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Vol. 52. Núm. 5.
Curso de endocrinología para posgraduados
Páginas 251-259 (Mayo 2005)
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Vol. 52. Núm. 5.
Curso de endocrinología para posgraduados
Páginas 251-259 (Mayo 2005)
Curso de endocrinología para posgraduados
Acceso a texto completo
Hipotiroidismo subclínico
Subclinical hypothyroidism
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J.J. Díez
Autor para correspondencia
mibarsd@infomed.es

Correspondencia: Dr. J.J. Díez. Servicio de Endocrinología. Hospital Ramón y Cajal. Ctra. de Colmenar, km 9,1. 28034 Madrid. España.
Servicio de Endocrinología. Hospital Ramón y Cajal. Madrid. España
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El hipotiroidismo subclínico, definido por la presencia de concentraciones elevadas de tirotropina en presencia de concentraciones normales de tiroxina libre es un trastorno frecuente en la población general, especialmente en mujeres de edad avanzada. Los pacientes con disfunción tiroidea subclínica moderada pueden evolucionar hacia el hipotiroidismo franco, hacia la estabilización de sus valores de tirotropina o hacia la normalización de la función tiroidea. La probabilidad de desarrollo de hipotiroidismo definitivo es superior en los pacientes que presentan concentraciones de tirotropina superiores a 10 mU/l, autoinmunidad tiroidea positiva y en los pacientes con enfermedad tiroidea previa o con tratamientos antitiroideos previos. Entre las rezones aducidas para el tratamiento farmacológico de los pacientes con hipotiroidismo subclínico se encuentra el alivio sintomático, la mejoría del perfil lipídico, la mejoría en la función cardíaca, los efectos beneficiosos sobre la aterosclerosis prematura y la prevención del desarrollo de hipotiroidismo franco. El tratamiento con tiroxina, sin embargo, no está desprovisto de inconvenientes. Entre ellos, se encuentra la ausencia de beneficio, la necesidad de medicación y revisiones médicas de por vida y la posibilidad de desarrollo de tirotoxicosis iatrogénica con los consecuentes efectos adversos sobre el hueso y el sistema cardiovascular. La mayoría de los expertos y sociedades científicas recomiendan instaurar tratamiento con tiroxina en pacientes con concentraciones de tirotropina superiores a 10 mU/l. En pacientes con concentraciones inferiores a este umbral se valorará también la posibilidad de tratamiento, especialmente en presencia de algunas circunstancias como embarazo, síntomas sugestivos de hipotiroidismo, bocio, anticuerpos antitiroideos positivos o elevación progresiva de las cifras de tirotropina.

Palabras clave:
Hipotiroidismo subclínico
Función tiroidea
Levotiroxina

Subclinical hypothyroidism is characterized by elevation of thyrotropin (TSH) concentrations with normal circulating concentrations of thyroid hormones. This mild thyroid failure is common in the general population, especially among elderly women. Patients with moderate subclinical hypothyroidism may progress to overt hypothyroidism, although other patients may show normalization of TSH concentrations or persistence of elevated serum TSH. The main risk factors for the development of overt thyroid failure in patients with subclinical hypothyroidism are TSH levels greater than 10 mU/l, thyroid autoimmunity, and a history of thyroid disease or thyroid treatments. Pharmacological therapy can be started in subclinical thyroid hypofunction to alleviate symptoms, improve lipid profile and cardiac function, ameliorate premature atherosclerotic changes, and prevent progression to overt disease. Replacement therapy with thyroxine is not without risks. Some concerns are the lack of benefit, and the need for life long medication and medical monitoring. Over-replacement with thyroxine is associated with the known adverse effects of thyrotoxicosis on bone mass and the cardiovascular system. Most authorities and scientific societies recommend starting thyroxine replacement therapy in patients with TSH concentrations higher than 10 mU/l. Patients who are pregnant, or who have symptoms of hypothyroidism, goiter, positive thyroid autoimmunity or progressive elevation of TSH levels can also to be considered for therapy, even when TSH concentrations are below 10 mU/l.

Key words:
Subclinical hypothyroidism
Thyroid function
Levothyroxine
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Bibliografía
[1.]
P.A. Bastenie, M. Bonnyns, P. Neve, L. Vanhaelst, M. Chailly.
Clinical and pathological significance of asymptomatic atrophic thyroiditis: a condition of latent hypothyroidism.
Lancet, 1 (1967), pp. 915-918
[2.]
