University Hospitals of Leicester NHS Trust

Department of Endocrinology

Leicester Royal Infirmary, Leicester, LE1 5WW

Hypothyroidism : About the Condition
Definition	· Hypothyroidism is an underactive thyroid gland. · Myxoedema is an older term for the same condition. · “Subclinical hypothyroidism” or “Compensated Euthyroidism” indicates the presence of elevated TSH with normal free T4. In LRI we will normally only use this term when TSH is below 10. · We use the term “Borderline hypothyroidism” when TSH is elevated slightly above 10 but free T4 remains normal
Symptoms	· Tiredness, cold intolerance, dry skin and hair, mental slowness, weight gain, constipation, aching muscles.
Signs	· Hypothyroid facies, slow relaxing reflexes, dry skin and hair. · Frequently no signs in except in severe cases
Investigations	· TSH is elevated above the normal range · Free T4 may be normal or low · Thyroid peroxidase (TPO) antibodies are typically positive
Other factors	· Hypothyroidism may occur on lithium or after iodine (including amiodarone treatment)

Hypothyroidism: When to Refer?
Referral Recommendations	· Uncomplicated hypothyroidism usually requires levothyroxine replacement, but rarely needs referral to the specialty Endocrinology clinic. · Levothyroxine treatment, dose adjustment and monitoring is usually performed in primary care. · Referral to the Leicestershire Thyroid Register for advice on dose adjustment and monitoring is appropriate if no equivalent within-practice mechanisms exist. · Patients who fail to achieve a euthyroid state despite large doses of levothyroxine (say 250mcg daily) or with apparent intolerance of thyroid replacement may benefit from assessment in the specialty Endocrinology clinic. · When thyroid function tests are normalised but symptoms persist for more than a few months after normalisation of TFTs, then this is almost always a sign that the symptoms are not related to the thyroid rather than a sign of inadequate replacement. Often these patients only had compensated euthyroidism prior to treatment.
Urgent Referral	· Hypothyroid coma is a medical emergency and should be referred as such.
References or Guidelines	· Joint BTF/RCP/SfE Statement on Treatment of Hypothyroidism
Which Clinic or Choose & Book Service?	· An “Adult Endocrinology Service - Endocrinology - LRI - RWE” referral will book an appointment on any of medical lists in clinics at Leicester Royal Infirmary where endocrine patients are seen.

Hypothyroidism: What to do before a hospital appointment?
Additional Investigations	· No additional thyroid function tests are required if TSH is above 10 – levothyroxine replacement is usually indicated. · TPO antibodies may be checked to confirm autoimmune aetiology, and stratify risk for progression to overt hypothyroidism in compensated cases. · Consider the possibility of associated autoimmune endocrinopathies if symptoms persist (consider assessment of adrenal function, calcium, ovarian function, pernicious anaemia)
Treatment prior to specialty appointment	· Routine replacement and dose optimisation as below
How to manage the patient if you do not refer	· If TSH level is above 10 then routine levothyroxine replacement is almost always indicated. · Aim at full replacement rather than partial replacement. · In a patient with no other comorbidities or cardiovascular risk factors: · Age <50 and TSH <50 – give levothyroxine 100mcg once daily, then adjust as appropriate in 25mcg increments. · Age >50 or TSH > 50 - give levothyroxine 50mcg once daily for 1 month, then increase to 100mcg once daily, then adjust as appropriate in 25mcg increments. · Check TFTs for first time approx 2 months after reaching a dose of 100mcg daily · In presence of known or suspected ischaemic heart disease or unstable cardiac arrhythmias or cardiac failure: · Start with levothyroxine 25mcg daily, increase to 50mcg after 2 weeks if no adverse effects and then increase in 25mcg increments to 100mcg. · The aim of therapy is a free T4 and TSH in the normal range (TSH typically in the bottom half of the normal range for optimum replacement). · Once normal levels are achieved, TFTs may be monitored at increasing intervals and typically annually in the long term. · Achieving a fully euthyroid state biochemically is important prior to any planned pregnancy. · If TSH is >5 and <10 then a trial of treatment may be indicated if the patient has symptoms which might feasibly be caused by hypothyroidism (although in most cases they will not resolve and therefore be unrelated). · Typically we recommend to commence levothyroxine 100mcg once daily in such cases. · In an asymptomatic patient with TSH >5 and <10, simply repeat TFTs at increasing intervals. Often TFTs will return to normal.
Patient Information	· Hypothyroidism

Hypothyroidism: What will we do in the specialty Endocrinology clinics?
Outline of Management	· We are happy to advise on cases where routine replacement has failed to normalise thyroid function tests, or where symptoms persist.
Treatment options	· Levothyroxine is the only form of thyroid replacement required in almost all cases.
Follow up plan	· We will not normally follow up patients in the Endocrinology clinic purely for the management of their hypothyroidism. · Patients with other associated endocrine deficiencies (Addison’s, Premature Ovarian Failure, Hypoparathyroidism) may continue long-term follow up in the Endocrinology clinic, and if so we are happy to advise on thyroid replacement at the same time.
Long term monitoring	· Usually in primary care, or via the Leicestershire Thyroid Register

Referrals to all clinics can be arranged via Choose and Book.

We are also happy to receive written referrals and will allocate patients to the most appropriate clinic slot.

If you consider that your patient needs urgent assessment, then all consultants are happy to discuss directly (by phone or email) and arrange prompt review if appropriate.

In the case of a real or potential endocrine emergency we will almost certainly be happy to see the patient the same or the next working day whether or not a clinic is available.

Contact the endocrinologist:

By email: endocrinology@uhl-tr.nhs.uk or individual consultant emails

By phone: 0116 258 6140 and ask to talk to one of the consultants

Fax: is less reliable and usually no faster than written mail