TWR Posted May 21, 2019 Share Posted May 21, 2019 Newly diagnosed Pt. with TSH of 8.4 and 112 kg. What dose would you start patient? Would you use formula 1.6 x kg and start at dose just below? Quote Link to comment Share on other sites More sharing options...
UGoLong Posted May 21, 2019 Share Posted May 21, 2019 Newly diagnosed Pt. with TSH of 8.4 and 112 kg. What dose would you start patient? Would you use formula 1.6 x kg and start at dose just below?The patient is still producing some thyroid hormone. I would start low and go slow. Maybe 25 or 50 and retest in 6 weeks. I had a radioactive ablation for Graves (which doesn’t necessarily wipe out all thyroid function; didn’t in my case) and that’s more or less what my endocrinologist did.Sent from my iPad using Tapatalk 1 1 Quote Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted May 21, 2019 Share Posted May 21, 2019 (edited) Article that I read last week (EM:RAP?) argued that even if TSH is elevated BUT T4 is normal, there is no long-term benefit to treating sub-clinical hypothyroidism. I plan on discussing with my internist later this summer, as well as the argument once again of actual benefit of using statins to lower TC/LDL values when a significant portion of ACS patients have normal values to begin with and aren't on statin therapy. With regard to your question, I'd start using the formula BUT I would also ask the patient to bite the bullet and pay for brand name until you figure the correct dosing due to variability of generic formulations (I've seen this in myself). Edited May 21, 2019 by GetMeOuttaThisMess 1 Quote Link to comment Share on other sites More sharing options...
mgriffiths Posted May 21, 2019 Share Posted May 21, 2019 Would depend on age and cardiac risk...but I generally start low and increase as needed. 1 Quote Link to comment Share on other sites More sharing options...
Moderator ventana Posted May 21, 2019 Moderator Share Posted May 21, 2019 < 10 TSH and normal T4 certainly reasonable if there is no other s/s of hypothyroidism to wait in recheck in 12-16 weeks if Obese, depression or other complaints which might be related to hypothyroidism I would start out at between 50 and 100 Just read another review last week that said treating these sub clinical hypothyroidism cases does NOT have a positive effect. I however still treat as long as there is something which might be helped with euthyroid.... ie mood.... 1 Quote Link to comment Share on other sites More sharing options...
Moderator ventana Posted May 22, 2019 Moderator Share Posted May 22, 2019 Medscape medical news did a nice summary article may 16. TSH under 10 with normal T4. No treatment for the most part. Quote Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted May 22, 2019 Administrator Share Posted May 22, 2019 1 hour ago, ventana said: Medscape medical news did a nice summary article may 16. TSH under 10 with normal T4. No treatment for the most part. You know, after sitting through an adrenal CME this week, and seeing in gory detail what "naturopathic" treatments with thyroid overreplacement can end up harming, I'd be inclined to treat with lower dose levothyroxine in order to keep a patient from that harm. 1 1 Quote Link to comment Share on other sites More sharing options...
Moderator ventana Posted May 22, 2019 Moderator Share Posted May 22, 2019 6 hours ago, rev ronin said: You know, after sitting through an adrenal CME this week, and seeing in gory detail what "naturopathic" treatments with thyroid overreplacement can end up harming, I'd be inclined to treat with lower dose levothyroxine in order to keep a patient from that harm. interesting perspective.... I also am unsure I will change my pattern of treating the 4-10 with low dose because...... I only give 3m script and then labs - - they are not going to become toxic on 3m of 50mcg a day.... with a tsh of 9..... 2 1 Quote Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted May 22, 2019 Share Posted May 22, 2019 (edited) 2 hours ago, ventana said: interesting perspective.... I also am unsure I will change my pattern of treating the 4-10 with low dose because...... I only give 3m script and then labs - - they are not going to become toxic on 3m of 50mcg a day.... with a tsh of 9..... Devil's advocate again. I come back to you in 3 mos., feel no different (reality in my case, and no, it didn't make a lick of difference with my weight because we all know that I'm only overweight because of my thyroid and it has nothing to do with my diet and lack of exercise), and my TSH is now 7.5. This is one of the reasons why I subscribed to the recommendation years back of not checking asx. patient's TSH. I never did just a TSH but rather did a profile so that I could see the big picture. I guess that I was before my time since to get the T4 you probably need to get the full profile as opposed to ordering it individually with the TSH ($$ was about the same). Edited May 22, 2019 by GetMeOuttaThisMess Quote Link to comment Share on other sites More sharing options...
UGoLong Posted May 22, 2019 Share Posted May 22, 2019 Devil's advocate again. I come back to you in 3 mos., feel no different (reality in my case, and no, it didn't make a lick of difference with my weight because we all know that I'm only overweight because of my thyroid and it has nothing to do with my diet and lack of exercise), and my TSH is now 7.5. This is one of the reasons why I subscribed to the recommendation years back of not checking asx. patient's TSH. I never did just a TSH but rather did a profile so that I could see the big picture. I guess that I was before my time since to get the T4 you probably need to get the full profile as opposed to ordering it individually with the TSH ($$ was about the same).My concern here is that overshooting the dose has consequences, like paroxysmal atrial fibrillation. I'd rather walk in on the correct dose.Sent from my XT1254 using Tapatalk 2 Quote Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted May 22, 2019 Administrator Share Posted May 22, 2019 I never order a TSH in a patient who's not currently on thyroid replacement WITHOUT a reflex FT4. Why would anyone? It's such a standard order it's preprinted on the lab slips around here... Quote Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted May 22, 2019 Share Posted May 22, 2019 There is an accepted belief that the initial dosing equation listed is appropriate. Quote Link to comment Share on other sites More sharing options...
UGoLong Posted May 22, 2019 Share Posted May 22, 2019 There is an accepted belief that the initial dosing equation listed is appropriate.Guess I’m living proof that it isn’t always.Sent from my iPad using Tapatalk Quote Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted May 22, 2019 Share Posted May 22, 2019 Nor am I. How dare we not follow the status quo. 1 Quote Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted May 25, 2019 Share Posted May 25, 2019 (edited) Can we take this on a side track for a moment? How many use the insulin initiation formula to start insulin? With regard to the initial issue, during our monthly doc meeting Thursday (as I'm loading up on Mexican food carbs) I ran this by our collaborating docs (FM) and the wheels were spinning as they pondered this and as I recall their responses were the same which was if asx. and <10 on the TSH then why initiate therapy? Now, if the patient is stable on it (me for example), cost is not a factor (isn't), then should we discontinue med and recheck labs in three months due to CV risk for example (when you get older like me, near retirement, and have no exciting plans why not contemplate some AF to keep one busy)? The answer was probably not. Are there any more tortilla chips? Edited May 25, 2019 by GetMeOuttaThisMess 2 1 Quote Link to comment Share on other sites More sharing options...
mgriffiths Posted May 28, 2019 Share Posted May 28, 2019 On 5/25/2019 at 9:42 AM, GetMeOuttaThisMess said: ...when you get older like me, near retirement, and have no exciting plans why not contemplate some AF to keep one busy)? That line is gold 1 Quote Link to comment Share on other sites More sharing options...
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