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StrangethyroidtestsfT4andTSH

fT4nl,TSH
fT4nl,TSH

fT4,TSH
fT4,TSH nl
nl

fT4,TSH
fT4,TSH

fT4,TSH
fT4,TSH

fT4,TSHnl
fT4,TSHnl or
or

Subclinical
Subclinical
hypothyroidism
hypothyroidism
Illness
Illness
Drugs(Iodine,
Drugs(Iodine,
Metaclopramide)
Metaclopramide)

T4treatment
T4treatment
Illness(rare)
Illness(rare)
Hyperemesis
Hyperemesis
Acutepsychosis
Acutepsychosis
Drugs
Drugs
FDH,RTH
FDH,RTH

Hypopituitary
Hypopituitary
(DoFSH,PRL,GH,etc)
(DoFSH,PRL,GH,etc)

RTH,TSHoma
RTH,TSHoma

Drugs,illness,hypopituitary
Drugs,illness,hypopituitary

TSHnl
TSHnl

T3nl
T3nl or
or

Goiter+
Goiter+
Ab
Ab ++
FDH
FDH
RTH
RTH
T4Rx
T4Rx

Probably
Probably
Hashimoto
Hashimoto
ss
T4replacement
T4replacement
Checkdose
Checkdose

Fam.Hist
Fam.Hist
IEF+
IEF+
Albppt
Albppt++

FDH
T4treatment
T4treatment
(normal)
(normal)

Psychosis
Psychosis
(usually
(usually
transient)
transient)
Pregnant(
Pregnant(
usually
usually
transient)
transient)
Fam.Hist
Fam.Hist
Ab
Ab
AbnormalT3suppression
AbnormalT3suppression

RTH

T3
T3
Propranorol
Propranorol
Steroids
Steroids
Amiodarone
Amiodarone

Adjust
Adjust
treatment
treatment

RT3or
RT3or
nl
nl

ASA
ASA
Dilantin
Dilantin
Othermed
Othermed

NTIS
NTIS

Observe
Observe

Therapy
Therapy

Poss
Posshypopituitary
hypopituitary

LH,FSH,PRL,
LH,FSH,PRL,
Testosteron
Testosteron
e,
e,
Estrogen,
Estrogen,
Cortisol,
Cortisol,
CT,MRI
CT,MRI
Consider
Consider
e.g.ITT,
e.g.ITT,
GnRH,TRH,
GnRH,TRH,

Treat
Treat
Hypopituitary
Hypopituitary

No.1
No.1

Managementofathyroidenlargement
SeeMNGalgorithm
SeeMNGalgorithm

fT4,TSH,Exam
fT4,TSH,Exam

Diffuse,measure
Diffuse,measure
Ab
Ab
fT4,TSH,Ab
fT4,TSH,Ab ++
Probably
Probably
Hashimotos
Hashimotos

fT4,TSH,Ab
fT4,TSH,Ab ++
Probably
Probably
Graves
Graves

Seepossible
Seepossible
hyperthyroidismor
hyperthyroidismor
treatmentalgorithms
treatmentalgorithms

multinodular
multinodular

Asymetric,nodular
Asymetric,nodular

Endemic
Endemic

US,TSH,Scan
US,TSH,Scan
TSH,
TSH,
singleor
singleor
multiple
multiple

TSHnl

Scan
Scan

FNA(S)
FNA(S)

Surgery,
Surgery,
131
131II

Symptomatic
Symptomatic

Asymptomatic
Asymptomatic

T4,Surgery,
T4,Surgery,

Observe,T4,
Observe,T4,
Iodine
Iodine

131
131I

See
See
nodule
nodule
algorithm
algorithm
No.2
No.2

PainfulorTenderThyroidGrandEvaluation
PainfulorTenderThyroidexamandUSifpossible
PainfulorTenderThyroidexamandUSifpossible

Diffusegoiter
Diffusegoiter

MNGorSingleTenderNodule
MNGorSingleTenderNodule

RAIU,fT4,TSH,Ab
RAIU,fT4,TSH,Ab ,WBC,CRP,Tg
,WBC,CRP,Tg
CRP,
CRP,
WBCornl
WBCornl
RAIU<3%
RAIU<3%
fT4,TSH,
fT4,TSH,
Tg
Tg

Swellingand
Swellingand
Lymphadenopathy
Lymphadenopathy

PossibleNecrosis,
PossibleNecrosis,
Observe
Observe

RAIU
RAIU nl
nl
fT4nl
or,
fT4nl or,
TSH
TSH nl
nl or
or

RAIU
RAIU
fT4,
fT4,
TSH
TSH

Resolves
Resolves

euthyroid
euthyroid

Toxic
Toxic

Follow
Follow

?AcuteThyroiditis,Lymphoma,Cancer
?AcuteThyroiditis,Lymphoma,Cancer
TSH,fT4,Ab,WBC,FNA,US,CT
TSH,fT4,Ab,WBC,FNA,US,CT

Doesnotresolve
Doesnotresolve
TSH,fT4,Ab,FNA,US,CT
TSH,fT4,Ab,FNA,US,CT

Acutethyroiditis
Acutethyroiditis

S.A.T.
S.A.T.

