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Knowledge is essential Applied, it is Wisdom Wisdom is Happiness. Charaka Samhita. Sukham Samagram Vijnane Vimale cha Pratishthitam. All happiness is rooted in the Good Science. www.drsarma.in. Abnormal Thyroid Function A Practical Approach.

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Drsarma

Knowledge is essential

Applied, it is Wisdom

Wisdom is Happiness

www.drsarma.in


Charaka samhita

Charaka Samhita

Sukham Samagram Vijnane Vimale cha Pratishthitam

All happiness is rooted in the Good Science

www.drsarma.in


Drsarma

www.drsarma.in

Abnormal

Thyroid Function

A Practical Approach

Dr.R.V.S.N.Sarma.,M.D., M.Sc.,

Consultant Physician and Chest Specialist

www.drsarma.in


Some interesting cases

Some interesting cases

  • Govindammal – Persistant diarrhea

  • Sridhar – HM – Cachexia 70 kg to 40 kg

  • Kavitha – Weight loss – lung shadow

  • Sulochana – Severe anaemia – CHF

  • Lady doctor – listlessness – anaemia

  • Kamatchi – Infertility after 16 yrs of ML

  • Siva – Atrial fibrillation – cachexia

  • Begum - Our staff member – weight loss

  • John – 32 yrs. Premature IHD

  • Kadirvelu – severe diabetes

  • Annaji – dyspnea – tracheal compression

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Clinical exam of thyroid

Have patient seated on a stool / chair

Inspect neck – also while drinking water

Examine with neck in relaxed position

Palpate from behind the patient

Remember the rule of finger tips

Use the tips of fingers for palpation

Palpate firmly down to trachea

Pemberton’s sign for RSG

Clinical Exam. of Thyroid

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Where to look for thyroid

Where to look for Thyroid ?

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Clinical anatomy of thyroid

Clinical Anatomy of Thyroid

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Clinical exam of thyroid1

Clinical Exam of Thyroid

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Clinical exam of thyroid2

Clinical Exam of Thyroid

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Clinical exam of thyroid3

Clinical Exam of Thyroid

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Thyromegaly

Thyromegaly

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Drsarma

Thyroid Gland

Hormonogenesis

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Thyroid regulation

HYPOTHALAMUS - TRH

ANT. PITUITARY - TSH

THYROID T4 and T3

PLASMA T4 + FT4

PLASMA T3 + FT3

TISSUES FT4 to FT3, rT3

Thyroid Regulation

TSH -R

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In the thyroid gland

There the following 5 steps in the hormonogenesis

Trapping of inorganic Iodine from dietary Iodides

Activation of Iodine to high valance I2

Incorporation of I2 into Tyrosine of Thyroid Globulin

Coupling of formed MIT and DIT to form T4 & T3

Proteolysis of Thyroglobulin to release T4 & T3

In the Thyroid Gland

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Metabolism of thyroid hormones

Metabolism of Thyroid Hormones

Thyroid Gland

100 nm

Thyroxine FT4

5 nm

< 5 nm

45 nm

35 nm

Reverse T3 (rT3)

Triiodothyronine (FT3)

20 nm

Tertrac etc.,

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What happens in fluorosis

Normal catabolism -Thyroxine

FT4 FT3

rT3 will be LOW

rT3 ÷ T3 ratio will be LOW

Normal deiodination of T4

Abnormal catabolism -Thyroxine

FT4 FT3

rT3 will be HIGH

rT3 ÷ T3 ratio will be HIGH

Fluoride affects the normal

deiodination of T4

rT3

rT3

What happens in Fluorosis

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The thyronines

Mono Iodo Tyrosine – MIT

Di Iodo Tyrosine – DIT

Tri Iodo Thyronine – T3 –half life 6 hours

Tetra Iodo Thyronine – T4 half life 7 days

Reverse T3 - metabolically inactive

T4 is 99.9% protein bound to TBG, TPA, TA

T3 is 99.5% protein bound to TBG, TPA, TA

Bound hormones are inactive – should not be measured

Only Free T4 and Free T3 are metabolically active

The Thyronines

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Drsarma

The Thyroxines

Tri Iodo Thyronine – T3

- 10% is from thyroid gland

- 90% derived from conversion of T4 to T3

Tetra Iodo Thyronine – T4

- Is exclusively from thyroid gland

From the thyroid gland

- 80% of hormone secreted is T4

- 20% of hormone secreted is T3

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Drsarma

Thyroid Function Tests

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Thyroid function tests

TSH

Free T4

Free T3

Anti-Thyroid Antibodies

Nuclear Scintigraphy

FNAC of nodule

Thyroid Function Tests

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What tests should i order

What tests should I order ?

