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Vol. 52. Núm. 7.
Páginas 358-364 (Septiembre 2005)
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Vol. 52. Núm. 7.
Páginas 358-364 (Septiembre 2005)
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Acceso a texto completo
Monitorización del tratamiento con tiroxina en el hipotiroidismo primario y central
Monitoring of thyroxine treatment in primary and central hypothyroidism
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G. Sesmilo
Autor para correspondencia
gsesmilo@clinic.ub.es

Correspondencia: Dr. G. Sesmilo. Servei d’Endocrinologia. Hospital Clínic. Villarroel, 170, Esc. 11, 2.° piso. 08036 Barcelona. España.
Servei d’Endocrinologia. Hospital Clínic i Institut Universitari Dexeus. Barcelona. España
Información del artículo

En general, el tratamiento del hipotiroidismo con levotiroxina es un tratamiento satisfactorio, aunque algunos pacientes refieren dificultad en retornar a la situación clínica premórbida. La monitorización del tratamiento se realiza mediante la clínica y las concentraciones de tirotropina y tiroxina libre, aunque algunos autores recomiendan, en algunos casos, determinar sólo concentraciones de tirotropina, siempre hay que individualizar en función de las características del paciente. El objetivo es obtener concentraciones de tiroxina libre en la mitad superior del intervalo de normalidad y concentraciones de tirotropina entre 0,4 y 2 mU/l, aunque para algunos expertos, en el hipotiroidismo primario, se aceptan concentraciones de tirotropina por debajo del límite normal si el paciente presenta clínica de hipotiroidismo cuando la tirotropina es normal. Para la determinación de la tirotropina debemos utilizar ensayos de sensibilidad funcional inferior o igual a 0,02 mU/l. Para la determinación de la tiroxina y la triyodotironina libre, podemos utilizar ensayos automatizados de ligandos, aunque es importante conocer que éstos tienen cierta dependencia de las proteínas transportadoras y que no todos los ensayos tienen la misma precisión.

La monitorización del hipotiroidismo central se realiza mediante determinación de tiroxina libre que debe mantenerse en el tercio más alto del límite normal, la triyodotironina libre puede añadir sensibilidad en la detección de casos de tratamiento no óptimo. La clínica, aunque es fundamental en el seguimiento de los pacientes, es muy inespecífica en la detección de la sobre e infradosificación. En el hipotiroidismo entral, a veces, otros parámetros bioquímicos como el receptor soluble de la interleucina-2, pueden ser útiles en la detección de casos de tratamiento no óptimo.

Palabras clave:
Hipotiroidismo
Tratamiento
Levotiroxina
Monitorización

In general, treatment of hypothyroidism with levothyroxine (LT4) is satisfactory, although some patients report difficulty in returning to their premorbid clinical status. Treatment monitoring is performed through symptom evaluation and determination of thyroid-stimulating hormone (TSH) and free T4 concentrations, although in selected patients, some authors recommend TSH determination alone, depending on the patient's characteristics and based on an individualized approach. The aim is to achieve free T4 concentrations in the upper half of the normal range and TSH concentrations of between 0.4 and 2 mUI/L, although some experts believe that in primary hypothyroidism, TSH concentrations below the normal limit are acceptable if the patient shows symptoms of hypothyroidism when TSH levels are normal. For TSH determination, assays with a functional sensitivity of less than or equal to 0.02 mUI/L should be used. For free T4 and T3 determination, automated ligand assays can be used, although these show a certain dependency on transport proteins and not all assays have the same precision.

Monitoring of central hypothyroidism is performed through free T4 determination and levels should be maintained in the upper third of the normal range. Free T3 may add sensitivity in the detection of cases of suboptimal treatment. Clinical findings, although fundamental in patient follow-up, are highly nonspecific in the detection of over- and under-dosing. In central hypothyroidism, sometimes other biochemical parameters such as the interleukin-2 soluble receptor can be useful in detecting cases of suboptimal treatment.

