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Thyroid disorders in everyday care Chris Vreeland, RN, MSN, NP-c Georgia Mountain Endocrinology, PC.

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Presentation on theme: "Thyroid disorders in everyday care Chris Vreeland, RN, MSN, NP-c Georgia Mountain Endocrinology, PC."— Presentation transcript:

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2 Thyroid disorders in everyday care Chris Vreeland, RN, MSN, NP-c Georgia Mountain Endocrinology, PC

3 Introduction One in ten Americans have a thyroid disorder Body’s response to thyroid disorders is fatigue - most common reason to seek healthcare. Women particularly affected by thyroid imbalance Weight Fertility Pregnancy Menopause Osteoporosis

4 Thyroid Hormone Action Activates nuclear receptors which regulate expression of thyroid hormone-responsive genes:  Fetus & neonate: differentiation of target tissues  Childhood: differentiation/proliferation  Adolescent: role in action of sex steroids

5 Thyroid Hormone Action Gene expression (continued) All ages: Regulates energy production Regulates functional /structural proteins Regulates action of other hormones - glucocorticoids, mineralocorticoids, growth factors, biologic amines (catecholamines)

6 Negative Feedback Loop Thyroid hormone inhibits pituitary secretion of TSH Hypothalamus plays crucial role TSH very sensitive indication index of action TSH & thyroid hormones maintained in a certain relationship Modified by TBG (thyroxine-binding globulin)

7 Negative Feedback Loop Hyperthyroidism Elevated serum thyroid level Decreased TSH Hypothyroidism Decreased serum thyroid levels Increased TSH

8 Serum Levels of Thyroid Hormones T3 regulates peripheral action of hormone T3 & T4 both released from gland Peripheral conversion of T4 to T3 occurs in liver and target tissues In presence of liver damage, T3 conversion may be low despite good levels of T4

9 TBG Metabolism T4 transported to tissue by TBG High serum TBG (liver damage, pregnancy, OCP’s, HRT) lowers serum concentrations of free T4 which decreases amount of substrate (T4) that can be converted to T3 Indirect measure of TBG abnormality is T3 uptake

10 Causes of Thyroid Disorders Hyperthyroidism Graves’ disease: Autoimmune TSH receptor antibodies Thyroiditis: Sub-acute Post-partum Pituitary tumor - TSH producing

11 Causes of Thyroid Disorders Hypothyroidism (High TSH, low T3, T4) Hashimoto thyroiditis: Autoimmune TPO and thyroglobulin antibodies RAI: radioactive iodine ablation Surgery Antithyroid drugs Goitrogens: lithium, amiodarone

12 Normal Hormone Levels TSH: MIU/L Total T3: NG/DL Total T4: MCG/DL T3 Uptake: 22-35%

13 Hypothyroidism Symptoms Fatigue Weight gain Cold feeling Dry hair, nails, skin Hair loss Heavier or longer menses Constipation Peripheral edema Periorbital edema Bradycardia Hypotension Infertility

14 Hypothyroidism Treatment: Hormone replacement (L-T 4 ) Absorbed from small intestine 6-day half-life Daily dosing: mgs Branded preparations preferred to generic Synthroid Levoxyl Tirosint

15 Hypothyroidism Treatment Initial dose: 1.7 mcg per kg Pregnant: may need 1.8 mcg per kg Elderly: usually start at lower doses, esp. with angina or CAD Monitoring 6-8 weeks after any dose change Annually once stable Each trimester in pregnancy

16 Hypothyroidism Myxedema Coma End stage of uncompensated hypothyroidism Presents most often in elderly and women in winter months Present in respiratory failure, hypotension, bradyarrythmia, along with serious precipitating illness Treatment is T4 1/10th dose of oral ICU admit for multi-system failure

17 Hypothyroidism Pearls Most patients reports feeling best with TSH between 1-2 If TSH normal, but patient still not feeling good, think low T3; may need Cytomel (oral T3) Depression very common Inadequate treatment can contribute to infertility Look for recent onset of symptom with family history of thyroid disease

18 Hyperthyroidism Symptoms Anxiety Palpitations Unintended weight loss Decreased or absent menses Oily skin Fine, silky, oily-appearing hair Heat intolerance Exopthalmos (not all cases) Tachycardia

19 Hyperthyroidism Treatment Anti-thyroid drugs Methimazole Inhibits thyroid hormone synthesis in the thyroid gland PTU Inhibits thyroid hormone synthesis in the thyroid gland & inhibits peripheral conversion of T 4 to T 3

