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S3 Case 4 - Endocrine > Hyperthyroidism > Flashcards

Hyperthyroidism Flashcards

1
Q

What are the signs + symptoms?

A

Brittle hair/hair loss
Reduced focus
Enlarged thyroid
Increased metabolism (weight loss)
Diarrhoea
Muscle weakness
Sweating

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2
Q

What can be a result of hyperthyroidism?

A

Graves’ disease
Nodular disease
Thyroiditis

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3
Q

What is Graves’ disease?

A

Eyelids retract
Bulging eyes
Redness

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4
Q

What is nodular disease?

A

Thyroid grows nodules
Single or multinodular goiter
Women over 60

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5
Q

What is thyroiditis?

A

Inflammation of thyroid follicles

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6
Q

What is thyroiditis caused by?

A

Infection, trauma, drug induced or autoimmune
= T3/T4 leak from inflamed cells

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7
Q

How do you diagnose?

A

Symptoms
TFTs
- TSH
- FT4
- FT3
TRABs

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8
Q

What does TFT show if hyperthyroidism of thyroidal origin?

A

TSH low
BUT FT4 + FT3 raised

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9
Q

What does a definitive diagnosis require?

A

2 sets of TFTs taken at least 6 weeks apart

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10
Q

What does TFT show if hyperthyroidism of extrathyroidal origin (pituitary/hypothalamic disease)?

A

TSH raised
FT3 + FT4 raised

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11
Q

What is thyroiditis confirmed with?

A

TRABs

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12
Q

What do you conduct if TRABs test comes back negative?

A

Radioactive iodine uptake scanning

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13
Q

What are the aims of treatment?

A

Acute = manage symptoms
Chronic = effectively supress thyroid hormone

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14
Q

What are the choices for treatment?

A

Antithyroid drugs
Radioactive iodine
Thyroidectomy

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15
Q

What is 1st line for Graves’ disease if likely to go into remission?

A

Thionamides
Carbimazole

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16
Q

What is 1st line for Graves’ disease if unlikely to go into remission?

A

Radioactive iodine

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17
Q

What is 1st line for Graves’ disease if concerns regarding compression/malignancy?

A

Thyroidectomy

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18
Q

What is 1st line for multinodular goitre?

A

Radioactive iodine
2nd line = thionamides/thyroidectomy

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19
Q

What is 1st line for single nodular?

A

Radioactive iodine/surgical intervention
2nd line = thionamides

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20
Q

What is 1st line in pregnancy?

A

Thionamides/propylthiouracil
2nd line = thyroidectomy

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21
Q

What is contraindicated in pregnancy + breastfeeding?

A

Radioactive iodine
= potentiate thyroid hormone release = precipitate thyroid crisis = teratogenic

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22
Q

What is 1st line for children with Grave’s disease?

A

Thionamides/carbimazole

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23
Q

What is 1st line for children with MNG/SN?

A

Thionamides
Long term = risk/benefits of radioactive iodine/thyroidectomy

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24
Q

What are the most common antithyroid (thionamides) drugs?

A

Thionamides
Carbimazole (1st line unless pregnant)
Propylthiouracil

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25
Q

How long does it take to see therapeutic effect with thionamides?

A

6-8 weeks

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26
Q

What are the choices for regime with thionamides?

A

Titration
OR
Block + replace = high dose = destroy + terminate thyroid hormone = given alongside with levothyroxine

27
Q

What is carbimazole?

A

Pro-drug undergoes hepatic metabolism
= problem with liver?

28
Q

How long does carbimazole take to show therapeutic effect?

A

4-8 weeks

29
Q

What is the mechanism of action of carbimazole?

A

Inhibition of organification of iodine + thyroglobulin + coupling of iodothyronine residues
= supress synthesis of thyroid hormones

30
Q

What is the initial dose of carbimazole?

A

20-60mg daily dose in divided doses

31
Q

How often should TFTs be checked with carbimazole?

A

Every 6-8 weeks

32
Q

What happens once thyroid levels are within reference range, carbimazole?

A

Choose either “titration” or “block + replace” + continue for 12-18 months

33
Q

What is the titration for carbimazole?

A

5-15mg OD
Regular TFTs

34
Q

What is block + replace for carbimazole?

