Hyperthyroidism Pathway

This is a visual format of the pathway for more pathway information such as assessment and diagnosis go to the Clinical Guidance tab.



  • Sweating
  • Diarrhoea
  • Cardiac failure
  • Anxiety
  • Weight loss
  • Tachycardia
  • Atrial fibrillation/flutter
  • New Tremor


  • TSH < 0.05mmol/L
  • Thyroid Antibodies (TPO) positive/negative
  • T3 biochemically raised
  • Free T4 biochemically raised
  • ECG: Tachycardia or AF

Clinical Causes:

  1. Graves Disease (autoimmune hyperthyroidism)
  2. Multinodular goitre
  3. Single nodule goitre within thyroid. Benign or malignant
  4. Drug induced
  5. Thyroiditis

Direct Secondary care referral: (follow link for referral information)

  1. Single nodular goitres
  2. Drug induced causes e.g. patients taking amiodarone
  3. Hyperthyroidism in pregnancy
  4. Eye disease
  5. Complex co-morbidities
  6. Relapsed diseases

If you are confident to treat simple hyperthyroidism then follow the steps below, if the patient has a more complicated presentation or  if there is any question about the diagnosis, referral to Acute Hospital care may be more appropriate.

  • Assess cardiac status and pulse rate. If there are clinical concerns,  refer on the same day for assessment or for telephone advice from the GHNHSFT  Endocrinology team.
  • Initiate CARBIMAZOLE (CMZ) 20mg daily in divided doses
  • Advise the patient if they develop a sore throat an FBC will be required immediately.
  • NB. Risk of agranulocytosis
  • If intolerant or sensitive to CMZ commence PROPYTHIOURACIL (PPU)150mg
  • Consider a beta blocker if patient has a tachycardia
  • Repeat biochemistry 4 weeks after starting medication and then according to clinical need
  • Aim to have TSH 0.05-5.0mmol/L
  • If TSH remains out of range either increase or decrease CMZ or PPU
  • Patients who have Graves’ Disease should be assessed for Ophthalmoplegia (eye signs). If signs are present the  patient should be referred to Ophthalmology for assessment.

Continue monitoring TSH monthly for at least 12 months and then attempt to stop medication.

Repeat TSH 6-12 monthly  thereafter as there is a high risk of relapse.

For patients where control is difficult using either Carbimazole or Propythiouracil, consider block and replace therapy with Carbimazole 30mg and Levothyroxine 50-100mcg with monitoring of TSH.

Patients with acute thyroiditis usually normalise after the acute episode.

Follow Up

For patients with Graves’ Disease, there is an increased risk of relapse.

For patients with multi-nodular goitre, remission is less successful and the patient may need an assessment for definitive therapy earlier.

Patients who relapse despite use of PPU/CMZ after prolonged treatment will require secondary care referral for assessment of definitive therapies of either partial thyroidectomy or Radioactive Iodine 131.

Please see Patient/Carer information for patient leaflets.