Hypothyroidism, a deficiency of thyroid hormone usually caused by primary thyroid
failure, is a common clinical problem. Levothyroxine therapy (LT4) is demonstrated
to improve signs, symptoms, and biochemical abnormalities and improve life.[[1]] However, a recent online survey published by the American Thyroid Association (ATA)
illustrates that 10%–15% of hypothyroid patients are not satisfied with their therapy,
and the challenge facing practicing physicians is to investigate alternative methods
of replacing thyroid hormone deficiency.[[2]]
Almost a decade ago, the American Association of Clinical Endocrinologists, in collaboration
with the ATA, published clinical practice guidelines and recommendations for diagnosing
and treating adults with hypothyroidism.[[3]] This was followed by a brief, updated, and very practical version from the Italian
Association of Clinical Endocrinologists published in 2016.[[4]] Unfortunately, it is not clear how widely these guidelines are accepted and their
impact on practice patterns by endocrinologists.
A 2013 survey of clinical endocrinologists cataloged treatment patterns in hypothyroidism
reported the following: universal preference for LT4 therapy; use of age-specific
therapeutic thyroid stimulating hormone (TSH) targets; a highly variable approach
to LT4 replacement; and exceptional attention to TSH targets in pregnant women.[[5]] It seems clear that there is much debate about strategies for thyroid hormone replacement
in hypothyroidism.
In this issue of the Journal, Beshyah et al. report on results of an online survey
of practice patterns in the management of hypothyroidism by physicians in the Middle
East and North Africa.[[6]] They show that overt hypothyroidism would be treated with LT4 alone by 97.2% of
respondents, and only 1.7% would consider combination T4 plus T3 therapy. The rate
of replacement would be gradual in most cases (66.5%); a target TSH of 2.0–2.9 mU/L
and 3.0–3.9 was preferred in 34.4% and 26%, respectively. Persistent hypothyroid symptoms
after LT4 therapy when target TSH is achieved would prompt 86.9% of respondents to
further investigate, with only 5.8% selecting combination T4 plus T3 therapy. Respondents
(45%) to the current survey preferred to keep TSH values below 2.4 mU/L in first-trimester
pregnancy, with thyroid tests repeated at 4-week intervals by most. The authors note
that the survey revealed a high preference for LT4 therapy, a low preference for treating
subclinical hypothyroidism; attention to TSH levels in pregnant and prepregnant women;
and a highly variable approach to thyroid therapy for hypothyroidism.
These authors are to be congratulated for outlining thyroid practice patterns in the
Gulf area and North Africa. Results show similar trends as that were found by researchers
in North America.[[5]] Nevertheless, a larger number of respondents would have increased the strength
and conclusions of this survey. It also shows that endocrinologists everywhere are
applying new guidelines to their practice. Further research into this area would help
endocrine patients and endocrinologists who face dilemmas in their daily practice.
Authors contribution
Single author.
Compliance with ethical principles
Ethical approval is not required for commentaries and editorials.
Data availability
Not applicable.
