We think you have liked this presentation. If you wish to download it, please recommend it to your friends in any social system. Share buttons are a little bit lower. Thank you!
Presentation is loading. Please wait.
Published byTomas Singley
Modified about 1 year ago
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View menu, select the Slide Show option * To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. in the clinic Hyperthyroidism
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. Who has an elevated risk for hyperthyroidism? Individuals with: Diffuse or nodular goiters Type 1 diabetes, other endocrine/ nonendocrine AI diseases Family histories of hyperthyroidism or hypothyroidism Medications that increase risk: Amiodarone Alpha-interferon Interleukin-2 Lithium Iodide Iodinated contrast agents in those with preexisting autoimmune or nodular thyroid disease
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. Should clinicians screen for hyperthyroidism? Screen: Individuals with risk factors High risk comorbid conditions, family Hx, medication use Consider screening: those with other medical conditions caused or aggravated by hyperthyroidism e.g., osteoporosis, supraventricular tachycardia, A-Fib Screen: Women >50 years 1 in 71 have unsuspected but symptomatic hyperthyroidism or hypothyroidism responsive to Rx
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. If clinicians screen for hyperthyroidism, which test should they use? Serum TSH levels Low in both overt and subclinical hyperthyroidism (due to negative feedback by thyroid hormone levels on pituitary gland) Screens for both hyperthyroidism & hypothyroidism TSH assays: standardized, accurate, widely available
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. CLINICAL BOTTOM LINE: Screening… Don’t screen: general population (not cost-effective) Do screen: those with… Diffuse or nodular goiters Type 1 diabetes, other endocrine/ nonendocrine AI diseases Osteoporosis, supraventricular tachycardia, or A-Fib Family Hx hyperthyroidism or hypothyroidism Amiodarone, α-interferon, interleukin-2, lithium, iodide use Women > 50 years of age Use serum TSH test
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. What symptoms should prompt clinicians to consider hyperthyroidism? Nervousness (frequency: 99%) Increased sweating (91%) Palpitations (89%) or tachycardia (82%) Heat intolerance (89%) Fatigue (88%) Weight loss (85%) Shortness of breath (75%), weakness (70%) Leg swelling (65%) Eye symptoms (54%) Hyperdefecation (33%) Menstrual irregularity (22%) Emotional lability (30–60%)
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. What physical examination findings indicate possible hyperthyroidism? Tachycardia (100% frequency) Goiter (100%) Skin changes (97%) Tremor (97%) Bruit (77%) Eye signs (30-45%) Atrial fibrillation (10%) Splenomegaly (10%) Gynecomastia (10%)
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. What lab tests should be used for diagnosis? Serum TSH measurement If low: order free T4 or free T4 index (FT4I) If free T4 or FT4I not elevated: order total T3 or free T3 Radioiodine uptake (RAIU): helps determine cause Thyroid scan: helps distinguish Graves disease, toxic multinodular goiter, toxic adenoma If radioisotope studies contraindicated… Blood tests: TSH-receptor antibodies; thyroid-stimulating immunoglobulins; thyroid-peroxidase antibodies; thyroglobulin; human chorionic gonadotropin; sed rate Color Doppler US (thyroid) Whole-body radioiodine scan
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. Differential Diagnosis (with radioiodine uptake ) High or Normal Graves disease Toxic multinodular goiter Toxic adenoma HCG-induced hyperthyroidism TSH-producing pituitary tumor Low Silent thyroiditis Postpartum thyroiditis Subacute (granulomatous) thyroiditis Iodine-induced hyperthyroidism Amiodarone-induced hyperthyroidism Iatrogenic hyperthyroidism Metastatic follicular thyroid cancer Struma ovarii
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. Lab and Other Studies for Hyperthyroidism (plus indication) TSH (suspected hyperthyroidism) Free thyroxine FT4 (suppressed TSH) Free triiodothyronine FT3 (suppressed TSH, normal FT4) Thyroglobulin (suspected thyroiditis) Erythrocyte sed rate ESR (suspected subacute thyroiditis) TSH-receptor antibodies (euthyroid Graves ophthalmopathy; assess remission with antithyroid drug Rx in Graves disease; assess neonatal risk in pregnant patients with Graves disease) Thyroid peroxidase antibodies (confirm Hashimoto thyroiditis and autoimmune thyroid disease; assess risk for Rx-induced thyroid dysfunction and postpartum thyroiditis RAIU (confirmed biochemical thyrotoxicosis, if cause unclear) Thyroid scan (confirmed biochemical thyrotoxicosis, if cause unclear) Whole body scan (suspected struma ovarii) Color Doppler US (type I vs. type II amiodarone-induced thyrotoxicosis) Human chorionic gonadotropin HCG (choriocarcinoma)
