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Abnormal Thyroid Function Tests (Tfts) Results in Adults Guidance Glossary

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Abnormal Thyroid Function Tests (Tfts) Results in Adults Guidance Glossary Abnormal Thyroid Function Tests (TFTs) Results in Adults Guidance Glossary TSH - Thyroid stimulating hormone HbA1c - Glycated haemoglobin FT4 - Free thyroxine TPOAb - Thyroid peroxidase antibodies Which patients to undertake TFTs in? There is no evidence for FT3 – Free tri-iodothyronine PPT - Postpartum thyroiditis FBC - Full blood count TBG – Thyroxine-binding globulin Symptoms present Type 1 diabetes screening healthy LFTs - Liver function tests Suspected goitre or Dyslipidaemia populations thyroid nodule Osteoporosis Target case finding in Atrial fibrillation Subfertility individuals with symptoms Other causes: Central hypothyroidism NB. Congenital hypothyroidism (incidence 1:4000) is a common preventable cause of Isolated TSH deficiency mental retardation in babies. The UK have a national screening programme in place. DIAGNOSIS ‘Overt Hyperthyroidism’ Consider whether your patient is taking any drugs TSH ↓ affecting thyroid hormone levels: ‘Subclinical FT3 / FT4 ↑ Other causes: ‘Non-thyroidal Hyperthyroidism’ Lithium can ↑ (rare) or ↓ thyroid hormone secretion - Check TFT Recent treatment Illness’ every 6-12 months whilst on treatment or earlier if goitre develops for TSH ↓ TSH ↓ Amiodarone can ↑ or ↓ thyroid hormone secretion - Check TFT hyperthyroidism FT3 / FT4 ↔ FT3 / FT4 ↓ / ↔ every 6 months including 12 months after treatment cessation ‘Normal’ Drugs e.g. steroids Oestrogens can ↑ T3, T4 and TBG TSH ↔ Androgens can ↓ T3, T4 and TBG Glucocorticoids can ↓ TSH, T3, T4 and TBG FT3 / FT4 ↔ Methadone can ↑ T3, T4 and TBG ‘Subclinical ‘Assay Hypothyroidism’ Interference’ TSH ↑ TSH ↑ / ↔ FT3 / FT4 ↔ FT3 / FT4 ↑ Check TFT annually in the following patients: ‘Overt Down’s syndrome Hypothyroidism’ Turner syndrome TSH ↑ Other causes: Previous postpartum thyroiditis FT3 / FT4 ↓ Levothyroxine replacement Previous neck irradiation or surgery Other causes: therapy (including poor- Type 1 diabetes Poor compliance with compliance) Addison’s disease levothyroxine Drugs e.g. amiodarone Radioiodine or surgery for hypothyroidism Malabsorption of levothyroxine Drugs e.g. amiodarone Non-thyroidal illness (including Assay interference acute psychiatric disorders) Neonatal period References Pathway created by: Alex Warner & Sarah Morgan, March 2013 British Thyroid Association - UK guidelines for the use of thyroid function tests (2006) Reviewed: June 2015, February 2019 (with thanks to Dr Bernard Khoo, RFH) NICE Clinical Knowledge Summaries (CKS) – Hypothyroidism (June 2018) and Hyperthyroidism (June 2016) Review due: Feb 2022 Clinical Endocrinology. What should be done when thyroid function tests do not make sense? Mark Gurnell, David J. Halsall, V. Krishna Chatterjee. 21st Feb 2011 THYROID. Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and Please refer to the Summary of Product Characteristics (SPC) of any drug considered. postpartum. E K Alexander et al. Volume 27, Number 3, 2017 This pathway has been developed from published guidance in collaboration with local endocrinologists. This guidance is to assist GPs in decision making and is not intended to replace clinical judgement. Clinical Contact for this pathway for queries: [email protected] Causes of hypothyroidism include: Hypothyroidism Arrange emergency admission for patients presenting Primary causes Secondary causes with suspected myxoedema coma. (Presents with typical (TSH ↑, FT4 ↓ or ↔, TPO antibody -/+) Iodine deficiency Pituitary dysfunction features of hypothyroidism with hypothermia, coma and (most common) due to e.g. tumours, occasional seizures) Autoimmune surgery History - Consider in anyone with the following non-specific signs & symptoms: thyroiditis e.g. Hypothalamic - Dry skin - Weight gain - Fatigue/lethargy - Hoarseness Refer 2ww if red flag symptoms/signs Hashimoto’s dysfunction due to e.g. - Constipation - Cold intolerance - Bradycardia - Oedema Patients presenting with a goitre, nodule or structural change Drugs tumours, surgery - Menstrual - Non-specific - Depression - Memory loss in the thyroid gland and suspected malignancy. Post-ablative therapy or surgery irregularities weakness Transient thyroiditis e.g. subacute or postpartum Refer the following patients for specialist input: If primary hypothyroidism is suspected: Investigations to confirm diagnosis Secondary hypothyroidism – Suggested Check FBC – check for associated anaemia Undertake TFT levels: TSH, FT4, TPOAb (if required) HbA1c – check for associated type 1 diabetes by low, normal or slightly raised TSH and low T4. Serum lipids – if elevated, this may improve with treatment of hypothyroidism NB. Secondary hypothyroidism