内分泌学会发布“明智选择”建议

内分泌学会(ES)和美国临床内分泌医师协会(AACE)发布了一系列建议，反对在患者诊断和治疗中进行一些不必要的检查和操作。

作为美国内科基金会“明智选择”行动的一部分，30多个健康组织已发布或即将发布治疗指南，目的是教育患者和医生避免进行不必要和潜在有害的检查和治疗。建议清单将于2014年初完成，这是希望“使患者和医生就哪些治疗对于特定疾病确有必要展开对话”的系列行动的一部分。

ES和AACE的建议如下：

·对于接受不导致低血糖药物治疗的成年稳定2型糖尿病患者，应避免进行常规每日多次自我血糖监测。此类检查对于血糖控制良好的患者是多余的，并且检查结果在很大程度上是可以预测的。也存在一些例外的情况，如当患者患病或体重减轻时，以及追加新的药物或糖化血红蛋白A1c数值偏离目标时。

·除非患者发生高钙血症或肾功能降低，请勿常规测定1,25-二羟维生素D。在维生素D缺乏的情况下，1,25-二羟维生素D水平升高，而非降低。血清1,25-二羟维生素D水平主要由甲状旁腺激素水平调控，与维生素D储备几乎无关联。当试图评估维生素D储备或诊断维生素D缺乏症（或中毒）时，25-羟维生素D才是正确的检查。

·如无可触及的甲状腺异常，请勿对甲状腺功能检查异常患者常规申请甲状腺超声检查。通过超声检测到的结节通常与甲状腺功能异常无关，并且可能使临床评估偏离甲状腺功能异常，转移到对结节的评定。

·当对于甲状腺功能低减患者评估左旋甲状腺素(T4) 剂量时，请勿申请总T3或游离T3水平的测定，因为总T3或游离T3的血液浓度可能具有误导性。对于多数患者，TSH正常提示T4剂量是适当的。

·除非存在强的睾酮缺陷生化证据，否则请勿处方睾酮治疗。很多男性性腺功能减退的症状在正常男性衰老过程中很常见，或为合并疾病所致。并且，睾酮治疗非常昂贵，对于一些患者，还可能导致严重不良反应。应在早上测定总睾酮水平，如睾酮水平降低，应在另外一天进行重复测定确认。

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By: MIKE BOCK, Clinical Endocrinology News Digital Network

The Endocrine Society and the American Association of Clinical Endocrinologists have released a series of recommendations that advise against unnecessary tests and procedures in patient diagnosis and treatment.

More than 30 health organizations have released or will release treatment guidelines as part of the American Board of Internal Medicine Foundation’s "Choosing Wisely" campaign, which is meant to educate patients and physicians about unnecessary and potentially harmful testing and treatment. The recommendation lists, expected to be completed by early 2014, are part of a series that hopes to "spark conversations between patients and physicians about what care is really necessary for specific conditions."

The Endocrine Society and AACE recommended the following:

·Avoid routine multiple daily self-glucose monitoring in adults with stable type 2 diabetes on agents that do not cause hypoglycemia. Such testing can be excessive for patients who are doing a good job of maintaining glycemic control, and testing results can become quite predictable. There are a number of exceptions, such as when a patient is sick or losing weight, or when new medications are added or hemoglobin A1c values stray from targets.

·Don’t routinely measure 1,25-dihydroxyvitamin D unless the patient has hypercalcemia or decreased kidney function. In vitamin D deficiency, 1,25-dihydroxyvitamin D levels go up, not down. Serum levels of 1,25-dihyroxyvitamin D are regulated primarily by parathyroid hormone levels and have little connection to vitamin D stores. When trying to assess vitamin D stores or diagnose vitamin D deficiency (or toxicity), 25-hydroxyvitamin D is the correct test.

·Don’t routinely order a thyroid ultrasound in patients with abnormal thyroid function tests if there is no palpable abnormality of the thyroid gland. Nodules detected via ultrasound are usually unrelated to the abnormal thyroid function and may divert the clinical evaluation to assess the nodules, rather than the thyroid dysfunction.

·Don’t order a total or free T3 level when assessing levothyroxine (T4) dose in hypothyroid patients, as the blood level of total or free T3 may be misleading. With most patients, a normal TSH indicates a correct dose of T4.

·Don’t prescribe testosterone therapy unless there is strong biochemical evidence of testosterone deficiency. Many of the symptoms attributed to male hypogonadism are common in the normal male aging process or are the result of a comorbid condition. In addition, testosterone therapy is expensive and has the potential for serious side effects in some patients. Total testosterone levels should be taken in the morning, and a low level should be confirmed on a different day.