What are the guideline sources, guidelines and references for Hashimoto_s thyroiditis ?
Guideline sources The following summarized guidelines for the evaluation and management of Hashimoto's thyroiditis (HT) are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2023), the European Academy of Dermatology and Venereology (EADV 2021), the Endocrine Society (ES 2020), the British Medical Journal (BMJ 2019), the American Thyroid Association (ATA 2017), the American College of Endocrinology (ACE/AACE 2016), and the American Thyroid Association (ATA/AACE 2012). 1 2 3 4 5 6 7 Guidelines 1. Screening and diagnosis Indications for screening: As per ADA 2023 guidelines: Consider screening for antithyroid peroxidase and anti-TG antibodies soon after diagnosis in pediatric patients with T1DM. C Measure TSH concentrations at diagnosis when clinically stable or soon after optimizing glycemia. Consider rechecking every 1-2 years or sooner if the initial screening is normal in https://web.pathway.md/diseases/rec3VlncUuayFMRMc 1/7 6/24/23, 12:31 PM Hashimoto's thyroiditis Pathway young patients with positive thyroid antibodies or developing symptoms or signs suggestive of thyroid dysfunction, thyromegaly, an abnormal growth rate, or unexplained glycemic variability. B As per AACE 2012 guidelines, consider obtaining screening for hypothyroidism in > 60 years old individuals. B Show 2 more Indications for testing (dyslipidemia): evaluate for and rule out hypothyroidism as the cause of hyperlipidemia before initiating lipid-lowering therapy in patients with hyperlipidemia. A Indications for testing (dermatitis herpetiformis): assess for HT in patients with dermatitis herpetiformis. B Indications for testing (infertility): assess serum TSH concentration in all females seeking care for infertility. B Indications for testing (poor lactation): measure TSH to assess for thyroid dysfunction in females experiencing poor lactation without other identified causes, as maternal hypothyroidism can adversely impact lactation. B 2. Diagnostic investigations Anti-TPO antibodies: measure anti-TPO antibodies in the evaluation of patients with subclinical hypothyroidism. B Show 3 more Thyroid hormone tests: measure serum free T4 (free T4 index or free T4 estimate and direct immunoassay of free T4 without physical separation using anti-T4 antibodies) instead of total T4 in the evaluation of hypothyroidism. A Show 2 more 3. Medical management Thyroid replacement therapy, indications, abnormal TSH: As per BMJ 2019 guidelines, do not initiate thyroid replacement therapy in adult patients with subclinical hypothyroidism. D As per ATA/AACE 2012 guidelines: Consider initiating levothyroxine in patients with serum TSH levels > 10 mIU/L, as these patients are at increased risk for HF and cardiovascular mortality. B Consider initiating treatment based on individual factors in patients with TSH levels between the upper limit of a given laboratory's reference range and 10 mIU/L, particularly if patients have symptoms suggestive of hypothyroidism, positive anti-TPO antibodies, or evidence of ASCVD, HF, or associated risk factors for these diseases. B https://web.pathway.md/diseases/rec3VlncUuayFMRMc 2/7 6/24/23, 12:31 PM Hashimoto's thyroiditis Pathway Thyroid replacement therapy (indications, normal TSH): Consider initiating levothyroxine therapy in female patients of childbearing age with serum TSH levels within the reference range for the local laboratory if: serum TSH is > 2.5 mIU/L in patients planning a pregnancy in the immediate future (including assisted reproduction) serum TSH is > 2.5 mIU/L during the first trimester of pregnancy serum TSH is > 3.0 mIU/L during the second trimester of pregnancy serum TSH is > 3.5 mIU/L during the third trimester of pregnancy. C Show 6 more Thyroid replacement therapy (choice of agent and dosing): initiate levothyroxine monotherapy for the treatment of hypothyroidism. A Show 5 more Thyroid replacement therapy (treatment targets): target the normal range of a third-generation TSH assay in nonpregnant patients with hypothyroidism. Consider targeting an ULN of 4.12 mIU/L in iodine-sufficient areas if an ULN for a third-generation TSH assay is not available, and a LLN of 0.45 mIU/L if a LLN is not available. B Management of thyroid nodules: measure anti-TPO antibodies in patients with increased levels of serum TSH. B Recognize that high serum anti-TPO antibody values associated with a firm, diffusely enlarged, or more often atrophic small thyroid, are compatible with HT. B Recognize that a nodular goiter may also harbor HT. B Show 3 more Management of dyslipidemia: avoid treating hyperlipidemia until the patient becomes euthyroid in order to more accurately assess the lipid profile in patients with overt hypothyroidism. D Show 2 more 4. Nonpharmacologic interventions Iodine supplementation (general population): do not use iodine