This document discusses thyroid disorders and their management. It covers the thyroid gland's function of producing hormones that regulate metabolism. It describes hypothyroidism and hyperthyroidism, their clinical presentations, and treatment approaches. It discusses subclinical thyroid disease and when treatment may be indicated. It also covers euthyroid sick syndrome, myxedema coma, thyroid storm, and their treatments.

1. Thyroid Disorders
Mikael Jones, Pharm.D., BCPS
Assistant Professor
University of Kentucky College of
Pharmacy

2. Thyroid Gland
 Produces, stores, and
releases metabolically
active hormones
 Maintains metabolic
stability
 Maintains growth and
development
 Maintains body
temperature and
energy use

3. Thyroid Gland

4. Thyroid Hormones

5. Thyroid Hormones

6. Thyroid Hormones

7. Hypothalamus-Pituitary-Thyroid
axis
Hypothalamus
Anterior Pituitary
Gland
Thyroid Gland Target Organs
TRH
TSH
T3/T4



T3/T4 binds to thyroid hormone
receptors which regulates the
transcription of genes




8. FT4/ FT3
+
Low TSH
Normal
TSH Range
FT4
w/in range
Low FT4
+
Elevated TSH
FT4
w/in range
+ TPOab
Overt Hyperthyroidism Overt Hypothyroidism
Subclinical
Hyperthyroidism
Subclinical
Hypothyroidism
1 4.5 10 100
0.4
0.1
0.01
TSH
U/L
TSH and Spectrum of Thyroid
Disorders

9. Hyperthyroidism

10. Clinical Presentation

11. Clinical Presentation

12. Hypothyroidism

13. Clinical Presentation

15. Subclinical Thyroid Disease
 Controversial on when to treat
 Patients have few to no symptoms of
thyroid dysfunction
 Subclinical Hypothyroid
 TSH >4.5 mIU/L
 Free T4 =WNL (0.8-1.5 ng/dL)
 Subclinical Hyperthyroid
 TSH below the reference range
 Free T4 and T3 = WNL

16. Subclinical Thyroid Disease
 Subclinical
Hypothyroidism
 Typically do not treat
 Consider treatment if
• Pregnant or considering
pregnancy
• TSH >7-10 mIU/L
 Increased risk for CHF in
elderly
 Increased risk in
developing hypothyroid
• Elderly
• Clinical sxs present
 Subclinical
Hyperthyroidism
 Typically treat if patient has
• TSH <0.1 mIU/L and any
of the following
 Heart disease (CHF, A-
fib, arrhythmias)
 Osteoporosis
 Age >60
 Typically monitor patient if
• TSH 0.1-0.45 mIU/L

17. Euthyroid Sick Syndrome
 Nonthyroidal Illness
 Acute and Chronic Illness can decrease T3
concentrations
• TSH will not change
• Decrease in T4 to T3 conversion
 Possible body adaptation
 Do not treat unless true hyperthyroidism is
present

18. Myxedema Coma
 End stage of long-standing, uncorrected
hypothyroidism
 Clinical s/sxs
 Hypothermia
 Advanced hypothyroid symptoms
 Altered sensorium
• Delirium to coma
 High Mortality

19. Myxedema Coma
 Treatment
 Thyroxine
• 300-500 mcg IV bolus
• 75-100 mcg IV daily
 Hydrocortisone
• 100mg IV q8h until adrenal suppression is ruled
out
 Supportive Therapy
• Maintain ventilation, euglycemia, BP, and body
temperature

20. Thyroid Storm
 Life-threatening medical
emergency
 Severe thyrotoxicosis
• High fever
• Tachycardia
• Tachypnea
• Dehydration
• Delirium
• Coma
• N/V/D
 Precipitating Factors
 Infection
 Trauma
 Surgery
 RAI treatment
 Withdrawal of antithyroid
drugs
 Occurs at any age
 Average duration 72
hours with treatment
 Mortality 20%

21. Thyroid Storm
 Therapeutic Measures
 Suppression of thyroid
hormone formation and
secretion
 Antiadrenergic activity
 Corticosteroids
 Treatment of complications
or coexisting factors that
may have precipitated the
storm
 PTU is preferred
 900-1200mg/day
 Can be given rectally or
through NG tube
 Iodides
 Give after PTU
 Propranolol
 40-80mg q6h
 Esmolol if cardiac disease
or risk of pulmonary
disease or cardiac failure
 No NSAIDS or aspirin
 APAP to treat fever