Graphical abstract: Abstract:Hyperthyroidism adversely affects quality of life (QoL), encompassing physical, mental and social functioning and well-being. Patients with hyperthyroidism often complain of anxiety, physical symptoms and tiredness. Concurrent thyroid eye disease (TED) further reduces QoL. With treatment of hyperthyroidism, QoL improves. Symptoms of hyperthyroidism, overall QoL and tiredness are among the domains that improve with a high effect size. Notwithstanding, the overall reduction in QoL persists compared to a matched general population, which seems to relate to residual tiredness, mental fatigue and concerns about levothyroxine substitution, ophthalmological symptoms and weight gain. Common factors contributing to reduced QoL in the long term have been described and include a high prevalence of thyroid dysfunction, the psychological burden of chronic illness, TED, possible inability of levothyroxine replacement to restore euthyroidism in all tissues, and central nervous system residual damage and/or dysfunction. The aetiology and treatment modality for hyperthyroidism may also play a role. In addition, a recently highlighted contributor and predictor of poor QoL is excessive weight gain, which given the global epidemic of obesity, mandates further attention. Regarding newer therapies for hyperthyroidism, notably radiofrequency ablation and molecular targeted immunotherapies, there is a dearth of objective data on QoL. New or improved tools for assessing QoL may be needed to better capture all concerns of these patients. There is a need for randomized controlled studies to guide practitioners regarding which pharmacological or non-pharmacological interventions offer the best long-term QoL outcomes in hyperthyroidism. Anti-obesity medications to mitigate weight gain could also be considered for such patients. Plain language summary:Thyroid overactivity (hyperthyroidism) worsens patients' QoL, which usually improves after treatment. However, QoL is not completely restored for many patients. The reasons are multiple, including excessive weight gain. New approaches in treating hyperthyroidism are needed to address the long-term effects on QoL.

Background: Graves’ orbitopathy (GO) affects approximately 0.1% of the population. GO in anophthalmic patients is extremely rare and may provide insights into the pathogenesis of this disease. Methods: We describe four cases of GO in patients with previously acquired anophthalmia in one eye. Results: In all cases, the anophthalmic eye showed both clinical and radiological evidence of GO. In two patients, optic nerve compression was present. In all cases, involvement of extraocular muscles was radiologically symmetrical when comparing the two orbits. Conclusions: GO in anophthalmic patients is a rare combination of ocular morbidities. Early recognition and appropriate management of GO in such patients are important if visual function is to be preserved. Whether anophthalmia predisposes to GO in susceptible patients is unclear. This rare group of patients may provide unique opportunities for studying the pathogenetic mechanisms in GO.

Background:Recent surveys have highlighted substantial variability in the management of hypothyroidism that is associated with physician demographic and geo-economic characteristics. This study aimed to assess preferences for thyroid hormone therapy among medical thyroid specialists in Korea. Methods:An online survey was conducted using the Treatment of Hypothyroidism in Europe by Specialists: An International Survey (THESIS) questionnaire. Participants were medical thyroid specialists who were members of the Korean Thyroid Association (KTA). Results:Among the 349 regular members of the KTA who were physicians, 53 (15.2%) completed the survey. All respondents reported prescribing levothyroxine (LT4) as the initial treatment of choice for hypothyroidism. For patients with biochemical euthyroidism, 64.2% of respondents indicated that treatment was unnecessary; however, several conditions were cited as potential indications for thyroid hormone use (multiple responses were allowed), including female infertility with elevated thyroid antibody levels (30.2%), enlarging simple goiter (17.0%), and severe hypercholesterolemia as adjunctive therapy (9.4%). Although 24.5% of respondents reported avoiding LT4+liothyronine (LT3) therapy because of low-quality evidence, 62.3% indicated that they would consider it for symptomatic patients receiving LT4 monotherapy with normal thyroid-stimulating hormone levels. Conclusion:Korean thyroid specialists generally adhere to current clinical guidelines, favoring LT4 as the standard treatment for hypothyroidism. However, there is considerable willingness to use LT4+LT3 combination therapy and to prescribe thyroid hormones for certain non-thyroid conditions. Ongoing educational efforts are needed to improve understanding that many persistent symptoms despite biochemical euthyroidism are influenced by psychosocial factors and to facilitate consistent implementation of evidencebased, guideline-aligned clinical practice.

