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PLOS One logoLink to PLOS One
. 2021 Feb 16;16(2):e0246195. doi: 10.1371/journal.pone.0246195

Dehydroepiandrostenedione sulphate (DHEAS) levels predict high risk of rheumatoid arthritis (RA) in subclinical hypothyroidism

Ravindra Shukla 1,*, Mayank Ganeshani 1,2, Monica Agarwal 1, Rakesh Jangir 1,3, Gaurav Kandel 1, Shrimanjunath Sankanagoudar 4, Shival Srivastava 5
Editor: Rosanna Di Paola6
PMCID: PMC7886134  PMID: 33592022

Abstract

Introduction

The presence of rheumatism is well recognized in primary hypothyroidism. Dehydroepiandrstenedione sulphate (DHEAS) is associated with rheumatological diseases like rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). This study aims to explore relationship between joint pains and DHEAS levels in primary hypothyroidism.

Methods

Retrospective study of 78 subjects with subclinical hypothyroidism, with TSH within reference range. The joint pains were evaluated by European Union League against rheumatism (EULAR-CSA) score and compared with serum DHEAS, RA factor, Anti-TPO antibody, highly sensitive C-recative protein (hsCRP), vitamin D levels.

Result

DHEAS levels <43.6 mcg/dl significantly predicted clinical features of pre RA as assessed by EULAR CSA criteria with acceptable specificity (82%). EULAR CSA score is fairly valid in assessing imminent RA in primary hypothyroidism.

Conclusion

Lower DHEAS predicts clinical features of imminent RA in subjects with primary hypothyroidism. This is akin to low DHEAS seen in many rheumatological disease with possibly similar mechanism. Another possibility is low DHEAS alters hepato-hypothalamo pituitary adrenal axis in presense of cytokines and induces a hitherto unrecognized state of pre rheumatoid arthritis like syndrome. Future studies on primary hypothyroidism should focus on role of lower DHEAS levels in inducing symptoms of fatigue and joint pains.

Introduction

Rheumatism is well recognized symptom in primary hypothyroidism While rheumatoid arthritis (RA) is associated with primary hypothyroidism, large subset of patients do not fulfill criteria for RA [1] European Union League against Rheumatism (EULAR) has released a validated criteria for clinically suspect arthralgia (CSA) to determine early RA. The EULAR-CSA criteria makes it possible to identify high risk of RA on clinical examination without need for RA factor or anti CCP antibodies [2]. Dihydroepiandrostenedione sulfate (DHEAS) is most abundant adrenal steroid, immunomodulator and found to be low in autoimmune diseases affecting joints e.g. RA, SLE [3] Low DHEAS has been documented previously in primary hypothyroidism [4]. We hypothesized DHEAS to be associated with arthralgias in autoimmune primary hypothyroidism. The study objective was to examine association of EULAR CSA criteria with DHEAS levels in primary hypothyroidism patients on adequate levothyroxine dose.

Subjects & methods

Retrospective data on primary hypothyroidism has been collected under the project “Clinico-biochemical profile of primary hypothyroidism in Western Rajasthan” between 2016–2018 in Department of Endocrinology AIIMS, Jodhpur. The study was approved by Institute Ethics Committee vide AIIMS/IEC/2017/357. The retrospective data was fully anonymized before access. The electronic medical records in the hospital are identified with unique bar code. Even the bar code patient ID was removed during statistical analysis. The IEC waived consent for retrospective data collection. Inclusion criteria used was: a diagnosis of primary hypothyroidism, Thyroid Stimulating Hormone (TSH) levels 2-5mU/L, at least one DHEAS value within 1 week of TSH, CSA evaluated as per EULAR consensus criteria, on levothyroxine replacement (between 25–125 mcg). Those with pregnancy, RA, SLE, diabetes, cardiovascular event, adrenal disease, or any other chronic illness were excluded. The sample size was calculated with 80% power to detect a difference of 20 mcg/dl serum DHEAS in both ways (bi-directional significance at p <0.05) with respect to EULAR score. The following formula was used, which gave sample size of 80 [5]:

n = 2 (Zα+Z1-β)2 σ2÷d2 where

Zα = 1.96 for 2 tailed results at p < 0.05

Z1-β = 0.8416 for power of 80%

σ = Standard Deviation = 50 mcg/dl calculated on based on previous study [6]

d = effect size = 20 mcg/dl

A total of 78 patients record were included out of 462 (Fig 1) and values for DHEAS, 25 hydroxyvitamin D, Anti TPO, Rheumatoid Arthritis (RA) factor, highly sensitive C-reactive protein (hsCRP) was obtained. Automated chemilumiscence was used to measure TSH (Advia Centaur XP,) DHEAS (Diasorin), 25 (OH) vitamin D (Advia Centaur XP), Anti TPO antibody (Advia Centaur XP). Rheumatoid factor was measured by immunoturbidometry method (Beckman-Coulter). A value of > 18 IU/ml and >16 IU/ml was considered positive for Anti-TPO and RA factor, respectively. The inter-assay and intra-assay Co-efficient of Variation (C.V.) was <10% for all parameters measured.

Fig 1. Study flow chart.

Fig 1

Of total 462 datasets screened, 78 datasets were included in present study.

EULAR in its position statement [2] had released a list of seven objective clinical parameters for diagnosis of clinically suspicious arthralgia (CSA) [henceforth called EULAR-CSA score] likely to progress to rheumatoid arthritis. EULAR CSA score has been incorporated in clinical practice of evaluating features of imminent RA in our Thyroid Clinic. Since this was a retrospective study, assessors of EULAR score were not aware of DHEAS levels of respective subjects. A positivity of > 4 is likely to have increased risk for rheumatoid arthritis [2]. EULAR- CSA score > 4 also predicted arthritis as evidenced by MRI. Hence study subjects were divided into two groups—one with score less than or equal to 3 (hence forth called CSA absent) and another with score more than or equal to 4 for analysis (henceforth called CSA present).

Statistical analysis

The age and DHEAS levels were log transformed. A bivariate correlation was performed between log age and log DHEAS. EULAR criteria was outcome variable. Normality of data was assessed using Kolmogarov-Smirnov test. Multiple linear regression was then performed to analyze whether DHEAS predicts joint pains as assessed by EULAR criteria with predictive variables being age and DHEAS. One way ANOVA was used separately with each of the variables (age, DHEAS, Anti TPO Ab, RA factor, vitamin D, hs CRP) to determine whether they are associated with EULAR CSA score. A correlation analysis of EULAR score with each of the above variable was also performed. Pearson correlation was used for parametric (age, DHEAS), Spearman correlation for non-parametric (RA factor, hsCRP) while Kendal Tau was used for non-parametric dependent Anti TPOAb. Only absolute values of anti TPO antibody and RA factor were taken in analysis. The DHEAS levels were divided into quartiles (supplementary material in S1 File). Receiver operator curves (ROC) were performed with each quartile to determine which DHEAS quartile predicts rheumatism as assessed by EULAR–CSA score. A binary logistic regression analyses was performed to ascertain the effect of DHEAS in first quartile on likelihood that subjects have on individual component of EULAR-CSA score and whether they have CSA score >4. A p value <0.05 was considered significant. SPSS version 21 was used for statistical calculation.

