- Autoimmune thyroiditis
- Hashimoto's thyroiditis (autoimmune thyroiditis and goitre; a positive test result for the thyroid autoantibodies antithyroglobulin and antiperoxidase will confirm the diagnosis)
- Subacute thyroiditis (tender thyroid)
- Amiodarone, lithium, interferon alfa, interleukin 2, macrophage colony stimulating factor, and oral and topical iodine are recognised causes of thyroid dysfunction.
- Check for history of thyroid surgery or head and neck irradiation and radioactive iodine therapy for thyrotoxicosis.
- Clinical symptoms of hypothyroidism with a raised TSH +/- thyroid microsomal autoantibodies.
Subclinical hypothyroidism (elevated TSH without
symptoms) should be managed according to the presence of
thyroid microsomal antibodies:
- Autoantibodies present: commence thyroxine.
- Autoantibodies absent and TSH less than 10mU/l should be managed by watchful waiting.
- Patients receiving long term lithium and amiodarone should also be monitored regularly.
- cardiac state
- symptoms of IHD
- FBC, lipids, glucose, autoantibodies, TFT
- Discuss and agree a clear treatment and monitoring plan with patient. Explain that treatment is likely to be life long, that treatment at the correct dosage has no serious side effects, and that the prognosis is excellent. Tell patient that it may take a few weeks for thyroxine to begin working and that patient should not expect all symptoms to disappear within a few days of starting treatment.
Tell patient that she is entitled to free prescriptions and to fill
in the prescription charge exemption certificate.
Indications for referral
- Pregnant or post partum
- Evidence of pituitary disease
- Ischaemic heart disease
- Treatment with amiodarone or lithium
Thyroxine 50 micrograms daily
Increasing Thyroxine by 50 micrograms daily until TSH is within normal range. TSH levels below the normal range may increase risk of atrial fibrillation.
Over 65 and/or Ischaemic Heart Disease
Thyroxine 25 micrograms daily
Increasing Thyroxine by 25 micrograms daily until TSH is in the normal range. A suboptimal dose may be necessary with angina or cardiac failure. TSH elevated despite Thyroxine dose 150-200 micrograms daily is probably due to non-compliance. TSH levels below the normal range may increase risk of atrial fibrillation.
Subsequently check T4 and TSH every 12 months.
Websites with information on thyroid disorders
|Thyroid UK, a support group for patients (www.thyroiduk.org/)|
|The US site www.thyroid.about.com/ has excellent information|
|British Thyroid Foundation (www.btf-thyroid.org/)|
|The Royal National Institute for the Blind website's "Eye info" section has information on thyroid eye disease (www.rnib.org.uk)|
- 100% of patients on thyroxine should have a current problem Hypothyroidism .
- 100% of patients with hypothyroidism should have had their thyroid function checked within 15 months.
- 100% of patients taking amiodarone or lithium should have had their thyroid function checked within 15 months.