Downloaded 420 times
Uploaded byDr. Mohammed Sadiq Azam M.D.
Medical management of Thyroid disease
This document discusses various thyroid disorders including thyrotoxicosis, hypothyroidism, thyroid disease complicating pregnancy, and medical emergencies related to thyroid disease. Key points include: 5% of the world population suffers from thyroid disease; congenital hypothyroidism is one of the most common causes of preventable mental retardation worldwide; thyrotoxicosis is defined as excess thyroid hormone levels and its main causes are Graves' disease and multinodular goiter; hypothyroidism is commonly caused by iodine deficiency or Hashimoto's thyroiditis; and medical emergencies related to thyroid disease include thyrotoxic crisis characterized by high fever and hypothyroidism coma which has a high mortality
More Related Content
Similar to Medical management of Thyroid disease
More from Dr. Mohammed Sadiq Azam M.D.
Medical management of Thyroid disease
- 1. In the Nameof God, Most Gracious, Most Merciful
- 4. The history ofman…
- 5. … is plaguedby disease
- 6. Today … We discuss …
- 7.
- 8.
- 9.
- 10.
- 11.
- 12.
- 13. 5 % OFTHE WORLD POPULATION SUFFERS FROM THYROID DISEASE
- 14. CONGENITAL HYPOTHYRIODISM ISONE OF THE MOST COMMON CAUSES OF PREVENTABLE MENTAL RETARDATION WORLD-WIDE
- 15. 20 MILLION PEOPLEIN THE WORLD HAVE VARIOUS DEGREES OF BRAIN DAMAGE CAUSED BY IODINE DEFICIENCY IN UTERO
- 16. MEDICAL MANAGEMENT OF THYROID DISEASE By- MOHAMMAD SADIQ III YR. M.B.B.S. M.M.C.R.I.
- 17. THYROID DISORDERS The conditionswe will deal with here are: 1. Thyrotoxicosis 3. Hypothyroidism 5. Medical Emergencies > Myxoedema coma > Thyrotoxic crisis • Congenital Hypothyroidism (Cretinism) • Thyroid Disease complicating pregnancy
- 18. THYROID DISORDERS MEDICAL MANAGEMENT Proper management is based upon: 1. Proper Clinical Diagnosis 3. Laboratory Evaluation 5. Treatment 7. Monitoring of patient
- 19. THYROTOXICOSIS INTRODUCTION “Defined as the state of thyroid hormone excess & is not synonymous with hyperthyroidism which is the result of excessive thyroid function” Top 2 causes are: Grave’s Disease (76%) Multi Nodular Goitre (14%)
- 20. HYPOTHYROIDISM ETIOPATHOGENESIS Iodine deficiency remains the leading cause World-wide. In areas of iodine sufficiency the causes are: • Hashimoto’s thyroiditis • Spontaneous Atrophic thyroiditis • Iatrogenic causes
- 21. HYPOTHYROIDISM PRESENTING COMPLAINT HASHIMOTO’S ATROPHIC THYROIDITIS: THYROIDITIS: • Symptoms of Goitre • Symptoms of more than that of Hypothyroidism more Hypothyroidism. than that of Goitre
- 22. HYPOTHYROIDISM QUEEN ANNE’S SIGN MYXOEDEMA FACIES
- 23. THYROID DISEASE CLINICAL PRESENTATION Cardinal Features HYPERTHYROIDISM: HYPOTHYROIDISM: • Presents with warm, • Presents with moist skin tiredness, weakness • Myxoedema • ↑ sweating, Heat intolerance • Dry coarse skin, Cool peripheral extremities • Von Muller’s Paradox • Cold intolerance
- 24. THYROID DISEASE CLINICAL PRESENTATION Dept. of General Medicine HYPERTHYROIDISM: 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)
- 25. THYROID DISEASE GI PRESENTATION ↓Transit time leads to diarrhoea in thyrotoxicosis
- 26. THYROID DISEASE Dept. of Dermatology HYPERTHYROIDISM: HYPOTHYROIDISM: • Pretibial myxoedema • Diffuse alopaecia • Thyroid acropachy Pretibial Myxoedema Acropachy
- 27. THYROID DISEASE CLINICAL PRESENTATION Dept. of Neurology HYPERTHYROIDISM: HYPOTHYROIDISM: • Fine tremor • Paraesthesia • Hyperreflexia • Pseudomyoclonus • Muscle wasting • Delayed tendon reflexes • Proximal myopathy • Difficulty in concentration • Hypokalemic periodic • Poor memory paralysis
- 28. THYROID DISEASE Dept. of OBG HYPERTHYROIDISM: • Oligomenorrhoea HYPOTHYROIDISM: • Menorrhagia
- 29. THYROID DISEASE Dept. of Psychiatry HYPERTHYROIDISM: HYPOTHYROIDISM: • Anxiety neurosis • Bipolar Disorder • Severe Depression • Depression
- 30. THYROTOXICOSIS CVSMANIFESTATION C/F: •Palpitations •Sinus Tachycardia •Bounding pulse •Widened pulse pressure •Aortic Systolic Murmur •Worsening of Angina •Atrial Fibrillation (>50yrs)
- 31. THYROTOXICOSIS MANAGEMENTOF 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.
