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1、SUBCLINICAL HYPOTHYROIDISM,Alex Gonzalez MD, FACPAlex Gonzalez MD, FACP,Dayan, C. M. et. al. N Engl J Med 1996;335:99-107,Age-Specific Rates for the Development of Hypothyroidism and Hyperthyroidism in Women,Causes of hypothyroidism,Autoimmune thyroiditis (Hashimotos)AtrophicGoitrous Radioactive iod
2、ine Rx for Graves. Thyroid surgery Neck irradiation Drugs,Hypothyroidism in the elderly,Symptoms of hypothyroidism are similar to symptoms due to aging.,78 y.o. fell at home and fractured a hip. He was very slow to recover after anesthesia.,TSH: 86 uU/L(n: 0.4- 5),Primary Hypothyroidism Recommended
3、screening:,A. Thyroid Assoc.:Screen every 5 years after age 35A.A. of Fam. Physicians/ A.A.of Clinical Endocrinologists:Periodic screening of asymptomatic women over 60. No screening for men. US Preventive Services Task Force:No screening recommended,Thyroid function studies,Serum TSH. 0.4- 5.0 mU/L
4、 Total T4. 5-11 mcg/dL, Free T4 0.8-1.8 ng/dL Total T3. 95-170 ng/dL, Free T3 2.0-4.4 pg/mL Total rT3 30-50 ng/dL aTPO and antithyroglobulin antibodies Thyroglobulin TSH receptor antibody (TSI)Thyroid Ultrasound Radioactive uptake/Scan Biopsy,Thyroid function screen,TSH (0.4- 5.0 mU/L),Screening for
5、 thyroid disease,Normal TSH = normal thyroid functionLow TSH = Hyperthyroidism.High TSH = Primary HypothyroidismWhen the TSH is abnormal, follow with a serum Free T4 for confirmation.,Diagnosis of Primary Hypothyroididsm,Elevated TSH Low Free T4,68 y.o. woman with fatigue, somnolence and cognitive d
6、ecline.Radioactive Iodine for Graves disease 20 years ago,TSH: 68 mU/L (0.4-5)Free T4: 0.2 (0.8-1.8 ng/dL)Dx: Primary Hypothyroidism,Subclinical hypothyroidism,Serum TSH above the upper limit of normalNormal Free T4,Subclinical hypothyroidism,After the six decade the prevalence is 10% and equal in m
7、en and women.80% have a TSH between 5 and 10 mIU/L,Example:,85 y.o. woman who lives by herself. She had recently lost her husband. She was tired, somnolent and forgetful. No goiter.TSH screen: 7.8 mU/L ( n: 0.4-5 ) Free T4: 1.0 ng/dL ( n: 0.8-1.8)Treatment?,Subclinical hypothyroidism,She was given 5
8、0 mcg of Levothyroxine daily.,Subclinical hypothyroidism,The patient was admitted 6 weeks later with severe dyspnea. She was on A.Fib.and congestive heart failureSerum TSH 10 mU/LPositive Antithyroid AntibodiesGoiter,Exceptions:,30 y.o. 6 weeks pregnantTSH: 5.6 uU/L (normal 10 uU/L TSH 5-10 uU/LWith
9、 positive thyroid antibodiesWith goiterClinically symptomatic Pregnant Women planning to get pregnant Children and adolescents,Treatment:,Levothyroxine (T4) onlyLiothyronine (T3, Cytomel), combinations of T4/T3 or Thyroid Extract are not recommended.,Treatment:,Levothyroxine:Starting dose 25 to 50 mcg/dRetest TSH in 6 weeks, adjust dose.When TSH is stable, retest in 6 months and yearlyTSH goals:0.4 to 2 uU/L in young patients1 to 3 in older individuals,Questions ?,
