eMedicine Specialties > Endocrinology > Thyroid

Hypothyroidism: Follow-up

Author: Shikha Bharaktiya, MD, Clinical Fellow, Department of Internal Medicine, Division of Endocrinology and Metabolism, University of Texas Medical School at Houston
Coauthor(s): Philip R Orlander, MD, Interim Chair of Medicine, Director of Endocrinology and Metabolism Fellowship, Director and Professor, Department of Medicine, Division of Endocrinology, University of Texas Health Science Center at Houston; Walter R Woodhouse, MD, MSA, Program Director of Transitional Year Program, St Vincent Mercy Medical Center; Associate Professor, Department of Family Practice, Medical College of Ohio; Anu Bhalla Davis, MD, Assistant Professor, Department of Internal Medicine, Division of Diabetes, Endocrinology, and Metabolism, University of Texas Medical School at Houston
Contributor Information and Disclosures

Updated: Jul 23, 2009

Follow-up

Further Inpatient Care

  • Most patients can be treated in an ambulatory care setting.
  • Patients with severe hypothyroidism, myxedema, require aggressive management in an inpatient setting.
  • Overreplacement with LT4 may precipitate tachyarrhythmias or, rarely, thyroid storm, which may require hospitalization. Risk is higher with T3.
  • Patients who require long-term continuous tube feeding require IV LT4 replacement, as the absorption of oral agents is impaired by contents of tube feeds.

Further Outpatient Care

  • Once appropriate therapeutic dose is obtained, patients can be monitored annually or semiannually with laboratory evaluation and physical examination.
  • Patients should take thyroid hormone as a single dose in the morning to avoid insomnia. Thyroid hormone is better absorbed in the small bowel; therefore, absorption can be affected by malabsorptive states, small bowel disease, and the patient's age. Many drugs (eg, iron, calcium carbonate, aluminum hydroxide, sucralfate [Carafate]) can interfere with absorption. Emphasize proper compliance at each visit.
  • In addition, monitor patients for signs of excess dosing (eg, nervousness, palpitations, diarrhea, excessive sweating, heat intolerance, chest pain). Monitor pulse rate, blood pressure, and vital signs. In children, sleeping pulse rate and basal temperature can be used as guides to adequate clinical response to treatment.

Deterrence/Prevention

No universal screening recommendations exist for thyroid disease for adults. All neonates should be screened for thyroid disease.
   
The American Thyroid Association recommends screening at age 35 years and every 5 years thereafter, with closer attention to patients who are at high risk (eg, pregnant women, women >60 y, patients with type 1 diabetes or other autoimmune disease, patients with history of neck irradiation).22  
 
The American College of Physicians recommends screening all women older than 50 years who have one or more clinical features of disease.23,24
  
The American Association of Clinical Endocrinologists recommends TSH measurements of all women of childbearing age before pregnancy or during the first trimester.20
 
 
The   US Preventive Task Force concludes that the evidence is insufficient to recommend for or against routine screening for thyroid disease in adults (grade I recommendation).12
             
Because screening prevents a delay in recognition and treatment of cretinism, governmental bodies frequently mandate screening of neonates.

Complications

  • Thyroid hormone replacement can precipitate adrenal crises in patients with untreated adrenal insufficiency. If suspected, the presence of adrenal insufficiency should be confirmed or ruled out and should be treated prior to treatment of hypothyroidism.
  • Aggressive replacement of thyroid hormone may compromise cardiac function in patients with existing cardiac disease. In these patients, administer smaller initial doses of LT4 with small incremental increases.
  • Subclinical hyperthyroidism, which can result from treatment with L-thyroxine, is more common, but its relationship to osteoporosis and fracture is unclear. Previously, osteoporosis was thought to be a risk of TSH suppression below the normal range; however, later studies did not consistently confirm this hypothesis except in postmenopausal women.25  Nonetheless, patients at risk for osteoporosis (eg, women who are estrogen deficient) and individuals receiving a long-term suppressive of LT4 (eg, patients with differentiated thyroid cancer) should be closely monitored. Note that patients with thyroid cancer are usually on a higher dose of LT4. Desired TSH depends on the staging of their thyroid cancer. In patients with stage IV thyroid cancer, it is desirable to keep their TSH below 0.1 mIU/L.
  • Advise patients that vision may temporarily worsen when starting hormone therapy. Rarely, pseudotumor cerebri occurs.
  • Patients with depression may develop mania, and psychosis may be exacerbated in patients with severe psychological illness.
  • Because most brain growth occurs in the first 2 years of life, untreated hypothyroidism in infants can cause irreversible mental retardation. Older infants are spared nervous system damage but continue to have slowed physical and linear bone growth. They also have delayed dental development.

Prognosis

  • Undertreatment leads to disease progression with gradual worsening of symptoms and further metabolic derangements.
  • Fortunately, in most patients older than 3 years, the signs and symptoms of hypothyroidism are reversed with thyroid hormone treatment.
  • With treatment, circulating lipid levels should improve to a mild degree. This may result in a decrease of coronary artery disease (CAD).

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Aggressive treatment in the presence or suggestion of cardiac disease may raise the risk of mortality.
  • A delay in the diagnosis and treatment of hypothyroidism in an infant with cretinism may lead to irreversible CNS damage. Legally mandated screening of neonates confers additional legal requirements on institutions, laboratories, and other nonphysician entities for compliance with, quality of, and follow-up for abnormal screening.
 


