The Endocrine Society of Australia: tests, treatments and procedures clinicians and consumers should question

Thyroid ultrasound is used to identify and characterize thyroid nodules, and is not part of the routine evaluation of abnormal thyroid function tests (over- or underactive thyroid function) unless the patient also has a palpably large goitre or a nodular thyroid. Incidentally discovered thyroid nodules on ultrasound are common. Overzealous use of ultrasound will frequently identify nodules, which are unrelated to the abnormal thyroid function, and may divert the clinical evaluation to assess the nodules, rather than the thyroid dysfunction, may lead to further unnecessary investigation, unwarranted patient anxiety and increased costs. Imaging may be needed in thyrotoxic patients; when needed, a radionuclide thyroid scan, not an ultrasound, is used to assess the aetiology of the thyrotoxicosis and the possibility of focal autonomy in a thyroid nodule or nodules.

Supporting evidence

  • Ahn HS. Korea's Thyroid-Cancer “Epidemic” — Screening and Overdiagnosis. New England Journal of Medicine 2014;371:1765-7.
  • Brito JP. Thyroid cancer: zealous imaging has increased detection and treatment of low risk tumours. British Medical Journal 2013;347.
  • Bahn CRS. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid 2011;21:593-646.

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Many of the symptoms attributed to male hypogonadism are commonly seen in normal male aging or in the presence of comorbid conditions. Testosterone therapy has the potential for serious side effects and represents a significant expense. It is therefore important to confirm the clinical suspicion of hypogonadism with biochemical testing. Current guidelines recommend the use of a total testosterone level obtained in the morning. A low level should be confirmed on a different day, again measuring the total testosterone. In some situations, for example conditions in which sex hormone-binding globulin concentrations are altered, a calculated free or bioavailable testosterone may be of additional value.

Supporting evidence

  • Corona G. Cardiovascular risk associated with testosterone-boosting medications: a systematic review and meta-analysis. Expert Opin Drug Saf 2014;13:1327-51.
  • Finkle WD. Increased risk of non-fatal myocardial infarction following testosterone therapy prescription in men. PLoS One 2014;9(1):e85805.
  • Baillargeon J. Risk of myocardial infarction in older men receiving testosterone therapy. The Annals of Pharmacotherapy 2014;48:1138-44.
  • Vigen R. Association of testosterone therapy with mortality, myocardial infarction, and stroke in men with low testosterone levels, JAMA 2013;310(17):1829-36.
  • Xu L. Testosterone therapy and cardiovascular events among men: a systematic review and meta-analysis of placebo-controlled randomized trials. BMC Medicine 2013;11:108.
  • Shores MM. Testosterone treatment and mortality in men with low testosterone levels. Journal of Clinical Endocrinology Metabolism 2012;97:2050-8.
  • Bhasin S. Testosterone therapy in men with androgen deficiency syndromes: an Endocrine Society clinical practice guideline. Journal of Clinical Endocrinology Metabolism 2010;95:2536-59.
  • Fernández-Balsells MM. Clinical review 1: Adverse effects of testosterone therapy in adult men: a systematic review and meta-analysis, Journal of Clinical Endocrinology Metabolism 2010;95(6):2560-75.

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Measurement of insulin either in the fasting state or during an oral glucose tolerance test is not a clinically useful method (and may be costly because of the insulin assay) to estimate insulin sensitivity. The hyperinsulinemic-euglycemic (HIEG) clamp is the gold standard for assessing insulin sensitivity as it is possible to assess tissue specific sensitivity and can be used in all types of populations. This feature is important because a method of standardisation must be developed to control for various factors prior to any methods for measurement.

Supporting evidence

  • Antuna-Puente R. How can we measure insulin sensitivity/resistance?, Diabetes & Metabolism 2011;37(3):179-88.
  • Teede HJ. Assessment and management of polycystic ovary syndrome Medical Journal of Australia 2011;195(6).
  • Borai A. Selection of the appropriate method for the assessment of insulin resistance. British Medical Journal 2011;11:158.
  • Samaras K. Insulin levels in insulin resistance: phantom of the metabolic opera? Medical Journal of Australia 2006;185(3):159-61.

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Once target control is achieved in adults with stable type 2 diabetes and the results of self-glucose monitoring become quite predictable, there is little gained in most individuals from repeatedly confirming. There are many exceptions, such as for acute illness, when new medications are added, when weight fluctuates significantly, when A1c targets drift off course and in individuals who need monitoring to maintain targets. Self-monitoring is beneficial as long as one is learning and adjusting therapy based on the result of the monitoring.

Supporting evidence

  • Welschen LMC. Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin. Cochrane Database of Systematic Reviews 2012; Issue 1.
  • Farmer AJ. Meta-analysis of individual patient data in randomised trials of self monitoring of blood glucose in people with non-insulin treated type 2 diabetes. British Medical Journal 2012;344:e486.
  • Department of Health and Ageing and University of South Australia 2012, Pharmaceutical Benefits Scheme Products Used in the Treatment of Diabetes, Part 1: Blood Glucose Test Strips.
  • Clar C. Self-monitoring of blood glucose in type 2 diabetes: systematic review. Health Technology Assessment. 2010;14(12):1-140.
  • McIntosh B. Efficacy of self-monitoring of blood glucose in patients with type 2 diabetes mellitus managed without insulin: a systematic review and meta-analysis. Open Medicine 2010;4(2):e102-13.
  • International Diabetes Federation 2009, Guideline: Self-Monitoring of Blood Glucose in Non-Insulin Treated Type 2 Diabetes.
  • Allemann S. Self-monitoring of blood glucose in non-insulin treated patients with type 2 diabetes: a systematic review and meta-analysis. Current Medical Research & Opinion. 2009;25(12):2903-13.

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T4 (thyroxine) is converted into T3 at the cellular level in virtually all organs. Intracellular T3 levels regulate pituitary secretion and blood levels of thyroid-stimulating hormone (TSH), as well as the effects of thyroid hormone in multiple organs; a normal TSH indicates an adequate T4 dose. Conversion of T4 to T3 at the cellular level may not be reflected in the T3 level in the blood. Compared to patients with intact thyroid glands, patients with hypothyroidism taking T4 may have higher blood T4 and lower blood T3 levels. Thus the blood level of total or free T3 may be misleading (low normal or slightly low); in most patients a normal TSH indicates a correct dose of T4.

Supporting evidence

  • Garber JR. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Thyroid 2012; 22(12):1200-35.

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The Medical Affairs sub-committee of the Endocrine Society of Australia (ESA) collaborated with the Royal Australasian College of Physicians (RACP) to compile a list of 44 possible low-value interventions using desktop research.

The list was examined and refined down to 8 interventions: comprising 6 that were deemed sufficiently common or important to warrant consideration and two additional practices identified by the committee. A review of the evidence for these 8 was completed and circulated to the whole ESA membership for feedback via an on-line survey.  Based on the results of the survey, which attracted 146 respondents, a top 5 was identified.

Last reviewed 01 March 2016