Can someone please point me toward guidelines for levo trial for subclinical Hashi's?

Hiya. Can someone please point me toward a really good link to treatment guidelines for people who are subclinical/tsh below 10? Someone in one of my fb groups has fertility problems and her tsh is around 5 and she's being refused treatment. I have this: thyroiduk.org.uk/tuk/diagno... but I thought I remembered reading something more explicitly endorsing levo trial on an individual basis for people who have symptoms even when their results are normal-ish. Does that ring a bell? Could it be Dr Toft?

I have googled it but not finding what I'm looking for.

Thanks in advance. :-)

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  • PB,these are the NICE recommendations for s/c hypothyroid women planning conception or newly pregnant:

    Aim for a TSH concentration in the low-normal range (0.4 mU/L to 2.0 mU/L) and an FT4 concentration in the upper reference range.

    If there is any uncertainty about what dose to prescribe, seek immediate specialist advice so that there is no delay in the woman receiving an adequate dose of levothyroxine.

    cks.nice.org.uk/hypothyroid...

  • Thanks Clutter. Do you agree that this would seem to endorse levo treatment? (I can't access the link unfortunately but this excerpt seems to say that treatment should be started.)

  • PB, yes, your friend should be started on Levothyroxine now. Not sure why the link hasn't worked, I've just copied the info in full on s/c hypo being treated and newly diagnosed. Formatting may go awry:

    Pre-existing subclinical hypothyroidism

    How should I manage a woman with pre-existing subclinical hypothyroidism who is pregnant or planning a pregnancy?

    Check thyroid function tests before conception if they have not been done in the past 6 months.

    Advise women planning a pregnancy to consult their GP as soon as they think they may be pregnant.

    For women with known subclinical hypothyroidism who are already receiving levothyroxine treatment (perhaps because their thyroid-stimulating hormone [TSH] concentration was greater than 10 mU/L):

    At confirmation of pregnancy, immediately increase the levothyroxine dose, and perform thyroid function tests while awaiting referral to a specialist:

    The dose should be increased usually by adding at least 25–50 micrograms levothyroxine; the size of the initial increase in dose will depend on the dose the woman is already taking and the TSH and free thyroxine (FT4) concentrations.

    Aim for a TSH concentration in the low-normal range (0.4 mU/L to 2.0 mU/L) and an FT4 concentration in the upper reference range.

    If there is any uncertainty about what dose to prescribe, seek immediate specialist advice so that there is no delay in the woman receiving an adequate dose of levothyroxine.

    Monitor TSH and FT4 levels:

    Every 4 weeks during titration of levothyroxine.

    Every 4 weeks during the first trimester, and again at 16 weeks and at 28 weeks of gestation, in a woman who is on a stable dose of levothyroxine.

    More frequent tests may be appropriate on specialist advice.

    All women with subclinical hypothyroidism who are pregnant or planning a pregnancy and are not receiving levothyroxine treatment should be started on levothyroxine therapy while waiting for referral to a specialist. Management is the same as for women with a new diagnosis of subclinical hypothyroidism who are pregnant or planning a pregnancy.

    Basis for recommendation

    These recommendations are based on information from a consensus guideline produced by the Association for Clinical Biochemistry, the British Thyroid Association, and the British Thyroid Foundation [BTA et al, 2006]; expert opinion in a guideline produced by the Endocrine Society [Abalovich et al, 2007]; expert opinion in a learning module [Edwards and Vanderpump, 2007]; and the opinion of CKS expert reviewers. Some of the evidence to support these recommendations is based on observational studies.

    In women with hypothyroidism, the need for levothyroxine is increased in pregnancy by 30–50% above the preconception dosage, and absorption of levothyroxine may be diminished, therefore it is important to increase the dose quickly in women already on levothyroxine [BTA et al, 2006; Abalovich et al, 2007; Reid et al, 2010].

    There is evidence of increased fetal loss, and psychomotor and IQ deficits, in infants born to mothers with undiagnosed or inadequately treated hypothyroidism (including subclinical hypothyroidism) [Casey et al, 2005].

    The increase in the levothyroxine dose is necessary to maintain normal serum thyroid-stimulating hormone (TSH) and free thyroxine (FT4) levels for the gestational age [BTA et al, 2006].

    The recommendations on monitoring of thyroid function (TSH and FT4 levels) are based on expert opinion in guidelines [BTA et al, 2006].

    New diagnosis of subclinical hypothyroidism

    How should I manage a woman with a new diagnosis of subclinical hypothyroidism who is pregnant or planning a pregnancy?

    All women with a new diagnosis of subclinical hypothyroidism who are pregnant or planning a pregnancy should be started on levothyroxine therapy while waiting for referral to a specialist.

    Follow local specialist advice regarding the dose, as experts recommend different starting doses (varying from 25 micrograms to 100 micrograms to be taken each morning).

    Monitor thyroid-stimulating hormone (TSH) and free thyroxine (FT4) levels:

    Every 4 weeks during titration of levothyroxine.

    Every 4 weeks during the first trimester, and again at 16 weeks and at 28 weeks of gestation, in a woman who is on a stable dose of levothyroxine.

    More frequent tests may be appropriate on specialist advice.

    Aim for a TSH concentration in the low-normal range (0.4–2.0 mU/L) and an FT4 concentration in the upper reference range.

    Basis for recommendation

    These recommendations are based on information from a consensus guideline produced by the Association for Clinical Biochemistry, the British Thyroid Association, and the British Thyroid Foundation [BTA et al, 2006]; expert opinion in a guideline produced by the Endocrine Society [Abalovich et al, 2007]; expert opinion in a learning module [Edwards and Vanderpump, 2007]; and the opinion of CKS expert reviewers. Some of the evidence to support these recommendations is based on observational studies.

    In women with hypothyroidism, the need for levothyroxine is increased in pregnancy by 30–50% above the preconception dosage, and absorption of levothyroxine may be diminished; therefore, it is important to increase the dose quickly in women already on levothyroxine [BTA et al, 2006; Abalovich et al, 2007; Reid et al, 2010].

    There is evidence of increased fetal loss, and psychomotor and IQ deficits, in infants born to mothers with undiagnosed or inadequately treated hypothyroidism (including subclinical hypothyroidism) [Casey et al, 2005].

    The increase in the levothyroxine dose is necessary to maintain normal serum thyroid-stimulating hormone (TSH) and free thyroxine (FT4) levels for the gestational age [BTA et al, 2006].

    The recommendations on monitoring of thyroid function (TSH and FT4 levels) are based on expert opinion in guidelines [BTA et al, 2006].

  • Many thanks, that's helpful. (The issue with the link is that it's not available outside the UK and I'm abroad at the moment.)

  • PB, that explains it :) I hope you're somewhere nice and sunny and warm. Beautiful sunshine in London but quite chilly.

  • Endless snowstorms here (last one left 8"). But it is sunny and pretty. I spent last week in Manhattan wading through ankle-deep filthy mucky slush and trying not to fall on my @rse, so this is an improvement. :-)

    Nice to have sunshine in London even if chilly. Lots of flowers must be surfacing about now. We had snowdrops and crocus before I left.

  • Would your friend like to be invited to this group? If so, please consider this an invitation. :-)

  • Thanks Rod. I don't know this lady outside the (only tangentially related) fb group we both belong to, but if she is interested I will extend an invitation. :-)

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