Hashimotos
Hashimotos
??
PainPersists,
PainPersists,
ConsiderFNA
ConsiderFNA

Hashimotos?
Hashimotos?
T4treatment
T4treatment
Observe
Observe
?Steroids
?Steroids
?Resect
?Resect forpain
forpain

Probably
Probably
Graves
Graves

Lymphoma
Lymphoma

Appropriate
Appropriate
Rx
Rx

Cancer
Cancer

benign
benign

Operate
Operate

Follow
Follow
?T4Rx
?T4Rx

Lymphoma
Lymphoma

Antibiotics
Antibiotics
Drainage
Drainage

Cyst
Cyst
Otheralgorithm
Otheralgorithm

Anaplastic
Anaplastic
Ca
Ca

Other
Other
Dx
Dx

?Ope
?Ope
Chemo
Chemo
Xray
Xray

Chemo
Chemo
Xray
Xray

No.4
No.4

PossibleHyperthyroidism:Diagnosis: fT4,TSH,(andT3)

fT4,TSH
Diffuse
Diffuse
goiter
goiter
Ab
Ab ++
Graves
Graves
disease
disease

Singleor
Singleor
Multiple
Multiple
nodules
nodules

Pregnant
Pregnant
Thyroid
Thyroid
function,nl
function,nl
or
or

US,scan
US,scan

hCG,Ab,
hCG,Ab,
vomiting
vomiting

Toxic
Toxic
nodule
nodule

?Postpartum
?Postpartum
?S.A.T.
?S.A.T.
?I2induced
?I2induced
?Transient
?Transient
thyrotoxicosis
thyrotoxicosis

RAIU<5%
RAIU<5%

fT4 TSHnl
Neonatal
Neonatal
CheckAb
CheckAb

TRAb+,
TRAb+,
FH,
FH,
Neonatal
Neonatal
Graves
Graves

Hyperemesis
Hyperemesis
syndrome
syndrome

Treatment
Treatment
Supportive
Supportive

T3elevated
T3elevated

Differentiate
Differentiate
Onhistory,
Onhistory,
exam,
exam,
Ab,course
Ab,course

TRAb,
TRAb,
Poss
PossFH,
FH,
?TSHR
?TSHR
mutation
mutation

Thyroidnl
Thyroidnl
Orsmall
Orsmall
Ab
Ab

?Factitious
?Factitious
?Struma
?Struma
ovary
ovary
Tg
Tg
Evaluate
Evaluate
Patient
Patient

RAIU
RAIU
Scan
Scan
pelvis
pelvis

fT4nl
fT4nl
TSH
TSH
0.050.3
0.050.3

fT4,T3
fT4,T3
TSHnl
TSHnl
or
or
Ab
Ab

fT3
fT3 nl
nl
SITSH
SITSH

fT3
fT3
T4Rx
T4Rx
FDH
FDH
Acute
Acute
Psychosis
Psychosis
Ab
Ab toT3,
toT3,
T4
T4
Propranorol
Propranorol
Steroids
Steroids
Amiodarone
Amiodarone
RarelyNTIS
RarelyNTIS

Subclinica
Subclinica
ll
Hyper
Hyper
thyroidism
thyroidism

Consider
Consider
sameDx.
sameDx.
?Treatmen
?Treatmen
tt
Seetext.
Seetext.

