Medical management of Thyroid disease
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  • 1. In the Name of God, Most Gracious, Most Merciful
  • 2. The history of man…
  • 3. … is plagued by disease
  • 4. Today … We discuss …
  • 5. THYROIDDISORDERS
  • 6. THYROTOXICOSIS
  • 7. MYXOEDEMA
  • 8. CRETINISM
  • 9. MEDICAL EMERGENCIES
  • 10. THYROID DISEASECOMPLICATING PREGNANCY
  • 11. 5 % OF THE WORLD POPULATIONSUFFERS FROM THYROID DISEASE
  • 12. CONGENITAL HYPOTHYRIODISM IS ONE OFTHE MOST COMMON CAUSES OF PREVENTABLE MENTAL RETARDATION WORLD-WIDE
  • 13. 20 MILLION PEOPLE IN THE WORLD HAVE VARIOUS DEGREES OF BRAIN DAMAGECAUSED BY IODINE DEFICIENCY IN UTERO
  • 14. MEDICAL MANAGEMENTOF THYROID DISEASE By- MOHAMMAD SADIQ III YR. M.B.B.S. M.M.C.R.I.
  • 15. THYROID DISORDERSThe conditions we will deal with here are: 1. Thyrotoxicosis 3. Hypothyroidism 5. Medical Emergencies > Myxoedema coma > Thyrotoxic crisis • Congenital Hypothyroidism (Cretinism) • Thyroid Disease complicating pregnancy
  • 16. THYROID DISORDERS MEDICAL MANAGEMENTProper management is based upon: 1. Proper Clinical Diagnosis 3. Laboratory Evaluation 5. Treatment 7. Monitoring of patient
  • 17. THYROTOXICOSIS INTRODUCTION“Defined as the state of thyroid hormone excess & isnot synonymous with hyperthyroidism which is the resultof excessive thyroid function” Top 2 causes are: Grave’s Disease (76%) Multi Nodular Goitre (14%)
  • 18. HYPOTHYROIDISM ETIOPATHOGENESISIodine deficiency remains the leading cause World-wide. In areas of iodine sufficiency the causes are: • Hashimoto’s thyroiditis • Spontaneous Atrophic thyroiditis • Iatrogenic causes
  • 19. HYPOTHYROIDISM PRESENTING COMPLAINTHASHIMOTO’S ATROPHICTHYROIDITIS: THYROIDITIS:• Symptoms of Goitre • Symptoms ofmore than that of Hypothyroidism moreHypothyroidism. than that of Goitre
  • 20. HYPOTHYROIDISMQUEEN ANNE’S SIGN MYXOEDEMA FACIES
  • 21. THYROID DISEASE CLINICAL PRESENTATION Cardinal FeaturesHYPERTHYROIDISM: HYPOTHYROIDISM:• Presents with warm, • Presents withmoist skin tiredness, weakness • Myxoedema• ↑ sweating, Heatintolerance • Dry coarse skin, Cool peripheral extremities• Von Muller’s Paradox • Cold intolerance
  • 22. THYROID DISEASE CLINICAL PRESENTATION Dept. of General MedicineHYPERTHYROIDISM: HYPOTHYROIDISM:• Diabetes Mellitus • Pleural Effusion• Palpitations • Pericardial Effusion• Diarrhoea • Constipation• Eyes: • Carpal Tunnel Syndrome Stellwag’s sign • Bradycardia• Fatigue & wt. loss • Peripheral edema (Elderly patients) • Hoarse voice (phone diag)
  • 23. THYROID DISEASE GI PRESENTATION ↓Transit time leads to diarrhoea in thyrotoxicosis
  • 24. THYROID DISEASE Dept. of DermatologyHYPERTHYROIDISM: HYPOTHYROIDISM:• Pretibial myxoedema • Diffuse alopaecia• Thyroid acropachy Pretibial Myxoedema Acropachy
  • 25. THYROID DISEASE CLINICAL PRESENTATION Dept. of NeurologyHYPERTHYROIDISM: HYPOTHYROIDISM:• Fine tremor • Paraesthesia• Hyperreflexia • Pseudomyoclonus• Muscle wasting • Delayed tendon reflexes• Proximal myopathy • Difficulty in concentration• Hypokalemic periodic • Poor memoryparalysis
  • 26. THYROID DISEASE Dept. of OBGHYPERTHYROIDISM:• OligomenorrhoeaHYPOTHYROIDISM:• Menorrhagia
  • 27. THYROID DISEASE Dept. of PsychiatryHYPERTHYROIDISM: HYPOTHYROIDISM:• Anxiety neurosis • Bipolar Disorder• Severe Depression • Depression
  • 28. THYROTOXICOSIS CVS MANIFESTATION C/F: •Palpitations •Sinus Tachycardia •Bounding pulse •Widened pulse pressure •Aortic Systolic Murmur •Worsening of Angina •Atrial Fibrillation (>50yrs)
  • 29. THYROTOXICOSIS MANAGEMENT OF ATRIAL FIBRILLATION• Generally control of serum T4 causes a return to sinus rhythm.• Drugs provide symptomatic relief. • VR responds little to Digoxin. • Good response to addition of β - blockers. • CARDIOVERSION to revert to sinus rhythm. (Only after TSH/T4 ↔ ) • Anti coagulation with Warfarin / Aspirin.
