HYPERTHYROIDISM

Farida Ulfa
1510211057
Definition
◦ is a condition in which the thyroid gland is overactive and makes excessive
amounts of thyroid hormone.
Risk factor
◦ Run in families
◦ more common in women.
Causes
◦ 70% overproduction of thyroid hormone by the entire thyroid gland
◦ Autoimmune disorder Graves’ disease. In this disorder, the body makes an antibody
called thyroid-stimulating immunoglobulin (TSI) that causes the thyroid gland to make
too much thyroid hormone.
◦ A toxic nodular or multinodular goiter, which are lumps or nodules in the thyroid gland
that cause the thyroid to produce excessive amounts of thyroid hormones.
◦ Thyroiditis may temporarily cause symptoms of hyperthyroidism.
◦ People who consume too much iodine (either from foods or supplements) or who take
medications containing iodine (such as amiodarone) may cause the thyroid gland to
overproduce thyroid hormones.
◦ Some women may develop hyperthyroidism during pregnancy or in the first year after
giving birth.
DIAGNOSIS
◦ based on symptoms, physical exam, and blood tests to measure levels of thyroid
stimulating hormone (TSH) and thyroid hormones T3 and T4.
◦ Thyroid function study results in hyperthyroidism are as follows:
Thyrotoxicosis is marked by suppressed TSH levels and elevated T 3and T 4 levels
Patients with milder thyrotoxicosis may have elevation of T 3 levels only
Subclinical hyperthyroidism features decreased TSH and normal T 3and T 4 levels
◦ Either an ultrasound or a nuclear medicine scan of your thyroid to see if it has nodules,
or whether it is inflamed or overactive.
◦ Autoantibody tests for hyperthyroidism are as follows:
◦ Anti–thyroid peroxidase (anti-TPO) antibody - Nonspecific elevation with autoimmune
thyroid disease found in 8% of Graves patients
◦ Thyroid stimulating antibody (TSab) - Also known as thyroid-stimulating immunoglobulin
(TSI), long-acting thyroid stimulator (LATS), or TSH-receptor antibody (TRab); found in 63-
81% of Graves disease; a positive test is diagnostic and specific for Graves disease
◦ Autoantibody titers in hyperthyroidism are as follows:
Graves disease - Significantly elevated anti-TPO, elevated TSab
Toxic multinodular goiter - Low or absent anti-TPO and TSab
Toxic adenoma - Low or absent anti-TPO and TSab
Patients without active thyroid disease may have mildly positive anti-TPO and TSab
Symptoms
◦ fatigue or muscle weakness
◦ hand tremors
◦ mood swings
◦ nervousness or anxiety
◦ rapid heartbeat
◦ heart palpitations or irregular heartbeat
◦ skin dryness
◦ trouble sleeping
◦ weight loss
◦ increased frequency of bowel movements
◦ light periods or skipping periods.
Complications
◦ Heart problems.
a rapid heart rate, atrial fibrillation and congestive heart failure.
◦ Brittle bones
osteoporosis
◦ Eye problems. People with Graves' ophthalmopathy develop eye problems, including
bulging, red or swollen eyes, sensitivity to light, and blurring or double vision. Untreated,
severe eye problems can lead to vision loss.
◦ Red, swollen skin. In rare cases, people with Graves' disease develop Graves' dermopathy,
which affects the skin, causing redness and swelling, often on the shins and feet.
◦ Thyrotoxic crisis. Hyperthyroidism also places you at risk of thyrotoxic crisis — a sudden
intensification of your symptoms, leading to a fever, a rapid pulse and even delirium. If this
occurs, seek immediate medical care.
 Treatment Options
1. Symptom relief medications
2. Anti Thyroid Drugs – ATD
 Methimazole, Carbimazole
 Propylthiouracil (PTU)
3. Radio Active Iodine treatment – RAI Rx.
4. Thyroidectomy – Subtotal or Total
5. NSAIDs and Corticosteroids – for SAT
Symptom Relief
1. Rehydration is the first step
2. β – blockers to decrease the sympathetic excess
 Propranalol, Atenelol, Metoprolol
3. Rate limiting CCBs if β – blockers contraindicated
4. Treatment of CHF, Arrhythmias
5. Calcium supplementation
6. SSKI or Lugol solution for ↓ vascularity of the gland
Anti Thyroid Drugs (ATD)
Imp. considerations Methimazole Propylthiouracil
Efficacy Very potent Potent
Duration of action Long acting BID/OD Short acting QID/TID
In pregnancy Contraindicated Safely can be given
Mechanism of action Iodination, Coupling Iodination, Coupling
Conversion of T4 to T3 No action Inhibits conversion
Adverse reactions Rashes, Neutropenia Rashes, ↑Neutropenia
Dosage 20 to 40 mg/ OD PO 100 to 150mg qid PO
How long to give ATD ?
◦ Reduction of thyroid hormones takes 2-8 weeks
◦ Check TSH and FT4 every 4 to 6 weeks
◦ In Graves, many go into remission after 12-18
months
◦ 40% experience recurrence in 1 yr. Re treat for 3 yrs.
◦ Treatment is not life long. Graves seldom needs
surgery
◦ MNG and Toxic Adenoma will not get cured by
ATD.
◦ For them ATD is not the best. Treat with RAI.
Radio Active Iodine (RAI Rx.)
◦ In women who are not pregnant
◦ In cases of Toxic MNG and TSA
◦ Graves disease not remitting with ATD
◦ RAI Rx is the best treatment of hyperthyroidism in adults
◦ The effect is less rapid than ATD or Thyroidectomy
◦ It is effective, safe, and does not require hospitalization.
◦ Given orally as a single dose in a capsule or liquid form.
◦ Very few adverse effects as no other tissue absorbs RAI
Radio Active Iodine (RAI Rx.)
◦ is used for Nuclear Scintigraphy (Dx.)
◦ is given for RAI Rx. (6 to 8 milliCuries)
◦ Goal is to make the patient hypothyroid
◦ No effects such as Thyroid Ca or other
malignancies
Surgical Treatment
◦ Subtotal Thyroidectomy, Total Thyroidectomy
◦ Hemi Thyroidectomy with contra-lateral
subtotal
◦ ATD and RAI Rx are very efficacious and
easy – so
◦ Surgical treatment is reserved for MNG with
1. Severe hyperthyroidism in children
2. Pregnant women who can’t tolerate ATD
3. Large goiters with severe Ophthalmopathy
4. Large MNGs with pressure symptoms
5. Who require quick normalization of thyroid function
Preoperative Preparation
◦ ATD to reduce hyper function before surgery
◦ βeta blockers to titrate pulse rate to 80/min
◦ SSKI 1 to 2 drops bid for 14 days
◦ This will reduce thyroid blood flow
◦ And there by reduce per operative bleeding
Dietary Advice
◦ Avoid Iodized salt, Sea foods
◦ Excess amounts of iodide in some

◦ Seaweed tablets, and health food

supplements, These should be avoided
because The iodide interferes with or
complicates the management of both ATD
and RAI Rx.