thyroid - pab2u.com · she had normal tfts on 100 mcg thyroxine till 6 months ago. she was...

ThyroidThyroid

Ajith GeorgeAjith GeorgeConsultant in diabetes and Consultant in diabetes and

endocrinologyendocrinologyTraffordTrafford

Topics to coverTopics to cover

1. Hyperthyroidism1. Hyperthyroidism2. Hypothyroidism2. Hypothyroidism3. Abnormal Thyroid function tests3. Abnormal Thyroid function tests4. People with normal TFTS4. People with normal TFTS5. Thyroid nodules/Enlargement5. Thyroid nodules/Enlargement

Case 1Case 1

35 year old lady presents with palpitations 35 year old lady presents with palpitations breathlessness on exertion and tremorsbreathlessness on exertion and tremors–– She had been fit and wellShe had been fit and well–– No regular medicationsNo regular medications

What is your management plan?What is your management plan?

T4 T4 43.0 43.0 TSH TSH <0.01<0.01

HyperthyroidismHyperthyroidism

ThyroiditisThyroiditis

Graves diseaseGraves disease

Autonomous noduleAutonomous nodule

Questions?Questions?Do I need an ultrasound scan?Do I need an ultrasound scan?

Do I need a Thyroid uptake scan?Do I need a Thyroid uptake scan?

BetablockersBetablockers vsvs AntithyroidAntithyroid drugsdrugs

When do I need to repeat TFT?When do I need to repeat TFT?

Do I need to check T3 levels?Do I need to check T3 levels?

What What antiboidesantiboides do I need to check?do I need to check?

Questions?Questions?Do I need an ultrasound scan?Do I need an ultrasound scan?

Do I need a Thyroid uptake scan?Do I need a Thyroid uptake scan?

BetablockersBetablockers vsvs AntithyroidAntithyroid drugsdrugs

When do I need to repeat TFT?When do I need to repeat TFT?

Do I need to check T3 levels?Do I need to check T3 levels?

What antibodies do I need to check?What antibodies do I need to check?

NoNo

NoNo

BetablockersBetablockers

6 Weeks6 Weeks

NoNo

NoneNone


Treatment OptionsTreatment Options–– BetablockersBetablockers–– CarbimazoleCarbimazole–– SurgerySurgery–– RadioiodineRadioiodine

Counseling patient about risks of Counseling patient about risks of CarbimazoleCarbimazole–– AllergiesAllergies–– AgranulocytosisAgranulocytosis


What dose of What dose of CarbimazoleCarbimazole do I start?do I start?–– 5mg twice daily increased to 20 5mg twice daily increased to 20 odod in 2 weeksin 2 weeks

How soon will How soon will TFTsTFTs return to baseline?return to baseline?–– 6 weeks6 weeks

What requires urgent referral?What requires urgent referral?–– Eye symptomsEye symptoms–– Painful/ enlarging Painful/ enlarging thryoidthryoid–– Severe hyperthyroidism Severe hyperthyroidism


What if the person is asymptomatic?What if the person is asymptomatic?–– Can repeat bloods in 4 Can repeat bloods in 4 –– 6 weeks6 weeks–– Sooner if symptoms startSooner if symptoms start–– Watch for weight loss/ Check for AFWatch for weight loss/ Check for AF

What if the person is 6 weeks post partum?What if the person is 6 weeks post partum?–– Usually self limitingUsually self limiting–– Low dose Low dose carbimazolecarbimazole

What if the person is in early stages of What if the person is in early stages of pregnancy?pregnancy?

HypothyroidismHypothyroidism

AetiologyAetiology

SymptomsSymptoms

SignsSigns


90% due to autoimmune hypothyroidism 90% due to autoimmune hypothyroidism ((HashimotosHashimotos))Usually picked up when asymptomaticUsually picked up when asymptomaticSigns are rareSigns are rare–– Weight gain, mental sluggishness, mental fog Weight gain, mental sluggishness, mental fog

etc come when T4 is also well below normal etc come when T4 is also well below normal rangerange

HypothyroidismHypothyroidismWhen should I start replacement?When should I start replacement?