  • As per the Guidelines of the AACE and ATA, ITS

  • 1. TSH alone if Hypothyroidism is suspected

  • 2. TSH and Free T4only if Hyperthyroidism is suspected or for routine evaluation

  • 3. Free T3 if T3 toxicosis is suspected

  • 4. For follow-up of treatment only TSH

  • Don’t order for Total T4 or Total T3

  • Never order RIU in pregnancy or lactation

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Which lab to choose

Depends on the method of estimation of hormones

EquilibriumDialysis is the gold Standard for TSH

Radio-immuno assay - 3rd or 4th gen. RIA is the best

Reliability of ELISA is not adequate

Chemiluminescence immuno assay - CIA is the gold standard for FT4 but expensive and less widely available

Choose a lab which offers 3rd or 4th generation RIA method

Which Lab to choose ?

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How to interpret results

How to interpret results ?

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The nine square game

The Nine Square Game

To evaluate our Thyroid patient

As per the AACE and ITS Guidelines

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Drsarma

BASIC THYROID EVALUATION

LOW NORMAL HIGH

FREE THYROXINE or FT4

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

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Drsarma

BASIC THYROID EVALUATION

LOW NORMAL HIGH

FREE THYROXINE or FT4

EUTHYROID

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

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Drsarma

BASIC THYROID EVALUATION

LOW NORMAL HIGH

FREE THYROXINE or FT4

PRIMARY

HYPOTHYROID

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

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Drsarma

BASIC THYROID EVALUATION

PRIMARY

HYPERTHYROID

LOW NORMAL HIGH

FREE THYROXINE or FT4

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

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Drsarma

BASIC THYROID EVALUATION

LOW NORMAL HIGH

FREE THYROXINE or FT4

SECONDARY

HYPOTHYROID

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

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Drsarma

BASIC THYROID EVALUATION

SECONDARY

HYPERTHYROID

LOW NORMAL HIGH

FREE THYROXINE or FT4

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

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Drsarma

BASIC THYROID EVALUATION

SUB-CLINICAL

HYPERTHYROID

LOW NORMAL HIGH

FREE THYROXINE or FT4

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

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Drsarma

BASIC THYROID EVALUATION

SUB-CLINICAL

HYPOTHYROID

LOW NORMAL HIGH

FREE THYROXINE or FT4

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

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Drsarma

BASIC THYROID EVALUATION

LOW NORMAL HIGH

FREE THYROXINE or FT4

NON THYROID

ILLNESS or NTI

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

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Drsarma

BASIC THYROID EVALUATION

NTI or Pt.

on ELTROXIN

LOW NORMAL HIGH

FREE THYROXINE or FT4

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

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Drsarma

BASIC THYROID EVALUATION

PRIMARY

HYPERTHYROID

NTI or Pt.

on ELTROXIN

SECONDARY

HYPERTHYROID

SUB-CLINICAL

HYPERTHYROID

SUB-CLINICAL

HYPOTHYROID

LOW NORMAL HIGH

FREE THYROXINE or FT4

EUTHYROID

SECONDARY

HYPOTHYROID

PRIMARY

HYPOTHYROID

NON THYROID

ILLNESS - NTI

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

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Drsarma

BASIC THYROID EVALUATION

LOW NORMAL HIGH

FREE THYROXINE or FT4

EUTHYROID

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

www.drsarma.in


Drsarma

BASIC THYROID EVALUATION

LOW NORMAL HIGH

FREE THYROXINE or FT4

PRIMARY

HYPOTHYROID

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

www.drsarma.in


Drsarma

BASIC THYROID EVALUATION

PRIMARY

HYPERTHYROID

LOW NORMAL HIGH

FREE THYROXINE or FT4

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

www.drsarma.in


Drsarma

BASIC THYROID EVALUATION

LOW NORMAL HIGH

FREE THYROXINE or FT4

SECONDARY

HYPOTHYROID

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

www.drsarma.in


Drsarma

BASIC THYROID EVALUATION

SECONDARY

HYPERTHYROID

LOW NORMAL HIGH

FREE THYROXINE or FT4

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

www.drsarma.in


Drsarma

BASIC THYROID EVALUATION

SUB-CLINICAL

HYPERTHYROID

LOW NORMAL HIGH

FREE THYROXINE or FT4

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

www.drsarma.in


Drsarma

BASIC THYROID EVALUATION

SUB-CLINICAL

HYPOTHYROID

LOW NORMAL HIGH

FREE THYROXINE or FT4

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

www.drsarma.in


Drsarma

BASIC THYROID EVALUATION

LOW NORMAL HIGH

FREE THYROXINE or FT4

NON THYROID

ILLNESS or NTI

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

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Drsarma

BASIC THYROID EVALUATION

NTI or Pt.

