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