Thyroid

Who to refer:

Thyrotoxicosis

All cases of thyrotoxicosis should be referred to an endocrinologis

• The lab will automatically add TSH Receptor Antibodies (TRAbs) to all new thyrotoxic bloods
• No further investigations are needed prior to referral
• If patients are very symptomatic, consider treatment with propranolol 40mg tds, or with a rate-limiting calcium channel blocker, such as verapamil, if beta-blockade is contraindicated.
• Many consultants will provide advice on treatment when triaging a new patient with Graves’ disease.  However, if there is concern that the patient is significantly unwell (e.g. significant tachycardia, uncontrolled AF) advice on initial management can be provided by paging the on call endocrine registrar at RIE or WGH. 

Hypothyroidism

Straightforward hypothyroidism can usually be managed in primary care but we are happy to offer advice (select ‘Advice only’ on SCI Gateway) or see cases that may not be straightforward, for example:

• Hypothyroidism during or within 12 months of pregnancy (this may be a transient thyroiditis)
• Cases where there is diagnostic uncertainty

• History of neck pain, systemic upset or earlier thyrotoxic symptoms suggesting transient thyroiditis
• TSH <20, particularly if there is a suspicion of pituitary pathology
• Cases associated with amiodarone or lithium therapy

Goitres and nodules

Thyroid nodules, particularly when solitary and clinically obvious should be investigated, as they carry a small but significant malignant potential (up to 10%).  Thyroid function tests should be requested by the GP and appended to the referral letter. Hyper– or hypothyroidism associated with a nodular goitre are unlikely to be thyroid cancer; these patients should be referred to a general endocrine clinic.  Initiation of other investigations (such as ultrasound scanning or autoantibodies) are unnecessary and may cause delay in making the diagnosis of cancer. Please see the primary care guidance on thyroid nodules.

Immediate (same day) referrals: Patients with stridor associated with a thyroid swelling should be referred immediately to the Thyroid Surgery Service (Call 0131 242 1715/4).

Urgent referrals for suspected cancer: The presence of the following symptoms or signs in association with a thyroid swelling may indicate more aggressive or advanced disease and should be referred urgently:

• Unexplained hoarseness or voice change
• Thyroid Nodule/goitre in a child    
•  Cervical lymphadenopathy associated with a thyroid lump (usually deep cervical or supraclavicular).
• A rapidly enlarging painless thyroid mass over a period of weeks (a rare presentation of thyroid cancer and usually associated with anaplastic thyroid cancer or thyroid lymphoma).

Patients with a history of sudden onset of pain in a thyroid lump (likely to have bled into a benign thyroid cyst) or a thyroid lump that has newly presented or has been increasing in size over several months should be referred to the Thyroid Nodule Clinic.

Euthyroid patients with a goitre should also be referred to the ‘Thyroid Nodule Clinic.

Thyroid eye disease

If you think a patient has dysthyroid eye disease, they should be referred the joint thyroid eye clinic via Dr Justine McKee at PAEP.  They will receive both ophthalmic and endocrine follow-up at this clinic, but if the patient requires endocrine input, it is advisable to send a duplicate referral to RIE endocrinology selecting the ‘Advice only’ option and marking the referral for the attention of Dr Anna Dover or Dr Nicola Zammitt.  Please see advice on the urgency of referral depending on symptoms and signs in resources and links.   advice on the urgency of referral depending on symptoms and signs.  Patients in West Lothian should be referred to Dr Jan Kerr in ophthalmology.  Prior to referral, please check TFTs (TSH, FT4 and TT3) and TRAb titres, stating the suspicion of thyroid eye disease on the request.  Patients may have Graves’ eye disease despite being hypothyroid or even euthyroid.  The referral can be sent before results are available. 

Who not to refer:

Hypothyroidism

Patients with straightforward primary hypothyroidism with positive anti-thyroid peroxidase antibodies and none of the features of diagnostic uncertainty highlighted in the ‘Who to refer’ section do not need further investigation or referral to endocrinology.  Treatment with levothyroxine can be managed in primary care.

Asymptomatic patients with subclinical hypothyroidism (FT4 normal and TSH <10) do not usually require treatment with levothyroxine.  Advice can be requested using the ‘Advice only’ option on SCI Gateway. Please see guidance on TFTs in primary care. 

Hyperthyroidism

The lab will routinely add TRAb antibody levels onto a sample where a new diagnosis of thyrotoxicosis has been made, meaning that this test does not need to be specifically requested.  Many consultants will provide advice on treatment when triaging a new patient with Graves’ disease.  However, if there is concern that the patient is significantly unwell (e.g. significant tachycardia) advice on initial management can be provided by paging the on call endocrine registrar.  If there is no contraindication to beta-blockers, propranolol 40mg tds will provide some symptomatic relief.  Rate limiting calcium channel blockers, such as verapamil, can be used where beta-blockade is contraindicated.

Please see the Resources and Links page for advice about testing and management of nodules and eye disease in Primary Care.

Hypothyroidism

Patients with straightforward primary hypothyroidism with positive anti-thyroid peroxidase antibodies and no features of diagnostic uncertainty (see ‘Who to refer’) do not need further investigation or referral to endocrinology.  Treatment with thyroxine can be managed in primary care. Please see resources and links for information on Thyroid function testing in primary care (including pregnancy)

Asymptomatic patients with subclinical hypothyroidism (FT4 normal and TSH <10) do not usually require treatment with levothyroxine.  Advice can be requested using the ‘Advice only’ option on SCI Gateway. Please see resources and links for guidance on TFTs in primary care.

Goitres and nodules

Thyroid function tests should be requested by the GP and appended to the referral letter. Hyper– or hypothyroidism associated with a nodular goitre is unlikely to be thyroid cancer; these patients should be referred to a general endocrine clinic.  Initiation of other investigations (such as ultrasound scanning or autoantibodies) are unnecessary and may cause delay in making the diagnosis of cancer. Please see resources and links for a primary care guide on Thyroid nodules.

2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum  https://www.liebertpub.com/doi/pdfplus/10.1089/thy.2016.0457

• Thyroid nodules – a guide for primary care
• Thyroid Function Testing in Primary Care Guidance
• Who to refer to Ophthalmology
• Picture guide to clinical activity in Thyroid Eye Disease
• BTA Hypothyroidism Statement
• BTA and BTF updated information on T3 plus T4

Patient information leaflets.

The ECED website has some patient information on Graves’ Disease.  This can be accessed on the following link:

www.edinburghdiabetes.com/graves

Excellent patient information leaflets are provided by the British Thyroid Foundation (BTF).  Patients can be directed to look at these on-line or individual leaflets can be printed from the website.  The BTF will also send out larger volumes of specific information leaflets, although this requires a payment.  Details are on their website and leaflets can be accessed on the following link:

http://www.btf-thyroid.org/information/leaflets

Patient information on thyroid eye disease can also be found on the Thyroid Eye Disease Charitable Trust (TED-CT) website, which can be accessed on the link below:

http://tedct.org.uk/