Graves' Disease/Hyperparathyroidism Flashcards

1
Q

Graves’ Disease therapy options

A

Antithyroid drug
Radioactive iodine
Thyroidectomy

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2
Q

Factors favoring an option for antithyroid drug

A
Mild disease
Increased surgical risk
Limited life expectancy
Moderate-severe GO
No surgeon access
Previous neck operation/irradiation
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3
Q

CIs to ATD

A

Previous known allergic reaction

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4
Q

Patient preference factors for ATD

A

High value on avoidance of lifelong LT4 therapy, exposure to radioactivity, and surgery

Low value on need for monitoring and possible relapse

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5
Q

Thioamides use

A

For Graves’ disease and to get patients chemically euthyroid before RAI/thyroidectomy

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6
Q

Will thioamides cure Graves’?

A

NO

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7
Q

Methimazole (MMI)

A

~10 times as potent as PTU

Preferred thioamide

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8
Q

MMI dosing

A

Depends on FT4:
1-1.5x ULN: 5-10mg QD
1.5-2x-ULN: 10-20mg/day QD or BID
2-3x-ULN: 30-40mg/day BID

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9
Q

MMI ADEs

A

Agranulocytosis, aplastic anemia, exfoliative dermatitis, hepatitis, abdominal pain, dark urine, jaundice, acholic stools

Most common are fatigue and rash

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10
Q

MMI baseline labs

A

CBC with diff

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11
Q

MMI monitoring

A

Leukopenia, pruritic rash, arthalgia

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12
Q

MMI treatment algorithm

A
  1. Consider CBC and liver panel to establish baseline values
  2. Start MMI and dose on FT4 level
  3. Check FT4, T3 levels in 2-6 weeks
    4a. If patient isn’t euthyroid, continue therapy at the MD (30-50% reduction from initial dose)
    4b. If patient IS euthyroid, taper dose down by 30-50% over a few weeks and repeat thyroid panel in 4-6 weeks
    5a. If patient isn’t euthyroid after that, increase dose slightly by 5-10mg/day and repeat the thyroid panel in 4-6 weeks
    5b. If patient IS euthyroid, continue therapy for 12-18 months and monitor thyroid labs every 2-3 months
  4. Consider stopping MMi if TSH and TRAb levels are normal after 12-18 months of therapy
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13
Q

Propylthiouracil (PTU)

A

Drug of choice in thyroid storm and 1st trimester of pregnancy

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14
Q

Factors favoring an option for radioactive drug

A

Increased surgical risk, planning pregnancy >6 months out, CIs to ATD use, no surgeon access, previous neck operation/irradiation

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15
Q

CIs to radioactive drug

A

Pregnancy, lactation, suspected or known cancer, unable to meet safety guidelines, informed caution for pregnancy 4-6 months out

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16
Q

Patient preference factors for radioactive drug

A

High value on definitive control and avoidance of surgery

Low value on rapid cure, development of GO, and need for lifelong LT4 replacement

17
Q

Radioactive iodine (Na 131I)

A

Used to render the patient hypothyroid

18
Q

Radioactive iodine counseling points

A
Avoid high-iodine foods before treatment
No contact with children for 5 days
No contact with pregnant women for 10 days
No more than 2 hours of contact at a time
Bathroom etiquette
Avoid bodily fluid contact for 4 days
Flush things with bodily fluid contact
Wash things separately
19
Q

Radioactive iodine side effects

A

Transient hyperthyroidism, release of orbital antigen, thyroid tenderness, salivary gland tenderness/enlargement, dysphagia

20
Q

Radioactive iodine CI

A

Pregnant/lactating

21
Q

When do you use propranolol?

A

For symptomatic patients

22
Q

Iodides

A

Potassium iodide (SSKI), Lugol’s solution

23
Q

When are iodides used?

A

Surgery-prep drug, adjunct to RAI treatment

24
Q

Iodides side effects

A

“Iodism”

Metallic taste, head cold, burning mouth/throat, sore teeth/gums, stomach upset, diarrhea

Hypersensitivity reactions, salivary gland swelling, gynecomastia

25
RAI treatment timeline: at diagnosis
Propranolol for symptoms MMI in severe disease 3-7 days before the RAI dose Females of childbearing potential do a pregnancy test before
26
RAI treatment timeline: after RAI dose
``` Start steroids (prednisone, 0.4-0.5 mg/kg/day) 1-3 days after RAI Start MMI PRN 3-7 days after RAI dose, taper weeks after RAI dose and D/C Taper steroids over 2 months and taper the propranolol if used ```
27
Post-RAI monitoring
Lab work q4-6 weeks that includes FT4, total T3, and TSH
28
Post-RAI treatment if successful
If successful, start IBW-based levothyroxine dosing
29
If hyperthyroidism persists after 6 months...
...suggest retreatment with radioactive iodine
30
Factors favoring thyroidectomy
Larger goiter, malignancy suspected, planning pregnancy <6 months out, moderate-severe GO, high TRAb levels
31
Thyroidectomy CIs
Substantial comorbidity, pregnancy, lack of access to high-volume surgeon
32
Patient preference factors for thyroidectomy
High value on prompt, definitive control and avoidance of exposure to radioactivity Low value on surgical risk and need for lifelong LT4 replacement
33
Thyroidectomy complications
Transient or permanent hypocalcemia, hyperthyroidism can persist, vocal cord abnormalities
34
Thyroidectomy prep goal
Get patient euthyroid and stable before surgery
35
Thyroidectomy prep
Start MMI 6-8 weeks before surgery Start iodide 10-14 days before surgery Start beta-blocker 7-10 days before surgery Consider normalizing calcium and vitamin D
36
What to do post-thyroidectomy
Obtain serum calcium, intact parathyroid hormone levels, wean beta-blocker, stop MMI, start levothyroxine
37
Drugs known to affect thyroid levels
Lithium and amiodarone