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Thyroid disorders in everyday care

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Presentation on theme: "Thyroid disorders in everyday care"— Presentation transcript:

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

2 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

3 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

4 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)

5 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)

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

7 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

8 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

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

10 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

11 Normal Hormone Levels TSH: 0.4-5.5 MIU/L Total T3: 60-181 NG/DL
Total T4: MCG/DL T3 Uptake: %

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

13 Hypothyroidism Treatment: Hormone replacement (L-T4)
Absorbed from small intestine 6-day half-life Daily dosing: mgs Branded preparations preferred to generic Synthroid Levoxyl Tirosint

14 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

15 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

16 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

17 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

18 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 T4 to T3

19 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

20 Hyperthyroidism Dosing: Monitor every 4-6 weeks
When TSH rises, may need to add T4 (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

21 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

22 Hyperthyroidism Radioactive Iodine Ablation
Administration of I131 iodine by mouth Used after TFT’s normal or if unable to control hyperthyroidism with drugs Usually destroys gland over 3-6 months

23 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

24 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

25 Hyperthyroidism Thyroid Storm Most often with Graves’ disease
Levels same as with Graves’ Cardinal signs: Temperature 102 to 1050 Profuse sweating Marked tachycardia ( pulse rate or higher) Atrial fibrillation Usually induced by concurrent infection or surgery on hyperactive gland

26 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

27 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

28 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

29 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

30 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

31 Thyroid Nodules Treatment
Multinodular gland without dominant nodule: T4 to shrink if TSH not suppressed Single nodule 1 cm or greater: fine needle aspiration biopsy Enlarging nodule despite “good” dose of T4 or indeterminate or malignant result from FNA indicates need for surgery

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

33 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

34 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

35 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

36 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

37 Questions?

38 Thank you!

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