Podcast - NICE Thyroid Disease Part 2: Thyrotoxicosis and Low TSH

The video version of this podcast can be found here:

·       https://youtu.be/68bAZA9H9hQ

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode, I go through a section of the NICE guideline on Thyroid disease: assessment and management [NG145], particularly the section on hyperthyroidism, always focusing on what is relevant in Primary Care only.

I am not giving medical advice; this episode is intended for health care professionals; it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

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There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·       Redcircle: https://redcircle.com/shows/primary-care-guidelines

·       Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·       Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The NICE clinical guideline on Menopause: identification and management

[NG23] can be found here:

·       https://www.nice.org.uk/guidance/NG23

The resources consulted can be found here:

Thyroid disease: assessment and management -NICE guideline [NG145] can be found here:

·       https://www.nice.org.uk/guidance/NG145

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to go through the NICE guideline on Thyroid disease, always focusing on what is relevant in Primary Care only.

So let’s jump into it.

Let’s now have a look at thyrotoxicosis

First, we will have confirmed the diagnosis with a low TSH and raised FT4 and / or FT3.

Then we will need to differentiate between thyrotoxicosis with hyperthyroidism (for example, Graves' disease or toxic nodular disease) and thyrotoxicosis without hyperthyroidism (for example, transient thyroiditis). We will do so by:

●    measuring TSH receptor antibodies (TRAbs) to confirm Graves' disease. and

●    considering technetium scanning of the thyroid gland if TRAbs are negative.

We will only consider ultrasound for thyrotoxicosis if they have a palpable thyroid nodule. In terms of treatment, we need to be aware that transient thyrotoxicosis without hyperthyroidism like in thyroiditis usually only needs supportive treatment (for example, beta-blockers).

Otherwise we can consider antithyroid drugs along with supportive treatment for adults with hyperthyroidism who are waiting for specialist assessment and further treatment, bearing in mind that the use of carbimazole is subject to MHRA advice on contraception (Drug Safety Update, February 2019) and risk of acute pancreatitis (Drug Safety Update, February 2019).

Before starting antithyroid drugs, we will check a full blood count and liver function tests.

Antithyroid drugs for hyperthyroidism secondary to a single or multiple toxic nodules, will normally be with a titration regimen of carbimazole.

However, we will consider propylthiouracil for adults:

●    who experience adverse reactions to carbimazole

●    who are pregnant or trying to become pregnant within the following 6 months or

●    with a history of pancreatitis.

We will stop and do not restart any antithyroid drugs if a person develops agranulocytosis and we will refer to a specialist for further management options.

For the monitoring of antithyroid drugs, we will check:

●    TSH, FT4 and FT3 every 6 weeks until their TSH is within the reference range, then

●    TSH every 3 months until antithyroid drugs are stopped, rechecking FT4 and FT3 if the TSH becomes suppressed at any stage.

We will not monitor full blood count and liver function while taking antithyroid drugs unless there is a clinical suspicion of agranulocytosis or liver dysfunction.

After stopping antithyroid drugs in adults, we will check:

●    TSH within 8 weeks of stopping the drug, then

●    TSH every 3 months for a year, then

●    TSH once a year.

●    Always rechecking FT4 and FT3 if the TSH becomes suppressed at any stage.

In terms of the management and monitoring of subclinical hyperthyroidism, that is, when TSH is low and FT4 and FT3 are normal, We will seek specialist advice if they have:

●    2 TSH readings lower than 0.1 Miu/litre at least 3 months apart and

●    evidence of thyroid disease (for example, a goitre or positive thyroid antibodies) or symptoms of thyrotoxicosis.

Otherwise, in untreated subclinical hyperthyroidism, we will check TSH every 6 months and if the TSH level is outside the normal range, we will also check FT4 and FT3.

We will consider stopping TSH measurement if the TSH level stabilises (that is, we have 2 similar measurements within the normal range 3 to 6 months apart

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.