A 2013 Survey of Clinical Practice Patterns in the Management of Primary Hypothyroidism

• Published in: The journal of clinical endocrinology and metabolism 2014-06, Vol.99 (6), p.2077-2085
• Main Authors: Burch, Henry B, Burman, Kenneth D, Cooper, David S, Hennessey, James V
• Format: Article
• Language: English
• Subjects: Adult; Age Factors; Aged; Aged, 80 and over; Data Collection; Female; Guideline Adherence - statistics & numerical data; Humans; Hypothyroidism - epidemiology; Hypothyroidism - therapy; Male; Middle Aged; Practice Patterns, Physicians' - standards; Practice Patterns, Physicians' - statistics & numerical data; Pregnancy; Societies, Medical - standards; Surveys and Questionnaires; Young Adult
• ISSN: 0021-972X; 1945-7197
• DOI: 10.1210/jc.2014-1046

Context: In 2012, comprehensive clinical practice guidelines (CPGs) were published regarding the management of hypothyroidism. Objective: We sought to document current practices in the management of primary hypothyroidism and compare these results with recommendations made in the 2012 American Thyroid Association (ATA)/American Association of Clinical Endocrinologists (AACE) hypothyroidism CPGs. In addition, we sought to examine differences in management among international members of U.S.-based endocrine societies and to compare survey results with those obtained from a survey of ATA members performed 12 years earlier. Methods: Clinical members of The Endocrine Society (TES), the ATA, and the AACE were asked to take a web-based survey consisting of 30 questions dealing with testing, treatment, and modulating factors in the management of primary hypothyroidism. Results: In total, 880 respondents completed the survey, including 618 members of TES, 582 AACE members, and 208 ATA members. North American respondents accounted for 67.6%, Latin American 9.7%, European 9.2%, Asia and Oceania 8.1%, and Africa and Middle East 5.5%. Overt hypothyroidism would be treated using l-T4 alone by 99.2% of respondents; 0.8% would use combination l-T4 and liothyronine (l-T3) therapy. Generic l-T4 would be used by 49.3% and a brand name by 49.9%. The rate of replacement would be gradual (38.5%); an empiric dose, adjusted to achieve target (33.6%); or a calculated full replacement dose (27.8%). A target TSH of 1.0 to 1.9 mU/L was favored in the index case, but 3.0 to 3.9 mU/L was the most commonly selected TSH target for an octogenarian. Persistent hypothyroid symptoms despite achieving a target TSH would prompt testing for other causes by 84.3% of respondents, a referral to primary care by 11.3%, and a change to l-T4 plus l-T3 therapy by 3.6%. Evaluation of persistent symptoms would include measurement of T3 levels by 21.9% of respondents. Subclinical disease with a TSH 5.0 to 10.0 mU/L would be treated without further justification by 21.3% of respondents, or in the presence of positive thyroid peroxidase antibodies (62.3%), hypothyroid symptoms (60.9%), high low-density lipoprotein (52.9%), or goiter (46.6%). The TSH target for a newly pregnant patient was