Familialhistory
Familialhistory
PituitaryMRI
PituitaryMRI
TSH
TSHgene
gene
TestT3suppression
TestT3suppression

GRTH
GRTH

TSHoma
TSHoma

PossibleATD
PossibleATD
Tx
Tx

No.5
No.5

PossibleHypothyroidism:Diagnosis: fT4,TSHandAb
fT4nl,TSH
fT4nl,TSH nl,
nl,
Ab
Ab +,
+,
Diffusegoiter+/
Diffusegoiter+/
Hashimotos
Hashimotos
NoRxrequired
NoRxrequired

fT4nl,TSH
fT4nl,TSH ,
,
Ab+/,
Ab+/,
Diffusegoiter+/
Diffusegoiter+/

fT4,TSH
fT4,TSH
,
,
Diffusegoiter+
Diffusegoiter+

Ab+
Ab+

SubClinical
SubClinical
Hypothyroidis
Hypothyroidis
m
m
See
See
Hypothyroidism
Hypothyroidism
Treatment
Treatment
Algorithm
Algorithm

Ab
Ab

fT4nl
fT4nl or,
or,
TSH
TSH

fT4,TSH
fT4,TSH nlor,
nlor,
Ab
Ab
Possible
Possible
Hypopituitary
Hypopituitary

Hashimotos
Hashimotos
Hypothyroidism
Hypothyroidism

SeePossible
SeePossible
Thryotoxicosis
Thryotoxicosis
Algorithm
Algorithm

OnDrugs
OnDrugs
ASA
ASA
Dilantin
Dilantin
Dopa
Dopa
Steroids
Steroids
NSAIDS
NSAIDS

T4treatment
T4treatment

Consider
Consider
Metabolicdefect
Metabolicdefect
Drugs
Drugs
SAT
SAT
Destruction
Destruction
Ab
Ab Hashimotos
Hashimotos

Seeother
Algorithm

LH,FSH,PRL,
LH,FSH,PRL,
Testosteron
Testosteron
e,
e,
Estrogen,
Estrogen,
Cortisol,
Cortisol,
CT,MRI
CT,MRI
Consider
Consider
e.g.ITT,
e.g.ITT,
GnRH,TRH,
GnRH,TRH,

TSHnl
TSHnl

No
No
Rx
Rx

Serious
Serious
Illness
Illness
T3
T3
RT3
RT3
ornl
ornl

NTIS
NTIS

Consider
Consider
Therapy
Therapy

Treat
Treat
Hypopituitary
Hypopituitary

No.6
No.6

SingleThyroidNoduleManagement
PossibleSingleNodule
<5mm

0.51cm,FNA
0.51cm,FNA
Ifdesired
Ifdesired

Notpalpable,>1cm,FNA
Notpalpable,>1cm,FNA

Nogrowth
Nogrowth
Follow
Follow

FNA
FNA
?Resect
?Resect

US,FNA,TSH,fT4
US,FNA,TSH,fT4

FollowbyUS
FollowbyUS
Growth
Growth

ClinicallyToxicNodule
ClinicallyToxicNodule

Canceror
Canceror
suspicious
suspicious

Suspiciousof
Suspiciousof
Follicularneoplasm
Follicularneoplasm
Considergenetic
Considergenetic
Cytology(BRAF)
Cytology(BRAF)

Non
Non
diagnostic
diagnostic

ReFNA
ReFNA
25yr*
25yr*

Riskincreased
Riskincreased
1.Xrayhistory
1.Xrayhistory
2.Familyhistory
2.Familyhistory
3.Nodes
3.Nodes
4.Growth
4.Growth
5.Male
5.Male
6.Age<20,>60
6.Age<20,>60
7.Pain
7.Pain
8.Hoarseness
8.Hoarseness
*ReFNAsoonerifFNAdoesnotfitthe
*ReFNAsoonerifFNAdoesnotfitthe
clinicaldiagnosisorthespecimenisscanty.
clinicaldiagnosisorthespecimenisscanty.

Repeatonce
Repeatonce

Cyst

Operate
Operate

RAIU,TSH,fT4
RAIU,TSH,fT4

Ablative
Ablative
Therapy
Therapy

Consider
Consider
resection
resection

Benign
Benign

FNA

Consider
Consider
T4Rx
T4Rx
ReFNA
ReFNA
2x
2x
Follow
Follow

serialUS

Recur
Recur

?Resect
?Resect

Suspicion
Suspicion
ofCancer
ofCancer

Resect
Resect

T4Rx
T4Rx

Cyst/SolidCheckcytology
Cyst/SolidCheckcytology
Growth
Growth
Operate
Operate

Same/Smaller
Same/Smaller
Follow
Follow

No.7
No.7

WhatistheCorrectThyroxineDosage
TSH,fT4
Replacement
Replacement

Pregnant
Pregnant
OnT4
OnT4

TSH0.42
TSH0.42
U/ml
U/ml
fT4nlor
fT4nlor

Dosage
Dosage
Increase
Increase
Expected
Expected
TSH
TSH
0.42.5or
0.42.5or
3U/ml
3U/ml
Trimesterspecific
Trimesterspecific

Revieweach
Revieweach
46weeks
46weeks

Nodule
Nodule
MultiNodular
MultiNodular
Suppression
Suppression

ResentCa.
CurrentCa.

