# Ata Ch AI Screening Lt4

> Evaluates central hypothyroidism (CH) patients for adrenal insufficiency (AI) prior to initiating levothyroxine (L‑T4) replacement. Triggers include consideration of L‑T4 start in central hypothyroidism needing thyroid replacement.

- Skill: `dromlakhani/ata-ch-ai-screening-lt4` (Agent Skill)
- Install (CLI): `npx skillmds add dromlakhani/ata-ch-ai-screening-lt4`
- Raw SKILL.md: https://api.skillmd.com/api/skills/dromlakhani/ata-ch-ai-screening-lt4/raw
- Safety review: pending (external: skill-scanner PASS, skillspector PASS)
- Works with: Claude Code, Claude.ai, OpenAI Codex
- Category: Coding & Dev Tools
- Author: dromlakhani (https://skillmd.com/u/dromlakhani)
- Updated: 2026-08-19
- Page: https://skillmd.com/skills/dromlakhani/ata-ch-ai-screening-lt4

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# Screen central hypothyroidism patients for adrenal insufficiency before levothyroxine

## STEP 1 — Gather Information
Confirm CH diagnosis: low or low‑normal free T4 (fT4) with non‑elevated TSH in the setting of pituitary disease; assess hypothyroid symptoms; obtain baseline morning serum cortisol (8‑9 AM) if feasible.

## STEP 2 — Rule In / Rule Out
Determine if AI testing is feasible (morning cortisol or ACTH stimulation test can be performed). If not feasible, proceed to empiric glucocorticoid therapy; if feasible, move to biochemical evaluation.

## STEP 3 — Classify or Stratify
Interpret morning cortisol: <3 µg/dL suggests AI; >15 µg/dL makes AI unlikely; values 3‑15 µg/dL require low‑dose (1 µg) or standard‑dose (250 µg) ACTH stimulation test, with peak cortisol <18.1 µg/dL indicating AI.

## STEP 4 — Decide
If AI is confirmed, initiate glucocorticoid replacement (e.g., hydrocortisone 15‑20 mg daily in divided doses) before starting L‑T4; if AI is ruled out, begin L‑T4 therapy targeting mid‑to‑upper reference range fT4; if testing was not feasible, prescribe empiric glucocorticoid therapy (same dosing) while arranging definitive AI evaluation.

## Clinical Guardrails / Mimics / Pitfalls
Do not start L‑T4 without assessing AI due to risk of precipitating adrenal crisis; avoid random cortisol for diagnosis; do not use fludrocortisone in secondary AI; ensure patients receive stress‑dose education and emergency glucocorticoid kit; remember that estrogen can raise total cortisol via CBG, potentially masking AI.

## Concrete Clinical Example
A 50‑year‑old man with non‑functioning pituitary adenoma post‑resection presents with low fT4 and normal TSH; morning cortisol is 2.5 µg/dL (<3 µg/dL), confirming AI; he receives hydrocortisone 10 mg on waking and 5 mg in the afternoon before L‑T4 is started.

**Source:** Hormonal Replacement in Hypopituitarism in Adults: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, DOI:10.1210/jc.2016-2118