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Levothyroxine
Autoimmune, post-radioiodine, post-surgery.
Low free T4 and elevated TSH (usually greater than 20mu/L).
Hypothyroidism should be managed very cautiously in patients with known ischaemic heart disease. Levothyroxine is likely to precipitate or exacerbate angina.
Resist the temptation to increase the levothyroxine above 150 or 200 micrograms to treat fatigue - especially if the TSH is suppressed. Iatrogenic 'apathetic' thyrotoxicosis will worsen symptoms.
Autoimmune, post-radioiodine, post-surgery.
Normal free T4, elevated TSH (greater than 4.5mu/L).
25-50% of these patients feel better when taking levothyroxine.
About 5% per annum progress to overt clinical hypothyroidism.
Predictors of progression = high titre thyroid peroxidise antibodies (greater than 1:1600) and age (over 65 years).
TSH greater than 10 mu/L - prevent progression by initiating levothyroxine therapy.
TSH less than 10mu/L with TPO antibodies – repeat thyroid function annually.
TSH less than 10mu/L without TPO antibodies – repeat thyroid function every 3 years.
If TSH greater than 4.5mu/L consider treatment if symptoms or high titres of thyroid peroxidase antibodies.
Hypothalamic or pituitary disease.
Hypothyroidism secondary to pituitary disease will often not be detected by the routine testing as TSH (the screening test) is often normal. This means if a diagnosis of secondary hypothyroidism is considered, this should be marked on the request form and a free T4 also requested. Hypopituitarism is the commonest cause of secondary hypothyroidism, so if this diagnosis is considered, the patient should be referred to the thyroid/endocrine clinic for full assessment of pituitary function before levothyroxine replacement is instituted. Treating secondary hypothyroidism in hypopituitary patients can precipitate an “adrenal" crisis.
Hypothyroidism in pregnancy is associated with maternal and fetal complications and should be treated.
In patients with pre-existing hypothyroidism, most patients will require an increased dose of levothyroxine to keep the TSH ideally less than 2.5mu/L. This increase often occurs early in the first trimester.
Patients with known hypothyroidism should increase the dose of levothyroxine by 50mcg daily as soon as pregnancy is confirmed. They should have their thyroid function tested early in the first trimester and then 6-8 weekly throughout the pregnancy.