Key words:
Hypothyroidism
Treatment
Levothyroxine
Monitoring
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Bibliografía
[1.]
H. Escobar Morreale.
Tratamiento actual del hipotiroidismo: una revisión crítica.
Endocrinol Nutr, 48 (2001), pp. 78-81
[2.]
P. Saravanan, W.F. Chau, N. Roberts, K. Vedhara, R. Greenwood, C.M. Dayan.
Psychological well-being in patients on ‘adequate’ doses of l-thyroxine: results of a large, controlled communitybased questionnaire study.
Clin Endocrinol (Oxf), 57 (2002), pp. 577-585
[3.]
A.D. Toft, G.J. Beckett.
Thyroid function tests and hypothyroidism - Restoring serum TSH to reference range should be goal of replacement - Letter. Reply.
BMJ, 326 (2003), pp. 1087
[4.]
M. Crilly.
Thyroid function tests and hypothyroidism - Reducing concentrations further would be harmful.
BMJ, 326 (2003), pp. 1086
[5.]
M.P. Vanderpump, J.A. Franklyn.
Thyroid function tests and hypothyroidism. Restoring serum TSH to reference range should be goal of replacement.
[6.]
S. Andersen, K.M. Pedersen, N.H. Bruun, P. Laurberg.
Narrow individual variations in serum T(4) and T(3) in normal subjects: a clue to the understanding of subclinical thyroid disease.
J Clin Endocrinol Metab, 87 (2002), pp. 1068-1072
[7.]
AACE Thyroid Task Force.
American Association of Clinical Endocrinologists medical guidelines for clinical practice for the evaluation and treatment of hyperthyroidism and hypothyroidism.
Endocrine Practice, 8 (2002), pp. 457-469
[8.]
A.D. Toft, G.J. Beckett.
Thyroid function tests and hypothyroidism-Measurement of serum TSH alone may not always reflect thyroid status.
BMJ, 326 (2003), pp. 295-296
[9.]
N.D. Roberts.
Psychological problems in thyroid disease.
British Thyroid Foundation Newsletter, 18 (1996), pp. 3
[10.]
R. Bunevicius, G. Kazanavicius, R. Zalinkevicius, A.J. Prange Jr.
Effects of thyroxine as compared with thyroxine plus triiodothyronine in patients with hypothyroidism.
N Engl J Med, 340 (1999), pp. 424-429
[11.]
H.F. Escobar-Morreale, F.E. Del Rey, M.J. Obregón, G.M. De Escobar.
Only the combined treatment with thyroxine and triiodothyronine ensures euthyroidism in all tissues of the thyroidectomized rat.
Endocrinology, 137 (1996), pp. 2490-2502
[12.]
P.R. Larsen.
Thyroid hormone metabolism in the central nervous system.
Acta Med Austr, 15 (1988), pp. 5-10
[13.]
P.R. Larsen.
The thyroid gland.
William's textbook of endocrinology, pp. 357-488
[14.]
J.E. Silva, T.E. Dick, P.R. Larsen.
The contribution of local tissue thyroxine monodeiodination to the nuclear 3,5,3’-triiodothyronine in pituitary, liver, and kidney of euthyroid rats.
Endocrinology, 103 (1978), pp. 1196-1207
[15.]
P.W. Clyde, A.E. Harari, E.J. Getka, K.M. Shakir.
Combined levothyroxine plus liothyronine compared with levothyroxine alone in primary hypothyroidism: a randomized controlled trial.
JAMA, 290 (2003), pp. 2952-2958
[16.]
A.M. Sawka, H.C. Gerstein, M.J. Marriott, G.M. MacQueen, R.T. Joffe.
Does a combination regimen of thyroxine (T4) and 3,5,3’-triiodothyronine improve depressive symptoms better than T4 alone in patients with hypothyroidism? Results of a doubleblind, randomized, controlled trial.
J Clin Endocrinol Metab, 88 (2003), pp. 4551-4555
[17.]
