# Controversy on TSH



## GD Women (Mar 5, 2007)

I lost the link to the below with my computer crash, I am going to post anyway. The below are quotes asked by professional to an AACE professional if I remember correctly:

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Quote:

A reference range is a set of values used by a health professional to interpret a set of medical test results. The range is usually defined as the set of values 95% of the normal population falls within. Reference range will vary, depending on the age, sex and race of a population, and even the machines the laboratory uses to do the tests, as well as the different types of thyroid conditions. Also remember that by definition 5% of the normal population will fall outside the reference range.

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Quote:

Levels have not changed per se or they have not changed much for most Labs, and they probably won't for a long time.

There has been a lot of controversy on TSH levels among medicals and thyroid organizations/org. Therefore leading to misconception of TSH levels by the thyroid communities, which are saying TSH 0.5 and 2.5-3.0 mIU/L is for diagnosing.

As well as, there are Links with pharmaceutical companies which leads to suspicion of the TSH levels 2.5-3.0 so more people will fall into the hypothyroid category thereby pharmaceutical companies can sell more drugs.

TSH between 0.5 and 2.5-3.0 mIU/L 
is the recommended target for L-T4 replacement dose adjustment which is still a controversy among medicals. So there is a diagnose and target level controversy among medicals and thyroid communities.

".......recent arguments for and against treatment have been proposed......

We believe that treatment is indicated in patients with TSH levels >10 uIU/mL or in patients with TSH levels between 5 and 10 uIU/mL in conjunction with goiter or positive anti-thyroid peroxi-das antibodies (or both). These patients have the highest rate of progression to overt hypothyroidism. The target TSH level should be between 0.3 and 3.0 uIU/mL."

Some medicals believe that TSH assays is only a problem if are trying to establish a rigid TSH reference range that covers all groups. Some medicals and thyroid origination/Orgs. believe that its better to abandon the concept of a fixed TSH range, because it cannot be rationalized on either a methodology, biologic or practical basis.

The US Government panel guidelines set forth by U.S. Preventive Services Task Force (USPSTF) Jan 14, 2004 as follows; Individuals with TSH levels between 4.5 and 10 mIU/L have symptoms compatible with hypothyroidism and Physicians and patients must understand that there is insufficient evidence to expect therapeutic benefit in patients in this group.

The available data do not confirm clear-cut benefits for early therapy compared with treatment when symptoms or overt hypothyroidism develop.

Therefore, the panel does not recommend routine levothyroxine treatment for patients with TSH levels between 4.5 and 10 mIU/L, but thyroid function tests should be repeated at 6- to 12-month intervals to monitor for improvement or worsening in TSH level.

American Thyroid Association, the American Association of Clinical Endocrinologists and the Endocrine Society convened a panel of experts to evaluate existing research and create practice guidelines. In hopes that the panel would confirm the TSH 0.03 to 3.0.

It back fired on them and instead the group/panel found no compelling evidence to treat patients, even those with symptoms, who have subclinical hypothyroidism, defined primarily as having slightly elevated (4.5 to 10 milliunits per liter) blood levels of thyroid stimulating hormone.

"It provoked a huge ruckus," in other words, it P.O.d the American Thyroid Association, the American Association of Clinical Endocrinologists and the Endocrine Society who were the medical groups that sponsored the review panel, strenuously disagreed and published a rebuttal in the January 2005 Journal of Clinical Endocrinology & Metabolism.

As much as I like and quote from American Thyroid Association, the American Association of Clinical Endocrinologists and the Endocrine Society, I personally think they don't want to be the bad guy, so they are letting certain thyroid advocates influence them over their own panels findings and other medicals.

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Quite:

US Government panel guidelines set forth by U.S. Preventive Services Task Force (USPSTF) Jan 14, 2004 as follows:

TSH below 0.1 mU/L are considered low and values above 6.5 mU/L are considered elevated.

TSH of 4.5 to 10:

Subclinical Hypothyroidism With Serum TSH of 4.5 to 10 mIU/L

early levothyroxine therapy does not alter the natural history of the disease, it may prevent symptoms and signs of overt disease in those who do progress.

Individuals with TSH levels between 4.5 and 10 mIU/L have symptoms compatible with hypothyroidism and Physicians and patients must understand that there is insufficient evidence to expect therapeutic benefit in patients in this group

The available data do not confirm clear-cut benefits for early therapy compared with treatment when symptoms or overt hypothyroidism develop.

Therefore, the panel does not recommend routine levothyroxine treatment for patients with TSH levels between 4.5 and 10 mIU/L, but thyroid function tests should be repeated at 6- to 12-month intervals to monitor for improvement or worsening in TSH level.

