medical management of thyroid disease
TRANSCRIPT
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In the Name of God, Most Gracious, Most Merciful
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The history of man…
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… is plagued by disease
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Today …
We discuss …
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THYROIDDISORDERS
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THYROTOXICOSIS
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MYXOEDEMA
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CRETINISM
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MEDICAL EMERGENCIES
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THYROID DISEASE COMPLICATING PREGNANCY
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5 % OF THE WORLD POPULATION
SUFFERS FROM THYROID DISEASE
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CONGENITAL HYPOTHYRIODISM IS ONE OF
THE MOST COMMON CAUSES OF PREVENTABLE
MENTAL RETARDATION WORLD-WIDE
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20 MILLION PEOPLE IN THE WORLD HAVE
VARIOUS DEGREES OF BRAIN DAMAGE
CAUSED BY IODINE DEFICIENCY IN UTERO
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MEDICAL MANAGEMENT
OF THYROID DISEASE
By-
MOHAMMAD SADIQIII YR. M.B.B.S.
M.M.C.R.I.
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THYROID DISORDERS
The conditions we will deal with here are:
1. Thyrotoxicosis
2. Hypothyroidism
3. Medical Emergencies > Myxoedema coma > Thyrotoxic crisis
4. Congenital Hypothyroidism (Cretinism)
5. Thyroid Disease complicating pregnancy
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THYROID DISORDERSMEDICAL MANAGEMENT
1. Proper Clinical Diagnosis
2. Laboratory Evaluation
3. Treatment
4. Monitoring of patient
Proper management is based upon:
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THYROTOXICOSISINTRODUCTION
“Defined as the state of thyroid hormone excess & is not synonymous with hyperthyroidism which is the result of excessive thyroid function”
Top 2 causes are:
Grave’s Disease (76%) Multi Nodular Goitre (14%)
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HYPOTHYROIDISMETIOPATHOGENESIS
Iodine deficiency remains the leading cause World-wide.
In areas of iodine sufficiency the causes are:
1. Hashimoto’s thyroiditis2. Spontaneous Atrophic thyroiditis3. Iatrogenic causes
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HYPOTHYROIDISM
PRESENTING COMPLAINT
HASHIMOTO’S THYROIDITIS:
• Symptoms of Goitre more than that of Hypothyroidism.
ATROPHIC THYROIDITIS:
• Symptoms of Hypothyroidism more than that of Goitre
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HYPOTHYROIDISM
QUEEN ANNE’S SIGN MYXOEDEMA FACIES
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THYROID DISEASE
CLINICAL PRESENTATION
Cardinal Features
HYPERTHYROIDISM:
• Presents with warm, moist skin
• sweating, Heat intolerance
• Von Muller’s Paradox
HYPOTHYROIDISM:
• Presents with tiredness, weakness
• Myxoedema
• Dry coarse skin, Cool peripheral extremities
• Cold intolerance
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THYROID DISEASECLINICAL PRESENTATION
Dept. of General Medicine
HYPERTHYROIDISM:• Diabetes Mellitus• Palpitations• Diarrhoea• Eyes: Stellwag’s sign• Fatigue & wt. loss (Elderly patients)
HYPOTHYROIDISM:• Pleural Effusion• Pericardial Effusion• Constipation• Carpal Tunnel Syndrome• Bradycardia• Peripheral edema• Hoarse voice (phone diag)
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THYROID DISEASE
GI PRESENTATION
Transit timeleads to
diarrhoea inthyrotoxicosis
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THYROID DISEASEDept. of Dermatology
HYPERTHYROIDISM:
• Pretibial myxoedema
• Thyroid acropachy
HYPOTHYROIDISM:
• Diffuse alopaecia
Acropachy
PretibialMyxoedema
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THYROID DISEASE
CLINICAL PRESENTATION
Dept. of Neurology
HYPERTHYROIDISM:
• Fine tremor
• Hyperreflexia
• Muscle wasting
• Proximal myopathy
• Hypokalemic periodic paralysis
HYPOTHYROIDISM:
• Paraesthesia
• Pseudomyoclonus
• Delayed tendon reflexes
• Difficulty in concentration
• Poor memory
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THYROID DISEASEDept. of OBG
HYPERTHYROIDISM:
• Oligomenorrhoea
HYPOTHYROIDISM:
• Menorrhagia
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THYROID DISEASE
Dept. of Psychiatry
HYPERTHYROIDISM:
• Anxiety neurosis
• Severe Depression
HYPOTHYROIDISM:
• Bipolar Disorder
• Depression
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THYROTOXICOSIS
CVS MANIFESTATION
C/F:•Palpitations
•Sinus Tachycardia
•Bounding pulse
•Widened pulse pressure
•Aortic Systolic Murmur
•Worsening of Angina
•Atrial Fibrillation (>50yrs)
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THYROTOXICOSIS
MANAGEMENT OF ATRIAL FIBRILLATION
• VR responds little to Digoxin.
