NRP/555 Week 4: Endocrine Condition Case, sample paper

A TSH of 7.2 and a Wish to Feel Less Tired: Why a 72-Year-Old Woman With Subclinical Hypothyroidism Did Not Start Levothyroxine, and What We Did Instead

[Student Name]

University of Phoenix

NRP/555: Adult and Geriatric Management I

Week 4 Assignment

[Instructor Name]

[Date]

The patient is a composite written for a model paper.

Mrs. R., a 72-year-old retired seamstress, has felt tired for several months. Her daughter read online that thyroid problems cause fatigue and asked for testing. Her thyroid-stimulating hormone is 7.2 mIU/L (reference range 0.4 to 4.5) and her free T4 is 1.1 ng/dL, normal. She has no goiter, and her thyroid peroxidase antibodies are not yet known. She takes amlodipine for hypertension and a daily multivitamin. Her daughter expects a prescription. This paper explains the decision.

Confirming the Finding

Thyroid-stimulating hormone varies, rises transiently after illness and can be affected by biotin in supplements. A single raised value should be repeated in two to three months before any decision (Pearce et al., 2013). Mrs. R.'s multivitamin contains biotin, which can interfere with some immunoassays; I ask her to stop it for several days before retesting. The repeat test eight weeks later shows a thyroid-stimulating hormone of 6.8 mIU/L and a normal free T4, confirming subclinical hypothyroidism.

What Age Changes

Thyroid-stimulating hormone levels rise with age in healthy people, so a value of 6.8 in a 72-year-old may partly reflect normal aging rather than thyroid failure. The European Thyroid Association guideline notes age-specific reference ranges and recommends caution about treating older patients with mildly raised levels (Pearce et al., 2013).

The Evidence on Treatment

The TRUST trial randomly assigned 737 adults aged 65 and older with subclinical hypothyroidism to levothyroxine or placebo. Levothyroxine lowered thyroid-stimulating hormone, but after one year there were no differences in hypothyroid symptom scores or tiredness scores between groups; the authors concluded that levothyroxine provided no apparent benefit in older persons with subclinical hypothyroidism (Stott et al., 2017). A BMJ guideline panel, drawing on this and other trials, made a strong recommendation against thyroid hormone treatment for most adults with subclinical hypothyroidism and thyroid-stimulating hormone below 20 mIU/L (Bekkering et al., 2019), excluding women trying to become pregnant and people with very high levels or severe symptoms.

Her tiredness is real; the evidence says the thyroid number is probably not its cause, and a pill aimed at the number is unlikely to help.

Why Not Treat Anyway

Levothyroxine seems harmless, but in older adults overtreatment can cause atrial fibrillation and bone loss, and many people started on treatment for mildly raised values end up with suppressed levels. Treating a number without benefit exposes her to these risks and to a daily pill she does not need, and it may stop the search for the actual cause of her fatigue.

Searching for the Real Cause

Fatigue in older adults has many causes. I review her sleep, which is fragmented by nocturia; her mood, with a depression screen showing mild symptoms since her husband's death a year ago; her medications, where amlodipine is unlikely to cause fatigue; and laboratory tests, including a complete blood count, metabolic panel, vitamin B12 and A1C, which are normal except for a mild anemia with low ferritin. The anemia requires its own evaluation, including a gastrointestinal assessment, and may explain part of her tiredness.

Explaining to Mrs. R. and Her Daughter

I explain that her thyroid is working slightly harder than usual but still makes enough hormone, that a large trial in people her age found treatment did not make them feel less tired and that we have found other possible causes, especially the low iron and grief, that we can address. Her daughter asks whether to recheck; I agree it should be monitored.

What the Trial Population Tells Us

The TRUST participants had a mean age of 74 and a mean thyroid-stimulating hormone of about 6.4 mIU/L at baseline, closely resembling Mrs. R. (Stott et al., 2017). This similarity strengthens the case for applying the trial's result to her. The trial did not include many people with levels above 10 mIU/L, which is why the monitoring plan treats a rise to that level as a reason to reconsider.