Results

All eligible patients were females. Mean TSH was 2.8 mU/L. Vitamin D, Anti-TPO Ab, hs CRP and RA factor was not available for all the subjects (Table 1). Age, DHEAS, Anti TPO antibody were normally distributed (Table 1). DHEAS level was found to be inversely correlated with age in years (r = 0.241, p = 0.03) (Fig 2).The correlation was weak (spearman rho coefficient of correlation = -0.241) but statistically significant (p = 0.03).There was no statistically significant correlation of Anti TPO Ab (r = -0.12, p = 0.69), vitamin D (r = 0.11, p = 0.61), RA factor (r = 0.4, p = 0.051), hsCRP (r = 0.46, p = 0.53) with EULAR-CSA (Table 2) On multiple regression analysis, serum DHEAS predicted rheumatism as defined by EULAR CSA score, F(1,11.5) = 4.09, p = 0.049. Only the ROC curve for the first DHEAS quartile predicted joint pains in primary hypothyroidism (Fig 3). The AUC was 0.67 (C.I = 0.52–0.83, p = 0.021) (Fig 3). The first quartile serum DHEAS value was <43.6 mcg/dl. Thus, DHEAS less than 43.8 mcg/dl predicted CSA of >5 with 82% specificity and 52% sensitivity. Although serum DHEAS < 43.6 was not a very strong predictor of presence of joint pains in primary hypothyroidism (mean AUC = 0.67), it was statistically significant. Binary logistic regression analysis revealed that DHEAS in lowest quartile (< 43.6 mcg/dl) predicted variables of EULAR CSA score (Table 3). Low DHEAS predicted metacarpophalangeal joint involvement and was found to be statistically significant (p = 0.044). It correctly classified 91% of cases but explained only 10% variance (Nagelkerke R2 = 0.12), suggesting a limited clinical value. The Odds Ration (OR) was around 1 for all seven components of EULAR-CSA score (Table 3), suggesting no single criteria can be used in isolation while evaluating joint pains in primary hypothyroidism. The results affirm symmetry of EULAR CSA score in evaluating primary hypothyroidism in context of decreased DHEAS. The mean DHEAS of those with CSA present (125.29 +/- 26.81) was lower than those with CSA absent (80.60 = /- 10). However, it was not statistically significant (p = 0.17). Despite low DHEAS predicting high grade of arthritis, mean DHEAS levels in those with EULAR CSA score > 4 were not statistically significant from those with lower CSA values (Fig 4).

Table 1. Descriptive characteristics of study subjects.

Number (n) Mean(+/- S.D.) Skewness Static
Age (in years) 78 43.23 +/- 10.21 -0.2
TSH (mU/L) 78 3.06 +/- 3.03 8.3
DHEAS (mcg/ml) 78 99.30 +/- 88.28 1.9
Vitamin D (ng/ml) 14 75.41 +/- 177.90 3.4
Anti -TPO Ab (IU/L) 8 352.02 +/- 321.47 0.05
hs CRP (mg/dl) 12 11.99 +/- 22.90 2.8
RA factor 16 15.64+/-30.33 3.6

As shown above Age, DHEAS, Anti TPO antibody were normally distributed (skewness static <2).

Fig 2. Inverse correlation between age and DHEAS levels.

Fig 2

The correlation was weak (spearman rho coefficient of correlation = -0.241) but statistically significant (0.03).

Table 2. Result of correlation of different parameters with EULAR-CSA score.

Bivariate correlation co-efficient p-value
Age 0.048 0.64
DHEAS -0.224 0.049
Anti-TPO -0.12 0.69
25(OH) Vitamin D 0.11 0.61
Hs CRP 0.46 0.53
RA factor 0.49 0.051

correlation with DHEAS.

DHEAS was inversely correlated with EULAR-CSA score and was statistically significant. RA factor was positively correlated but statistically insignificant.

Fig 3. Low DHEAS as predictor of rheumatism in primary hypothyroidism.

Fig 3

ROC curve for low DHEAS as a predictor of rheumatism in primary hypothyroidism. The AUC curve was 0.67 (C.I = 0.52–0.83, p = 0.021).The cut off point for <43.6 mcg/dl was found. DHEAS, 43.8 predicted CSA of >5 with 82% specificity but low sensitivity (52%).

Table 3. Results binary logistic regression analyses to ascertain the effect of DHEAS on different variables.

OR (95% C.I.) P value
CSA present 1.01 (1–1.01) 0.181
Onset < 1 year 1.01 (1–1.01) 0.6
MCP joint involvement 1.01 (1–1.01) 0.044
Morning stiffness > 1 hour 1.01 (1–1.01) 0.37
Symptoms more in morning 1.01 (1–1.01) 0.38
First degree relaive with RA 1.01 (1–1.01) 0.63
Difficulty in making fist 1.01 (1–1.01) 0.062
Positive squeeze test 1.01 (1–1.01) 0.13

Only MCP joint involvement was found to be statistically significant. Low DHEAS does not increase likelihood of having CSA. The results affirm symmetry of EULAR CSA score in evaluating primary hypothyroidism in context of decreased DHEAS.

Fig 4. Comparison of mean DHEAS according to CSA status.

Fig 4

CSA was considered present if CSA score was greater or equal to 4. The mean DHEAS of those with CSA present (125.29 +/- 26.81) was lower than those with CSA absent (80.60 = /- 10). However it was not statistically significant. (p = 0.17).

Discussion

Decreased QoL and non-specific symptoms in subclinical primary hypothyroidism

Primary hypothyroidism is most common organ specific autoimmune disease. The treatment for primary hypothyroidism involves thyroid hormone replacement, mostly in form of oral levothyroxine [7]. Therapy is monitored by periodic TSH levels and clinical evaluation. Despite adequate levothyroxine supplementation as assessed by thyroid hormone levels, pain and impaired QoL persist [8]. These non specific symptoms are attributed to other associated disorders, somatization or inadequate peripheral 3,3’,5-Triiodothyronine (T3) availability. Peripheral T3 is availability is dependent on T4 to T3 conversion and also degradation of T4 & t3 to inactive 3,3’,5’ Triiodothyronine (rT3). This in turn is dependent on ubiquitous enzymes -the deiodinases [9]. There has been much interest in exploring therapeutic avenues to ameliorate non specific symptoms and improve this “localised” hypothyroidism [10]. Localized hypothyroidism of synovial cells have been documented in euthyroid subjects of RA to the extent that fT3 is nearly absent in synovial fluid [11]. Just like primary hypothyroidism, impaired QoL persist despite controlled disease activity in rheumatological diseases like RA, systemic lupus erythemtosus (SLE), Sjogren syndrome [12]. Also, autoimmune hypothyroidism is strongly associated with disease like RA, SLE, Sjogren syndrome leading to overlap of symptoms [13].

