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• 39 year old woman• Congenital hypothyroidism• Required up to 200µcg thyroxine daily in childhood and adolescence
• High TSH despite high thyroxine dose
– Date TSH Daily T4 dose– 5/01 11.3 200µcg– 8/02 16.0 250µcg– 10/02 13.3 300µcg– 1/03 17.7 400µcg
• Talk about compliance– Should involve some mention of LT4 half-life
• Explore drug interactions– Ferrous salts– Calcium carbonate (eg. calcichew, rennie)– Gaviscon etc.– PPIs– Cholestryamine etc.
• Think about malabsorption (Coeliac Abs)
Actions
• Prescribe dosette box
• Re-iterate taking thyroxine before breakfast on an empty stomach
• Suggest that thyroxine taken at bedtime
• Review 8 weeks to recheck TSH
• Remember, they’re probably not taking their other medication either
Next steps
• Refer
• Peak dosage effects (tachy, headache)– Suggest split dose (eg. 50 mcg bd)– Try thyroxine liquid solution
• Supervised dosing– Eg. 1000 mcg once per week
• Thyroxine absorption test
• 79 year old woman• Palpitations• Weight loss
• Sinus rhythm
• TSH <0.05 (0.3-4.7 mU/l)• FT4 18.0 (9.5-21.5 pmol/l)
• 79 year old woman• Palpitations• Weight loss
• Sinus rhythm
• TSH <0.05 (0.3-4.7 mU/l)• FT4 18.0 (9.5-21.5 pmol/l)• FT3 9.4 (3.5-6.5 pmol/l)
Actions
• Prescribe beta blocker– Eg. Propranolol LA 80 mg od or bd
• Refer
• Indications for urgent referral– Atrial fibrillation– Worsening angina– Heart failure
• Consider starting Carbimazole 20mg od or bd– Need to warn about agranulocytosis risk
Next steps
• For mild-moderate Graves’ disease– Carbimazole therapy– Block & replace for 12 months
• Discuss radioiodine therapy with patient– Permanent hypothyroidism risk (50% or 95%)– Short-term radiation protection measures (11 d)– No cancer risk, no fertility risk, no alopecia
• In the case of AF, angina, heart failure:– Warfarin– Early RAI– May cover with carbimazole for 4-6 months post RAI
• 34 year old woman• On thyroxine for 12 years for hypothyroidism
• Period 10 days late• Boots pregnancy test positive• Stopped thyroxine yesterday, worried about
effect of drugs on her baby• Second pregnancy; miscarriage at 10 weeks in
first pregnancy
• Last recorded TSH 6 months ago = 3.9 mU/l
Actions
• Check TSH urgently
• Recommend increase dose LT4 of 25 mcg/d pending TSH result
• Explain fetal thyroid hormone synthesis doesn’t start until 10-12 years
• Thyroxine critical for brain development
• Thyroxine is the same as natural thyroid hormone
Next steps
• Low or suppressed TSH is normal in first trimester
• 4 to 8 weekly TFT monitoring throughout pregnancy
• Increased thyroxine dose very likely
• Refer joint medical obstetric clinic
• 28 year old F• Sister noticed neck lump last
week
• No pain
• O/e– Anterior triangle neck lump 4x4 cm
Actions
• Ask about alarm features:– Airway compromise– Voice change
• Check TSH
• Refer (endocrine, endocrine surgery, ENT)
• We will generally see within 2 weeks
• We will see urgently if alarm features
Next steps
New onset anterior triangle lump
Check TSH & refer
FNA cytology
Management decision
If surgery, symptoms etc. then imaging
• 45 year old woman• Feels tired• Daytime somnolence• Forgetfulness & emotional lability
• TSH 6.2 mU/l• Hb 13.5 g/l• RBG 5.9 mmol/l
Actions
• Recheck TSH, with FT4 & TPO antibodies
• Assess symptoms
• If TSH persistently elevated, discuss trial of thyroxine therapy
• Close to full replacement dose (75 or 100mcg/d) for 3 or 4 months
• Continue if symptoms are improved