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FOLLOW-UP MANAGEMENT

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FOLLOW-UP MANAGEMENT Empty FOLLOW-UP MANAGEMENT

Post  krisna luis Fri Feb 19, 2010 7:44 pm

Submitted by:
Cura, Jonathan
Luis, Mary Ann Krisna

Follow-up care is necessary to ensure compliance with thyroid hormone replacement. (Bharaktiya, S.2009). Noncompliance is a common cause of treatment failure.

A case report of a 50-year old woman was treated with L-thyroxine after thyroidectomy two years ago, has stopped the treatment for three months without consulting the physcian. She then experienced cold intolerance, nausea and lethargy. She was prescribed with L-thyroxine treatment and was followed-up thereafter. (Sari, R., Sevinc, A., 2003). L-thyroxine should be immediately started if stopped for any reason to avoid hypothyroid exacerbations.

Furthermore, a follow-up of 224 cases of treated hypothyroidism detected 14 clinically euthyroid patients who discontinued taking thyroxine treatment without knowledge of the physician. They were prescribed with an additional 50mcg/day of thyroxine which resulted in clinical symptoms of hyperthyroidism. (Sari, R., Sevinc, A., 2003). Inadequate dosage of thyroxine was the probable cause because the replacement dose must be related individually to body mass (Vaidya, B., and Pearce, S.H., 2008). Therefore, closer observation before making adjustments in the dose of thyroxine is necessary. Patients on thyroxine replacement should have a regular check-up to ensure compliance and adjust dose in relation to changing body requirements.

On the other hand, there are a number of patients with hypothyroidism who fail to normalize thyroid function (TFTs) despite thyroxine (LT4) replacement. A study of 185 hypothyroid patients receiving levothyroxine were evaluated. Closer observation during 27 months showed that only around 60% of patients on thyroxine replacement have normal TSH levels. (Canaris, GJ., Manowitz. N.R., et.al., 2000). Periodic monitoring of thyroid function tests (TFTs) is essential in the management of patient to judge the response to therapy. Consequently, if the TSH level still remains elevated and the patient continues to have symptoms of hypothyroidism, a referral to an endocrinologist for further evaluation and management is appropriate.

For newly diagnosed hypothyroid patients, the (AACE) American Association of Clinical Endocrinologists (2002) recommends reassessment and repeat laboratory work for at least 6 weeks after any change in levothyroxine dose for the reason that levothyroxine has a 1-week plasma half-life; a steady state is achieved about 6 weeks after the start of treatment or a change in dose. On the other hand, the American Academy of Pediatrics (2006) suggests that laboratory and clinical evaluations must be performed regularly in infants with congenital hypothyroidism during the first three years to ensure optimal dosing and adherence to therapy.

Meanwhile, the length of interval of follow-up for treated hypothyroid patients is still a big question. The ideal screening interval has not been ascertained and there are no published studies on the appropriate frequency of follow-up for treated hypothyroid patients. With this, a retrospective analysis between 18-month follow-up vs annual follow-up for treated hypothyroid patients found out that 18 month follow-up is only applicable in patients who have a stable thyroxine dose or have less abnormal thyroid function tests. Annual surveillance, then, is more preferred than 18-month follow-up. (Viswanath, A.K., Avenell, A., et.al. 2007). 18-month follow-up for treated hypothyroid patients may only be an option for those who present a nearly stable condition.

- To conclude, newly diagnosed as well as treated hypothyroid patients are required to have a regular check-up to be able to monitor their condition. Poor compliance either suggests insufficient knowledge and understanding of the seriousness of the disease or it is merely based on the patient’s decision and participation if he/she wants to comply or not.


References:
Sari, R., Sevinc, A. (2003). Life-Threatening Hyponatremia Due to Cessation of L-Thyroxine. J Natl Med Assoc. 2003;95:991-994.)

Bharaktiya, S. (2009). Hypothyroidism: Follow-up. Last updated 23-July-2009. Retrieved February 18, 2010 from Emedicine Database: http://emedicine.medscape.com/article/122393-followup

Vaidya, B. and Pearce, S.H. (2008). Management of Hypothyroidism in Adults. BMJ 2008;337:a801, doi: 10.1136/bmj.a801

Sevinc, A. and Savli, H. (2004). Hypothyroidism Masquerading as Depression: The Role of Noncompliance. Journal of the National Medical Association 2004March:96(3):379-82

Viswanath, A.K., Avenell, A., et.al. (2007). Is Annual Surveillance of Treated Hypothyroid Patients Necessary? BMC Endocrine Disorders 2007, 7:4 doi:10.1186/1472-6823-7-4

Hueston, W.J, (2001). Treatment of Hypothyroidism. Am Fam Physician 2001;64:1717–24

Canaris, GJ., Manowitz. N.R., et.al. (2000). The Colorado Thyroid Disease Prevalence Study. Arch Intern Med. 2000;160:526-534

Wirsing, N. and Hamilton, A. (2009). How Often Should You Follow-Up on a Patient With Newly
Diagnosed Hypothyroidism? The Journal of Family Practice 2009January:58(1):40

Yang, R.L., Zhu, Z.W., et.al. (2005). Treatment and Follow-up of Children With Transient Congenital Hypothyroidism. Journal of Zhejiang University SCIENCE B. 2005 6(12):1206-1209. doi:10.1631/jzus.2005.B1206

American Association of Clinical Endocrinologists (2002). Medical Guidelines for Clinical Practice for the Evaluation and Treatment of Hyperthyroidism and Hypothyroidism. Endocrine Practice, 2002:8(6):457-69

Olivieri, A. (2009). The Italian National Register of Infants with Congenital Hypothyroidism: Twenty Years of Surveillance and Study of Congenital Hypothyroidism. Italian Journal of Pediatrics 2009, 35:2 doi:10.1186/1824-7288-35-2

American Academy of Pediatrics (2006). Updated AAP Guidelines on Newborn Screening and Therapy for Congenital Hypothyroidism. Pediatrics 2006;117;2290-2303. DOI: 10.1542/peds.2006-0915

krisna luis

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Join date : 2010-02-14

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