DHEAS and autoimmunity

DHEAS decrease with age and are also low in premenopausal females [14]. We found DHEAS to be inversely related with age. Physiologic conditions with high DHEAS levels have lower incidence of rheumatological diseases e.g. males, post menopausal females. DHEAS is important adrenal androgen in context of rheumatological diseases. Previous studies have documented low DHEAS levels in SLE, RA and Sjogren syndrome [15,16]. Here, we find DHEAS levels to be inversely correlated with EULAR-CSA score in females with primary hypothyroidism. The relationship between DHEAS levels and arthralgia in primary hypothyroidism can be explained by three hypotheses.

Cytokine hypothesis

The primary hypothyroidism is associated with increase in serum cytokines like Interleukin-6 (IL-6), tumor necrosis factor alfa (TNF-α) and hs CRP [17] and possibly IL 10, IL 4 [17]. Although levothyroxine brings down the level of cytokines, they do not return to same level as healthy controls after euthyroid state is achieved [18]. Paradoxically, T4 (but not T3) may induce IL-6 production in synovial cells [11]. Since IL-6 is primary mediator in pathogenesis of rheumatoid arthritis [19]; this common pathogenetic link explains the usefulness of EULAR-CSA score in hypothyroidism. DHEAS has suppressive effect on inflammatory cytokines, and local DHEA deficiency precedes synovial joint inflammation [20]. Thus low DHEAS in primary hypothyroidism can lead to clinical features of early RA.

Bystander association

The decreased DHEAS could very well be a bystander effect of generalized HPA axis suppression in these subjects. Adrenocortical function has been found to be decreased in patients primary hypothyroidism taking levothyroxine therapy [21]. Decrease HPA axis activity has also been postulated as pathogenetic mechanism of RA. The circadian dip in serum cortisol leads to increased cytokine build up early morning, leading to increased morning stiffness [22]. Increased DHEAS but not serum cortisol, androstenedione or testosterone was associated with improved disease activity in RA patients [23]. This points to a role of DHEAS independent of HPA axis, and questions the bystander association.

Role of 11β hydroxysteroid dehydrogenase-1 (HSD1)

A novel concept of hepato-hypothalamo-pituitary-adrenal-renal axis postulates the important role of 11 β HSD enzymes in HPA axis regulation in context of rheumatological diseases [24]. 11 beta HSD1 has been involved in cortisone conversion to active cortisol at tissue level and thus important for localized immunomodulation. Both thyroid hormone and DHEAS inhibit 11βHSD1 enzyme. 11βHSD1activity has been found to be increased in hypothyroidism [25]. Increased 11βHSD1 activity in pituitary, in presence of inflammatory cytokines, leads to downregulation of HPA axis [24]. This may lead to joint pains only when low DHEAS is co-existent with hypothyroidism.

DHEAS levels and CSA severity

DHEAS in lowest quartile (<43.5) predicted clinical features of pre-RA. The decreased serum DHEAS does not favorably predict a particular EULAR CSA component over other. This symmetric prediction makes likely the conclusion, that serum DHEAS < 43.5 might induce a pre-RA like syndrome in women with primary hypothyroidism on adequate levothyroxine replacement. TNF-α which is raised in primary hypothyroidism [7] can lead to localized DHEA deficiency in synovial cells [9]. It can be hypothesized that low DHEAS (i.e <43.5 mcg/dl) induces localized androgen deficiency and synovitis, seen in the study subjects. The mean DHEAS level of CSA present group was lower as compared to CSA absent group but was statistically not significant. This in important in several ways. First, subjects in former group had DHEAS levels (80 mcg/dl) much higher than those described in RA subjects (18 mcg/dl) [8] These were not RA patients (see exclusion criteria) and may never progress to overt RA. Rather tissue hypothyroidism may be responsible for arthralgias. Secondly, there exists no cut-off of DHEAS where severity of rheumatism increases in disproportionate manner. There may exist a spectrum of joint pains predicted by DHEAS in primary hypothyroidism patients which clinically follows RA like onset, but its progression is not determined by increased positivity of CSA components. However, testing of the assumption would need a prospective follow up. The result of binary logistic regression implied that all of the EULAR parameters have equal value in terms of weightage. There exists no gold standard to evaluate joint pains in primary hypothyroidism, which could be used to compare EULAR CSA score. But based on symmetry of Odds Ratio (OR), EULAR CSA score can be taken as valid measure to evaluate features of pre RA in primary hypothyroidism for future studies.

Novel therapeutic approach to autoimmune hypothyroidism

Our findings advocate an approach to primary hypothyroidism from lens of rheumatological disease. DHEAS has been tried in SLE with some success and has been suggested as therapeutic option in PMR [26]. Thus, DHEAS supplementation may be evaluated in hypothyroidism and considered for those with lower serum DHEAS (< 43mcg/dl) and arthralgias. Conversely, T3+T4 combination which have been used to treat localized hypothyroidism, can be used in hypothyroid subjects with arthralgias and by extension in RA. Secondly, it is likely that our study subjects had low QoL. Although low QoL in primary hypothyroidism is documented, more studies are needed to ascertain role of DHEAS with decreased QoL in primary hypothyroidism. Lowered oxidative defense in overt and sub-clinical hypothyroidism may affect QoL [27] and DHEAS has protective effect during oxidative stress [28] Thirdly, all of the patients fulfilling study criteria were women. Although rheumatological diseases are more common in women, this finding implies to rule out joint pains in women with subclinical hypothyroidism.

This study unravels research questions. Is low DHEAS also associated with complaints of generalized pain and fatigue in patients of primary hypothyroidism? Is intervention with Disease Modifying Anti Rheumatoid Arthritis Drugs (DMARD) like hydroxychloroquine indicated in women of primary hypothyroidism with joint pains? and most important, although DHEAS is well associated with RA onset in prospective study, what is relationship of DHEAS with respect to EULAR CSA criteria in general?

Study limitations

Our study had certain drawbacks. This was retrospective cross sectional study. Only those with EULAR CSA examination done were included. It is possible that those with low DHEAS were examined more closely for RA-like symptoms and EULAR scoring done. Secondly, we did not measure serum inflammatory cytokines. This would have been crucial in proving cytokine hypothesis. Thirdly, RA was excluded on clinical basis, no anti-cyclic citrullinated peptide (CCP) antibody was done. Finally we analyzed low DHEAS as compared to EULAR CSA which is fairly specific scoring system, but we may have missed joint symptoms not covered EULAR CSA, yet important in context of primary hypothyroidism.

Conclusion

This study finds low DHEAS levels to predict features of imminent RA in women with primary hypothyroidism. There can be three possible hypotheses to explain the finding. This study emphasizes that those on adequate levothyroxine replacement, as judged by thyroid hormones in reference range, may not be physiologically euthyroid. This study also used EULAR CSA criteria for the first time in hypothyroidism subjects. Future studies on primary hypothyroidism should focus on role of DHEAS in improving low QoL.