  • 30. THYROTOXICOSIS GRAVES’ OPTHALMOPATHY• Gritty sensation, Discomfort, ↑ lacrymation• Exopthalmous• Periorbital oedema, Chemosis, Scleral injection
  • 31. THYROTOXICOSISMANAGEMENT - GRAVES’ OPTHALMOPATHY 1. Reassurance 2. Methyl cellulose drops → ↓ grittiness, discomfort 3. Tinted glasses / Side shields → ↓ excess lacrymation Complications: 2. Corneal Ulcer: Lid lengthening Sx 3. Papilloedema/Loss of acuity/Field defects: URGENT trt. with PREDNISOLONE 60mg/d
  • 32. GRAVES’ OPTHALMOPATHY EFFECT OF THERAPY BEFORE AFTER
  • 33. THYROTOXICOSIS MANAGEMENT3 approaches 1. Antithyroid drugs • Radioactive Iodine I131 5. Subtotal thyroidectomy
  • 34. THYROTOXICOSIS MEDICAL MANAGEMENT1. ANTITHYROID DRUGS: > Carbimazole > Propyl thiouracilDosage of Carbimazole: 0-3 weeks → 40-60 mg daily 4-8 weeks → 20-40 mg daily Maintainence → 5-20 mg daily for 18-24 monthsADR: Rash, AgranulocytosisC/I: Lactating Mothers
  • 35. THYROTOXICOSIS MEDICAL MANAGEMENT2. RADIOACTIVE I131 :MOA: > Destroys functioning thyroid cells > Inhibits their ability to replicateDose: 180-370 MBq (5-10mCi) orally (Dep. on goitre size)• 4-6 weeks to be effective (long lag period)∀ β-blockers control symptoms in lag period.• Severe cases: Carbimazole within 48 hrs of I131
  • 36. THYROTOXICOSIS MEDICAL MANAGEMENT3. Role of β-blockers: ONLY SYMPTOMATIC RELIEF (within 12-24 h) Propronolol: 160 mg/day Nadolol: 40-80 mg/dayT3 toxicosis : I131(555-110Mbq), Hemithyroidectomy
  • 37. THYROTOXICOSIS EFFECT OF TREATMENTBEFORE AFTER
  • 38. THYROTOXICOSIS EFFECT OF TREATMENTBEFORE AFTER
  • 39. THYROTOXICOSIS SPECIAL CASES1. PENDRED’S SYNDROME: Dyshormonogenesis (↓T4) + Deafness2. HAMBURGER THYROTOXICOSIS
  • 40. HYPOTHYROIDISM MEDICAL MANAGEMENT Life long therapy with Levothyroxine (T4) is the sheet anchor Start slowly with 50µg/day OD – 3 weeks Then ↑ to 100µg/day OD – 3 weeks Finally ↑ to 150µg/day ODHypothyroidism following Grave’s Disease → 75-125µg/day OD Improvement takes 2-3 weeks
  • 41. HYPOTHYROIDISM MEDICAL MANAGEMENTRATIONALE IN USING T4 IN HASHIMOTO’S:2. Treatment of Hypothyroidism3. Goitre shrinkage T4 vs. T3 – Why T4? T3 in high doses causes: • Angina • Arrythmias • Heart Failure
  • 42. HYPOTHYROIDISM MONITORING THERAPY• Correct dose of drug: Restores serum TSH to lower part of reference range when T4 is ↔ / slightly ↑.• Advise & reinforce need for regular medication.• TFT screening every 1-2 years. ↑ T4 & ↑ TSH - ?
