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Management of Hyperthyroidism. Baylor College of Medicine Med-Peds Continuity Clinic Anoop Agrawal, M.D. Epidemiology. Incidence in adults: 2% of women 0.2% of men In children and adolescents: Seen in 0.02% (1:5000) Girls:boys ratio 5:1. Diagnosis. Clinical features

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management of hyperthyroidism
Management of Hyperthyroidism
  • Baylor College of Medicine
  • Med-Peds Continuity Clinic
  • Anoop Agrawal, M.D.
epidemiology
Epidemiology
  • Incidence in adults:
    • 2% of women
    • 0.2% of men
  • In children and adolescents:
    • Seen in 0.02% (1:5000)
    • Girls:boys ratio 5:1
diagnosis
Diagnosis
  • Clinical features
  • Confirm with measurement of serum thyrotropin (TSH) and total or free thyroxine (T4)
    • low TSH, and high T4
  • Occassionally, T4 will be normal - T3 should be measured for the possibility of triiodothyronine toxicosis
case 1
Case 1
  • A 27 yo female with the following thyroid function tests:
    • TSH normal, Free T4 normal, Tot T4 elevated
  • What are the likely scenarios?
    • pregnancy, OCPs, inherited increase in TBG
differential diagnosis
Differential Diagnosis
  • What is the most common cause of hyperthyroidism?
    • Grave’s Disease
  • What are the other common causes?
    • Toxic nodular goiter - single or multiple
    • Thyroiditis - subacute, silent, postpartum
    • Iatrogenic
case 2
Case 2
  • A 40 year old woman presents with symptoms of tachycardia, anxiety and jitteriness. Physical exam finds a slightly enlarged thyroid gland. Her serum studies show a low TSH with elevated Free T4. What is your next step?
    • radioiodine uptake measurement
case 2 continued
Case 2 continued
  • Her radioiodine uptake demonstrated diffuse uptake of iodine. What is the diagnosis and what are her treatment options?
    • Grave’s disease
    • Tx options: 1) antithyroid medications, 2) radioablation, 3)surgery
antithryoid drugs
Antithryoid Drugs
  • Thionamides
  • Beta blockers
  • Inorganic Iodide
how are thionamides used
How are thionamides used?
  • Thionamides try to cause permanent remission of Grave’s disease.
    • Mechanism of action: inhibit the organification of iodide and coupling of iodothyrinones
    • Two main types: Methimazole (MME), Propylthiouracil (PTU)
how are thionamides used11
How are thionamides used?
  • MME is once daily vs. TID for PTU
  • MME is has a more rapid effect.
  • Hence, MME is preferred over PTU except in pregnancy because MME can cause .... to the fetus
    • aplasia cutis congenita
aplasia cutis congenita
Aplasia Cutis Congenita

Congenital absence of skin

what is their efficacy
What is their efficacy?
  • Clinical trials have varied and controversy hangs over various aspects of their use.
  • Rates of remission has ranged from 10-75%. In the US, only a 30% remission is seen.
  • Studies with a longer duration of therapy (2 years) had higher rates of remission.
  • Disadvantage of long term therapy - need of monitoring, and poor compliance
management of thionamides
Management of Thionamides
  • Starting dose of MME is 10 to 20mg daily.
  • MME has a dose dependent response time - the higher the dose, the more rapid the effect
  • After initiation, follow TFTs in 4 to 6 weeks to adjust dosing.
  • Use T3 and T4 levels to adjust dose, as TSH levels may remain low for up to several months after T3 and T4 have normalized
management of thionamides15
Management of Thionamides
  • Monitor for side effects
  • Agranulocytosis is a dose dependent side effect of MME. For PTU, it is not dose related.
  • Monitoring involves recognition of clinical signs: fever or sore throat
  • Routine WBC measurement not needed
  • Agranulocytosis is an absolute contraindication to drug therapy
other drugs
Other Drugs
  • β-Blockers: aid in reducing symptoms and signs of disease
    • some inhibition of peripheral conversion
    • all agents in this class are effective, hence selecting once a day drugs (i.e. atenolol) may improve compliance
  • Inorganic Iodide: inhibits release of hormones for a few days to weeks, hence useful for short term therapy, i.e. thyrotoxic crisis
radioiodine therapy
Radioiodine Therapy
  • Mechanism: destroy thyroid tissue to achieve either a euthyroid or hypothyroid state
  • In the US, over 60% of endocrinologists select radioiodine as first-line therapy for Grave’s disease.
  • It is the preferred therapy for women desiring pregnancy in the near future. After RAI, they must wait 4-6 months before conceiving.
why rai for graves
Why RAI for Graves?
  • Advantages: higher remission rates - 10% will fail first treatment and require a second dose of 131I
  • Disadvantage: hypothyroidism - is dose dependent
  • Contraindications: pregnancy (absolute), ophthalmopathy (relative - RAI may cause or worsen this condition)
management with rai
Management with RAI
  • If pt is on an antithyroid drug, it should be stopped 3-4 days prior to RAI, and resumed 3-4 days after.
  • However, it is uncertain how drug therapy impacts RAI efficacy.
  • Post-ablation: common to see radiation thyroiditis - manifested by thyroid pain, tenderness, and swelling. Also, transient worsening of hyperthyroidism for 1-2 wks.
treatment of other causes
Treatment of other causes
  • Toxic nodular goiter: RAI only!, antithyroid drugs ineffective
    • RAI destroys the autonomous nodules, leaving remainder of thyroid intact
    • these patients rarely will become hypothyroid
  • Painless thyroiditis: resolves within weeks, symptomatic tx with β-blocker sufficient
conclusion
Conclusion
  • There are various methods to manage Grave’s disease.
  • Selection of choice will depend upon discussion of risks and benefits with the patient.
  • Surgery (partial thyroidectomy) is reserved for treatment failures.
  • Other causes of hyperthyroidism have more clear treatment choices.
references
References
  • Franklyn, JA. The Management of Hyperthyroidism. NEJM 1994;330:1731-1738.
  • Ross, DS. Treatment of Grave’s hyperthyroidism. UpToDate 2006.