Recommendation on screening adults for asymptomatic thyroid dysfunction in primary care (2019)

Presentation for free use to disseminate Guidelines

1. Putting  Prevention  into  Practice Recommendation  on  screening  adults   for  asymptomatic  thyroid  dysfunction   in  primary  care  (2019) Canadian  Task  Force  on  Preventive  Health  Care  (CTFPHC)
2. Use  of  Slide  Deck • These  slides  are  made  available  publicly  following  the   guideline’s  release  as  an  educational  support  to  assist   with  the  dissemination,  uptake  and  implementation  of  the   guidelines  into  primary  care  practice   • Some  or  all  of  the  slides  in  this  slide  deck  may  be  used   in  educational  contexts   2
3. Overview  of  Webinar • Presentation • Background  on  screening adults  for  asymptomatic  thyroid   dysfunction  in  primary  care • Methods  of  the  Task  Force • Key  Findings • Recommendations • Implementation  Considerations • Conclusions   • Questions  and  Answers 3
4. Canadian  Task  Force  on  Preventive  Health  Care  (CTFPHC) Task  Force  Members: • Richard  Birtwhistle • James  A  Dickinson   • Donna  L.  Reynolds • Brett  D.  Thombs Public  Health  Agency  of   Canada: • Kate  Morissette* • Francesca  Reyes  Domingo* • Marc  T.  Avey* • Rachel  Rodin* Knowledge  Translation   Program,  Li  Ka  Shing   Knowledge  Institute,  St.   Michael’s  Hospital *non-­voting  member 4
5. BACKGROUND 5 Recommendation  on  screening  adults  for   asymptomatic  thyroid  dysfunction  in  primary  care  
6. Background • Thyroid  dysfunction  (i.e.,  hyperthyroidism  or   hypothyroidism)  is  a  disorder  affecting  the  thyroid  gland – Hyperthyroidism:  when  the  thyroid  gland  produces  too  much   thyroid  hormone – Hypothyroidism:  when  the  thyroid  gland  produces  insufficient   thyroid  hormone • About  10%  of  Canadians  aged  45  years  and  older  have   thyroid  dysfunction – Higher  prevalence  in  women  (16%)  than  men  (4%) 6
7. Background • Signs  and  symptoms  are  often  non-­specific,  and  some   people  are  asymptomatic   – Hypothyroidism:  tiredness,  sensitivity  to  cold,  dry  skin,  hair  loss,   weight  gain  and  slowed  movements  and  thoughts – Hyperthyroidism:  increased  heart  rate,  atrial  fibrillation,   hyperactivity  or  irritability,  intolerance  to  heat,  tremor  and  weight   loss • Screening  for  thyroid  dysfunction  involves  a  blood  test  to   measure  serum  thyroid-­stimulating  hormone  (TSH). 7
8. Guideline  Scope • This  guideline  presents  an  evidence-­based   recommendation  on  screening  asymptomatic   nonpregnant adults  aged  18  years  and  older  for  thyroid   dysfunction   • The  recommendation  does  not apply  to  patients  with   previously  diagnosed  thyroid  disease  or  thyroid  surgery,   exposure  to  medications  known  to  affect  thyroid  function   (e.g.,  lithium,  amiodarone),  exposure  to  thyroid   radioiodine  therapy,  or  radiotherapy  to  the  head  or  neck,   or  pituitary  or  hypothalamic  diseases. 8
9. METHODS 9 Recommendation  on  screening  adults  for   asymptomatic  thyroid  dysfunction  in  primary  care  
10. Methods • Task  Force  is  an  independent  panel  of: • Clinicians  and  methodologists   • Expertise  in  prevention,  primary  care,  literature  synthesis,  and  critical   appraisal • Application  of  evidence  to  practice  and  policy Working  Group • 4  Task  Force  members   • Established  research   questions  and  analytical   framework Public  Health  Agency  of  Canada • Conducted  systematic  reviews  of   the  literature  based  on  the   analytical  framework  and  GRADE   methodology • Systematic  reviews  addressed:   benefits  and  harms  of  screening;;   benefits  and  harms  of  treating   screen-­detected  thyroid   dysfunction;;  and  patient  values  and   preferences. 10
