Choosing Wisely for Thyroid Conditions: Recommendations of SBEM

Recommendations of the Task Force

Task Force Grades
(n = 14)

Do not repeat autoantibodies (anti thyroperoxidase [anti-TPO] and antithyroglobulin) measurements in the follow-up of patients with Hashimoto's hypothyroidism who have a previous positive antibody

9.4 ± 1.2

Do not order total T3 and/or free T3 measurements in patients without clinical suspicion or diagnosis of hyperthyroidism/thyrotoxicosis

9.1 ± 1.6

Do not order thyroid ultrasound for nodule detection in patients without thyroid anatomic anomalies on clinical examination*

9.1 ± 1.2

Do not prescribe triiodothyronine (T3), alone or combined with levothyroxine (T4), for hypothyroidism treatment

8.6 ± 1.8

Do not order reverse T3 (rT3) for evaluation of thyroid function

8.9 ± 1.3

Do not order thyroglobulin in the initial evaluation of thyroid nodules

8.9 ± 1.9

Do not perform frequent monitoring (interval less than 6 months) with TSH and free T4 in patients with hypothyroidism who are treated with a stable dose of levothyroxine (LT4) and have no specific clinical indication

8.6 ± 1.8

Do not order molecular markers in the initial evaluation of patients with thyroid nodules

8.6 ± 1.8

Do not administer high radioactive iodine activities for patients with thyroid carcinoma considered to be of low risk

8.3 ± 2.4

Do not maintain suppressive doses of levothyroxine (LT4) in patients with differentiated thyroid carcinoma with excellent response

8.2 ± 2.3

Recommendation

Rationale

Do not order reverse T3 (rT3) for evaluation of thyroid function

Reverse T3 is derived from the inactivation of T4, which occurs predominantly through type 3 deiodinase activity. It is an inactive hormone, and its serum level does not reflect thyroid function. Thus, its measurement has specific indications (most of them in a research setting) and should not be done to evaluate thyroid function

Do not prescribe triiodothyronine (T3), alone or combined with levothyroxine (T4), for hypothyroidism treatment

Although the thyroid produces small amounts of T3, there is no evidence that the treatment of hypothyroidism should include T3 seeking improvement of symptoms. T4 is inexpensive, has rapid intestinal absorption and a long half-life (7 days), and allows for single daily intakes and plasma stability of T3 and T4. T4 depends on tissue deiodination for conversion to T3. T3 has a short half-life and requires several daily intakes. Although some experimental animal data suggest that the combination of T4 and T3 may be superior to T4 alone, there is no clear evidence of this effect on humans, so the combination is not routinely recommended

Do not repeat autoantibodies (anti thyroperoxidase [anti-TPO] and antithyroglobulin) measurements in the follow-up of patients with Hashimoto's hypothyroidism who have a previous positive antibody

Once the autoantibodies (anti-TPO and antithyroglobulin) are positive, the etiology of hypothyroidism is defined, and there is no need to repeat them

Do not order thyroglobulin in the initial evaluation of thyroid nodules

Thyroglobulin, a tissue-specific protein, is one of the main parameters in the follow-up of patients with thyroid cancer who have undergone surgery. Serum thyroglobulin levels may increase in various thyroid (benign and malignant) diseases. Thus, serum thyroglobulin measurement does not add information about the nature of thyroid nodules and has no role in thyroid cancer detection

Do not order molecular markers in the initial evaluation of patients with thyroid nodules

Fine-needle aspiration biopsy (FNAB) is the most accurate and cost-effective method for evaluating thyroid nodules. Molecular markers should only be used if they improve clinical decision-making. The usefulness of a molecular test should be based on strong evidence that the result will add to the decision-making process, thus justifying its incorporation into clinical practice. It is not the case of molecular markers in the diagnosis of thyroid nodules, which have their nature clarified in about 85% of patients undergoing FNAB. The role of molecular markers may be justified in some cases of nodules in which the FNAB did not provide a definitive diagnosis, respecting the particular context of the patient and the health care setting