Assessment of Quality of Life in Euthyroid Post-Thyroidectomy Subjects 1,2 1 2 2 Emma Gugerty , Michal-Ann Derezil , Samima Habbsa and Shuchie Jaggi 1Donald
and Barbara Zucker School of Medicine at Hofstra/Northwell 2 Department of Endocrinology, Diabetes, and Metabolism, Northwell Health
Background Total thyroidectomy is a common treatment for differentiated thyroid cancer, suspicious thyroid nodules, Graves’ disease, and multinodular goiter. After total thyroidectomy, the recommended treatment to restore biochemical euthyroidism is thyroid hormone replacement with levothyroxine (T4).1 Many patients, despite being euthyroid based on serum levels, are unable to obtain their baseline quality of life with levothyroxine alone.2 80% of the active thyroid hormone, T3, is formed by 5’-deiodination of T4 in the periphery.3 Three deiodinase genes (DIO1, DIO2, DIO3) encode for deiodinase enzymes that convert T4 to T3. Common genetic polymorphisms in the DIO2 gene may be responsible for poorer conversion of T4 to T3 in the periphery.4 The subjects in previous studies have not been total thyroidectomy patients. Therefore, we will be assessing quality of life (QOL) in euthyroid athyreotic subjects.
Billewicz Diagnostic Index for Hypothyroidism Signs & Symptoms
Present
Absent
Diminished sweating
+6
-2
Dry skin
+3
-6
Cold intolerance
+4
-5
Weight gain
+1
-1
Constipation
+2
-1
Hoarseness
+5
-4
Hearing impairment
+2
0
Weakness/fatigue
+2
-1
Laziness/sleepiness
+2
-1
Slow movement
+11
-3
Coarse skin
+7
-7
Puffiness under eyes
+4
-6
Cold skin
+3
-2
Inclusion Criteria Northwell Health Physician Partners ambulatory endocrinology practices
History of total thyroidectomy On levothyroxine therapy Do not require suppressive doses of levothyroxine TSH within normal limits and below 2 uIU/mL within the past 3 months
GHQ SCORE
General Health Questionnaire Scores
40 20 0
41
n=44
• A higher score on the GHQ survey indicates a lower QOL. • If a patient is euthyroid after total thyroidectomy, we would not expect their quality of life to be significantly impacted; we expect a score of +4 on the GHQ survey. • For the 44 patients in our study who completed the GHQ, the average score was 7.6 (figure 1). • There was a slight worsening in GHQ score post thyroidectomy for our set of patients. • A score of -39 on the Bellewicz questionnaire rules out hypothyroidism. • For the 36 patients in our study who completed the Bellewicz survey, the average score was -21.2 (figure 2). • This indicates the presence of some hypothyroid symptoms in post-thyroidectomy patients although they are euthyroid. • These data sets are preliminary.
• We plan to continue surveying patients to obtain a larger sample size for this preliminary data collection. • We plan to perform a randomized control trial to assess QOL in euthyroid post-thyroidectomy patients receiving T4 monotherapy versus euthyroid post-thyroidectomy patients receiving T4/T3 combination therapy.
Resources
EXPECTED SCORE AVERAGE SCORE OF PATIENTS IN STUDY
Billewicz Score of Hypothyroidism
n=36
-39
Figure 7: Independent CRISPR knockout of CDK4 or CDK6 does not cause dropout in most breast cancer cell lines studied.
-19 -39
7.6
4
21 1
Conclusions
Future Direction
-21.2 AVERAGE SCORE OF PATIENTS IN STUDY
EXPECTED SCORE
1 Atruktsang,
Figure 2
Adults ≥18 years
Exclusion Criteria Patients taking liothyronine or dessicated porcine/bovine thyroid extract Patients requiring suppressive doses of thyroid hormone due to intermediate/high risk thyroid cancer Patients unable to fill out quality of life surveys due to cognitive impairment
60
BILLEWICZ SCORE
• QOL assessed by two validated questionnaires: i) Short Form Health Survey (SF-36) focusing on 21 questions related to general health, limitations of activities, energy and emotions, and social activities • The Billewicz Scoring System was used for evaluation of hypothyroidism-related symptoms.
All of the time- 0 Most of the time- 0 A good bit of the time- 0 Some of the time- 1 A little bit of the time- 2 None of the time-3
Figure 1
Methods
Does your health now limit you in these activities? If so, how much? Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports. For each question, give the answer that comes closest to how you have been feeling in the past 4 weeks. Did you feel full of pep?
Response Scores Excellent- 0 Very good- 0 Good- 1 Fair- 2 Poor-3 Yes, limited a lot- 3 Yes, limited a little- 2 Not limited at all- 0
Results
Hypothesis We hypothesize that 10-15% of post-thyroidectomy patients have a lower quality of life despite being euthyroid on levothyroxine therapy.
Sample GHQ Questions In general, how would you say your health is compared to prior to thyroid surgery?
T. S., et al. (2019). Identifying predictors of prolonged levothyroxine dose adjustment after thyroidectomy. Journal of Surgical Research, 242, 166-171. https://doi.org/10.1016/j.jss.2019.03.049. 2 Saravanan P., et al. (2002). Psychological well-being in patients on adequate doses of L-thyroxine: result of a large controlled communitybased questionnaire study. Clinical Endocrinology, 57, 577–585. https://doi.org/10.1046/j.1365-2265.2002.01654.x. 3Nygaard, B., et al. (2009). Effect of combination therapy with thyroxine (T4) and 3,5,3’-triiodothyronine versus T4 monotherapy in patients with hypothyroidism, a double-blind, randomized cross-over study. European Journal of Endocrinology, 161, 895-902. DOI: 10.1530/EJE-09-0542. 4 Panicker, V., et al. (2009). Common variation in the DIO2 gene predicts baseline psychological well-being and response to combination thyroxine plus triiodothyronine therapy in hypothyroid patients. Journal of Clinical Endocrinology and Metabolism, 94(5), 1623-1629. doi: 10.1210/jc.2008-1301.