Atypical Rise in TSH level in Hypothyrodism Despite Taking Daily High Dose of Thryoxine Tablet: Is It just a Noncompliance or a Rare pathology?
A patient came to our outpatient department complaining of fatigue, and weight loss. She added that she have had progressively increasing throat pain for last 7 months. She has a history of hypothyroidism. She was taking 150 micro-gram thryoxine tablet daily and despite the same continued doses her previously reported TSH level was on the rising level of 150 uIU/mL since last 4 year. Her repeated TSH level on the same day appeared to be 114 uIU/ml.Then the patient was asked to change his thyroxine tablets due to possible expiry date of medications and counseled to take properly the medications and advised to follow up after a week.
Rakesh Biswas It appears that she never had a T3, T4 done in the past 4 years!! This patient is from Asansol Partha.
Saptarshi Quizzer Hmm..T3 T4 levels must be assessed to throw further light on the issue
Saptarshi Quizzer Thanks
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Saptarshi Quizzer Is it possible to rule out thyroid hormone resistance or TSH secreting tumors?
Saptarshi Quizzer A thorough investigation using newer techniques to measure TSH might help along with checking the compliance and family history.
Saptarshi Quizzer Any chance of TSH secreting tumor?
Rakesh Biswas Just rechecked FT3 and FT4 and it is reduced. FT3 2.0 (normal 4.0 to 8.3 pmol /L), FT4-5.4 (9.0-20.0 pmol/L).
Aadipta Ghosh Check for thyroid peroxidase antibodies Rakesh Biswas sir. I believe thyroid resistance syndrome would have ft3 and ft4 elevated
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Karthik Balachandran The three commonest causes of this pattern are
1. non compliance
2. non compliance...
1. non compliance
2. non compliance...
3. Non compliance
So the first step is to assess compliance. An objective way is to do a Thyroxin load test. We give 10 tablets of 100 mcg thyroxine (under observation) and check serum FT4 or TT4 levels at hourly intervals for 6 hours. If the patient shows a sharp spike , usually within one to two hours, then it rules out true thyroxine malabsorption. If no spike is seen, thyroxine malabsorption can be considered. Then again isolated malabsorption is very rare. So malabsorption of fat, protein and carbs to be assesed to rule out the more common diseases associated with malabsorption.
Resistance to thyroid hormone patients are generally euthyroid. TSH secreting adenomas clinically present with hyperthyroidism. Inteference with antibodies are less likely since not only TSH, but also FT4 and FT3 are abnormal. Drugs interfering with thyroid absorption (iron,calcium tablets) can cause mild hypothyroidism even when the dose is otherwise adequate, but not severe enough to raise TSH to >150 as in this case. The last possibility is the poor quality thyroxine ( can happen in government hospitals when some obscure brand is given), which is not the case here.
So the first step is to assess compliance. An objective way is to do a Thyroxin load test. We give 10 tablets of 100 mcg thyroxine (under observation) and check serum FT4 or TT4 levels at hourly intervals for 6 hours. If the patient shows a sharp spike , usually within one to two hours, then it rules out true thyroxine malabsorption. If no spike is seen, thyroxine malabsorption can be considered. Then again isolated malabsorption is very rare. So malabsorption of fat, protein and carbs to be assesed to rule out the more common diseases associated with malabsorption.
Resistance to thyroid hormone patients are generally euthyroid. TSH secreting adenomas clinically present with hyperthyroidism. Inteference with antibodies are less likely since not only TSH, but also FT4 and FT3 are abnormal. Drugs interfering with thyroid absorption (iron,calcium tablets) can cause mild hypothyroidism even when the dose is otherwise adequate, but not severe enough to raise TSH to >150 as in this case. The last possibility is the poor quality thyroxine ( can happen in government hospitals when some obscure brand is given), which is not the case here.
Rakesh Biswas Excellent inputs Dr Karthik. We shall try the thyroxine load test. Vivek please see if you can share a link to it here.
Ashwani K Gupta Formulations
of thyroxine can have varying bioavailable. If this patient is taking a
brand that is made in your neighborhood backyard. be careful.
Aadipta Ghosh Just rechecked FT3 and FT4 and it is reduced. FT3 2.0 (normal 4.0 to 8.3 pmol /L), FT4-5.4 (9.0-20.0 pmol/L).
Rakesh Kumar How Do You Approach the Problem of TSH Elevation?http://www.medscape.com/viewarticle/705879
Boudhayan Dm RakeshKumar KarthikBalachandran
Thank you for the excellent inputs. We have checked most of the points
which u have mentioned except for Malabsorption. The history did not
reveal NON compliance . Thyroid hormone resistance syndromes
.........pls check serum cortisol......
This looks like hypothyroidism..... The patient said that she got her
tablets from CMC Vellore in 2015..... Karthik Sir is there any expiry
date of thyroid hormone tablets and data regarding that.... Lets
see....... As mentioned by Sasthi Narayan Chakraborty
da thank u.we can get the antibody status checked but that will only
indicate the predisposition........ we need to check the formulation the
next day .... I would like a change of preparation as suggested by
Karthik Sir .... Having learnt most of my Endocrinology under Sir I
agree we have seen change of brand bringing abt a drastic change in the
values often
Karthik Balachandran No
data on what happens if one consumes thyroxine after expiry date. By
the way, in most cases of non compliance the patient doesn't tell the
truth 
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Boudhayan Dm I know Sir. But we don't have narco analysis:-)
Rakesh Biswas We
sent her home yesterday on a changed preparation of thyroxine and will
move over to the thyroxine load test if this doesn't work However Vivek
I guess you were unable to search for Indian injectable brands of
thyroxine? Is it available in India Boudhayan?
Karthik Balachandran Injectable
thyroxine is available in Chennai, but is extremely costly. Inj
thyroxine 100 mcg costs Rs.18000. So for most patients it wouldn't be
economically viable to use it to test thyroxine absorption
Rakesh Biswas Vivek Poddar
can you put this conversation into a blog so that we can share the link
wider? This patient is likely to get admitted soon for the thyroxine
load test suggested by Dr Karthik Balachandran
Boudhayan Dm Sir what happened.... Did she follow up
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