Background: Mild thyroid eye disease (TED) is the most common form of TED, yet it is the least studied. Uncertainties about the natural history and prevention, and underfunding for clinical research, are an obstacle to improving the management of this important group of patients. Summary: The available evidence suggests that the prevalence of mild TED can reach up to two-thirds of all cases, depending on the expertise of the assessor and the criteria used for diagnosis. Prevalent symptoms and signs of mild TED predominantly arise from lid changes, soft tissue involvement and ocular surface disease, but disease presentation is heterogeneous and in some patients proptosis and eye motility changes may be underrated with the current classification. Little is known about the impact of the various manifestations of mild disease on patients’ risk of progression and quality of life (QoL). Although in most patients with mild TED the disease remits spontaneously, some patients progress, and a significant proportion evolve to persistent, inactive TED. Current therapeutic options for these patients are based on scarce, low-to-moderate quality and sometimes conflicting evidence, resulting in significant differences in the management of mild TED in different countries and by different specialists. Among the most recommended therapeutic interventions, selenium supplementation was mainly studied in selenium-insufficient populations with active mild TED and it lacks efficacy in longstanding, inactive disease. The use of immunosuppressive drugs and targeted therapies for mild TED are commonly reported by surveys of medical professionals in a clinical setting, but the indication and efficacy of these agents in mild TED remain unclear. Conclusions: Mild TED has a significant psychosocial and functional burden that should be reconsidered and addressed by local, systemic or surgical treatments in an individualized manner. Given the overall effect on QoL and the socioeconomic impact, it is of immediate importance to highlight the knowledge gaps and the need for research in mild TED.

Objective: Several thyroid hormone formulations are available for treatment of hypothyroidism. This study aimed at evaluating the use of these treatment options by Israeli endocrinologists in various clinical scenarios. Methods: Israeli Endocrine Society members were invited to participate in a web-based questionnaire, Treatment of Hypothyroidism in Europe by Specialists: An International Survey. Results: 99.2% of respondents used LT4 tablets as first line therapy for hypothyroidism. Thyroid hormone replacement options considered by respondents included LT4 tablets (100%), soft-gel capsules (4.0%), liquid solution (15.4%), combined LT4 + LT3 (2.4%) and LT3 tablets (17.8%). In cases of impaired absorption or persistent symptoms, most would continue LT4 tablets (86.1% and 95.1%, respectively), of whom 39.0% noted that only tablets are available in Israel. In patients with normal serum TSH and persistent symptoms, 95.1% would continue LT4 tablets, 57.5% would consider the addition of LT3 whereas 24.4% stated that LT4/LT3 combination should never be used. In euthyroid patients, LT4 therapy was considered in infertile women with high levels of thyroid antibodies (33.6%) and for simple goiter growing over time (11.4%). Conclusions: In Israel, LT4 tablets are the treatment of choice for hypothyroidism in most clinical scenarios, including in patients with impaired absorption or with persistent symptoms, for whom a combination therapy with LT4 + LT3 is considered by half of respondents. Other LT4 formulations are not widely available in Israel, thus are infrequently considered compared to other European countries. These data suggest that international guidelines regarding the use of various thyroid hormone formulations in specific clinical scenarios are warranted.

Levothyroxine (LT4) is the established treatment for hypothyroidism but some controversies, such as whether combining it with liothyronine (LT3) for hypothyroid patients and whether prescribing it to euthyroid patients, exist on its use. This survey was conducted to investigate current trends about thyroid hormone use in hypothyroid and euthyroid patients in Japan. Members of the Japan Thyroid Association (JTA) were invited to participate in an online questionnaire based on the THESIS (Treatment of Hypothyroidism in Europe by Specialists: An International Survey) survey. Anonymous responses from 207 of 874 (23.7%) JTA-certified thyroid specialists were analyzed. LT4 was the first line treatment for hypothyroidism by all respondents. 18.8% and 28.0% would also use LT3 and LT3 + LT4 combination, respectively. LT3 + LT4 combination was preferred for patients on LT4 with residual symptoms or low serum T3 levels. Psychological factors and comorbidities were considered as the main contributors to residual symptoms. Respondents would prescribe thyroid hormones in euthyroid subjects for female infertility with positive anti-thyroid antibodies (46.9%), for Hashimoto's disease with a huge goiter (29.0%), and for pregnant or infertile women with TSH between 2.5-4 mU/L irrespective of anti-thyroid antibody status (43.0 and 76.8%, and 46.9 and 77.3%, respectively). In conclusion, Japanese thyroid specialists chose LT4 as first line treatment for hypothyroidism in accordance with current guidelines. The use of LT3 + LT4 combination is less frequent in Japan than in other countries, whereas the use of thyroid hormones for non-hypothyroid indications is similarly high worldwide, which is not necessarily in accord with pertinent society guidelines.

