Stopping thyroid medication when used as augmenting agent

[psychres23]

Hey, I have a patient that I inherited from another resident who is currently receiving Cytomel 25mcg as augmenting agent for depression. They have been on the medication for about 10 months. Most recent TSH was in April with level of 0.08 (low) and normal T4. This medication has not been working and I want to discontinue it, however am not sure how to do so. Does it need a taper? Is there a certain protocol for stopping thyroid medication when it has been used this long? TIA

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[DisorderedDoc417]

The medicine only works if there is an underlying issue with the thyroid. Great way to piss off a patients endocrinologist is to do the above. I’d stop it in a hot second.

 

[psychres23]

The medicine only works if there is an underlying issue with the thyroid. Great way to piss off a patients endocrinologist is to do the above. I’d stop it in a hot second.

Does it require a taper though, or can you just stop all of a sudden like that? His TSH is basically non-existent given he's getting the exogenous hormone, but will he just start producing TSH immediately and regulating thyroid hormones again without a taper?

 

[splik]

The medicine only works if there is an underlying issue with the thyroid. Great way to piss off a patients endocrinologist is to do the above. I’d stop it in a hot second.

This isn’t true I use cytomel to augment TCA and MAOIs (no evidence for SSRIs) when lithium isn’t an option. When it works it works. Thyroid status is not relevant.

BTW it’s a problem if his TSH is non existent though... that can happen but does not normally. If you want to get him off it you should refer to endocrinology

 

[NITRAS]

You guys do know that cytomel is T3, and the T4 levels are not helpful.

 

[psychres23]

This isn’t true I use cytomel to augment TCA and MAOIs (no evidence for SSRIs) when lithium isn’t an option. When it works it works. Thyroid status is not relevant.

BTW it’s a problem if his TSH is non existent though... that can happen but does not normally. If you want to get him off it you should refer to endocrinology

Thanks splik! Will talk to my attending about this and likely do this.

 

[psychres23]

Does anyone know the process an endocrinologist does to get someone off of this btw?

 

[clausewitz2]

You guys do know that cytomel is T3, and the T4 levels are not helpful.

In the absence of a largely theoretical peripheral enzyme deficiency T3 and T4 levels are actually highly correlated.

 

[WiseOne]

AFAIK, Synthroid does not require a taper because it has a very long half-life. Cytomel however has a much shorter half life so the strategy is likely different. In any case an endocrine referral is probably appropriate.

 

[futuredo32]

I used it last year when my thyroid levels were off and my TSH was really elevated after just stopping, I would definitely get an endo consult.

 

[psychres23]

What about a taper as follows: take one tablet of 25mcg every other day for 1 week, then take half tab every other day for one week, then re-check TSH (and if TSH approaching normal then just d/c)?

I wouldn't mind referring to endo, but if we are starting this medication for adjunct treatment of depression, shouldn't we also know how to stop it?

 

[psychres23]

the issue is the patient now has a low TSH. That is why you would refer to endo, not simply to taper off. if you have the ability to get a curbside or put in an econsult that might suffice but don’t just make it up. Psychiatrists don’t usually manage drug induced diabetes either.

Shouldn't the TSH correct itself as the Cytomel is tapered off though since there is no underlying thyroid condition causing hypothyroidism? I guess I'm just wondering what the endocrinologist would do different than I would if its just a taper and re-check the TSH to make sure it is corrected?

 

[WiseOne]

Shouldn't the TSH correct itself as the Cytomel is tapered off though since there is no underlying thyroid condition causing hypothyroidism? I guess I'm just wondering what the endocrinologist would do different than I would if its just a taper and re-check the TSH to make sure it is corrected?

They might not do anything different. Surely you could use the same reasoning about managing renal toxicity from lithium but I don't think any psychiatrist would be tempted to do that (despite having been the one who started the medication). There are a lot of things you can do on your own but should be left to someone who is more ideally suited to do it (in my opinion, this is why in large academic hospitals you see the fellows taking all the procedures from the interns and so on).