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Central hypothyroidism

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of central hypothyroidism are prepared by our editorial team based on guidelines from the Endocrine Society (ES 2018,2016), the European Thyroid Association (ETA 2018), and the American Thyroid Association (ATA/AACE 2012). ...
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Screening and diagnosis

Indications for screening
As per ES 2018 guidelines:
Obtain lifelong annual screening for TSH deficiency in childhood cancer survivors treated for tumors in the region of the hypothalamic-pituitary axis or exposed to ≥ 30 Gy hypothalamic-pituitary radiation.
B
Obtain the same biochemical tests to screen for TSH deficiency in childhood cancer survivors as used in the non-cancer population.
Do not obtain serum T3, TSH surge analysis, or thyrotropin-releasing hormone stimulation to diagnose TSH deficiency.
B
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  • Indications for testing

Diagnostic investigations

Thyroid function tests: as per ETA 2018 guidelines, suspect CeH in every subject with low serum concentrations of free T4 and low/normal TSH on a screening examination.
B
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  • Genetic testing

  • Evaluation for adrenal insufficiency

Medical management

Thyroid replacement therapy: as per ETA 2018 guidelines, initiate levothyroxine as first-line therapy for CeH.
A
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Perioperative care

Perioperative replacement therapy
As per ES 2016 guidelines:
Initiate levothyroxine therapy before non-emergency pituitary surgery and throughout the perioperative period in cases of preoperative CeH.
B
Measure free T4 levels 6-8 weeks postoperatively to assess for CeH in patients with intact preoperative thyroid function undergoing pituitary surgery.
B

Follow-up and surveillance

Assessment of treatment response: as per ETA 2018 guidelines, assess the adequacy of replacement therapy 6-8 weeks after initiation of levothyroxine therapy with concomitant free T4 and TSH measurements in patients with CeH, provided that blood is withdrawn before the morning replacement dose or at least 4 hours after the levothyroxine administration. Aim to maintain free T4 levels above the median value of the normal range.
B
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  • Serial laboratory assessment