How do I install the Es Tshd Treatment Approach skill?

Run npx skillmds@latest add dromlakhani/es-tshd-treatment-approach in your terminal (requires Node.js), paste this page's agent-chat prompt into Claude, Cursor, or any MCP-connected agent, or download the SKILL.md file and copy it into your agent's skills directory.

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Is Es Tshd Treatment Approach free to use?

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Who published Es Tshd Treatment Approach?

dromlakhani (@dromlakhani) published this skill. Their other Agent Skills are listed on their SkillMD profile.

Es Tshd Treatment Approach by dromlakhani

Name: Es Tshd Treatment Approach
Rating: 4.2 (5 reviews)
Author: dromlakhani

Es Tshd Treatment Approach

This skill determines the appropriate treatment approach for thyroid-stimulating hormone deficiency (TSHD) in childhood cancer survivors. It recommends using the same levothyroxine dosing and monitoring strategies (e.g., target free T4 levels) as in the noncancer population, triggered by questions such as "How should I treat central hypothyroidism in this survivor?" or "What levothyroxine dose is appropriate for TSHD?"

dromlakhani Updated Sep 8, 2026 10 repo stars

File contents

Select TSHD treatment strategy

STEP 1 — Gather Information

Collect history of hypothalamic-pituitary radiation ≥30 Gy, tumors/surgery involving HP region, other pituitary deficits, symptoms of central hypothyroidism, baseline free T4 and TSH, and assess adrenal axis function.

STEP 2 — Rule In / Rule Out

Rule in TSHD if free T4 is low or low-normal with normal or mildly elevated TSH (not elevated as in primary hypothyroidism); rule out primary hypothyroidism (high TSH) and non-thyroidal illness.

STEP 3 — Classify or Stratify

Classify based on free T4 level (low vs low-normal) and confirm adrenal sufficiency before thyroid hormone replacement.

STEP 4 — Decide

Initiate levothyroxine replacement using weight-based dosing (e.g., 1.6 µg/kg/day) as in noncancer population; aim for free T4 in middle to upper half of normal range; recheck free T4 4–6 weeks after dose change or starting GH; monitor annually; do not use TSH for monitoring adequacy.

Clinical Guardrails / Mimics / Pitfalls

Do not rely on TSH to assess thyroid hormone adequacy in TSHD; ensure adrenal axis is adequate before starting levothyroxine to prevent adrenal crisis; be aware of enzyme‑inducing antiepileptics (e.g., phenytoin, carbamazepine) that may increase levothyroxine metabolism; avoid using TSH surge analysis or TRH stimulation for diagnosis.

Concrete Clinical Example

A 16‑year‑old survivor treated with craniospinal irradiation 35 Gy presents with fatigue, free T4 at low‑normal limit, TSH normal, and normal adrenal function. Start levothyroxine 1.6 µg/kg/day, target free T4 mid‑normal, recheck in 6 weeks.

Source: Hypothalamic Pituitary and Growth Disorders in Survivors of Childhood Cancer: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2018, doi:10.1210/jc.2018-01175

---name: es-tshd-treatment-approachdescription: This skill determines the appropriate treatment approach for thyroid-stimulating hormone deficiency (TSHD) in childhood cancer survivors. It recommends using the same levothyroxine dosing and monitoring strategies (e.g., target free T4 levels) as in the noncancer population, triggered by questions such as "How should I treat central hypothyroidism in this survivor?" or "What levothyroxine dose is appropriate for TSHD?"---# Select TSHD treatment strategy## STEP 1 — Gather InformationCollect history of hypothalamic-pituitary radiation ≥30 Gy, tumors/surgery involving HP region, other pituitary deficits, symptoms of central hypothyroidism, baseline free T4 and TSH, and assess adrenal axis function.## STEP 2 — Rule In / Rule OutRule in TSHD if free T4 is low or low-normal with normal or mildly elevated TSH (not elevated as in primary hypothyroidism); rule out primary hypothyroidism (high TSH) and non-thyroidal illness.## STEP 3 — Classify or StratifyClassify based on free T4 level (low vs low-normal) and confirm adrenal sufficiency before thyroid hormone replacement.## STEP 4 — DecideInitiate levothyroxine replacement using weight-based dosing (e.g., 1.6 µg/kg/day) as in noncancer population; aim for free T4 in middle to upper half of normal range; recheck free T4 4–6 weeks after dose change or starting GH; monitor annually; do not use TSH for monitoring adequacy.## Clinical Guardrails / Mimics / PitfallsDo not rely on TSH to assess thyroid hormone adequacy in TSHD; ensure adrenal axis is adequate before starting levothyroxine to prevent adrenal crisis; be aware of enzyme‑inducing antiepileptics (e.g., phenytoin, carbamazepine) that may increase levothyroxine metabolism; avoid using TSH surge analysis or TRH stimulation for diagnosis.## Concrete Clinical ExampleA 16‑year‑old survivor treated with craniospinal irradiation 35 Gy presents with fatigue, free T4 at low‑normal limit, TSH normal, and normal adrenal function. Start levothyroxine 1.6 µg/kg/day, target free T4 mid‑normal, recheck in 6 weeks.**Source:** Hypothalamic Pituitary and Growth Disorders in Survivors of Childhood Cancer: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2018, doi:10.1210/jc.2018-01175

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