An 82-year-old female with known hypothyroidism was admitted to hospital after being found on the floor. On examination, she was unkempt, confused, bradycardic, hypothermic, and barely arousable. Initial biochemistry revealed a thyroid stimulating hormone (TSH) of >100 mU/L and free thyroxine (FT4) level of 1.5 pmol/L which supported a diagnosis of myxoedema coma. She was resuscitated and commenced on liothyronine, levothyroxine, and hydrocortisone and some improvement was made. It became apparent that she was hiding and spitting out her oral levothyroxine including levothyroxine elixir. Given the need for prompt alternative control, we sought advice from international experts where intramuscular levothyroxine was recommended. She was managed from day 50 onwards with intramuscular levothyroxine 200 mcg once a week, which was subsequently increased to 500 mcg. Thyroid function normalized and she made continual cognitive and physical progress and was discharged to a rehabilitation hospital. Her intramuscular levothyroxine was stopped and she was subsequently restarted on oral levothyroxine, with a plan for on-going close monitoring of her thyroid function. This report highlights the potential to use intramuscular levothyroxine in individuals with severe hypothyroidism arising from poor compliance with levothyroxine treatment or other potential causes such as impaired absorption.

Journal WatchEfficacy and safety of evolocumab in reducing lipids and cardiovascular events Sabatine MS, Giugliano RP, Wiviott SD, et al. N Engl J Med 2015; 372: 1500-1509 Inhibition of proprotein convertase subtilisin-kexin type 9 (PCSK9) is a novel strategy for LDL cholesterol (LDL-C) reduction, which has delivered promising results in phase 3 trials. In particular, marked reductions in LDL-C, but also triglycerides and lipoprotein(a), have been noted, even in patients already treated with statins. However, hard outcome data are likely to be required for these agents to achieve widespread acceptance.This report analysed combined data from open label trials of evolocumab, a monoclonal antibody against PCSK9, and identified a significant reduction in cardiovascular events in the treatment arm (hazard ratio 0.47 vs. control group, P ¼ 0.003) after 12 months of treatment. One point of potential concern was a higher incidence of neurocognitive adverse events (0.9% vs. 0.3%), although this was not related to extent of LDL-C reduction.In summary, this (and another article from the same edition reporting similar results with a related agent) provides the first evidence that PCSK9 inhibition reduces cardiovascular events -a finding that has been expected but nevertheless required confirmation.

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