  • 43. HYPOTHYROIDISM EFFECT OF TREATMENT BEFORE AFTER
  • 44. HYPOTHYROIDISM EFFECT OF TREATMENTBEFORE AFTER
  • 45. THYROID DISORDERS INVESTIGATIONS Disorder TSH Free T4 Free T3 (0.3-3.5 mU/L) (10-25 pmol/L) (3.5-7.5 pmol/L)Thyrotoxicosis ↓↓ ↑ ↑ (<0.05mU/L) Primary ↑ (>10 mU/L) ↓ or ↔/↓Hypothyroidism low normalTSH deficiency Low normal / ↓ or ↔/↓ sub normal low normal T3 Toxicosis ↓↓ ↔ ↑ (<0.05 mU/L)Compensated Slightly ↑ ↔ ↔Euthyroidism (5-10 mU/L)
  • 46. MEDICAL EMERGENCIES 2 Situations : 1. HYPERTHYROID CRISIS (= Thyrotoxic crisis / Thyroid storm) 4. MYXOEDEMA COMA
  • 47. HYPERTHYROID CRISIS
  • 48. HYPERTHYROID CRISIS MANAGEMENT• Rehydrated• Broad spectrum antibiotic• Propronolol 80 mg 6th hrly orally / 1-5 mg 6th hrly i.v.• Large doses of Propyl thiouracil 600 mg loading dose & 200-300 mg every 6 hrs orally/NGT/PR is the DOC.• Stable Iodine 1 hr later.• Saturated sol of KI / Na iopodate 500 mg/d orally restores normal levels of T3 within 48-72 hrs.• Others: Glucocorticoids, Cooling, Oxygen
  • 49. MYXOEDEMA COMA CLINICAL PICTURE∀ ↓ level of consciousness usually in an elderly patient who appears myxoematous• Body temperature as low as 25oC• Convulsions• CSF pressure & proteins ↑• Mortality rate around 50% (EARLY DETECTION is essential)
  • 50. MYXOEDEMA COMA MANAGEMENT TREATMENT must begin IMMEDIATELY• Triiodothyronine i.v. bolus 20µg followed by 20µg 8th hourly till there is sustained clinical improvement.• Liothyronine (T3) i.v. / NGT 10-25 µg 8-12th hourly (v. rapid)• T3 (25µg) + T4 (200µg) as a single initial i.v. bolus followed by daily trt. with Levothyroxine 50-100 µg 8th hrly. Others: Slow rewarming (if <30oC), Cautious use of i.v. fluids, Broad Spectrum antibiotics, High flow oxygen, Assisted ventilation
  • 51. CRETINISM “Children who are hypothyroid from birth / before are called cretins.” WHO IS A CRETIN?“What should have been an angel of Godhas been a pariah of nature just for the wantof a little iodine in mother’s blood.”
  • 52. CRETINISMGUESS MY AGE? 22 yr. old female Pot belly Umbilical hernia Coarse facial features Supra clavicular pad of fat
  • 53. CRETINISMGUESS MY AGE? 17 yr. old female Congenital hypothyroidism Large ears Enlarged protruded tongue Wide set eyes Depressed nasal bridge Short limbs Estim. bone age : 9 months
  • 54. CRETINISMRADIOLOGICAL PICTURE
  • 55. CRETINISM MANAGEMENT Monitoring of thyroid status of mother is important If mother is… Euthyroid Hypothyroid• Dev. normal until birth • Iodine def. is commonest cause• Manifests at birth • MR is more severe• Treatment started at birth • Less responsive to trt. has good prognosis • Deaf mutism & rigidity + Intake of iodised salt has ↓ this
  • 56. CRETINISM TREATMENT Sodium Levothyroxine 100µg tab is the DOCDose: Neonates: 10-15 µg/kg/day Older children: 4-8 µg/kg/dayNeonates & Children < 1yr.: INITIATE trt. on DIAGNOSIS DON’T WAIT for INVESTIGATIONS
  • 57. CRETINISM MONITORING1. Assess Clinical Milestones2. Periodic TFT3. Radiological estimation of bone age annually Antenatal screening: > Regular TFT – mother > Foetus USG
  • 58. THYROID DISEASECOMPLICATING PREGNANCYHYPOTHYROIDISM HYPERTHYROIDISM
  • 59. THYROID DISEASECOMPLICATING 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 Radioactive Iodine is C/I If Hyperthyroid mother wants to feed?
  • 60. THYROID DISEASECOMPLICATING PREGNANCY HYPOTHYROIDISM - MANAGEMENT Why treat? On the basis of serum TSH measurements most pregnant women with primary hypothyroidism require an additional 50µg thyroxine to their usual dose ( TBG ↑ in pregnancy).
  • 61. MEDICAL MANAGEMENT OF THYROID DISORDERS CONCLUSION1. 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 allsuspected cases. The cost of the TFT is noting compared to thedire consequences of a missed diagnosis.7. Treatment must be started immediately in all suspected casesof thyroid storm/myxoedema coma/cretinism as a delay in treatmentmight be fatal to the patient or may land the child in permanentmental retardation.