Hypothyroidism Follow-up

  • Author: Shikha Bharaktiya, MD; Chief Editor: George T Griffing, MD   more...
 
Updated: Jul 22, 2011
 

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.

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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. A study by Zamfirescu and Carlson suggested calcium acetate may interfere with levothyroxine absorption as well.[25]

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.

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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).[26]

The American College of Physicians recommends screening all women older than 50 years who have one or more clinical features of disease.[27, 28]

The American Association of Clinical Endocrinologists recommends TSH measurements of all women of childbearing age before pregnancy or during the first trimester.[23]

TheUS Preventive Task Force concludes that the evidence is insufficient to recommend for or against routine screening for thyroid disease in adults (grade I recommendation).[15]

Because screening prevents a delay in recognition and treatment of cretinism, governmental bodies frequently mandate screening of neonates.

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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; however, its relationship to osteoporosis and fracture is not consistent and is best studied in postmenopausal women. A large, population-based, nested, case control study demonstrated a 2-fold to 3-fold increase in fractures in individuals older than 70 years; the increase was dose-related.[29] Thyroid function studies were not performed, so the relationship between subclinical hyperthyroidism and osteoporosis requires further study. However, this study does support careful dose titration in elderly patients.

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.

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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).

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Patient Education

Clearly discuss the life-long nature of hypothyroidism, the need for life-long therapy, the proper way to take medicine, and the minimum need for annual TSH testing.

For patient education resources, visit the Endocrine System Center and Muscle Disorders Center, as well as Thyroid Problems and Chronic Fatigue Syndrome.

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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  Assistant Dean for Educational Affairs, Vice-Chair of Medicine for Education, Director and Professor, 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  Associate Clinical 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.

Specialty Editor Board

Frederick H Ziel, MD  Associate Professor of Medicine, University of California, Los Angeles, David Geffen School of Medicine; 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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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 Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Informatics Association, American Society for Bone and Mineral Research, Endocrine Society, and International Society for Clinical Densitometry

Disclosure: Nothing to disclose.

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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