When to go to the hospital for uncontrolled hypothyroidism (underactive thyroid disease)?

From the Guidelines

Seek emergency medical care for uncontrolled hypothyroidism if you experience severe symptoms such as extreme lethargy, confusion, decreased consciousness, severe swelling, difficulty breathing, very low body temperature, or extremely slow heart rate, as these could indicate myxedema coma, a life-threatening complication of severe hypothyroidism that requires immediate hospital treatment. You should also go to the hospital if you have chest pain, severe weakness that prevents basic activities, or if you're unable to take your thyroid medication for several days. While most hypothyroidism is managed through outpatient care with medications like levothyroxine (typically starting at 25-50 mcg daily for older adults or those with heart disease, or 75-100 mcg for others), severe cases may require intravenous thyroid hormone replacement in a hospital setting. Uncontrolled hypothyroidism can affect multiple body systems, leading to dangerous complications including heart problems, respiratory failure, and hypothermia. Don't wait for symptoms to become severe - contact your doctor promptly if your regular hypothyroidism symptoms worsen or if your medication doesn't seem effective, as noted in studies such as 1 and 1.

Key Considerations

• The most common cause of hypothyroidism in the United States is chronic autoimmune (Hashimoto) thyroiditis, with risk factors including female sex, advancing age, white race, type 1 diabetes, Down syndrome, family history of thyroid disease, goiter, previous hyperthyroidism, and external-beam radiation in the head and neck area, as discussed in 1 and 1.
• The principal treatment for hypothyroidism is oral T4 monotherapy (levothyroxine sodium), with treatment generally recommended for patients with a TSH level that is undetectable or less than 0.1 mIU/L, particularly those with overt Graves disease or nodular thyroid disease, as mentioned in 1.
• The optimal screening interval for thyroid dysfunction is unknown, and evidence that screening for thyroid dysfunction improves important health outcomes is lacking, highlighting the need for long-term randomized, blinded, controlled trials, as noted in 1.

Important Outcomes

• Cardiovascular- and cancer-related morbidity and mortality
• Falls, fractures, functional status, and quality of life
• Intermediate biochemical outcomes, such as serum TSH levels, are less important and not reliable evidence of treatment effectiveness, as discussed in 1.

Clinical Approach

• Detection and treatment of abnormal TSH levels (with or without abnormal T4 levels) in asymptomatic persons is common practice, but evidence that this clinical approach improves important health outcomes is lacking, as mentioned in 1.
• Treatment is typically not recommended for patients with TSH levels between 0.1 and 0.45 mIU/L or when thyroiditis is the cause, as noted in 1.

From the FDA Drug Label

The general aim of therapy is to normalize the serum TSH level TSH may not normalize in some patients due to in utero hypothyroidism causing a resetting of pituitary-thyroid feedback. Failure of the serum T4 to increase into the upper half of the normal range within 2 weeks of initiation of levothyroxine sodium therapy and/or of the serum TSH to decrease below 20 IU per litre within 4 weeks may indicate the patient is not receiving adequate therapy Assess compliance, dose of medication administered, and method of administration prior to increasing the dose of levothyroxine sodium

When to go to the hospital for uncontrolled hypothyroidism:

• If there is failure of the serum T4 to increase into the upper half of the normal range within 2 weeks of initiation of levothyroxine sodium therapy
• If there is failure of the serum TSH to decrease below 20 IU per litre within 4 weeks
• If the patient is not receiving adequate therapy as indicated by persistent clinical and laboratory evidence of hypothyroidism despite an apparent adequate replacement dose of levothyroxine sodium
• If there are serious risks related to overtreatment or undertreatment with levothyroxine sodium tablets, such as negative effects on growth and development, cardiovascular function, bone metabolism, reproductive function, cognitive function, gastrointestinal function, and glucose and lipid metabolism 2

From the Research

Symptoms of Uncontrolled Hypothyroidism

• Cold intolerance, fatigue, weight gain, dry skin, constipation, and voice changes are common symptoms of hypothyroidism 3, 4
• If left untreated, hypothyroidism can lead to severe complications like mental retardation, delayed milestones, heart failure, infertility, myxedema coma, etc. 4, 5

When to Seek Hospital Care

• Myxedema coma is a life-threatening disorder characterized by severe hypothyroidism leading to multiorgan failure and even death, and requires immediate hospital care 6, 5, 7
• Patients with symptoms such as deterioration of mental status, hypothermia, hypotension, hyponatremia, and hypoventilation should seek hospital care immediately 6, 5
• If hypothyroidism is not responding to treatment, or if symptoms persist or worsen, patients should seek hospital care for reassessment and management 3, 4

Emergency Care for Myxedema Coma

• Myxedema coma requires intensive supportive care and appropriate management of the underlying thyroid hormone deficiency 6, 5
• Treatment with levothyroxine and liothyronine has been shown to be effective in managing myxedema coma 6, 5
• Early recognition and treatment of myxedema coma are essential to reduce mortality rates 6, 7