Supporting information

S1 File. Supplementary material 1: The EULAR-CSA score.

(DOCX)

Acknowledgments

The authors acknowledge contribution of Dr Divyangi Mishra in data collection.

Abbreviations

RA

Rheumatoid Arthritis

EULAR

European league against Rheumatism

CSA

Clinically Significant Arthralgias

Anti-CCP

Anti cyclic citrullinated peptide

DHEAS

Dehydroepiandrostenedione Sulphate

SLE

Systemic Lupus Erythematous

Anti-TPO Ab

Anti-thyroperoxidase Antibody

hsCRP

high sensitive C- reactive protein

TSH

Thyroid Stimulating Hormone

AUC

Area under curve

T3

tri-iodothyronine

T4

tetra-iodothyronine

rT3

reverse tri-iodothryronine

QoL

Quality of Life

IL-6

Interleukin 6

IL-10

Interleukin 10

IL-4

Interleukin 4

HPA

Hypothalamopituitary Axis

11βHSD1

11β hydroxysteroid dehydrogenase-1

Data Availability

The data that support finding of study is available in excel format at the Open Science framework (https://osf.io/t4gxj/?view_only=614b6b07b0c7465ab50d1b06b5b4878f) under project name "Clinico-biochemical profile of primary hypothyroidism in Western Rajasthan."

Funding Statement

The authors received no specific funding for this work.

References

  • 1.Emamifar A, Hangaard J, Jensen Hansen IM. Thyroid disorders in patients with newly diagnosed rheumatoid arthritis is associated with poor initial treatment response evaluated by disease activity score in 28 joints-C-reactive protein (DAS28-CRP): An observational cohort study. Medicine (Baltimore). 2017;96(43): e8357 10.1097/MD.0000000000008357 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.van Steenbergen HW, Aletaha D, Beaart-van de Voorde LJJ, Brouwer E, Codreanu C, Combe B, et al. EULAR definition of arthralgia suspicious for progression to rheumatoid arthritis. Ann Rheum Dis 2016. –209846 10.1136/annrheumdis-2016-209846 [DOI] [PubMed] [Google Scholar]
  • 3.Rutkowski K, Sowa P, Rutkowska-Talipska J, Kuryliszyn-Moskal A, Rutkowski R. Dehydroepiandrosterone (DHEA): hypes and hopes. Drugs. 2014;74(11):1195–1207. 10.1007/s40265-014-0259-8 [DOI] [PubMed] [Google Scholar]
  • 4.Tagawa N, Tamanaka J, Fujinami A, Kobayashi Y, Takano T, Fukata S, et al. Serum dehydroepiandrosterone, dehydroepiandrosterone sulfate, and pregnenolone sulfate concentrations in patients with hyperthyroidism and hypothyroidism. Clin Chem 2000. April;46(4):523–8. [PubMed] [Google Scholar]
  • 5.Kadam P, Bhalerao S. Sample size calculation. Int J Ayurveda Res 2010;1(1):55–7. 10.4103/0974-7788.59946 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Lashkari M., Noori A., Oveisi S., & Kheirkhah M. (2018). Association of serum testosterone and dehydroepiandrosterone sulfate with rheumatoid arthritis: a case control study. Electronic physician, 10(3), 6500–6505. 10.19082/6500 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Jonklaas J, Bianco AC, Bauer AJ, et al. Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid. 2014;24(12):1670–1751. 10.1089/thy.2014.0028 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Kelderman-Bolk N, Visser TJ, Tijssen JP, Berghout A. Quality of life in patients with primary hypothyroidism related to BMI. Eur J Endocrinol 2015. October;173(4):507–15. 10.1530/EJE-15-0395 [DOI] [PubMed] [Google Scholar]
  • 9.Cicatiello AG, Di Girolamo D and Dentice M (2018) Metabolic Effects of the Intracellular Regulation of Thyroid Hormone: Old Players, New Concepts. Front. Endocrinol. 9:474 10.3389/fendo.2018.00474 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Hennessey JV, Espaillat R. Current evidence for the treatment of hypothyroidism with levothyroxine/levotriiodothyronine combination therapy versus levothyroxine monotherapy. Int J Clin Pract. 2018;72(2):e13062 10.1111/ijcp.13062 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Pörings A., Lowin T., Dufner B. et al. A thyroid hormone network exists in synovial fibroblasts of rheumatoid arthritis and osteoarthritis patients. Sci Rep 9, 13235 (2019). 10.1038/s41598-019-49743-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Chaigne B, Finckh A, Alpizar-Rodriguez D, Courvoisier D, Ribi C, Chizzolini C. et al. Differential impact of systemic lupus erythematosus and rheumatoid arthritis on health-related quality of life. Qual Life Res 2017. July;26(7):1767–1775. 10.1007/s11136-017-1534-4 [DOI] [PubMed] [Google Scholar]
  • 13.Stathatos N, Daniels GH. Autoimmune thyroid disease. Curr Opin Rheumatol. 2012;24:70–5. 10.1097/BOR.0b013e32834ddb27 [DOI] [PubMed] [Google Scholar]
  • 14.Orentreich N, Brind JL, Rizer RL, et al. Age changes and sex differences in serum dehydroepiandrosterone sulfate concentrations throughout adulthood. J Clin Endocrinol Metab 1984;59:551–5. 10.1210/jcem-59-3-551 [DOI] [PubMed] [Google Scholar]
  • 15.Durcan L, Petri M. Immunomodulators in SLE: Clinical evidence and immunologic actions. J Autoimmun 2016;74:73–84. 10.1016/j.jaut.2016.06.010 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Vernerova L, Mravcova M, Paulikova L, Vlcek M, Marko A, Meskova M, et al. Contribution of Genetic Factors to Lower DHEAS in Patients with Rheumatoid Arthritis. Cell Mol Neurobiol 2018. January;38(1):379–383. 10.1007/s10571-017-0522-0 Epub 2017 Jul 15. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Cleare AJ, McGregor A, O’Keane V. Neuroendocrine evidence for an association between hypothyroidism, reduced central 5-HT activity and depression. Clin Endocrinol (Oxf) 1995;43:713–9 TNF alfa and IL 6. 10.1111/j.1365-2265.1995.tb00540.x [DOI] [PubMed] [Google Scholar]
  • 18.Tayde PS, Bhagwat NM, Sharma P, Sharma B, Dalwadi PP, Sonawane A, et al. Hypothyroidism and Depression: Are Cytokines the Link? Indian J Endocrinol Metab 2017. Nov-Dec;21(6):886–892. 10.4103/ijem.IJEM_265_17 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Hashizume M, Mihara M. The roles of interleukin-6 in the pathogenesis of rheumatoid arthritis. Arthritis. 2011;2011:765624 10.1155/2011/765624 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Weidler C, Struharova S, Schmidt M, Ugele B, Schölmerich J, Straub RH. Tumor necrosis factor inhibits conversion of dehydroepiandrosterone sulfate (DHEAS) to DHEA in rheumatoid arthritis synovial cells: a prerequisite for local androgen deficiency. Arthritis Rheum 2005. June;52(6):1721–9. 10.1002/art.21112 [DOI] [PubMed] [Google Scholar]
  • 21.Lizcano F, Rodríguez JS. Thyroid hormone therapy modulates hypothalamo-pituitary-adrenal axis. Endocr J. 2011;58(2):137–42. Epub 2011 Jan 21. 10.1507/endocrj.k10e-369 [DOI] [PubMed] [Google Scholar]
  • 22.Sternberg EM, Silverman MN, Cizza G. The neuroendocrine system and rheumatoid arthritis: insights from anti-tumor necrosis factor-alpha therapy. J Rheumatol 2007. July;34(7):1443–5. [PubMed] [Google Scholar]
  • 23.Ernestam S, Hafström I, Werner S, Carlström K, Tengstrand B. Increased DHEAS levels in patients with rheumatoid arthritis after treatment with tumor necrosis factor antagonists: evidence for improved adrenal function. J Rheumatol 2007. July;34(7):1451–8. [PubMed] [Google Scholar]
  • 24.Spies CM, Straub RH, Cutolo M, Buttgereit F. Circadian rhythms in rheumatology—a glucocorticoid perspective. Arthritis Res Ther 2014. November 13;16 Suppl 2:S3 10.1186/ar4687 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Di Silvestro D, Petrosino J, Aldoori A, Melgar-Bermudez E, Wells A, Ziouzenkova O. Enzymatic intracrine regulation of white adipose tissue. Horm Mol Biol Clin Investig. 2014;19(1):39–55. 10.1515/hmbci-2014-0019 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Sawalha AH, Kovats S. Dehydroepiandrosterone in systemic lupus erythematosus. Curr Rheumatol Rep 2008;10(4):286–91. 10.1007/s11926-008-0046-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Reddy VS, Gouroju S, Suchitra MM, Suresh V, Sachan A, Srinivasa Rao PV, et al. Antioxidant defense in overt and subclinical hypothyroidism. Horm Metab Res 2013. September;45(10):754–8. 10.1055/s-0033-1348262 [DOI] [PubMed] [Google Scholar]
  • 28.Ding X, Yu L, Ge C, Ma H. Protective effect of DHEA on hydrogen peroxide-induced oxidative damage and apoptosis in primary rat Leydig cells. Oncotarget 2017. March 7;8(10):16158–16169. 10.18632/oncotarget.15300 [DOI] [PMC free article] [PubMed] [Google Scholar]