Background:A substantial proportion of patients taking thyroid hormone replacement for hypothyroidism show persistent symptoms. We sought to explore the prevalence and degree of fatigue in this patient group. Methods:An online survey including the FACIT-F fatigue scale was distributed by two UK patient support organisations, the British Thyroid Foundation (BTF) and The Thyroid Trust (TTT). Overall, 1,334 responses were received, of which 1,251 were complete, unique and from patients with primary hypothyroidism/Hashimoto thyroiditis who reported taking thyroid hormone replacements. Results:Ninety eight percent of respondents were women and the mean duration of treatment was 10.8 years (SD: 9.74). The mean fatigue score on the FACIT-F scale was 20.5 (SD: 10.5), with 89% of respondents fulfilling criteria for abnormal fatigue. Fatigue scores were not significantly different between respondents of different ages, gender, treatment type or treatment duration. FACIT-F scores were positively correlated with self-declared overall health state (Pearson r = 0.576, P < 0.001). Conclusions:Fatigue in treated hypothyroidism is very common, and the FACIT-F scores reported are comparable or worse than those recorded for many other chronic conditions. This study suggests that addressing fatigue in this patient group will be key to improving wellbeing and quality of life.

OBJECTIVE:The practice of treating hypothyroid and euthyroid patients with thyroid hormones varies between countries, as observed in the recent surveys of European thyroid experts, THESIS. As part of the THESIS initiative, we investigated Canadian endocrinologists' perspectives on this topic, focusing on combination therapy with either liothyronine (LT3) plus levothyroxine (LT4) or desiccated thyroid extract (DTE). DESIGN:Members of the Canadian Society of Endocrinology and Metabolism (CSEM) were invited to participate in an anonymous online survey. RESULTS:Out of 348 eligible CSEM members, 68 (19.5%) respondents were included in the analysis. All respondents used LT4 as the first-line treatment for hypothyroid patients. Many respondents (64.7%) would consider LT4 + LT3 for patients on LT4 with persistent symptoms, whereas fewer would consider DTE (16.2%). Most respondents attributed persistent symptoms in LT4-treated patients to psychosocial factors, comorbidities, or unrealistic expectations. Approximately half of the respondents stated that thyroid hormone therapy is never indicated for euthyroid patients. The remaining respondents considered thyroid hormones for euthyroid women with infertility and high thyroid antibody levels (36.8%), depression (13.2%), and growing goiter (7.4%). CONCLUSIONS:Following current guidelines, LT4 tablet is the preferred treatment for hypothyroidism. Most respondents would consider triiodothyronine-containing therapy for patients with persistent symptoms, preferring LT4 + LT3 over DTE. The number of endocrinologists considering combination therapy for hypothyroid patients in Canada was higher than in Europe. Finally, at variance with current guidelines, a fraction of the respondents would consider thyroid hormones in patients with non-thyroidal conditions.

Hashimoto’s thyroiditis (HT) is the most common autoimmune endocrine disease worldwide with an annual incidence of 0.3–1.5 per 1000 people and a prevalence of 8

