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Hyperthyroidism Care Pathway Overview

Hyperthyroidism is over activity of the thyroid gland, which results in a number of symptoms and signs. It’s causes can be related to a primary or secondary diagnosis:

  • Primary hyperthyroidism is the term used when the pathology is within the thyroid gland.
  • Secondary hyperthyroidism is the term used when the thyroid gland is stimulated by excessive thyroid-stimulating hormone (TSH) in the circulation.

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Red Flags
Thyroid Storm - Admit as a medical emergency a person with symptoms of ‘Thyroid storm’: sudden and drastic increase in thyroid hormones, which can be life threatening.
Symptoms include:
  • Fever
  • Diarrhoea or vomiting
  • Extreme sweating
  • Severe weakness
  • Seizures
  • Irregular heartbeat
  • Symptoms of heart failure
  • Very low blood pressure
  • Loss of consciousness
Non Toxi Thyropid Mass - Refer using suspected 2ww Head and Neck Cancer pathway if a person has a thyroid nodule or goitre and malignancy is suspected. Note: thyroid function tests are usually normal in people with thyroid cancer.
Presentation

Risk factors

These include:

  • Family history.
  • High iodine intake.
  • Smoking (particularly for thyroid-associated ophthalmopathy).
  • Trauma to the thyroid gland (including surgery).
  • Toxic multinodular goitre (which is especially associated with an increased iodine intake, either from a change in diet or an acute dose from iodine-containing agents (e.g. amiodarone, contrast agents)).
  • Childbirth.
  • Highly active antiretroviral therapy (HAART).

Symptoms and signs

Symptoms

Signs

  • Weight loss despite an increased appetite.
  • Weight gain.
  • Increased or decreased appetite.
  • Irritability.
  • Weakness and fatigue.
  • Diarrhoea ± steatorrhoea.
  • Sweating.
  • Tremor.
  • Mental illness: may range from anxiety to psychosis.
  • Heat intolerance.
  • Loss of libido.
  • Oligomenorrhoea or amenorrhoea.
  • Palmar erythema.
  • Sweaty and warm palms.
  • Fine tremor.
  • Tachycardia - may be atrial fibrillation and/or heart failure (common in the elderly).
  • Hair thinning or diffuse alopecia.
  • Urticaria, pruritus.
  • Brisk reflexes.
  • Goitre.
  • Proximal myopathy (muscle weakness ± wasting).
  • Gynaecomastia.
  • Lid lag (may be present in any cause of hyperthyroidism).

 

NB: although these symptoms may be present, the symptoms and signs can be variable and in some patients they are very mild.

Thyrotoxic periodic paralysis is a serious complication characterised by muscle paralysis and hypokalaemia due to a massive intracellular shift of potassium. An annual incidence of up to 2% has been reported in Asian people with thyrotoxicosis.

Causes of thyrotoxicosis

  • This is the most common cause of hyperthyroidism and has an autoimmune basis.
  • It is an autoimmune disease mediated by antibodies that stimulate the TSH receptor (Thyrotropin Receptor Antibodies - TRAb) leading to excess secretion of thyroid hormones and hyperplasia of thyroid follicular cells, resulting in hyperthyroidism and diffuse goitre.
  • Eye changes - exophthalmos, ophthalmoplegia, conjunctival oedema, papilloedema and keratopathy.
  • Diffuse moderate enlargement of the thyroid gland which feels firm on palpation.
  • Some patients have pretibial myxoedema called thyroid dermopathy (as can occur anywhere, particularly following trauma). This is usually associated with moderate-to-severe ophthalmopathy. 10-20% have clubbing (thyroid acropathy).
  • There may also be lymphoid hyperplasia including splenomegaly and an enlarged thymus.
  • There may be a personal or family history of autoimmune disease.

  • The presence of a multinodular goitre without the above symptoms (i.e. specific features of Graves' disease) suggests toxic nodular goitre (common in the elderly).

