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Interferences With Thyroid Function Immunoassays: Clinical Implications and Detection Algorithm
Open accessAbstract
Automated immunoassays used to evaluate thyroid function are vulnerable to different types of interference that can affect clinical decisions. This review provides a detailed overview of the six main types of interference known to affect measurements of thyroid stimulating hormone (TSH), free thyroxine (T4) and free triiodothyronine (T3): macro-TSH, biotin, antistreptavidin antibodies, anti-ruthenium antibodies, thyroid hormone autoantibodies, and heterophilic antibodies. Because the prevalence of some of these conditions has been reported to approach 1% and the frequency of testing for thyroid dysfunction is important, the scale of the problem might be tremendous. Potential interferences in thyroid function testing should always be suspected whenever clinical or biochemical discrepancies arise. Their identification usually relies on additional laboratory tests, including assay method comparison, dilution procedures, blocking reagents studies, and polyethylene glycol precipitation. Based on the pattern of thyroid function test alterations, to screen for the six aforementioned types of interference, we propose a detection algorithm, which should facilitate their identification in clinical practice. The review also evaluates the clinical impact of thyroid interference on immunoassays. On review of reported data from more than 150 patients, we found that ≥50% of documented thyroid interferences led to misdiagnosis and/or inappropriate management, including prescription of an unnecessary treatment (with adverse effects in some situations), inappropriate suppression or modification of an ongoing treatment, or use of unnecessary complementary tests such as an I123 thyroid scan. Strong interaction between the clinician and the laboratory is necessary to avoid such pitfalls.
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In the citing paper
“Rarely, more extreme analytical errors are present137 (Table 5).”
In the citing paper
“A number of medications can affect the thyroid function tests not only by interfering with the synthesis, transport, and metabolism of TSH and thyroid hormones but also by interfering with thyroid function immunoassays (30, 37–40) ( Table 1 ).”
From Levothyroxine therapy in elderly patients with hypothyroidism (2021) · cites this paper as [38]
In the citing paper
“Furthermore, assay variability, potential interference with rheumatoid factors or heterophilic antibodies, occasional cases of macro-TSH, the observed age related shift towards higher TSH concentrations in older iodine sufficient patients, and obesity may affect this population based sample to an extent.45 46 47 48”
From Thyroid replacement therapy, thyroid stimulating hormone concentrations, and long term health outcomes in patients with hypothyroidism: longitudinal study (2019) · cites this paper as [45]
In the citing paper
“It is worth highlighting that whilst immunoassay platforms are currently the method of choice for the measurement of thyroid function tests [116], there are limitations; as well as macro-TSH, interference from biotin, thyroid hormone autoantibodies, heterophilic antibodies, antistreptavidin antibodies, anti-ruthenium antibodies, and heterophilic antibodies can occur [116].”
From Age-related variation in thyroid function – a narrative review highlighting important implications for research and clinical practice (2023) · cites this paper as [116]
In the citing paper
“It is worth highlighting that whilst immunoassay platforms are currently the method of choice for the measurement of thyroid function tests [116], there are limitations; as well as macro-TSH, interference from biotin, thyroid hormone autoantibodies, heterophilic antibodies, antistreptavidin antibodies, anti-ruthenium antibodies, and heterophilic antibodies can occur [116].”
From Age-related variation in thyroid function – a narrative review highlighting important implications for research and clinical practice (2023) · cites this paper as [116]
In the citing paper
“Low free T4 combined with inappropriately low or normal TSH is also frequent in several other situations where treatment is not required, e.g.due to heterophilic antibodies or other interfering factors in the serum of the patient/person under study (Favresse et al., 2018).”
From The hypothalamus-pituitary-thyroid (HPT)-axis and its role in physiology and pathophysiology of other hypothalamus-pituitary functions (2021) · cites this paper as Favresse et al., 2018
In the citing paper
“Biotin, antistreptavidin antibodies, antiruthenium antibodies, and thyroid hormone autoantibodies provide other sources of interference with the TSH test that may lead to an aberrant result [36].”
From Challenges in Interpreting Thyroid Stimulating Hormone Results in the Diagnosis of Thyroid Dysfunction (2019) · cites this paper as [36]
In the citing paper
“Immunoassay platforms can be susceptible to interferences, potentially leading to incorrect clinical decisions.”
From Refractory hypothyroidism: unraveling the complexities of diagnosis and management (2023) · cites this paper as [81]
In the citing paper
“Suspecting macro-TSH interference is advised with isolated TSH elevation (typically higher than 10 mUI/L) and thyroid hormones within the upper normal range, without clinical evidence of thyroid dysfunction.”
From Refractory hypothyroidism: unraveling the complexities of diagnosis and management (2023) · cites this paper as [81]
In the citing paper
“Anti-T4 and anti-T3 autoantibodies, found in 40% of autoimmune thyroid disease cases, can lead to false hormone elevations”
From Refractory hypothyroidism: unraveling the complexities of diagnosis and management (2023) · cites this paper as [81]
In the citing paper
“Biotin (in doses higher than 1.5 mg/d) can cause falsely low TSH levels and elevated fT4 and fT3, with its impact depending on the platform used, and being avoided with a washout period.”
From Refractory hypothyroidism: unraveling the complexities of diagnosis and management (2023) · cites this paper as [81]
In the citing paper
“interference from heterophilic antibodies can result in both low and high measures, with elevated values being more common.”
From Refractory hypothyroidism: unraveling the complexities of diagnosis and management (2023) · cites this paper as [81]
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Metadata
- Authors
- Favresse, J., Burlacu, M.-C., Maiter, D., & Gruson, D.
- Affiliations
- Cliniques Universitaires Saint-Luc (BE)
- Corresponding author
- Gruson, Damien
- Venue
- Endocrine Reviews
- Publisher
- The Endocrine Society
- Published
- 2018-07-04
- Volume
- 39
- Issue
- 5
- Pages
- 830-850
- ISSN
- 0163-769X (ISSN-L)
- 1945-7189
- OpenAlex
- W2894797166
- Cited by
- 258
- References
- 158
- Citations by year
- 2026: 33 · 2025: 27 · 2024: 20 · 2023: 47 · 2022: 35 · 2021: 36 · 2020: 37 · 2019: 21 · 2018: 2
- FWCI
- 3.15
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Endocrine Reviews (publishedVersion)
- PubMed (publishedVersion)
- DIAL (Catholic University of Leuven) (submittedVersion, other-oa)
- Funders
- Université Catholique de Louvain
- Topics
- Health Sciences › Health Professions › Medical Laboratory Technology › Clinical Laboratory Practices and Quality Control
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Thyroid Disorders and Treatments
- Health Sciences › Medicine › Surgery › Thyroid and Parathyroid Surgery
- Keywords
- thyroid function tests, immunoassay interference, thyroid-stimulating hormone, free thyroxine, free triiodothyronine, biotin interference, heterophile antibodies, detection algorithm, misdiagnosis, inappropriate treatment
- MeSH terms
- Algorithms, Humans, Immunoassay, Sensitivity and Specificity, Thyroid Function Tests, Thyrotropin, Thyroxine, Triiodothyronine
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