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Hyperthyroidism (Thyrotoxicosis)

Incidence 1 in 2000 in Europe

Thyrotoxicosis is confirmed by either raised T4 or T3 or both with a suppressed TSH

Click herefor causes

 

Red flags

  • Thyroid storm- admit as medical emergency
  • Suspected thyroid malignancy – refer on 2ww head and neck pathway

 

Refer:

  • Overt hyperthyroidism  ( Routine Endocrinology)
  • Amiodarone induced hyperthyroidism ( Urgent Endocrinology)
  • Persistent subclinical hyperthyroidism ( see below) (Routine Endocrinology)
  • Hyperthyroidism whilst pregnant ( Urgent joint Endocrinology/antenatal clinic)
  • Do not start treatment  in primary care if pregnant

 Pending appointment if the GP has specific concerns or clinical / biochemical deterioration please email an endocrine consultant for advice

 

If Subclinical hyperthyroidism ( low TSH with normal fT4, fT3):

  • Assess for clinical features of hyperthyroidism
  • Assess for other causes of low TSH
  • Non thyroid illness
  • Drugs-supressing TSH: glucocorticoids, dopaminergic [anti-parkinsonian] medication, or octreotide)
  • Drugs that alter thyroid hormone secretion (lithium, amiodarone, and iodide in contrast media dyes)

 

  • If other causes excluded, initially rpt TFTS in 3-6months ( sooner if elderly or cardiovascular disease) and refer if persistent
  • If untreated subclinical hyperthyroidism, continue to check TFTS 6-12monthly

 

Investigations– pre referral:

 

·         Request TSH, T4, T3, thyroid peroxidase antibodies (please note the lab will however only check T3 if T4 is normal/ near normal)

·         Pregnancy test if appropriate

o   If pregnant request TSH receptor antibodies as well

Please do NOT

·         request an USS

·         request a radionuclide uptake scan 

 

Primary care treatment- whilst awaiting specialist assessment

  • Consider B-Blocker (if no contraindications), if tremor or tachycardia ( propranolol  up to 20mg tds)
  • Consider carbimazole (seek specialist advice via email prior to starting) 

T4 LEVEL

DOSE OF CARBIMAZOLE

>60

40mg

40-60

20mg

25-40

10mg

 

 Counsel patients of the risk of agranulocytosis and what are the warning symptoms and signs.

Please repeat TFTs every month and adjust carbimazole dose accordingly until seen in clinic

  • Atrial fibrillation – anticoagulate and rate control as per RMS guidance / cardiology / AF

Patient resources:

British Thyroid foundation, www.btf-thyroid.org

Thyroid UK, www.thyroiduk.org.uk

 

References

CKS NICE Hyperthyroidism

Personal communication with Duncan Browne, Consultant Endocrinologist, RCHT

 

Guidelines Revised     02/06/2019

Due review                  02/06/2020

Dr B Wesson ( RMS GP Endocrinology lead)

 

Version 3.0