Decision Letter 0

Rosanna Di Paola

20 Nov 2020

PONE-D-20-22641

Dehydroepiandrostenedione Sulphate  (DHEAS)  Levels Predict high risk of  Rheumatoid Arthritis (RA) in Subclinical Hypothyroidism

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Reviewer #1: Several abbreviations are used in the abstract without defining them: DHEAS, EULAR CSA, TPO, hsCRP.

While the meaning is clear and understandable, the manuscript should be edited for English grammar.

The use of hsCRP rather than CRP for the measurement of inflammation in the context of arthritis is not universally accepted, as the meaning of hsCRP in this context is not as well-documented as that of CRP or ESR.

If ESR data are available, these should also be included.

The absence of males from the cohort significantly weakens the generalizability of the results.

The sensitivity of DHEAS for predicting CSA was low, DHEAS levels < 43.6 while statistically significant did not have very strong predictive value of joint pains, and as seen in Figure 4, the confidence intervals of the mean DHEAS levels in those who did and did not meet CSA status were overlapping.

The statement in the discussion that DHEA supplementation has a proven role in SLE and PMR is not widely accepted, and the authors provide only one reference article to support this controversial statement in SLE and no evidence at all to support such a claim in PMR.

Overall, the paper's conclusion that the potential role of DHEAS in improving low QoL in hypothyroid patients with joint pain and normal TSH should be further investigated is not strongly supported by the findings described.

Reviewer #2: To start, the terminology, methods, and hypothesis used in this study are confusing. Is this a study to demonstrate a correlation of DHEAS levels with “early RA,” pre-RA, or simply with “rheumatism” - which I take to mean joint pains and arthralgia but not clinical synovitis (the term “rheumatism” is not precisely defined by the authors). This is not a trivial point. In fact, it is central to the whole narrative of the study. Yet, all of these terms are used interchangeably throughout the paper.

To be clear, “early RA” is not “pre-RA”, and rheumatism can describe any, all, or neither of those terms. The EULAR-CSA score was established to identify specific patients in the pre-clinical stage of RA disease development, as RA likely develops in a multi-step approach from pre-clinical autoimmunity to overt systemic and articular inflammatory disease. The score does not determine who has early (classifiable) RA. Indeed, the EULAR CSA score was validated against clinical acumen that was able at its best to identify a 20% chance of someone with CSA developing early RA in the next few years.

With that point made, the authors then study whether there is a relationship between DHEAS levels in subclinical hypothyroidism and “rheumatism” or “early RA” as measured by a the CSA score. Here are some issues:

1. DHEAS levels significantly and inversely correlated with CSA score. However – they did NOT correlate with CSA being present. When the CSA score was dichotomized, binary logistic regression found no association (an odds ratio of 1.01) between whether CSA was present or absent and DHEAS levels. And mean DHEAS was not significantly different in those with CSA and those without. So the statement that “serum DHEAS predicted rheumatism” is NOT correct (line 109) based on those data. Again, it depends upon how one defines “rheumatism,” because MCP pain can be considered a feature of “rheumatism,” but DHEA as a whole did not correlate with higher risk arthralgias predictive of developing RA as defined by a CSA score>4.

2. When DHEAS levels were dichotomized as well, then there was a correlation between a DHEAS level <43.6 and CSA present. The author’s state that “low levels of DHEAS” predict clinical features of “early RA” in primary hypothyoid patients. This is misleading. First, is DHEAS < 43.6 low or not? Physiologic rather than pathological levels of DHEA may be relevant to the immunologic/inflammatory effects mentioned in the paper. No reference is made to what is considered a normal level physiologically in women other than general mention of lower and higher levels by age and menopausal status. Second, the authors selectively drew their cutoff at that level not because it was low physiologically per se but because it granted them the most favorable characteristics on an ROC curve, such that only those DHEAS levels in the bottom quartile were considered. And even then, the AUC was weak. Third, because DHEAS levels correlate with age and other factors (as shown, albeit weakly) selectively reporting results comparing only the lowest quartile could introduce bias by comparing patients with different demographic characteristics (and lower DHEAS levels) to those with higher levels and different demographics.