W. Siegmund, K. Spieker, A.I. Weike, T. Giessmann, C. Modess, T. Dabers, et al.
Replacement therapy with levothyroxine plus triiodothyronine (bioavailable molar ratio 14:1) is not superior to thyroxine alone to improve well-being and cognitive performance in hypothyroidism.
Clin Endocrinol (Oxf), 60 (2004), pp. 750-757
[18.]
J.P. Walsh, L. Shiels, E.M. Lim, C.I. Bhagat, L.C. Ward, B.G. Stuckey, et al.
Combined thyroxine/liothyronine treatment does not improve well-being, quality of life, or cognitive function compared to thyroxine alone: a randomized controlled trial in patients with primary hypothyroidism.
J Clin Endocrinol Metab, 88 (2003), pp. 4543-4550
[19.]
C.M. Dayan, P. Saravanan, G. Bayly.
Whose normal thyroid function is better-Yours or mine?.
[20.]
D. Carr, D.T. Mcleod, G. Parry, H.M. Thornes.
Fine adjustment of thyroxine replacement dosage - comparison of the thyrotropin releasing hormone test using a sensitive thyrotropin assay with measurement of free thyroid-hormones and clinical-assessment.
Clinl Endocrinol (Oxf), 28 (1988), pp. 325-333
[21.]
P.R. Larsen.
Thyroid-pituitary interaction: feedback regulation of thyrotropin secretion by thyroid hormones.
N Engl Med, 306 (1982), pp. 23-32
[22.]
A.D. Toft.
Thyroxine therapy.
N Engl J Med, 331 (1994), pp. 174-180
[23.]
L.H. Fish, H.L. Schwartz, J. Cavanaugh, M.W. Steffes, J.P. Bantle, J.H. Oppenheimer.
Replacement dose, metabolism, and bioavailability of levothyroxine in the treatment of hypothyroidism. Role of triiodothyronine in pituitary feedback in humans.
N Engl J Med, 316 (1987), pp. 764-770
[24.]
G. Sesmilo, O. Simó, J. Gaya, J. Orrego, I. Halperín.
Concentraciones de tiroxina y triiodotironina en el hipotiroidismo central y primario. Comunicación personal.
Congreso de la SEEN, (2003),
[25.]
D.S. O’Reilly.
Thyroid function tests-time for a reassessment.
BMJ, 320 (2000), pp. 1332-1334
[26.]
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
[27.]
G. Morreale, M.J. Obregón, F. Escobar.
Is neuropsychological development related to maternal hypothyroidism or to maternal hypothyroxinemia?.
J Clin Endocrinol Metab, 85 (2000), pp. 3975-3987
[28.]
E.K. Alexander, E. Marqusee, J. Lawrence, P. Jarolim, G.A. Fischer, P.R. Larsen.
Timing and magnitude of increases in levothyroxine requirements during pregnancy in women with hypothyroidism.
N Engl J Med, 351 (2004), pp. 241-249
[29.]
A. Toft.
Increased levothyroxine requirements in pregnancy-Why, when, and how much?.
N Engl J Med, 351 (2004), pp. 292-294
[30.]
M.P. Vanderpump, W.M. 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
[31.]
Laboratory medicine practice guidelines: laboratory support for the diagnosis and monitoring of thyroid disease,
[32.]
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
[33.]
C. Bernutz, K. Horn, A. Konig, C.R. Pickardt.
Advantages of sensitive assays for thyrotropin in the diagnosis of thyroid disorders.
J Clin Chem Clin Biochem, 23 (1985), pp. 851-856
[34.]
J. Kalra, I.R. Hart.
Value of free thyroxine (FT4), free triiodothyronine (FT3), and sensitive thyrotropin (TSH) assay in the assessment of optimal thyroxine therapy.
Clin Biochem, 20 (1987), pp. 265-267
[35.]
T. Wheatley, P.M. Clark, J.D. Clark, P.R. Raggatt, O.M. dwards.
