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Dangerous Dogmas in Medicine: The Nonthyroidal Illness Syndrome

For more than 3 decades it has been known that serum thyroid hormone levels drop during starvation and illness. In mild illness, this involves only a decrease in serum T3 levels. However, as the severity of the illness increases, there is a drop in both serum T3 and T4 (1). This decrease in serum thyroid hormone levels is seen in starvation (2), sepsis (3, 4), surgery (5), myocardial infarction (6, 7), bypass (8), bone marrow transplantation (9), and, in fact, probably any severe illness. Based on the conviction that patients with these abnormalities are not hypothyroid despite the low hormone levels in blood, the condition has been called the euthyroid sick syndrome. An alternative designation, which does not presume the metabolic status of the patient, is nonthyroidal illness syndrome (NTIS). NTIS seems a preferable name in light of present knowledge and will be used in this review..
Conclusion I argue for the administration of replacement T3 and T4 hormone in patients with NTIS as the most logical way to do no evil. However, it is impossible to be certain at this time that it is beneficial to replace hormone, or whether this could be harmful. Only a prospective study will be adequate to prove this point, and probably this would need to involve hundreds of patients (1). One cannot envisage that replacement of T4 or T3 would cure all patients with NTIS. The probable effect, if any is achieved, will be a modest increment in overall physiological function and a decrease in mortality. Perhaps this would be 5%, 10%, or 20%. If effective, thyroid hormone replacement will be one of many beneficial treatments given to the patient, rather than a single magic bullet that would reverse all of the harmful metabolic changes occurring in these severely ill patients.


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