Thyrotoxicosis

Diagnosis

Clinical Diagnosis + Undetectable TSH + raised T4

Less common causes of hyperthyroidism

Toxic multinodular goitre

Toxic solitary nodule

Subacute thyroiditis

Painless thyroiditis

Iodide induced hyperthyroidism

Factitious hyperthyroidism

Secondary causes of of Raised T4

Pregnancy

Oestrogens

Contraceptive pill

HRT

Clofibrate

Amiodarone

Amphetamine

Management

Propranolol 120-160mg per day to all patients until other Rx becomes effective.
Carbimazole 15mg 8 hourly .
Check TFTs at 4 weekly intervals until clinically and biochemically euthyroid.
Reduce Carbimazole to 10mg 8 hourly for further 4 weeks.
Subsequent reduction in dose determined by clinical status and T4 + TSH. T4 should lie in middle of normal range and TSH should not be elevated. Resistance to thyroid drugs does not occur and failure to control hyperthyroidism can be assumed to be a result of poor patient compliance.
Review every 2 months for 12-18 months.
RELAPSE WILL OUR IN 50-70% WITHIN 2 YEARS So then consider:
- If under 40 years - subtotal thyroidectomy .
- If over 40 years - referral for radioactive iodine ( Patient advice leaflet available).
- Follow all patients up clinically +/- biochemically every 12 months.

Radio-iodine therapy

Following the radio-iodine treatment administered to the above patient, observe the following precautions for the periods indicated:

Blood and urine specimens
No blood or urine specimens should be taken from the patient, unless it is clinically imperative to do so, for one week after the date of administration (see above). Any specimens taken for tests involving radioactivity (e.g. radioimmunoassay tests) may be affected for up to 3 months after administration of the treatment, and any laboratory receiving such specimens should be notified that the patient has received radio-iodine.

Post mortem or embalming
In the event that the patient should die within I month of the radio-iodine administration, special precautions are required if a post mortem is required or if it is desired to embalm the body. In such an event, advice should be obtained from the Radiation Protection Adviser, Dr M.J. Keir, at the Royal Victoria Infirmary (tel 0191 2275158 or2275175). There are no restriction if the body is to be directly interred or cremated.

Patient advice leaflet - radio-iodine therapy

Hyperthyroidism and pregnancy