Clinical Implications of Off Target TSH Levels and Importance of Patient Education in Managing Hypothyroidism

Antonio Bianco, MD, PhD:Can we talk a little about conclusions here? Based on this conversation and everything I read about this, one thing that strikes me is that many patients on levothyroxine have an off-target serum TSH [thyroid-stimulating hormone] level: a larger one than I expected or wanted. Today it’s maybe around 20% of patients who we should keep an eye on and make sure we do a better job keeping normal TSH levels for these patients. This is important because there are clinical outcomes that are secondary to keeping an off-target TSH level that are not good.

James Hennessey, MD, FACP: No, they’re not.

Antonio Bianco, MD, PhD: Both high and low TSH levels will have clinical implications: mortality, osteoporosis, atrial fibrillation, or stroke. We talked about hospital readmission and mortality after admission. These are important consequences of keeping an off-target TSH level. If we can share a message to colleagues and clinicians, it is that this is important.

James Hennessey, MD, FACP: I thoroughly agree with you. It’s very important to achieve that normal TSH level, and I don’t think it’s been emphasized enough over the years. I remember in medical school being told that substitution of hypothyroidism was the simplest therapy I would ever experience. But the more I learn about it, the more nuances I see, and the more stumbling blocks there are to achieving consistent outcomes, the less I believe that simple statement as we identify more factors that need to be kept in mind and educate our patients better.

Antonio Bianco, MD, PhD: I learned that in my first year of medical school. That’s exactly what my professor said: “Hypothyroidism is the simplest disease to manage. You just give thyroid hormone replacement therapy.” Maybe in many cases that’s what it is, but as it turns out, there are lots of challenges associated with that. We should educate our patients as much as we can and stress the adherence issues: how to take the tablets, not to forget the tablets, and what to do if they forget. Talk to their pharmacist in terms of monitoring what they are taking and being consistent with what they’re taking. It doesn’t matter whether they take generic or brand name medications, but they need to be consistent on that. It’s important to share this with our colleagues and educate patients so they can be mindful that these are important factors that will decide the outcome of their treatment.

James Hennessey, MD, FACP: Consistency is the key word here. One trick that I have stumbled across is to suggest the 7-day pill organizer. I tell them, “Your favorite day of the week is when you would reload this. Put the entire week’s dosage in the individual slots in your 7-day pill organizer, and then on Tuesday, when you discover that you forgot to take the pill on Monday, take both of them.”

Antonio Bianco, MD, PhD: That’s right.

James Hennessey, MD, FACP: Make sure at the end of the week that all 7 slots have been addressed. If they’re only taking the tablets 6 times a week, that’s fine; leave 1 blank. But at the end of the week, everything needs to be gone.

Antonio Bianco, MD, PhD: That’s an important rule of thumb that we need to stress more with our patients. They have the flexibility of doing this in case they forget.

James Hennessey, MD, FACP: For my colleagues, I would also try to make sure they understood that an unexpected, abnormal TSH level in a patient with primary hypothyroidism on thyroid hormone therapy is an opportunity for them to consider an interesting differential diagnostic array. Why did this happen? Was this an error? Was this nonadherence? Did the patient run out of the thyroid medication? Did they get a different product that has a difference in bioavailability? Not infrequently, I wind up getting a cryptic email saying a patient was in for their annual exam and asking me to comment on their TSH level. And I’ll say, “Well, it looks abnormal. Were they going to follow up with me so I can follow through on this?” I would hope that my primary care colleagues would get more engaged and excited thinking about the reasons for this particular outcome.

Transcript edited for clarity