Following a diagnosis of hyperthyroidism, many patients are started on thionamides(carbimazole or propylthiouracil), usually followed by definitive treatment with radioiodine
Response to thionamide therapy is judged by serial measurement of FT4 and TSH,allowing dose adjustment and avoidance of iatrogenic hypothyroidism. Note that useof TSH alone is inadequate, since TSH is frequently suppressed for many monthsfollowing initiation of thionamides. Suggested intervals for TFTs are every 4-6 weeksin the first few months, once on a stable maintenance dose every 3 months. Reducethe dose where FT4 falls to low normal or below normal range or where TSH rises.
'Block and replace' regimens (where treatment is initially with thionamide alone, thenadding thyroxine once FT4 has normalised) have been shown not to be superior to adose titration regimen (as above) and may be associated with more side-effects.Again, monitor TSH and FT4 levels.
Persistently elevated FT4 despite seemingly adequate prescription of thionamides ismost likely to indicate poor compliance.Following radioiodine therapy:
FT4 and TSH should be performed every 4-6 weeks for at least 6 months. Thefrequency of tests may be reduced when FT4 remains within reference range.
After an interval of euthyroidism of at least a year, the patient may have annual tests.
A serum TSH of >20 mU/L following radioiodine therapy in a patient not receivingthionamides in the previous 6 weeks should trigger thyroxine treatment.
Primary hypothyroidism occurs as a result of undersecretion of thyroid hormone from thethyroid gland. Secondary hypothyroidism may occur as a result of damage or disease of thepituitary or hypothalamus.
To diagnose primary hypothyroidism, one needs to measure both TSH and FT4.Where TSH is >10 mU/L and FT4 below reference range, the diagnosis is overtprimary hypothyroidism and the patient needs treatment with thyroid replacementtherapy.
Secondary hypothyroidism is suggested by low, within or mildly elevated TSHcombined with a low FT4. Differentiating this from non-thyroidal illness can bedifficult and clinical history, FT3 and sometimes anterior pituitary hormone tests are
necessary.Additional diagnostic tests may include:
Thyroid auto-antibodies - antithyroid peroxidase and antithyroglobulin antibodies.
Ultrasound examination of the thyroid gland.