on ELTROXIN

LOW NORMAL HIGH

FREE THYROXINE or FT4

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

www.drsarma.in


Drsarma

BASIC THYROID EVALUATION

PRIMARY

HYPERTHYROID

NTI or Pt.

on ELTROXIN

SECONDARY

HYPERTHYROID

SUB-CLINICAL

HYPERTHYROID

SUB-CLINICAL

HYPOTHYROID

LOW NORMAL HIGH

FREE THYROXINE or FT4

EUTHYROID

SECONDARY

HYPOTHYROID

PRIMARY

HYPOTHYROID

NON THYROID

ILLNESS - NTI

LOW NORMAL HIGH

THYROID STIMULATING HORMONE - TSH

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Thyroid hormones

THYROID HORMONES

TSH upper limit will soon be revised to 2.5 mU/L

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T f t in progressive hypothyroidism

TSH

T.F.T. in Progressive Hypothyroidism

Mild

Moderate

Severe

Normal Range

Free T3

Free T4

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Nucleotide scintigraphy

I 123 and TC 99m Radio Nucleotide Scintigraphy

This test is not at all required in hypothyroidism

This is only to confirm a hyper functioning thyroid or

To assess whether a nodule is ‘hot’ or ‘cold’

Never order for this test for hypothyroidism

Similar is the case with FNAC – in hypothyroid goiter

If TSH is high and FT4 is low there is no role for FNAC

Nucleotide Scintigraphy

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Thyroid antibodies

Anti Microsomal (TM ) Antibodies

Anti Thyroglobulin (TG) Antibodies

Anti Thyroxine Per Oxidase (TPO) Ab.

Anti Thyroxine antibodies

Thyroid Stimulating (TSA) Antibodies

Thyroid Antibodies

  • High titres TPO Ab in Hashimotos & Reidle’s thyroiditis

  • Anti thyroxine Ab in peripheral resistance to Thyroxine

  • TSA (TSI) in Graves’ Hyperthyroidism

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Current trends in dx and rx

Current Trends in Dx. and Rx.

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HYPOTHYROIDISM

[email protected]


General considerations

General Considerations

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Hypothyroidism

Epidemiology

Most common endocrine disease

Females > Males – 8 : 1

Presentation

Often unsuspected and grossly under diagnosed

90 % of the cases are Primary Hypothyroidism

Menstrual irregularities, miscarriages, growth retard.

Vague pains, anaemia, lethargy, gain in weight

In clear cut cases - typical signs and symptoms

Low free T4 and High TSH

Easily treatable with oral Levo-thyroxine

Hypothyroidism

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Classification

Classification

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Classification of hypothyroidism

Primary contd..

3. Post Ablative

- Permanent

- Transient

- Sub-clinical

4. Congenital

B. Secondary / Central

Pituitary/ hypothalamic

A. Primary

1. Enlarged Thyroid

- Hashimoto’s (65%)

- Iodine Deficiency (25%)

- Drug-induced (Lithium)

- Dysharmonogenesis

2. Normal Thyroid

- Spontaneous Atrophic

Classification of Hypothyroidism

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Drsarma

IDD

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Clinical considerations

Clinical considerations

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Drsarma

Disease Burden

5% of the general population are Sub-clinically Hypothyroid

15 % of all women > 65 yrs. are hypothyroid

Detecting sub-clinical hypothyroidism in pregnancy is highly essential – order for TSH and FT4 routinely in all pregnant women at the beginning of each trimester

