Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX
Consider referring a patient with Graves' disease to an endocrinologist for specialist management or investigations in the following situations:
- If the patient has new-onset overt hyperthyroidism confirmed by thyroid function tests, referral urgency depends on clinical judgement but should generally be arranged for specialist assessment and management NICE CKS.
- If there is a goitre, thyroid nodule, or structural thyroid change raising suspicion of malignancy, refer urgently via a suspected cancer pathway NICE CKS.
- If the patient is planning a pregnancy, specialist input is recommended to optimise management NICE CKS.
- If the patient has troublesome symptoms despite beta-blocker treatment, or beta-blockers are contraindicated or not tolerated, seek specialist advice about starting antithyroid drugs such as carbimazole NICE CKS.
- If the patient is at risk of complications from hyperthyroidism or is taking drugs like amiodarone or lithium that affect thyroid function, liaise with an endocrinologist NICE CKS.
- If subclinical hyperthyroidism is persistent with TSH <0.1 mIU/L on at least two occasions 3 months apart, and there is evidence of thyroid disease (e.g., positive TSH receptor antibodies or goitre) or symptoms of thyrotoxicosis, consider specialist advice NICE CKS,NICE NG145.
- If there is suspicion of a pituitary or hypothalamic disorder (e.g., TSH-producing pituitary adenoma), arrange urgent specialist referral NICE CKS.
- If thyroid function tests are atypical or difficult to interpret, specialist assessment is warranted to exclude rare causes such as thyroid hormone resistance NICE CKS.
While awaiting specialist assessment, consider prescribing beta-blockers for adrenergic symptoms if there are no contraindications, adjusting dose according to response, and tapering once euthyroid NICE CKS.