TSH Higher Than 10: (Overt (With normal or low normal F/T-4))

Subclinical Hypothyroidism With Serum TSH Higher Than 10 mIU/L. Levothyroxine therapy is reasonable for patients with subclinical hypothyroidism and serum TSH higher than 10 mIU/L.

The rate of progression is 5% in comparison with patients with lower levels of TSH, and treatment may potentially prevent the manifestations and consequences of hypothyroidism in those patients who do progress. Still, the evidence that therapy will reduce total and LDL cholesterol levels and improve symptoms in these patients is inconclusive.

www.aace.com/pub/pdf/guidelines/hypo_hyper.pdf

http://pop.aace.com/pub/guidelines/


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## GD Women (Mar 5, 2007)

"AACE feels that the physician who has performed a comprehensive history and physical examination should decide on treatment of each individual patient."

*USA*
As of February 2010, at most laboratories in the U.S., the official "normal" reference range for the Thyroid Stimulating Hormone (TSH) blood test runs from approximately .5 to 4.5/5.0.

*TSH 0.3-3.0 is just a suggested target level for already diagnosed and treated patients*"We believe that treatment is indicated in patients with TSH levels >10 uIU/mL. or in patients with TSH levels between 5 and 10 uIU/mL in conjunction with goiter or positive antti-thyroid peroxidase antibodies. "The target level should be between 0.3 and 3.0 uIU/mL." 
AACE thyroid guidelines. Endocr Pract. 2002;8:457-469.
ENDOCRINE PRACTICE Vol 8 No. 6 November/December 2002 457
www.aace.com/pub/pdf/guidelines/hypo_hyper.pdf

*"Studies, data and dialogue needed to determine TSH range June 10, 2008 *The decision is one that puts endocrinologists and practicing physicians in a quandary over the conflicting opinions and evidence surrounding the upper limit of the TSH reference range. Age-specific ranges and screening pregnant women are among topics of debate. As a result of inconsistent data and various studies published about the upper limit of the reference range, experts are at a disconnect in terms of what the limit should be, how the limit should be established and which population the limit - or limits - should apply to." 
http://www.endocrinetoday.com/view.aspx?rid=28716

*"New TSH Reference Range Guidance *While the endocrinologists and obstetricians hammer things out, it's unlikely that laboratorians will see a change in thyroid test volumes. However, the draft ES guidelines' suggested upper limit for the TSH reference range for pregnant women and preconception-below 2.5 mIU/L in the first trimester and preconception and 3.0 mIU/L in the second and third trimesters" http://www.aacc.org/publications/cln/2007/sept/pages/cover2_0907.aspx

*The general view in the UK*If there is controversy about the treatment of subclinical hypothyroidism there is uproar about the treatment of the alleged hypothyroid patient with TSH levels well within the reference range. The general view in the UK is that such patients are not hypothyroid and do not need treatment with thyroxine. Thyroxine therapy when clinically indicated is not without its dangers. Studies in the USA and the UK have shown that a high percentage of patients on thyroxine take the wrong dose risking the development of heart and bone disease. There is a view among some doctors and some members of the lay public that thyroxine is indicated for patients with a TSH within the reference range who have symptoms suggestive if hypothyroidism. The argument is that most doctors are treating the biochemistry and not the patient and that the upper limit of the TSH reference range should be lowered to 2.5mU/l. Mr Lynn does not support this view. The argument has been heated and has been presented to members of the UK Parliament and to the General Medical Council. 
http://www.endocrinesurgeon.co.uk/index.php/how-is-hypothyroidism-treated

*Endocrinology, Department of Medical Sciences 'M. Aresu', University of **Cagliari, Cagliari, Italy.* Serum TSH is universally considered the best laboratory test to evaluate thyroid function. Current TSH reference ranges are 0.3-5.0 mU/l, but a narrower range (0.4-2.5) has been recently advocated, which better defines normal thyroid function. The question is still debated and matter of controversy, since it has been argued that with the narrower range, an additional 10% of the general population could be diagnosed as mild or subclinically hypothyroid, although most of them do not have thyroid disease or do not require thyroid hormone therapy http://www.endocrine-abstracts.org/ea/0022/ea0022s13.4.htm

*University of Greifswald, Greifswald, Germany*There is controversy on the upper thyrotropin (TSH) reference level.
http://www.endocrine-abstracts.org/ea/0022/ea0022S13.1.htm


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## lainey (Aug 26, 2010)

Custodial medicine. What a great thing for endocrinologists to have a stable of patients who need regular care--appointments, blood work, scans. Of course, anything that increases the number of them is great for the doctor's bottom line.

Take a close look at the falling "standards" for diagnosing diabetes type 2, or the falling recommended levels for cholesterol to initiate treatment---much, much more custodial medicine.

>>"AACE feels that the physician who has performed a comprehensive history and physical examination should decide on treatment of each individual patient."<<

In the end, this is the way it should work.


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