When should I consider referring a patient with Graves' disease to an endocrinologist?

Consider referring a patient with Graves' disease to an endocrinologist for specialist management or investigations in the following situations:

• If the patient has new-onset overt hyperthyroidism confirmed by thyroid function tests, referral urgency depends on clinical judgement but should generally be arranged for specialist assessment and management ¹.
• If there is a goitre, thyroid nodule, or structural thyroid change raising suspicion of malignancy, refer urgently via a suspected cancer pathway ¹.
• If the patient is planning a pregnancy, specialist input is recommended to optimise management ¹.
• If the patient has troublesome symptoms despite beta-blocker treatment, or beta-blockers are contraindicated or not tolerated, seek specialist advice about starting antithyroid drugs such as carbimazole ¹.
• If the patient is at risk of complications from hyperthyroidism or is taking drugs like amiodarone or lithium that affect thyroid function, liaise with an endocrinologist ¹.
• If subclinical hyperthyroidism is persistent with TSH <0.1 mIU/L on at least two occasions 3 months apart, and there is evidence of thyroid disease (e.g., positive TSH receptor antibodies or goitre) or symptoms of thyrotoxicosis, consider specialist advice ¹,³.
• If there is suspicion of a pituitary or hypothalamic disorder (e.g., TSH-producing pituitary adenoma), arrange urgent specialist referral ¹.
• If thyroid function tests are atypical or difficult to interpret, specialist assessment is warranted to exclude rare causes such as thyroid hormone resistance ².

While awaiting specialist assessment, consider prescribing beta-blockers for adrenergic symptoms if there are no contraindications, adjusting dose according to response, and tapering once euthyroid ¹.