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Is it another case of non-compliance?
A Falinska, K Ahmed
Department of Endocrinology and Diabetes, West Middlesex University Hospital, Middlesex

Case History:
A 48-year-old woman is under our endocrinology department for hypothyroidism. She has
been diagnosed with hypothyroidism and primary billiary cirrhosis around 10 years ago. Over
this time she was seen irregularly at both endocrinology and gastroenterology clinics due to
failure to attend. Each time the abnormal result of her thyroid function was assumed to be
due to non-compliance. Patient admitted herself a few times to not taking her medications on
a regular basis. She was prescribed oral Levothyroxine in doses between 100- 200 mcg with
no symptomatic or biochemical improvement.
During the last clinic appointment she complained of coarse and very itchy skin, weight gain,
persistent fatigue, lack of energy. She denied constipation, hair loss, breathlessness and
cold intolerance. She assured me that the only medication she is taking consistently is
Levothyroxine. She lives in a flat with her son and hardly ever goes outside. She described
herself as struggling to mobilise at home. She does not drink any alcohol now but used to
drink excessively. She smokes 8-10 cigarettes a day. On physical examination her heart rate
was regular at 76/min, blood pressure was 96/56 mm Hg, and weight was 55.5 kg. The
thyroid was small, with no palpable nodules. There was no proximal myopathy and power
was normal in both arms and legs. Tendon reflexes were present but reduced. There was no
periorbital puffiness, no loss of the lateral third of the eyebrows. There were signs of chronic
liver disease (palmar erythema, spider nevi, scratch marks).
Her other significant medical history includes primary billiary cirrhosis with portal
hypertension and oesophageal varices, osteoporosis, hypercholesterolemia, iron-deficiency
anaemia, migraines, depression and anxiety. Over the years she was prescribed various
medications including ursodeoxycholic acid, colestyramine, spironolactone, omeprazole,
ferrous sulphate, calcium and vitamin D3 but compliance was always debatable as patient
herself admitted to not taking them. Her mother died of liver cancer and was also diagnosed
with PBC.
Investigations and method:
Available laboratory data show persistent elevation of TSH level, ranging from 20.73 to
339.93 mIU/L (0.4-5.5 mIU/L) and persistently low T4 ranging from 2.4 to 12.1 pmol/l (10.3-
23.2 pmol/l). Her cholesterol is elevated at 6.19 mmol/L with high LDL (4.63mmol/L).
Short Synacthen test was within normal range (baseline Cortisol 458 nmol/L raising to 727
nmol/L after Synacthen, ACTH 12 pg/mL). Liver function tests are abnormal but stable over
the last few months. US abdomen revealed generalised fatty liver texture with focal areas of
increased echogenicity and normal bile ducts and pancreas. Coeliac screen was negative.
OGD was negative for H.pylori 2 years ago.
Results and treatment:
Persistently high TSH and low T4 requiring replacement and Levothyroxine 150mcg daily
prescribed.
Conclusions and points for discussion:
This case addresses the issue of management of persistently elevated TSH despite
thyroxine replacement. It is most commonly related to lack of compliance and it is a very
likely cause in our case. Other causes include malabsorption, gastritis in H.pylori infection,
liver cirrhosis and drugs that may interfere with levothyroxine absorption (colestyramine,
aluminium hydroxide, sucralfate, omeprazole, rifampicine, phenytoin, iron and calcium
carbonate).

Source: http://www.bioscilibrary.com/resource/clinicalupdate/cu10/Is%20it%20another%20case%20of%20non-compliance.pdf