A Step-Wise Approach to the Evaluation and Treatment of Subclinical Hyperthyroidism
Endocrine Practice, 07/16/2012
Mai VQ et al. – The authors present a stepwise approach to the management of patients presenting with an isolated suppression of serum thyroid stimulating hormone (TSH), which focuses on the differential diagnosis, a prediction of the likelihood of persistence, an assessment of potential risks posed to the patient, and finally, an individualized choice of therapy.Methods
- Articles published from 2007-2012 were reviewed and applied to the clinical management of subclinical hyperthyroidism.
- Subclinical hyperthyroidism is encountered on a daily basis in clinical practice.
- When evaluating patients with a suppressed serum thyroid stimulating hormone (TSH) value, it is important to exclude other potential etiologies such as overt T3-toxicosis, drug effect, nonthyroidal illness, and central hypothyroidism.
- In younger patients with mild TSH suppression, it is acceptable to repeat testing in 3-6 months to assess for persistence before performing further diagnostic testing.
- In older patients or those with TSH values less than 0.1 mU/L, diagnostic testing should proceed without delay.
- Persistence of TSH suppression is more typical of nodular thyroid autonomy, whereas thyroiditis and mild Graves' disease frequently resolve spontaneously.
- The clinical consequences of subclinical hyperthyroidism such as atrial dysrhythmia, accelerated bone loss, increased fracture rate, and higher rates of cardiovascular mortality are age and severity dependent.
- The decision to treat subclinical hyperthyroidism is directly tied to an assessment of the potential for clinical consequences in untreated disease.
- Definitive therapy is generally selected for patients with nodular autonomous function whereas antithyroid drug therapy is more appropriate for mild persistent Graves' disease.