All persons aged above 60 years – Order for TSH

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Drsarma

Multi system effects - Hypothyroidism

  • Neuromuscular

  • Aches and pains

  • Muscle stiffness

  • Carpel tunnel syndrome

  • Deafness, Hoarseness

  • Cerebellar ataxia

  • Delayed DTR, Myotonia

  • Depression, Psychosis

  • Gastro-intestinal

  • Constipation, Ileus, Ascites

  • Dermatological

  • Dry flaky skin and hair

  • Myxoedema, Malar flushes

  • Vitiligo, Carotenimia, Alopecia

  • General

  • Lethargy, Somnalence

  • Weight gain, Goitre

  • Cold Intolerence

  • Cardiovascular

  • Bradycardia, Angina

  • CHF, Pericardial Effusion

  • HyperlipIdemia, Xanthelsma

  • Haematological

  • Iron def. Anaemia,

  • Normo cytic /chromic Anaemia

  • Reproductive system

  • Infertility, Menorrhagia

  • Impotence, Inc. Prolactin

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Drsarma

Clinical Signs of Hypothyroidism

  • Coarse Hair; Dry cool and pale skin

  • Goitre (not in all cases), Hoarseness of voice

  • Non-pitting oedema (myxoedema)

  • Puffiness of eyes and face

  • Delayed relaxation of DTR

  • Slow hoarse speech and slow movements

  • Thinning of lateral 1/3 of eye brows

  • Bradycardia, pericardial effusion

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What the mind knows the eyes see

Psychiatric patients

Elderly women / men

Patients of OSA

Hypercholesterolemia

Lithium, Amiodarone

Postpartum women

What the mind knows the eyes see !!

Order for TSH alone as a screen

  • Other Autoimmune disease

  • Rx. Grave’s Ophthalmopathy

  • Family H/o thyroid disease

  • Neck irradiation therapy

  • Previous Rx for thyrotoxicosis

  • Autoimmune Thyroiditis

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Thyroid failure organ systems

Cardiovascular

Decreased ventricular contractility

Increased diastolic blood pressure

Decreased heart rate

Central Nervous

Decreased concentration

General lack of interest

Depression

Gastro-instestinal

Decreased GI motility

Constipation

Thyroid Failure - Organ Systems

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Drsarma

Thyroid Failure - Organ Systems

  • Musculoskeletal

  • Muscle stiffness, cramps, pain, weakness, myalgia

  • Slow muscle-stretch reflexes, muscle enlargement, atrophy

    Renal

  • Fluid retention and oedema

  • Decreased glomerular filtration

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Drsarma

Reproductive

Arrest of pubertal development

Reduced growth velocity

Menorrhagia, Amenorrhea

Anovulation, Infertility

Hepatic

Increased LDL / TC

Elevated LDL + triglycerides

Thyroid Failure - Organ Systems

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Drsarma

Thyroid Failure - Organ Systems

Skin and Hair

  • Thickening and dryness of skin

  • Dry, coarse hair, Alopecia

  • Loss of scalp hair and / or lateral eyebrow hair

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Clinical photographs

Clinical Photographs

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Congenital hypothyroidism

Congenital Hypothyroidism

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Drsarma

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Drsarma

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Endemic goiter

Endemic Goiter

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Drsarma

Urine Iodine Conc. < 50 µg/L

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Drsarma

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Drsarma

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Cassava plant

Cassava Plant

Topiaco - Sago (Javva Arisi)

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Tapioca root sago

Tapioca Root - Sago

Dried Tapioca - Sago

Tapioca (tubers)

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Myxedema

Myxedema

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Myxedema1

Myxedema

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Macroglossia

Macroglossia

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Xanthomata

Xanthomata

Tuberous Xanthoma

Xanthelasma

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Drsarma

Solid Oedema

Xanthomata

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Drsarma

Myxoedema with Carotineamia

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Drsarma

Recovery after L-Thyroxine

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Drsarma

Pituitary Tumor – Secondary Hypo

Normal Pituitary Fossa

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Drsarma

20.2.98

Massive Pericardial Effusion in Hypo

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Drsarma

26.7.98

Clearing of Pericardial Effusion with Rx.

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Drsarma

14.9.99

Reappearance of Pericardial Effusion

after treatment is discontinued

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Co morbidity

Hypercholosterolemia

Depression

Infertility – Menstrual Irregularities

Diabetes mellitus

Co-morbidity

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Hypothyroidism and hypercholesterolemia

14% of patients with elevated cholesterol have hypothyroidism

Approximately 90% of patients with overt hypothyroidism have increased cholesterol and / or triglycerides

Hypothyroidism and Hypercholesterolemia

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Lipids in patient with hypothyroidism

Hypercholesterolemia(>200 mg/dL)

Hypertriglyceridemia(>150 mg/dL)

Hypercholesterolemia and mild Hyper TG

Normal Lipids

Lipids in Patient with Hypothyroidism

N= 268

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Ldl c levels increase with increasing hypothyroidism grade

LDL-C Levels Increase With Increasing Hypothyroidism Grade

246

191

168

144

137

133

LDL-C(mg/dL

C

1

2

3

4*

5†

Hypothyroidism Grade

Basal TSH (mU/L) 1.1 3.0 8.6 22.7 44.4 63.7

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Effect of thyroxine therapy on hypercholesterolemia in patients with mild thyroid failure

“The decrease in total cholesterol achieved with [Thyroxine replacement] substitution therapy in patients with subclinical hypothyroidism [mild thyroid failure] may be considered as an important decrease in cardiovascular risk favouring treatment.”

