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Hashimoto's thyroiditis

Key sources
The following summarized guidelines for the evaluation and management of Hashimoto's thyroiditis are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2023), the European Academy of Dermatology and Venereology (EADV 2021), the Endocrine Society (ES 2020), the British Medical Journal (BMJ 2019), the American Thyroid Association (ATA 2017), the American College of Endocrinology (ACE/AACE 2016), and the American Thyroid Association (ATA/AACE 2012).
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Guidelines

1.Screening and diagnosis

Indications for screening
As per ADA 2023 guidelines:
Consider screening for antithyroid peroxidase and anti-TG antibodies soon after diagnosis in pediatric patients with T1DM.
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Measure TSH concentrations at diagnosis when clinically stable or soon after optimizing glycemia. Consider rechecking every 1-2 years or sooner if the initial screening is normal in young patients with positive thyroid antibodies or developing symptoms or signs suggestive of thyroid dysfunction, thyromegaly, an abnormal growth rate, or unexplained glycemic variability.
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  • Indications for testing (dyslipidemia)

  • Indications for testing (dermatitis herpetiformis)

  • Indications for testing (infertility)

  • Indications for testing (poor lactation)

2.Diagnostic investigations

Anti-TPO antibodies: measure anti-TPO antibodies in the evaluation of patients with subclinical hypothyroidism.
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  • Thyroid hormone tests

3.Medical management

Thyroid replacement therapy, indications, abnormal thyroid-stimulating hormone, BMJ: do not initiate thyroid replacement therapy in adult patients with subclinical hypothyroidism.
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  • Thyroid replacement therapy (indications, normal TSH)

  • Thyroid replacement therapy (choice of agent and dosing)

  • Thyroid replacement therapy (treatment targets)

  • Management of thyroid nodules

  • Management of dyslipidemia

4.Nonpharmacologic interventions

Iodine supplementation, general population: do not use iodine supplementation, including kelp or other iodine-containing functional foods, in the management of hypothyroidism in iodine-sufficient areas.
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  • Iodine supplementation (during pregnancy)

  • Iodine supplementation (during breastfeeding)

  • Selenium supplementation

5.Specific circumstances

Pregnant patients, screening: obtain verbal screening for any history of thyroid dysfunction and prior or current use of either thyroid hormone or antithyroid medications in all pregnant patients at the initial prenatal visit.
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  • Pregnant patients (evaluation)

  • Pregnant patients (management of autoantibodies)

  • Pregnant patients (management of normal TSH levels)

  • Pregnant patients (thyroid replacement therapy)

  • Pregnant patients (treatment targets)

  • Pregnant patients (monitoring)

  • Pregnant patients (postpartum)

  • Breastfeeding patients

  • Patients with infertility

  • Patients with combined adrenal insufficiency

6.Patient education

General counseling
As per ATA 2017 guidelines:
Advise patients receiving levothyroxine therapy to independently increase their dose of levothyroxine by 20-30% (such as taking 2 additional tablets weekly of the current daily levothyroxine dosage) and urgently notify their caregiver for prompt testing and further evaluation in case of a suspected or confirmed pregnancy (positive home pregnancy test).
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Counsel treated hypothyroid female patients of reproductive age regarding the likelihood of increased demand for levothyroxine during pregnancy. Advise such patients to contact their caregiver immediately upon a confirmed or suspected pregnancy.
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7.Follow-up and surveillance

Indications for specialist referral: manage most patients with primary hypothyroidism by non-endocrinologist physicians familiar with the diagnosis and treatment of hypothyroidism. Refer patients with hypothyroidism meeting any of the following criteria for a consultation with an endocrinologist:
infant and pediatric patients
female patient planning conception
pregnant patients
patients difficult to render and maintain in a euthyroid state
cardiac disease
presence of goiter, nodule, or other structural changes in the thyroid gland
presence of other endocrine diseases, such as adrenal or pituitary disorders
unusual constellation of thyroid function test results
unusual causes of hypothyroidism, such as induced by agents interfering with the absorption of levothyroxine, impacting thyroid gland hormone production or secretion, affecting the hypothalamic-pituitary-thyroid axis (directly or indirectly), increasing clearance, or peripherally impacting metabolism
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  • Serial laboratory assessment