D.C. Evered, B.J. Ormston, P.A. Smith, R. Hall, T. Bird.
Grades of hypothyroidism.
Br Med J, 1 (1973), pp. 657-662
[3.]
D.S. Ross.
Serum thyroid-stimulating hormone measurement for assessment of thyroid function and disease.
Endocrinol Metab Clin North Am, 30 (2001), pp. 245-264
[4.]
D.S. Cooper.
Subclinical hypothyroidism.
N Engl J Med, 345 (2001), pp. 260-265
[5.]
M.T. McDermott, E.C. Ridgway.
Subclinical hypothyroidism is mild thyroid failure and should be treated.
J Clin Endocrinol Metab, 86 (2001), pp. 4585-4590
[6.]
J.W. Chu, L.M. Crapo.
The treatment of subclinical hypothyroidism is seldom necessary.
J Clin Endocrinol Metab, 86 (2001), pp. 4591-4599
[7.]
M.I. Surks, E. Ortiz, G.H. Daniels, C.T. Sawin, N.F. Col, R.H. Cobin, et al.
Subclinical thyroid disease: scientific review and guidelines for diagnosis and management.
JAMA, 291 (2004), pp. 228-238
[8.]
J.G. Hollowell, N.W. Staehling, W.D. Flanders, W.H. Hannon, E.W. Gunter, C.A. Spencer, et al.
Serum TSH, T4, and thyroid antibodies in the United States population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III).
J Clin Endocrinol Metab, 87 (2002), pp. 489-499
[9.]
Laboratory Medicine Practice Guidelines.
Report of the National Academy of Clinical Biochemistry.
Thyroid, 13 (2003), pp. 33-37
[10.]
Stephens PA. Current issues in thyroid disease management: leading experts discuss new JAMA and JCE&M reports during endocrine society audioconference. Endocrine News. 2004;29:17-20. Disponible en: http://www.endo-society.org/news/endocrine_news/2004/thyroid-april2004.cfm
[11.]
V. Fatourechi, G.G. Klee, S.K. Grebe, R.S. Bahn, M.D. Brennan, I.D. Hay, et al.
Effects of reducing the upper limit to normal TSH value.
JAMA, 290 (2003), pp. 3195-3196
[12.]
W.M.G. Tunbridge, D.C. Evered, R. Hall, D. Appleton, M. Brewis, F. Clark, et al.
The spectrum of thyroid disease in the community: The Whickham Survey.
Clin Endocrinol (Oxf), 7 (1977), pp. 481-493
[13.]
G.J. Canaris, N.R. Manowitz, G.M. Mayor, E.C. Ridgway.
The Colorado thyroid disease prevalence study.
Arch Intern Med, 160 (2000), pp. 526-534
[14.]
G. Rivolta, R. Cerutti, R. Colombo, G. Miano, P. Dionisio, E. Grossi.
Prevalence of subclinical hypothyroidism in a population living in the Milan metropolitan area.
J Endocrinol Invest, 22 (1999), pp. 693-697
[15.]
C.T. Sawin, D. Chopra, F. Azizi, J.E. Mannix, P. Bacharach.
The aging thyroid: increased prevalence of elevated serum thyrotropin levels in the elderly.
JAMA, 242 (1979), pp. 247-250
[16.]
M.J. Rosenthal, W.C. Hunt, P.J. Garry, J.S. Goodwin.
Thyroid failure in the elderly. Microsomal antibodies as discriminant for therapy.
JAMA, 258 (1987), pp. 209-213
[17.]
N. Bagchi, T.R. Brown, R.F. Parish.
Thyroid dysfunction in adults over age 55 years. A study in an urban US community.
Arch Intern Med, 150 (1990), pp. 785-787
[18.]
J.V. Parle, J.A. Franklyn, K.W. Cross, S.C. Jones, M.C. Sheppard.
Prevalence and follow-up of abnormal thyrotrophin (TSH) concentrations in the elderly in the United Kingdom.
Clin Endocrinol (Oxf), 34 (1991), pp. 77-83
[19.]
R.D. Lindeman, D.S. Schade, A. LaRue, L.J. Romero, H.C. Liang, R.N. Baumgartner, et al.
Subclinical hypothyroidism in a biethnic, urban community.
J Am Geriatr Soc, 47 (1999), pp. 703-709
[20.]
A.E. Hak, H.A.P. Pols, T.J. Visser, H.A. Drexhage, A. Hofman, J.C.M. Witteman.
