Department of Clinical Sciences, Division of Psychiatry, Sunderby Research Unit, Umeå University, Umeå, Sweden.
Department of Health Sciences, University of York, York, United Kingdom.
Front Endocrinol (Lausanne). 2023 Jul 12;14:1204842. doi: 10.3389/fendo.2023.1204842. eCollection 2023.
Subclinical hypothyroidism (SCH) is a common endocrine problem with prevalence estimates between 4% and 20%. Symptoms are often non-specific but can substantially affect well-being leading to repeated medical consultations. The effect of thyroid hormone replacement therapy (THRT) in patients with SCH remains uncertain. Current guidelines, limited by the lack of high-quality evidence, have been controversial with limited adherence in clinical practice.
Three-round modified Delphi method to establish consensus regarding diagnosis and treatment of individuals with SCH with and without affective disorder or anxiety, conducted with clinicians from three specialties, general practice, endocrinology and psychiatry, and two countries, Sweden and the United Kingdom.
Sixty clinicians, 20 per specialty, were recruited. Fifty-three (88%) participants completed all three rounds. The participants reached consensus on five of the 26 practice statements that (a) repeated testing was required for the diagnosis of subclinical hypothyroidism, (b) antibody screening should usually occur, and (c and d) antibody screening would strengthen the indication for thyroid hormone replacement therapy in both individuals with or without affective disorder or anxiety. The participants disagreed with (e) a requirement of a TSH threshold ≥ 20 mIU/L for thyroid hormone replacement therapy start. Psychiatrists and GPs but not endocrinologists, agreed that there was a frequent discrepancy between laboratory results and clinical symptoms, and disagreed that testing for thyroid dysfunction was overused in patients presenting with depression or anxiety, or fatigue.
In many aspects, attitudes toward diagnosing and treating SCH remain diverse. The inability of our Delphi panel to achieve consensus on most items and the disagreement with a TSH ≥ 20 mIU/L threshold for treatment suggest that the concept of SCH may need rethinking with a better understanding of the hypothalamic-pituitary-thyroid physiology. Given that the scientific evidence is currently not conclusive, guidelines in this area should not be taken as definitive.
亚临床甲状腺功能减退症（SCH）是一种常见的内分泌问题，患病率估计在 4%至 20%之间。症状通常是非特异性的，但会严重影响幸福感，导致反复就医。甲状腺激素替代治疗（THRT）对 SCH 患者的疗效仍不确定。由于缺乏高质量的证据，目前的指南存在争议，在临床实践中的遵循度有限。
采用三轮改良 Delphi 法，就伴有或不伴有情感障碍或焦虑的 SCH 患者的诊断和治疗达成共识，参与者来自三个专业领域，包括普通科、内分泌科和精神病科，以及两个国家，瑞典和英国。
共招募了 60 名临床医生，每个专业 20 名。53 名（88%）参与者完成了所有三轮调查。参与者就 26 个实践陈述中的 5 个达成了共识，即：（a）需要重复检测来诊断亚临床甲状腺功能减退症；（b）通常应进行抗体筛查；（c 和 d）抗体筛查将加强对伴有或不伴有情感障碍或焦虑的个体进行甲状腺激素替代治疗的指征。参与者不同意（e）TSH 阈值≥20 mIU/L 作为开始甲状腺激素替代治疗的要求。精神病医生和全科医生，但不是内分泌医生，同意实验室结果和临床症状之间经常存在差异，不同意在出现抑郁或焦虑或疲劳的患者中甲状腺功能障碍的检测被过度使用。
在许多方面，诊断和治疗 SCH 的态度仍然存在差异。我们的 Delphi 小组未能就大多数项目达成共识，以及不同意 TSH≥20 mIU/L 作为治疗阈值的意见表明，需要重新思考 SCH 的概念，以更好地了解下丘脑-垂体-甲状腺生理学。鉴于目前的科学证据尚不确定，该领域的指南不应被视为定论。
