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Thyroid disease

About

What is covered

This NICE Pathway covers investigating all suspected thyroid disease and managing primary thyroid disease (related to the thyroid rather than the pituitary gland). It does not cover managing thyroid cancer or thyroid disease in pregnancy. It aims to improve quality of life by making recommendations on diagnosis, treatment, long-term care and support.
NICE is also developing a guideline on thyroid cancer (publication expected April 2022).

Updates

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on thyroid disease in children, young people and adults in an interactive flowchart

What is covered

This NICE Pathway covers investigating all suspected thyroid disease and managing primary thyroid disease (related to the thyroid rather than the pituitary gland). It does not cover managing thyroid cancer or thyroid disease in pregnancy. It aims to improve quality of life by making recommendations on diagnosis, treatment, long-term care and support.
NICE is also developing a guideline on thyroid cancer (publication expected April 2022).

Sources

NICE guidance and other sources used to create this interactive flowchart.
Thyroid disease: assessment and management (2019) NICE guideline NG145
High-intensity focused ultrasound for symptomatic benign thyroid nodules (2019) NICE interventional procedures guidance 643
Minimally invasive video-assisted thyroidectomy (2014) NICE interventional procedures guidance 499
Intraoperative nerve monitoring during thyroid surgery (2008) NICE interventional procedures guidance 255
Retrobulbar irradiation for thyroid eye disease (2005) NICE interventional procedures guidance 148

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Provide people with hypothyroidism, and their family or carers if appropriate, with written and verbal information on:
  • possible drug interactions of thyroid hormone replacements, including interactions with over-the-counter medicines
  • how and when to take levothyroxine.
Offer levothyroxine as first-line treatment for adults, children and young people with primary hypothyroidism.
Do not routinely offer liothyronine for primary hypothyroidism, either alone or in combination with levothyroxine, because there is not enough evidence that it offers benefits over levothyroxine monotherapy, and its long-term adverse effects are uncertain.
Do not offer natural thyroid extract for primary hypothyroidismNatural thyroid extract does not have a UK marketing authorisation so its safety is uncertain. because there is not enough evidence that it offers benefits over levothyroxine, and its long-term adverse effects are uncertain.
Aim to maintain TSH levels within the reference range when treating primary hypothyroidism with levothyroxine. If symptoms persist, consider adjusting the dose of levothyroxine further to achieve optimal wellbeing, but avoid using doses that cause TSH suppression or thyrotoxicosis.
Be aware that the TSH level can take up to 6 months to return to the reference range for people who had a very high TSH level before starting treatment with levothyroxine or a prolonged period of untreated hypothyroidism. Take this into account when adjusting the dose of levothyroxine.
When discussing whether or not to start treatment for subclinical hypothyroidism, take into account features that might suggest underlying thyroid disease, such as symptoms of hypothyroidism, previous radioactive iodine treatment or thyroid surgery, or raised levels of thyroid autoantibodies.
Be aware that transient thyrotoxicosis without hyperthyroidism usually only needs supportive treatment (for example, beta-blockers).
Discuss with adults, children and young people with thyrotoxicosis with hyperthyroidism (and their families and carers as appropriate):
  • the possible benefits and risks of all treatment options (antithyroid drugs, radioactive iodine, surgery)
  • the likelihood of a good response to each option.
Ensure that people can actively participate in decisions about their treatment by following the recommendations in the NICE Pathway on patient experience in adult NHS services. This includes presenting information about possible outcomes in a way the person (and their families and carers as appropriate) can understand.
Offer antithyroid drugsUse of carbimazole is subject to MHRA advice on contraception (Drug Safety Update, February 2019) and risk of acute pancreatitis (Drug Safety Update, February 2019). to control hyperthyroidism in adults, childrenAt the time of publication (November 2019), carbimazole did not have a UK marketing authorisation for children under 2 years. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing medicines – guidance for doctors for further information. and young people who are waiting for treatment with radioactive iodine or surgery.
Before starting antithyroid drugs for adults, children and young people with hyperthyroidism, check full blood count and liver function tests.
Consider propylthiouracil for adults:
  • who experience adverse reactions to carbimazole
  • who are pregnant or trying to become pregnant within the following 6 months
  • with a history of pancreatitis.
Stop and do not restart any antithyroid drugs if a person develops agranulocytosis. Consider referral to a specialist for further management options.
Consider stopping TSH measurement for adults, children and young people with untreated subclinical hyperthyroidism if the TSH level stabilises (2 similar measurements within the reference range 3 to 6 months apart).
NICE has published guidance on high-intensity focused ultrasound for symptomatic benign thyroid nodules with special arrangements for clinical governance, consent, and audit or research.
NICE has published guidance on ultrasound-guided percutaneous radiofrequency ablation for benign thyroid nodules with standard arrangements for clinical governance, consent and audit.

Glossary

(people aged 16 years and over)
(measuring FT4 in the same sample if TSH is above the reference range and measuring FT4 and FT3 in the same sample if TSH is below the reference range)
(people under 16 years)
free tri-iodothyronine
free thyroxine
(excess production and/or secretion of thyroid hormones [overactive thyroid gland])
(inadequate production and secretion of thyroid hormones [underactive thyroid gland])
(this includes women in perimenopause and postmenopause)
(TSH levels below the reference range, with FT3 and FT4 within the reference range)
(TSH levels above the reference range, with FT4 within the reference range)
(a disorder of excess circulating thyroid hormones caused by increased production and secretion [hyperthyroidism] or by the release of stored thyroid hormones [thyroiditis])
thyroid peroxidase antibodies
TSH receptor antibodies
thyroid-stimulating hormone
(people under 16 years)

Paths in this pathway

Pathway created: November 2019 Last updated: November 2019

© NICE 2019. All rights reserved. Subject to Notice of rights.

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