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Hyperthyroidism

Checked: 21-12-2023 by Vicky Ryan Next Review: 19-12-2025

Overview

These guidelines have been provided by the Endocrinology Team at NBT so pathways might be slightly different at UHBW

Definition

Biochemically defined as a suppressed TSH and a raised free T4 or T3

Important points

The most common causes in clinical practice include Graves’ disease, thyroiditis (usually transient), toxic multinodular goitre (MNG) and a toxic adenoma
It is important to consider the most likely underlying diagnosis as it will guide further investigation and management

Who to refer

Refer all patients with hyperthyroidism to secondary care (routine referral) via eRS - see 'Before Referral' section below about when to refer and what to do while awaiting an appointment.

If still awaiting secondary care appointment and advice is needed regarding dose titration of anti-thyroid medication, please contact for advice via eRS advice & guidance.

Amiodarone and hyperthyroidism

If a patient is taking amiodarone, please contact for advice via eRS Advice & Guidance. If possible, aim to stop the amiodarone (may need discussion with Cardiology)

Red Flags

Thyroxic crisis/ significant symptoms

If significantly symptomatic or thyrotoxic crisis (1) is suspected then please contact the on call endocrinology registrar via hospital switchboard (there is an Endocrine SpR mobile).

Thyrotoxicosis in pregnancy

If thyrotoxicosis is identified in pregnancy (1) please contact the on call endocrinology registrar for advice via hospital switchboard.

Suspected Malignancy

If thyroid cancer is suspected please refer directly using the Head & Neck incl Thyroid - USC (2WW) pathway.

Before referral

Review previous thyroid function tests

If already known to Endocrinology at NBT/UHBW, contact for further advice e.g. anti-thyroid drug dosing via email or A&G on eRS.
If relapsed Graves’ disease – re-refer to Endocrinology and treat using the guidance below.

Ensure a history is taken regarding the severity of symptoms, chance of pregnancy and relevant medications e.g. amiodarone. Examine for signs of thyroid eye disease (see the Thyroid Eye Disease page)

If first episode of thyrotoxicosis

If the patient is well with minimal symptoms, repeat TFTs in 2 weeks with TSH receptor antibody (in case of a transient thyroiditis)
If well but moderately symptomatic, commence propranolol 40mg TDS with repeat TFTs in 2 weeks as above.
If persistent biochemical hyperthyroidism after 2 weeks, for those in the minimally or moderately symptomatic category, commence Carbimazole (3,4) (unless pregnant, see the Thyroid disease and pregnancy page) using the dosing advice below. Please send an urgent referral via eRS.
If significantly symptomatic or thyrotoxicosis in pregnancy, please contact directly via the Endocrine SpR mobile.
Send an urgent eRS referral if T4 is > 45.0 (pmol/L) OR free T3 is >20.0 (pmol/L) AND commence treatment immediately (see dosing below) without waiting for the repeat blood test at 2 weeks

	free T4 (pmol/L) (normal range 7.9 -14.4)	free T3 (pmol/L) (normal range 3.8 - 6.0)
Carbimazole 20mg OD	14.4 - 30	6.0 -13.0
Carbimazole 30mg OD	30 -45.0	13.0 -20.0
Carbimazole 40mg OD	>45.0	>20.0

NB. Prescribe Carbimazole at the higher dose if falls between the T4 and T3 value

Counsel ALL patients commenced on anti-thyroid medications regarding the risk of agranulocytosis/neutropaenia (See Appendix 1)
Risk is 0.1-0.3% and is most likely to occur in the first 3 months

Patients who develop a severe sore throat, fever or mouth ulcers should have a same day/urgent FBC done

Once anti thyroid medication has been commenced, repeat TFTs (TSH, free T4 and free T3) in 4 weeks. Contact for ongoing dosing advice via A&G.

USS thyroid

Ultrasound is not routinely indicated unless there are concerns about a large goitre e.g. compressive symptoms, or possible malignancy (although hyperthyroidism in this case is rare)

Services

Endocrinology NBT

Endocrinology UHBW

Resources

References

(1) Hyperthyroidism | Health topics A to Z | CKS | NICE

(2) Thyroid disease: assessment and management | Guidance | NICE -NG 145

(3) BNSSG Formulary Chapter 6.9 Thyroid disorders

(4) Carbimazole | Drugs | BNF | NICE

Appendix 1

Information leaflet for patients taking Carbimazole or Propylthiouracil

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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