Choosing Wisely for Thyroid Conditions: Recommendations of the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism

Dora, Jose Miguel; Biscolla, Rosa Paula Mello; Caldas, Gustavo; Cerutti, Janete; Graf, Hans; Hoff, Ana O.; Mazeto, Glaucia M. F. S.; Magalhães, Patrícia Kunzle Ribeiro; Mesa, Cleo Otaviano; Scheffel, Rafael Selbach; Teixeira, Patricia de Fatima dos Santos; Vaisman, Fernanda; Villagelin, Danilo; Maia, Ana Luiza

doi:10.20945/2359-3997000000323

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Brief report • Arch. Endocrinol. Metab. 65 (2) • Mar-Apr 2021 • https://doi.org/10.20945/2359-3997000000323 copy

Choosing Wisely for Thyroid Conditions: Recommendations of the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

Choosing Wisely (CW) is an initiative that aims to advance the dialogue between physicians and patients about low-value health interventions. Given that thyroid conditions are frequent in clinical practice, we aimed to develop an evidence-based list of thyroid CW recommendations.

Materials and methods:

The Thyroid Department of the Brazilian Society of Endocrinology and Metabolism (SBEM) named a Task Force to conduct the initiative. The Task Force work was based on an electronic Delphi approach. The 10 recommendations that received the highest scores by the Task Force were submitted for voting by all SBEM associates. The 5 recommendations that received the highest scores by SBEM associates are presented herein.

Results:

The Task Force was composed of 14 thyroidologists from 10 tertiary-care, teaching-based Brazilian institutions. The brainstorming/ideation phase resulted in 69 recommendations. After the removal of duplicates and recommendations that did not adhere to the initiative's scope, 35 remained. Then the Task Force voted to attribute a grade (0 [lowest agreement] to 10 [highest agreement]) for each recommendation. The 10 recommendations that received the highest scores by the Task Force were submitted to all SBEM associates. A total of 683 associates voted electronically, attributing a grade (0 to 10) for each recommendation. The 5 recommendations that received the highest scores by the SBEM associates compose our final list.

Conclusion:

A set of recommendations to avoid unnecessary medical tests, treatments, or procedures for thyroid conditions are offered with a transparent methodology. This initiative aims to foster productive interactions between physicians and patients, stimulating shared decision-making.

Keywords
Choosing Wisely; overuse; thyroid; endocrinology

Recommendations of the Task Force	Task Force Grades (n = 14)
Do not repeat autoantibodies (antithyroperoxidase [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^* * This recommendation do not applies for patients with thyroid cancer predisposing conditions such as multiple endocrine neoplasia type 2 (MEN 2) mutations, patients with two or more family members with thyroid carcinoma and for patients with prior radiation of the neck.	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 (⁴4. de Carvalho GA, Paz-Filho G, Mesa Junior C, Graf H. Management of endocrine disease: Pitfalls on the replacement therapy for primary and central hypothyroidism in adults. Eur J Endocrinol. 2018;178(6):R231-R244.–⁷7. Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL, et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid. 2016;26(10):1343-421.).
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 (⁴4. de Carvalho GA, Paz-Filho G, Mesa Junior C, Graf H. Management of endocrine disease: Pitfalls on the replacement therapy for primary and central hypothyroidism in adults. Eur J Endocrinol. 2018;178(6):R231-R244.–⁶6. Brenta G, Vaisman M, Sgarbi JA, Bergoglio LM, Andrada NC, Bravo PP, et al. Clinical practice guidelines for the management of hypothyroidism. Arq Bras Endocrinol Metab. 2013;57(4):265-98.).
Do not repeat autoantibodies (antithyroperoxidase [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 (⁴4. de Carvalho GA, Paz-Filho G, Mesa Junior C, Graf H. Management of endocrine disease: Pitfalls on the replacement therapy for primary and central hypothyroidism in adults. Eur J Endocrinol. 2018;178(6):R231-R244.–⁶6. Brenta G, Vaisman M, Sgarbi JA, Bergoglio LM, Andrada NC, Bravo PP, et al. Clinical practice guidelines for the management of hypothyroidism. Arq Bras Endocrinol Metab. 2013;57(4):265-98.).
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 (⁸8. Rosário PW, Ward LS, Carvalho GA, Graf H, Maciel RMB, Maciel LMZ, et al. Thyroid nodules and differentiated thyroid cancer: update on the Brazilian consensus. Arq Bras Endocrinol Metab. 2013;57(4):240-64.–¹⁰10. Francis GL, Waguespack SG, Bauer AJ, Angelos P, Benvenga S, Cerutti JM, et al.; American Thyroid Association Guidelines Task Force. Management Guidelines for Children with Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2015;25(7):716-59.).
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 (⁸8. Rosário PW, Ward LS, Carvalho GA, Graf H, Maciel RMB, Maciel LMZ, et al. Thyroid nodules and differentiated thyroid cancer: update on the Brazilian consensus. Arq Bras Endocrinol Metab. 2013;57(4):240-64.–¹⁰10. Francis GL, Waguespack SG, Bauer AJ, Angelos P, Benvenga S, Cerutti JM, et al.; American Thyroid Association Guidelines Task Force. Management Guidelines for Children with Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2015;25(7):716-59.).

Sociedade Brasileira de Endocrinologia e Metabologia Rua Botucatu, 572 - Conjuntos 81/83, 04023-061 São Paulo SP Brasil, Tel: (55 11) 5575-0311 - São Paulo - SP - Brazil
E-mail: aem.editorial.office@endocrino.org.br

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[1] Correspondence to: José Miguel Dora, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Unidade de Tireoide, Serviço de Endocrinologia, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos 2350, 90035-003 – Porto Alegre, RS, Brasil.jdora@hcpa.edu.br