Thyroid stimulating hormone measurement by an ultrasensitive assay during thyroxine replacement: comparison with other tests of thyroid function.
Ann Clin Biochem, 24 (1987), pp. 614-619
[36.]
G. Benker, M. Raida, T. Olbricht, R. Wagner, W. Reinhardt, D. Reinwein.
TSH secretion in Cushing's syndrome: relation to glucocorticoid excess, diabetes, goitre, and the sick euthyroid syndrome’.
Clin Endocrinol (Oxf), 33 (1990), pp. 777-786
[37.]
J. Hangaard, M. Andersen, E. Grodum, O. Koldkjaer, C. Hagen.
Pulsatile thyrotropin secretion in patients with Addison's disease during variable glucocorticoid therapy.
J Clin Endocrinol Metab, 81 (1996), pp. 2502-2507
[38.]
B.G. Van den, F. De Zegher, P. Lauwers.
Dopamine and the sick euthyroid syndrome in critical illness.
Clin Endocrinol (Oxf), 41 (1994), pp. 731-737
[39.]
K. Liewendahl, H. Mahonen, S. Tikanoja, T. Helenius, M. Turula, M. Valimaki.
Good correlation between free thyroid hormone concentrations as measured by equilibrium dialysis and analog radioimmunoassays.
Clin Chem, 32 (1986), pp. 2209-2210
[40.]
G.C. Zucchelli, A. Pilo, M.R. Chiesa, S. Masini.
Systematic differences between commercial immunoassays for free thyroxine and free triiodothyronine in an external quality assessment program.
Clin Chem, 40 (1994), pp. 1956-1961
[41.]
H. Zulewski, B. Muller, P. Exer, A.R. Miserez, J.J. Staub.
Estimation of tissue hypothyroidism by a new clinical score: evaluation of patients with various grades of hypothyroidism and controls.
J Clin Endocrinol Metab, 82 (1997), pp. 771-776
[42.]
M. Horimoto, M. Nishikawa, T. Ishihara, N. Yoshikawa, M. Yoshimura, M. Inada.
Bioactivity of thyrotropin (TSH) in patients with central hypothyroidism: comparison between in vivo 3,5,3’-triiodothyronine response to TSH and in vitro bioactivity of TSH.
J Clin Endocrinol Metab, 80 (1995), pp. 1124-1128
[43.]
S.R. Rose.
Cranial irradiation and central hypothyroidism.
Trends Endocrinol Metab, 12 (2001), pp. 97-104
[44.]
E. Ferretti, L. Persani, M.L. Jaffrain-Rea, S. Giambona, G. Tamburrano, P. Beck-Peccoz.
Evaluation of the adequacy of levothyroxine replacement therapy in patients with central hypothyroidism.
J Clin Endocrinol Metab, 84 (1999), pp. 924-929
[45.]
G. Sesmilo, B.M. Biller, J. Llevadot, D. Hayden, G. Hanson, N. Rifai, et al.
Effects of growth hormone (GH) administration on homocyst(e)ine levels in men with GH deficiency: a randomized controlled trial.
J Clin Endocrinol Metab, 86 (2001), pp. 1518-1524
[46.]
H. Al Adsani, L.J. Hoffer, J.E. Silva.
Resting energy expenditure is sensitive to small dose changes in patients on chronic thyroid hormone replacement.
J Clin Endocrinol Metab, 82 (1997), pp. 1118-1125
[47.]
J. Auer, R. Berent, B. Eber.
Subclinical thyroid dysfunction and the heart.
Ann Intern Med, 139 (2003), pp. 865-866
[48.]
M.K. Horne III, K.K. Singh, K.G. Rosenfeld, R. Wesley, M.C. Skarulis, P.K. Merryman, et al.
Is thyroid hormone suppression therapy prothrombotic?.
J Clin Endocrinol Metab, 89 (2004), pp. 4469-4473
[49.]
S.L. Greenspan, F.S. Greenspan.
The effect of thyroid hormone on skeletal integrity.
Ann Intern Med, 130 (1999), pp. 750-758
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