Thyroid hormones, including SYNTHROID, either alone or with other therapeutic agents, should not be used for the treatment of obesity or for weight loss. In euthyroid patients, doses within the range of daily hormonal requirements are ineffective for weight reduction. Larger doses may produce serious or even life-threatening manifestations of toxicity, particularly when given in association with sympathomimetic amines such as those used for their anorectic effects.
Patients should be instructed to take thyroxine 30–60 minutes before breakfast in order to maximise absorption. If this is too difficult or threatens compliance, the patient may try taking the thyroxine last thing at night on an empty stomach. Patients who still decide to take their tablets with, rather than before, breakfast need to do this consistently, to avoid fluctuating thyroxine concentrations. Depending on the fibre and milk content of the meal, taking thyroxine with food may require a larger dose to maintain euthyroidism, because of the decreased bioavailability.
While most patients take a daily dose, the long half-life of thyroxine lends itself to longer dosing intervals, such as alternate daily dosing. Once-weekly dosing is also possible although a slightly larger dose than seven times the normal daily dose may be required. This regimen may be suitable for poorly compliant patients who require supervised dosing.3
For patients, particularly children, who cannot swallow tablets, the tablets may be crushed in 10–20 mL of water, breast milk or non-soybean formula. The resulting mixture should be used immediately and any remainder discarded.2Breast milk contains only 20–30% of the calcium concentration of cows milk, making the likelihood of decreased thyroxine bioavailability less likely. Nonetheless, if breast milk is used to deliver the thyroxine, it should be used consistently, in order to minimise any variation in absorption.
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Sanjay Kalra, Navneet Agarwal,1 Rashmi Aggarwal,2 Sameer Agarwal,3 Sarita Bajaj,4 Ganapathi Bantwal,5 A. K. Das,6 Sujoy Ghosh,7 Pritam Gupta,8 Deepak Khandelwal,9 Vijay Negalur,10 Banshi Saboo,11 Rakesh Sahay,12 Mangesh Tiwaskar,13 and A. G. Unnikrishnan14
Sanjay Kalra
Department of Endocrinology, Bharti Hospital, Karnal, Haryana, India
Find articles by Sanjay Kalra
Navneet Agarwal
1Department of Medicine, Diabetes, Obesity and Thyroid Center, Gwalior, Madhya Pradesh, India
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Rashmi Aggarwal
2Department of Thryoidology, INMAS, New Delhi, India
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Sameer Agarwal
3Department of Endocrinology, PGIMS, Rohtak, Haryana, India
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Sarita Bajaj
4Department of Medicine, MLN Medical College, Allahabad, Uttar Pradesh, India
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Ganapathi Bantwal
5Department of Endocrinology, St. Johns Medical College, Bengaluru, Karnataka, India
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A. K. Das
6Department of Endocrinology, JIPMER, Puducherry, India
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Sujoy Ghosh
7Department of Endocrinology, IGPGMR, Kolkata, West Bengal, India
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Pritam Gupta
8Department of Medicine, Dr. Pritam Gupta's Clinic, New Delhi, India
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Deepak Khandelwal
9Department of Endocrinology, Maharaja Agrasen Hospital, New Delhi, India
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Vijay Negalur
10Department of Medicine, Diabetes and Thyroid Specialities Center, Thane, Maharashtra, India
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Banshi Saboo
11Department of Medicine, Dia Care, Ahmedabad, Gujarat, India
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Rakesh Sahay
12Department of Endocrinology, Osmania Medical College, Hyderabad, Telangana, India
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Mangesh Tiwaskar
13Department of Medicine, Shilpa Medical Research Centre, Mumbai, Maharashtra, India
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A. G. Unnikrishnan
14CEO, Chellaram Diabetes Institute, Pune, Maharashtra, India
Find articles by A. G. Unnikrishnan
Author information Copyright and License information Disclaimer
Department of Endocrinology, Bharti Hospital, Karnal, Haryana, India
1Department of Medicine, Diabetes, Obesity and Thyroid Center, Gwalior, Madhya Pradesh, India
2Department of Thryoidology, INMAS, New Delhi, India
3Department of Endocrinology, PGIMS, Rohtak, Haryana, India
4Department of Medicine, MLN Medical College, Allahabad, Uttar Pradesh, India
5Department of Endocrinology, St. Johns Medical College, Bengaluru, Karnataka, India
6Department of Endocrinology, JIPMER, Puducherry, India
7Department of Endocrinology, IGPGMR, Kolkata, West Bengal, India
8Department of Medicine, Dr. Pritam Gupta's Clinic, New Delhi, India