What advice should I give about medications?What advice should I give about medications?

What dose can I start on?What dose can I start on?

When should I recheck When should I recheck TFTsTFTs??

What if symptoms persist?What if symptoms persist?

Should I start T3 as well?Should I start T3 as well?

Why is the TSH never in the normal range?Why is the TSH never in the normal range?


When should I start When should I start replacement?replacement?

What advice should I give What advice should I give about medications?about medications?

What dose can I start on?What dose can I start on?

When should I recheck When should I recheck TFTsTFTs??

If TSH >10 on two If TSH >10 on two occasionsoccasions

On Empty stomach, On Empty stomach, breakfast after 30 minbreakfast after 30 min

50mcg daily50mcg daily

In 6 In 6 –– 8 weeks8 weeks


What if symptoms What if symptoms persist?persist?

Should I start T3 as Should I start T3 as well?well?

Why is the TSH never Why is the TSH never in the normal range?in the normal range?

Reassess after Reassess after TFTsTFTsnormalisenormalise

No No –– Useful in a small Useful in a small minorityminority

Usually due to Usually due to absorption/ Dose absorption/ Dose concordanceconcordance

Hypothyroidism Hypothyroidism –– When to referWhen to refer

Feels unwell of thryoxine replacementFeels unwell of thryoxine replacement

Persistent symptomsPersistent symptoms

Planning PregnancyPlanning Pregnancy–– TPO antibodiesTPO antibodies–– Dose adjustmentDose adjustment

Question 4Question 4A 28 year old lady diagnosed to have hashimotos A 28 year old lady diagnosed to have hashimotos thyroiditis and primary hypothyroidism 3 years ago, thyroiditis and primary hypothyroidism 3 years ago, presents with tiredness. She had normal TFTs on 100 presents with tiredness. She had normal TFTs on 100 mcg thyroxine till 6 months ago. She was diagnosed mcg thyroxine till 6 months ago. She was diagnosed to have iron deficiency anemia 6 months ago and to have iron deficiency anemia 6 months ago and started on iron replacementstarted on iron replacementHer TFTs today are Ft4 8.7 TSH 10.4 what is the likely Her TFTs today are Ft4 8.7 TSH 10.4 what is the likely cause for her abnormalitiescause for her abnormalitiesA) Iron deficiencyA) Iron deficiencyB) Progression of her hashimotos ThyroiditisB) Progression of her hashimotos ThyroiditisC) coexistant coeliac diseaseC) coexistant coeliac diseaseD) Addisons diseaseD) Addisons diseaseE) Iron TabletsE) Iron Tablets

Question 4Question 4A 21 year old lady presents with history of bipolar A 21 year old lady presents with history of bipolar disorder and weakness. She is concerned about disorder and weakness. She is concerned about weight loss.. She has lost about a stone (7KG) in weight loss.. She has lost about a stone (7KG) in weight over the past 6 months and has been weight over the past 6 months and has been amenorrhoeic over the past year. Examination reveals amenorrhoeic over the past year. Examination reveals a blood pressure of 100/70 , slow relaxing tendon a blood pressure of 100/70 , slow relaxing tendon reflexes and a normochromic anemia. What is the reflexes and a normochromic anemia. What is the most likely diagnosis?most likely diagnosis?A) Antipsychotic medications A) Antipsychotic medications B) HypothyroidismB) HypothyroidismC) HyperthyroidismC) HyperthyroidismD) Anorexia nervosaD) Anorexia nervosaE) HypopituitarismE) Hypopituitarism