When Treatment Would Be Reasonable

The BMJ panel excluded several groups from its recommendation against treatment: women who are pregnant or trying to become pregnant, people with thyroid-stimulating hormone above 20 mIU/L and those with very severe symptoms or recent thyroid surgery or radioactive iodine (Bekkering et al., 2019). The European guideline suggests that younger adults with symptoms and a level above 10 mIU/L may benefit from a trial of treatment (Pearce et al., 2013). None of these applies to Mrs. R. now.

Shared Decision

Mrs. R. and her daughter wanted to know whether a short trial of levothyroxine would do any harm. I explained that a trial is sometimes offered, but that in people like her the larger trial found no difference in how tired people felt, and that feeling better on a pill can reflect expectation rather than effect. Mrs. R. chose to address the anemia and grief first and revisit the thyroid at her next test.

Monitoring Plan

I will recheck thyroid-stimulating hormone and free T4 every 6 to 12 months, or sooner if symptoms change. Treatment would be reconsidered if thyroid-stimulating hormone rises to 10 mIU/L or higher, as some guidelines suggest considering treatment above this level in selected patients (Pearce et al., 2013), if free T4 falls below normal or if she develops a goiter. I order thyroid peroxidase antibodies; if positive, they increase the chance of progression to overt hypothyroidism.

Symptoms That Are Not Specific

Fatigue, weight gain, feeling cold and constipation are common in older adults with normal thyroid function as well as in those with hypothyroidism. In the TRUST trial, symptom scores at baseline were similar to those of the general older population, and treatment did not change them (Stott et al., 2017). This nonspecificity is why attributing symptoms to a mildly raised thyroid-stimulating hormone is so tempting and so often mistaken.

Her Daughter's Role

Her daughter will help track energy, sleep and mood in a simple weekly note, which will show whether treating the anemia and grief changes the fatigue.

Medications That Affect Thyroid Tests

I also review her medications for drugs that can alter thyroid tests, such as amiodarone, lithium or high-dose biotin. Apart from the biotin in her multivitamin, now stopped, none apply.

Addressing the Other Causes

For the anemia, I start oral iron and refer for evaluation of iron loss. For grief, I offer a referral to a grief support group and schedule a follow-up to recheck her mood. For nocturia, I review evening fluid intake.

Conclusion

Mrs. R.'s subclinical hypothyroidism was confirmed on repeat testing, and age-related rises in thyroid-stimulating hormone may explain part of it. The TRUST trial showed no benefit of levothyroxine on symptoms or tiredness in adults her age, and a guideline recommends against routine treatment at her level. The decision not to treat freed the visit to find more likely causes of her fatigue, iron deficiency anemia and grief, while monitoring her thyroid with clear thresholds for reconsidering treatment.

References

Bekkering, G. E., Agoritsas, T., Lytvyn, L., Heen, A. F., Feller, M., Moutzouri, E., Abdulazeem, H., Aertgeerts, B., Beecher, D., Brito, J. P., Farhoumand, P. D., Singh Ospina, N., Rodondi, N., van Driel, M., Wallace, E., Snel, M., Okwen, P. M., Siemieniuk, R., Vandvik, P. O., . . . Vermandere, M. (2019). Thyroid hormones treatment for subclinical hypothyroidism: A clinical practice guideline. BMJ, 365, Article l2006. https://doi.org/10.1136/bmj.l2006

Pearce, S. H. S., Brabant, G., Duntas, L. H., Monzani, F., Peeters, R. P., Razvi, S., & Wemeau, J.-L. (2013). 2013 ETA guideline: Management of subclinical hypothyroidism. European Thyroid Journal, 2(4), 215-228. https://doi.org/10.1159/000356507

Stott, D. J., Rodondi, N., Kearney, P. M., Ford, I., Westendorp, R. G. J., Mooijaart, S. P., Sattar, N., Aubert, C. E., Aujesky, D., Bauer, D. C., Baumgartner, C., Blum, M. R., Browne, J. P., Byrne, S., Collet, T.-H., Dekkers, O. M., den Elzen, W. P. J., Du Puy, R. S., Ellis, G., . . . Gussekloo, J. (2017). Thyroid hormone therapy for older adults with subclinical hypothyroidism. New England Journal of Medicine, 376(26), 2534-2544. https://doi.org/10.1056/NEJMoa1603825