Burch Henry B, Burman Kenneth D, Cooper David S, Hennessey James V
Endocrinology Division (H.B.B.), Walter Reed National Military Medical Center, Bethesda, Maryland 20889, and Uniformed Services University of Health Sciences, Bethesda, Maryland 20814; Endocrinology Section (K.D.B.), Washington Hospital Center, Washington, DC 20010; Georgetown University Medical Center (K.D.B.), Washington, DC 20007; Division of Endocrinology (D.S.C.), The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205; Division of Endocrinology (J.V.H.), Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215; and Harvard Medical School (J.V.H.), Boston, Massachusetts 02115.
J Clin Endocrinol Metab. 2014 Jun;99(6):2077-85. doi: 10.1210/jc.2014-1046. Epub 2014 Feb 14.
In 2012, comprehensive clinical practice guidelines (CPGs) were published regarding the management of hypothyroidism.
We sought to document current practices in the management of primary hypothyroidism and compare these results with recommendations made in the 2012 American Thyroid Association (ATA)/American Association of Clinical Endocrinologists (AACE) hypothyroidism CPGs. In addition, we sought to examine differences in management among international members of U.S.-based endocrine societies and to compare survey results with those obtained from a survey of ATA members performed 12 years earlier.
Clinical members of The Endocrine Society (TES), the ATA, and the AACE were asked to take a web-based survey consisting of 30 questions dealing with testing, treatment, and modulating factors in the management of primary hypothyroidism.
In total, 880 respondents completed the survey, including 618 members of TES, 582 AACE members, and 208 ATA members. North American respondents accounted for 67.6%, Latin American 9.7%, European 9.2%, Asia and Oceania 8.1%, and Africa and Middle East 5.5%. Overt hypothyroidism would be treated using l-T4 alone by 99.2% of respondents; 0.8% would use combination l-T4 and liothyronine (l-T3) therapy. Generic l-T4 would be used by 49.3% and a brand name by 49.9%. The rate of replacement would be gradual (38.5%); an empiric dose, adjusted to achieve target (33.6%); or a calculated full replacement dose (27.8%). A target TSH of 1.0 to 1.9 mU/L was favored in the index case, but 3.0 to 3.9 mU/L was the most commonly selected TSH target for an octogenarian. Persistent hypothyroid symptoms despite achieving a target TSH would prompt testing for other causes by 84.3% of respondents, a referral to primary care by 11.3%, and a change to l-T4 plus l-T3 therapy by 3.6%. Evaluation of persistent symptoms would include measurement of T3 levels by 21.9% of respondents. Subclinical disease with a TSH 5.0 to 10.0 mU/L would be treated without further justification by 21.3% of respondents, or in the presence of positive thyroid peroxidase antibodies (62.3%), hypothyroid symptoms (60.9%), high low-density lipoprotein (52.9%), or goiter (46.6%). The TSH target for a newly pregnant patient was <2.5 mU/L for 96.1% of respondents, with 63.5% preferring a TSH target <1.5 mU/L. Thyroid hormone levels would be checked every 4 weeks during pregnancy by 67.7% and every 8 weeks by an additional 21.4%. A hypothyroid patient with TSH of 0.5 mU/L who becomes pregnant would receive an immediate l-T4 dose increase by only 36.9% of respondents.
The current survey of clinical endocrinologists catalogs current practice patterns in the management of hypothyroidism and demonstrates 1) a nearly exclusive preference for l-T4 alone as initial therapy, 2) the widespread use of age-specific TSH targets for replacement therapy, 3) a low threshold for treating mild thyroid failure, 4) meticulous attention to TSH targets in the pregnant and prepregnant woman, and 5) a highly variable approach to both the rate and means of restoring euthyroidism for overt disease. Both alignment and focal divergence from recent CPGs are demonstrated.
2012年，发布了关于甲状腺功能减退症管理的综合临床实践指南（CPG）。
我们试图记录原发性甲状腺功能减退症管理的当前实践，并将这些结果与2012年美国甲状腺协会（ATA）/美国临床内分泌学家协会（AACE）甲状腺功能减退症CPG中的建议进行比较。此外，我们试图研究美国内分泌学会国际成员在管理上的差异，并将调查结果与12年前对ATA成员进行的调查结果进行比较。
内分泌学会（TES）、ATA和AACE的临床成员被要求进行一项基于网络的调查，该调查由30个关于原发性甲状腺功能减退症管理中的检测、治疗和调节因素的问题组成。
共有880名受访者完成了调查，其中包括618名TES成员、582名AACE成员和208名ATA成员。北美受访者占67.6%，拉丁美洲占9.7%，欧洲占9.2%，亚洲和大洋洲占8.1%，非洲和中东占5.5%。99.2%的受访者会单独使用左甲状腺素（l-T4）治疗显性甲状腺功能减退症；0.8%会使用左甲状腺素（l-T4）和碘塞罗宁（l-T3）联合治疗。49.3%的人会使用通用左甲状腺素（l-T4），49.9%的人会使用品牌药。替代率将是逐渐增加的（38.5%）；根据经验调整剂量以达到目标（33.6%）；或计算出的完全替代剂量（27.8%）。在索引病例中，最青睐的促甲状腺激素（TSH）目标是1.0至1.9 mU/L，但对于八十多岁的人，最常选择的TSH目标是3.0至3.9 mU/L。尽管TSH达到目标，但仍有持续的甲状腺功能减退症状，84.3%的受访者会促使检测其他原因，11.3%的人会转诊至初级保健，3.6%的人会改为左甲状腺素（l-T4）加碘塞罗宁（l-T3）治疗。21.9%的受访者对持续症状的评估将包括测量T3水平。促甲状腺激素（TSH）为5.0至10.0 mU/L的亚临床疾病，21.3%的受访者在没有进一步理由的情况下会进行治疗，或者在存在甲状腺过氧化物酶抗体阳性（62.3%）、甲状腺功能减退症状（60.9%）、高低密度脂蛋白（52.9%）或甲状腺肿（46.6%）的情况下进行治疗。96.1%的受访者认为新怀孕患者的促甲状腺激素（TSH）目标是<2.5 mU/L，63.5%的人更喜欢促甲状腺激素（TSH）目标<1.5 mU/L。67.7%的人会在怀孕期间每4周检查一次甲状腺激素水平，另外21.4%的人会每8周检查一次。促甲状腺激素（TSH）为0.5 mU/L的甲状腺功能减退患者怀孕后，只有36.9%的受访者会立即增加左甲状腺素（l-T4）剂量。
当前对临床内分泌学家的调查记录了甲状腺功能减退症管理的当前实践模式，并表明1）几乎完全倾向于单独使用左甲状腺素（l-T4）作为初始治疗；2）广泛使用针对年龄的促甲状腺激素（TSH）目标进行替代治疗；3）治疗轻度甲状腺功能减退的阈值较低；4）对孕妇和孕前妇女的促甲状腺激素（TSH）目标给予细致关注；5）对于显性疾病恢复甲状腺功能正常的速率和方法采用高度可变的方法。与最近的CPG既有一致性，也有局部差异。
