Are there National Guidelines for when a GP should start treatment?

[serenfach]

At what level should a GP start treatment for a raised TSH? Over 5 or 10, or what?

Thanks!

[Hidden]

BTA first link - under 'Sub clincal'

(b) Some patients, particularly those whose TSH level is greater than 10mU/l, may benefit from treatment with thyroxine in the same way as for hypothyroidism as above, as indicated in national guidelines (Thyroid function testing, Association of Clinical Biochemists, British Thyroid Association, British Thyroid Foundation, July 2006:

british-thyroid-association...

I posted a link to a paper and flowchart from the BMJ re. a therapeutic trial over TSH 5...

"Sub-clinical (mild) with TSH 5-10 If patients have symptoms consistent with hypothyroidism and the increase in thyroid stimulating hormone persists, then a therapeutic trial of levothyroxine for three to six months is a reasonable approach. If the patient feels improved by therapy—as a third to one half do—it is reasonable to continue treatment." (BMJ clinical review 2008)

bmj.com/content/337/bmj.a80...

and yes, the second link no longer works..... ?? J

[lilliput]

I am on a trial of Levothyroxine 25mcg. My symptoms are mild but I take anti-depressants which coud mask some. My TSH is 7.7 and T4 is 10. something. I was first borderline 20 years ago and had worse symptoms then.I should add that I'm not working at the mo, which could make a difference as well.

[shaws Administrator in reply to lilliput]

25mcg is too low especially when you have a TSH of 7.7. The fact that you are taking anti-d's as well when in fact T3 could have been added instead. Your levo should have been increased gradually till your TSH is 1 or below.

thyroiduk.healthunlocked.co...

[Hidden]

No Guidelines, only Guidance.

xx

[NBob]

The short answer to your question is: there are NO National Guidelines for when a GP should start treatment.

The only guidelines a doctor has a duty to have regard to are those produced by the government body the National Institute for Health and Care Excellence (NICE). So far, NICE have not produced any guidelines on the treatment of hypothyroidism or when a GP should start treatment.

There is a statement produced by the British Thyroid Association(BTA) and the Royal College of Physicians (RCP) about the treatment of hypothyroidism but this statement does not give a value of TSH that should initiate treatment. Plus it is a statement and not guidance. Further, it is a consensus statement with no back up evidence, so the statement itself does not represent top quailty evidence based medicine. Both the BTA and the RCP are private organisations. The statement has no legal authority.

The BTA and the Association of Clinical Biochemists (ACB) are both private organisations that have no connection to government. They have published a document themselves called

"UK guidelines for the use of thyroid function tests. 2006" - link in spareribs post- that they pass off as National Guidelines. They have no legal authority. In that document, the BTA/RCP recognise that there is controversy on the normal reference range for TSH stating that a group of doctors say the higher cut off figure is 2.5 mlU/L, but the BTA/RCP recommend a range of 0.4-4.5 mlU/L.

in any event, guidelines are just guidelines. It is not an offence to not follow guidelines. I have a copy of a letter from the Department of Health reiterating that guidelines are just guidelines and there is no compulsion to follow them. Even NICE say that rigid adherance to guidlines is not to be encouraged. Further, NICE say that "NICE guidance does not override the individual responsibility of health professionals to make appropriate decisions according to the circumstances of the individual patient in consultation with the patient and/or their guardian/carer".

nice.org.uk/media/8BD/2B/Le...

if you examine each individual element of that sentence, it is a powerful statement.

Doctors should not rely on guidance

Doctors should make decisions according to the circumstances of the individual patient

Doctors should make decisions in consultation with patients.

Doctors are free to follow any guidlines they like that are in the patients best interests(provided they are logical).

[serenfach]

Thanks for all your help. My daughter is showing all the signs of hypothyroid, and had a test 3 months ago, TSH was 5.44. This time it was 6.9 (0.27 - 4.20). GP has said this is "satifactory" and no further appointments or treatment. Furious for her.

[Hidden in reply to serenfach]

She should have had a FT4 test as the TSH is well out of range (FT3 too but often labs don't do this for GPs).

Also a Thyroid antibodies test (TPO Ab) to confirm. - Dr Toft's book 'Understanding Thyroid Disorders' page 40.

" Thyroid blood tests should not be interpreted in isolation and correct medical care will also depend on careful assessment of symptoms and clinical examination" in capitals with red background - Dr Toft's book page 88. J x

[trevg in reply to serenfach]

Private hospital pointed me back to GP when TSH got to 5.

Now on T3 only after 3 wasted endos visits and getting sense from teaching hospital pathologist who agreed to follow up my heavy metal poisoning which can lead to HypoT.

Mt TSH goes to less than 0.1 readily now with no hyper effects.