5: Diagnosis and management of hyperthyroidism and hypothyroidism.

The most common cause of hyperthyroidism in Australia is Graves disease, caused by a defect in immunoregulation in genetically predisposed individuals, leading to production of thyroid-stimulating antibodies. Each of the three modalities of therapy for Graves disease--thionamide drugs, subtotal or total thyroidectomy, and radioactive iodine ablation--can render the patient euthyroid, but all have potential adverse effects and may not eliminate recurrences. Hypothyroidism occurs in about 5% of the adult population; most present with "subclinical" hypothyroidism (mild thyroid failure), characterised by raised levels of serum thyroid stimulating hormone (TSH) but normal free thyroxine (T(4)). The most common cause of hypothyroidism in Australia is autoimmune chronic lymphocytic thyroiditis, characterised by raised circulating levels of thyroid peroxidase antibody. Symptoms and signs of hypothyroidism are often mild or subtle and, when there is clinical suspicion, thyroid function tests are needed; if serum TSH level is raised, free T(4) and thyroid peroxidase antibody should be measured. Replacement therapy with thyroxine is the cornerstone of therapy (1.6 microg/kg lean body weight daily, taken on an empty stomach); combination therapy with thyroxine and liothyronine (T(3)) is promoted, but there is little evidence of its clinical benefit. Despite the development of highly sensitive laboratory tests, clinical assessment and judgement remain paramount