BackgroundManaging patients with fatigue is a clinical challenge. Because fatigue is often reported in hypothyroidism, thyroid hormone (TH) therapy may sometimes be incorrectly considered for biochemically euthyroid individuals. This study aimed to evaluate the prevalence and determinants of this practice in different European countries.MethodsWe analyzed aggregate data from the THESIS (Treatment of Hypothyroidism in Europe by Specialists: an International Survey) online survey. We analyzed responses from 5,695 members of 28 national endocrine/thyroid societies’ specialists to the statement: “Thyroid hormones may be indicated in biochemically euthyroid patients with unexplained fatigue”.ResultsOverall, 7.5% (426/5695) of respondents indicated that TH therapy might be considered for euthyroid patients with unexplained fatigue. The proportion of positive responses varied widely across different countries (between 1.1% in Switzerland and 29.3% in Serbia; p=2 ×10-16) and regions (between 4.7% in Western Europe and 8.7% in Western Asia or 8.8% in Eastern Europe; p=0.004). TH were more frequently prescribed for unexplained fatigue by male respondents (Odds Ratio, OR 1.45, 95% CI 1.18-1.78) and physicians practicing in private practice (OR 1.27, 95% CI 1.02-1.58), and less frequently by endocrinologists (OR 0.62, 95% CI 0.46-0.83).ConclusionA small, yet not negligible percentage of European thyroid-focused physicians consider using TH for euthyroid patients with unexplained fatigue, with significant variations based on geographic, demographic, and practice-related factors. Using levothyroxine and/or liothyronine in such cases lacks evidence and may partially contribute to the concerning overuse of TH therapy.

Thyroid hormone (TH) prescribing practices, particularly on hypothyroid and euthyroid patients, were compared between Japan Thyroid Association (JTA)-certified thyroid specialists and non-certified members. A nationwide questionnaire survey (Treatment of Hypothyroidism in Europe by Specialists: An International Survey) was conducted among all 2,938 JTA members, including 874 certified specialists and 2,064 non-certified members, to assess self-reported TH prescription choices in various clinical scenarios. Responses from certified specialists and non-certified members were statistically compared. A total of 207 certified specialists (23.7%) and 129 non-certified members (6.3%) responded and completed the questionnaire. Although all certified specialists and non-certified members selected levothyroxine (LT4) as first-line therapy for hypothyroidism, certified specialists more often used liothyronine (LT3) plus LT4 combination therapy than non-certified members (28% vs. 12%, p < 0.001), particularly for LT4-treated patients with persistent hypothyroid-like symptoms (9% vs. 2%, p = 0.02). For euthyroid individuals, 71% of certified specialists and 60% of non-certified members considered TH treatment (p = 0.043). Non-certified members who see >100 hypothyroid patients per year were more inclined to use combination therapy for hypothyroid patients and TH for euthyroid patients than those of ≤100 patients (p < 0.049 and 0.001, respectively). In conclusion, JTA-certified thyroid specialists and non-certified members exhibit distinct TH prescribing patterns. Certified specialists are more open to combination therapy and treating selected euthyroid patients, whereas non-certified members favor guideline-based LT4 monotherapy. These differences underscore the impact of specialization on clinical practice and suggest a need for updated guidelines and targeted education to rationalize thyroid care.

PurposeTreatment-resistant depression (TRD) is most commonly defined as depression that has not responded to two different pharmacological agents used for an adequate period of time. We explored the views of European specialists via survey, regarding the use of thyroid hormone (TH) in euthyroid patients with TRD as part of ‘Treatment of Hypothyroidism in Europe by Specialists: An International Survey’ (THESIS).MethodsThe question “Thyroid hormones may be indicated in biochemically euthyroid patients with treatment resistant depression” was posed to specialists from 28 countries.Results5695 valid responses were received following 17,232 invitations (33.0% response rate; 65% female, 90% endocrinologists). 348 (6.1%) stated that TH may be indicated in biochemically euthyroid patients with TRD. This view was more common in males (p<0.01), respondents who saw ≥100 patients with hypothyroidism per year (p<0.01), respondents who worked in private practice (p=0.05) and respondents who were not members of international specialist associations (p=0.05). Geographical variation existed with respondents in Eastern Europe significantly more likely to use TH in TRD (p<0.01). Linear regression showed a statistically significant reduction in the use of TH for TRD with increasing gross national income (F-statistic=7.35, CI -0.15 - -0.02, p=0.01). TH in TRD was recommended in psychiatry guidelines but not endocrinology guidelines.ConclusionWhile there is limited evidence for their use, over 6% of respondents stated that TH may be indicated in TRD. Due to the risk of iatrogenic thyrotoxicosis and increased morbidity the use of TH should be addressed in relevant endocrinology guidelines and consensus should be reached between specialties.