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. What alternative explanations should clinicians consider? Infection Sepsis Anxiety Depression Chronic fatigue syndrome Atrial fibrillation of other causes Pheochromocytoma TSH testing usually distinguishes these from hyperthyroidism But serum TSH levels often low in pregnancy; hyperemesis gravidarum; euthyroid sick syndrome; central hypothyroidism; with some medications (glucocorticoids, dopamine, heparin)
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. When should clinicians consult an endocrinologist? Presence of hyperthyroidism uncertain Serum TSH level low, but T4 and T3 within reference range TSH level normal, but T4 or T3 above reference range Cause unclear RAIU low or undetectable (Dx usually clear when elevated) Uncertain or suspicious about risk for or presence of thyroid storm or Graves orbitopathy
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. CLINICAL BOTTOM LINE: Diagnosis… To make diagnosis, use: History and physical exam Low serum TSH level with elevated serum levels for free T4, FT4 I, total T3, or free T3 To identify cause, use: Clinical features RAIU and thyroid scan Additional tests (TRAb, TSI, TPO antibodies, thyroglobulin, ESR, HCG, color Doppler US, whole-body scanning)
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. What nondrug therapies should clinicians recommend? Until thyroid disease adequately controlled… Avoid heavy physical exertion Reduce or eliminate caffeine intake Avoid OTC decongestants and cold remedies Discontinue smoking Avoid exogenous sources of iodine
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. How should clinicians choose and prescribe drug therapy? Beta-adrenergic blockade Propranolol, atenolol, metoprolol, nadolol For symptomatic hyperthyroidism of any cause Side effects: CHF, asthma exacerbation Antithyroid medications Methimazole: preferred Propylthiouracil: alternative (in 1 st trimester pregnancy, if methimazole allergy, thyroid storm); beware liver failure Inhibit thyroid hormone synthesis, lower thyroid hormone Use for: Graves, toxic multinodular goiter, toxic adenoma Don’t use for: low RAIU hyperthyroidism Agranulocytosis occurs in 0.2%-0.4%
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. Ancillary Therapy Potassium iodine Acutely reduces thyroid hormone release Use before thyroidectomy for Graves Don’t use before radioactive iodine therapy Lithium Reduces thyroid hormone release Cholestyramine Binds thyroid hormone in intestines Nonsteroidal anti-inflammatory Treats subacute thyroiditis Glucocorticoids For severe subacute thyroiditis
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. When should clinicians consider I-131 as primary therapy for hyperthyroidism? Graves disease Achieves remission in ≈90% Good choice if no remission with antithyroid medications Side effects Hypothyroidism: in almost all patients within 3–6 months Sialadenitis (due uptake by salivary glands) Worsening of Graves orbitopathy Possible small increase in thyroid cancer
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. When should clinicians consider I-131 as primary therapy for hyperthyroidism? Toxic multinodular goiters & toxic adenomas Note: Contraindicated in pregnancy! Side effects Hypothyroidism: 50%-75% Worse symptoms from thyroid hormone in first 2 weeks Thyroid storm, if severely hyperthyroid Pretreat with β-adrenergic blockade &/or methimazole: if very symptomatic or free T4 or FT4I levels exceed upper limit of reference range more than 2-fold Discontinue methimazole 7 days before I-13
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. When should clinicians consider thyroidectomy as primary therapy? High RAIU hyperthyroidism (primary therapy) Refractory amiodarone-induced cases (primary therapy) Most often recommended for… Those with thyroid nodules and suspected cancer Those who can’t tolerate or refuse alternative forms Rx Pregnancy Patients who don’t achieve remission with antithyroid Rx
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. How should clinicians monitor patients who are being treated for hyperthyroidism? At baseline: Perform CBC w/ differential WBC count, liver panel Once euthyroid: Assess clinically Measure serum TSH every 6 to 12 months for lifetime Monitoring differs depending on chosen treatment…
