The effect of thyroid hormone therapy on muscle function, strength and mass in older adults with subclinical hypothyroidism-an ancillary study within two randomized placebo controlled trials.

BACKGROUND: loss of skeletal muscle function, strength and mass is common in older adults, with important socioeconomic impacts. Subclinical hypothyroidism is common with increasing age and has been associated with reduced muscle strength. Yet, no randomized placebo-controlled trial (RCT) has investigated whether treatment of subclinical hypothyroidism affects muscle function and mass. METHODS: this is an ancillary study within two RCTs conducted among adults aged ≥65 years with persistent subclinical hypothyroidism (thyrotropin (TSH) 4.60-19.99 mIU/l, normal free thyroxine). Participants received daily levothyroxine with TSH-guided dose adjustment or placebo and mock titration. Primary outcome was gait speed at final visit (median 18 months). Secondary outcomes were handgrip strength at 1-year follow-up and yearly change in muscle mass. RESULTS: we included 267 participants from Switzerland and the Netherlands. Mean age was 77.5 years (range 65.1-97.1), 129 (48.3%) were women, and their mean baseline TSH was 6.36 mIU/l (standard deviation [SD] 1.9). At final visit, mean TSH was 3.8 mIU/l (SD 2.3) in the levothyroxine group and 5.1 mIU/l (SD 1.8, P < 0.05) in the placebo group. Compared to placebo, participants in the levothyroxine group had similar gait speed at final visit (adjusted between-group mean difference [MD] 0.01 m/s, 95% confidence interval [CI] -0.06 to 0.09), similar handgrip strength at one year (MD -1.22 kg, 95% CI -2.60 to 0.15) and similar yearly change in muscle mass (MD -0.15 m2, 95% CI -0.49 to 0.18). CONCLUSIONS: in this ancillary analysis of two RCTs, treatment of subclinical hypothyroidism did not affect muscle function, strength and mass in individuals 65 years and older.

[Quality of life assessment as a gateway to the patient's individuality]. / Évaluation de la qualité de vie comme ouverture sur l'individualité du patient.

In the context of increasing life expectancy and complex medical situations, quality of life assessment can be a gateway to the patient's individuality and support medical decision making. There are different qualitative and quantitative assessment tools, ranging from a simple question that starts the discussion to standardized questionnaires. It is necessary to distinguish quality of life assessment in its economic, research and quality of care improvement perspective, from its evaluation within the doctor-patient relationship. Questionnaires such as Patient-Reported Outcome Measures (PROMs) could be interesting in daily clinical practice to improve communication and consultation efficiency, but their routine implementation still remains a challenge.

Dans le contexte de l'augmentation de l'espérance de vie et de situations médicales complexes, l'évaluation de la qualité de vie permet de s'ouvrir à l'individualité du patient et soutient la décision médicale. Il existe différents outils qualitatifs et quantitatifs pour l'évaluer allant d'une simple question qui ouvre le dialogue à des questionnaires standardisés. Il convient de dissocier l'évaluation de la qualité de vie dans sa perspective économique, de recherche et d'amélioration de la qualité des soins, de son évaluation au sein de la relation médecin-malade. Les questionnaires de type Patient-Reported Outcome Measures (PROMs) pourraient s'avérer intéressants dans la pratique quotidienne pour améliorer la communication et l'efficience d'une consultation, mais leur mode d'implémentation en routine reste un défi.

Prevalence and factors associated with chronic use of levothyroxine: A cohort study.

IMPORTANCE: Levothyroxine prescriptions are rising worldwide. However, there are few data on factors associated with chronic use. OBJECTIVE: To assess the prevalence of chronic levothyroxine use, its rank among other chronic drugs and factors associated with chronic use. To assess the proportion of users outside the therapeutic range of thyroid-stimulating hormone (TSH). DESIGN: Cohort study (CoLaus|PsyCoLaus) with recruitment from 2003 to 2006. Follow-ups occurred 5 and 10 years after baseline. PARTICIPANTS: A random sample of Lausanne (Switzerland) inhabitants aged 35-75 years. MAIN OUTCOMES: We evaluated the prevalence of chronic levothyroxine use and we then ranked it among the other most used chronic drugs. The ranking was compared to data from health insurance across the country. We assessed the association between each factor and chronic levothyroxine use in multivariable logistic regression models. The proportion of chronic levothyroxine users outside the usual TSH therapeutic range was assessed. RESULTS: 4,334 participants were included in the analysis (mean±SD age 62.8±10.4 years, 54.9% women). 166 (3.8%) participants were chronic levothyroxine users. Levothyroxine was the second most prescribed chronic drug after aspirin in the cohort (8.2%) and the third most prescribed when using Swiss-wide insurance data. In multivariable analysis, chronic levothyroxine use was associated with increasing age [odds ratio 1.03, 95% confidence interval 1.01-1.05 per 1-year increase]; female sex [11.87 (5.24-26.89)]; BMI [1.06 (1.02-1.09) per 1-kg/m2 increase]; number of concomitant drugs [1.22 (1.16-1.29) per 1-drug increase]; and family history of thyroid pathologies [2.18 (1.37-3.48)]. Among chronic levothyroxine users with thyroid hormones assessment (n = 157), 42 (27%) were outside the TSH therapeutic range (17% overtreated and 10% undertreated). CONCLUSIONS: In this population-based study, levothyroxine ranked second among chronic drugs. Age, female sex, BMI, number of drugs and family history of thyroid pathologies were associated with chronic levothyroxine use. More than one in four chronic users were over- or undertreated.