Subclinical hypothyroidism is an independent risk factor for atherosclerosis and myocardial infarction in elderly women: the Rotterdam Study.
Ann Intern Med, 132 (2000), pp. 270-278
[21.]
M.P.J. Vanderpump, W.M.G. Tunbridge, J.M. French, D. Appleton, D. Bates, F. Clark, et al.
The incidence of thyroid disorders in the community: a twenty-year follow-up of the Whickham Survey.
Clin Endocrinol (Oxf), 43 (1995), pp. 55-68
[22.]
H. Huber, J.J. Staub, C. Meier, C. Mitrache, M. Guglielmetti, P. Huber, et al.
Prospective study of the spontaneous course of subclinical hypothyroidism: prognostic value of thyrotropin, thyroid reserve, and thyroid antibodies.
J Clin Endocrinol Metab, 87 (2002), pp. 3221-3226
[23.]
J.J. Díez, P. Iglesias.
Spontaneous subclinical hypothyroidism in patients older than 55 years: an analysis of natural course and risk factor for the development of overt thyroid failure.
J Clin Endocrinol Metab, 89 (2004), pp. 4890-4897
[24.]
C. Meier, J.J. Staub, C.B. Roth, M. Guglielmetti, M. Kunz, A.R. Miserez, et al.
TSH-controlled L-thyroxine therapy reduces cholesterol levels and clinical symptoms in subclinical hypothyroidism: a double blind, placebo-controlled trial (Basel Thyroid Study).
J Clin Endocrinol Metab, 86 (2001), pp. 4860-4866
[25.]
N. Caraccio, E. Ferrannini, F. Monzani.
Lipoprotein profile in subclinical hypothyroidism: response to levothyroxine replacement, a randomized placebo-controlled study.
J Clin Endocrinol Metab, 87 (2002), pp. 1533-1538
[26.]
F. Monzani, N. Caraccio, M. Kozàkowà, A. Dardano, F. Vittone, A. Virdis, et al.
Effect of levothyroxine replacement on lipid profile and intima-media thickness in subclinical hypothyroidism: a double-blind, placebo-controlled study.
J Clin Endocrinol Metab, 89 (2004), pp. 2099-2106
[27.]
S.J.L. Bakker, J.C. Ter Matten, C. Popp-Snijders, J.PJ. Slaets, R.J. Heine, R.O.B. Gans.
The relationship between thyrotropin and low density lipoprotein cholesterol is modified by insulin sensitivity in healthy euthyroid subjects.
J Clin Endocrinol Metab, 86 (2001), pp. 1206-1211
[28.]
A.J. Bindels, R.G. Westendorp, M. Frolich, J.C. Seidell, A. Blokstra, A.H. Smelt.
The prevalence of subclinical hypothyroidism at different total plasma cholesterol levels in middle aged men and women: a need for case-finding?.
Clin Endocrinol (Oxf), 50 (1999), pp. 217-220
[29.]
W.J. Hueston, W.S. Pearson.
Subclinical hypothyroidism and the risk of hypercholesterolemia.
Ann Fam Med, 2 (2004), pp. 351-355
[30.]
M.P. Vanderpump, W.M. Tunbridge, J.M. French, D. Appleton, F. Bates Clark, J. Grimley Evans, et al.
The development of ischemic heart disease in relation to autoimmune thyroid disease in a 20-year follow-up study of an English community.
Thyroid, 6 (1996), pp. 155-160
[31.]
M. Imaizumi, M. Akahoshi, S. Ichimaru, E. Nakashima, A. Hida, M. Soda, et al.
Risk for ischemic heart disease and all-cause mortality in subclinical hypothyroidism.
J Clin Endocrinol Metab, 89 (2004), pp. 3365-3370
[32.]
B. Biondi, E.A. Palmieri, G. Lombardi, S. Fazio.
Effects of subclinical thyroid dysfunction on the heart.
Ann Intern Med, 137 (2002), pp. 904-914
[33.]
G.J. Kahaly.
Cardiovascular and atherogenic aspects of subclinical hypothyroidism.
Thyroid, 10 (2000), pp. 665-679
[34.]
F. Monzani, N. Caraccio, G. Siciliano, L. Manca, L. Murri, E. Ferrannini.
Clinical and biochemical features of muscle dysfunction in subclinical hypothyroidism.
J Clin Endocrinol Metab, 82 (1997), pp. 3315-3318
[35.]