Other issues:

3. Were the assessors of CSA blinded to DHEAS levels? I assume since CSA is part of the clinical practice and that this is a retrospective review, the answer is that the assessors had no knowledge of present or past DHEAS levels. But that needs to be stated.

4. How were patients with RA excluded? Was this based on ACR 1987 or ACR/EULAR 2010 criteria? Or simply a “clinical diagnosis” of RA. If the latter, then this is problematic. The authors did not measure CCP levels in their patients, but CCP+ patients (even those without arthritis) could have a diagnosis of “RA” in their chart because of the positive test and thus could have been excluded. If so, then the authors may have excluded pre-RA patients (with CSA for example) from the study, thus skewing their results. CCP+ patients without synovitis are 50% likely to develop clinical RA in the subsequent 3 years, hence it is the best predictor of pre-clinical RA.

5. Figure 4 is backwards in the text compared to what is actually in the figure.

6. Line 163: the statement appears to be misworded (they do NOT return?) “Although levothyroxine brings down the level of cytokines , they do return to the same level as healthy controls after euthyroid state is achieved (18)

Again – this all gets back to the central question of what the study is actually trying to answer. Is this a study that “predicts clinical features of early RA” as stated in line 24 or correlate with those patients who have evidence of “rheumatism” as per line 248. This paper has to be rewritten in more clear, precise, and consistent terminology of what is being studied: I would recommend stating that lower (not necessarily low) levels of DHEAS in women with subclinical hypothyroidism correlate with clinically suspect arthralgia that is at higher risk for evolving into rheumatoid arthritis. I would also mention in the paper that the data do not support a correlation between DHEAS levels in general and higher risk arthralgias, although there is a weak but statistically significant association between high risk arthralgia and the lowest quartile of serum DHEAS levels, suggesting the possibility of a threshold effect of DHEAS at physiologic levels.

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PLoS One. 2021 Feb 16;16(2):e0246195. doi: 10.1371/journal.pone.0246195.r002

Author response to Decision Letter 0


24 Dec 2020

Reviever 1

Q1. Several abbreviations are used in the abstract without defining them: DHEAS, EULAR CSA, TPO, hsCRP.

While the meaning is clear and understandable, the manuscript should be edited for English grammar.

Response: We have added abbrevations and rectified grammatical errors

Q2. The use of hsCRP rather than CRP for the measurement of inflammation in the context of arthritis is not universally accepted, as the meaning of hsCRP in this context is not as well-documented as that of CRP or ESR

Response: We agree that CRP has been traditional and widely accepted marker of RA. hsCRP measures CRP in 5 to 10 mg/dl range . Its increased sensitivity may come at cost of specificity. Last few years have seen increase in use of hsCRP as disease activity marker (1) Since hsCRP is now widely available, most of our arthritis patients get done hsCRP. From perspective of our study, in which we excluded those with established RA, and we need to pick up inflammation (even at CRP <10) , use of hs CRP is more pragmatic.

1. Dessein PH, Joffe BI, Stanwix AE. High sensitivity C-reactive protein as a disease activity marker in rheumatoid arthritis. J Rheumatol. 2004 Jun;31(6):1095-7. PMID: 15170920.

Q3 The absence of males from the cohort significantly weakens the generalizability of the results.

Response: Both Rheumatoid arthritis and primary hypothyroidism is more common in females. In fact most studies of RA , including validation for EULAR has disproportionate female preponderance.

Q4 The sensitivity of DHEAS for predicting CSA was low, DHEAS levels < 43.6 while statistically significant did not have very strong predictive value of joint pains, and as seen in Figure 4, the confidence intervals of the mean DHEAS levels in those who did and did not meet CSA status were overlapping.

Response: There was overlapping as shown in figure 4 . That’s why, DHEAS levels , although low in CSA were not statistically significant. However, DHEAS < 43.6 had a specificity of 82 % and sensitivity of 52%, which is fairly acceptable for a retrospective analysis. If we prospectively do a study specifically asking and examining joint pains in all hypothyroid patients, the sensitivity will improve.

Q5 The statement in the discussion that DHEA supplementation has a proven role in SLE and PMR is not widely accepted, and the authors provide only one reference article to support this controversial statement in SLE and no evidence at all to support such a claim in PMR.

Response:

Thank you. I understand we should not be so emphatic. We have changed “DHEA supplementation has a proven role in SLE and PMR” to “ DHEA has been tried in SLE with some success (1) and has been suggested as therapeutic option in PMR (2)” We also change the reference accordingly

Regarding SLE and DHEA : There have been 7 RCTs till 2007 of which only one found benefit. We have attached Cochrane reference in which authors concluded “there was evidence that DHEA had a modest but clinically significant impact on health related quality of life in the short term”

Regarding PMR and DHEA:

We thank you for pointing out that there are no studies evaluating DHEA supplementation in PMR. The authors of one study (2)conclude “combination therapy with corticosteroids and DHEA may be a better therapeutic approach than prednisolone monotherapy.”

1. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005114.pub2/full

2. R. H. Straub, T. Glück, M. Cutolo, J. Georgi, K. Helmke, J. Schölmerich, P. Vaith, B. Lang, The adrenal steroid status in relation to inflammatory cytokines (interleukin‐6 and tumour necrosis factor) in polymyalgia rheumatica, Rheumatology, Volume 39, Issue 6, June 2000, Pages 624–631, https://doi.org/10.1093/rheumatology/39.6.624

It came as surprise to us there are no studies of DHEA supplementation in PMR , especially since Low DHEAS is well documented in PMR. We quote a total of 13 studies. However , we do not wish them to add in references

1: Narváez J, Bernad B, Díaz Torné C, Momplet JV, Montpel JZ, Nolla JM,

Valverde-García J. Low serum levels of DHEAS in untreated polymyalgia

rheumatica/giant cell arteritis. J Rheumatol. 2006 Jul;33(7):1293-8. Epub 2006

Jun 15. PMID: 16783861.

2: Nilsson E, de la Torre B, Hedman M, Goobar J, Thörner A. Blood

dehydroepiandrosterone sulphate (DHEAS) levels in polymyalgia rheumatica/giant

cell arteritis and primary fibromyalgia. Clin Exp Rheumatol. 1994 Jul-

Aug;12(4):415-7. PMID: 7955606.

3: Cutolo M, Montecucco CM, Cavagna L, Caporali R, Capellino S, Montagna P,

Fazzuoli L, Villaggio B, Seriolo B, Sulli A. Serum cytokines and steroidal

hormones in polymyalgia rheumatica and elderly-onset rheumatoid arthritis. Ann

Rheum Dis. 2006 Nov;65(11):1438-43. doi: 10.1136/ard.2006.051979. Epub 2006 Apr

27. PMID: 16644782; PMCID: PMC1798362.

4: Cutolo M, Straub RH, Foppiani L, Prete C, Pulsatelli L, Sulli A, Boiardi L,

Macchioni P, Giusti M, Pizzorni C, Seriolo B, Salvarani C. Adrenal gland

hypofunction in active polymyalgia rheumatica. effect of glucocorticoid

treatment on adrenal hormones and interleukin 6. J Rheumatol. 2002

Apr;29(4):748-56. PMID: 11950017.

