Thyroid hormones treatment for subclinical hypothyroidism: a clinical practice guidelineBMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l2006 (Published 14 May 2019) Cite this as: BMJ 2019;365:l2006
Visual summary of recommendation
©BMJ Publishing Group Limited.
Disclaimer: This infographic is not a validated clinical decision aid. This information is provided without any representations, conditions or warranties that it is accurate or up to date. BMJ and its licensors assume no responsibility for any aspect of treatment administered with the aid of this information. Any reliance placed on this information is strictly at the user's own risk. For the full disclaimer wording see BMJ's terms and conditions: https://www.bmj.com/company/legal-information/
- G E Bekkering, guideline expert, methodologist1 2,
- T Agoritsas, doctor in general internal medicine, expert in shared decision making research3 4,
- L Lytvyn, patient partnership expert, methodologist4,
- A F Heen, general internist5,
- M Feller, general practitioner6 7,
- E Moutzouri, doctor in general internal medicine6 7,
- H Abdulazeem, patient partner8,
- B Aertgeerts, general practitioner1 2,
- D Beecher, patient partner9,
- J P Brito, endocrinologist10,
- P D Farhoumand, doctor in general internal medicine11,
- N Singh Ospina, endocrinologist12,
- N Rodondi, doctor in general internal medicine6 7,
- M van Driel, general practitioner13,
- E Wallace, general practitioner14,
- M Snel, endocrinologist15,
- P M Okwen, general practitioner16,
- R Siemieniuk, doctor in general internal medicine17,
- P O Vandvik, doctor in general internal medicine18 19 20,
- T Kuijpers, guideline expert, methodologist21,
- M Vermandere, general practitioner1
- 1Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Belgium
- 2Belgian Centre for Evidence-Based Medicine, Cochrane Belgium
- 3Division of General Internal Medicine and Division of Clinical Epidemiology, University
- Hospitals of Geneva, Geneva, Switzerland
- 4Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
- 5Department of Medicine, Innlandet Hospital Trust-division, Gjøvik, Norway
- 6Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- 7Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- 8Munich, Germany
- 9Milan, Italy
- 10Knowledge and Evaluation Research Unit in Endocrinology (KER_Endo), Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
- 11Division General Internal Medicine, University Hospitals of Geneva, 1205 Geneva, Switzerland
- 12Department of Medicine, Division of Endocrinology, University of Florida, Gainesville, Florida, USA
- 13Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane Qld 4029, Australia
- 14HRB Centre for Primary Care Research and Department of General Practice, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
- 15Department of Endocrinology/General Internal Medicine, Leiden University Medical Center, Leiden, Netherlands
- 16Effective Basic Services (eBASE), Bamenda, Cameroon
- 17Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- 18Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
- 19Department of Medicine, Innlandet Hospital Trust-division, Gjøvik, Norway
- 20Norwegian Institute of Public Health, Oslo, Norway
- 21Dutch College of General Practitioners, Utrecht, Netherlands
- Correspondence to: G E Bekkering
Clinical question What are the benefits and harms of thyroid hormones for adults with subclinical hypothyroidism (SCH)? This guideline was triggered by a recent systematic review of randomised controlled trials, which could alter practice.
Current practice Current guidelines tend to recommend thyroid hormones for adults with thyroid stimulating hormone (TSH) levels >10 mIU/L and for people with lower TSH values who are young, symptomatic, or have specific indications for prescribing.
Recommendation The guideline panel issues a strong recommendation against thyroid hormones in adults with SCH (elevated TSH levels and normal free T4 (thyroxine) levels). It does not apply to women who are trying to become pregnant or patients with TSH >20 mIU/L. It may not apply to patients with severe symptoms or young adults (such as those ≤30 years old).
How this guideline was created A guideline panel including patients, clinicians, and methodologists produced this recommendation in adherence with standards for trustworthy guidelines using the GRADE approach.
The evidence The systematic review included 21 trials with 2192 participants. For adults with SCH, thyroid hormones consistently demonstrate no clinically relevant benefits for quality of life or thyroid related symptoms, including depressive symptoms, fatigue, and body mass index (moderate to high quality evidence). Thyroid hormones may have little or no effect on cardiovascular events or mortality (low quality evidence), but harms were measured in only one trial with few events at two years’ follow-up.
Understanding the recommendation The panel concluded that almost all adults with SCH would not benefit from treatment with thyroid hormones. Other factors in the strong recommendation include the burden of lifelong management and uncertainty on potential harms. Instead, clinicians should monitor the progression or resolution of the thyroid dysfunction in these adults. Recommendations are made actionable for clinicians and their patients through visual overviews. These provide the relative and absolute benefits and harms of thyroid hormones in multilayered evidence summaries and decision aids available in MAGIC (https://app.magicapp.org/) to support shared decisions and adaptation of this guideline.
This BMJ Rapid Recommendation article is one of a series that provides clinicians with trustworthy recommendations for potentially practice changing evidence. BMJ Rapid Recommendations represent a collaborative effort between the MAGIC group (http://magicproject.org/) and The BMJ. A summary is offered here, and the full version including decision aids is on the MAGICapp (https://app.magicapp.org/public/guideline/nyqWPn), for all devices in multilayered formats. Those reading and using these recommendations should consider individual patient circumstances, and their values and preferences and may want to use consultation decision aids in MAGICapp to facilitate shared decision making with patients. There will no active dissemination of these results to patients. We encourage adaptation and contextualization of our recommendations to local or other contexts. Those considering use or adaptation of content may go to MAGICapp to link or extract its content or contact The BMJ for permission to reuse content in this article.
Competing interests: All authors have completed the BMJ Rapid Recommendations interests disclosure form and a detailed, contextualised description of all disclosures is reported in appendix 2 on bmj.com. As with all BMJ Rapid Recommendations, the executive team and The BMJ judged that no panel member had any relevant financial conflict of interest. Professional and academic interests are minimised as much as possible, while maintaining necessary expertise on the panel to make fully informed decisions. M Feller, M Snel, E Moutzouri, and N Rodondi participated in writing the systematic review that formed the evidence base for this guideline. JP Brito and N Singh Ospina wrote an editorial about the overuse of levothyroxine.
Funding: This guideline was not funded.
Transparency: G E Bekkering affirms that the manuscript is an honest, accurate, and transparent account of the recommendation being reported; that no important aspects of the recommendation have been omitted; and that any discrepancies from the recommendation as planned (and, if relevant, registered) have been explained.