F. Monzani, N. Caraccio, P. Del Guerra, A. Casolaro, E. Ferrannini.
Neuromuscular symptoms and dysfunction in subclinical hypothyroid patients: beneficial effects of L-T4 replacement therapy.
Clin Endocrinol (Oxf), 51 (1999), pp. 237-242
[36.]
A. Misiunas, H.N. Ravera, G. Faraj, E. Faure.
Peripheral neuropathy in subclinical hypothyroidism.
Thyroid, 5 (1995), pp. 283-286
[37.]
I.W. Beyer, R. Karmali, N. DeMesester-Mirkine, E. Cogan, M.J. Fuss.
Serum creatine kinase levels in overt and subclinical hypothyroidism.
Thyroid, 8 (1998), pp. 1029-1031
[38.]
F. Monzani, P. Del Guerra, N. Caraccio, C.A. Pruneti, E. Pucci, M. Luisi, et al.
Subclinical hypothyroidism: neurobehavioral features and beneficial effect of L-thyroxine treatment.
Clin Invest, 71 (1993), pp. 367-371
[39.]
I.M. Baldini, A. Vita, M.C. Maura, V. Amodei, M. Carrisi, S. Bravin, et al.
Psychological and cognitive features in subclinical hypothyroidism.
Prog Neuropsychopharmacol Biol Psychiatry, 21 (1997), pp. 925-935
[40.]
M. Ganguli, L.A. Burmeister, E.C. Seaberg, S. Belle, S.T. DeKosky.
Association between dementia and elevated TSH: a community- based study.
Biol Psychiatry, 40 (1996), pp. 714-725
[41.]
J. Gussekloo, E. Van Exel, A.J.M. De Craen, A.E. Meinders, M. Frölich, R.G.J. Westerdorp.
Thyroid status, disability and cognitive function, and survival in old age.
JAMA, 292 (2004), pp. 2591-2599
[42.]
J.E. Haddow, G.E. Palomaki, W.C. Allan, J.R. Williams, G.J. Knight, J. Gagnon, et al.
Maternal thyroid deficiency during pregnancy and subsequent neuropsychological development of the child.
N Engl J Med, 341 (1999), pp. 549-555
[43.]
M.L. Mitchell, R.Z. Klein.
The sequelae of untreated maternal hypothyroidism.
Eur J Endocrinol, 151 (2004), pp. U45-U48
[44.]
J.V. Parle, P. Maissonneuve, M.C. Sheppard, P. Boyle, J.A. Franklyn.
Prediction of all-cause and cardiovascular mortality in elderly people from one low serum thyrotropin result: a 10-year cohort study.
[45.]
D.S. Cooper, R. Halpern, L.C. Wood, A.A. Levin, E.C. Ridgway.
LThyroxine therapy in subclinical hypothyroidism. A doubleblind, placebo-controlled trial.
Ann Intern Med, 101 (1984), pp. 18-24
[46.]
E. Nystrom, K. Caidahl, G. Fager, C. Wikkelso, P.A. Lundberg, G. Lindstedt.
A double-blind cross-over 12-month study of Lthyroxine treatment of women with ‘subclinical’ hypothyroidism.
Clin Endocrinol (Oxf), 29 (1988), pp. 63-75
[47.]
R. Jaeschke, G. Guyatt, H. Gerstein, C. Patterson, W. Molloy, D. Cook, et al.
Does treatment with L-thyroxine influence health status in middle-aged and older adults with subclinical hypothyroidism?.
J Gen Intern Med, 11 (1996), pp. 744-749
[48.]
W.M. Kong, M.H. Sheikh, P.J. Lumb, D.B. Freedman, M. Crook, C.J. Doré, et al.
A 6-month randomized trial of thyroxin treatment in women with mild subclinical hypothyroidism.
Am J Med, 112 (2002), pp. 348-354
[49.]
B.C. Tanis, R.G.J. Westendorp, A.H.M. Smelt.
Effect of thyroid substitution on hypercholesterolaemia in patients with subclinical hypothyroidism: a re-analysis of intervention studies.
Clin Endocrinol (Oxf), 44 (1996), pp. 643-649
[50.]
M.D. Danese, P.W. Ladenson, C.L. Meinert, N.R. Powe.
Effect of thyroxine therapy on serum lipoproteins in patients with mild thyroid failure: a quantitative review of the literature.
J Clin Endocrinol Metab, 85 (2000), pp. 2993-3001
[51.]