can be Subclinical Hypothyroidism with Overt Hypothyroidism differentiated from non-thyroid causes by TSH >10mU/L (FT4 < reference range) Subclinical Hypothyroidism with TSH >10mU/L (FT4 within reference range) history, TSH, FT4, FT3 and other tests of other anterior pituitary hormones TSH 4-10mU/L (FT4 within reference range) ΔUnresponsive to therapy Start treatment with levothyroxine (even Treat with levothyroxine o TSH not in normal range despite if asymptomatic) if aged ≤ 70 years Most patients - Start at 50-100micrograms once Repeat TSH and FT4 (ideally at the same time of day) 3–6 >200micrograms of levothyroxine daily, then increase every 3-4 weeks in months after initial result to exclude non-thyroidal and compliant with treatment OR 25-50 microgram increments according to illness/drug effects and to confirm the diagnosis o Symptoms continue despite If <65 years - consider trial of levothyroxine on clinical and biochemical (TFTs) response. Usual apparently adequate thyroid individual patient basis (see dosage maintenance dose is 100-200 micrograms once replacement (TSH within reference No symptoms Symptoms present instructions in ‘treat with levothyroxine’ box). daily. range) Assess response to treatment 3-4 months If older (>50 years) AND cardiac disease or Planning a pregnancy, pregnant or after TSH stabilises within reference range. severe hypothyroidism present - Consider postpartum Observe and repeat If TSH normalised - starting at 25micrograms once daily, then adjust If >80 years - follow a 'watch and wait' Undergoing fertility investigation / TFTs in 6 months Check serum TPOAb dose every 4 weeks in 25microgram increments strategy. If a decision is made to treat, treatment according to clinical and biochemical (TFTs) prescribe levothyroxine and recheck TSH after Other pituitary disease If TSH remains elevated, 2 months and adjust the dose accordingly. response (to avoid any sudden increase in If asymptomatic, Pre-existing cardiac disease arrange repeat TFTs metabolic demands). Maintenance dose 50-200 TPOAb negative and Drug treatment e.g. lithium etc. every 6 months for the micrograms once daily. no goitre - no further Suspected subacute thyroiditis first 2 years and then If after 3-6 months, If after 3-6 months, If >80 years - follow a 'watch and wait' strategy. testing needed Adverse reaction to levothyroxine annually symptoms have symptoms have If a decision is made to treat, prescribe improved, consider not improved/ levothyroxine and recheck TSH after 2 months therapy lifelong treatment adverse effects and adjust the dose accordingly. Are suspected of having associated endocrine disease Check serum TPOAb reported, stop (Expert opinion suggests that age dependent titration Nodule, goitre or structural change in levothyroxine. may not be required or the ‘watch and wait’ strategy in Once TSH has Δ thyroid gland – if malignancy suspected, Refer to specialist. >80 year olds, however the above reflects NICE CKS/BNF) TPOAb positive TPOAb negative normalised, refer as 2ww or goitre present measure TFTs at Once TSH is stable and adequate dose least annually determined, monitor TSH every 4-6 Liothyronine prescribing is restricted to Monitor TFT months, and then annually (or earlier if certain indications within North Central Arrange annual TFTs every 3 years symptoms develop) London (NCL). Please see the local liothyronine position statement for further If serum lipids were elevated at initial assessment, recheck to see if levels have adequately improved or details. if there is a need for dyslipidaemia treatment Causes of hyperthyroidism Arrange emergency admission for patients presenting Primary causes include: Hyperthyroidism with thyroid storm. Clinical features include tachycardia, Graves disease (NB. TPOAb test (TSH ↓, FT4 and/or FT3 ↑ or ↔) fever, atrial fibrillation, heart failure, fever, diarrhoea etc. not required for diagnosis) Toxic multinodular goitre Refer 2ww if red flag symptoms/signs History - Consider in anyone with the following non-specific signs & symptoms: Toxic thyroid nodule (adenoma) Patients presenting with a thyroid nodule or goitre and - Warm moist skin - Fatigue - Palpitations - Diarrhoea Drugs e.g. iodine (i.e. in drugs such suspected malignancy. NB. TFTs are usually normal in people - Muscle weakness - Insomnia - Irritability - Anxiety as amiodarone), lithium with thyroid cancer. - Breathlessness, dysphagia, - Heat intolerance - Polyuria, thirst, generalised itch Secondary causes include: neck pressure - Infertility, oligomenorrhoea, amenorrhoea Pituitary adenoma (rare) - Increased appetite with weight loss (or occasional weight gain) Thyroid hormone resistance syndrome (rare) High levels of human chorionic If TSH within gonadotrophin reference range – Investigations to confirm diagnosis further investigations
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