Endocrine Abstracts

The NICE guidelines on the assessment and management of benign thyroid disorders were published in November 2019. They provide evidence based guidance on how to investigate thyroid dysfunction and thyroid enlargement as well as on the management and follow-up of these conditions. In addition, they include a chapter on important information to be provided to patients with thyroid diseases. The guidelines propose a cascading approach to measurement of thyroid function with measurement of TSH only and determination of fT4 and fT3 if this is abnormal. They propose that repeated TPO measurements are not needed in those with raised TSH. NICE proposes to treat primary hypothyroidism with levothyroxine monotherapy but advises against routine use of liothyronine alone or in combination in view of insufficient evidence of benefit and concerns about potential adverse effects of combination therapy. They propose that subclinical hypothyroidism be treated with levothyroxine if TSH is ≧10 mIU/L on repeated occasion and to give a trial of levothyroxine replacement if TSH is greater than the reference range but below 10 mIU/L and the patient has symptoms of hypothyroidism. NICE emphasises the importance of TSH-receptor antibody measurement in distinguishing thyrotoxicosis with and without hyperthyroidism and they propose to offer radioiodine as first-line treatment for Graves’ disease unless remission with antithyroid drugs is likely. They also advise that radioiodine or thyroidectomy is offered for relapsed Graves’ thyrotoxicosis and for toxic nodular hyperthyroidism. NICE advises that specialist advice is sought for patients with subclinical hyperthyroidism with evidence of thyroid disease and TSH <0.1 mIU/l on repeated occasion. NICE guidance emphasises the need for use of a recognised ultrasound grading system to classify thyroid nodules. The different sections of the NICE guidelines and the controversies arising from the guidance will be discussed in the session.