【正文】 rinol Metab. 2022。89:336570. HLJ 業(yè)精于勤荒于嬉 行成于思毀于隨 →【醫(yī)學生物 PPT，歡迎收藏分享】網(wǎng)友 30 Pregnant Women with Hypothyroidism Require increased LThyroxine Dose Early in the First Trimester (N Engl J Med. 2022。351:2419. ) ? This report relates to the issue of increased Lthyroxine replacement requirements when women with hypothyroidism bee pregnant . Increased estrogen production during pregnancy leads to increased binding capacity of thyroid hormone transport proteins. This effect would cause subphysiologic levels of free thyroxine and elevated levels of TSH if not for stimulation of thyroid hormone production by chorionic gonadotropin. ? Current evidence suggests that pregnant women with elevated serum TSH levels may need Tx with Lthyroxine to avoid adverse pregnancy outes, such as a higher frequency of premature birth, lowbirthweight offspring, placental abruption, gestational hypertension, miscarriage or fetal death, and offspring with a lower IQ. ? These adverse outes occur with overt hypothyroidism, but they may also occur in women with subclinical hypothyroidism. ? In women with primary hypothyroidism, the thyroid gland cannot respond to the increased demand during pregnancy, and it bees necessary to increase the dose of exogenous thyroid hormone. The increased requirement for Lthyroxine during pregnancy begins early in the first trimester. This study was designed to determine the optimal time during pregnancy to increase the dose of Lthyroxine and the optimal dose. N Engl J Med. 2022。351:2419. HLJ 業(yè)精于勤荒于嬉 行成于思毀于隨 →【醫(yī)學生物 PPT，歡迎收藏分享】網(wǎng)友 31 ? The protocol involved hypothyroid women who were planning to bee pregnant. Thyroid function was measured before conception, every 2 weeks during the first trimester, and then monthly until delivery. By the end of the study, 20 pregnancies in 19 women resulted in 17 fullterm births. The researchers adjusted each participant39。s dose of Lthyroxine to maintain preconception levels of serum TSH. An incremental increase in Lthyroxine dose was necessary in 17 pregnancies. ? The mean increase was 47%, and 8 weeks39。 gestation was the median point at which an increase was required to maintain preconception levels of serum TSH. Additional increases in doses were not necessary after 16 weeks39。 gestation, but maintenance of the increased dose was required until delivery. N Engl J Med. 2022。351:2419. HLJ 業(yè)精于勤荒于嬉 行成于思毀于隨 →【醫(yī)學生物 PPT，歡迎收藏分享】網(wǎng)友 32 ? The study shows that hypothyroid women have an increased requirement for Lthyroxine as early as week 5 of pregnancy. In order to forestall any potential consequences of maternal thyroid hormone deficiency on the pregnancy, the authors remended an automatic 30% increase in the Lthyroxine dose as soon as pregnancy is confirmed. This concept is important for primary care physicians to know because they are the principal providers of care to hypothyroid women of childbearing age. ? Internists and family physicians must advise young women with hypothyroidism to obtain thyroid function testing as soon as they bee pregnant and to expect to increase their Lthyroxine dose early in pregnancy. ? Moreover, I remend that physicians obtain a repeated serum TSH determination monthly during each prenatal visit (at least until week 20) and adjust the Lthyroxine dose to maintain the preconception level of serum TSH. After delivery, the dose of Lthyroxine typically may be reduced back to the prepartum level. N Engl J Med. 2022。351:2419. HLJ 業(yè)精于勤荒于嬉 行成于思毀于隨 →【醫(yī)學生物 PPT，歡迎收藏分享】網(wǎng)友 33 不要輕視微小 人類的視角和視野 從不是最寬廣的 有時候 甚至顯得太小 HLJ 業(yè)精于勤荒于嬉 行成于思毀于隨 →【醫(yī)學生物 PPT，歡迎收藏分享】網(wǎng)友 34 Diabetic p39。ts with Preexisting Coronary Disease Are Most Likely To Benefit from LipidLowering Therapy (Ann intern Med. 2022。140:6508. ) ? The aim of this study was to determine whether lipidlowering therapy will reduce frequency of CV events in diabetic p39。ts and whether p39。ts with evidence of preexisting coronary disease benefit more than those without. ? The authors performed a metaanalysis of 12 randomized, controlled trials evaluating the effect of statins and fibrates on major CV events in p39。ts with type 2 DM. Four trials focused on primary prevention (6460 participants), 6 focused on secondary prevention (2515 participants), and 2 examined both primary and secondary prevention (6586 participants). ? Participants in control groups received placebo in 11 of 12 trials, and 1 trial pared moderate versus aggressive lipid lowering. Major end points included MI, stroke, and CV death. HLJ 業(yè)精于勤荒于嬉 行成于思毀于隨 →【醫(yī)學生物 PPT，歡迎收藏分享】網(wǎng)友 35 ? In the 8 secondary prevention trials, the relative risk for a CV event was (CI, to – )。 the absolute risk reduction was (CI, to – ). in the primary prevention trials, the relative risk was (CI, to ) after an average of years of therapy, and the absolute risk reduction was (CI, to – ). Tx of 34 to 35 p39。ts was needed to prevent a major CV event in 1 p39。t. Not surprisingly, the benefit of lipid lowering to prevent cardiac events in diabetic p39。ts is most clear in p39。ts with preexisting CAD—more than double the reduction seen in diabetic p39。ts without known CAD. ? The investigators concluded that lipidlowering therapy in type 2 DM lowers the frequency of CV events in all p39。ts but to a greater degree in those with known coronary disease. The data suggest that type 2 diabetic p39。ts who are at very low risk for CV events may not benefit significantly from therapy with lipidlowering agents. Of note, this analysis serves as the evidence underlying the current American College of Physicians guidelines that remend statins to all p39。ts with type 2 DM and CAD regardless of their serum cholesterol levels. Ann intern Med. 2022。140:6508. HLJ 業(yè)精于勤荒于嬉 行成于思毀于隨