Effect of Thyroxine therapy on Hypercholesterolemia in Patients with mild Thyroid failure

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Hypothyroidism and depression

Depressive symptoms are common in hypothyroidism

Many hypothyroid patients fulfill DSM-IV criteria for a depressive disorder

Depressed patients may be more likely than normal individuals to be hypothyroid

All depressed patients should be evaluated for thyroid dysfunction

Hypothyroidism and Depression

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Hypothyroidism and depression1

Depression

Hypothyroidism and Depression

Hypothyroidism

Constipation

Decreased Conc.

Decreased libido

Depressed mood

Diminished interest

Weight increase

Fatigue

Bradycardia

Cardiac and lipid Abnormalities

Cold intolerance

Hair and skin changes

Delayed reflexes

Goiter

Sleep decreaseSuicidal ideation Weight change Delusions

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Thyroxine in depression

1. Thyroxine therapy is recommended for

patients with depression who have

persistently elevated serum TSH

2. Antidepressants may be less effective if

thyroid function not normalized

Thyroxine in Depression

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Hypothyroidism and infertility

1. Hypothyroidism associated with infertility,

miscarriage, stillbirth

2. Infertility : Evaluate thyroid function, treat

hypothyroidism

3. Equivocal results: Begin therapy; discontinue

if no pregnancy for several months.

Hypothyroidism and Infertility

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Suspect hypothyroidism

Amenorrhea

Oligomenorrhea

Menorrhogia

Galactorrhea

Premature ovarian failure

Infertility

Decreased libido

Precocious / delayed puberty

Chronic urticaria

Suspect Hypothyroidism

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Hypothyroidism and diabetes

Approximately 10% of patients with type 1 diabetes mellitus develop sub-clinical hypothyroidism

In diabetic patients - examine for goitre

TSH measurement at regular intervals

Hypothyroidism and Diabetes

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Drsarma

Algorithm for

Hypothyroidism

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Drsarma

Algorithm for Hypothyroidism

Measure TSH

Elevated TSH

Normal TSH

Measure FT4

Considering Pituitary

Normal

Low

No

Yes

No tests

Sub-clinical hypo

Primary hypothyroid

Measure FT4

TPO -

TPO -

TPO +

TPO +

Low

Normal

Hashimoto

Evaluate Pituitary

Sick Euthyroid

Drugs effect

T4 repl

Annual FU

No tests

Others

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Hormone replacement

Hormone replacement

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Many causes one treatment

Goal : Normalize TSH level regardless of cause of hypothyroidism

Treatment : Once daily dosing with Levothyroxine sodium (1.6µg/kg/day) this comes to 100 mcg per day

Monitor TSH levels at 6 to 8 weeks, after initiation of therapy or dosage change

Many Causes, One Treatment

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Drsarma

Treatment of choice is levothyroxin

Branded thyroxine recommended

Brand consistency recommended

No divided doses - illogical

Not recommended for use :

Desiccated thyroid extract

Combination of thyroid hormones

T3 replacement except in Myxedema coma

Many Causes, One Treatment

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Drsarma

Age (in elderly start with half dose)

Severity and duration of hypothyroidism (↑ dose)

Weight (0.5µg/kg/day ↑ upto 3.0µg/kg/day)

Malabsorption (requires ↑ dose)

Concomitant drug therapy (only on empty stomach)

Pregnancy ( 25% ↑ in dose), safe in lactating mother

Presence of cardiac disease (start alt. day Rx)

Dosage Adjustments

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Drsarma

Goal : normalize TSH level – 25, 50 and 100 mcg tablets avail.

Starting dose for healthy patients< 50 years at 1.0 µg/kg/day

Starting dose for healthy patients > 50 years should be < 50 µg/day. Dose ↑ by 25 µg, if needed, at 6 to 8 weeks intervals.

