Hypothyroidism

Any patient in whom a solitary nodule, a suspicious or dominant nodule within a multinodular goitre, or lymph nodes are palpated requires urgent ultrasound guided aspiration.

Patients with suspected eye disease require evaluation by an endocrinologist or ophthalmologist experienced in Graves' ophthalmopathy. Simple lubricants, avoidance of smoky environments and avoidance of bright sunlight and strong winds by wearing sunglasses should be advised in all patients with Graves’ ophthalmopathy.

Patients with incomplete lid closure require taping at night to protect from corneal abrasion and require rapid specialist ophthalmological assessment. Patients with reduced acuity require urgent assessment for the consideration of medical or surgical decompression.

Patients with asymmetry, periorbital oedema and abnormalities of external ocular movements also require rapid assessment for consideration of steroid or other medical therapy. Radiotherapy may also be considered in the acute phase.

Prism spectacles may be helpful in diplopia. 

Orbital muscle surgery, and reconstructive and corrective orbital and lid surgery are usually not conducted in the acute phase, but patients should be reassured that treatment is available and is highly effective. An explanatory leaflet is available from the British Thyroid Association.

Smoking increases the risk and severity of ophthalmopathy, as well as increasing cardiovascular risk.

Any patient with severe clinical or biochemical hypothyroidism should be assessed for cardiac disesase and risk factors before starting replacement therapy. 

Usual starting dose is 50mcg thyroxine. The dose can then be increased after two weeks if tolerated to 100mcg. Thyroid stimulating hormone (TSH) should then be reassessed at around six weeks and 12 weeks and dose titrated accordingly, aiming for good improvement in symptoms and a normal TSH.

25mcg thyroxine is suitable for most patients with severe biochemical disease. However, patients with severe hypothyroidism and unstable cardiac disease, will require very gentle initiation of therapy. Liothyronine is short acting and may be started in extremely low doses in such cases. Tiny doses as low as 1.25mcg may be used in very severe cases, and titrated over a two week period up to 30mcg daily in divided doses. Patients tolerating this with no adverse effects, can be switched to thyroxine 25mcg, which is then uptitrated every six weeks according to symptoms and aiming for a normal serum TSH.

Patients who are planning or are currently pregnant should be treated with the aim of achieving a TSH of approximately 1mU/L.

Patients should be advised that thyroxine requirements invariably increase with pregnancy and many services suggest a dose increase of 25mcg as soon as pregnancy is confirmed.

It is appropriate to monitor TSH every three months during pregnancy and breast feeding, and six weeks after any dose adjustment to ensure that the dose is appropriate. 

Long term monitoring should be performed by the general physician and may take the form of an annual TSH only.