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,但可能会严重影响健康,导致反复的医疗咨询。甲状腺激素替代疗法(THRT)对SCH患者的影响尚不确定。目前的指导方针,由于缺乏高质量的证据,在临床实践中依从性有限一直存在争议。
三轮改良Delphi方法,就患有或不患有情感障碍或焦虑的SCH患者的诊断和治疗达成共识。与来自三个专业的临床医生一起进行,一般实践,内分泌学和精神病学,还有两个国家,瑞典和英国。
60位临床医生,每个专业20个,被招募。53名(88%)参与者完成了所有三轮比赛。参与者就26项实践声明中的5项达成共识,即(a)亚临床甲状腺功能减退症的诊断需要重复测试,(b)通常应进行抗体筛查,(c和d)抗体筛查将加强有或没有情感障碍或焦虑的个体的甲状腺激素替代疗法的指征。参与者不同意(e)甲状腺激素替代疗法开始的TSH阈值≥20mIU/L的要求。精神科医生和全科医生,但不是内分泌学家,同意实验室结果和临床症状之间经常存在差异,并不同意甲状腺功能障碍检测在患有抑郁或焦虑的患者中被过度使用,或疲劳。
在很多方面,对SCH的诊断和治疗的态度仍然不同。我们的Delphi小组无法就大多数项目达成共识,并且对TSH≥20mIU/L阈值的治疗存在分歧,这表明SCH的概念可能需要重新考虑,并更好地了解下丘脑-垂体-甲状腺生理学。鉴于科学证据目前尚无定论,这方面的指导方针不应被视为决定性的。
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.