Newly diagnosed hypothyroidism
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7477.1271 (Published 25 November 2004) Cite this as: BMJ 2004;329:1271
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sir,
The views i express in my letter are from a psychiatrist's
perspective. I currently work in a rural teaching hospital and do see many
patients with depression and hypothyroidism. These are the things I have
observed during treating the patients and their families :
1. 10 minutes is hardly sufficient--at least 20 to 30 minutes are
required.
2.Due to significant overlap between the effects of the Hypothalamo-
Pituitary-Thyroid Axis and the effects of STRESSORS on the body, it takes
time to delineate features of Hypothyroidism.
3.A significant number of the depressed have wt gain contrary to the
expected wt loss and have a visible neck swelling -- which means a thyroid
screen is required -- they also report easy fatiguability, intolerance to
cold, hoarseness of voice and only some report irregularities in menstrual
cycles.
4.The Question of FINANCES -- A thyroid test profile costs about Rs.300 to
400 and takes about 48 hours even in the best laboratory.
5.Of all the thyroid results obtained, a significant proportion (>70-
80%) fall within the normal range and improve within 4 to 6 weeks with an
adequate dose of an antidepressant and psychotherapy.
6.This trend has been observed even in Recurrent Depressive Disorder and
Bipolar Affective Disorder which have a high predisposition for BIOLOGICAL
CAUSES.
7.This has always been puzzling me for the past 3 years -- in the minority
of those who are hypothyroid, there is a clear dissociation between T3/T4
and TSH values. Unfortunately, many patients are unable to afford higher
biochemical investigations.
8.I would like to know from experienced seniors answers to atleast few of
my questions as I know that answering all queries listed above is
difficult. I have asked these questions many times to my seniors whenever
we have encountered such T3/T4 dissociations or when we have suspected
that somebody is clinically hypothyroid and that person is biochemically
euthyroid and has improved with adequate doses of antidepressants.
9.Finally, it is my view that a diagnosis of Hypothyroidism cannot be made
in 10 minutes as the whole system has to be examined in detail and the
caregiver's anxiety has to be allayed by the treating physician.
Srivatsa Gopal Vyasarayani,
Consultant Psychiatrist,
SRM Medical College Hospital and Research Center,
Kattangolathur, Kancheepuram (dist),
Tamilnadu.
Competing interests:
None declared
Competing interests: No competing interests
Rehman and Bajwa1 state that if anginal pains occur on initiating
thyroxine for newly diagnosed patients with ischaemic heart disease,
treatment can be restarted in a couple of days at a lower dose. This
approach is too relaxed in my view. Thyroxine will increase stroke volume
and heart rate so the development of anginal pains indicates relative
coronary insufficiency which may lead to further myocardial ischaemia
unless treated. I would advise that if anginal pain occurs, thyroxine
should be stopped and a resting ECG and troponin T (TnT) are obtained. If
there are new ischaemic changes on ECG or TnT is raised, the patient
should be admitted immediately for inpatient evaluation. If ECG and TnT
are normal an urgent treadmill test should be ordered off thyroxine. Only
if the treadmill is normal should thyroxine be restarted. If treadmill
shows ischaemic changes, again urgent cardiological evaluation is required
and thyroxine replacement is delayed until coronary disease is treated.
The authors rightly mention other organ specific auto immune disease
but omit to mention Addison’s disease. Commencing thyroxine in untreated
Addison’s will exacerbate the cortisol deficiency and should be considered
as a reason why patients may not feel better and indeed may feel worse
after commencing thyroxine.
Dr. Thomas Ulahannan FRCP
Consultant Physician
Gloucestershire Hospitals NHS Trust
1. BMJ 2004;329:1271
Competing interests:
None declared
Competing interests: No competing interests
'10 minute consultations' are meant to be evidence based, although
for many common conditions, the evidence base is incomplete. Drs Rehman
and Bajwa suggest a number of probably superfluous examinations and tests.
Examination is usually said to be part of the diagnostic process that
comes before blood tests and other investigations. I am unclear what the
value of examination signs of hypothyroidism is after a biochemical
diagnosis has been made. Would the presence of signs of bradycardia,
proximal weakness or carpal tunnel syndrome make any difference (is there
any treatment apart from thyroxine indicated in the absence of significant
symptoms?). Like a previous correspondent, Pemberton's sign was a new one
to me, but unless the authors know of evidence for how useful it is as a
screening test for significant retrosternal goitre in the absence of
symptoms or a palpable goitre, its inclusion here is questionable.
Some of their suggested blood tests seem to be because of
associations between hypothyroidism and other diseases, but again their
relevance to this patient is low. Notwithstanding an association with type
1 diabetes at population level, it seems highly unlikely that anyone newly
diagnosed with hypothyroidism will be simultaneously developing type 1
diabetes, so the value of a single fasting glucose as a screen seems very
low (unless the authors have evidence to the contrary), and measuring
glycated haemoglobin adds nothing. As others have pointed out, cholesterol
might be better measured after thyroxine treatment is stable, but more
importantly, if it is going to be measured it should be part of an
assessment of cardiovascular risk rather than a stand alone test.