5: Straub RH, Glück T, Cutolo M, Georgi J, Helmke K, Schölmerich J, Vaith P,

Lang B. The adrenal steroid status in relation to inflammatory cytokines

(interleukin-6 and tumour necrosis factor) in polymyalgia rheumatica.

Rheumatology (Oxford). 2000 Jun;39(6):624-31. doi:

10.1093/rheumatology/39.6.624. PMID: 10888707.

6: Sulli A, Montecucco CM, Caporali R, Cavagna L, Montagna P, Capellino S,

Fazzuoli L, Seriolo B, Alessandro C, Secchi ME, Cutolo M. Glucocorticoid effects

on adrenal steroids and cytokine responsiveness in polymyalgia rheumatica and

elderly onset rheumatoid arthritis. Ann N Y Acad Sci. 2006 Jun;1069:307-14. doi:

10.1196/annals.1351.029. PMID: 16855158.

7: Pacheco MJ, Amado JA, Lopez-Hoyos M, Blanco R, Garcia-Unzueta MT, Rodriguez-

Valverde V, Martinez-Taboada VM. Hypothalamic-pituitary-adrenocortical axis

function in patients with polymyalgia rheumatica and giant cell arteritis. Semin

Arthritis Rheum. 2003 Feb;32(4):266-72. doi: 10.1053/sarh.2003.49993. PMID:

12621591.

8: Cutolo M, Foppiani L, Minuto F. Hypothalamic-pituitary-adrenal axis

impairment in the pathogenesis of rheumatoid arthritis and polymyalgia

rheumatica. J Endocrinol Invest. 2002;25(10 Suppl):19-23. PMID: 12508908.

9: Demir H, Tanriverdi F, Ozoğul N, Caliş M, Kirnap M, Durak AC, Keleştimur F.

Evaluation of the hypothalamic-pituitary-adrenal axis in untreated patients with

polymyalgia rheumatica and healthy controls. Scand J Rheumatol. 2006 May-

Jun;35(3):217-23. doi: 10.1080/03009740500474586. PMID: 16766369.

10: Pearce G, Ryan PF, Delmas PD, Tabensky DA, Seeman E. The deleterious effects

of low-dose corticosteroids on bone density in patients with polymyalgia

rheumatica. Br J Rheumatol. 1998 Mar;37(3):292-9. doi:

10.1093/rheumatology/37.3.292. PMID: 9566670.

11: Cutolo M, Sulli A, Pizzorni C, Craviotto C, Prete C, Foppiani L, Salvarani

C, Straub RH, Seriolo B. Cortisol, dehydroepiandrosterone sulfate, and

androstenedione levels in patients with polymyalgia rheumatica during twelve

months of glucocorticoid therapy. Ann N Y Acad Sci. 2002 Jun;966:91-6. doi:

10.1111/j.1749-6632.2002.tb04206.x. PMID: 12114263.

12: Cutolo M, Sulli A, Pizzorni C, Craviotto C, Straub RH. Hypothalamic-

pituitary-adrenocortical and gonadal functions in rheumatoid arthritis. Ann N Y

Acad Sci. 2003 May;992:107-17. doi: 10.1111/j.1749-6632.2003.tb03142.x. PMID:

12794051.

13: de la Torre B, Fransson J, Scheynius A. Blood dehydroepiandrosterone

sulphate (DHEAS) levels in pemphigoid/pemphigus and psoriasis. Clin Exp

Rheumatol. 1995 May-Jun;13(3):345-8. PMID: 7554562.

Q6 Overall, the paper's conclusion that the potential role of DHEAS in improving low QoL in hypothyroid patients with joint pain and normal TSH should be further investigated is not strongly supported by the findings described.

Response: Thank you for pointing this out. We have changed “the potential role of DHEAS in improving low QoL in hypothyroid patients with joint pain and normal TSH should be further investigated” to “the potential role of DHEAS supplementation in natural history of hypothyroid patients with joint pains”

Reviever 2

To start, the terminology, methods, and hypothesis used in this study are confusing. Is this a study to demonstrate a correlation of DHEAS levels with “early RA,” pre-RA, or simply with “rheumatism” - which I take to mean joint pains and arthralgia but not clinical synovitis (the term “rheumatism” is not precisely defined by the authors). This is not a trivial point. In fact, it is central to the whole narrative of the study. Yet, all of these terms are used interchangeably throughout the paper.

To be clear, “early RA” is not “pre-RA”, and rheumatism can describe any, all, or neither of those terms.

The EULAR-CSA score was established to identify specific patients in the pre-clinical stage of RA disease development, as RA likely develops in a multi-step approach from pre-clinical autoimmunity to overt systemic and articular inflammatory disease. The score does not determine who has early (classifiable) RA. Indeed, the EULAR CSA score was validated against clinical acumen that was able at its best to identify a 20% chance of someone with CSA developing early RA in the next few years.

Response: By “rheumatism” we mean “clinical features of pre RA as mentioned in EULAR CSA score “ and not early RA. EULAR CSA criteria is for pre RA, but in the entire document they have used the word “imminent RA”. Thus imminent RA or high risk of RA and pre RA convey same meaning.

In line 200 we have used the term “pre-RA like” not pre-RA. As shown below the scope of conditions qualifing for pre-RA has been expanding. By usage of “pre-RA like” we speculate {lower DHEAS + primary hypothyroidism} subjects may fit into some of following pre-RA criteria (ref). Our present study is to have basis for further research in this direction.

Pre-RA

a. Genetic risk factors for RA

b. Environmental risk factors for RA Asymptomatic

c. Systemic autoimmunity associated with RA

d. Symptoms without clinical evidence of arthritis

e. Early undifferentiated arthritis. Symptomatic

Ref:

Gerlag DM, Raza K, Van Baarsen LG, Brouwer E, Buckley CD, Burmester GR, et al. EULAR recommendations for terminology and research in individuals at risk of rheumatoid arthritis: report from the Study Group for Risk Factors for Rheumatoid Arthritis. Ann Rheum Dis. 2012;71:638–41.

1. DHEAS levels significantly and inversely correlated with CSA score. However – they did NOT correlate with CSA being present. When the CSA score was dichotomized, binary logistic regression found no association (an odds ratio of 1.01) between whether CSA was present or absent and DHEAS levels. And mean DHEAS was not significantly different in those with CSA and those without. So the statement that “serum DHEAS predicted rheumatism” is NOT correct (line 109) based on those data. Again, it depends upon how one defines “rheumatism,” because MCP pain can be considered a feature of “rheumatism,” but DHEA as a whole did not correlate with higher risk arthralgias predictive of developing RA as defined by a CSA score>4.