Presumedcuredcancer
Presumedcuredcancer

TSH0.21U/ml
TSH0.21U/ml
fT4nlor
fT4nlor

Other
Other
Medical
Medical
Problem
Problem

TSH0.42
TSH0.42
U/ml
U/ml
fT4nlor
fT4nlor

+
Valueand
Valueand
Durationuncertain
Durationuncertain
SeeText
SeeText

TSH0.41
TSH0.41
U/ml
U/ml
fT4nlor
fT4nlor

TSH<0.1
TSH<0.1 U/ml
U/ml
fT4nlor
fT4nlor

No.8
No.8

PossibleThyroidEyeDisease
Exophthalmos
ClearlyGraves

DxUncertain
MRI,CT,TSH,fT4,TRAB

Treathyperthyroidism
Treathyperthyroidism
131I
ConsideroralorIVSteroids+
I
ConsideroralorIVSteroids+131
ConsiderThyroidectomy
ConsiderThyroidectomy

Minimal
Protection
Protection
Lubricants
Lubricants
Diuretics
Diuretics
Tarsorrhaphy
Tarsorrhaphy
CosmeticSurgery
CosmeticSurgery

Moderate
Consider
Consider
Xray
Xray
Therapy
Therapy

Graves

SeriousProgressive
Steroids,Xray
Steroids,Xray
Decompression
Decompression
Corrective
Corrective
Surgery
Surgery
Eyemuscle
Eyemuscle
SUrgery
SUrgery

Considerthyroid
Considerthyroid
ablation
ablation
131
131I+Steroids
I+Steroids
131I
orSurgery+
orSurgery+131
I

Otherdiagnosis
Otherdiagnosis
NoDisease
NoDisease

LocalorSpecific
LocalorSpecific
treatment
treatment

Follow
Follow

Consider
Consider
Rituximab
Rituximab
Immunosuppression
Immunosuppression
Plasmapheresis
Plasmapheresis

No.9
No.9

ThyroidCancerPatientTriage
FamilyHistory
OfCancer

Pressure
Pressure
Sx
Sx

Hoarseness
Hoarseness
Pain
Pain

History
ofXray

Thyroid Cervica
l
Mass
Nodes

SuspicionofThyroidCancer

Positivediagnosis
Positivediagnosis
Ofother
Ofother
ThyroidDisease
ThyroidDisease

Dxofother
Dxofother
NeckDisease
NeckDisease

Exam,US,andchestXray

Thyroid
Mass

Thyroid
Thyroid
Mass
Mass
+Nodes
+Nodes

Nodesor
Nodesor
Massonly
Massonly

Thyroidmass
Distant
metastases

Metastases
?Thyroid

Metastatic
Metastatic
Primary
Primary

SeeThyroidCancerOperationsorMetastaticDiseaseAlgorithms
SeeThyroidCancerOperationsorMetastaticDiseaseAlgorithms
No.10
No.10

DecidingonanOperationforThyroidCancer
ThyroidMass

ThyroidMass+Nodes
ThyroidMass+Nodes

NeckNodesorMass

Seenodulealgorithm

131Iscan
FNA,US,? 131

131
131Iscan,US,?FNA

ThyroidOpconsidered

FNAorBiopsy
FNAorBiopsy

Operation
Operation
not
not
indicated
indicated

T4Rx
OtherRx

Surgery
Surgery
Contra
Contra
indicated
indicated
Cellular
Cellular
adenoma
adenoma

FrozenSect.
FrozenSect.
And
And
Op=benign
Op=benign

FrozenSect.
FrozenSect.
And
And
Op=cancer>1c
Op=cancer>1c
m
m

FinalPath+
FinalPath+

LOB+STT
LOB+STT

Lobectomy
Lobectomy

See
See
Correct
Correct
Dosage
Dosage
Algorithm
Algorithm

TTorNTT
TTorNTT
CentralNode
CentralNode
BIopsy
BIopsy

FinalDx=Ca
FinalDx=Ca
Nodesneg.
Nodesneg.
PapillaryCa<1cm
PapillaryCa<1cm

Thyroid
Thyroid
Ca
Ca
InvasiveDIesase
InvasiveDIesase

Nodes
Nodes

Removetumorand
Removetumorand
metastasesaspossible
metastasesaspossible

NTTand
NTTand
Node
Node
Dissection
Dissection

FinalDx=Ca,Nodes+
FinalDx=Ca,Nodes+

T4Rx

Ablation
Ablation
optional
optional

Other
Other
Dx
Dx
OtherRx
OtherRx

30100mCiThyroidAblation
30100mCiThyroidAblation

TT=TotalThyroidectomy,NTT=NearTotalThyroidectomy
TT=TotalThyroidectomy,NTT=NearTotalThyroidectomy

