Weekly Intramuscular Injection of Levothyroxine following Myxoedema: A Practical Solution to an Old Crisis

Abstract

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.

The Level of Serum C-Reactive Protein and Neutrophil Lymphocyte Ratio According to Thyroid Function Status

“…Despite advanced laboratory techniques and increased awareness of the disease, there are still cases of excessive dysfunction. (14,15). Hypo -and hyperthyroidism are usually caused by pathological processes in the thyroid gland, but may be caused by hypothalamus or pituitary (central hypothyroidism) or functional thyroid disorders in certain situations (16).…”

Global epidemiology of hyperthyroidism and hypothyroidism

“…Thyroid dysfunction is common, readily identifiable and easily treatable but if undiagnosed or untreated can have profound adverse consequences 2,3 . Despite an increase in thyroid disease awareness and the availability of sensitive laboratory assays for the measurement of thyroid hormones it is remarkable that instances of extreme thyroid dysfunction continue to occur 4,5 . Hypothyroidism and hyperthyroidism most commonly arise from pathology within the thyroid gland (primary thyroid disease), although rarely they may arise from disorders of the hypothalamus or pituitary (central) or from peripheral causes 6 .…”

Intramuscular levothyroxine: a solution to a mental health related thyroid crisis

“…There are records of parenteral levothyroxine use as early as 1984,3 however just a handful of case studies since. Studies have demonstrated the successful use of intramuscular levothyroxine therapy in patients with both non-adherence4 and malabsorption 5. That being said, there are no well-established guidelines on its use6 and just five adult cases have been examined in the literature.…”