American Thyroid Association guidelines for detection of thyroid dysfunction.

OBJECTIVE: To define the optimal approach to identify patients with thyroid dysfunction. PARTICIPANTS: The 8-member Standards of Care Committee of the American Thyroid Association prepared a draft, which was reviewed by the association's 780 members, 50 of whom responded with suggested revisions. EVIDENCE: Relevant published studies were identified through MEDLINE and the association membership's personal resources. CONSENSUS PROCESS: Consensus was reached at group meetings. The first draft was prepared by a single author (P.W.L.) after group discussion. Suggested revisions were incorporated after consideration by the committee. CONCLUSIONS: The American Thyroid Association recommends that adults be screened for thyroid dysfunction by measurement of the serum thyrotropin concentration, beginning at age 35 years and every 5 years thereafter. The indication for screening is particularly compelling in women, but it can also be justified in men as a relatively cost-effective measure in the context of the periodic health examination. Individuals with symptoms and signs potentially attributable to thyroid dysfunction and those with risk factors for its development may require more frequent serum thyrotropin testing.

Treatment of Graves' disease: the American way.

The treatment of patients with Graves' disease involves a physician making a clinical decision between one of the three modalities available for treatment, administering the treatment and following the patients. There appears to be a difference in treatment bias for treating the 'average' patient with Graves' disease, with American physicians preferring radioactive iodine while their European and Japanese cohorts prefer long-term anti-thyroid drugs. There are no facts to support this bias. The treating physician usually makes the decision based on his or her preference. In addition, American physicians are under pressure to prescribe the most cost-effective therapy, leading to an even stronger bias towards radioactive iodine.

Treatment guidelines for patients with thyroid nodules and well-differentiated thyroid cancer. American Thyroid Association.

A set of minimum clinical guidelines for use by primary care physicians in the evaluation and management of patients with thyroid nodules or thyroid cancer was developed by consensus by an 11-member Standards of Care Committee (the authors of the article) of the American Thyroid Association, New York, NY. The participants were selected by the committee chairman and by the president of the American Thyroid Association based on their clinical experience. The committee members represented different geographic areas within the United States, to reflect different practice patterns. The guidelines were developed based on the expert opinion of the committee participants, as well as on previously published information. Each committee participant was initially assigned to write a section of the document and to submit it to the committee chairman, who revised and assembled the sections into a complete draft document, which was then circulated among all committee members for further revision. Several of the committee members further revised and refined the document, which was then submitted to the entire membership of the American Thyroid Association for written comments and suggestions, many of which were incorporated into a final draft document, which was reviewed and approved by the Executive Council of the American Thyroid Association.

Treatment guidelines for patients with hyperthyroidism and hypothyroidism. Standards of Care Committee, American Thyroid Association.

OBJECTIVE: To develop a set of minimum clinical guidelines for use by primary care physicians in the evaluation and management of patients with hyperthyroidism and hypothyroidism. PARTICIPANTS: Guidelines were developed by a nine-member ad hoc Standards of Care Committee of the American Thyroid Association (the authors of this article). The participants were selected by the committee chair and the president of the American Thyroid Association on the basis of their clinical experience. The committee members represented different geographic areas within the United States, in order to take into account different practice styles. EVIDENCE: Guidelines were developed on the basis of expert opinion of the participants, as well as on available published information. CONSENSUS PROCESS: Input was obtained from all of the participants, each of whom wrote an initial section of the document. A complete draft document was then written by three participants (P.A.S., D.S.C., and E.G.L.) and resubmitted to the entire committee for revision. The revised document was then submitted to the entire membership of the American Thyroid Association for written comments, which were then reviewed (mainly by P.A.S., D.S.C., and E.G.L.). Many of the suggestions of the American Thyroid Association members were incorporated into the final draft, which was then approved by the Executive Council of the American Thyroid Association. The entire process, from initial drafts to final approval, took approximately 18 months. CONCLUSIONS: A set of minimum clinical guidelines for the diagnosis and treatment of hyperthyroidism and hypothyroidism were developed by consensus of a group of experienced thyroidologists. The guidelines are intended to be used by physicians in their care of patients with thyroid disorders, with the expectation that more effective care can be provided, and at a cost savings.

Thyroid disease in the elderly.

As people in our society live longer, it is important for clinicians to know more about problems commonly seen in the elderly. Thyroid problems are especially important to understand because they do occur with rather high frequency, and their mode of presentation is frequently different from those seen in younger patients. The thyroid gland does undergo certain age-related changes in anatomy and physiology, but overall the thyroid is able to produce a normal amount of thyroid hormone throughout the years. Hypothyroidism is frequently difficult to diagnose in the elderly, because many of the symptoms of hypothyroidism can easily be confused with symptoms of aging. When hypothyroidism is looked for in large population studies of elderly patients, the incidence varies from 1% to as high as 17%, with women being more commonly affected than men, and subclinical hypothyroidism being more common than overt hypothyroidism. Virtually all cases of hypothyroidism are due to autoimmune thyroid disease, with most patients having measurable titers of thyroid autoantibodies. The therapy of hypothyroidism is done with extreme caution, as older patients are frequently very sensitive to the effects of excess thyroid hormone. In addition, the metabolism of thyroid hormone slows down with age, making the full replacement dose much less in an older patient than in a younger one. Hyperthyroidism is also quite common, occurring in from 0.5% to 3% of all elderly patients. The presentation is frequently atypical, as patients often lack the hyperdynamic symptomatology and instead have a more sedated, apathetic presentation. Weight loss and cardiac symptoms frequently predominate, and the presence of a goiter is frequently absent, making the diagnosis less obvious than in a younger patient. Therapy is usually radioactive iodine, after an adequate course of antithyroid drugs, to render the patient euthyroid. Thyroid nodules do occur with increasing frequency in the elderly, but most of them are not malignant. Fine-needle aspiration for cytology is very helpful in determining which patients should be referred for surgery. Well-differentiated cancers do predominate, but their course is frequently less predictable than in younger patients. Lymphoma of the thyroid and undifferentiated cancers do occur with increasing frequency in the elderly. Multinodular goiter, usually of longstanding, is frequently seen in elderly patients, and thyroid hormone suppressive therapy not only is not indicated but may contribute to exogenous hyperthyroidism.

Graves' disease in a patient with thyroid hemiagenesis.

A case is presented of Graves' disease occurring in a patient with hemiagenesis of the thyroid gland. The diagnosis was suspected clinically and was confirmed by laboratory tests and imaging studies, as well as by the presence of thyroid-stimulating antibody.