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Thyroid Diseases. Steve Orme Leeds. Introduction. Background Basic Principles Clinical Syndromes Summary. Hypothesis Testing?. Appreciate Limitation of Laboratory Investigations Treat ‘Normal Ranges’ with the Disdain they Deserve Avoid Medicine by Proxy Do not Over Investigate.

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thyroid diseases

Thyroid Diseases

Steve Orme

Leeds

introduction
Introduction
  • Background
  • Basic Principles
  • Clinical Syndromes
  • Summary
hypothesis testing
Hypothesis Testing?
  • Appreciate Limitation of Laboratory Investigations
  • Treat ‘Normal Ranges’ with the Disdain they Deserve
  • Avoid Medicine by Proxy
  • Do not Over Investigate
basic principles
Basic Principles
  • Too Much Hormone Measure at Nadir Try to Suppress Evaluate Their 24 Hour Secretion Measure the preceding Hormone (Elevated Free T4, Measure TSH)
basic principles1
Basic Principles
  • Too Little Hormone Measure at Peak Try to Stimulate Measure the preceding Hormone (Low Free T4, Measure TSH)
basic principles2
Basic Principles
  • Try to Determine Aetiology Supplementary Hormone Tests Immunology *Radiology/ Nuclear Medicine (* Use Sparingly)
basic principles3
Basic Principles
  • Remember 1 in 20 Blood Investigations Will be ‘Abnormal’ In An Average ‘Normal’ PatientReference Range :- Mean (95 % Confidence Interval) Small Sample Size
thyroid disease
Thyroid Disease
  • Hypothyroidism
  • Thyrotoxicosis
  • Thyroid Nodules/ Cancer
  • Amiodarone Induced Thyroid Disease
hypothyroidism
Hypothyroidism
  • Myxoedema
  • Hashimoto’s Thyroiditis
  • Post Surgery/Radioactive Iodine Therapy
  • Secondary/Tertiary
hypothyroidism1
Hypothyroidism
  • Free T4 & TSH
  • TPO Antibodies
  • Investigate possible co-existing Auto-immune Diseases
  • Thyroid Imaging Not Indicated
graves disease pharmacology of cbz ptu
CBZ Plasma T 1/2 6-8 Hrs Crosses Placenta & Breast Epithelium >10 more Potent than PTU Duration of Action >24 Hrs

PTU Plasma T 1/2 1-2 Hrs Minimal Placental & Breast Transfer

Duration of Action 12-24 Hrs

Graves DiseasePharmacology of CBZ/PTU
graves disease drug therapy adverse effects
Graves DiseaseDrug Therapy (Adverse Effects)
  • Minor/Common (5-10%) Pruritis Urticarial Rash Arthralgia Fever
graves disease drug therapy adverse effects1
Graves DiseaseDrug Therapy (Adverse Effects)
  • Uncommon Abnormal Taste (CBZ) GI Upset Hypoglycaemia (Anti-Insulin Antibodies)
graves disease drug therapy adverse effects2
Graves DiseaseDrug Therapy (Adverse Effects)
  • Major (Rare or *Very Rare) Agranulocytosis Aplastic Anaemia* Thrombocytopenia* Hepatitis (PTU)* Cholestatic Jaundice (CBZ)* Lupus-like Syndrome*
graves disease drug therapy adverse effects3
Graves DiseaseDrug Therapy (Adverse Effects)
  • Minor Usually Transient
  • Major (Agranulocytosis) Idiosyncratic. Onset more Likely in the First 3 Months, High-Dose Therapy and the Elderly.
graves disease managing relapse
Graves DiseaseManaging Relapse
  • Relapse Rate 60% (10 Years Off Rx)
  • No difference between 6 Months of Block and Replacement Regimen and 18 Months of Titration
  • Further Relapses Inevitable After First Failed Trial Of Medication.
graves disease predicting relapse
Graves DiseasePredicting Relapse
  • Young Patients
  • Large Goitre
  • Presence of TAO
  • High Levels of TSH-receptor Antibody at Diagnosis.
graves disease managing relapses
Graves DiseaseManaging Relapses
  • I131
  • Thyroid Surgery
  • Long-term Low-dose Thionamide Therapy
radioactive iodine therapy
Radioactive Iodine Therapy
  • Counsel Patients
  • Avoid Pre-Treatment with PTU
  • Special Measures
  • Carefully Monitor Thyroid Status for at Least 6 Months
thyroid surgery
Thyroid Surgery
  • Choose Your Surgeon Carefully
  • Counsel Patients
  • Pre-Treatment Mandatory
  • Special Measures
  • Carefully Monitor Thyroid and Calcium Status for at Least 6 Months Post OP
  • Long-term Data Base Follow UP
thyroid nodules cancer
Thyroid Nodules & Cancer
  • Nodules are Common Thyroid Cancer is not (80 Cases per year in West Yorkshire)
  • Refer Palpable nodules
  • Early Diagnosis Improves Prognosis
  • Management Should be through an Endocrine Cancer MDT
thyroid nodules cancer1
Thyroid Nodules & Cancer
  • Prognosis for Most Cases of Well Differentiated Thyroid Carcinoma is Good
  • Most Patients Require Total-Thyroidectomy , I131 Radio-ablation and TSH Suppressive Doses of T4
  • Life Long Specialist Monitoring is Mandatory
amiodarone
Amiodarone
  • Benzofuranic Derivative
  • Contains 37% Iodine
  • 50-100 times RDI
amiodarone1
Amiodarone
  • Inhibits Type I & II 5’- deiodinase
  • Cytotoxic to Thyroid Cells
  • Affects Thyroid Autoimmunity
  • Acts on Thyroid Hormone Receptors
euthyroid patients on amiodarone
Euthyroid Patients on Amiodarone
  • Have Elevated Free T4
  • Low Normal Total T3
  • High Normal or Transiently Elevated TSH
amiodarone2
Amiodarone
  • Pattern of Thyroid Disease is related to Population Iodine Intake
  • In the UK 2 % AIT 15% AIH
amiodarone induced thyrotoxicosis
Amiodarone Induced Thyrotoxicosis
  • Onset Explosive
  • Median Duration of Therapy 3Yrs
  • Unexplained Deterioration
  • Weight Loss
  • Overt Signs of Thyrotoxicosis Absent
amiodarone induced thyrotoxicosis1
Type I Goitre Present Iodine Uptake & Colour Flow Doppler Increased

Type II No Small/Goitre Inflammatory Markers Increased Low Iodine uptake and Colour Flow Doppler Subsequent Hypothyroidism

Amiodarone Induced Thyrotoxicosis
amiodarone induced thyrotoxicosis2
Type I Carbimazole Potassium Perchlorate Radioactive Iodine Surgery

Type II Prednisolone Surgery

Amiodarone Induced Thyrotoxicosis
amiodarone induced hypothyroidism
Amiodarone Induced Hypothyroidism
  • Females
  • Pre-existing Autoimmune Thyroid Disease
  • Positive TPO Antibodies
  • Treat as Primary Hypothyroidism
summary
Summary
  • ‘Where Observation is Concerned, Chance Favours Only The Prepared Mind’(Lois Pasteur 1822-95AD)
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