An 82-year-old woman comes to the office due to fatigue. For the last 6 months since her husband died, she has had low energy associated with decreased appetite. The patient has had no weight change, fevers, chills, or night sweats. She sleeps 5-6 hours a night. Medical history is notable for hypertension, depression, and osteoporosis, for which she takes hydrochlorothiazide, sertraline, and alendronate, respectively. She does not smoke, and she drinks alcohol only once or twice a year on social occasions.
Temperature is 36.8 C (98.2 F) , blood pressure is 128/82 mm Hg, and pulse is 68/min. BMI is 24 kg/m². On examination, the patient is awake, alert, and cooperative. Neck examination is normal with no goiter. Cardiopulmonary examination is normal. Neurologic examination shows normal cranial nerves and motor strength. Ankle reflexes are absent.
Laboratory studies show normal glucose, electrolytes, and blood counts. TSH is 7.2 µU/mL, and free T4 is 1.1 ng/dL (normal: 0.9-1.7 ng/dL) .
Which of the following is the most appropriate next step in management of this patient's symptoms?

Question

Quizplus · Accepted Answer

11ec193a_97d5_c782_853d_09b642abb9d2_MD0002_00 This patient has subclinical hypothyroidism, defined as a serum TSH above the upper limit of normal with serum free T4 in the normal range. Subclinical hypothyroidism is often associated with symptoms that suggest a hypothyroid state, but in most cases symptoms are vague and highly nonspecific (eg, fatigue, constipation). Treatment of subclinical hypothyroidism is recommended for all patients with TSH ≥10 or those age <70 with convincing hypothyroid symptoms or features associated with progression to overt hypothyroidism (eg, enlarging goiter, elevated anti-thyroid peroxidase antibody titer). In contrast, older (age ≥70) patients with subclinical hypothyroidism warrant more conservative management. Levothyroxine replacement in this population confers less benefit than in younger patients and carries an increased risk for adverse events (eg, atrial fibrillation). In addition, some experts believe that the true normal TSH range in older patients may be higher than in younger patients, and levels as high as 8 µU/mL may represent physiologic euthyroidism in patients age >80. In lieu of treatment, older patients should be monitored with periodic retesting (eg, in 1-3 months and every 6-12 months thereafter), and treatment should be considered for those who progress to overt hypothyroidism (Choice A). (Choice C) T3 is produced primarily in peripheral tissues; serum levels correlate poorly with thyroid status. Free T3 levels have some utility in evaluating hyperthyroidism but are not recommended in hypothyroidism. (Choice D) Thyroid ultrasound is primarily used for evaluation of patients with a palpable goiter or thyroid nodules. It is not indicated in routine evaluation of hypothyroid conditions. (Choice E) Thyrotropin (TSH) receptor antibodies are involved in the pathogenesis of Graves disease, the most common cause of hyperthyroidism. Serum titers have little utility in evaluation of hypothyroidism. Educational objective: Subclinical hypothyroidism is defined as a serum TSH above the upper limit of normal with a serum free T4 level in the normal range. Patients age ≥70 with subclinical hypothyroidism should generally not be treated but should have periodic monitoring for progression to overt hypothyroidism. __________ References: Thyroid hormone therapy for older adults with subclinical hypothyroidism. (http://www.ncbi.nlm.nih.gov/pubmed/28402245)

An 82-Year-Old Woman Comes to the Office Due to Fatigue