Sometimes a simple little pill make the difference between happily buzzing around in life and dreary, miserable exhaustion. I wish more doctors understood that you have to treat a patient, not a number, no matter what the high tech lab test shows. This article is well-written….
http://www.nytimes.com/2005/11/08/health/08hypo.htmlNovember 8, 2005
FOR THYROID HORMONES, HOW LOW IS TOO LOW?
By KATE MURPHY
As an author of several books about thyroid disease who also moderates a Web site on the topic, Mary J. Shomon gets more than 1,000 e-mail messages a week.
“I hear from people all the time who are fighting to be treated,” said Ms. Shomon, a patient advocate. Most of the postings on her online message board at thyroid.about.com (presented by a division of The New York Times Company) are from women who report weight gain, fatigue, memory problems and depression. Many say they have thinning hair, dry skin and cold hands and feet. These are classic signs of an underactive thyroid, or hypothyroidism. But the patients say their doctors will not prescribe medicine because their blood tests are normal.
But just what is “normal” is “an incredibly controversial question,” said Dr. David Cooper, director of the endocrinology division at Sinai Hospital in Baltimore and a professor at Johns Hopkins School of Medicine.
For two years, endocrinologists have been arguing about where to set the bar for the diagnosis and treatment of a failing thyroid, the gland in the neck responsible for secreting metabolism-regulating hormones. Some say a single, mildly elevated blood test is enough to start drug therapy; others advocate for more compelling evidence.
Hypothyroidism, characterized by slowing mental and physical performance and other symptoms, is the most common thyroid disorder in the United States, affecting an estimated 13 million people.
The controversy began when the American Thyroid Association, the American Association of Clinical Endocrinologists and the Endocrine Society convened a panel of experts to evaluate existing research and create practice guidelines. They published their findings in The Journal of the American Medical Association in January 2004.
“It provoked a huge ruckus,” said Dr. Martin Surks, chairman of the panel and director of endocrinology training at Montefiore Medical Center and Albert Einstein College of Medicine in the Bronx.
The group found no compelling evidence to treat patients, even those with symptoms, who have subclinical hypothyroidism, defined primarily as having slightly elevated (4.5 to 10 milliunits per liter) blood levels of thyroid stimulating hormone.
Produced in the pituitary gland, the hormone, T.S.H., is thought to be the most sensitive and reliable barometer of thyroid function, rising when the gland is failing. Most testing laboratories consider T.S.H. levels to be normal when they are between 0.4 milliunits per liter and 4.5 milliunits per liter.
Dr. Surks’s team advised against populationwide screening, while recommending that doctors be alert to the symptoms in high-risk groups like women over 60 and Type I diabetes patients. “We didn’t say never treat people with subclinical hypothyroidism,” Dr. Surks said. “It’s just that you shouldn’t always reach for the prescription pad when you see elevated T.S.H.”
The medical groups that sponsored the review panel strenuously disagreed and published a rebuttal in the January 2005 Journal of Clinical Endocrinology & Metabolism.
Referring to Dr. Surks and his colleagues, Dr. Hossein Gharib, an endocrinologist at the Mayo Clinic and the lead author of the critique, said, “They say there’s no evidence that treatment is helpful, and we argue that there is no evidence that says it’s not helpful.”
The usual treatment for hypothyroidism is hormone replacement therapy. The most widely prescribed drug is levothyroxine, sold as a generic or under brands like Synthroid, Levoxyl and Unithroid.
Dr. Gharib concedes that there is no rigorous scientific evidence to support treating patients with subclinical hypothyroidism. But, he said, “What I’ve found in my personal practice is that it alleviates symptoms even if it’s just placebo effect.”
Dr. Gharib is a director of the American Association of Clinical Endocrinologists which, like the American Thyroid Association and the Endocrine Society, accepts substantial financing from companies that make levothyroxine, like Abbott Laboratories and King Pharmaceuticals.
Doctors also disagree about whether to lower the “normal” upper limit for T.S.H. from 4.5 milliunits per liter to 2.5 milliunits per liter, and opposing articles on the issue appeared in Clinical Endocrinology & Metabolism in September.
Dr. Surks was the lead dissenting author. “There is no evidence to suggest adverse health consequences for patients with a T.S.H. below 10, so why would you decrease the upper limit to 2.5?” he said.
The authors of the article that advocated the change, including Dr. Leonard Wartofsky, president-elect of the Endocrine Society, wrote that the patients who were studied to come up with the current T.S.H. reference range included people with varying degrees of undiagnosed thyroid dysfunction.
“My good friend Marty Surks is not impressed and doesn’t think you should treat patients with a T.S.H. between 5 and 10, but there’s mounting evidence that over 2.5 is abnormal,” said Dr. Wartofsky, an endocrinologist and professor at Georgetown School of Medicine.
For example, he said, a study by the National Academy of Clinical Biochemistry found that 95 percent of Americans have a T.S.H. of less than 2.5 milliunits per liter. The academy also accepts financing from manufacturers of levothyroxine.
Dr. Surks, who does not personally accept compensation or grants from drug makers, notes that all professional societies take pharmaceutical industry money, “but I’d like to think that that doesn’t cloud anyone’s judgment.”
The three societies say that they accept only unrestricted grants from drug companies and that there has been no undue influence.
A study published in The Journal of the American Medical Association estimated that lowering the T.S.H. reference range would probably increase the percentage of the population whose condition was diagnosed as hypothyroidism to 20 percent from 5 percent. Synthroid, by Abbott, is the second most widely prescribed drug in the United States (behind Lipitor, for high cholesterol) with annual sales of more than $873 million, according to Drug Topics, an online publication for pharmacists.
Advocates like Ms. Shomon, whose hypothyroidism was diagnosed in 1995, dispute the premise of a normal level. “What’s normal for me may not be normal for you,” she said. “We’re patients, not lab values.”
In fact, some small-scale studies indicate that the normal range for T.S.H. may differ from person to person. “We could all have a different thermostat,” said Dr. Philip Orlander, director of endocrinology and metabolism at the University of Texas Health Science Center at Houston.
Complicating matters is that T.S.H. levels fluctuate according to season, health status, time of day and activity level. Several studies indicate that 20 percent to 30 percent of those with mildly elevated T.S.H. revert to normal within months.
Many alternative medicine practitioners argue that T.S.H. readings are inaccurate. They advocate monitoring armpit temperature. Consistently low temperature suggests hypothyroidism.
Others, like Dr. Steven F. Hotze, who has appeared on television talk programs promoting his book “Hormones, Health and Happiness,” rely solely on symptoms. “You can have a normal blood test and not feel normal,” Dr. Hotze said. “I listen to the patient, and if she tells me she has cold hands and feet, brain fog and lethargy, I put her on a therapeutic trial of thyroid hormone.”
Dr. Hotze, of Houston, says he sees more than 2,000 new patients a year. Most are women who cannot persuade doctors to treat them based on their symptoms alone.
Endocrinologists like Dr. Surks, Dr. Cooper and Dr. Orlander said they required blood tests beyond T.S.H. screening before prescribing hormones. Symptoms like weight gain and lethargy are often too vague for a diagnosis, they said. And needlessly taking thyroid hormones can lead to cardiac dysfunction and osteoporosis.
“I see patients all the time who are miserable and unhappy and want to blame something,” Dr. Cooper said. “There are tears and anger when you tell them that it’s not their thyroid that’s causing their problems.”
Copyright 2005 The New York Times Company