BACKGROUND:There is evidence of quality of life (QoL) impairment and weight gain in treated hyperthyroidism. It is not known whether treatment-related weight gain is associated with QoL impairment in this patient group of this cohort. Our primary aim was to examine whether percentage weight gain (PWG) after treatment of hyperthyroidism was associated with QoL impairment. METHODS:We enrolled patients with treated hyperthyroidism 6 months to 8 years after diagnosis. We obtained anthropometric measurements from a prospectively completed database. With a cross-sectional study design, we assessed QoL using the thyroid-specific patient-reported outcome (ThyPRO) tool. We pre-specified three dependent variables in ThyPRO: "cosmetic complaints," a composite of "tiredness and overall QoL" and "depressivity and anxiety" domains. We included age, sex, thyrotropin categories, comorbidities, and disease duration as covariates. We applied a generalized linear model (GLM) for the analysis. RESULTS:We included 108 patients, including 68 (63%) females, with a mean (standard deviation [SD]) age 50 (14.5) years. The median weight at diagnosis was 65.5 (interquartile range [IQR]: 58.7, 75.5) kg and BMI was 23.9 (21.9, 27.1) kg/m2, and at final evaluation, weight was 72.7 (64.1, 83.8) kg (p < 0.001) and BMI was 26.5 (23.9, 30.8) kg/m2 (p < 0.001). The mean (SD) weight gain observed was 7.2 (6.2) kg over a mean (SD) disease duration of 41 (22.5) months. Median PWG was 8.8% (4.3%, 17%). There was a significantly reduced QoL in all comparable domains against general population normative data. PWG was associated with "cosmetic complaints" (odds ratio = 1.11, p = 0.008 via logistic regression; b = 0.47, p = 0.022, q (adjusted p) = 0.033 via GLM) and "tiredness and overall QoL" (b = 0.62, p = 0.011, q = 0.017), but not with the "anxiety and depressivity" domains (b = -0.005, p = 0.661). CONCLUSIONS:Our study suggests that weight gain after treatment of hyperthyroidism is associated with a large adverse effect on QoL, with reduced scores on appearance, combined "tiredness and overall QoL" domains of the ThyPRO questionnaire. Management of weight change upon treatment of hyperthyroidism merits further clinical attention and research.

IntroductionOver-diagnosis and over-treatment of hypothyroidism is a growing concern. The role of patient knowledge has not been previously investigated. The aim was to explore patient knowledge in relation to diagnosis and treatment of hypothyroidism.MethodsCross-sectional, international online survey. Participants were people with treated hypothyroidism amounting to 3421 valid respondents from 68 countries. A questionnaire was used, which included knowledge statements about hypothyroidism relating to recommendations by international guidelines. The principal knowledge statement was “A patient with a normal thyroid blood test does not need to be treated with thyroid hormones (even if they have positive thyroid antibodies and symptoms)”, and participants were asked to classify it as “false”, “true”, or “don’t know”. Responses were divided into corresponding groups: “Incorrect”, “Correct”, and “Unsure”. Associations of groups with respondent characteristics and patient reported outcomes were investigated. Responses to a further seven knowledge statements explored ampliative knowledge about hypothyroidism.ResultsWith regards to the principal knowledge statement, “Correct”, “Incorrect” and “Unsure” comprised 15.3%, 50.7% and 34.0% of responses to the respectively. “Incorrect” respondents were more likely than expected to live in the United Kingdom, have Hashimoto’s thyroiditis, have a recent low self-reported serum thyrotropin, be treated with liothyronine-containing medication, and use social media and the internet for hypothyroidism-related information daily. “Incorrect” responses were associated with dissatisfaction, poor perceived control of symptoms and negative impact of hypothyroidism on everyday activities. The proportion of “Incorrect” responses for seven other knowledge statements ranged between 1.8-34.9%.DiscussionIncorrect responses to the principal knowledge statement were common in this sample of people with hypothyroidism, and associated with several demographic variables and adverse patient outcomes. Our findings suggest that knowledge gaps about the significance of symptoms in relation to the diagnosis and treatment of hypothyroidism may be important in driving over-diagnosis and over-treatment. The high number of “Unsure” respondents suggests that patient education may be an effective intervention.

