Successful Withdrawal of Thyroid Hormone Therapy
Successful Withdrawal of Thyroid Hormone Therapy
Background: Studies of community-dwelling patients have indicated that substantial numbers of patients might have had thyroid hormone therapy prescribed inappropriately and that thyroid hormone therapy in some can be discontinued without adverse effects or evidence of clinical hypothyroidism. We wanted to find out whether thyroid hormone therapy in selected nursing home patients could be withdrawn without adverse effect.
Methods: Participants for the study were drawn from four skilled nursing facilities in Connecticut. All patients on thyroid hormone therapy who resided in one of the four facilities at the time the study began were eligible if they met the inclusion criteria and gave consent to participate in the study. We measured baseline thyrotropin (TSH) levels and reduced thyroid hormone therapy by approximately one-half if baseline TSH levels were 7 mU/L or less. If at a 1-month follow-up measurement a patient's TSH level was 7 mU/L or less, we discontinued thyroid hormone therapy. If TSH levels remained 7 mU/L or less at the next follow-up measurement 1 month later, we measured the free thyroxine (T4) level. If the free T4 level was normal, the patient remained off thyroid hormone therapy, and a final TSH value was measured after a further 2 months.
Results: There were 915 patients residing at the four homes at the time the study began. One hundred fifteen were on thyroid hormone therapy; 40 had elevated TSH levels in their nursing home records; and 31 refused to participate in the study. Twenty-two patients were excluded because they died or were discharged before completion of the study, had an elevated baseline TSH reading, or were taking medications that could complicate the accurate measurement of TSH. Twenty-two patients began hormone withdrawal. One patient had an increase in psychiatric symptoms during the withdrawal phase. No other adverse effects were noted. Eleven patients (50%) had the thyroid hormone therapy withdrawn successfully.
Conclusion: Thyroid hormone therapy was successfully withdrawn from one half of the nursing home residents studied. Previous studies conducted in community-dwelling patients have shown similar findings. Many older patients began taking thyroid hormone therapy when younger either for inappropriate reasons or for what turned out to be transient hypothyroidism. If the findings of this study are generalizable for other nursing home residents, there are important implications for health and health care costs.
The prevalence of hypothyroidism increases with age and is more common in older women than older men. Framingham data on community-dwelling patients showed a prevalence of 5.9% for women and 2.3% for men older than 60 years of age. Data from a community-dwelling population aged more than 60 years in Massachusetts showed a prevalence of 5.9%. Both studies used a thyrotropin (TSH) level of more than 10 mU/L to make the diagnosis. Data from Norway showed previously diagnosed hypothyroidism in 3.5% of women older than 70 years and in no men older than 70 years. Eleven percent of patients in a large state veterans' home had evidence of hypothyroidism. This finding might underestimate the prevalence of hypothyroidism in nursing homes because most residents at this home were men. Chronic autoimmune thyroiditis and previous treatment for hyperthyroidism are the most common causes of clinical hypothyroidism.
Previous studies of community-dwelling patients have indicated that many patients might have started thyroid hormone therapy inappropriately. Older patients might have begun therapy years ago when the laboratory evaluation of thyroid disorders was less accurate and when some physicians treated fatigue, weight gain, hair loss, and hypercholesterolemia with thyroid hormone therapy without laboratory evidence of hypothyroidism. Spontaneous resolution of transient hypothyroidism can occur. In several studies community-dwelling patients have had thyroid hormone therapy discontinued without adverse effect and without evidence of subsequent clinical hypothyroidism. Successful withdrawal of thyroid hormone therapy from nursing home patients has not previously been reported.
Background: Studies of community-dwelling patients have indicated that substantial numbers of patients might have had thyroid hormone therapy prescribed inappropriately and that thyroid hormone therapy in some can be discontinued without adverse effects or evidence of clinical hypothyroidism. We wanted to find out whether thyroid hormone therapy in selected nursing home patients could be withdrawn without adverse effect.
Methods: Participants for the study were drawn from four skilled nursing facilities in Connecticut. All patients on thyroid hormone therapy who resided in one of the four facilities at the time the study began were eligible if they met the inclusion criteria and gave consent to participate in the study. We measured baseline thyrotropin (TSH) levels and reduced thyroid hormone therapy by approximately one-half if baseline TSH levels were 7 mU/L or less. If at a 1-month follow-up measurement a patient's TSH level was 7 mU/L or less, we discontinued thyroid hormone therapy. If TSH levels remained 7 mU/L or less at the next follow-up measurement 1 month later, we measured the free thyroxine (T4) level. If the free T4 level was normal, the patient remained off thyroid hormone therapy, and a final TSH value was measured after a further 2 months.
Results: There were 915 patients residing at the four homes at the time the study began. One hundred fifteen were on thyroid hormone therapy; 40 had elevated TSH levels in their nursing home records; and 31 refused to participate in the study. Twenty-two patients were excluded because they died or were discharged before completion of the study, had an elevated baseline TSH reading, or were taking medications that could complicate the accurate measurement of TSH. Twenty-two patients began hormone withdrawal. One patient had an increase in psychiatric symptoms during the withdrawal phase. No other adverse effects were noted. Eleven patients (50%) had the thyroid hormone therapy withdrawn successfully.
Conclusion: Thyroid hormone therapy was successfully withdrawn from one half of the nursing home residents studied. Previous studies conducted in community-dwelling patients have shown similar findings. Many older patients began taking thyroid hormone therapy when younger either for inappropriate reasons or for what turned out to be transient hypothyroidism. If the findings of this study are generalizable for other nursing home residents, there are important implications for health and health care costs.
The prevalence of hypothyroidism increases with age and is more common in older women than older men. Framingham data on community-dwelling patients showed a prevalence of 5.9% for women and 2.3% for men older than 60 years of age. Data from a community-dwelling population aged more than 60 years in Massachusetts showed a prevalence of 5.9%. Both studies used a thyrotropin (TSH) level of more than 10 mU/L to make the diagnosis. Data from Norway showed previously diagnosed hypothyroidism in 3.5% of women older than 70 years and in no men older than 70 years. Eleven percent of patients in a large state veterans' home had evidence of hypothyroidism. This finding might underestimate the prevalence of hypothyroidism in nursing homes because most residents at this home were men. Chronic autoimmune thyroiditis and previous treatment for hyperthyroidism are the most common causes of clinical hypothyroidism.
Previous studies of community-dwelling patients have indicated that many patients might have started thyroid hormone therapy inappropriately. Older patients might have begun therapy years ago when the laboratory evaluation of thyroid disorders was less accurate and when some physicians treated fatigue, weight gain, hair loss, and hypercholesterolemia with thyroid hormone therapy without laboratory evidence of hypothyroidism. Spontaneous resolution of transient hypothyroidism can occur. In several studies community-dwelling patients have had thyroid hormone therapy discontinued without adverse effect and without evidence of subsequent clinical hypothyroidism. Successful withdrawal of thyroid hormone therapy from nursing home patients has not previously been reported.
