Simon Pearce

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5 Thyroid cases

• Simon Pearce

RVI, Endocrine Unit
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Unusual Thyroxine Requirement
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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

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What to do now?
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• 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)

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• 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, theyre probably not taking their other
  medication either

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• 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

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Palpitations
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• 79 year old woman
• Palpitations
• Weight loss
• Sinus rhythm
• TSH lt0.05 (0.3-4.7 mU/l)
• FT4 18.0 (9.5-21.5 pmol/l)

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• 79 year old woman
• Palpitations
• Weight loss
• Sinus rhythm
• TSH lt0.05 (0.3-4.7 mU/l)
• FT4 18.0 (9.5-21.5 pmol/l)
• FT3 9.4 (3.5-6.5 pmol/l)

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What to do now?
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• 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

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• 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

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Oh Baby!
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• 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

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What to do now?
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• Actions
• Check TSH urgently
• Recommend increase dose LT4 of 25 mcg/d pending
  TSH result
• Explain fetal thyroid hormone synthesis doesnt
  start until 10-12 years
• Thyroxine critical for brain development
• Thyroxine is the same as natural thyroid hormone

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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

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Lump in my neck
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• 28 year old F
• Sister noticed neck lump last week
• No pain
• O/e
• Anterior triangle neck lump 4x4 cm

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What to do now?
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• 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

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• Next steps

New onset anterior triangle lump Check TSH
refer FNA cytology Management decision If
surgery, symptoms etc. then imaging
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Im tired and emotional
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• 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

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What to do now?
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• 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

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• Next steps
• Symptoms are worse on thyroxine
• ? Addisons disease
• ? Hypopituitary
• Consider other diagnoses
• Depression, mood disturbance, alcohol etc.
• Sleep apnoea
• Vitamin D deficiency
• Iron deficiency
• B12 deficiency
• Many other possibilities