  • Diffuse swelling of thyroid.
  • These include amiodarone, lithium and exogenous iodine. There may be no symptoms at presentation.
  • Self-medication including over-the-counter iodine supplements and ‘energy boosting’ preparations containing thyroid hormones.

  • Single palpable mass, possible pain, possible lymph node involvement.

  • Acute inflammation usually related to viral illness with flu like symptoms, pain in neck, temperature etc. with raised inflammatory markers; become acutely toxic then rapidly underactive.
  • Do not treat with Carbimazole – use NSAIDs etc.
  • Usually self-limit but may end up hypothyroid; should have long-term TFTs checks even if settles.
  • Post-partum thyroiditis presents around 3-4 months postnatally and again usually self-limits but if not settling discuss with secondary care.
Initial Primary Care Assessment
  • Request Thyroid-stimulating Hormone (TSH),( Free Thyroxine (T4), free triiodothyronine (T3) will be added by lab if TSH is suppressed), (note a normal TSH result excludes hyperthyroidism with high probability)
  • Electrocardiogram (ECG)
  • Pregnancy test if appropriate
Initial Primary Care Management

Abnormal biochemistry:

  • Thyroid-stimulating Hormone (TSH) < 0.05mmol/L
  • Free triiodothyronine (T3) raised
  • Free thyroxine (T4) raised
  • Electrocardiogram ECG: Tachycardia / Atrial Fibrillation (AF)

 

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, seek guidance or refer

  • Assess cardiac status and pulse rate. If there are clinical concerns of cardiac decompensation, admit on the same day for assessment.

 

  • Initiate Carbimazole (CMZ) 20mg daily
  • Advise the patient if they develop a sore throat a Full Blood Count (FBC) will be required immediately.
  • NB. Risk of agranulocytosis
  • If intolerant or sensitive to CMZ commence PropthiouracylL (PPU)150mg
  • Consider a beta blocker if patient has a tachycardia
  • Repeat TSH request + TRAb 6 weeks after starting medication. If TRAb is positive then Graves Disease is confirmed. Note: If TRAb is significantly raised >12 then consider secondary care referral as the individual may be unlikely to respond to simple treatments and require definitive Rx earlier.
  • Repeat TSH 6 weekly until TSH is normalised and stable. Aim to have Thyroid-stimulating Hormone (TSH) 0.05-5.0mmol/L with FT4 and FT3 also within normal limits.
  • If Thyroid-stimulating Hormone (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

After TSH has normalised with normal FT4 and FT3 and reducing medication accordingly, continue monitoring Thyroid-stimulating Hormone (TSH) 3 monthly for at least 12 months.

In Graves Disease repeat TRAb test at 12-18 months as low levels at this point indicate a low risk of relapse and medication can be stopped. If TRAb levels continue to be very elevated then refer to secondary care for consideration of Definitive Therapy.

Repeat Thyroid-stimulating Hormone (TSH) annually thereafter as there is a risk of relapse.

For further prescribing information please see the Gloucestershire Joint Formulary information on thyroid and anti-thyroid drugs.

When to Refer

Consider either Advice & Guidance or referral to Endocrinology if any of the following are present:

  • Complicated presentation or co-morbidities / question about diagnosis
  • Poor control of thyroid disease whilst taking adequate medications
  • Single toxic nodular goitres
  • Drug induced causes e.g. patients taking amiodarone
  • Eye disease. (usually Graves disease)
  • Presence of atrial fibrillation or significant cardiac failure, start heart failure treatment as well as referral.
  • Relapsed disease
  • Pregnancy or pregnancy planning
Ongoing Primary Care Management
  • Monitor TSH/T4 and T3 levels every 6-7 weeks and adjust Carbimazole/Propothiouracyl accordingly, aiming to reduce doses to the lowest tolerated amounts.
  • When TFT levels are stable, continue low dose treatment for at least 12 months.
  • Stop thyroid treatments but monitor TSH annually watching for relapse of condition
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