Thyroid

Who to refer:

Thyrotoxicosis

All cases of thyrotoxicosis should be referred

• The lab will automatically add T3 and TSH Receptor Antibodies (TRAbs) to all new thyrotoxic bloods
• No further investigations are needed prior to referral
• If patients are very symptomatic, consider treatment with propranolol 10-40mg tds, or with a rate-limiting calcium channel blocker, such as verapamil, if beta-blockade is contraindicated.
• In cases of clear-cut Graves disease (overt thyrotoxicosis with clearly positive TRAb) it is expected that patients will need to commence 40 mg carbimazole (20 mg in the case of mild thyrotoxicosis) prior to being seen in endocrine clinic. Advice should be given regarding the potential for agranulocytosis in around 1 in 1000 people, and the need for urgent full blood count in the event of fever, sore throat or mouth ulcers, and plan to recheck TSH, fT4 and fT3 at 6 weeks after starting therapy.  Consultants can provide advice on treatment via Diabetes & Endocrine inbox or when triaging a new patient with Graves’ disease if not already commenced.  However, if there is concern that the patient is significantly unwell (e.g. significant tachycardia, uncontrolled AF) they can be referred in to general medicine on call or urgent advice sought via the oncall endocrine consultant by contacting via bleep 6698

Subclinical Hyperthyroidism

• Subclinical hyperthyroidism occurs with low or suppressed TSH in the presence of normal free T4 and free T3.
• If this pattern occurs please repeat in six-eight weeks in the first instance
• People with persistent subclinical hyperthyroidism, TSH < 0.1, should be referred to the endocrine clinic
• Those who are >65, have a strong family or personal history of heart disease or osteoporosis may be treated with radioactive iodine or anti-thyroid drugs

Hypothyroidism

Straightforward hypothyroidism can usually be managed in primary care but we can offer advice by email or see cases that may not be straightforward, for example:

• Hypothyroidism during or within 12 months of pregnancy (this may be a transient thyroiditis)
• Cases where there is diagnostic uncertainty
• History of neck pain, systemic upset or earlier thyrotoxic symptoms suggesting transient thyroiditis
• TSH <20 with low fT4, particularly if there is a suspicion of pituitary pathology
• Cases associated with amiodarone or lithium therapy
• Cases where the person is asking for T3 combination treatment-T3 should not be initiated in primary care

Thyroid nodules

• Thyroid nodules, particularly when solitary and clinically obvious should be investigated, as they carry a small but significant malignant potential (up to 10%). 
• Thyroid function tests should be requested by the GP and appended to the referral letter.
• Hyper– or hypothyroidism associated with a nodular goitre are unlikely to be thyroid cancer.
• Patients with a thyroid nodule on examination, and normal or high TSH, should have a thyroid US requested by GP and referred to endocrinology. Those with a suppressed TSH should be referred to endocrinology and not have an interim ultrasound requested.
• Patients with stridor/acute airway compromise associated with a thyroid swelling should be sent to the closest Emergency Department as an emergency

Urgent referrals to endocrine for suspected cancer

The presence of the following symptoms or signs in association with a thyroid swelling may indicate more aggressive or advanced disease and should be referred urgently:

• Unexplained hoarseness or voice change
• Cervical lymphadenopathy associated with a thyroid lump (usually deep cervical or supraclavicular).
• A rapidly enlarging painless thyroid mass over a period of weeks (a rare presentation of thyroid cancer and usually associated with anaplastic thyroid cancer or thyroid lymphoma).

Patients with a history of sudden onset of pain in a thyroid lump (likely to have bled into a benign thyroid cyst) or a thyroid lump that has newly presented or has been increasing in size over several months should be referred routinely to the endocrine clinic.

Goitre

• Please check TFTs and refer those people with hyperthyroidism and goitre
• People who are euthyroid who are experiencing discomfort, distress, swallowing issues or minor breathing issues with a goitre can be referred to the endocrine clinic
• People with goitre and stridor/acute airway compromise should be sent to the closest Emergency Department as an emergency

Who not to refer:

Hypothyroidism

Patients with straightforward primary hypothyroidism with positive anti-thyroid peroxidase antibodies and none of the features of diagnostic uncertainty highlighted in the ‘Who to refer’ section do not need further investigation or referral to endocrinology.  Treatment with levothyroxine can be managed in primary care.

Please note that none of the endocrinologists in BGH will prescribe desiccated thyroid extract (also known as DTE, natural desiccated thyroid, NDT or Armour thyroid), in line with advice from the British Thyroid Association.  Please see the British Thyroid Association statement on the management of hypothyroidism.

How to refer

Please send referrals to Endocrinology through SciGateway:

Borders General Hospital -> Endocrinology & Diabetes -> Borders General Referral

If any queries please contact the endocrinology email advice on: diabetes.endocrinology@borders.scot.nhs.uk

Hypothyroidism

Patients with straightforward primary hypothyroidism with positive anti-thyroid peroxidase antibodies and no features of diagnostic uncertainty (see ‘Who to refer’) do not need further investigation or referral to endocrinology.  Treatment with thyroxine can be managed in primary care. Please see resources and links for information on Thyroid function testing in primary care (including pregnancy)

Asymptomatic patients with subclinical hypothyroidism (FT4 normal and TSH <10) do not usually require treatment with levothyroxine.  Advice can be requested using the ‘Advice only’ option on SCI Gateway. Please see resources and links for guidance on TFTs in primary care.

Subclinical Hypothyroidism

• Subclinical hypothyroidism is where TSH is raised with a normal free T4, where this pattern is seen, it should be repeated in three months as it can be a transient finding
• In those <65 years, a trial of levothyroxine is recommended if TSH is >10
• In those <65 years with TSH between 5-10 and with symptoms suggestive of hypothyroidism, a trial of levothyroxine can be considered. If symptoms do not improve with levothyroxine when TSH is in the normal range, the levothyroxine should be stopped and an alternative cause for symptoms reviewed.
• TSH tends to rise with age, so in those >65 years TSH should be >10 and symptoms present for a trial of levothyroxine
• Patients with subclinical hypothyroidism do not need to be seen in the endocrine clinic but if there is uncertainty whether a trial of treatment should be offered, email advice can be sought

2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum  https://www.liebertpub.com/doi/pdfplus/10.1089/thy.2016.0457

Clinical Guidance

• Thyroid Function Testing in Primary Care Guidance
• BTA Hypothyroidism Statement
• BTA and BTF updated information on T3 plus T4

Thyroid Patient information leaflets

The ECED website has some patient information on Graves’ Disease.  This can be accessed on the following link:

www.edinburghdiabetes.com/graves

Excellent patient information leaflets are provided by the British Thyroid Foundation (BTF).  Patients can be directed to look at these on-line or individual leaflets can be printed from the website.  The BTF will also send out larger volumes of specific information leaflets, although this requires a payment.  Details are on their website and leaflets can be accessed on the following link:

http://www.btf-thyroid.org/information/leaflets

Patient information on thyroid eye disease can also be found on the Thyroid Eye Disease Charitable Trust (TED-CT) website, which can be accessed on the link below:

http://tedct.org.uk/

diabetes.endocrinology@borders.scot.nhs.uk