1. Management of Hyperthyroidism
Dr Mojgan Sanjari
Associate Professor of endocrinology and metabolism
Kerman university of medical sciences
2017/20/04

2. Outlines: Case presentation Possible differential diagnosis
Treatment options
Based on :
2016 American Thyroid Association Guidelines
for Diagnosis and Management of Hyperthyroidism
and Other Causes of Thyrotoxicosis
And Vol 388 August 27, 2016

3. Hypothetical patient
Patient is a 28 year old nurse referred to you by gynecologist due to abnormal TSH. She complains palpitation , fatigue and mild weight loss since 2 weeks ago . She had cesarean section 10 weeks ago and common cold 2 weeks ago. She is not on medication .Positive history of hashimoto thyroiditis in her sister. Physical exam has no significant finding except tachycardia and thyroid enlargement, most prominent in left lobe.

4. Causes of thyrotoxicosis
Thyrotoxicosis associated with a normal or elevated RAIuptake over the neck
Graves Disease
Toxic Adenoma or TMNG
Trophoblastic disease
TSH-producing pituitary adenomas
Resistance to thyroid hormone (T3 receptor beta mutation,THRB)

5. Thyrotoxicosis associated with a near-absent RAI uptake over the neck
Painless (silent) thyroiditis
Amiodarone-induced thyroiditis
Subacute (granulomatous, de Quervain’s) thyroiditis
Palpation thyroiditis
Iatrogenic thyrotoxicosis
Factitious ingestion of thyroid hormone
Struma ovarii
Acute thyroiditis
Extensive metastases from follicular thyroid cancer

6. Hypothetical patient
Patient is a 28 year old nurse referred to you by gynecologist due to abnormal TSH. She complains palpitation , fatigue and mild weight loss since 2 weeks ago . She had cesarean section 10 weeks ago and common cold 2 weeks ago. She is not on medication .Positive history of hashimoto thyroiditis in her sister. Physical exam has no significant finding except tachycardia and thyroid enlargement, most prominent in left lobe.

7. Determination of etiology(R1)
Depending on available expertise and resources,
Measurement of TRAb,
Determination of the radioactive iodine uptake (RAIU)
Measurement of thyroidal blood flow on ultrasonography.
A 123I or 99mTc pertechnetate scan should be obtained when the clinical presentation suggests a TA or TMNG.
Strong recommendation, moderate-quality evidence.

8. Symptomatic management(R2)
Beta-adrenergic blockade:
Symptomatic thyrotoxicosis,
Elderly patients
Resting heart rates in excess of 90 beats per minute
Coexistent cardiovascular disease.
Strong recommendation, moderate-quality evidence

9. Beta-Adrenergic Receptor Blockade in the Treatment of Thyrotoxicosis

10. How should overt hyperthyroidism due to GD be managed?(R3)
Patients with overt Graves’ hyperthyroidism should be
treated with any of the following modalities:
RAI therapy,
ATDs, or
Thyroidectomy
Strong recommendation, moderate-quality evidence

11. Anti Thyroid drug:
Patients with high likelihood of remission (patients,
especially women, with mild disease, small goiters,
and negative or low-titer TRAb);
Pregnancy;
The elderly or others with comorbidities increasing surgical
risk or with limited life expectancy; individuals in
Nursing homes or other care facilities
Patients with previously operated or irradiated necks;
Patients with lack of access to a high-volume thyroid surgeon;
Patients with moderate to severe active GO;
and Patients who need more rapid biochemical disease control

12. Side-effects Minor side-effects of ATDs occur in about 5% of patients.
These side-effects include pruritus, arthralgia,
and gastrointestinal distress.
In patients with minor skin reactions, an antihistamine can be added or one ATD can be substituted for the other

13. Major side-effects of ATDs:
Agranulocytosis, in which the absolute granulocyte count is less than 500 cells/mm3, is the most frequent major side-effect. Patients usually present with fever or sore throat, or both, and sometimes chills, diarrhea, and myalgia. The annual incidence of agranulocytosis has been estimated to be 0・1–0・3%and generally occurs within 90 days after initiation of therapy.

14. Agranuolocytosis:
When patients receiving ATDs present with these symptoms, a white blood cell count with differential should be obtained and the ATD should be immediately discontinued if the granulocyte count is less than 1000 cells/mm3. Treatment of agranulocytosis and its associated infections might be also necessary, such as administration of broad-spectrum antibiotics and granulocyte colony-stimulating factor , which has been shown to reduce the recovery time.

15. Hepatotoxicity occurs in 0・1–0・2% of patients.
It usually develops within 3 months of therapy
incidence peaks in the first 30 days of treatment.
The ATA/AACE guidelines recommend:
Obtaining a serum liver profile at baseline
, but recommend against periodic monitoring unless the patient complains of symptoms of hepatic dysfunction, such as pruritic rash, jaundice, light-coloured stool, or dark urine.

16. Patients at higher risk of recurrence are:
Those with severe hyperthyroidism,
Large goitre,
High T3:T4 ratios,
Persistently suppressed TSH,
and high baseline concentrations of TRAb.

17. RAI therapy: Women planning a pregnancy in the future(>6months)
Comorbidities increasing surgical risk,
Previously operated or externally irradiated necks,
lack of access to a high-volume thyroid surgeon,
contraindications to ATD use or failure to achieve euthyroidism during treatment with ATDs.
Periodic thyrotoxic hypokalemic paralysis,
Right heart failure
Pulmonaryhypertension, or
Congestive heart failure

18. Surgery: Women planning a pregnancy in <6 months
Symptomatic compression or large goiters (‡80 g);
relatively low uptake of RAI;
when thyroid malignancy is documented or suspected
(e.g., suspicious or indeterminate cytology);
Large thyroid nodules especially if greater than 4 cm or if nonfunctioning, or hypofunctioning
coexisting hyperparathyroidism
and patients with moderate to severe active GO.

19. If surgery is chosen as treatment (R24):for GD, patients should be
Rendered euthyroid prior to the procedure with ATD pretreatment, with or without b-adrenergic blockade. A KI containing preparation should be given in the immediate preoperative period.
Strong recommendation, low-quality evidence

20. Following thyroidectomy for GD:
L-thyroxine should be started at a daily dose appropriate for the patient’s weight(0.8 µg/kg or 1.6 µg/kg), with elderly patients needing somewhat less,
Serum TSH measured 6–8 weeks postoperatively.
Strong recommendation, low-quality evidence

21. Take home message:
In patients with symptoms of hyperthyroidism consider all causes of thyrotoxicosis .
If any doubt check TRAB, RAIU, Thyroid ultrasonography or scan
Long term ATD , Surgery or Radioablation can be used for treatment of hyperthyroidism.

22. Thanks for your attention
Question or comments
Thanks for your attention