supplementation, including kelp or other iodine-containing functional foods, in the management of hypothyroidism in iodine- sufficient areas. D Iodine supplementation, during pregnancy: As per ATA 2017 guidelines, advise ingestion of approximately 250 g of dietary iodine daily in all pregnant females. A Show 4 more As per ATA/AACE 2012 guidelines, do not use iodine supplementation, including kelp or other iodine-containing functional foods, in the management of hypothyroidism in iodine-sufficient areas. D Iodine supplementation (during breastfeeding): Advise ingestion of approximately 250 g of dietary iodine daily in all breastfeeding females. A https://web.pathway.md/diseases/rec3VlncUuayFMRMc 3/7 6/24/23, 12:31 PM Hashimoto's thyroiditis Pathway Offer daily oral supplements containing 150 g of iodine in breastfeeding females, preferably in the form of potassium iodide (such as present in a multivitamin) because kelp and other forms of seaweed do not provide consistent delivery of daily iodine. Avoid exceeding 500-1,100 g/day of iodine intake during breastfeeding because of concerns about the potential for inducing hypothyroidism in the infant. B Selenium supplementation: do not use selenium for the prevention or treatment of hypothyroidism. D 5. Specific circumstances Pregnant patients (screening): obtain verbal screening for any history of thyroid dysfunction and prior or current use of either thyroid hormone or antithyroid medications in all pregnant patients at the initial prenatal visit. A Show 3 more Pregnant patients, evaluation: As per ATA 2017 guidelines, measure serum TSH before conception in patients treated with levothyroxine and planning pregnancy. Adjust levothyroxine dose to achieve a TSH < 2.5 mU/L. B Show 3 more As per ATA/AACE 2012 guidelines: Measure total T4 or a free T4 index, in addition to TSH, to assess thyroid status during pregnancy. Obtain direct immunoassay measurement of free T4 (because of the wide variation in the results of different free T4 assays) only when method-specific and trimester-specific reference ranges for serum free T4 are available. B Set the target range for TSH in pregnant patients with hypothyroidism based on trimester- specific ranges for the local laboratory. Use the following upper-normal reference ranges if trimester-specific reference ranges are not available in the local laboratory: Situation Guidance 2.5 mIU/L First trimester 3.0 mIU/L Second trimester 3.5 mIU/L. B Third trimester Pregnant patients (management of autoantibodies): consider initiating levothyroxine (at a starting dose of 25-50 g/day) in euthyroid pregnant patients with positive anti-TPO antibodies and a history of pregnancy loss. C Show 2 more Pregnant patients (management of normal TSH levels): Consider initiating levothyroxine therapy in female patients of childbearing age with serum TSH levels within the reference range https://web.pathway.md/diseases/rec3VlncUuayFMRMc 4/7 6/24/23, 12:31 PM Hashimoto's thyroiditis Pathway for the local laboratory if: serum TSH is > 2.5 mIU/L in patients planning a pregnancy in the immediate future (including assisted reproduction) serum TSH is > 2.5 mIU/L during the first trimester of pregnancy serum TSH is > 3.0 mIU/L during the second trimester of pregnancy serum TSH is > 3.5 mIU/L during the third trimester of pregnancy. C Show 3 more Pregnant patients (thyroid replacement therapy): initiate levothyroxine treatment in patients with overt hypothyroidism during pregnancy. B Show 5 more Pregnant patients, treatment targets: As per ATA 2017 guidelines, consider targetting a TSH in the lower half of the trimester-specific reference range. Consider targetting maternal TSH levels < 2.5 mU/L when trimester-specific reference ranges are not available. C As per ATA/AACE 2012 guidelines, measure serum TSH promptly after conception in pregnant patients with hypothyroidism being treated with levothyroxine, and adjust levothyroxine dose with a TSH goal of < 2.5 mIU/L during the first trimester., B < 3 mIU/L during the second trimester, and < 3.5 mIU/L during the third trimester. B Pregnant patients, monitoring: As per ATA 2017 guidelines, monitor patients with overt and subclinical hypothyroidism (treated or untreated) or patients at risk for hypothyroidism (such as euthyroid patients with positive anti- TPO or anti-TG antibodies, post-hemithyroidectomy, or patients treated with radioactive iodine) with a serum TSH measurement approximately every 4 weeks until midgestation and at least once near 30 weeks of gestation. A As per ATA/AACE 2012 guidelines, obtain monitoring every 4 weeks in the first 20 weeks of pregnancy for the development of hypothyroidism in patients with positive levels of serum anti- TPO antibodies or with a serum TSH > 2.5 mIU/L not being treated with levothyroxine. B Pregnant patients (postpartum): reduce the dose of levothyroxine following delivery to the