More on Hypothyroidism

Overview: Hypothyroidism
Differential Diagnoses & Workup: Hypothyroidism
Treatment & Medication: Hypothyroidism
Follow-up: Hypothyroidism
References
Further Reading
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References

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Further Reading

Related eMedicine topics:
Autoimmune Thyroid Disease and Pregnancy
Congenital Hypothyroidism
Embryology of the Thyroid and Parathyroids
Hyperthyroidism [Endocrinology]
Hyperthyroidism [Pediatrics: General Medicine]
Hypothyroidism [Pediatrics: General Medicine]
Hypothyroidism and Myxedema Coma
Hypothyroid Myopathy
Thyroid Anatomy
Thyroid Disease
Thyroid Nodules

Clinical guidelines:
Management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society clinical practice guideline. The Endocrine Society - Disease Specific Society.  2007.  79 pages.  NGC:005884

Screening for congenital hypothyroidism: U.S. Preventive Services Task Force reaffirmation recommendation statement. United States Preventive Services Task Force - Independent Expert Panel.  1996 (revised 2008 Mar).  6 pages.  NGC:006354

Screening for thyroid disease: recommendation statement. United States Preventive Services Task Force - Independent Expert Panel.  1996 (revised 2004 Jan 20).  7 pages.  NGC:003266

Subclinical thyroid disease: scientific review and guidelines for diagnosis and management. Consensus Conference Panel on Subclinical Thyroid Disease - Independent Expert Panel.  2004 Jan 14.  11 pages.  NGC:003902

Update of newborn screening and therapy for congenital hypothyroidism. American Academy of Pediatrics - Medical Specialty Society
American Thyroid Association - Professional Association.  2006 Jun.  14 pages.  NGC:005029

Clinical trials:
Evaluation of Patients With Thyroid Disorders

Generic vs. Name-Brand Levothyroxine

Growth Hormone and GnRH Agonist in Adolescents With Acquired Hypothyroidism

Maternal Hypothyroidism in Pregnancy

Neurocognitive and Metabolic Effects of Mild Hypothyroidism

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Keywords

hypothyroidism, thyroid, thyroiditis, thyroid hormone, thyroid function, thyroid nodule, thyroid treatment, thyroid goiter, thyroid medication, thyroid medicine, thyroid problem, myxedema coma, cretinism, hypothyrosis, hypothyroidea, thyrotropin, TSH, tertiary hypothyroidism, thyrotropin releasing-hormone, TRH, thyroxine, T4, triiodothyronine, T3, Hashimoto disease, Hashimoto thyroiditis, primary hypothyroidism, secondary hypothyroidism, congenital hypothyroidism, cold intolerance, weight gain, menstrual disturbances, periorbital puffiness, goiter, autoimmune thyroiditis, iodine deficiency, de Quervain thyroiditis, subacute thyroiditis, postpartum autoimmune thyroid disease, amiodarone, interferon alpha, thalidomide, stavudine, central hypothyroidism, subclinical hypothyroidism

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Contributor Information and Disclosures

Author

Shikha Bharaktiya, MD, Clinical Fellow, Department of Internal Medicine, Division of Endocrinology and Metabolism, University of Texas Medical School at Houston
Disclosure: Nothing to disclose.

Coauthor(s)

Philip R Orlander, MD, Interim Chair of Medicine, Director of Endocrinology and Metabolism Fellowship, Director and Professor, Department of Medicine, Division of Endocrinology, University of Texas Health Science Center at Houston
Philip R Orlander, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American Diabetes Association, Endocrine Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Walter R Woodhouse, MD, MSA, Program Director of Transitional Year Program, St Vincent Mercy Medical Center; Associate Professor, Department of Family Practice, Medical College of Ohio
Walter R Woodhouse, MD, MSA is a member of the following medical societies: American Academy of Family Physicians, American Academy of Pain Medicine, and Society of Teachers of Family Medicine
Disclosure: Nothing to disclose.

Anu Bhalla Davis, MD, Assistant Professor, Department of Internal Medicine, Division of Diabetes, Endocrinology, and Metabolism, University of Texas Medical School at Houston
Disclosure: Nothing to disclose.

Medical Editor

Frederick H Ziel, MD, Associate Professor of Medicine, David Geffen School of Medicine at UCLA; Physician-In-Charge, Endocrinology/Diabetes Center, Director of Medical Education, Kaiser Permanente Woodland Hills; Chair of Endocrinology, Co-Chair of Diabetes Complete Care Program, Southern California Permanente Medical Group
Frederick H Ziel, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Endocrinology, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Diabetes Association, American Federation for Medical Research, American Medical Association, American Society for Bone and Mineral Research, California Medical Association, Endocrine Society, and International Society for Clinical Densitometry
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Arthur B Chausmer, MD, PhD, FACP, FACE, FACN, CNS, Professor of Medicine (Endocrinology, Adj), Johns Hopkins School of Medicine; Affiliate Research Professor, Bioinformatics and Computational Biology Program, School of Computational Sciences, George Mason University; Principal, C/A Informatics, LLC
Arthur B Chausmer, MD, PhD, FACP, FACE, FACN, CNS is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Endocrinology, American College of Nutrition, American College of Physician Executives, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Informatics Association, American Society for Bone and Mineral Research, American Society of Law Medicine and Ethics, Endocrine Society, and International Society for Clinical Densitometry
Disclosure: Nothing to disclose.

CME Editor

Mark Cooper, MBBS, PhD, FRACP, Head, Diabetes & Metabolism Division, Baker Heart Research Institute, Professor of Medicine, Monash University
Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD, Professor of Medicine, St Louis University School of Medicine
George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, International Society for Clinical Densitometry, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

 
 
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