Frontiers in Endocrinology publishes rigorously peer-reviewed research from basic molecular and cellular communication to clinical care, advancing our understanding of the endocrine system, and leading to novel therapies for some of the most prevalent health issues such as obesity, diabetes, reproduction and aging
Front. Endocrinol., 22 March 2019
Overt and Subclinical Hypothyroidism in the Elderly: When to Treat?
Valeria Calsolaro1,2*, Filippo Niccolai1, Giuseppe Pasqualetti1, Alessia Maria Calabrese1, Antonio Polini1, Chukwuma Okoye1, Silvia Magno3, Nadia Caraccio1 and Fabio Monzani1
1 Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
2 Neurology Imaging Unit, Imperial College, London, United Kingdom
3 Obesity Center at the Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
Hypothyroidism is characterized by increased thyrotropin (TSH) levels and reduced free thyroid hormone fractions while, subclinical hypothyroidism (sHT) by elevated serum TSH in the face of normal thyroid hormones.
The high frequency of hypothyroidism among the general population in Western Countries made levothyroxine (LT4) one of the 10 most prescribed drugs.
However, circulating TSH has been demonstrated to increase with aging, regardless the existence of an actual thyroid disease. Thus, when confronting an increase in circulating TSH levels in the elderly, especially in the oldest old, it is important to carry an appropriate diagnostic path, comprehensive of clinical picture as well as laboratory and imaging techniques. In the current review, we summarize the recommendations for a correct diagnostic workup and therapeutic approach to older people with elevated TSH value, with special attention to the presence of frailty, comorbidities, and poly-therapy.
The treatment of choice for hypothyroid patients is hormone replacement with LT4 but, it is important to consider multiple factors before commencing the therapy, from the age dependent TSH increase to the presence of an actual thyroid disease and comorbidities.
When treatment is necessary, a tailored therapy should be chosen, considering poly-pharmacy and frailty.
A careful follow-up and treatment re-assessment should be always considered to avoid the risk of over-treatment.
It is important to stress the need of educating the patient for a correct administration of LT4, particularly when poly-therapy is in place, and the importance of a tailored therapeutic approach and follow-up, to avoid overtreatment.
FIGURE 1 | Suggested strategy of care according to either serum TSH value or the clinical features in ﬁt older patients
FIGURE 2 | Suggested strategy of care according to either serum TSH value or the clinical features in frail older patients.
Hypothyroidism, overt or subclinical, is a very frequent chronic disease among the older population;
however, TSH circulating levels have been demonstrated to increase with aging, regardless the existence of an actual thyroid disease.
For this reason, when confronting an increase in TSH circulating level in a patient older than 65 years of age, and even more carefully in the oldest old, it is important to carry an appropriate diagnostic path, comprehensive of clinical picture, laboratory tests, in particular checking for anti-thyroid autoantibodies, and US scan.
Moreover, in the older population, the presence of frailty needs to be considered and addressed (77).
The therapy of choice is hormone replacement with LT4, whichever pharmacologic form is more adequate, starting with a dosage of 0.3–0.4 µg/Kg/day and titrating by 10–15% after 6–8 weeks, aiming to keep an optimal TSH level of 2.5–3.5 mIU/L.
It is important to stress the need of educating the patient for a correct administration of the therapy, particularly when poly-therapy is in place and the importance of a tailored therapeutic approach and follow up, to avoid overtreatment
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