Clinical Pearls & Morning Reports

Posted by Carla Rothaus

Published June 20, 2018


Are there data from randomized trials to guide the treatment of subclinical hyperthyroidism?

The causes of subclinical hyperthyroidism are the same as the causes of overt hyperthyroidism. The potential clinical consequences of subclinical hyperthyroidism include progression to overt hyperthyroidism, cardiovascular conditions, bone loss, fractures, and dementia. Listen to the latest Clinical Practice Audio here.

Clinical Pearls

Q: How is subclinical hyperthyroidism defined?

A: In overt hyperthyroidism, serum levels of free thyroxine (T4) and triiodothyronine (T3) or levels of T3 alone are elevated, and serum thyrotropin levels are suppressed. In subclinical hyperthyroidism, levels of free T4 and T 3 are normal, thyrotropin levels are suppressed, and thyroid hormone levels are usually in the middle to upper range of normal. Levels of free T4 and T3 should be promptly assessed in patients with a serum thyrotropin level of less than 0.1 mU per liter to rule out overt hyperthyroidism. In the absence of overt disease, it is reasonable to defer further evaluation for 2 to 3 months, at which time repeat testing should be performed; subnormal serum thyrotropin levels are transient in up to 50% of patients, most often in those with mild disease.

Q: What is thebest predictor of progression from subclinical hyperthyroidism to overt hyperthyroidism?

A: The best predictor of progression from subclinical hyperthyroidism to overt hyperthyroidism is the baseline serum thyrotropin level rather than the cause of the disease. Serum thyrotropin levels in patients with mild subclinical hyperthyroidism frequently normalize during follow-up, whereas patients with thyrotropin levels lower than 0.1 mU per liter usually have persistent disease or progression to overt hyperthyroidism. Patients with nodular thyroid disease and subclinical hyperthyroidism are at increased risk for progression to overt hyperthyroidism after exposure to a large iodine load.

Morning Report Questions

Q: Are there data from randomized trials to guide the treatment of subclinical hyperthyroidism?

A: Data from randomized trials are lacking regarding the effects of treatment on symptoms and adverse outcomes in patients with previously untreated subclinical hyperthyroidism. Data are lacking in regard to the effectiveness of treatment in reducing the risks of the adverse outcomes associated with subclinical hyperthyroidism. It is not known whether the effects of treatment vary according to the cause of subclinical hyperthyroidism, patient age, or serum thyrotropin level. The U.S. Preventive Services Task Force found insufficient evidence to recommend screening or treatment for subclinical thyroid disease.

Q: Describe a general approach to the management of subclinical hyperthyroidism.

A: Although data are lacking from randomized clinical trials to guide treatment decisions, professional organizations recommend treatment of subclinical hyperthyroidism in persons older than 65 years of age and postmenopausal women, especially when serum thyrotropin levels are less than 0.1 mU per liter. Premenopausal women and younger patients should be considered for treatment if serum thyrotropin levels are less than 0.1 mU per liter and they have symptoms of hyperthyroidism or coexisting conditions such as osteopenia, osteoporosis, or cardiovascular disease. There is no indication for treatment in younger patients who do not have coexisting conditions if the serum thyrotropin level is 0.1 mU per liter or higher.

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