RESUMO
Background: Nonadherence to medications is a common clinical issue. We describe a case in which weekly visits to assess medication adherence achieved euthyroidism in a patient with persistent primary hypothyroidism and suspected nonadherence to levothyroxine. The patient, however, did not report nonadherence. Case Presentation: A male aged 67 years with multinodular goiter underwent total thyroidectomy for abnormal thyroid nodule biopsy. Surgical pathology revealed papillary thyroid cancer with lymph node metastasis for which he received radioactive iodine treatment. His plasma thyrotropin (TSH) was noted to be 0.28 uIU/mL (reference range 0.35-4.00 uIU/mL) 7 months postsurgery while taking 224 mcg levothyroxine tablets daily. His plasma TSH remained elevated for about 5 years despite titrations of the levothyroxine dosage, counseling, and multiple follow-up visits. A home care nurse was involved in monitoring the patient taking levothyroxine daily and correctly but was unsuccessful. The patient and his son reported taking levothyroxine daily and correctly. The patient was asked to visit the primary care clinic every week for 6 weeks with all his medications. Repeat plasma TSH normalized to 1.01 uIU/mL. The suspected etiology of previously high plasma TSH was nonadherence to levothyroxine, which was discussed in detail with the patient. The patient verbalized understanding, was willing to follow recommendations and ended the weekly clinic visits. Repeat plasma TSH was again high and the patient claimed adherence, but weekly visits to primary care clinic were resumed, and life-threatening consequences of hypothyroidism were discussed with the patient and his son. After 9 weeks of visits, he was noted to have low plasma TSH (0.23 uIU/mL). Conclusions: Weekly visits seem impractical but may help in cases of persistent hypothyroidism in which the patient admits to being or is suspected to be nonadherent to levothyroxine. Knowing their medication use will be checked at weekly clinic visits may motivate the patient to be adherent.
RESUMO
Background: After the initial thyroid nodule diagnosis, a patient's thyrotropin is often monitored. However, the American Thyroid Association guidelines do not offer recommendations for follow-up thyrotropin testing for patients with thyroid nodules who have no history of conditions or known medications that affect thyroid hormone levels. Methods: At the Veterans Affairs Dayton Healthcare System in Ohio, we conducted a retrospective chart review from January 2010 to December 2016 of 100 patients diagnosed with ≥ 1 thyroid nodule on imaging studies who had normal blood thyrotropin at the time of nodule diagnosis. The thyrotropin value was studied at and after diagnosis. A 95% CI was determined for the true population rate of patients with an abnormal thyrotropin at their most recent testing. χ2 tests for categorical variables and independent sample t tests for continuous variables were used to compare the abnormal and normal most recent thyrotropin groups. Results: One hundred patients (male [83%], White race [82%]) with normal thyrotropin at nodule diagnosis had thyrotropin monitoring for a mean (SD) of 5.7 (2.5) years. Six of 100 patients (6%; 95% CI, 2.5%-12.7%) developed abnormal thyrotropin levels in a mean (SD) of 6.9 (3.1) years. When comparing the 6 patients with abnormal thyrotropin vs the 94 with normal thyrotropin, there were no significant differences in sex (P = .99), race (P = .55), age at diagnosis (P = .12), initial thyrotropin level (P = .24), most recent thyrotropin level (P = .98), or time from diagnosis to most recent thyrotropin level (P = .23). Conclusions: This study found no significant change in thyrotropin levels over time in patients with thyroid nodules and no history of medical conditions or medications known to affect thyrotropin levels. Monitoring thyrotropin over time may not be required in these patients. More studies are needed to provide additional data on thyrotropin monitoring for thyroid nodules so that clinicians can make evidence-based decisions.