Focusing on irrelevant doctor driven action like this will only get
in the way of talking to the patient about their symptoms and potential
effects of treatment, which is surely the main function of such a
consultation.
Competing interests:
None declared
Competing interests: No competing interests
I am amazed what some doctors can achieve in a 10 minute
consultation!
Perhaps the reference to autoantibodies and haemoglobin levels was meant
that there was a possibility of a diagnosis of systemic lupus or other
similar
or other autoimmune disease - www.lupus.org.
What the authors forgot to mention was the effect of thyroid
abnormalities
during pregnancy and the serious consequence for the child often resulting
in
serious disabilities
http://www.foxriverwatch.com/thyroid_humans_pcbs_1.html. It is not only a
history of miscarriages but that of history of having children with
disabilities
that should be noted.
The health of a parent of a child with disabilities is often
overlooked and
treated for depression when, in fact, they have an underlying medical
disorder particularly where they have the same medical condition as their
child albeit at a different end of the spectrum or had hypothryoidism in
pregnancy.
Depression, bipolar disorder, manic depression, leg cramps and other
symptoms as described in the following website:
http://www.aboutchronicwellness.com/symptoms.htm masking as
hypothyroidism and result in misdiagnosis. Rarely is the thyroid tested.
It
can take many years to actually ascertain the real problem for the
depression!
The lack of national protocols about treating so-called normal levels
is of
concern particularly where there is other substantive evidence of sub-
clinical
hypothryoidism along with pre-existing evidence of hypoparathryoidism.
This is described in Weetman AP(1)
In addition to the conditions listed in Weetman's article, patients
showing a
22q11.2 deletion should be screened; hypothryoidism, hypoparathryoidism,
Graves, Hashimotos are all found in the spectrum of disorder of deletion
22q11.2. The second most common disorder other than Downs Syndrome
and yes there are adults with the VCFS/DiGeorge who lead relatively normal
lives but happen to have relatively minor haemotological/immunological
problems associated with their condition.
References
1. Weetman AP: Hypothryoidism: screening and subclinical disease
BMJ
1997, 314:1717 (19 April) http://bmj.bmjjournals.com/cgi/content/full/314/
7088/1175
Competing interests:
None declared
Competing interests: No competing interests
We read the 10-minute consultation on hypothyroidism with interest.
Whilst agreeing with most of the points there are a couple of issues that
we feel warrant comment:-
1. In the article it was rightly suggested that hypothyroidism is
associated with hypercholesterolaemia. It was not commented, however that
the dyslipidaemia will likely improve with treatment and that cholesterol
levels should be re-checked when the patient is euthyroid before
considering statin therapy. Untreated hypothyroidism may enhance the risk
of myositis with statins and these drugs should be used with great caution
in this situation. By suggesting measuring the cholesterol at diagnosis
rather than when the patient is euthyroid we feel that the article
increases the liklihood of statin use in untreated hypothyroid patients
with the possible associated dangers.
2. Autoimmune hypothyroidism is associated with other autoimmune
disease as suggested. However, HbA1c is not a diagnostic test for diabetes
and is relatively expensive and therefore should not be included along
with measurement of glucose. Other associated endocrinopathies are rare
and it would seem more sensible to raise awareness of the possible
association rather than suggest testing everyone as the pick-up rate will
be very small.
Competing interests:
None declared
Competing interests: No competing interests
Rehman and Bajwa have provided a short and comprehensive treatise on
the management of newly diagnosed hypothyroidism(1), but have ignored the
brief that this is meant to be a ten-minute consultation in a primary care
setting.
I defy any doctor to do all of the following, as advocated by the
authors, within the allotted consultation time: assess current and
previous drug use, check past medical history, take a menstrual and
obstetric history, assess the patient’s psychological needs, examine the
neck, examine her generally, examine the skin for vitiligo, assess the
cardiovascular and nervous systems for bradycardia, proximal weakness,
peripheral neuropathy, carpel [sic] tunnel syndrome and Pemberton’s sign,
examine the eyes, carry out further investigations, make a referral if
indicated, prescribe oral thryoxine [sic], discuss and agree a treatment
and monitoring plan. Add to this the (unstated) need to ask the patient
about her ideas, fears and expectations, and then address these, and I
estimate that a good thirty minutes is required.
The authors have misjudged their target audience when they advise
examining the patient for Pemberton’s sign. I wonder how many general
practitioners had to look this one up; I did, and I am not ashamed to
admit it. It does not appear in my Dictionary of Medical Eponyms(2), but
does get a single mention in the Oxford Textbook of Medicine(3).
