Leonard Wartofsky, MD
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Leonard Wartofsky, MD, Washington Hospital Center, 110 Irving Street NW, Washington, DC 20010.
Wartofsky L.; Update in Endocrinology. Ann Intern Med. 2005;143:673-682. doi: 10.7326/0003-4819-143-9-200511010-00011
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Published: Ann Intern Med. 2005;143(9):673-682.
This Update in endocrinology represents a critical examination of articles selected from more than 25 peer-reviewed journals from the fields of endocrinology and general internal medicine. Criteria for selection included both the importance of the observations and their applicability to clinical practice today. The articles are broadly grouped into various areas of endocrinology.
American Diabetes Association (ADA) guidelines (1) recommend routine exercise electrocardiogram (ECG) stress testing to detect silent coronary artery disease in diabetic patients when 2 or more additional risk factors are present. The Detection of Ischemia in Asymptomatic Diabetics (DIAD) study tested the effectiveness of these guidelines. Patients with type 2 diabetes ranging in age from 50 to 75 years (n = 1123) with no known coronary artery disease were randomly assigned to 2 groups: One group (n = 522) underwent standard exercise ECG stress testing followed by ECG-gated regional myocardial perfusion imaging by single-photon emission computed tomography (SPECT) at rest and after exercise, whereas the second group (n = 522) did not undergo testing. Both groups were reevaluated 5 years later.
Michael M. Goldman
Beth Israel Medical Center, New York, NY
January 29, 2006
Increased dose of L-thyroxine in pregnancy
In a recent Update in Endocrinology(1), Dr. Wartofsky discusses two articles which appear to have contradictory conclusions. The first article by Anselmo et al (2), suggested that employing the model of RTH (resistance to thyroid hormone) in pregnancy, subclinical hyperthyroidism has the potential for fetal loss. The most common cause of subclinical hyperthyroidism in the U.S. is iatrogenic overdose with L-thyroxine.
The second article by Alexander et al (3) recommends an automatic 30% increase in the L-thyoxine dose of hypothyroid women in pregnancy as soon as pregnancy is confirmed. Dr. Wartofsky, himself, recommends obtaining thyroid function tests as soon as hypothyroid women become pregnant and to expect to increase their dose.
In our experience, some women require increased doses later in pregnancy and others do not require increases at all. Automatic increases in thyroid hormone can lead to subclinical hyperthyroidism in pregnancy which has the potential for fetal loss (2).
1. Wartofsky, L. Update in Endocrinology Ann Intern Med, Nov 2005; 143: 673 - 682.
2. Anselmo J, Cao D, Karrison T, et al. Fetal loss associated with excess thyroid hormone exposure. JAMA. 2004;292:691-5. [PMID: 15304465]
3. Alexander EK, Marqusee E, Lawrence J, et al. Timing and magnitude of increases in levothyroxine requirements during pregnancy in women with hypothyroidism. N Engl J Med. 2004;351:241-9. [PMID: 15254282]
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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