Response : When binary logistic regression was done it was done for particular EULAR criteria (seven in all) The OR of 1.01 assuaged the symmetry of EULAR i.e no one criteria (for example morning stiffness) was driving the significance . The mean DHEAS level in CSA absent and CSA present was not statistically significant. This does not mean DHEA does not correlare. In results section we have given the correlation analysis (line 129)

2. When DHEAS levels were dichotomized as well, then there was a correlation between a DHEAS level <43.6 and CSA present. The author’s state that “low levels of DHEAS” predict clinical features of “early RA” in primary hypothyoid patients. This is misleading. First, is DHEAS < 43.6 low or not? Physiologic rather than pathological levels of DHEA may be relevant to the immunologic/inflammatory effects mentioned in the paper. No reference is made to what is considered a normal level physiologically in women other than general mention of lower and higher levels by age and menopausal status. Second, the authors selectively drew their cutoff at that level not because it was low physiologically per se but because it granted them the most favorable characteristics on an ROC curve, such that only those DHEAS levels in the bottom quartile were considered. And even then, the AUC was weak.

Response: We have not deliberately mentioned level considered physiological in women, coz while normative ranges of DHEAS levels in healthy population are available, its not known what are normal levels in any of disease states..We agree with your suggestion that instead of “lower” we should use the term “low” .

The AUC is 0.67 (line 114) which is reasonably strong for clinical interpretation.

Third, because DHEAS levels correlate with age and other factors (as shown, albeit weakly) selectively reporting results comparing only the lowest quartile could introduce bias by comparing patients with different demographic characteristics (and lower DHEAS levels) to those with higher levels and different demographics.

Response:

As linear correlation age and DHEAS were inversely correlated. This fact we have mentioned in results. We are also attaching Spearman and Pearson correlation results for reference

Coefficientsa

Model Unstandardized Coefficients Standardized Coefficients t Sig. 95.0% Confidence Interval for B

B Std. Error Beta Lower Bound Upper Bound

1 (Constant) 4.833 .290 16.643 .000 4.255 5.412

DHEAS -.004 .002 -.224 -2.002 .049 -.009 .000

2 (Constant) 4.880 .950 5.136 .000 2.987 6.773

DHEAS -.004 .002 -.225 -1.943 .056 -.009 .000

Age -.001 .020 -.006 -.052 .959 -.040 .038

a. Dependent Variable: EULARscore

Regardiing the effect of age on quaratiles (which could potentially affect the results), we did one way ANOVA for age in four quartile of DHEAS and it was statistically non significant. We are attaching table for reference.

ANOVA

Age

Sum of Squares df Mean Square F Sig.

Between Groups 702.515 3 234.172 2.364 .078

Within Groups 7331.332 74 99.072

Total 8033.846 77

Other issues:

3. Were the assessors of CSA blinded to DHEAS levels? I assume since CSA is part of the clinical practice and that this is a retrospective review, the answer is that the assessors had no knowledge of present or past DHEAS levels. But that needs to be stated.

Assesors of CSA were blind to DHEAS levels. We have stated that in revised version (Line 79-81)

4. How were patients with RA excluded? Was this based on ACR 1987 or ACR/EULAR 2010 criteria? Or simply a “clinical diagnosis” of RA. If the latter, then this is problematic. The authors did not measure CCP levels in their patients, but CCP+ patients (even those without arthritis) could have a diagnosis of “RA” in their chart because of the positive test and thus could have been excluded. If so, then the authors may have excluded pre-RA patients (with CSA for example) from the study, thus skewing their results. CCP+ patients without synovitis are 50% likely to develop clinical RA in the subsequent 3 years, hence it is the best predictor of pre-clinical RA.

Response: ACR 1987 criteria was used to exclude RA. In addotion those who had documentation of RA diagnosis in past with /without DMARDs were also deemed to have RA and excluded .Also a previous history of RA and /or being on DMARD. We understand the drawback of 1987 criteria .We did not have anti-CCP and this we have acknowledged as well. Due to retrospective nature of study, we agree we may have missed pre RA patients. While there are a number of studies of hypothyroidism in RA,there are no studies on prevalence of anti-CCP in hypothyrodism. There is no historical cohort or published literature to “estimate” how many anti-CCP + patients without synovitis hypothyroidism we might have missed. This is selection bias which is inherent in all observational studies.

5. Figure 4 is backwards in the text compared to what is actually in the figure

Figure 4 is now mentioned in line no 133, after figures 1 , 2 and 3 in Results section

6. Line 163: the statement appears to be misworded (they do NOT return?) “Although levothyroxine brings down the level of cytokines , they do return to the same level as healthy controls after euthyroid state is achieved (18)

Response: Thank you. We have rectified typo error

Again – this all gets back to the central question of what the study is actually trying to answer. Is this a study that “predicts clinical features of early RA” as stated in line 24 or correlate with those patients who have evidence of “rheumatism” as per line 248. This paper has to be rewritten in more clear, precise, and consistent terminology of what is being studied: I would recommend stating that lower (not necessarily low) levels of DHEAS in women with subclinical hypothyroidism correlate with clinically suspect arthralgia that is at higher risk for evolving into rheumatoid arthritis.

Thank you for valuable suggestion. We have revised to incorporate “lower (not low) levels of DHEAS” in line 26 and line 31. Actually this is what we wanted to emphasize.We accept in line 248 (which is conclusion), we should not use vague terminology like “rheumatism”. We have corrected “rheumatism” for “clinical features of early RA”. To make the maniuscipt more precise we

I would also mention in the paper that the data do not support a correlation between DHEAS levels in general and higher risk arthralgias, although there is a weak but statistically significant association between high risk arthralgia and the lowest quartile of serum DHEAS levels, suggesting the possibility of a threshold effect of DHEAS at physiologic level

Yes we agree the data does not support correlation between DHEAS and risk of arthralgias in linear manner. But there is correlation with DHEAS quartiles.As shown, lower DHEAS levels do correlate.

We have hypothesized a mechanism for threshold effect of DHEAS at physiologic level in discussion section, including the possibility of further studies, preferably prospective to delineate natural history.

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Decision Letter 1

Rosanna Di Paola

15 Jan 2021

Dehydroepiandrostenedione Sulphate  (DHEAS)  Levels Predict high risk of  Rheumatoid Arthritis (RA) in Subclinical Hypothyroidism

PONE-D-20-22641R1

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Acceptance letter

Rosanna Di Paola

25 Jan 2021

PONE-D-20-22641R1

Dehydroepiandrostenedione Sulphate  (DHEAS)  Levels Predict high risk of  Rheumatoid Arthritis (RA) in Subclinical Hypothyroidism

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Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 File. Supplementary material 1: The EULAR-CSA score.

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    Submitted filename: response to revievers.docx

    Data Availability Statement

    The data that support finding of study is available in excel format at the Open Science framework (https://osf.io/t4gxj/?view_only=614b6b07b0c7465ab50d1b06b5b4878f) under project name "Clinico-biochemical profile of primary hypothyroidism in Western Rajasthan."


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