'I Don't Have a Crystal Ball' - Why Do Doctors Tend to Avoid Prognostication?

Uncertainty, fear to harm the patient, discomfort handling the discussion and lack of time are the most cited barriers to prognostic disclosure. Physicians can be reassured that patients desire the truth about prognosis and can manage the discussion without harm, including the uncertainty of the information, if approached in a sensitive manner. Conversational guides could provide support in preparing such difficult conversations. Communicating 'with realism and hope' is possible, and anxiety is normal for both patients and clinicians during prognostic disclosure. As a clinician pointed out: 'I had asked a mentor once if it ever got easier. - No. But you get better at it.'

[Treatment of subclinical hypothyroidism†: an update of the evidence and the new Rapid Recommendations]. / Traitement de l'­hypothyroïdie ­infraclinique†: mise à jour des ­connaissances et nouvelles «â€ Rapid ­Recommendations†¼ dans le BMJ.

Subclinical hypothyroidism is frequent and its treatment by thyroid hormones is debated. Current guidelines tend to recommend a treatment for symptomatic adults or for thyrotropin (TSH) levels > 10 mIU/l. Nevertheless, new evidence from systematic review, -including 21 trials and 2192 participants, demonstrated that thyroid hormone replacement has no clinically relevant benefit on patients' symptoms or prognosis. An international and independent panel -including physicians, methodologists and patients issues a strong recommendation (BMJ Rapid Recommendation) against thyroid hormones therapy for adults with subclinical hypothyroidism. This recommendation does not apply to women who are pregnant or trying to conceive or to patients with TSH > 20 mIU/l.

L'hypothyroïdie infraclinique est une entité fréquente et les bénéfices d'un traitement de substitution hormonal sont peu clairs. Les diverses guidelines recommandent actuellement de traiter les adultes symptomatiques ou avec des niveaux de thyrotropine (TSH) > 10 mUI/l. Les études observationnelles montrent en effet une association entre le taux de TSH et le risque cardiovasculaire. Cependant, selon les nouvelles données (large étude randomisée, revue systématique incluant 21 études), le traitement de l'hypothyroïdie infraclinique chez l'adulte n'a pas démontré de bénéfice symptomatique ni pronostique. Un panel d'experts internationaux indépendants, incluant médecins, épidémiologistes et patients, s'est donc prononcé en défaveur d'un traitement hormonal de ­l'hypothyroïdie infraclinique chez l'adulte. Cette recommandation ne s'applique pas aux femmes enceintes ou essayant de concevoir, ainsi qu'aux patients avec des niveaux de TSH > 20 mUI/l.

[Prognostication : prophecy or medical practice ?] / Pronostic : prophétie ou bonne pratique médicale ?

The issue of prognostication is seldom approached in medical education, even though it represents an important question for the patients. Clinical assessment alone is inaccurate and systematically over-optimistic, especially if the question is formulated in temporal terms (how long will the patient live ?). The inaccuracy augments if the doctor has known the patient for a long time. However, other ways of addressing the question exist, and several validated clinical tools are available to improve the accuracy of the prognosis. The patients' self-rating and the evaluation by the nursing staff should also be considered as valuable information.

L'aspect pronostique est souvent peu thématisé dans la formation mais reste une question fréquente de la part des patients. L'évaluation clinique seule, surtout si approchée avec une question temporelle (combien de temps le patient va-t-il encore vivre ?) est très peu précise et systématiquement optimiste, surtout de la part des médecins qui connaissent bien le patient. Il existe cependant d'autres manières d'aborder la question ainsi que des outils cliniques validés permettant d'étayer une impression clinique. Le ressenti du patient lui-même ainsi que l'évaluation de la part des soignants sont également des éléments à considérer.