Geen behandeling bij subklinische hypothyreoïdie?!
Geplaatst: 16 mei 2019, 14:42
Thyroid hormones treatment for subclinical hypothyroidism: a clinical practice guideline
BMJ
ABSTRACT
Clinical question
What are the benefits and harms of thyroid hormones for adults with subclinical hypothyroidism (SCH)?
This guideline was triggered by a recent systematic review of randomised controlled trials, which could alter practice.
Current practice
Current guidelines tend to recommend thyroid hormones for adults with thyroid stimulating hormone (TSH) levels >10 mIU/L and for people with lower TSH values who are young, symptomatic, or have specific indications for prescribing.
Recommendation
The guideline panel issues a strong recommendation against thyroid hormones in adults with SCH (elevated TSH levels and normal free T4 (thyroxine) levels). It does not apply to women who are trying to become pregnant or patients with TSH >20 mIU/L. It may not apply to patients with severe symptoms or young adults (such as those ≤30 years old).
How this guideline was created
A guideline panel including patients, clinicians, and methodologists produced this recommendation in adherence with standards for trustworthy guidelines using the GRADE approach.
The evidence
The systematic review included 21 trials with 2192 participants. For adults with SCH, thyroid hormones consistently demonstrate no clinically relevant benefits for quality of life or thyroid related symptoms, including depressive symptoms, fatigue, and body mass index (moderate to high quality evidence). Thyroid hormones may have little or no effect on cardiovascular events or mortality (low quality evidence), but harms were measured in only one trial with few events at two years’ follow-up.
Understanding the recommendation
The panel concluded that almost all adults with SCH would not benefit from treatment with thyroid hormones. Other factors in the strong recommendation include the burden of lifelong management and uncertainty on potential harms. Instead, clinicians should monitor the progression or resolution of the thyroid dysfunction in these adults. Recommendations are made actionable for clinicians and their patients through visual overviews. These provide the relative and absolute benefits and harms of thyroid hormones in multilayered evidence summaries and decision aids available in MAGIC (https://app.magicapp.org/) to support shared decisions and adaptation of this guideline.
What you need to know
* Thyroid hormones should not be routinely offered to adults with SCH (strong recommendation according to GRADE).
* Thyroid hormones do not lead to important benefits for adults with SCH for quality of life or thyroid related symptoms including depressive symptoms and fatigue.
* Taking a pill and attending periodic testing on an ongoing or lifelong basis is burdensome.
* This recommendation builds on a recent systematic review and meta-analysis, which included the results of a new randomised controlled trial
If implemented, this recommendation may substantially alter prescribing trends, which show that thyroid hormones are increasingly prescribed, most probably due to SCH.
How was this recommendation created?
Our international panel included methodologists, general practitioners, internists, endocrinologists, and patient partners with subclinical hypothyroidism (SCH) (see appendix 1 on bmj.com for details of panel members). They decided on the scope of the recommendation and identified patient-important outcomes to inform the recommendations.
The panel met online to discuss the evidence and formulate a recommendation. No member had a financial conflict of interest; intellectual and professional conflicts were minimised and are transparently described (appendix 2 on bmj.com). The panel followed the BMJ Rapid Recommendations procedures for creating a trustworthy recommendation, including using the GRADE approach to critically appraise the evidence and create recommendations (appendix 3 on bmj.com).28 The panel considered the benefits, harms, and burdens and other practical issues related to thyroid hormones in the context of SCH, as well as expected variations in patient values and preferences. Within the GRADE approach, recommendations can be either strong or weak (also known as conditional), and for or against a specific course of action.
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BMJ
ABSTRACT
Clinical question
What are the benefits and harms of thyroid hormones for adults with subclinical hypothyroidism (SCH)?
This guideline was triggered by a recent systematic review of randomised controlled trials, which could alter practice.
Current practice
Current guidelines tend to recommend thyroid hormones for adults with thyroid stimulating hormone (TSH) levels >10 mIU/L and for people with lower TSH values who are young, symptomatic, or have specific indications for prescribing.
Recommendation
The guideline panel issues a strong recommendation against thyroid hormones in adults with SCH (elevated TSH levels and normal free T4 (thyroxine) levels). It does not apply to women who are trying to become pregnant or patients with TSH >20 mIU/L. It may not apply to patients with severe symptoms or young adults (such as those ≤30 years old).
How this guideline was created
A guideline panel including patients, clinicians, and methodologists produced this recommendation in adherence with standards for trustworthy guidelines using the GRADE approach.
The evidence
The systematic review included 21 trials with 2192 participants. For adults with SCH, thyroid hormones consistently demonstrate no clinically relevant benefits for quality of life or thyroid related symptoms, including depressive symptoms, fatigue, and body mass index (moderate to high quality evidence). Thyroid hormones may have little or no effect on cardiovascular events or mortality (low quality evidence), but harms were measured in only one trial with few events at two years’ follow-up.
Understanding the recommendation
The panel concluded that almost all adults with SCH would not benefit from treatment with thyroid hormones. Other factors in the strong recommendation include the burden of lifelong management and uncertainty on potential harms. Instead, clinicians should monitor the progression or resolution of the thyroid dysfunction in these adults. Recommendations are made actionable for clinicians and their patients through visual overviews. These provide the relative and absolute benefits and harms of thyroid hormones in multilayered evidence summaries and decision aids available in MAGIC (https://app.magicapp.org/) to support shared decisions and adaptation of this guideline.
What you need to know
* Thyroid hormones should not be routinely offered to adults with SCH (strong recommendation according to GRADE).
* Thyroid hormones do not lead to important benefits for adults with SCH for quality of life or thyroid related symptoms including depressive symptoms and fatigue.
* Taking a pill and attending periodic testing on an ongoing or lifelong basis is burdensome.
* This recommendation builds on a recent systematic review and meta-analysis, which included the results of a new randomised controlled trial
If implemented, this recommendation may substantially alter prescribing trends, which show that thyroid hormones are increasingly prescribed, most probably due to SCH.
How was this recommendation created?
Our international panel included methodologists, general practitioners, internists, endocrinologists, and patient partners with subclinical hypothyroidism (SCH) (see appendix 1 on bmj.com for details of panel members). They decided on the scope of the recommendation and identified patient-important outcomes to inform the recommendations.
The panel met online to discuss the evidence and formulate a recommendation. No member had a financial conflict of interest; intellectual and professional conflicts were minimised and are transparently described (appendix 2 on bmj.com). The panel followed the BMJ Rapid Recommendations procedures for creating a trustworthy recommendation, including using the GRADE approach to critically appraise the evidence and create recommendations (appendix 3 on bmj.com).28 The panel considered the benefits, harms, and burdens and other practical issues related to thyroid hormones in the context of SCH, as well as expected variations in patient values and preferences. Within the GRADE approach, recommendations can be either strong or weak (also known as conditional), and for or against a specific course of action.
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