RAITherapycycle
RAITherapycycle
Seealgorithm
Seealgorithm

Invasivedisease
Invasivedisease
Age>50
Age>50
131
131II Therapy
Therapy
Consider
Consider
Radiotherapy
Radiotherapy

No.11
No.11

RAIablationandTherapyCycle
TotalThyroidectomyorNearTotalThyroidectomy+
TotalThyroidectomyorNearTotalThyroidectomy+ removaloftumorandmets
removaloftumorandmets
FirstPostOptreatment
FirstPostOptreatment
TSH>30
TSH>30
T33weeks,off3weeks
T33weeks,off3weeks

doseprotocol
doseprotocol
rhTSH
rhTSH

PostRxScan+,tumorN1orM1
PostRxScan+,tumorN1orM1
T4Rx36mo.
T4Rx36mo.
withTSH,Tg<1ng/ml
withTSH,Tg<1ng/ml

T4Rx1224mo.
T4Rx1224mo.
RepeatScan12x
RepeatScan12x
OrfollowUS
OrfollowUS
TSH,Tg<1ng/ml
TSH,Tg<1ng/ml

T4Rx
T4Rx

Consider
Consider
Tg,US
Tg,US
only
only

T4Rx36mo.
T4Rx36mo.
TSH,Tg24ng/ml
TSH,Tg24ng/ml
Leveluncertain
Leveluncertain

WholeBodyScam,
WholeBodyScam,
US,CT,MRI
US,CT,MRI
?PET,boneScan
?PET,boneScan
Resectifpossible
Resectifpossible

?OtherRx
?OtherRx
Follow
Follow

131
Ablate30150mCi
Ablate30150mCi131II
Dependentontumorstage
Dependentontumorstage

Invasivedisease
Invasivedisease
RAIUintumor
RAIUintumor
DistantMets
DistantMets
Potentially
Potentially
treatablelesion
treatablelesion

131II
100200mCi
100200mCi131

Post
Post
Rx
Rx
Scan+
Scan+

131I
24mCi
24mCi131
IWholeBodyScan
WholeBodyScan
T33weeks,off3weeks
T33weeks,off3weeks
doseprotocol
doseprotocol
rhTSH
rhTSH

131IWholeBodyScan
24mCi
24mCi131
IWholeBodyScan
(?optional)
(?optional)

T4Rx36mo.
T4Rx36mo.
TSH,Tg>4ng/ml
TSH,Tg>4ng/ml

Notumorfound
Notumorfound
orresectable
orresectable

FollowupScan

Post
Post
Rx
Rx
Scan+
Scan+
Tg>4ng/ml
Tg>4ng/ml
ConsiderRepeat
ConsiderRepeat

T4Rx69mo.
T4Rx69mo.
Thyroidablation
Thyroidablation
131
3050mCi
3050mCi131II
RAIU
RAIU
Thyroidonly
Thyroidonly

75200mCI
75200mCI
131
131II ScanafterRx
ScanafterRx

T4Rx36mo.
T4Rx36mo.
Repeat
Repeat
imaging
imaging
US,Tg,
US,Tg,
131
131I,surgery,
I,surgery,
orXray
orXray
Forgrowth
Forgrowth

ConsiderotherRx
ConsiderotherRx
Chemotherapy
Chemotherapy
ThyrosineKinase
ThyrosineKinase
inhibitor
inhibitor
??Immunotherapy
??Immunotherapy

No.12
No.12

Evaluatingmetastaticcancer,possiblyfromThyroid
Thyroidmass+,metastases,FNA+
ThyroidOp

SolitaryMet

Metastaticdisease,?Thyroid
Metastaticdisease,?Thyroid

Tg+

MultipleMets

Excision

Immunostain
Immunostain
ScanorUS
ScanorUS

Immunostain+,
Immunostain+,
Tg
Tg
ScanorUS+
ScanorUS+

Tg

Tyroidectomy
Tyroidectomy
FordiagandRAIU
FordiagandRAIU

131
131IScan
IScan

131
131IThyroidAblation
IThyroidAblation

Therapy
Therapy

AndTherapy
AndTherapy

NoRAIU
NoRAIU

Otherdiag
Otherdiag
OtherRx
OtherRx

2mCiBodyScan
2mCiBodyScan

Scan+
Scan+

RAITherapy
RT,?Chemo
RT,?Chemo

Scan
Scan

OtherRx
No.13
No.13

PostpartumThyroiditisDiagnosisandManagement
SuspectPPT,testTSH,fT4andantiTPOAborantiTgAb
SuspectPPT,testTSH,fT4andantiTPOAborantiTgAb

