Graves Disease/Hyperthyroidism

Question 1

Grave’s Disease - Pre surgical preparation

Answer 1

1) Give an Methimazole preop to normalize FT4 and FT3 levels before surgery
2) Once the FT4 and FT3 levels are normal or near normal: SSKI or Lugol’s solution is given for 5-10 days prop -
- SSKI (50mg iodide/gtt = 1gram/mL): 1-2 gtts (0.05-0.1mL) TID in water or juice for 5-10 days preop
- Lugol’s Solution (5%): 5-7 gtts in 8 oz glass of water po TID in water or juice for 5-14 days preop (Note: this is much less expensive than SSKI and is available OTC on Amazon)
3) Check the patient’s T4 and T3 levels on the day before surgery - these should be normal on the day before surgery
- Don’t check the TSH preop because it takes much longer to normalize on SSKI or Lugol’s therapy. Use T3 and T4 as preop guide
4) Surgery should be performed on day 9 or 10 of Lugol’s or SSKI
5) Post Op:
- Stop Methimazole post op
- Don’t start Synthroid post op until free T4 normalizes. This can take up to one week post op to normalize.
- Start the patient on Synthroid 100 mcg po QD once the serum T4 normalizes

Question 2

Grave’s Disease - Presurgical Preparation in patients who are non compliant or allergic to ATDs

Answer 2

1) In patients who are non compliant or intolerant to
ATDs, thyroidectomy can still be performed by reducing T4 and T3 using steroids and, in some instances, Cholestyramine along with potassium iodide.
2) In those who are hyperthyroid before surgery due to intolerance of ATDs or are symptomatic, ensuring adequate beta-blockade preoperatively and during surgery with Propranolol or longer acting Atenolol is essential.
a. Give SSKI or Lugol’s solution 5-10 days preop
b. Give adequate Beta blockade with Propranolol or longer acting beta-blockers (Atenolol)
- Propranolol (20-40mg po Q6 hours)
- Atenolol
- Note: don’t use beta-blockers in patients with RAD
- High dose Propranolol blocks peripheral conversion of T4 to T3
3) Check and optimize vitamin D levels before surgery to reduce the risk of hypoparathyroidism

Question 3

Plummer’s Disease - Definition

Answer 3

Toxic nodular goiter (TNG): hyperthyroidism resulting from an autonomously functioning thyroid nodules independent of TSH regulation.
- Autonomous nodules are the second most common overall cause of thyrotoxicosis: they account for 5-15% of all causes of hyperthyroidism.

Question 4

What is primary hyperthyroidism?

Answer 4

Primary hyperthyroidism is a condition in which the thyroid gland synthesizes and secretes inappropriately high levels of thyroid hormone(s) causing signs and symptoms of hypermetabolism and excess sympathetic nervous system activity.

Question 5

What is thyrotoxicosis?

Answer 5

Thyrotoxicosis is a clinical state in which there is an inappropriately high thyroid hormone action in tissues. This can result from hyperthyroidism as well as from other etiologies.

Question 6

When can thyrotoxicosis occur that is not attributed to hyperthyroidism?

Answer 6

1) Subacute, painless, or radiation-induced thyroiditis
2) Excess thyroid hormone ingestion
3) Struma ovarii
4) Functional metastatic thyroid cancer

Question 7

What are the causes of hyperthyroidism?

Answer 7

1) Grave’s disease
2) Toxic multinodular goiter
3) Solitary toxic adenomatous nodule
4) Viral infection
5) Autoimmune (Hashimoto’s) thyroiditis
6) Amiodarone-induced thyrotoxicosis
7) TSH producing pituitary tumor (rare)