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. Antithyroid medications Agranulocytosis, liver injury, vasculitis: discontinue Fever or pharyngitis: repeat CBC with differential WBC Symptoms of liver injury: order liver profile Once symptoms resolved + results in reference range… Discontinue β-adrenergic blocker + reduce antithyroid Rx Continue clinical and lab assessments every 3–6 months After months reduced dose + normal TSH: ? remission Taper or stop antithyroid Rx Measure TRAb: normal = greater likelihood remission No remission: consider I-131 or surgery
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. Radioactive iodine (I-131) Repeat clinical and lab assessments at 1-2 months Measure TSH and free T4 in first 1-3 months TSH suppression may last up to 6 wks after T4 and T3 fall to normal range Start thyroid hormone-replacement when free T4 level low or TSH elevated Adjust dose every 6-8-weeks until TSH in desired range Thyroidectomy Start levothyroxine before hospital discharge Adjust dose every 6-8 weeks until TSH in desired range
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. What is subclinical hyperthyroidism, and what are the indications for treatment? Definition: Low serum TSH levels + T4 and T3 levels within reference ranges Asymptomatic or mild symptoms RAIU typically in reference range Thyroid scan findings consistent with underlying cause TSH levels often normalize w/o treatment Treat: if TSH <0.1 mU/L or symptomatic Consider treating: if TSH ≥0.1 mU/L but still lower than reference range
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. How does a clinician recognize thyroid storm? “Thyroid crisis” exaggerated manifestations of thyrotoxicosis Unrecognized or inadequately treated thyrotoxicosis + precipitating event (infection, trauma) Radioiodine therapy may precipitate Dx often based on suspicious, nonspecific clinical findings Cardinal manifestation: fever >102° F Other features: Tachycardia, tachypnea; nausea/vomiting, diarrhea, CNS manifestations, anemia, hyperglycemia Elevated serum total, free T4 and T3 levels; undetectable serum TSH level Use Thyroid Storm Scoring System
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. Fever ° FScore 99– – >10430 CNS agitation Absent 00 Mild10 Moderate20 Severe30 Cardiac–pulse, bpm 99– – – –13920 ≥14025 Atrial fibrillation10 Cardiac–CHF Absent0 Mild (edema)5 Moderate (rales)10 Severe (pulm edema) 15 Thyroid Storm Scoring System (feature, score) GI signs Absent0 N, V, D, Pain10 Jaundice20 Precipitant history Absent0 Present10 Total Score <25 = unlikely = suggestive >45 = likely
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. How does a clinician treat thyroid storm? 1. Decrease thyroid hormone synthesis Propylthiouracil or methimazole 2. Inhibit thyroid hormone release Sodium iodide (IV) or potassium iodide (oral) 3. Reduce heart rate β-blocker (esmolol, metoprolol, propranolol) or diltiazem 4. Support circulation Glucocorticoids in stress doses Fluids (IV), oxygen, cooling 5. Treat precipitating cause
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. When should patients be hospitalized? When thyroid storm present, impending, or suspected Prognosis with aggressive therapy ≈20% mortality (was once 100%) Dx usually based on suspicious, nonspecific findings Do not wait for test results on serum TSH levels: delays potentially lifesaving therapy Also, TSH levels don’t reliably distinguish thyroid storm from uncomplicated thyrotoxicosis
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. When should clinicians consult an endocrinologist or ophthalmologist? Endocrinologist Help developing optimal management plan Unexpected events or Rx complications Significant Graves eye disease present Patient is pregnant Thyroid storm present, impending, or suspected Some guidelines suggest co-management in all cases Ophthalmologist Double vision or impaired visual acuity, visual fields, color vision Significant eye discomfort Proptosis >22 mm or extraocular muscle dysfunction
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (1): ITC1-1. CLINICAL BOTTOM LINE: Treatment… If RAIU high or normal: Rx usually required Inform patients on benefits and risks and jointly decide on preferred treatment Graves disease: antithyroid meds, I-131, thyroidectomy Toxic multinodular goiter: I-131 or thyroidectomy Toxic adenoma:I-131 or thyroidectomy Before definitive treatment, use antithyroid medications to improve thyroid hormone levels If RAIU low: treat underlying cause or monitor Condition may be transient
Hyperthyroidism. TRH –Thyrotropin-releasing hormone Produced by Hypothalamus Release is pulsatile Downregulated by T 3 Travels through portal.
