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Key Findings from Recent JAMA Articles on Subclinical Thyroid Disease
The ATA would like to highlight the findings from two recent publications
on subclinical thyroid disease. A complete response to these articles
is being formulated by the three societies that initiated the consensus
conference; the ATA, The Endocrine Society and American Association
of Clinical Endocrinologists. The article by Surks and colleagues
in JAMA (291:228-238, 2004) provides recommendations for the diagnosis
and treatment of subclinical thyroid disease, based on a systematic
and rigorous review of the current literature by a panel that included
8 endocrinologists as well as experts in lipid disorders, cardiology,
women's health, evidenced-based medicine and screening. The consensus
report highlights several susceptible populations in whom aggressive
case finding is indicated, although routine screening for, or treatment
of, subclinical thyroid disease is not recommended. Susceptible
populations include pregnant women or women planning pregnancy,
women older than 60 years, and others at high risk for thyroid dysfunction.
It also states that published data do not support a recommendation
for routine treatment of all patients with subclinical hypothyroidism
(serum TSH concentration > 4.5 <10 mIU/l). However, all pregnant
women should be treated. In a related article in the same issue
by Col and colleagues (JAMA 291:239-243, 2004), the clinical application
of evidence-based medicine is demonstrated in several thyroid disease
case scenarios. The importance of patient preferences are emphasized
when the clinician is making a decision to treat or not treat a
patient with subclinical thyroid disease. The ATA hopes that these
results will stimulate support for large prospective randomized
trials of treatment of subclinical thyroid disease. The emphasis
for clinicians should continue to be on testing those who are symptomatic
or at high risk for thyroid disease, including those with a family
history of thyroid disease, other autoimmune disorders including
Type I diabetes, vitiligo, and premature menopause. Finally, the
ultimate treatment decision must involve the clinician considering
multiple factors; their clinical evaluation and judgment, patient
preference, clinical outcome studies, potential risks of overtreatment
with levothyroxine, and new bodies of evidence from well-designed
studies that are logical and grounded in well-established principles
of pathophysiology.
Additional information related to January 14, 2004 JAMA articles
