New diagnosis of hyperthyroidism in primary careBMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k2880 (Published 24 August 2018) Cite this as: BMJ 2018;362:k2880
- Gabriella Bathgate, specialist trainee in general practice,
- Efthimia Karra, consultant in endocrinology,
- Bernard Khoo, senior clinical lecturer in endocrinology and honorary consultant
- Royal Free London NHS Trust, London, UK
- Correspondence to G Bathgate
- Accepted 18 June 2018
What you need to know
When hyperthyroidism is identified, arrange initial investigations including thyroid auto-antibodies, and offer referral for endocrinology assessment.
Pending specialist review, offer beta blockers to manage adrenergic symptoms. If symptomatic and a non-transient cause is likely, start anti-thyroid drugs and recheck thyroid function tests after 2-4 weeks.
Avoid pregnancy until normal thyroid function is restored.
A 36 year old woman presents to her GP with a six week history of palpitations, agitation, and unintentional weight loss of 12 kg over four months. She initially attributed her symptoms to stress relating to work pressures and a recent house move. Blood tests are arranged, which show a fully suppressed thyroid stimulating hormone (TSH) of<0.01 mU/L and free thyroxine of 86.1 pmol/L.
Hyperthyroidism describes excess hormone production from the thyroid gland. Thyrotoxicosis is the clinical state arising from excess circulating thyroid hormones due to any cause, including hyperthyroidism (fig 1).
Hyperthyroidism is a biochemical diagnosis. Establishing the underlying aetiology is essential to determine appropriate management.
Overall population prevalence of hyperthyroidism is 0.3%-2% and annual incidence is 0.1-4 per 1000.12 Graves’ disease accounts for up to 80% of cases, with peak incidence at age 30-50 (F:M 10:1). In older adults, toxic adenoma/multinodular goitre are responsible for a higher proportion of cases.
This article describes the first reasonable steps in diagnosing and managing hyperthyroidism for non-specialists in primary care.
What you should cover
Establish the severity and duration of thyrotoxic symptoms. If the patient has evidence of possible thyroid storm (box 1) this requires emergency referral.
Explain that the condition is likely to be reversible with treatment. Box 2 covers key points for explanation to patients. Box 3 lists useful patient resources.
Try to establish the likely cause. It is clinically relevant to distinguish between:
Transient causes of …