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Referral of the month – hypothyroidism



Thyroiditis

Thyroiditis

Source: Science Photo Library

Dear consultant,

Thank you for seeing this lady with hypothyroidism. She was diagnosed two years ago when she presented with malaise and some weight gain, and was found to be biochemically hypothyroid (on repeat blood testing).

Despite repeated manipulation of her thyroxine dosage and assurances that she is complying with treatment, we cannot seem to reach consistently satisfactory TFTs. Indeed, quite minor changes in her thyroxine dose seem to result in dramatic biochemical fluctuations, and we have reached a state of mutual exasperation.

In addition, she is disappointed that, despite her treatment, she feels as unwell as ever. She has joined an internet forum and has become convinced that all her problems would be solved if I prescribed her T3, which I have so far resisted.
I would appreciate your view on this.

She is on no other medication and has no other significant medical history.

Yours sincerely, GP

 

Dear GP,

It was a pleasure to see Mrs A in my endocrine clinic again today. You will recall that I first met her four months ago when you referred her with symptoms of persistent lethargy and difficult control of hypothyroidism. 

At the time she had been markedly frustrated by her symptoms and had inquired specifically about T3, which she had researched extensively on the internet. 

At the initial visit I had reviewed her thyroxine therapy. She was on an adequate dose for her body weight and her tablets were dispensed from the same pharmacy and were consistent in brand. She was not taking other medications that could interfere with thyroxine absorption. She claimed good medication compliance, but admitted that due to her busy schedule she took her tablet at various times each day often with coffee or a glass of wine in the evenings. 

She reported sleeping poorly and being constantly exhausted. Although she denied feeling low in mood, she admitted to a hectic schedule balancing the demands of a full-time job and caring for three young children. As a result she had given up walking, which she previously enjoyed and had since observed a gradual increase in weight. 

At the review four months ago, I had advised her to take her tablets on an empty stomach with water. I had also stressed the need for thyroxine to be administered at a constant time each day, ideally first thing in the morning or last thing before bed, as this allows greater stability in thyroid status. Lastly we had discussed the potential benefits of a healthier diet and physical activity on her general wellbeing.   

Today, I was pleased to see that she has joined a gym and resumed regular walking. She has lost an impressive 3kg in weight and now grades her lethargy as mild compared to severe. We reviewed the blood tests I had earlier requested for potential causes of lethargy. These have all returned negative, including screens for coeliac disease, diabetes, anaemia, Addison’s disease, and vitamin B12 and vitamin D deficiencies. 

She is now taking her tablets correctly and it was reassuring to see that her TSH level is now within the lower half of the laboratory reference range. She is on a stable thyroxine dose and I would suggest that future dose changes should only be considered after careful review of common factors that affect thyroxine dose, such as poor compliance, incorrect tablet administration, and concomitant use of medications like iron and antacids.   

Today we revisited the issue of T3 therapy. As you know, current guidelines do not support routine use of T3 in hypothyroidism and evidence from controlled trials has shown no added benefit of combined therapy with T3 and thyroxine over thyroxine therapy alone, although some experts will occasionally consider a trial of T3 under strict supervision in carefully selected patients. Today she was clearly less enthusiastic about T3 than previously, and agreed to persevere with the lifestyle changes that have proven effective.

I have provided her with literature on hypothyroidism and advised her to be wary of unregulated internet health advice. While many websites provide factual information, a number are inaccurate and misleading. I have directed her to the website of the British Thyroid Foundation.

She seemed satisfied with her progress and is happy to be discharged back to your care. I have not arranged another appointment but would be happy to see her again if problems arise in future.

Thank you for the referral. 

Yours sincerely,

Dr O Okosieme

 

Dr Onyebuchi Okosieme is a consultant endocrinologist at the Prince Charles Hospital, Merthyr Tydfil, Wales.