RICHARD PLOTZKER, MD, Endocrinology, Metabolism, 11:28AM Mar 14, 2013
This past month a few consults came my way to assess borderline TSH elevations in people into their late 80’s and early 90’s. There is some literature on this which makes it fair game for Endocrinology Boards. In fact it was taught at board review.
The evidence from this Dutch study and several others seems to be that people in their advanced years maintain better function and maybe even better longevity if the TSH is left slightly above the population normals. So my gentleman with the TSH of 5.31 and normal thyroid exam had the low dose levothyroxine ordered by the resident cancelled and advised to just follow this. The TSH assay in its original form become readily available in the 1970’s with a refinement that we use today in the 1980’s. Yet despite common familiarity that most clinicians have with hypothyroidism, there remains some uncertainty over who benefits from treatment and with what level of intensity, despite the treatment’s simplicity.
The same comment could be expanded for many other common diseases. This same gentleman had low grade diabetes and had been on metformin at age 87. Is there an age related end point to terminating therapy as there is a package insert limitation on age for starting therapy? Our prescription pads enable us to correct most any lab number, or in the parlance of physicians of my generation, make most patients euboxic. HbA1c can be brought under 7%, LDLC can be brought under 100mg/dl, testosterone in geriatric men can be raised to the level that they had in their reproductive years. But as the thyroid study seems to suggest, winning the battle of lab work may be counterproductive to the real goal of maintaining optimal function to the end of life and perhaps making life a little longer than it might otherwise have been.
Within the VA system, the largest cohort of beneficiaries over the years has been the World War II veterans, the youngest of whom now are in their mid-80’s. People of comparable age comprise many office visits and hospitalizations as well. Yet despite the increasing prevalence of these people who tend to have more medical challenges per capita than most, it remains very unclear as to whether the principles of medical management of chronic common endocrine disorders for which guidelines are well established really remain appropriate life-long.