11. Research  Questions   • The  key  questions  for  the  systematic  reviews  were: – KQ1:  Does  screening  asymptomatic,  nonpregnant adults  for  Thyroid   Dysfunction  (TD)  reduce  morbidity  and  mortality? – KQ2:  What  are  the  harms  of  screening  asymptomatic,  nonpregnant adults   for  TD? – KQ3:  Does  treatment  of  screen-­detected  overt  or  subclinical  TD  improve  (a)   morbidity  or  mortality  or  (b)  intermediate  outcomes? – KQ4:  What  are  the  harms  of  treating  screen-­detected  TD  in  asymptomatic,   nonpregnant adults? – KQ5:  What  are  asymptomatic,  nonpregnant adults’  preferences  and  values   concerning  screening  for  TD? – KQ6:  If  screening  asymptomatic,  nonpregnant adults  for  TD  is  clinically   effective,  then  what  is  the  cost  effectiveness  and  associated  resource  use?   (this  was  not  completed  as  there  was  no  evidence  of  benefits) • For  more  detailed  information,  please  access  the  systematic   review  www.canadiantaskforce.ca 11
12. Study  Eligibility  Criteria Population:  nonpregnant adults  18  years  and  older  with  no  clear  symptoms  of   thyroid  dysfunction   KQ1-­‐4 Study  Type Randomized controlled  trials,  or  controlled  observational  studies Intervention KQ1-­‐2: Screening KQ3-­‐4:  Treatment  including   thyroid  hormone  replacement  therapy,   antithyroid medications,  surgery,  and  ablation  therapy Outcomes KQ1: clinical  outcomes  (mortality  (all-­‐cause  and  cardiovascular),  fatal   and  non-­‐fatal  cardiovascular  events,  atrial  fibrillation,   fractures,  quality   of  life,  and  cognitive  function) KQ2:  psychological  effects,  harms  of  workup,  overdiagnosis,   overtreatment KQ3:  clinical  outcomes  in  KQ1  +  intermediate  outcomes  (cholesterol,   blood  pressure,  weight  change,  bone  density) KQ4:  harms  of  treatment   12
13. How  does  the  Task  Force  “GRADE”  Evidence?   13 The  “GRADE”  System: • Grading of  Recommendations,  Assessment,  Development  &   Evaluation 1.  Certainty  of  Evidence 2.  Strength of  Recommendation • Confidence  that  the   available  evidence   correctly  reflects  the   theoretical  true  effect • Certainty  of  supporting  evidence • Desirable  and  undesirable  effects • Values and  preferences • Resource  use High,  Moderate,  Low,   Very  Low Strong,  Conditional
14. Internal  and  External  Review  Processes • Internal review process: – Guideline working group, full Task Force, scientific officers • External review process: – External review is undertaken at key stages: • Protocol, systematic review, and draft guideline – Reviewers include: • Generalist and disease-­specific stakeholders • Federal and Provincial/Territorial stakeholders • Academic peer reviewers • CMAJ conducts an independent peer review process to review guidelines prior to publication. 14
15. FINDINGS 15 Recommendation  on  screening  adults  for   asymptomatic  thyroid  dysfunction  in  primary  care  
16. Key  Findings • No  studies  were  found  on  screening  for  thyroid  dysfunction • The  effectiveness  of  treating  asymptomatic  adults  for   screen-­detected  hypothyroidism  results  in  little  to  no   difference  in  clinical  outcomes. • No  studies  on  treating  screen-­detected  hyperthyroidism   were  found.   • No  studies  on  patient  values  and  preferences  were  found. 16
17. Recommendation • For  practitioners  on  preventive  health  screening   in  a  primary  care  setting • Strong  recommendation,  low-­certainty  evidence   v The  recommendation  does  not  apply  to  patients  with  previously   diagnosed  thyroid  disease  or  thyroid  surgery,  exposure  to  medications   known  to  affect  thyroid  function  (e.g.,  lithium,  amiodarone),  exposure  to   thyroid  radioiodine  therapy,  or  radiotherapy  to  the  head  or  neck,  or   pituitary  or  hypothalamic  diseases. 17 We  recommend  against  screening  for  thyroid   dysfunction  among  asymptomatic  nonpregnant adults  aged  18  years  and  older
18. Certainty  of  Evidence • Overall  certainty  of  evidence  supporting   this  recommendation  is  considered low: – The  included  studies  on  treating  screen-­ detected  hypothyroidism  had  issues  with   indirectness (some  studies  only  included   adults  65  years  and  older);;  imprecision (some  of  the  estimates  of  effect  came  from   studies  with  small  sample  sizes),  and  study   design  (cohort  studies). 18