20 Hyperthyroidism Dosing: Tapazole: 10 mg BID or TID PTU: only 50 mg tablets available Usual starting dose: 2 tabs TID; may double dose if necessary Both very effective at lowering thyroid hormone levels TSH will stay suppressed several month

21 Hyperthyroidism Dosing: Monitor every 4-6 weeks When TSH rises, may need to add T 4 (thyroid hormone) Want to leave on ATD’s long enough to allow TSH receptor antibodies to decrease & induce remission; usually months Plan to withdraw med at months to evaluate remission status

22 Hyperthyroidism Side effects of anti-thyroid drugs: Leucocytopenia Agranulocytosis-most serious Pernicious anemia Thrombocytopenia Hepatic dysfunction Allergy (discoid rashes) Evaluate with CMP, CBC, & thyroid hormone levels every 4-6 months

23 Hyperthyroidism Radioactive Iodine Ablation Administration of I 131 iodine by mouth Used after TFT’s normal or if unable to control hyperthyroidism with drugs Usually destroys gland over 3-6 months

24 Hyperthyroidism Radioactive Iodine Ablation Induces permanent hypothyroidism May cause post-treatment thyroid storm (rare) May cause aggravation of Graves’ eye disease Pregnancy should be prevented within 6 months after treatment

25 Hyperthyroidism Surgery When disease state or gland size can’t be controlled with drugs When gland causing obstructive signs Difficulty breathing either supine or upright -Evaluated by PA & LAT CXR Difficulty swallowing food -Evaluated by barium swallow

26 Hyperthyroidism Thyroid Storm Most often with Graves’ disease Levels same as with Graves’ Cardinal signs: Temperature 102 to Profuse sweating Marked tachycardia ( pulse rate or higher) Atrial fibrillation Usually induced by concurrent infection or surgery on hyperactive gland

27 Hyperthyroidism Thyroid storm Treatment PTU orally or by NG tube Tapazole not favored because it does not inhibit peripheral conversion of T4 to T3 Beta blockade, PO or IV Supportive therapy for fever, dehydration Perhaps iodine solution or corticosteroids

28 Hyperthyroidism Graves’ Eye Disease: Caused by antibody effect on orbital tissue Symptoms include: Edema Inflammation Hypertrophy of extra ocular muscles & orbital fat Exopthalmos upper & lower lid retraction, strabismus, herniated orbital fat

29 Hyperthyroidism Graves’ Eye Disease: Should be stabilized for 6 months prior to any other treatment modality Exception is optic neuropathy caused by strangulation of optic nerve Extent of protrusion measured by increase in distance between lateral orbital rim and anterior aspect of eye

30 Thyroid Nodules May be a single nodule or larger of multiple nodules 95% benign More common in women More likely malignant in men Increase in size while on T4 therapy worrisome for malignancy

31 Thyroid Nodules Note size, consistency and mobility on physical exam Evaluate for tracheal deviation or esophageal obstruction Usually TSH suppressed, T3 and T4 levels normal Antibodies may be present, but more likely they are not not Ultrasound best way to diagnose

32 Thyroid Nodules Treatment Multinodular gland without dominant nodule: T 4 to shrink if TSH not suppressed Single nodule 1 cm or greater: fine needle aspiration biopsy Enlarging nodule despite “good” dose of T 4 or indeterminate or malignant result from FNA indicates need for surgery

33 Thyroiditis Most common cause: chronic autoimmune thyroiditis or post- partum thyroiditis Next is sub acute thyroiditis More rare: acute suppurative thyroiditis

34 Thyroiditis Post-partum thyroiditis May occur anytime in the first year, but most common in first 3 months Usually have hyperthyroid symptoms first, followed by hypothyroid findings Gland usually enlarged Will not have other markers for inflammation: fever, tenderness, high sed rate

35 Thyroiditis Post-partum thyroiditis Usually spontaneously resolve May need temporary medication support for symptoms Beta blockers for tachycardia Tranquilizers for anxiety T4 for hypothyroidism Can progress to permanent hypothyroidism

36 Thyroiditis Sub acute Usually follows viral illness Gland is swollen, tender Sed rate elevated >50mm/hour May have fever, even fairly mild Leucocytosis Follows usual pattern of transient hyperthyroidism, then hypothyroidism, then euthyroid

37 Thyroiditis Sub acute Treatment: Symptomatic NSAIDS for pain, fever Prednisone for severe pain unrelieved by above Beta blockers for hyper phase Thyroid replacement for hypo phase Resolve spontaneously

38 Questions?

39 Thank you!


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