Diagnosis of Hypothyroidism

Control of thyroid hormones
secretion
Diagnosis of Hypothyroidism
 The lab investigation of hypothyroidism is extremely
simple. Usually clinical assessment, combined with a
single estimation of thyroid hormones and TSH is
sufficient to make diagnosis.
 In primary disease, the free T3 and T4 are low and TSH
level raise markedly.
 Some labs offer the only the TSH as a 1st line test of
thyroid function though this can result in delayed
diagnosis of secondary and tertiary hypothyroidism,
which should be suspected on the basis of a low free
T4 along with low TSH level.
 Elevation of TSH occur in early course of thyroid
failure and may before appearing clinical
manifestation.
 Early hypothyroidism may be asymptomatic or
symptoms less obvious and non-specific but a normal
TSH with normal free T4 effeectively excludes the
diagnosis.
 A chest radiography may detect the presence of
effusion, and ECG is useful.
 All modern TSH assays now employ double antibody
immunometeric techniques, which are robust and
highly reliable. These assays are now so sensitive.
 Commercial free T3 and T4 are indirect methods
because both T3 and T4 can be decreased as a non-
specific consequence of systemic illness ( sick
euthyroid syndrome) and depression along with host
of drugs.
 Such a patient required specialist assessment and
collaboration with the local lab to rule out confusing
disease and pituitary failure
Treatment
 Aim of treatment
 Treatment with thyroxine are to ensure that patient receive
a dose that will restore well-being and that usually returns
the TSH level to lower end of the normal range.
 In all patient the drug has long half life, it should be given
once daily in the morning.
 After 6 weeks thyroid function tests should be checked.
 The TSH conc. is the best indicator of thyroid state, and
this should be used for further the dosage adjustment
 The raised TSH concentration indicates, inadequate
treatment, poor adherence or both.
 The majority of patients will be controlled with dose of
100-200µcg daily with few patient requiring more than
200µcg.
 In adult the median dose require to suppress TSH to
normal is 125µcg daily. During pregnancy an increase
in the dose of thyroxine 25-50% is needed to maintain
normal TSH level
 Exacerbation of myocardial ischemia, infarction and
sudden death are well-recognized complications of T4
replacement therapy.
 Patient with coronary heart disease may be unable to
tolerate full replacement dose because of palpitaions,
angina, or heart failure and elderly patients may have
undiagnosed ischemic heart disease.
 In these two group of patients treatment should therefore
started with 25 µcg and increase slowly by 25 µcg evrey 4-6
weeks. During this time clinical progress should be
monitored
 In some patients T4 may be better tolerated if β-blocker
such as propranolol is given concomitantly.
 It is important to avoid both under and overtreatment.
Hypothyroidism is very rarely life threatening but
adverse effects may result from prolong overtreatment.
 Patient Care Plan
 Patients on long-term drug therapy are recognized to
have low adherence with medication regimen.
 Patients terminate the treatment because they fell well
and think that treatment is no longer required.
 Patient should understand the effect of drug holidays
on their health and thyroid function tests and they
should know the normal TSH indicate the adequate
dose.
 Written advice should be provided and monitoring of
dosage should continue annually.
 Patient information leaflets available on the British
Thyroid Association website at www.british-thyroid-
association.org
 Despite the adequate counselling, some patients
persistently forgot to take medicines reliably and other
patient lack capacity of self-medicated reliably.
 In these patient weekly dose of T4 is safe and
acceptable to manage them, in whom family or
community staff can supervise treatment.
 There are no guidelines yet available, but in practice
patients are normally started with 500-700 µcg
 Dosing changes are made in exactly the same way by
assessing TSH levels after 6 weeks of stable dose.

Diagnosis of Hypothyroidism

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Diagnosis of Hypothyroidism

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Control of thyroid hormones

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