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De-escalation in the Care of Thyroid Disorders

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The recently concluded 2023 Endocrine Society Annual Conference in Chicago brought together a diverse range of attendees from across the world and showcased cutting-edge research across various disciplines of endocrinology. 

Most sessions were standing-room only, and presentations related to thyroid disorders were extremely popular. This year's overarching theme in thyroid disorders was the concept of de-escalation of therapies to provide effective outcome-based treatment to our patients. Both overdiagnosis and overtreatment contribute to increased health care costs and place our patients at risk of potential harm. 

Deprescribing is defined as a patient-centered process to taper or stop medications with the intention to achieve improved health outcomes by reducing exposure to said medications that can be either harmful or no longer required. Levothyroxine is one of the most prescribed medications. Dr. Maria Papaleontiou from the University of Michigan discussed the appropriate use of thyroid hormone replacement in older adults. Aging is associated with an increase in serum TSH levels, and most laboratories lack age-adjusted reference ranges for clinicians. This has led to inappropriate use of levothyroxine in older adults, which carries the risk of bone loss and atrial fibrillation, among other detrimental effects. Approximately 6-25% of elderly patients taking levothyroxine develop iatrogenic thyrotoxicosis. Dr. Papaleontiou advocates for the judicious use of levothyroxine in older adults and consideration of deprescribing to reduce potential complications in the elderly.  

Overdiagnosis is defined as detection of a medical condition that, if left undiagnosed, would cause no harm. Dr. Naykky Singh Ospina from the University of Florida, Gainesville, discussed the inappropriate evaluation of many thyroid nodules, resulting in overdiagnosis of low-risk thyroid cancer. American Thyroid Association (ATA) guidelines for the evaluation and management of thyroid nodules are not consistently followed, and a recent study looking at Physician Perspectives in the work-up of thyroid nodules showed that 64% of clinicians recommended evaluation that led to overdiagnosis of low-risk thyroid cancer. The potential harms of cancer overdiagnosis extend beyond unnecessary surgeries and possible complications, encompassing emotional and financial tribulations incurred by the cancer diagnosis.

In 2012, the Endocrine Society, under the auspices of the Choosing Wisely initiative, recommended against ordering thyroid ultrasounds in individuals with subclinical or overt hypothyroidism and a normal neck exam. Despite clear guidelines, studies have shown that thyroid ultrasounds continue to be ordered inappropriately and result in further medical encounters, repeat ultrasound, biopsy, thyroid surgery, and subspecialty consultation, all increasing cost of care. Dr. Juan Brito from the Mayo Clinic addressed the overuse of thyroid ultrasound in practice and emphasized that there is a limited or no role of ultrasound in patients with thyroid dysfunction.

Thyroid cancer is a common endocrine malignancy, and most patients are diagnosed with low-risk differentiated thyroid cancer. Neck ultrasonography and serum thyroglobulin measurements are the mainstays in long-term thyroid cancer surveillance. Dr. Megan Haymart from the University of Michigan addressed the uncertainties regarding optimal surveillance in patients with low-risk differentiated thyroid cancer. She argued for tailoring our follow-up strategies to individual patients and de-escalating ultrasonographic surveillance in patients at low risk for recurrence. 

Multiple factors influence the adoption of any new guidelines and recommendations. Barriers to adherence are multifactorial: encompassing clinician knowledge and attitudes as well as patient behavior and resistance. Clinician knowledge barriers include lack of awareness of, or familiarity with the guidelines. Clinicians may disagree with specific guidelines based on individual experiences and motivations. Clinician behavior may also be related to a perceived increase in malpractice liability. Enhancing the clarity of guidelines and providing adequate clinician education may help facilitate meaningful changes in the future. 

Overall, the 2023 Endocrine Society conference provided valuable insights into thyroid disorders, with a focus on the de-escalation of therapies to ensure value-based treatment for patients.

Dr. Bhan has no conflicts of interest to report.

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