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Thyroid Function Assessment Using a Cost-Effective and Time-Efficient Testing Algorithm New Thyroid Function Screening Cascade Bronson Laboratory Services introduces a new laboratory testing cascade for the initial screening and diagnosis of thyroid disease in nonhospitalized patients. The cascade uses an algorithmic approach beginning with thyroid stimulating hormone (TSH). Further tests are performed automatically, at an additional charge, as illustrated in this flowchart: Nonhospitalized patients Not on thyroid replacement Without known or suspected pituitary disease TSH Low TSH <0.10 mIU/L Borderline low TSH 0.1-0.26 mlU/L Normal TSH 0.27-4.2 mlU/L High TSH >4.2 mlU/L Suspect Hyperthyroidism Free T4 to evaluate for possible Hyperthyroidism No further testing unless clinically indicated Suspect Hypothyroidism Free T4 and Thyroid peroxidase antibodies Free T4 fT4 <2.0 ng/dL fT4 2.0 ng/dL or greater Total T3 to evaluate for possible T3 toxicosis Consistent with primary Hyperthyroidism Monitoring Patients on Thyroid Replacement The complete thyroid screening cascade is not designed for monitoring patients receiving thyroid replacement therapy. For monitoring, TSH and/or free T4 should be ordered individually. Patients on a stable dose of thyroid medication may be monitored with TSH alone. After initiating thyroid replacement therapy or changing dosage, free T4 levels should be followed until TSH levels stabilize (3-6 weeks).