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Cited by 287Thyroid Disorders and TreatmentsClinical Laboratory Practices and Quality ControlThyroid Cancer Diagnosis and Treatment

The Thyrotropin Reference Range Should Remain Unchanged

Surks, Martin I., Goswami, Gayotri, Daniels, Gilbert H.·2005·The Journal of Clinical Endocrinology & Metabolism
DOI 10.1210/jc.2005-0170
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Abstract

CONTEXT: Recent recommendations to decrease the upper limit of the TSH reference range from 4.5 to 2.5 mIU/liter, based on the high proportion of normal people whose serum TSH is less than 2.5 mIU/liter and the observation that those with TSH between 2.5 and 4.5 mIU/liter [upper reference range (URR)] have increased risk of progression to overt hypothyroidism (Whickham, 20-yr data), have not been subjected to critical analysis. STUDY SUBJECTS: The study subjects were from the Reference Group of NHANES III, 14,333 people more than 12 yr old, without known thyroid disease or antithyroid antibodies; 85% had TSH levels below 2.5 mIU/liter, and 2.3% had subclinical hypothyroidism (SCH). An additional 9.7% had URR TSH, representing 20.6 million Americans, who would also be identified as SCH if the upper TSH limit were decreased. Many with URR TSH do not have thyroid disease. INTERVENTION: The time of phlebotomy is important, because the TSH level varies throughout the day, with early morning values greater than later ones, and is accentuated by sleep deprivation, strenuous exercise, or working during the night or evening shifts. Repeated measurements in the same individual vary considerably over months. RESULTS: About half of those with URR TSH probably have thyroid disease, but most with thyroid disease, antithyroid peroxidase antibodies, have TSH below 2.5 mIU/liter. Those with URR TSH with thyroid disease probably have minimal thyroid deficiency, without any reported adverse health consequences or benefit of treatments with levothyroxine. CONCLUSION: Because routine levothyroxine treatment is not recommended for SCH, it is certainly not warranted in individuals with URR TSH. For all patients with URR TSH, it is reasonable to determine serum TSH every 1-2 yr.

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Crossref · 10.1210/jc.2005-0170

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  • Lowering the TSH upper limit would classify 15-20% of the elderly population as subclinical hypothyroidism, a condition for which treatment benefits are unproven.

    “Thus, lowering the TSH upper limit would classify 15–20% of the elderly population as subclinical hypothyroidism, a condition for which treatment benefits are unproven [55].”

    From Age-related variation in thyroid function – a narrative review highlighting important implications for research and clinical practice (2023) · cites this paper as [55]

  • An alternative argument accepts that a substantial proportion of people in the upper part of the TSH reference range will indeed have some form of occult thyroid disease but with a sufficiently benign prognosis that it is unnecessary to alter reference ranges to reclassify these by defining healthy people as thyroid patients.

    “An alternative argument accepts that a substantial proportion of people in the upper part of the TSH reference range will indeed have some form of occult thyroid disease but with a sufficiently benign prognosis that it is unnecessary to alter reference ranges to reclassify these by defining healthy people as thyroid patients [57].”

    From Challenges in Interpreting Thyroid Stimulating Hormone Results in the Diagnosis of Thyroid Dysfunction (2019) · cites this paper as [57]

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Authors
Surks, M. I., Goswami, G., & Daniels, G. H.
Affiliations
  • Albert Einstein College of Medicine (US)
  • Harvard University (US)
Corresponding author
Surks, Martin I.
ORCID
Daniels, Gilbert H.
Venue
The Journal of Clinical Endocrinology & Metabolism
Publisher
The Endocrine Society
Published
2005-09
Volume
90
Issue
9
Pages
5489-5496
ISSN
  • 0021-972X (ISSN-L)
  • 1945-7197
DOI
10.1210/jc.2005-0170
OpenAlex
W2098761773
Cited by
287
References
65
Citations by year
2026: 4 · 2025: 3 · 2024: 3 · 2023: 4 · 2022: 12 · 2021: 7 · 2020: 4 · 2019: 9 · 2018: 15 · 2017: 15 · 2016: 15 · 2015: 14 · 2014: 18 · 2013: 24 · 2012: 16
FWCI
13.66
Type
journal article
Language
en
Open access
closed
Locations
  • The Journal of Clinical Endocrinology & Metabolism (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Thyroid Disorders and Treatments
  • Health Sciences › Medicine › Physiology › Clinical Laboratory Practices and Quality Control
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Thyroid Cancer Diagnosis and Treatment
Keywords
upper reference limit, subclinical hypothyroidism, levothyroxine therapy, thyroid peroxidase antibodies, thyroid dysfunction, NHANES III, thyroid screening
MeSH terms
Humans, Hypothyroidism, Reference Values, Thyrotropin, Thyroxine

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