Things We Do for No Reason™: Routine Thyroid-Stimulating Hormone Testing in the Hospital

• Do not routinely order TSH on admission given the low pretest probability of clinically significant thyroid disease.
• Do not routinely check TSH for inpatients on stable outpatient doses of thyroid hormone replacement.
• Reserve TSH testing for clinical scenarios in which there is either a high pretest probability of thyroid disease (five or more symptoms) or for the evaluation of specific clinical syndromes for which thyroid dysfunction is a known reversible contributor (such as atrial fibrillation, SIADH, unexplained sinus tachycardia, and delirium).
• Do not attempt to diagnose subclinical thyroid disease in the hospital.
• If NTIS is suspected, avoid further testing in the hospital. Repeating TFTs as an outpatient may be appropriate after resolution of the acute illness.

Routine TSH testing in hospitalized patients is unhelpful and often yields confusing results because of the low prevalence of unrecognized thyroid disease, the high prevalence of NTIS, and the resulting difficulty with interpretation of results. Mild TSH abnormalities in hospitalized patients do not predict clinically significant thyroid disease.^4,11 The patient in the previously described clinical scenario has NTIS caused by acute on chronic illness and the effect of glucocorticoids. As the hospitalist suspected, the patient’s AMS was caused by hypercapnia. Reserving TSH testing for patients with clinical signs and symptoms of thyroid disease or for those with specific conditions has the potential to save healthcare dollars, prevent harm to patients associated with overtesting or overtreatment, and decrease time spent interpreting abnormal results of unclear significance.

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