What is your approach to persons who have a TSH level between 4.5 and 10? Do they all get treated, or are there other stratification criteria—i.e., the presence of antithyroid antibodies—you use to determine the need for thyroid hormone therapy?
What do you do with patients that are between 4.5 and 10? That's the where the controversy comes. And for those patients, what we do is we treated on on a individual basis. We have to address each patient differently because it will be uh the outcome. It really requires a unique uh approach for each patient. Number one, we should think about the age. Uh the older we get, the higher we should tolerate elevated serum TSH. So an individual that's 65 or 70 that has a TSH of seven or eight. Uh we should tolerate that really uh without problems if the patient has no symptoms. So we should not go straight ahead and say, well let's start therapy for this patient because just the age group, we know that serum TSH levels will increase. The other thing that's important to think when we have we are not sure is to ask for antibodies, uh thyroid uh Microsoft antibodies or T. P. O. Those are very important because if a patient has a TSH that's borderline between 4.5 and 10 but has high levels high titles of anti thyroid peroxide days. So that's telling me that there is an active autoimmune process going on in that patient's thyroid. And if the TSH is already slightly elevated that will favor for me initiation of treatment. And of course I'm going to discuss this with the patient and ultimately that this decision should be combined between the patient and the physician. What's the alternative to that? The alternative to that is say, you know what you don't have. If you tell the patient you don't have major symptoms, come back in three months, come back in four months. We'll do another assessment of your TSH and free T four and uh antibodies. And we'll see what's the what's going on is the TSH going up? It means that the active immunological processes destroying your thyroid. So you're moving towards having hypothyroidism or if you after three or four months you repeat the TSH and the patient still has the same TSH level or similar levels and symptoms are not evidence, you should say. Uh you know, but it's good that we waited uh We should maybe wait three or four more months maybe I'll see you next year and we'll evaluate again. We should not rush to start treatment for patients. Uh We should only start treatment for those patients that we are absolutely convinced that have hypothyroidism.