Management of Hyperthyoidism Iraj Nabipour Bushehr University of Medical Sciences.
Thyroid Disease in Pregnancy Perinatal Conference April 14, 2006.
GENERAL MEDICINE CONFERENCE HYPERTHYROIDISM Selim Krim, MD Assistant Professor Texas Tech University Health Sciences Center.
Hyperthyroidism Dr. Januchowski 2012 Picture courtesy: Hyperthyroidism Stephanie L Lee, MD, PhD; Chief Editor: George T Griffing, MD, Medscape reference.
Diagnosis and Management of Hyperthyroidism, A Rational Approach Kashif Munir, M.D. Assistant Professor of Medicine Division of Endocrinology, Diabetes.
THYROID DISORDERS HOW TO PROPERLY ASSESS, DIAGNOSE AND TREAT YOUR PATIENTS Dacy Gaston South University Dacy Gaston South University.
Hyperthyroidism Clinical Applications Gail Nunlee-Bland, M.D. Division of Endocrinology.
Thyroid disorders. Diseases of the thyroid predominantly affect females and are common, occurring in about 5% of the population.
Richard M. Jordan, MD, Regional Dean, School of Medicine Texas Tech Health Sciences Center at Amarillo.
Subclinical Thyroid Disease Karen Earlam PGY - 1.
Secretes three hormones essential for proper regulation of metabolism ◦ Thyroxine (T 4 ) ◦ Triiodothyronine (T 3 ) ◦ Calcitonin Located near the parathyroid.
DR SALWA NEYAZI ASSISTANT PROF./CONSULTANT OBGYN PEDIATRIC & ADOLESCENT GYNECOLOGIST.
Thyroid gland The normal circulating thyroid hormones are Thyroxine T4 (90%),Triiodothyronine T3 (9%) and rT3 (1%). Reverse T3 (rT3) is biologically inactive.
Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. CHAPTER 30 Thyroid and Antithyroid Drugs.
Subclincal Thyroid Disease and the Work-up of a Thyroid Nodule Jared Bunevich MS IV LECOM.
A Pain in the Back COPYRIGHT © 2013, ALL RIGHTS RESERVED From the Publishers of.
Frank P. Dawry Therapy of Hyperthyroid Thyroid Disease with Iodine-131.
Hyperthyroidism 于明香 Endocrinology Department Zhongshan Hospital, Fudan University Endocrinology Department Zhongshan Hospital, Fudan University.
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. CHAPTER 31 Thyroid and Antithyroid Drugs.
Hyperthyroidism Hypothyroidism Dr. Meg-angela Christi Amores.
Radioiodine Therapy for Graves’ Disease Dr. Khalid B. Makhdomi Nuclear Medicine Physician Aga Khan University Hospital, Nairobi.
