EXAM 3 Hyperthyroidism Dr. Hess Flashcards
Patient presentation in hyperthyroidism - Head
EXAM!
-Nervousness
-Irritability
-Difficulty sleeping
Patient presentation in hyperthyroidism - Face
EXAM!
Bulging eyes - Graves disease
Unblinking stare
-Swelling of the thyroid (Goiter)
Patient presentation in hyperthyroidism - inner body
-menstrual irregularities/lighter period
-excessive vomiting in pregnancy
-first trisemester miscarriage
-frequent bowel movements
-rapid or irregular heartbeat (tachycardia)
-infertility
-weight loss
-heat intolerance
-sweating
-family history of thyroid disease
-warm, moist palms
Medical term for bulging eyes?
Exophthalmos (Proptosis)
patietns may also have double vission (diplopia)
-in severe cases it damages the eye
-no sufficient distribution of tears since the eyelid doesn’t cover the whole eye
Lid lag
the upper eyelid is higher than normal
(one lid is lagging behind - seen when looking down)
Which drug works by inhibitng IGF-1 in the eye?
Teprotumumab-trbw (Tepezza)
-Tx for Exophthalmos
IGF-1 is responsible for causing bulging eyes
What are the chronic consequences of untreated Hyperthyroidism?
-Arrhythmias
-CVD
-Osteoporosis
What is the onset of ß-blockers in Hyperthyroidism treatment?
-Hours
-> only treats tachycardia, so start with hormone reducing therapy
Which symptoms are reduced rapidly by ß-blockers?
tremors and anxiety
What is the onset of ß-blockers in Hyperthyroidism treatment?
hours to days -> max effect after 10 days
-> only short term, before surgery or after radioactive iodine treatment
What is the onset of thionamines in hyperthyroidism treatment?
weeks
start with beta-blocker
What is the onset of radioactive iodine (RAI) in Hyperthyroidism treatment?
months
-> often leads to hypothyroidism, since the radioactive iodine destroys the hypersecreting thyroid tissue
What is the common drug regimen for a patient who just got diagnosed with Hyperthyroidism?
-ß-blocker: tx tachycardia
-Thionamides: short or long -term
-> simultouensly
What is the HR goal when using a ß-blocker in hypothyroidism?
HR < 90
may also impair T4 to T3 conversion
-used short-term until T4 and T3 are reduced, then can discontinue (approx. use of 6 months)
Which patients may be prone to DDI with ß-blockers?
COPD and asthma patients
-> especially when using a non-selective ß-blocker like carvedilol, labetalol, propranolol, nadolol
Which ß-blockers may impair T4 to T3 conversion?
-propranolol
-nadolol
but plays a minor role when choosing a ß-blocker, we even see selective ß-blocker like metoprolol quite often
MOA for Methimazole and Propylthiouracil (PTU)
-block thyroid peroxidase
->responsible for thyroid synthesis in the gland
-in 40-50% the patient stay in remission and may stop
What is the onset of Thionamide agents?
6-8 weeks
-it takes 6-8 weeks to work
-> bc there are already synthesized T4s ready to go, and they need to be depleted before we start seeing effects
What is the Blackbox warning of PTU
hepatoxicity risk
-> Methimazole use is preferred!!!
Which of the Thionamides is preferred in the first trimester of pregnancy?
PTU for the 1st trimester, then switch back
-> Methimazole has a higher risk for tetragenicity in the 1st trimester
Thionamide agents dosing
Methimazol (Tapazol):
15-20 mg/day 1x day -> better adherence
Propylthiouracil (PTU):
150-600 mg/day 2-3x per day
ADE Thionamides
-Hepatoxicty (BBW for PTU, may also cause liver damage with Methimazole but less likely) - in the first 3 months
-Benign transient leukopenia (WBC <4000/mm3)
-Agranulocytosis (rare, can be fatal) - in the first 3 months
-> fever granulocate < 250/mm3)
-Rash
-GI upset
-Arthralgia (joint stiffness)
How would a patient present with liver toxicity?
-jaundice
-colroing of the urine (brown)
-pale colored feces (ash-color)
-N/V
-abdominal pain
Symptoms for Agranulocytosis
-fever
-flu-like symptoms
-sore throat
-> they should get a CBC
In what time frame should thyroid hormones levels be checked?
every 6 weeks until stable
-TSH, T3 and T4
Which levels should be monitored?
-TSH, T3 and T4
-CBC with diff (all types of white blood cells)
-signs and symptoms of infection
-hepatoxicity
MOA of Iodides
-acutely decrease the RELEASE (so it works faster than the other drugs) of preformed hormones (iodide)
-> negative feedback when giving high concentration of iodide (Wolff–Chaikoff effect)
What is the role of Iodides in therapy?
-short-term use prior to surgery (removing the thyroid)in Graves disease (to prevent thyroid release during the procedure) or in thyroid storm
(FYI: thyroid causes diarrhea, patients can die from a thyroid storm because of dehydration)
-to inhibit thyroid release following radioactive iodine treatment -> inhibiting thyroid release temporarily with iodide will help radioactive iodine to manifest in the thyroid and work there
-Lugol’s solution
-saturated solution of potassium iodide (SSKI)
When is iodide treatment contraindicated?
Pregnancy
also avoid radioactive iodine
What is the drug of choice in Graves disease?
Radioactive Iodine I-131
What is the consequence of radioactive iodine treatment?
irreversible destruction of the thyroid glands
-> the patient may end up needing treatment for hypothyroidism
-> LT4 supplementation
Onset in radioactive iodine treatment
slowest onset
What are the thyroid hormone levels in Subclinical Hyperthyroidism?
low TSH
free T4 is normal
-treatment controversial
-> increased risk for Afib and bone fractures
- if treated, then with low dose thionamides (radioactive iodine is not appropriate in this case)
Treatment regimen - radioactive iodine
-continue β blockers until symptoms resolve
-Stop thionamide agents 4-7 days prior and may restart 4 days after
-if iodides used, give 3-7 days after
How to treat Graves disease during pregnancy?
-Thionamide agents
-> PTU in the first trimester -> then change to Methimazole
-ß-blockers for symptomatic treatment as needed
Time frame to monitor thyroid levels
monitor TSH, free T4 and free T3 monthly
Which drug may cause Hyperthyroidism or Hypothyroidsm?
-Amiodarone - similar stutcure to LT4
Hyperthyroidsim (2%) vs hypothyroidism (5%)
-Lithium (used for bipolar disorder)
hyperthyroidism (1%) vs hypothyroidism (20%)
Which drug may cause Hypothyroidsm?
Tyrosine kinase inhibitors
-Sunitinib (50%)