• Good response to addition of - blockers.
• CARDIOVERSION to revert to sinus rhythm.
(Only after TSH/T4 )
• Anti coagulation with Warfarin / Aspirin.
• Generally control of serum T4 causes a return to sinus rhythm.
• Drugs provide symptomatic relief.
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THYROTOXICOSIS
GRAVES’ OPTHALMOPATHY
• Gritty sensation, Discomfort, lacrymation
• Exopthalmous
• Periorbital oedema, Chemosis, Scleral injection
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THYROTOXICOSIS
MANAGEMENT - GRAVES’ OPTHALMOPATHY
1. Reassurance
2. Methyl cellulose drops grittiness, discomfort
3. Tinted glasses / Side shields excess lacrymation
Complications:1. Corneal Ulcer: Lid lengthening Sx
2. Papilloedema/Loss of acuity/Field defects:
URGENT trt. with PREDNISOLONE 60mg/d
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GRAVES’ OPTHALMOPATHY
EFFECT OF THERAPY
BEFORE AFTER
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THYROTOXICOSIS
MANAGEMENT
3 approaches 1. Antithyroid drugs
2. Radioactive Iodine I131
3. Subtotal thyroidectomy
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THYROTOXICOSISMEDICAL MANAGEMENT
1. ANTITHYROID DRUGS: > Carbimazole
> Propyl thiouracil
Dosage of Carbimazole:
0-3 weeks 40-60 mg daily
4-8 weeks 20-40 mg daily
Maintainence 5-20 mg daily for 18-24 months
ADR: Rash, Agranulocytosis
C/I: Lactating Mothers
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THYROTOXICOSISMEDICAL MANAGEMENT
2. RADIOACTIVE I131 :
MOA: > Destroys functioning thyroid cells
> Inhibits their ability to replicate
Dose:
180-370 MBq (5-10mCi) orally (Dep. on goitre size)
• 4-6 weeks to be effective (long lag period)
-blockers control symptoms in lag period.
• Severe cases: Carbimazole within 48 hrs of I131
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THYROTOXICOSISMEDICAL MANAGEMENT
3. Role of -blockers: ONLY SYMPTOMATIC RELIEF
(within 12-24 h)
Propronolol: 160 mg/day
Nadolol: 40-80 mg/day
T3 toxicosis : I131(555-110Mbq), Hemithyroidectomy
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THYROTOXICOSISEFFECT OF TREATMENT
BEFORE AFTER
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THYROTOXICOSISEFFECT OF TREATMENT
BEFORE AFTER
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THYROTOXICOSISSPECIAL CASES
PENDRED’S SYNDROME:Dyshormonogenesis (T4) + Deafness
1.
HAMBURGER THYROTOXICOSIS2.
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HYPOTHYROIDISMMEDICAL MANAGEMENT
Life long therapy with Levothyroxine (T4) is the sheet anchor
Start slowly with 50g/day OD – 3 weeks
Then to 100g/day OD – 3 weeks
Finally to 150g/day OD
Hypothyroidism following Grave’s Disease 75-125g/day OD
Improvement takes 2-3 weeks
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HYPOTHYROIDISMMEDICAL MANAGEMENT
RATIONALE IN USING T4 IN HASHIMOTO’S:
1. Treatment of Hypothyroidism
2. Goitre shrinkage
T4 vs. T3 – Why T4?
T3 in high doses causes:• Angina• Arrythmias• Heart Failure
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HYPOTHYROIDISMMONITORING THERAPY
1. Correct dose of drug: Restores serum TSH to lower part of reference range when T4 is / slightly .
2. Advise & reinforce need for regular medication.
3. TFT screening every 1-2 years.
T4 & TSH - ?