OBJECTIVE:Several thyroid hormone formulations are available for treatment of hypothyroidism. This study aimed at evaluating the use of these treatment options by Israeli endocrinologists in various clinical scenarios. METHODS:Israeli Endocrine Society members were invited to participate in a web-based questionnaire, Treatment of Hypothyroidism in Europe by Specialists: An International Survey. RESULTS:99.2% of respondents used LT4 tablets as first line therapy for hypothyroidism. Thyroid hormone replacement options considered by respondents included LT4 tablets (100%), soft-gel capsules (4.0%), liquid solution (15.4%), combined LT4 + LT3 (2.4%) and LT3 tablets (17.8%). In cases of impaired absorption or persistent symptoms, most would continue LT4 tablets (86.1% and 95.1%, respectively), of whom 39.0% noted that only tablets are available in Israel. In patients with normal serum TSH and persistent symptoms, 95.1% would continue LT4 tablets, 57.5% would consider the addition of LT3 whereas 24.4% stated that LT4/LT3 combination should never be used. In euthyroid patients, LT4 therapy was considered in infertile women with high levels of thyroid antibodies (33.6%) and for simple goiter growing over time (11.4%). CONCLUSIONS:In Israel, LT4 tablets are the treatment of choice for hypothyroidism in most clinical scenarios, including in patients with impaired absorption or with persistent symptoms, for whom a combination therapy with LT4 + LT3 is considered by half of respondents. Other LT4 formulations are not widely available in Israel, thus are infrequently considered compared to other European countries. These data suggest that international guidelines regarding the use of various thyroid hormone formulations in specific clinical scenarios are warranted.

Background/Objective:The management of hypothyroidism has evolved over time as the development of new guidelines and formulations of thyroid hormone have become available. Methods:A survey of American Association of Clinical Endocrinology members in the United States examining the treatment of hypothyroidism, including questions about initial choice of therapy, use of liothyronine (LT3)-containing regimens, and use of thyroid hormones in hypothyroid and non-hypothyroid patients. Results:Survey links were opened by 387 of 4000 potential respondents and completed by 299 (7%). Respondents unanimously cited levothyroxine (LT4) as the initial treatment choice for hypothyroidism. Forty-seven percent indicated they would use thyroid hormones in patients with euthyroidism with infertility and elevated thyroid antibodies, with smaller numbers for goiter, depression, hypercholesterolemia, fatigue, and obesity. About 60% would consider combination LT4/LT3 in a patient with euthyroidism who does not feel well on treatment or has persistent symptoms. In contrast, a much smaller minority (16% for LT4/LT3 and 5% for desiccated thyroid extract) used such regimens to manage their own hypothyroidism. Persistent symptoms in treated patients with a normal TSH were most often attributed to psychosocial factors, unrealistic patient expectations, and comorbidities. Significant associations were identified between respondent demographics and treatment choices, most notably age, practice setting, and volume of patients with hypothyroidism. Conclusions:LT4 monotherapy is overwhelmingly employed as first line therapy for hypothyroidism by U.S. clinicians. However, the high usage of thyroid hormones for patients whose symptoms were considered to be unrelated to hypothyroidism is at odds with current international guidelines for the management of hypothyroidism.

OBJECTIVE:A relationship among hypothyroidism and lipid disorders is well established. However, current evidence and guidelines do not support the use of thyroid hormones (TH) in euthyroid patients with hyperlipidaemia as potential harms are considerable. This European survey investigated the use of TH in euthyroid patients with severe hypercholesterolemia as a complementary treatment. DESIGN:Data were derived from the THESIS (Treatment of Hypothyroidism in Europe by Specialists) project that surveyed TH use. Univariable and multivariable analyses were used to explore associations. RESULTS:Out of 17,232 invitations, 5695 (33.0%) valid responses were received, and of these, 328 (5.8%) stated that TH are indicated in euthyroid patients with severe hypercholesterolemia. Univariable analyses disclosed significant differences and associations: (a) more non-endocrinologists (8.9%) than endocrinologist (5.4%) used TH (p < 0.001), (b) the number of hypothyroid patients treated per year was inversely related to use of TH (p = 0.024), (c) members of international endocrine/thyroid societies were more likely to use TH than non-members (p < 0.001), (d) significant variations by country and geographical region (p < 0.001), and (e) inverse relationship between gross national income per capita (GNIPC) and TH use (p < 0.001). Multivariable analyses yielded significant associations between use of TH, and male gender, specialty and GNIPC (p < 0.001). CONCLUSIONS:This study suggests that a small but noteworthy minority of European thyroid specialists may be using TH to treat of severe hypercholesterolemia in euthyroid patients. If confirmed, this finding highlights the importance of raising awareness among thyroid specialists, professional societies, and healthcare providers to ensure adherence to evidence-based practices.