hyperthyroidism Flashcards
management of acute phase of hyperthyroidism
give the patient propranolol (10-40mg)
gradually withdraw once thyroid levels return to normal
Medical management of hyperthyroidism , Graves disease
give antithyroid drugs for 12-18 months;
Carbimazole or neomercazole or methiomazole with a dosage of 30-40 mg for 1 to 2 months then reduce to 15-20 mg
or give PTU for 1 to 2 months at a dose of 100-150 mg every 6 hours then reduce to 50-200mg
what are the complications of the antithyroid drugs
Propylthiouracil (hepatotoxic),
carbimazole (agranulocytosis-leukopenia presents with fever and sore throat and teratogenic)
Surgical management of graves disease
Antithyroid drugs must first be taken to reach euthyroid (about 6 weeks) and then a full thyroidectomy can be performed,
SSKI 2 weeks before the surgery also be taken to decrease vascularity
what are the complications of surgical management of graves disease ?
hypoparathyroidism
recurrent laryngeal nerve damage (hoarseness )
external laryngeal nerve damage ( poor vocal volume)
when can radioactive therapy in Graves disease be given
is usually the preferred treatment in most patients
but patient must reach euthyroid first
can be administered immediately except in:
elderly patients
patients with IHD
severe thyrotoxicosis
large glands
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must not get pregnant 6-12 months after
may worsen eye disease and hypothyroidism happens in most cases
Management of ophthalmology in Graves disease
1- Give prednisolone after RAI 100mg , in gradually diminishing doses for 6-12 weeks
2- keep head elevated at night to diminish periorbital oedema
if steroid therapy is not effective , X-ray too the retrobulbar area may be helpful
orbital decompression if vision is threatened
management of hyperthyroidism/graves disease during pregnancy
1- Radioactive iodine therapy is contraindicated,
2- PTU in the first 3 months then switch to carbimazole
3- thyroidectomy can be performed in the second trimester
4- PTU has no effect on breastfeeding
what is toxic adenoma ?
1- also known as plummer’s disease,
2- almost always follicular adenoma (never malignant )
3- signs of hyperthyroidism without any ophthalmic features
4- nodule on one siide
thyroid scan findings of toxic adenoma?
hot nodule with suppressed uptake contralaterally
best treatment for toxic adenoma
thyroidectomy
what are the findings of toxic multinodular goitre on RAI?
patchy distribution may show, multiple functioning nodules appear
what is the Jod-basedow phenomenon ?
also known as iodine induced hyperthyroidism, pts with multi nodular goitre can often be precipitated by jod basedow
what is the treatment for toxic multinodular goitre ?
surgery; thyroidectomy
What is Subacute thyroiditis
inflammatory disorder of the thyroid gland , usually after a viral infection usually resolves over weeks or months
signs and symptoms of subacute thyroiditis
tender thyroid gland, no signs of ophthalmology, accompanied with signs of thyrotoxicosis ,fever malaise soreness in the neck
what are the lab findings in Subacute thyroiditis and findings on RAI ?
T3 and T4 will be high whilst TSH will be low initially , as the disease progresses T4 and T3 will drop and TSH will rise
RAI uptake is initially low but as the patient recovers the uptake increases
what is the management of subacute thyroiditis ?
1- symptomatic treatment , give paracetamol 0.5g four times a day
2- L-thyroxine is indicated in the hypothyroid phase of the disease and may need to continue on L thyroxine long term
when does a thyroid storm (thyrotoxic crisis) happen?
usually if the patient stops taking anti thyroid medications in Graves disease, due to infection or due to surgical stress
what are the clinical clues to thyrotoxic crisis (thyroid storm ) ?
fever, coma , anorexia , tacchycardia which may evolve to tachyarrythmias, pulmonary oedema, shock, confusion
what are the general measures for the management of thyrotoxic crisis ?
after Measuring T3 and T4 levels along with TSH general measures :
fluids used as indicated
a cooling blanket for the pyrexia
propranolol may be given to decrease conversion of T4 to T3
what are the specific measures for the management of thyrotoxic crisis ?
PTU is the anti thyroid drug of choice and is used in high doses as 1000 mg of PTU p.o or given nasogastrically,
followed by by PTU 250 mg of it every 6 hours
then an hour later give Lugol’s solution or SSKI to inhibit the release of thyroid hormone
finally dexamethasone should be given to lower body temperature
Graves disease syndrome
pretibial myxedema , exopthalmous, ptosis, thyrtoxicosis and goitre
what are the RAI findings in Graves disease
diffuse increased uptake
RAI findings in subacute thyroiditis ?
decreased uptake
when not to use RAI
in pregnant women , with large goitres and with compressive symptoms and elderly patients
management in toxic multi nodular goitre ?
start on propanolol and then reach euthyroid stage and then perform a thyroidectomy
what is the rhythmn in which TSH is released in ?
released in a pulsatile diurinal rhythm ( highest at night)
which hormones would change first in any thyroid affection ?
TSH first before T3 and T4
what medication is known to cause hyperthyroidism?
amiodarone
what is the NO SPECS classification of Graves’s ?
class 0 : no signs or symptoms
class 1 : only ocular signs
class 2 : soft tissue involvement
class 3 : proptosis
class 4 : extraocular muscle involvement
class 5 : corneal involvement
class 6 : sight loss
how is a diagnosis of graves disease made ?
1- if eye disease is present , graves can be diagnosed with no further tests
2- no eye disease ? hyperthyroid patient with or without goitre should do a radioiodine uptake test
what are the results seen with radioiodine uptake test in graves disease ?
increased diffuse uptake
what specific lab test can be used for graves disease?
TSH receptor antibody
what if steroid therapy is not effective in managing eye disease in Graves ?
external X ray therapy too the retrobulbar area
if vision is threatened orbital decompression can be used
what are the TFT results in hyper, hypo thyroidism , in hypopituitarism and in TSH secreting tumors
hyperthyroidism - TSH low , T3,T4 is high
hypothyroidism - TSH high, T3,T4 is low
hypopituitarism - TSH low, T3,T4 low
TSH secreting tumor - TSH high, T3,T4 high
what is the presentation of TSH secreting tumors ?
- FT4 & FT3 is elevated but TSH is normal or elevated
- Visual field examination may reveal temporal defects
MRI usually shows a pituitary tumor
what are the contraindications to using beta blockers (propranolol) ?
asthma
COPD