(Pemberton’s sign indicates the possibility of a retrosternal goitre:
elevation of the arms above the head causes venous obstruction with facial
congestion and respiratory distress.)
The value of any article is greatly enhanced if the correct spelling
and terminology is used. Rehman and Bajwa advise examination for carpel
[sic] tunnel syndrome. The carpel is found in flowers; what they refer to
is the carpal tunnel. European Law requires use of the Recommended
International Non-proprietary Name (rINN) for medications, rather than the
former British Approved Name (BAN)(4). How disappointing, then, to find
the drug levothyroxine (rINN) referred to as thyroxine (BAN).
This article is not aimed at primary care physicians with ten minutes
for the patient, but at doctors in a hospital setting with far more time
at their disposal. I am concerned that its inclusion in the ten-minute
consultation series gives it the status of a benchmark of care against
which primary care physicians will be judged and found wanting.
References
1. Rehman HU, Bajwa TA. Newly Diagnosed Hypothyroidism. BMJ
2004;329: 1271 (27 November 2004)
2. Firkin BG, Whitworth JA. Dictionary of Medical Eponyms. Carnforth:
Parthenon; 1990
3. Weatherall DJ, Ledingham JGG, Warrell DA (eds). Oxford Textbook of
Medicine on CD-ROM Version 1.10. Oxford: Oxford University Press; 1996
4. Joint Formulary Committee. British National Formulary. 48 ed.
London: British Medical Association and Royal Pharmaceutical Society of
Great Britain; 2004
Competing interests:
None declared
Competing interests: No competing interests
Although this article of interest to perhaps a new medical student I
fail to see the validity for the majority of patients in General Practice.
A far more likely scenario is that a Thyroid patient would not be
diagnosed for years until the TSH budged a tadge over it's limit, that the
patient would not be returned to full wellness with Thyroxine treatment or
that the TSH was kept within the normal range but not suppressed to the
lower end of the scale, giving rise to continued hypo symptoms.
I was officially diagnosed following two late miscarriages, by auto immune
antibody testing and still had to wait another 3 years for my TSH to creep
above the normal range (along with a laundry list of hypo symptoms)to get
treatment. As yet, 9 years on I still have hypo symptoms and am resorting
to Armour natural thyroid treatment which even in the space of two weeks
has improved many of my functions.
When will the medical profession wake up to the fact that it takes
years for the TSH test to show a deficiency? Mean while you have a very
unwell patient displaying hypothyroid symptoms and being fobbed off with
placations until the blood tests prove otherwise.
What ever happened to good clinical skills?
Competing interests:
None declared
Competing interests: No competing interests
Primary hypothyroidism is a chauvinistic disease commonly affecting
young women of child-bearing potential. I always try to address the
following points when seeing someone with hypothyroidism for the first
time :
1. The importance of adequate replacement in any young women not
using contraception given the studies showing reduction in IQ of offspring
of mothers inadequately replaced during pregnancy. And for young women to
increase their dose by ~ 30 % if they think they may be pregnant pending
medical review.
2. Exclusion of coeliac disease, the prevalence of which is between 2
-15% in individuals with Hashimotos. This also has important implications
for pregnancy given the possibility of adverse pregnancy outcomes with
undiagnosed coeliac disease. Coeliac disease should also be considered in
any individual requiring unusually large doses of thyroxine, or with
persisting symptoms of tiredness etc. despite adequate biochemical
replacement with thyroxine.
3. To always take thyroxine fasting - many foods especially those
containing iron and calcium can interfere with thyroxine absorption.
And two important rarities which may save a life:
4. I tell people I am starting on thyroxine about symptoms of
Addisons disease. While rare this is a life-threatening disorder if
undiagnosed, symptoms are often non-specific, Hashimotos and Addisons may
coexist as a polyglandular autoimmune syndrome, and thyroxine
administration may precipitate an Addisonian crisis in those with the
condition not on treatment.
5. I tell anyone with Hashimotos who notices sudden enlargement of
their thyroid to seek medical attention immediately in view of the rare
association of thyroid lymphoma and Hashimotos.
Competing interests:
None declared
Competing interests: No competing interests
The issue of optimal treatment of hypothyroidism is unfortunately not
addressed.
Many patients whose TSH is restored to the reference range fail to
achieve wellbeing. Only when TSH is suppressed quality of life returns.
This discrepancy between clinical theory and practice raises some
questions: Could it be that TSH in fact triggers autoimmunity? And,
consequently, that suppression of TSH in some patients is a prerequisite
for calming autoimmune activity?
Competing interests:
None declared
Competing interests: No competing interests
British Thyroid Associatioin statement on Armour
For those interested in Armour I suggest you read this regarding the
BTA's concerns about Armour.
http://www.british-thyroid-association.org/armour.htm
Competing interests:
None declared
Competing interests: No competing interests