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This article provides a step-by-step approach to counselling patients about levothyroxine in an OSCE setting.
Opening the consultation
Wash your hands and don PPE if required.
Introduce yourself including your name and role.
Confirm the patient’s name and date of birth.
Explain the reason for the consultation: “Today I’d like to talk to you about the new medication you’ve been prescribed, would that be ok?”.
Establish rapport and an open line of communication: “Feel free to interrupt me if you have any questions at any point”.
Make sure to check the patient’s understanding at regular intervals throughout the consultation and provide opportunities to ask questions (this is often referred to as ‘chunking and checking’).
Ideas, concerns and expectations
A key component of counselling involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE).
Asking about a patient’s ideas, concerns and expectations can provide insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation. It can sometimes be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided some examples for each of the three areas below.
“Do you know what hypothyroidism is?”
“Have you heard of levothyroxine?”
“What do you know about levothyroxine?”
“Do you know what levothyroxine is used for?”
“Is there anything, in particular, that’s worrying you about taking levothyroxine?”
“What were you hoping to get from our discussion today?”
“Is there anything, in particular, you would like to discuss today?”
Although the purpose of this station is to counsel the patient, it is a good idea to gather a quick, focusedhistory early in the consultation.
It would be appropriate to ask about specific symptoms of hypothyroidism that the patient may be experiencing such as weight gain, cold intolerance, dry skin and constipation.
It is also important to clarify what medications the patient takes, to identify possible interactions with levothyroxine.
What is hypothyroidism?
You should begin your explanation by discussing hypothyroidism, as this will form a foundation of understanding to then build upon with your description of levothyroxine.
“Your thyroid sits at the base of your neck and produces a hormone called thyroxine that regulates many aspects of your metabolism, such as heat control, weight and energy levels. When your thyroid doesn’t produce enough thyroxine, we call this hypothyroidism.”
If the patient has already mentioned some symptoms of hypothyroidism, try to integrate these into your tailored explanation.
“You mentioned you have been feeling tired recently which is a common symptom of hypothyroidism. Other symptoms of hypothyroidism can include weight gain, dry skin, constipation and feeling colder than usual.”
What is levothyroxine and how does it work?
Move on to explaining that levothyroxine is a synthetic form of thyroxine that can be used to increase the level of thyroid hormones in people with hypothyroidism.
“Levothyroxine is a medication that can be used to top up the level of thyroxine in people whose bodies are unable to make enough thyroid hormones on their own. By using this medication, we can restore normal levels of thyroid hormones and prevent you from experiencing the symptoms associated with hypothyroidism.”
How to take levothyroxine
Explain that levothyroxine is prescribed as a once a day tablet.
The medication should be taken at least 30 minutes before breakfast. This is because food and coffee can reduce the absorption of levothyroxine.1
Explain that the treatment is lifelong and make it clear that they shouldn’t suddenly stop taking levothyroxine or change their dose without speaking to a doctor first.
If they forget to take a dose, advise them to take it as soon as they remember but to avoid double dosing.
“You should take levothyroxine every morning before breakfast because food and coffee can reduce the amount of the medication you absorb. Unfortunately, you’ll most likely need to continue this treatment for the rest of your life, as your thyroid is very unlikely to recover and be able to produce enough of its own hormones.”
“It’s important that you don’t stop taking the medication suddenly or change the number of tablets you’re taking without talking to a doctor. You can always get in touch if you have any questions or concerns.”
“If you miss a tablet, try to take it as soon as you remember, but avoid taking two doses in the same day.”
Monitoring of thyroid function tests (TFTs) is essential for patients taking levothyroxine.
The following intervals are recommended:
2-3 weeks after initiation of treatment, tweaking levothyroxine dose as required
2-3 monthly intervals after a dose change
Annually once thyroid hormone levels are within the normal range and stable
“When you first start taking levothyroxine, it can be difficult for us to know what is the right dose for you as everyone is slightly different. As a result, we’ll need to check your thyroid hormone levels 2-3 weeks after starting the treatment to see if we need to adjust the dose. We’ll then re-check your thyroid hormone levels every 2-3 months until your levels are stable after which you’ll need your levels checking once a year.”
Levothyroxine’s side effects most commonly relate to either underdosing or overdosing (i.e. symptoms of hypothyroidism or hyperthyroidism respectively).
An excessive dose of levothyroxine can result in symptoms of hyperthyroidism such as:
An inadequate dose of levothyroxine can result in symptoms of hypothyroidism such as:
“There are very few side effects associated with levothyroxine when the dose is correct for you. However, when commencing treatment, the dose may be either too low resulting in your hypothyroidism symptoms continuing or too high causing symptoms of hyperthyroidism such as weight loss, tremor and heat intolerance. This is why we’ll be checking your thyroid hormones more frequently at first, to make sure we get your dose right as quickly as possible.”
Closing the consultation
Check the patient’s understanding of the information given and ask if they have any questions.
Summarise what you have discussed to emphasise the key points to the patient.
Advise the patient that because they have hypothyroidism, they are now eligible to claim free prescriptions for all of their medications moving forward. Signpost them towards the appropriate resources to apply for free prescriptions.
Thank the patient and offer them relevant leaflets or websites to learn more about hypothyroidism and levothyroxine.
Remind the patient to get in touch with their doctor if they have any further questions.
Dispose of PPE and wash your hands.
“That’s all the information I have for you today. Could I just ask if you feel like you have understood everything we’ve talked about today and if you have any questions for me?”
“Just before we finish, I’d like to quickly summarise what we’ve talked about. We’ve discussed your diagnosis of hypothyroidism and the rationale behind taking lifelong levothyroxine to replace your thyroid hormones. We also discussed how to take levothyroxine and the importance of not missing doses. Finally, we discussed the potential side effects of levothyroxine and the monitoring required to make sure you’re taking the correct dose.”
“Thank you for taking the time to talk today, I understand this is a lot of information to take in, so please read through the leaflets I’ve provided and get back in touch if you have further questions.”
Dr Emily Clothier
Consultant GP at Brooks Bar Medical Centre
Patient.info. Levothyroxine. Published 2020. Available from: [LINK]
NHS.uk. Levothyroxine. Published 2018. Available from: [LINK]
NICE Guidelines. Levothyroxine. Published 2021. Available from: [LINK]