- 32. THYROTOXICOSIS GRAVES’ OPTHALMOPATHY • Gritty sensation, Discomfort, ↑ lacrymation • Exopthalmous • Periorbital oedema, Chemosis, Scleral injection
- 33. THYROTOXICOSIS MANAGEMENT - 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
- 34. GRAVES’ OPTHALMOPATHY EFFECT OF THERAPY BEFORE AFTER
- 35. THYROTOXICOSIS MANAGEMENT 3 approaches 1. Antithyroid drugs • Radioactive Iodine I131 5. Subtotal thyroidectomy
- 36. THYROTOXICOSIS MEDICAL MANAGEMENT 1. ANTITHYROID DRUGS: > Carbimazole > Propyl thiouracil Dosage of Carbimazole: 0-3 weeks → 40-60 mg daily 4-8 weeks → 20-40 mg daily Maintainence → 5-20 mg daily for 18-24 months ADR: Rash, Agranulocytosis C/I: Lactating Mothers
- 37. THYROTOXICOSIS MEDICAL MANAGEMENT 2. RADIOACTIVE I131 : MOA: > Destroys functioning thyroid cells > Inhibits their ability to replicate Dose: 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
- 38. THYROTOXICOSIS MEDICAL MANAGEMENT 3. Role of β-blockers: ONLY SYMPTOMATIC RELIEF (within 12-24 h) Propronolol: 160 mg/day Nadolol: 40-80 mg/day T3 toxicosis : I131(555-110Mbq), Hemithyroidectomy
- 39. THYROTOXICOSIS EFFECT OFTREATMENT BEFORE AFTER
- 40. THYROTOXICOSIS EFFECT OF TREATMENT BEFORE AFTER
- 41. THYROTOXICOSIS SPECIAL CASES 1. PENDRED’S SYNDROME: Dyshormonogenesis (↓T4) + Deafness 2. HAMBURGER THYROTOXICOSIS
- 42. 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 OD Hypothyroidism following Grave’s Disease → 75-125µg/day OD Improvement takes 2-3 weeks
- 43. HYPOTHYROIDISM MEDICAL MANAGEMENT RATIONALE IN USING T4 IN HASHIMOTO’S: 2. Treatment of Hypothyroidism 3. Goitre shrinkage T4 vs. T3 – Why T4? T3 in high doses causes: • Angina • Arrythmias • Heart Failure
- 44. 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 - ?
- 45. HYPOTHYROIDISM EFFECTOF TREATMENT BEFORE AFTER
- 46. HYPOTHYROIDISM EFFECT OF TREATMENT BEFORE AFTER
- 47. 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 normal TSH deficiency Low normal / ↓ or ↔/↓ sub normal low normal T3 Toxicosis ↓↓ ↔ ↑ (<0.05 mU/L) Compensated Slightly ↑ ↔ ↔ Euthyroidism (5-10 mU/L)
- 48. MEDICAL EMERGENCIES 2Situations : 1. HYPERTHYROID CRISIS (= Thyrotoxic crisis / Thyroid storm) 4. MYXOEDEMA COMA
- 49.
- 50. 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
- 51. 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)
- 52. 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
- 53. CRETINISM “Children who are hypothyroid from birth / before are called cretins.” WHO IS A CRETIN? “What should have been an angel of God has been a pariah of nature just for the want of a little iodine in mother’s blood.”
- 54. CRETINISM GUESS MY AGE? 22 yr. old female Pot belly Umbilical hernia Coarse facial features Supra clavicular pad of fat
- 55. CRETINISM GUESS 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
- 56.
- 57. 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
- 58. CRETINISM TREATMENT Sodium Levothyroxine 100µg tab is the DOC Dose: Neonates: 10-15 µg/kg/day Older children: 4-8 µg/kg/day Neonates & Children < 1yr.: INITIATE trt. on DIAGNOSIS DON’T WAIT for INVESTIGATIONS
- 59. CRETINISM MONITORING 1. Assess Clinical Milestones 2. Periodic TFT 3. Radiological estimation of bone age annually Antenatal screening: > Regular TFT – mother > Foetus USG
- 60. THYROID DISEASE COMPLICATING PREGNANCY HYPOTHYROIDISM HYPERTHYROIDISM
- 61. THYROID DISEASE COMPLICATING 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?
- 62. THYROID DISEASE COMPLICATING 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).
- 63. MEDICAL MANAGEMENT OF THYROID DISORDERS CONCLUSION 1. Thyroid disease may have a variable clinical presentation. Hence, it is very essential to have a high degree of caution before declaring a patient euthyroid. It is better to do a TFT in all suspected cases. The cost of the TFT is noting compared to the dire consequences of a missed diagnosis. 7. Treatment must be started immediately in all suspected cases of thyroid storm/myxoedema coma/cretinism as a delay in treatment might be fatal to the patient or may land the child in permanent mental retardation.