19. Rationale  for  a  Recommendation  Against Screening • Low  certainty  evidence  was  available  on  the  effectiveness   of  screening  (benefits  and  harms)  among  adults  aged  18   years  and  older. – No  evidence  on  screening  effectiveness. – Low-­certainty  evidence  on  effectiveness  of  treating  screen-­ detected  hypothyroidism  showed  little  to  no  benefit  to   patients. – Potential  harms  include:  diagnosis  of  transient  thyroid   dysfunction,  the  need  for  follow-­up  testing  and  long-­term   monitoring,  increased  treatment  burden. – Screening  for  thyroid  dysfunction  in  asymptomatic   nonpregnant adults  is  not  likely  to  confer  clinical  benefit,  but   could  lead  to  unnecessary  treatment  for  some  patients  and   consume  resources. 19
20. 20 Other  recommendations   Organization Recommendation British  Columbia   Ministry  of  Health Routine  thyroid  function  testing  is  not  recommended  in  asymptomatic  adults.   However,  testing  may  be  indicated  when  non-­‐specific  signs  and  symptoms  are   present  in  patients  at  risk  for  thyroid  disease. Considering  the  high  prevalence  of  thyroid  disease,  particularly  hypothyroidism   in  women,  and  the  fact  that  some  studies  have  shown  that  affected  women   may  benefit  from  early  treatment,  it  is  recommended  that  clinicians  maintain  a   high  index  of  suspicion  and  investigate  individuals  with  vague  symptoms  that   could  be  related  to  thyroid  dysfunction. Toward  Optimized   Practice   Do not test  patients  who  are  asymptomatic,  seemingly  healthy,  having  a   periodic  exam. United  States   Preventive  Services   Task  Force   The  United  States  Preventive  Services  Task  Force  concludes  that  the  current   evidence  is  insufficient  to  assess  the  balance  of  benefits  and  harms  of   screening  for  thyroid  dysfunction  in  nonpregnant,  asymptomatic  adults.   American  Thyroid   Association  and   American  Association   of  Clinical   Endocrinologists   Screening  for  hypothyroidism  should  be  considered  in  patients  over  the  age  of   60. This  recommendation  was  downgraded  because  there  is  strong  evidence  that   hypothyroidism  is  common  in  this  group  but  insufficient  evidence  of  benefit  or   cost  effectiveness.
21. Knowledge  Gaps • Future  trials  should  evaluate: – The  effectiveness  of  screening  versus  not  screening   asymptomatic  nonpregnant adults  for  thyroid  dysfunction – The  effectiveness  of  screening  versus  not  screening   adults  with  other  concomitant  conditions  (e.g.,   cardiovascular  diseases,  type  1  diabetes  mellitus,  or   other  autoimmune  diseases) 21
22. IMPLEMENTATION  CONSIDERATIONS 22 Recommendation  on  screening  adults  for   asymptomatic  thyroid  dysfunction  in  primary  care  
23. Implementation  Considerations   • This  recommendation  only  applies  to  screening   asymptomatic  nonpregnant adults  aged  18  years  and   older.   • While  the  Task  Force  recommends  against  routinely   screening  for  thyroid  dysfunction  in  this  population,   clinicians  should  remain  alert  to  signs  and  symptoms   (e.g.,  unusual  fatigue,  unexpected  weight  gain,   menstrual  irregularities,  goiter,  etc.)  or  risk  factors  (e.g.,   pituitary  or  hypothalamic  diseases)  suggestive  of  thyroid   dysfunction  and  investigate  accordingly. 23
24. Knowledge  Translation  (KT)  Tools • The  Task  Force  has  created  a   Q&A  KT  tool  to  support  the   implementation  of  the  guideline   into  clinical  practice • After  the  public  release,  this   tool  will  be  freely  available  for   download  in  both  French  and English on  the  website:   www.canadiantaskforce.ca 24
25. More  Information For  more  information  on  the  details  of  this  guideline  please   see: • Canadian  Task  Force  on  Preventive  Health  Care   website:  www.canadiantaskforce.ca • Email:  info@canadiantaskforce.ca 25
26. Endorsements The  following  organizations  have  endorsed  the  guideline: -­ Canadian  Society  of  Endocrinology  and  Metabolism -­ Nurse  Practitioner  Association  of  Canada -­ College  of  Family  Physicians  of  Canada 26
27. Questions  &  Answers Thank  you 27