Current recommendations in the management of hypothyroidism: developed from a statement by the British Thyroid Association Executive.

Abstract

Hypothyroidism is present in about 2–5% of the population and is routinely managed in general practice.1 Uncorrected disease carries significant morbidity and is associated with an increased risk of lipid disorders, cardiovascular disease, osteoporosis, and cognitive dysfunction.2 Most cases are due to chronic autoimmune thyroiditis, and are followed by destructive treatment of the thyroid gland with radioactive iodine or surgery.2 The prevalence of spontaneous hypothyroidism rises with age and is 10 times more common in women than in men.1 In primary hypothyroidism the earliest biochemical abnormality is an increase in serum thyrotropin (TSH) level with normal free T4 (FT4) and free T3 (FT3) concentrations (subclinical hypothyroidism).2 A proportion of individuals with subclinical hypothyroidism (approximately 2–4% per annum) will progress to overt hypothyroidism (decreased FT4 associated with increased serum TSH).1 Patients with overt disease typically manifest symptoms and usually benefit from thyroid hormone treatment. Synthetic levothyroxine (L-T4) remains the treatment of choice for hypothyroidism2–4 and is prescribed to an estimated 1.5 million people in the UK.2 It is simple to administer, and within weeks of initiation most patients achieve normal serum TSH levels, and enjoy restored health.2 However, a proportion of treated patients continue to suffer ill-health even after normalisation of their thyroid hormone levels.5 Most GPs will be familiar with the patient who is persistently dissatisfied with L-T4 therapy or those for whom a stable euthyroid state appears unachievable. The management of such individuals is challenging and sometimes frustrating for patients and clinicians alike. In addition recent community-based surveys have highlighted a series of pressing concerns including the indiscriminate use of thyroid tests,6 overdiagnosis, and excessive treatment of patients with mild hypothyroidism,7 and an …