T. Diekman, P.J. Lansberg, J.J. Kastelein, W.M. Wiersinga.
Prevalence and correction of hypothyroidism in a large cohort of patients referred for dyslipidemia.
Arch Intern Med, 155 (1995), pp. 1490-1495
[52.]
S. Miura, M. Iitaka, H. Yoshimura, S. Kitahama, N. Fukasawa, Y. Kawakami, et al.
Disturbed lipid metabolism in patierns with subclinical hypothyroidism: effect of L-thyroxin therapy.
Intern Med, 33 (1994), pp. 413-417
[53.]
B. Biondi, S. Fazio, E.A. Palmieri, C. Carella, N. Panza, A. Cittadini, et al.
Left ventricular diastolic dysfunction in patients with subclinical hypothyroidism.
J Clin Endocrinol Metab, 84 (1999), pp. 2064-2067
[54.]
F. Monzani, V. Di Bello, N. Caraccio, A. Bertini, D. Giorgi, C. Giusti, et al.
Effect of levothyroxine on cardiac function and structure in subclinical hypothyroidism: a double blind, placebocontrolled study.
J Clin Endocrinol Metab, 86 (2001), pp. 1110-1115
[55.]
J.V. Parle, J.A. Franklyn, K.W. Cross, S.R. Jones, M.C. Sheppard.
Thyroxine prescription in the community: serum thyroid hormone stimulating level assay as an indicator of undertreatment or overtreatment.
Br J Gen Pract, 43 (1993), pp. 107-109
[56.]
J.G. Watsky, M.A. Koeniger.
Prevalence of iatrogenic hyperthyroidism in a community hospital.
J Am Board Fam Pract, 11 (1998), pp. 175-179
[57.]
S.L. Greenspan, F.S. Greenspan.
The effect of thyroid hormone on skeletal integrity.
Ann Intern Med, 130 (1999), pp. 750-758
[58.]
B. Uzzan, J. Campos, M. Cucherat, P. Nony, J.P. Boissel, G.Y. Perret.
Effects on bone mass of long term treatment with thyroid hormones: a meta-analysis.
J Clin Endocrinol Metab, 81 (1996), pp. 4278-4289
[59.]
C.T. Sawin, A. Geller, P.A. Wolf, A.J. Belanger, E. Baker, P. Bacharach, et al.
Low serum thyrotropin concentrations as a risk factor for atrial fibrillation in older persons.
N Engl J Med, 331 (1994), pp. 1249-1252
[60.]
V. Fatourechi, M. Lankarani, P.G. Schryver, D.J. Vanness, K.H. Long, G.G. Klee.
Factors influencing clinical decisions to initiate thyroxine therapy for patients with mildly increased serum thyrotropin (5.1-10.0 mIU/L).
Mayo Clin Proc, 78 (2003), pp. 554-560
[61.]
M.D. Danese, N.R. Powe, C.T. Sawin, P.W. Ladenson.
Screening for mild thyroid failure at the periodic health examination: a decision and cost-effectiveness analysis.
JAMA, 276 (1996), pp. 285-292
[62.]
P.W. Ladenson, P.A. Singer, K.B. Ain, N. Bagchi, S.T. Bigos, E.G. Levy, et al.
American Thyroid Association guidelines for detection of thyroid dysfunction.
Arch Intern Med, 160 (2000), pp. 1573-1575
[63.]
G.C. Glenn.
Practice parameter on laboratory panel testing for screening and case finding in asymptomatic adults. Laboratory Testing Strategy Task Force of the College of American Pathologists.
Arch Pathol Lab Med, 120 (1996), pp. 929-943
[64.]
American College of Physicians.
Screening for thyroid disease.
Ann Intern Med, 129 (1998), pp. 141-143
[65.]
Periodic Health Examination: summary of AAFP policy recommendations and age charts, revision 4.0. Kansas City, Mo.: American Academy of Family Physicians; 2000.
[66.]
American Association of Clinical Endocrinologists.
American Association of Clinical Endocrinologists medical guidelines for clinical practice for the evaluation and treatment of hyperthyroidism and hypothyroidism.
Endocr Pract, 8 (2002), pp. 457-459
[67.]
M.P. Vanderpump, J.A. Ahlquist, J.A. Franklyn, R.N. Clayton.
Consensus statement for good practice and audit measures in the management of hypothyroidism and hyperthyroidism.
BMJ, 313 (1996), pp. 539-544
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