byrd K J Leveno Subclinical hypothyroidism and pregnancy outcomesObstet Gynecol200510522394510.1097/01.AOG.0000152345.99421.22

30 

R Negro A Schwartz R Gismondi A Tinelli T Mangieri A Stagnaro-Green Increased pregnancy loss rate in thyroid antibody negative women with TSH levels between 2.5 and 5.0 in the first trimester of pregnancyJ Clin Endocrinol Metab200195944810.1210/jc.2010-0340

31 

N Benhadi W M Wiersinga J B Reitsma T G Vrijkotte G J Bonsel Higher maternal TSH levels in pregnancy are associated with increased risk for miscarriage, fetal, or neonatal deathEur J Endocrinol200116069859110.1530/EJE-08-0953

32 

S R Lincoln R W Ke W H Kutteh Screening for hypothyroidism in infertile womenJ Reprod Med19994454557

33 

C U Pae L Mandelli C Han B J Ham P S Masand A A Patkar Thyroid hormones affect recovery from depression during antidepressant treatmentPsychiatry Clin Neurosci20096333051310.1111/j.1440-1819.2009.01938.x

34 

G Bona F Prodam A Monzani Subclinical hypothyroidism in children: natural history and when to treatJ Clin Res Pediatr Endocrinol2013523810.4274/Jcrpe.851

35 

J Jonklaas A C Bianco A J Bauer K D Burman A R Cappola F S Celi American Thyroid Association Task Force on Thyroid Hormone Replacement. Guidelines for the treatment of hypothyroidism: prepared by the American thyroid association task force on thyroid hormone replacementThyroid20142412167075110.1089/thy.2014.0028

36 

D S Cooper Wood Halpern R Levin Lc Aa E C Ridgway L-thyroxine therapy in subclinical hypothyroidism: a double-blind, placebo-controlled trial. Annals of internal medicineAnn Intern Med19841011182410.7326/0003-4819-101-1-18

37 

E Nyström K Caidahl G Fager C Wikkelsö P A Lundberg G Lindstedt A double-blind cross-over 12-month study of L-thyroxine treatment of women with 'subclinical' hypothyroidismClin Endocrinol1988291637510.1111/j.1365-2265.1988.tb00250.x

38 

R W Flynn S R Bonellie R T Jung T M Macdonald A D Morris G P Leese Serum thyroid-stimulating hormone concentration and morbidity from cardiovascular disease and fractures in patients on long-term thyroxine therapyJ Clin Endocrinol Metab20019511869310.1210/jc.2009-1625



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Received : 13-05-2021

Accepted : 24-05-2021


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https://doi.org/10.18231/j.jpmhh.2021.005


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