Division of Nuclear Medicine
560 First Avenue
New York, N.Y. 10016
Phone: (212) 263-7410
Fax: (212) 263-7519
Thyrogen Information and Consent Form
Thyrogen is a synthetic version of thyroid stimulating hormone (TSH). Thyrogen injections
stimulate radioactive iodine uptake in functioning thyroid tissue which is important for the
detection and treatment of thyroid cancer. Thyrogen is used to assist in monitoring of serum
thyroglobulin levels (a marker of thyroid cancer), and also helps increase the sensitivity of
nuclear medicine thyroid scans.
Thyrogen stimulation avoids the adverse side effects of discontinuation of thyroid hormone
therapy and is useful in individuals who are unable to tolerate hypothyroidism or cannot produce
sufficient levels of their own TSH. Your doctor has selected Thyrogen preparation as an
alternative to hormone withdrawal.
There are minimal risks associated with Thyrogen injections. Among the risks is infection or
soreness at the injection site due to the needle puncturing the skin. We minimize this risk by
maintaining strict sanitary precautions using gloves and alcohol wipes. There is also a possibility
of an allergic reaction, albeit rare. Please let us know if you have had a reaction to Thyrogen in
the past. Thyrogen is also known in rare cases to exacerbate conditions related to heart
disease or high blood pressure. The most commonly reported symptoms of Thyrogen injections
are dizziness (3%), vomiting (3%), fatigue (3%), headache (7%) and nausea (12%).
Thyrogen should not be used during pregnancy or breastfeeding unless advised by your doctor.
Please let us know if you think you are pregnant.
I, _________________ consent to intramuscular administration of Thyrogen.
Dr. ________________ has answered all my questions and explained to me the benefits, risks,
side effects and alternatives to this procedure. If I am a woman of childbearing age, I am not
pregnant.
Witness _________________________________
Patient Signature__________________________
Date____/____/____
Consent version: March 31, 2011