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Thyrotoxicosis

General points:

·         Affects about 1 in 2000 people annually in Europe

 

Click here for causes

 

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


Investigations – please perform

·         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 radionuctleotide uptake scan

 

 

REFER TO ENDOCRINOLOGY via CHOOSE AND BOOK - ROUTINE

·         ROUTINE referral unless on amiodarone – in which case URGENT

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

 

 

START TREATMENT IN PRIMARY CARE

 

With carbimazole thus:

 

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

If severely symptomatic then add B blocker (propranolol 20mg tds)

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

 

IF PREGNANT

·         DON’T start treatment

·         DO refer urgently to the joint endocrine / antenatal clinic via C&B

 

Follow up:

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

 

 

References

Personal communication with Dr Duncan Browne, endocrinologist, Royal Cornwall Hospital October 2014

BMJ Clinical Review 2014: Diagnosis and management of thyrotoxicosis

http://dx.doi.org/10.1136/bmj.g5128