A

High starting dose till production suppressed
Levothyroxine alongside

35
Q

What are the side effects of carbimazole?

A

Macropapular rash
Bone marrow suppression

36
Q

What do you do is patient develops macropapular rash?

A

Generic antihistamine

37
Q

What do patients on carbimazole need to look out for?

A

Signs + symptoms of blood dyscrasis - FATAL

38
Q

What are the signs + symptoms of blood dyscrasias?
ANY SYMPTOMS = STOP MEDICATION

A

Sore throat
Bruising
Bleeding
Mouth ulcers
Fever
Malaise

39
Q

What should be done to prevent blood dyscrasias?

A

Full blood count every 6 months

40
Q

What are the contraindications of carbimazole?

A

Severe hepatic impairment
pre-existing blood disorders
History of pancreatitis (check amylase)

41
Q

What is the counselling for carbimazole?

A

Need for additional medications for symptoms
6-8 weeks to work
Urgency of reporting symptoms of blood dyscrasias
Start contraception = teratogenic
Intensify effects of warfarin

42
Q

What is the mechanism of action of propylthiouracil?

A

Inhabitation of enzyme peroxidase

43
Q

What is propylthiouracil used for?

A

2nd line for contraindications/side effects/with carbimazole/pregnancy

44
Q

What are the side effects of propylthiouracil?

A

Macropapular rash
Severe hepatic reaction
Bone marrow suppression

45
Q

What are the contraindications of propylthiouracil?

A

Hepatic impairment
Pre-existing blood disorders
History of pancreatitis

46
Q

What is the monitoring for propylthiouracil?

A

Every 6 weeks (TSH, T4, T3) till in reference range
THEN every 3 months until complete

47
Q

What is the aim of radioactive iodine?

A

Resolve hyperthyroidism without post-ablation hypothyroidism

48
Q

What are the physician choices for radioactive iodine?

A

Fixed dose
Adjusted dose dependent on size of thyroid
Adjusted dose to administer specific dose of radiation

49
Q

What problem with radioactive iodine?

A

Radioactive for up to 6 weeks
14 days after = no close contact
Avoid contact with pregnant women + children for 24 days

50
Q

How long must thionamides be stopped before radioactive iodine?

A

1 week prior

51
Q

How long will radioactive iodine take to have an effect?

A

2-3 months

52
Q

What happens in severe cases?

A

Antithyroid medications restarted 3 days post op
Normally safe not to restart

53
Q

What is the monitoring for radioactive iodine?

A

Measure TSH every 6 weeks until within reference range
Stop antithyroid medication once in range

54
Q

When is a thyroidectomy vital?

A

Symptoms of windpipe compression

55
Q

What is the surgical intervention of SND?

A

Partial or hemi-thyroidectomy

56
Q

What is the surgical intervention of MND?

A

Dependent on nodule effected

57
Q

What must you start post-thyroidectomy?

A

1.6mcg/kg levothyroxine immediately after

58
Q

What is a hyperthyroid crisis?

A

Manifestation of thyrotoxicosis = overproduction of thyroid hormones

59
Q

What are the symptoms of thyroid crisis?

A

Hyperthermia
Dehydration
Tachycardia (>140bpm)
Atrial dysrhythmias
Hypotension
Sweating
N/V/D/abdominal pain
Confusion/agitation

60
Q

What are the 4 mechanisms of treatment for thyroid crisis?

A

Inhibition of thyroid hormone synthesis
Inhibition of thyroid hormone release
Inhibition of peripheral action of excess thyroid hormone
Supplementary management

61
Q

What is used for inhibition of thyroid hormone synthesis for thyroid crisis?

A

20-30mg carbimazole every 4-6hrs
Oral/NG/rectal

62
Q

What is used for inhibition of thyroid hormone release for thyroid crisis?

A

Iodine
BUT need to leave at least an hour between anti thyroid medication + iodine

63
Q

What is used for the inhibition of peripheral hormone action for thyroid crisis?

A

Propranolol IV 1-2mg every 15mins until HR controlled
MAX 10mg
Cardioselective if COPD or asthma

64
Q

What is used for supplementary management for thyroid crisis?

A

Paracetamol = antipyretic effects
Cholestyramine 4g every 6-12hrs = enhance thyroid hormone excretion

S3 Case 4 - Endocrine (17 decks)

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