TSH>4.0U/ml
TSH>4.0U/ml
fT4nl,Ab+/
fT4nl,Ab+/

TSH>4.0U/ml
TSH>4.0U/ml
fT4,Ab+/
fT4,Ab+/

Subclinical
Subclinical
HJypothyroid
HJypothyroid

PossibleAITD
PossibleAITD
HJypothyroid
HJypothyroid

TSH0.34.0
TSH0.34.0
U/ml
U/ml
fT4nl,Ab+
fT4nl,Ab+

TSH<1U/ml
TSH<1U/ml
Ab+
Ab+

fT4
fT4

RepeatTSH
RepeatTSH
In36months
In36months

fT4nl
fT4nl

DiagnoseHyperthyroid
DiagnoseHyperthyroid

LT4Rx
Reevaluate
Reevaluate
In36months
In36months

TSH>4.0
TSH>4.0
U/ml
U/ml
fT4
fT4

Consider
Consider
TaperingT4Rx
TaperingT4Rx

RepeatTSH
RepeatTSH
TSH>4.0
TSH>4.0
U/ml
U/ml

TSH0.34.0
TSH0.34.0
U/ml
U/ml

Folllow
Folllow

TSH0.34.0
TSH0.34.0
U/ml
U/ml
fT4nl
fT4nl

TSH<1U/ml
TSH<1U/ml

Folllow
Folllow
Note:
Note:
PriorPPTepisode
PriorPPTepisode
Familyhistoryofautoimmunedisease
Familyhistoryofautoimmunedisease
Orthyroiddisease
Orthyroiddisease
PositiveantiTPOorantiTgAb
PositiveantiTPOorantiTgAb
Diabetes
Diabetes
Goiter
Goiter
Depression
Depression
Signsandsymptomsofthyroiddisease
Signsandsymptomsofthyroiddisease

fT4
fT4
PossibleHypopituitary
PossibleHypopituitary

?Subclinical
?Subclinical
Hyperthyroid
Hyperthyroid
ExcessiveLT4
ExcessiveLT4
T3toxicosis
T3toxicosis
Toxicthyroidnodule
Toxicthyroidnodule
Glucocorticoids
Glucocorticoids
Dopamine
Dopamine

No.14
No.14

HyperthyroidismManagementwithAntithyroidDrugs
HyperthyroidismGraves Disease
RxAntithyroidDrugs
4weeks
4weeks
TestTSHandfT4
TestTSHandfT4

TSH<0.5U/m
TSH<0.5U/m
ll
fT4High
fT4High

TSH<0.5U/m
TSH<0.5U/m
ll
fT4nl
fT4nl

AvoidPTUifpossible
AvoidPTUifpossible
MildPTU50mg8h
MildPTU50mg8h
MMI10mg12h
MMI10mg12h
SeverePTU100150mg8h
SeverePTU100150mg8h
MMI2030mg12h
MMI2030mg12h

TSH<0.5U/m
TSH<0.5U/m
ll
fT4Low
fT4Low

Reducedose
Reducedose
oraddT4
oraddT4

Continueor
Continueor
Increase
Increase
Antithyroid
Antithyroid
Drugs
Drugs

MonitorEvery
MonitorEvery
12months:
12months:
ReducedoseProgressively
ReducedoseProgressively
ifTSHandfT4normal
ifTSHandfT4normal

48weeks
48weeks
Monitor36and9
Monitor36and9
12Months,
12Months,
thenannually
thenannually

TSH>0.5U/m
TSH>0.5U/m
ll
fT4nlorLow
fT4nlorLow

Signsof
Signsof
remission
remission

ReduceDose
ReduceDose
after612mo.
after612mo.