patient's preconception dose. Obtain additional thyroid function testing at approximately 6 weeks postpartum. B Show 4 more Breastfeeding patients: measure TSH to assess for thyroid dysfunction in females experiencing poor lactation without other identified causes, as maternal hypothyroidism can adversely impact lactation. B Show 4 more Patients with infertility: measure serum TSH concentration in all female patients seeking care for infertility. B Show 6 more https://web.pathway.md/diseases/rec3VlncUuayFMRMc 5/7 6/24/23, 12:31 PM Hashimoto's thyroiditis Pathway Patients with combined adrenal insufficiency: initiate corticosteroids before treatment with levothyroxine in patients with combined adrenal insufficiency and hypothyroidism. B 6. Patient education General counseling: As per ATA 2017 guidelines: Advise patients receiving levothyroxine therapy to independently increase their dose of levothyroxine by 20-30% (such as taking 2 additional tablets weekly of the current daily levothyroxine dosage) and urgently notify their caregiver for prompt testing and further evaluation in case of a suspected or confirmed pregnancy (positive home pregnancy test). A Counsel treated hypothyroid female patients of reproductive age regarding the likelihood of increased demand for levothyroxine during pregnancy. Advise such patients to contact their caregiver immediately upon a confirmed or suspected pregnancy. A As per AACE 2012 guidelines: Advise patients to take levothyroxine with water consistently 30-60 minutes before breakfast or at bedtime 4 hours after the last meal, and not take it with substances or medications interfering with its absorption. B Inform patients taking dietary supplements and nutraceuticals for hypothyroidism that commercially available thyroid-enhancing products are not a remedy for hypothyroidism and counsel about the potential side effects of various preparations, particularly those containing iodine or sympathomimetic amines as well as those marked as "thyroid support" since they could be adulterated with levothyroxine or T3. B 7. Follow-up and surveillance Indications for specialist referral: Manage most patients with primary hypothyroidism by non- endocrinologist physicians familiar with the diagnosis and treatment of hypothyroidism. Refer patients with hypothyroidism meeting any of the following criteria for a consultation with an endocrinologist: infant and pediatric patients female patient planning conception pregnant patients patients difficult to render and maintain in a euthyroid state cardiac disease presence of goiter, nodule, or other structural changes in the thyroid gland presence of other endocrine diseases, such as adrenal or pituitary disorders unusual constellation of thyroid function test results unusual causes of hypothyroidism, such as induced by agents interfering with the absorption of levothyroxine, impacting thyroid gland hormone production or secretion, affecting the https://web.pathway.md/diseases/rec3VlncUuayFMRMc 6/7 6/24/23, 12:31 PM Hashimoto's thyroiditis Pathway hypothalamic-pituitary-thyroid axis (directly or indirectly), increasing clearance, or peripherally impacting metabolism. B Serial laboratory assessment: measure serum TSH at 4-8 weeks after initiating treatment or after a change in dose. Obtain periodic TSH measurements, once an adequate replacement dose has been determined, after 6 months and then at 12-month intervals, or more frequently if the clinical situation dictates otherwise. B Show 2 more References 1. Steven E. Kahn, Cheryl A.M. Anderson, John B. Buse et al. Standards of Care in Diabetes 2023. Diabetes Care. 2023 Jan;46 Supplement_1 S1 S291. Open 2. Erik K Alexander, Elizabeth N Pearce, Gregory A Brent et al. 2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum. Thyroid. 2017 Mar;27 3 315 389. Open 3. Garber JR, Cobin RH, Gharib H et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. 2012 Nov-Dec;18 6 988 1028. Open 4. G E Bekkering, T Agoritsas, L Lytvyn et al. Thyroid hormones treatment for subclinical hypothyroidism: a clinical practice guideline. BMJ. 2019 May 14;365:l2006. Open 5. Connie B Newman, Michael J Blaha, Jeffrey B Boord et al. Lipid Management in Patients with Endocrine Disorders: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2020 Dec 1;105 12):dgaa674. Open 6. Camacho PM, Petak SM, Binkley N et al. American Association of Clinical Endocrinologists and American College of Endocrinology Clinical Practice Guideline for the Diagnosis and Treatment of Postmenopausal Osteoporosis 2016. Endocr Pract. 2016 Sep 2;22 Suppl 4 1 42. Open 7. A G r g, E Antiga, M Caproni et al. S2k guidelines (consensus statement) for diagnosis and therapy of dermatitis herpetiformis initiated by the European Academy of Dermatology and Venereology EADV . J Eur Acad Dermatol Venereol. 2021 Jun;35 6 1251 1277. Open https://web.pathway.md/diseases/rec3VlncUuayFMRMc 7/7