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Hypothyroidism

· Hypothyroidism entails an underactive thyroid.

· The thyroid gland produces insufficient hormones.

· Women above 60 years are more affected by the condition (Alexander et al., 2017).

· Signs and symptoms depend on the severity of hormone deficiency.

Untreated hypothyroidism has severe impacts including goiter and memory loss.

Incidence and Prevalence

· Presently, incidence and prevalence are conducted in small community cohorts.

· Prevalence and incidence are reported as 2-4 per 1000 individuals per year.

· Prevalence is 0.2%-0.4% for undiagnosed cases (Seo & Chung, 2015).

· Prevalence is 1%-2% for previously diagnosed cases.

· Women above 60 years are more easily affected by hypothyroidism

In 2002, NHANES III (United States National Health and Nutrition Examination Survey) reported the detection of overt hypothyroidism is 0.3% in general population while 0.7% had the subclinical hypothyroidism

Pathophysiology

· The thyroid gland is responsible for producing triiodothyronine (T3) and thyroxine (T4).

· TSH is responsible for regulating the hormone synthesis and release by thyroid glands.

· TSH is influenced by the TRH from the hypothalamus (Donzelli et al., 2016).

· Both TRH and TSH are regulated by negative feedback from thyroid hormone (T3)

· Increase in circulating thyroid hormone result in blunting of both secretion and synthesis of serum TSH.

Low T3 and T4 increase TSH levels as a compensatory function.

Clinical Presentations

· Hypothyroidism symptoms vary with hormone deficiency.

· Initially, noticing the symptoms may be challenging

· One may relate fatigue and weight gain to old age (Seo & Chung, 2015)

· Main signs and symptoms include fatigue, cold intolerance, constipation, dry skin, puffy face, hoarseness, muscle weakness, elevated blood cholesterol, muscle stiffness and tenderness, joint pains, irregular or heavier menstrual periods, slowed heart rate, impaired memory, and depression.

Untreated symptoms result in severe conditions such as goiter and memory loss.

CPG Authors and Publication

· The clinical practice guideline (CPG) entails hypothyroidism in adults.

· The CPG was developed by the American Association of Clinical Endocrinologists and American Thyroid Association

· The CPG was developed by 9 authors including Garber, Cobin, Gharib, Hennessey, Klein, Mechanick, Pessah-Pollack, Singer, and Woeber.

· The most recent publication of the CPG article was 2012.

Updates to CPG was 2008 and 2010, with revisions which are seen in the 2012 CPG.

Applicability in Primary Care Setting

· Hypothyroidism is characterized by various manifestations and etiologies

· Effective management requires proper diagnosis and is influenced by coexisting medical conditions (Garber et al., 2012)

· This CPG aids in profoundly understanding the condition and its presentation

The CPG develops recommendations which can be applied in the diagnosis and treatment of the condition.

Clinical Applications

· The CPG enhances awareness on epidemiology, associated hypothyroidism disorders, signs and symptoms, and measurement approaches of T4 and T3

· In managing recommendations, key aspects included are when antithyroid antibodies should be measured, the importance of clinical scoring approach in performing diagnosis, and use of diagnostic tests (Garber et al., 2012).

· CPG also focuses on pregnant women with hypothyroidism and effective approaches that should be implemented such as monitoring them.

Areas of future research are identified including cardiac and cognitive benefits from managing subclinical hypothyroidism and screening for pregnancy.

Key Actions

· Recommendation 1: Anti-thyroid peroxidase antibody (TPOAb) evaluations are essential to consider when examining patients with subclinical hypothyroidism: Grade B evidence.

· Grade B is considered for the recommendation since the evidence is only predictive in nature.

· In case there are positive thyroid antibodies, the condition occurs at 4.3% and 2.6 annually in negative thyroid antibodies.

Recommendation 7: Besides pregnancy, serum free T4 assessment should be conducted rather than total T4 in evaluating hypothyroidism. Grade A evidence

· Recommendation 13: Patients being treated for hypothyroidism should have TSH serum measured at 4-8 weeks after first treatment of dose change. Grade B

· Consistent valuation aims at examining the effectiveness of the treatment

· Recommendation 16: Treatment centered on personal factors for individuals with TSH levels between 10 mIU/L and laboratory reference range should be considered if the patient demonstrates positive findings for hypothyroidism. Grade B

Recommendation 20.2: Hypothyroidism screening for aged patients above 60 years should be considered. Grade B

Application to Clinical

· Mrs. J.R, a 62-year-old African American presents to the clinic

· Her chief complaint was fatigue, feeling the cold, and low energy.

· Physical assessment reveals a high BMI of 31.2, dry skin, and hoarseness.

· Patient has diabetes and hypertension.

Patient’s husband is 72 year and suffering from HTN, and Dementia.

Diagnosis and Management

· Primary evaluation entails evaluating the physical symptoms.

· Diagnosis entails measuring TSH where high level reveals underactive thyroid.

· Other diagnoses as outlined in the CPG include BMR(Basic Metabolic Rate) and total cholesterol.

· Patient’s TSH was 11.2 mlU/L which revealed hypothyroidism.

· L-thyroxine at a strength of 50 mcg PO qDay was prescribed as suggested by the CPG (Garber et al., 2012).

Follow-up was scheduled after 30 days of the first dosage.

Conclusion

· Hypothyroidism is described by the underactive thyroid gland

· Key symptoms are fatigue, cold sensitivity, increase in weight, dry skin, and pain in the joints

· CPG outlines key recommendations including diagnosis and management approaches

· These guidelines can profoundly be applied to the primary care setting

· Hypothyroidism evaluation entails TSH levels, total cholesterol, and BMR

Management involves L-thyroxine and a follow-up after 4 weeks.