Diabetes and Hypothyroidism Aaron Rockoff MD Fellow in Endocrinology, UC-Irvine.
Thyroid Storm Case Study -Develop knowledge of the etiologies, manifestations, and treatment of endocrine and metabolic disorders. -Demonstrate understanding.
THYROID PATHOPHYSIOLOGY. Hypothalamic-Pituitary-Thyroid Axis This is a negative feedback system. TRH produced in the paraventricular nuclei of the hypothalamus.
Clinical pharmacology Thyroid disorders. Thyroid Function Tests "TSH" Test -- Thyroid Stimulating Hormone / Serum thyrotropin Under.4 can indicate possible.
DRUGS USED IN HYPERTHYROIDISM. Objectives At the end of 1 st lecture the studetns will be able to : At the end of 1 st lecture the studetns will be able.
Clean Coronaries But a Broken Heart COPYRIGHT © 2014, ALL RIGHTS RESERVED From the Publishers of.
Graves’ Disease: An Overview Matthew Volk Morning Report November 17 th, 2009.
MANAGEMENT. Goal: restoration of clinical and biochemical euthyroid state by omitting or reducing the dosage of medications and other measures as needed.
Dr.Elwassiela Salih MD. Thyroid disease is a disorder that results when the thyroid gland produces more or less thyroid hormone than the body needs Divided.
WHO SHOULD BE TESTED FOR THYROID DYSFUNCTION? Groups with an increased likelihood of thyroid dysfunction Previous thyroid disease or surgery Goitre.
Atrial Fibrillation: How Controlled is Well Controlled? COPYRIGHT © 2014, ALL RIGHTS RESERVED From the Publishers of.
Clinical diagnostic biochemistry - 15 Dr. Maha Al-Sedik 2015 CLS 334.
Thyroid Disease in Pregnancy District 1 ACOG Medical Student Teaching Module 2011.
© Copyright Annals of Internal Medicine, 2013 Ann Int Med. 159 (9): ITC5-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View.
Hyperthyroidism in Pregnancy D. WANG Learning Objectives Describe the pathophysiology and common causes of hyperthyroidism in pregnancy Describe.
By: Mark Torres Human Anatomy and Physiology II TR3:15-6:00.
Hypothyroidism Randi Schutz. The Thyroid Gland that regulates metabolism Located in the front of the neck just below the voice box (larynx) The thyroid.
HYPOTHYROIDISM. INTRODUCTION Hypothyroidism is defined as a deficiency in thyroid hormone secretion and action that produces a variety of clinical signs.
Graves’ disease Department of Internal Medicine № 2.
The Asymptomatic Carotid Bruit: Not Such a Pain in the Neck After All? COPYRIGHT © 2015, ALL RIGHTS RESERVED From the Publishers of.
Terry Kotrla, MS, MT(ASCP)BB Unit 3 Autoimmunity Part 4 Hashimoto’s Thyroiditis Part 5 Grave’s Disease.
THYROID DISEASE IN PREGNANCY. Physiologic Changes in Pregnancy Free thyroxine levels remain within the normal range during pregnancy (though total thyroxine.
Thyroid Hormones. Thyroid Hormone Action Thyroid gland is the largest endocrine gland in the body Thyroid hormones facilitate normal growth and maturation.
Interpretation of Thyroid Function Tests Fadi Nabhan, MD Assistant Professor of Medicine Endocrinology, Diabetes & Metabolism.
MLAB 2401: Clinical Chemistry Keri Brophy-Martinez Thyroid Gland.
1 Thyroid Drugs Kaukab Azim, MBBS, PhD. Learning Outcomes By the end of the course the students should be able to discuss in detail Physiology, synthesis.
1 Dr: Wael H.Mansy, MD Assistant Professor College of Pharmacy King Saud University.
Endocrine Block 1 Lecture Dr. Usman Ghani Biochemistry of Thyroid Hormones and Thermogenesis.
© 2017 SlidePlayer.com Inc. All rights reserved.