Evaluation and Management of Hypothyroidism in the Primary Care文档.pptVIP

Evaluation TSH FT4 Primary Hypothyroidism Subclinical Hypothyroidism Secondary or Tertiary Hypothyroidism Thyroid Hormone Resistance (pt is clinically hypothyroid) Basic Thyroid Labs * Evaluation Primary hypothyroidism Proceed to treatment Further evaluation generally not indicated For postpartum hypothyroidism, serial TSH and FT4, treat only if significantly symptomatic * Evaluation Secondary or tertiary hypothyroidism Image the sellar and suprasellar regions with MRI to evaluate for mass Screen for other hypothalamic or pituitary disease Adrenocortical, posterior pituitary, and gonadal dysfunction Consider consultation * Evaluation Thyroid hormone resistance Exceedingly rare If suspected – consultation is appropriate Subclinical hypothyroidism Addressed in later section * Treatment Guidelines Standard Replacement Therapy Synthetic thyroxine (T4) 1.6 mcg/kg/day – lean body mass 112 mcg in 70kg adult Full dose recommended regardless of degree of hypothyroidism Reassess after 6 weeks with TSH Roos, A, Linn-Rasker, SP, van Domburg, RT, et al. The starting dose of levothyroxine in primary hypothyroidism treatment: a prospective, randomized, double-blind trial. Arch Intern Med 2005; 165:1714. * Treatment Guidelines Special situations Elderly patients Start at 50 mcg/day and increase by 25 mcg/day every 6 weeks until TSH is normalized Known CAD Start at 25 mcg/day and increase by 25 mcg/day every 6 weeks until TSH is normalized Larsen PR, Kronenberg HM, Melmed S, Polonsky KS, editors. Williams textbook of endocrinology. 10th edition. Philadelphia: Saunders, 2003; 423-55. * Treatment Guidelines Special situations Postpartum hypothyroidism Treat based on moderate or severe clinical symptoms not based on labs Only 1 in 4 will require treatment 50 to 100 mcg per day x 12 weeks Discontinue and recheck thyroid labs 6 wks later Stuckey, BG, Kent, GN, Allen, JR. The biochemical and clinical course of postpartum thyroid dysfunction: the treatment decision. Clin En