Special situationsSpecial situations

Thyroid stormThyroid storm

Myxoedema comaMyxoedema coma

The patient unable to swallowThe patient unable to swallow

HypopituitarismHypopituitarism

Question 5Question 5A 60 year old man presents to A and E after having become unwellA 60 year old man presents to A and E after having become unwellover the past 48 hours. He complained of a headache prior to theover the past 48 hours. He complained of a headache prior to theevent. CT scan was normal but a LP showed Xanthochromia and the event. CT scan was normal but a LP showed Xanthochromia and the followingfollowingRBC 1024RBC 1024WBC 2 (all lymphocytes)WBC 2 (all lymphocytes)Protein and glucose normalProtein and glucose normalTFT 7.0 TSH 1.3TFT 7.0 TSH 1.3

What would you doWhat would you doA) Further tests and clinical examination are indicatedA) Further tests and clinical examination are indicatedB) Start Levothyroxine 50 mcg dailyB) Start Levothyroxine 50 mcg dailyC) Reassure the patientC) Reassure the patientD) Ask about previous medicationsD) Ask about previous medicationsE) Check 24 hour urine thyroxine excretion E) Check 24 hour urine thyroxine excretion

Abnormal Thyroid function testsAbnormal Thyroid function tests

Assay interferenceAssay interference

Sick euthyroid syndromeSick euthyroid syndrome

Thyroid hormone resistanceThyroid hormone resistance

T4

TSH

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T4

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T4

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T4

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T4

TSH

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TSH

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T4

TSH

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T4

TSH

T4

TSH

T4

TSH

T4

TSH

T4

TSHSub clinical

hyperthyroidism Medication effect

T4

TSHSub clinical

hyperthyroidismMedication effect

Assay interferencePoor concordance

Drug effect (heparin/ amiodarone)

TSH secreting tumourResistance to TSH




Sub clinical hypothyroidismPoor concordanceMalabsorption

Drugs – AmidaroneAssay interferenceTSH resistance

Sub clinical hypothyroidismPoor concordanceMalabsorption

Drugs – AmidaroneAssay interferenceTSH resistance

T4

TSH

Central HypothyroidismIsolated TSH deficiency

T4

TSH


T4

TSH

T4

TSH

T4

TSH

T4

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T4

TSH

T4

TSH

T4

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T4

TSH







T4

TSH

T4

TSH

T4

TSH

T4

TSH

Sub clinical hypothyroidism

Poor concordanceMalabsorption

Drugs – AmiodaroneAssay interference

TSH resistance

Sub clinical hypothyroidism

Poor concordanceMalabsorption

Drugs – AmiodaroneAssay interference

TSH resistance

T4

TSH


T4

TSH


T4

TSH

T4

TSH

T4

TSH

T4

TSH

People with normal TFTPeople with normal TFT

Am tired all the timeAm tired all the timeAm gaining weightAm gaining weightAm losing hairAm losing hairwant Armourwant Armour--thyroidthyroidI have slow conversion of T4 to T3I have slow conversion of T4 to T3I have constant mental fogI have constant mental fogI donI don’’t sleep wellt sleep well

Thyroid nodulesThyroid nodules

Multinodular goitreMultinodular goitre

Solitary noduleSolitary nodule

Thyroid cancerThyroid cancer

Thyroid ultrasoundThyroid ultrasound

Needs to be done by a specialist Needs to be done by a specialist ultrasonographer..ultrasonographer..U Classification U Classification –– U1 BenignU1 Benign–– U3 and up U3 and up -- FNACFNAC–– U5 MalignancyU5 Malignancy

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4729706/

Clinical features Clinical features

Age <20 or > 60 yearsAge <20 or > 60 yearsThe nodule is firm on palpationThe nodule is firm on palpationA history of fastA history of fast--growing nodulegrowing noduleVocal cord paralysis, which should be Vocal cord paralysis, which should be further investigatedfurther investigatedRegional lymphadenopathyRegional lymphadenopathyPrevious radiotherapy to the neck regionPrevious radiotherapy to the neck regionFamily history of thyroid cancerFamily history of thyroid cancer

Any Questions?Any Questions?

thyroid - pab2u.com · she had normal tfts on 100 mcg thyroxine till 6 months ago. she was...

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