DiscontinueDrugs
DiscontinueDrugs
after1218mo.
after1218mo.
No.15
No.15

ManagingPrimaryHypothyroidism
TSH>4.0U/ml,fT4lowornl
Patient1550years

Patient>50yearsor
Patient>50yearsor
known/suspectedHeartDisease
known/suspectedHeartDisease

LT450100g/d,48wk
LT450100g/d,48wk

LT42550g/d,48wk
LT42550g/d,48wk

RepeatTSH
RepeatTSH

TSH>4.0U/ml
TSH>4.0U/ml

TSH0.44.0
TSH0.44.0
U/ml
U/ml

TSH<4.0U/ml
TSH<4.0U/ml

IncreaseLT4
IncreaseLT4
doseby
doseby
12.525g/d
12.525g/d

IncreaseLT4
IncreaseLT4
doseby
doseby
12.5g/d
12.5g/d

DecreaseLT4
DecreaseLT4
doseby
doseby
12.525g/d
12.525g/d

68weeks
68weeks

TSH0.52U/ml
TSH0.52U/ml
Continuedose
Continuedose

68weeks
68weeks

ConditionsRequiring
ConditionsRequiring
SpecialAttention:
SpecialAttention:
1.Cardiaccompromised
1.Cardiaccompromised
2.Stupor;coma
2.Stupor;coma
3.Amiodaronetreatment
3.Amiodaronetreatment
4.Preoppatient
4.Preoppatient
5.ICU/CCUpatient
5.ICU/CCUpatient
6.Age<15years
6.Age<15years
7.Sodium<130mEq/l
7.Sodium<130mEq/l
8.Pregnancy
8.Pregnancy
9.Postpartumthyrotoxicosis
9.Postpartumthyrotoxicosis
10.TSHpersistentlyhighor
10.TSHpersistentlyhighor
nonresponsivetoT4
nonresponsivetoT4
11.Symptomsofpituitary
11.Symptomsofpituitary
disease
disease
12.Nonsuppressiblefunction
12.Nonsuppressiblefunction
inHashimotosorGraves
inHashimotosorGraves
13.RememberGRTHandPRTH
13.RememberGRTHandPRTH

Seealso:
Seealso:
CorrectThyroxine
CorrectThyroxine
DosageAlgorithm
DosageAlgorithm

RepeatTSHannually
RepeatTSHannually
OrwhenSymptomatic
OrwhenSymptomatic

No.16
No.16

ScanningafterAblation
>6mo.Postopandpostablation
HighRiskorTgonT4>2ng/ml

LowRiskandTgonT41ng/ml
LowRiskandTgonT41ng/ml

WholebodyScanandTg
OneYear
OneYear

ScanNeg.
Tg 1ng/ml

OneYear
OneYear

Scannegative
Scannegative
Tg
Tg 1ng/ml
1ng/ml
Noclinicaldisease
Noclinicaldisease

Scan+
Tg >1ng/ml

Scan+or
Tg >2ng/ml

(Orotherarbitrarylevel)
(Orotherarbitrarylevel)

ScanandTgneg.
ScanandTgneg.
12X
12X
Annualexam
Annualexam
Periodic
Periodic
NeckUS,Tgtesting
NeckUS,Tgtesting

doseT4
doseT4
T33wk,off23wk
T33wk,off23wk
rhTSH
rhTSH
131IScan
Then
IScan
Then131

(Orotherarbitrarylevel)
(Orotherarbitrarylevel)

ReviewExam
ReviewExam
CXR,US,MRI,chestCT
CXR,US,MRI,chestCT
Bonescanasneeded,
Bonescanasneeded,
131I,Surgery
Consider
I,Surgery
Consider131
SeeCanceralgorithm
SeeCanceralgorithm

131Itreatment
Probable
Probable131
Itreatment
Afterwithdrawalscan
Afterwithdrawalscan
(IndividualizeforRAIUinThyroid
(IndividualizeforRAIUinThyroid
Bedonly)
Bedonly)

PersistentRAIUorelevatedTg
PersistentRAIUorelevatedTg

No.17
No.17

NeonatalThyroidDysfunction(PartA SeealsoPartBandPartC)
Lateonsetofhypoor
hyperthyroidism

Abnormalresultsonscreening
Abnormalresultsonscreening
clinicalsignofthyroidabnormality
clinicalsignofthyroidabnormality
OrTSH,fT4,T4abnormal
OrTSH,fT4,T4abnormal
If<6months,evaluate
If<6months,evaluate
within2days
within2days

Transient
Transient
hypothyroidism
hypothyroidism
withprematurity,
withprematurity,
illness
illness

Normal
Normal or
or

TSH,fT4,T4,Ab,US

?Hyperthyroidism
?Hyperthyroidism

Testsnl
Testsnl
in4weeks
in4weeks
Observe
Observe

Clinically
Clinically
toxic
toxic

fT4,T3,
fT4,T3,
TSH
TSH nlor
nlor
TSH
TSH nl
nl

TSHwithhigh
TSHwithhigh
T3
T3
Clinicallyeuthyroid
Clinicallyeuthyroid
OrHypothyroid
OrHypothyroid