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HYPOTHYROIDISMEFFECT OF TREATMENT
BEFORE AFTER
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HYPOTHYROIDISMEFFECT OF TREATMENT
BEFORE AFTER
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THYROID DISORDERSINVESTIGATIONS
Disorder TSH
(0.3-3.5 mU/L)
Free T4
(10-25 pmol/L)
Free T3
(3.5-7.5 pmol/L)
Thyrotoxicosis (<0.05mU/L)
Primary Hypothyroidism
(>10 mU/L) or
low normal
/
TSH deficiency Low normal / sub normal
or
low normal
/
T3 Toxicosis (<0.05 mU/L)
Compensated Euthyroidism
Slightly (5-10 mU/L)
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MEDICAL EMERGENCIES
1. HYPERTHYROID CRISIS (= Thyrotoxic crisis / Thyroid storm)
2. MYXOEDEMA COMA
2 Situations :
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HYPERTHYROID CRISIS
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HYPERTHYROID CRISISMANAGEMENT
1. Rehydrated
2. Broad spectrum antibiotic
3. Propronolol 80 mg 6th hrly orally / 1-5 mg 6th hrly i.v.
4. Large doses of Propyl thiouracil 600 mg loading dose & 200-300 mg every 6 hrs orally/NGT/PR is the DOC.
5. Stable Iodine 1 hr later.
6. Saturated sol of KI / Na iopodate 500 mg/d orally restores normal levels of T3 within 48-72 hrs.
7. Others: Glucocorticoids, Cooling, Oxygen
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MYXOEDEMA COMACLINICAL PICTURE
1. level of consciousness usually in an elderly patient who appears myxoematous
2. Body temperature as low as 25oC
3. Convulsions
4. CSF pressure & proteins
5. Mortality rate around 50%
(EARLY DETECTION is essential)
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MYXOEDEMA COMAMANAGEMENT
TREATMENT must begin IMMEDIATELY
1. Triiodothyronine i.v. bolus 20g followed by 20g
8th hourly till there is sustained clinical improvement.
2. Liothyronine (T3) i.v. / NGT 10-25 g 8-12th hourly (v. rapid)
3. T3 (25g) + T4 (200g) as a single initial i.v. bolus followed
by daily trt. with Levothyroxine 50-100 g 8th hrly.
Others: Slow rewarming (if <30oC), Cautious use of i.v. fluids, Broad Spectrum antibiotics, High flow oxygen, Assisted ventilation
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CRETINISM
“Children who are hypothyroid from birth / before are called cretins.”
WHO IS A CRETIN?
“What should have been an angel of God has been a pariah of nature just for the want of a little iodine in mother’s blood.”
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CRETINISMGUESS MY AGE?
22 yr. old femalePot bellyUmbilical herniaCoarse facial featuresSupra clavicular pad of fat
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CRETINISMGUESS MY AGE?
17 yr. old femaleCongenital hypothyroidismLarge earsEnlarged protruded tongueWide set eyesDepressed nasal bridgeShort limbsEstim. bone age : 9 months
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CRETINISMRADIOLOGICAL PICTURE
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CRETINISMMANAGEMENT
Monitoring of thyroid status of mother is important
If mother is…
Euthyroid• Dev. normal until birth• Manifests at birth• Treatment started at birth has good prognosis
Hypothyroid• Iodine def. is commonest cause• MR is more severe• Less responsive to trt.• Deaf mutism & rigidity +Intake of iodised salt has this
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CRETINISMTREATMENT
Sodium Levothyroxine 100g tab is the DOC
Dose: Neonates: 10-15 g/kg/day
Older children: 4-8 g/kg/day
Neonates & Children < 1yr.: INITIATE trt. on DIAGNOSIS
DON’T WAIT for INVESTIGATIONS
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CRETINISMMONITORING
1. Assess Clinical Milestones
2. Periodic TFT
3. Radiological estimation of bone age annually
Antenatal screening:
> Regular TFT – mother
> Foetus USG
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THYROID DISEASE COMPLICATING PREGNANCY
HYPERTHYROIDISMHYPOTHYROIDISM
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THYROID DISEASE COMPLICATING PREGNANCY
HYPERTHYROIDISM - MANAGEMENT
Carbimazole is the drug used
• Crosses placenta and also treats foetus• Imp to use the smallest dose possible• Review every 4 weeks
• Discontinue Carbimazole 4 weeks before EDD
If Hyperthyroid mother wants to feed?
Radioactive Iodine is C/I
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THYROID DISEASE COMPLICATING PREGNANCY
HYPOTHYROIDISM - MANAGEMENT
Why treat?
On the basis of serum TSH measurements
most pregnant women with primary hypothyroidism
require an additional 50g thyroxine to their
usual dose ( TBG in pregnancy).
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MEDICAL MANAGEMENTOF THYROID DISORDERS
CONCLUSION
1. Thyroid disease may have a variable clinical presentation.Hence, it is very essential to have a high degree of caution beforedeclaring a patient euthyroid. It is better to do a TFT in all suspected cases. The cost of the TFT is noting compared to the dire consequences of a missed diagnosis.
2. Treatment must be started immediately in all suspected casesof thyroid storm/myxoedema coma/cretinism as a delay in treatment might be fatal to the patient or may land the child in permanentmental retardation.
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