Initial evaluation of thyroid dysfunction - Are simultaneous TSH and fT4 tests necessary?

Claudio Schneider, Martin Feller, Douglas C. Bauer, Tinh Hai Collet, Bruno R. daCosta, Reto Auer, Robin P. Peeters, Suzanne J. Brown, Alexandra P. Bremner, Peter C. O’Leary, Peter Feddema, Peter J. Leedman, Drahomir Aujesky, John P. Walsh, Nicolas Rodondi

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16 Citations (Scopus)


Objective Guidelines for thyroid function evaluation recommend testing TSH first, then assessing fT4 only if TSH is out of the reference range (two-step), but many clinicians initially request both TSH and fT4 (one-step). Given limitations of previous studies, we aimed to compare the two-step with the one-step approach in an unselected community-dwelling study population, and develop a prediction score based on clinical parameters that could identify at-risk patients for thyroid dysfunction. Design Cross-sectional analysis of the population-based Busselton Health Study. Methods We compared the two-step with the one-step approach, focusing on cases that would be missed by the two-step approach, i.e. those with normal TSH, but out-of-range fT4. We used likelihood ratio tests to identify demographic and clinical parameters associated with thyroid dysfunction and developed a clinical prediction score by using a beta-coefficient based scoring method. Results Following the two-step approach, 93.0% of all 4471 participants had normal TSH and would not need further testing. The two-step approach would have missed 3.8% of all participants (169 of 4471) with a normal TSH, but a fT4 outside the reference range. In 85% (144 of 169) of these cases, fT4 fell within 2 pmol/l of fT4 reference range limits, consistent with healthy outliers. The clinical prediction score that performed best excluded only 22.5% of participants from TSH testing. Conclusion The two-step approach may avoid measuring fT4 in as many as 93% of individuals with a very small risk of missing thyroid dysfunction. Our findings do not support the simultaneous initial measurement of both TSH and fT4.

Original languageEnglish
Article numbere0196631
JournalPLoS One
Issue number4
Publication statusPublished - 1 Apr 2018


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