9Department of Endocrinology, Maharaja Agrasen Hospital, New Delhi, India
10Department of Medicine, Diabetes and Thyroid Specialities Center, Thane, Maharashtra, India
11Department of Medicine, Dia Care, Ahmedabad, Gujarat, India
12Department of Endocrinology, Osmania Medical College, Hyderabad, Telangana, India
13Department of Medicine, Shilpa Medical Research Centre, Mumbai, Maharashtra, India
14CEO, Chellaram Diabetes Institute, Pune, Maharashtra, India
Address for correspondence: Dr. Sanjay Kalra, Department of Endocrinology, Bharti Hospital, Karnal - 132 001, Haryana, India. E-mail: moc.liamg@lnkedirb
Copyright : © 2017 Indian Journal of Endocrinology and Metabolism
This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
Abstract
This communication from the National Indian Patient-centered Thyroid management group [InPACT] deals with a novel, yet essential, aspect of hypothyroidism management. The authors describe the role and scope of patient-centered care in this condition. They focus on the relevance of a patient-centered clinical approach, which will help decide appropriate targets, as well as techniques to achieve those targets. Means of helping persons with hypothyroidism live a healthy life, such as education about precaution in concomitant food and medications intake, as well as sick day management, are discussed.
Keywords: Hashimoto's thyroiditis, medication counseling, patient education, thyroid-stimulating hormone, thyroxin
INTRODUCTION
Patient-centered care [PCC] is the provision of care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.[1] This concept is especially important in chronic disease management, which depends on a healthy relationship between patient and provider, which is marked by reciprocal respect.[2] In the past, the Indian Journal of Endocrinology and Metabolism has promoted the cause of PCC in endocrinology.[3] This call is based on realization of the relevance of PCC[1] and importance of practicing patient-centered professionalism.[4]
Recently, calls have also been made to focus on patient-centric behavior in the management of thyroid disease.[5,6] In this communication, we focus on the various components of hypothyroidism management, where patient-centered, or informed and shared decision-making is required. Such a discussion will promote better dialog between patient and physician and contribute to enhanced quality of care.
DIAGNOSIS
The symptoms of hypothyroidism are many and varied. They span virtually every organ system, and their list of differential diagnosis is endless.[7] In fact, “the physician who knows thyroid knows medicine.”
A detailed history taking is required to identify possible causes of symptoms. Supposedly “subclinical” hypothyroidism is often accompanied by symptoms, which may or may not be due to thyroid dysfunction. More often than not, “symptoms of hypothyroidism” may actually be due to anemia, hypovitaminoses D, dyselectrolytemia, poor sleep hygiene, or lack of physical conditioning. At the same time, innocuous looking complaints, such as hair fall, may be a marker of hypothyroidism.[8]
Such clinical considerations can be resolved only through an empathic history, taken in a patient central manner. Used in this context, the phrase implies that the patient's needs and concerns should form the center of the patient–physician conversation, with the physician playing the role of an active listener. The physician's ear plays the role of a diagnostic or triage tool[9] in such a dialog and should be given the same importance as other tools.
INVESTIGATIONS
Investigations should be ordered in a rational manner, depending on what information is required. For example, screening for autoimmune hypothyroidism requires only a thyroid-stimulating hormone [TSH] estimation while a workup for central hypothyroidism is incomplete without a thyroxin or free thyroxin [T4 or FT4] test. Follow-up of primary thyroid patients on levothyroxine therapy is done with TSH and that of central hypothyroid patients with T4 or FT4.[7]
Choice of investigations may also depend on availability, accessibility, and affordability as well as trustworthiness. Thyroid antibody estimation, for example, should be ordered only if the results will impact clinical decision-making, and if the report is expected to be reliable.
Patients should also be informed about the timing of investigations in advance and about whether to take their thyroid medication on the day of testing. There is no need to miss levothyroxine if TSH monitoring is planned. If a person chooses to get her TSH checked in the afternoon or evening, she should preferably get it tested at the same time, each time.
TARGET OF THERAPY
All hypothyroid patients are not the same, and all patients should not have the same target for therapy. Therapeutic TSH targets are usually decided according to etiology of hypothyroidism and phase of life. Patients treated for thyroid cancer with surgery should aim for a lower TSH target [TSH