PRTH
PRTH
TRbetasequencing
TRbetasequencing

GRTH
GRTH

ReplaceT4until
ReplaceT4until
CNSmature
CNSmature

StopT44weeks
StopT44weeks
NormalorHypothyroid
NormalorHypothyroid
Thyroidectopicorabsent
Thyroidectopicorabsent

?Hypotyhyroid
?Hypotyhyroid
fT4,
fT4,
T3,TSH
T3,TSH

?Hypotyhyroid
?Hypotyhyroid
fT4,T3,TSH
fT4,T3,TSH

Pituitaryor
Pituitaryor
Hypothalamic
Hypothalamic
Defect
Defect
TSHmutation
TSHmutation

TSHRmutation
TSHRmutation
IImetabolic
metabolic
defect
defect

SeepartC
SeepartC

SeepartB
SeepartB
Ab+
Ab+
MaternalAITD
MaternalAITD

AITD
AITD
Hypothyroidism
Hypothyroidism

No.18
No.18

NeonatalThyroidDysfunction(PartB)
Lateonsetofhypoor
hyperthyroidism

Abnormalresultsonscreening
Abnormalresultsonscreening
clinicalsignofthyroidabnormality
clinicalsignofthyroidabnormality
OrTSH,fT4,T4abnormal
OrTSH,fT4,T4abnormal
If<6months,evaluate
If<6months,evaluate
within2days
within2days

ReplaceT4until
ReplaceT4until
CNSmature
CNSmature

TSH,fT4,T4,Ab,US
Examnl
T4,fT4nl,TSH
nl

Examnl
T4,fT4nl,TSHnl

PresumedTBG

PresumedTBG

ExcludeASA,
ExcludeASA,
Dilantin
Dilantin
AbtoT3orT4
AbtoT3orT4

ConsiderTBG,
ConsiderTBG,
FDH,antibodies,
FDH,antibodies,
estrogen,
estrogen,
AbnormalTTRor
AbnormalTTRor
albumin
albumin

StopT44weeks
StopT44weeks
?Hypertyhyroid
?Hypertyhyroid
fT4,T3,TSH
fT4,T3,TSH

Ab
Ab
Familialhistory+/
Familialhistory+/
Mildonset
Mildonset

Ab+
Ab+
MaternalAITD
MaternalAITD

TSHR
TSHR
activatingmutation
activatingmutation

Graves
Graves disease
disease
No.19
No.19

?CongenitalHypothyroidism(PartC)
OnlyTSH

fT4,T4,T3,TSHnlor or

US,RAIU,IScan

Thyroidabsent
Thyroidabsent
orectopic
orectopic

Absent

Among
Among
Causes
Causes
Pax8,TTF2
Pax8,TTF2

Thyroidpresentorectopic
Thyroidpresentorectopic

Ectopic

ExcessIodide
ExcessIodide
(Rare)
(Rare)

KClO4dischargetest
KClO4dischargetest

RAIU
RAIU or
or

Goiter
Goiter
S/Sratio<4
S/Sratio<4

NIS
NIS
defect
defect
MRI,Pituitary
MRI,Pituitary
tests
tests

Thyroidfunc.
Thyroidfunc.

S/Sratio>4
S/Sratio>4
TSH
TSH
Pit.or
Pit.or
Hypothalamic
Hypothalamic
defect
defect
TRHdefect
TRHdefect
TSHmutation
TSHmutation
Pit1,HesX1,Prop1
Pit1,HesX1,Prop1

Peroxidase
Peroxidase
Defect
Defect

Salivary/SerumI123
Salivary/SerumI123
UrinaryIodide
UrinaryIodide

AmongCauses
AmongCauses
TTF1,?Pax8
TTF1,?Pax8
mutation
mutation
UrinaryIodide
UrinaryIodide
Veryelevated
Veryelevated

RAIU+
RAIU+
or
or

Hearing
Hearing
Normal
Normal
TPOdefect
TPOdefect

Hearing
Hearing
abnormal
abnormal
Pendreds
Pendreds

TSH
TSH
TSHreceptor
TSHreceptor
defect
defect
mutations
mutations
TTF1,Pax8,
TTF1,Pax8,
Gsalpha
Gsalpha

RAIU
RAIU
Rapid
Rapid
turnover
turnover
Deiodinase
Deiodinase
defect
defect

Urine,Serum
Urine,Serum
Iodothyrosine
Iodothyrosine

Tg
Tg
defect
defect

Abnormal
Abnormal
Serum
Serum
Iodoprotein
Iodoprotein

No.20
No.20