Starting dose for patients with heart disease should be 12.5 to 25 µg/day and increase by 12.5 to 25 µg/day, if needed, at 6 to 8 weeks intervals

Start Low and Go Slow

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Drsarma

How the patient improves

  • Feels better in 2 – 3 weeks

  • Reduction in weight is the first improvement

  • Facial puffiness then starts coming down

  • Skin changes, hair changes take long time to regress

  • TSH starts showing decrements from the high values

  • TSH returns to normal eventually

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Drsarma

Malabsorption Syndromes

Reduced Absorption

Cholestyramine resin

Sucralfate

Ferrous sulfate

Soybean formula

Aluminum hydroxide

Colestipol hydrochloride

Drug Interactions

  • Drugs that affect metabolism

    • Rifampin

    • Carbamazepine

    • Phenytoin

    • Phenobarbitol

    • Amiodarone

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Drsarma

Over-replacement risks

Reduced bone density / osteoporosis

Tachycardia, arrhythmia. atrial fibrillation

In elderly or patients with heart disease, angina,

arrhythmia, or myocardial infarction2

Under-replacement risks

Continued hypothyroid state

Long-term end-organ effects of hypothyroidism

Increased risk of hyperlipidemia

Inappropriate Dosage

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Diet in iodine deficiency

Diet in Iodine deficiency

  • Iodized salt

  • Selenium supplementation

  • Avoid Cassava

  • Avoid cabbage (goitrogens)

  • Avoid formula milk

  • Fish, meat, milk & eggs

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Special situations

Special situations

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Sub clinical hypothyroidism

Chronic autoimmune thyroiditis

Graves’ hyperthyroidism with radioiodine, surgery

Inadequate replacement therapy for hypothyroidism

Lithium carbonate therapy (for depressive illness)

Sub-clinical Hypothyroidism

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Post partum thyroiditis ppt

Definition

Occurrence of hyperthyroidism and / or hypothyroidism during the postpartum period in women who were euthryroid during pregnancy

At Highest Risk

Patients with type 1 diabetes, previous history of PPT or other autoimmune disease such as Hashimoto’s disease and Graves’ disease

Post-Partum Thyroiditis (PPT)

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Myxedema coma

Precipitating factors :

Infection, trauma, stroke, cardiovascular, hemorrhage drug overdose, diuretics

Signs and Symptoms :

Mental confusion, hypothermia, bradycardia, older age,

↓Na, ↓ glucose, ↑ CO2, ↓ WBC, ↓ Hct, ↑CPK

↓ EKG voltage, myxedema, b-carotnenemia

Treatment

ICU transfer, T3 100 µg IV sixth hourly, 500 µg of T4 , antibiotics, ventilation, hydrocortisone IV, passive warming, careful volume management

Myxedema Coma

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Sick Euthyroid Syndrome

  • Total T3 reduced

  • FT3 reduced

  • Total T4 reduced

  • FT4 Normal

  • TSH Normal

  • Clinically Euthyroid

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The Commandments

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Drsarma

The Commandments

  • All obese patients TSH a must

  • For all pregnant -test TSH, FT4

  • Postmenopausal 15% Hypothy

  • Start low and go slow

  • Use Levothyroxine only

  • Always on empty stomach

  • Thyroxine - avoid empirical use

  • Highly suspect hypothyroidism

  • Growth and pubertal delay

  • Unexplained depression

  • TSH is the test in Hypothy.

  • TSH, FT4 to confirm Dx.

  • Nine square magic

  • Test cord blood for TSH

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Question 1

Should a serum TSH be a routine component of the periodic health exam in women?

Question # 1

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Question 2

What is the appropriate biochemical end point for adequate thyroid hormone replacement in hypothyroid patient?

Question # 2

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Question 3

Are there risks associated with over replacement?

Question # 3

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Question 4

Are all L-thyroxine products therapeutically equivalent? Should combination T4/T3 preparations be used?

Question # 4

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Question 5

What is the impact of pregnancy on Thyroxine replacement therapy in a hypothyroid women?

Question # 5

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Question 6

What is the impact of breast feeding on the management of maternal hypo and hyperthyroidism?

Question # 6

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Question 7

Should women with sub-clinical hypothyroidism be treated with L-Thyroxine?

Question # 7

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Question 8

Should euthyroid patient with benign thyroid nodules be placed on thyroid hormone suppression therapy?

Question # 8

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Drsarma

We need to apply the current knowledge

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Drsarma

Hyperthyroidism

After Tea Break

Please Remain

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