Diseases | Chief physician: Medicines for hypothyroidism may have been prescribed for no reason – “Some of the cases would correct themselves”

Thyroid gland impairment has been diagnosed and treated in Finland on varying grounds, but the Käypä hoito recommendation published at the end of last year has been hoped to unify treatment. Previously, there was no specific recommendation for hypothyroidism.

Chief physician of the endocrinology outpatient clinic at Tampere University Hospital (Tays), who chaired the Käypä hoito recommendation working group Saara Metso estimates that the treatment recommendation is likely to correct the problems related to the diagnosis and treatment of the disease.

The available treatment recommendations are prepared by the Finnish Medical Association Duodecim and specialist medical associations, and they are made for doctors, for example, as a basis for treatment decisions.

“Both the Thyroid Association and the treating body tried for a long time to get their own Käypä hoito recommendation for hypothyroidism, but the disease was considered simple and easy to treat. Then it was noticed that the diagnostic criteria were not uniform, but varied all over Finland, and the number of patients taking thyroid medication even doubled in 15 years.”

Thyroid Association based on member surveys, patients have received unequal treatment in Finland. A similar case that meets the diagnostic criteria may have been diagnosed somewhere and left undiagnosed elsewhere. According to Metso, the different practices and the varying level of expertise of general practitioners can be explained by the fact that hypothyroidism is covered more quickly in medical studies compared to many other diseases.

Metso estimates that some of the medications prescribed for hypothyroidism in Finland may be unnecessary. An estimated 85 percent of patients take a thyroid hormone preparation for mild or incipient thyroid insufficiency, and the medication may have been prescribed based on one slightly abnormal laboratory test.

“In reality, some of these cases would correct themselves over time, that is, before prescribing medication, a three-month follow-up should be carried out,” says Metso.

Thyroid gland medications have also been prescribed for dysfunction based solely on the symptoms appropriate to the disease, says the chairman of the Finnish Endocrinology Association and a specialist in endocrinology at Kuopio University Hospital (Kys) Reeta Rintamäki.

The new Käypä hoito recommendation underlines that there is no such thing as hypothyroidism that does not show up in laboratory tests as an increase in the TSH hormone, which regulates thyroid function, above the reference range. Instead, the thyroid hormone T4-V itself can remain within the reference range despite the disease.

“Symptoms suitable for hypothyroidism – such as fatigue, coldness, constipation, dry skin and swelling – are very diverse and suitable for many other diseases, menopause or even a stressful life situation. Hypothyroidism is easily the first thing that comes to mind, and it is often used to explain the symptoms, even though more extensive research should really be done,” says Rintamäki.

Capercaillie points out that elevated TPO antibodies, which indicate autoimmune inflammation of the thyroid gland, do not indicate thyroid dysfunction, even with the appropriate symptoms, if TSH and T4-V are in the reference range.

Instead, the finding means that the person has a higher risk of getting sick later, which is why thyroid values ​​should be monitored regularly.

A valid treatment recommendation according to the end of 2022, approximately 344,000 Finns used thyroid hormone preparations. The most common cause of hypothyroidism is autoimmune thyroiditis. Clearly, the majority of those affected are women, and the disease becomes more common with age.

Good treatment -recommendation has also been criticized. The Suomen Kilpirauhaspotilat ry feels that there are individual problems related to the recommendation, which can weaken the patients’ position.

“The dominance of the TSH value is one of the most central problems of the recommendation, even though there is research evidence that it should not be used alone for diagnosis and treatment guidance, and T4-V should always be examined alongside it,” says a member of the board of the association Niina Lehtonen.

The Thyroid Association also takes care of using the TSH value as the primary and only laboratory test.

According to the Thyroid Patients’ Association, the Käypä hoito recommendation focuses too much on just T4 thyroid hormone medication, even though some patients do not become symptom-free with it and could benefit from T4+T3 combination therapy or animal-derived preparations. The Thyroid Association also feels that various treatment trials have played an important role in the treatment of patients.

According to Saara Metso, TSH is the most accurate laboratory test in the diagnosis and treatment of hypothyroidism, and it has the most research evidence. The T4-V value can be more sensitively affected by, for example, other diseases and medications.

Metso considers that in addition to T4 treatment, other treatment methods are also well reviewed in the recommendation.

If thyroid hormone medication is rushed to be prescribed based on the symptoms, the risk is that the real cause of the symptoms remains hidden. When the patient does not get help from his unnecessary medication, the dose of the medicine is slowly increased. The fact that a person receives too much thyroid hormone is a more dangerous situation than the fact that he receives too little, says Metso.

“Overmedication exposes a person to atrial fibrillation, cerebral infarction, pulmonary embolism and mortality. The risk of heart events increases by 18 percent every six months with too much thyroid medication,” says Metso.

According to Reeta Rintamäki, too high a drug dose increases the risk of osteoporosis, especially in women over 65. Other symptoms of overmedication can be, for example, increased heart rate, nervousness, anxiety, sweating, diarrhea and weight loss.

If thyroid medication has been started on the basis of symptoms alone and the patient still feels that it helps, the underlying cause may be the stimulating or invigorating effect of the thyroid hormone.

“However, the effect that raises the level of alertness weakens quite soon and the disadvantages emerge.”

The Käyä hoito recommendation also contains instructions for situations where overmedication or unnecessarily prescribed medication is suspected.