Thyroid

Potency: T3>>T4 Prevalence: T4>>T3

Diagnosis: (1= thyroid dysfunction, 2=hypothalamus or pituitary dysfunction) TSH + T4 = 1 HYPOthyroidism Caused by: Hashimotos Thyroiditis, Iatrogenic radiation of head,neck Iodine insufficiency (rare in US)

TSH + T4 = 2 HYPOthyroidism Casued by: Pituitary disease (TSH) , hypothalamic hypothyroidism (TRH, mainly in children)

TSH + T4 =1 HYPERthyroidism Caused by: Graves Disease (T3>T4) Thyroid Autonomy (toxic adenoma, multinodular goiter) Exogenous thyroid (meds: Amiodarone, Lithium, Interferon or foods: ingesting necks of animals)

TSH + T4 = 2 HYPERthyroidism RAIU = HYPERthyroidism RAIU=HYPOthyroidism

(or thyrotoxicosis e.g. subacute & painless Thyroiditis)

Antithyroid Peroxide Antibody = Hashimotos Thyroiditis TSH Receptor Stimulating Antibodies = Graves Disease

Symptoms

Treatment

Hypothyroidism (slow metabolism) Dry coarse skin, cold intolerance, weight gain, lethargy, fatigue, depression, bradycardia, DOC: Levothyroxine (T4) 1.6g/kg/day Start elderly (>75yo) @ 1g/kg/day Pregnancy =45%dose IVdose=50%PO dose Need lifetime replacement Congenital hypothyroidism: aggressive Tx for 45 days (10-15mcg/kg/day)

Hyperthyroidism (fast metabolism) Thinning hair, proptosis (bulging eyes), brisk reflexes, enlarged goiter (bruits, thrills) Methamizole (Tapzole):30-60 mg/day 3 divided doses (initial) 5-30mg/day (maintenance) No liver issues, 1st line over PTU but associated w/ birth defects. Give only 2nd & 3rd trimester PTU: 300-600mg/day 4 divided doses (initial) 50300 (maintenance) DOC 1st trimester. Associated w/Liver injury & failure Inhibit peroxidase enzyme system Inhibit coupling of T4 &T3 w/MIT & DIT RAI (Radioactive Iodine) Therapy (disrupts hormone synthesis through incorporation) Iodides (large doses block thyroid hormone release & size of thyroid. Give 14 days after RAI) -blockers or CCB (to control symptoms) Propranolol 20-40mg QID or diltiazem 120mg q8H Surgery Minor: Rash, arthralgia, fever, leukopenia Major: Agranulocytosis (more common w/ methamizole) Aplastic Anemia Lupus-like syndrome Pt. Compliance S/S TSH & T4 q 6-8 weeks until normalized WBC, CBC Thyroid Storm(delirium, coma, high fever, tachypnea, N,V, tachycardia, dehydration) Precipitated by stressful events Avg~72hrs but up to 8 days High doses of PTU (900-1200mg/day 4-6 divided doses)* Iodine to block T4 production (SSKI:1-2drops, Lugols 5-10drops TID) B-blockers to control symptoms (propranolol 25mg IV or 20-80mg PO q 6h) Corticosteroids Supportive: antipyretics, fluids, electrolytes, sedatives, digoxin *PTU must be given 1st otherwise Iodide will produce large amounts of thyroid hormone

AEs of TX

Monitor:

Severe Case:

Tx for Severe Case

Pt. compliance S/S TSH & T4 q 6-8 weeks until normalized 6-12 thereafter Myxedema Coma (altered mental status,stupor,coma, hypothermia, hypoglycemia,hypoventilation w/ respiratory acidosis, usually in elderly w/ long standing hypothyroidism) IV Levothyroxine (400-500g) or Liothyronine* + pharmacological doses of Corticosteroids (in case pt. really has hypopituitarism) *Liothyronine has been advocated because since it contains T3, it does not require conversion of T4T3 and will act faster

Factors affecting successful levothyroxine therapy in Hypothyroidism 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Noncompliance Ileojejunal bypass Short bowel syndrome Cholestyramine Colestipol Ferrous sulfate Antacids Sucralfate Lovastatin & other statins Soybean infants formula

11. Concurrent administration of enzyme inducers may need higher T4 doses 12. Preparation for Surgery to correct Hyperthyroidism: 1. PTU or Methamizole for 6-8 weeks prior to surgery 2. Iodides (500mg/day) for 10-14 days before surgery (to shrink thyroid) 3. Propranolol as adjunct