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Approach to thyroid disorders hypothyroid hyperthyroid
- 2. By: DR.QAMAR SAJAD SENIOR REGISTRAR MEDICINE UNIT 3 M.B.B.S, F.C.P.S M.R.C.P, (GLASG) M.R.C.P, SCE(UK) Endo and diabetes
- 4. • Most of T4 is transported in plasma as protein-bound 1.Thyroxin binding globulin (TBG) bound -70% 2.Albumin-bound-25% 3.Transthyretin-bound-5% T3 IS MOST BIOLOGICALLY ACTIVE FORM The unbound form of T3 & T4 are biologically active METABOLISM
- 5. TSH = 0.3-4mU/L T3 = 1.4-4.4pg/dL T4 = 0.7-2.1ng/dL Remember: Upper limit of normal TSH of the euthyroid is 2.5 mU/L NORMAL VALUES
- 7. To evaluate our Thyroid patient As per the AACE Guidelines The Nine Square Game
- 9. HYPOTHYROIDISM Winfrey diagnosed with thyroid problem in 2007. Before she was diagnosed with hypothyroidism she struggled with weight gain and felt exhausted all the time.
- 10. • Occurs when thyroid gland produces less than normal amount of thyroid hormone. • In US and other areas of World with adequate iodine intake. The most common cause is HASHIMITO’S THYROIDITIS HYPOTHYROIDISM
- 11. SYMPTOMS OF HYPOTHYROIDISM • Weight Gain • Cold Intolerance • Constipation • Dry Skin • Weakness • Menorrhagia • Memory loss • Fatigue • Hair loss • Myalgias • Depression • Difficulty concentrating Everything Goes down except weight which is INCREASE
- 13. • Autoimmune(Most Common) • Treatment for hyperthyroidism • Status post thyroid surgery • Medication-induced • Pituitary disorder CAUSES OF HYPOTHYROIDISM
- 14. HOW TO INVESTIGATE SCREENING TEST FOR HYPOTHYROIDISM IS TSH
- 16. • FT3 • FT4 • TPO Antibodies(Autoimmune) • USG Neck for goitre • Nuclear sintigraphy • FNAC for thyroid nodule If TSH high: Go for
- 19. • CBC • FLP • BMP • S/Cr Which shows Anemia, Hyperlipidemia, Hyponatremia & revesible increase in serum creatinine OTHER INVESTIGATIONS
- 26. Subclinical hypothyroidism is defined biochemically as: • A normal serum free thyroxine (T4) level • Elevated serum thyroid-stimulating hormone (TSH) level SUBCLINICAL HYPOTHYROIDISM
- 27. • The initial screening test is the serum TSH • If the serum TSH concentration is elevated, Then • TSH measurement should be repeated along with a serum free T4.
- 29. HYPERTHYROIDISM
- 30. SYMPTOMS OF HYPERTHYROIDISM Everything Speeds up due to high metabolism • Irritability • Nervousness • Increase Sweating • Heat Intolerance • Diarrhea • Insomnia • Palpitations • Weight loss • Increase appetite • Irregular menses • Pretibial Myxedema • Exophlamos
- 32. INVESTIGATIONS • TSH LOW • T3 HIGH • T4 HIGH • TPO & TSI Antibodies(Graves disease)
- 34. • Decreased TSH level • Normal total or free T4 & T3 level • Few or no symptoms of hyperthyroidism SUBCLINICAL HYPERTHYROIDISM
- 35. Should subclinical hyperthyroidism be treated???
- 36. Should be treated if: • TSH level is < 0.1 • If TSH is between 0.1-0.5 Observe & follow for overt hyperthyroidism Should consider treatment if evidence if complications of hyperthyroidism( Osteopenia, Osteoprosis & Atrial firbrillation)
- 38. TREATMENT OPTIONS • Anti-thyroid drugs • Beta-blockers • Radioactive iodine • Thyroidectomy
- 40. • Methimazole & Propylthiouracil are choice. • Titrate dose every 6 weeks until thyroid level normalize. • Goal is to inhibit synthesis if T3 & T4 THIONAMIDES
- 41. Radioactive Iodine: • It causes fibrosis & destruction of thyroid over weeks to months. • Dose is intended to render the patient hypothyroid.So monitor thyroid levels 6 weeks until normalize. Surgical Resection: • Remove hyperplastic & edenomatous tissue
- 42. ADJUNCTIVE THERAPY • Beta-blockers • Corticosteroid therapy • Bile acid sequestrants • Iodide
- 44. • HCG-mediated hyperthyroidism occurs due to homology between the beta-subunits of hCG and TSH. • It may cause hyperthyroidism during the period of highest serum hCG concentration. • HCG level peaks at 10-12 weeks. HCG-MEDIATED HYPERYHYROIDISM
- 45. HCG-MEDIATED HYPERYHYROIDISM Includes three conditions: 1.Gestational transient thyrotoxicosis(GTT) 2.Hyperemesis Gravidarum 3.Trophoblastic hyperthyroidism
- 46. GESTATIONAL TRANSIENT THYROTOXICOSIS During peak HCG con: • Slightly low serum TSH concentrations • High-normal or mildly elevated serum free T4 concentrations. • Leads to overt hyperthyroidism. • Occurs near the end of 3rd trimester & subsides as HCG con. Falls( 14-18 weeks of gestation).
- 47. HYPEREMESIS GRAVIDARUM • It is a syndrome of nausea and vomiting associated with weight loss of 5 percent or more during early pregnancy • These women has higher serum hCG and estradiol concentrations • Their serum TSH concentrations are often lower.T3 & T4 HIGH (Overt hypothyroidism) • Doesn’t require treatment, subsides as hcG falls
- 48. TROPHOBLASTIC HYPERTHYROIDISM • A hydatidiform mole (molar pregnancy) is benign but may give rise to choriocarcinoma. • Both are associated with high serum hCG concentrations and abnormal hCG isoforms i.e TSH leading to hyperthyroidism. • It needs treatment of underlying cause.
- 50. INDICATIONS OF TREATMENT • Symptomatic, moderate to severe, overt hyperthyroidism. • TSH values below 0.05 mU/L. • FT4 and/or total T4 and T3 concentrations that exceed 1.5 times the upper limit of normal for nonpregnant patients.
- 51. THERAPEUTIC OPTIONS • Thionamides Primary treatment of hyperthyroidism due to Graves' disease, toxic adenoma, or toxic multinodular goiter during pregnancy • Beta blockers Primary treatment for patients with hydatidiform mole or gestational trophoblastic neoplasia who generally cannot wait for three to 6 week for thionamides to control hyperthyroidism prior to surgery
- 52. Thyroidectomy –women who cannot tolerate thionamides because of allergy or agranulocytosis. The choice of thionamide depends upon which trimester the drug is being initiated. Methimazole is preferred to PTU except during the first trimester of pregnancy
- 53. REFERENCES • UpToDate • Journal of Endocrinology & Metabolism • Clinical Endocrinology • Thyroid.org