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Patient > The thyroid gland and hormones > Flashcards

The thyroid gland and hormones Flashcards

1
Q

where is the thyroid located?

A

in the neck region on the anterior surface of the trachea

just below the larynx

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2
Q

which hormone is most commonly used for hypothyroidism treatment?

A

T4

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3
Q

define primary thyroid disease?

A

the pituitary produces more TSH as the thyroid gland isn’t responding

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4
Q

define secondary thyroid disease?

A

disease in the pituitary

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5
Q

what are secondary and tertiary thyroid disease usually accompanied by?

A

a whole other array of endocrine diseases

tertiary more than secondary

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6
Q

what is tertiary thyroid disease?

A

at the level of the hypothalamus

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7
Q

what is the most common type of hyperthyroidism and endocrine disorder?

A

primary hypothyroidism

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8
Q

define primary hypothyroidism

A

decreased production of thyroid hormone at the level of the thyroid gland

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9
Q

prevalence of primary hypothyroidism is ___%

A

2

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10
Q

primary ht is more common in …..

A

women by 10-20 times

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11
Q

causes of primary ht?

A

autoimmune disease
result of previous treatment for hyperthyroidism e.g. surgery
iodine imbalance
congenital hypothyroidism

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12
Q

why is iodine imbalance uncommon in the uk?

A

as its in flour which is highly abundant

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13
Q

what is congenital hypothyroidism?

A

born without a properly functioning thyroid or without a thyroid

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14
Q

how are new borns tested for congenital hypothyroidism?

A

prick heel for blood after born to test for a variety of conditions

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15
Q

hypothyroid patient symptoms are _____

A

unspecific

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16
Q

examples of hypothyroid symptoms

A 
lethargy 
dry skin 
sensitive to cold 
depression 
hair loss 
memory loss
weight gain 
constipation 
puffy face
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17
Q

how can you do thyroid function tests?

A

test for:
TSH
T4
thyroid peroxidase antibody- uncommon outside secondary care

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18
Q

why is thyroid peroxidase antibody uncommonly tested for?

A

its expensive and you can test in other ways

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19
Q

management of primary hypothyroidism in adults?

A

treat with lifelong T4

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20
Q

how high does TSH need to be till you treat it with lifelong T4?

A

> 10mU/L

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21
Q

how to treat is TSH is normal but you have low free T4?

A

LIFE LONG T4

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22
Q

initial treatment to primary hypothyroidism in adults under 50?

A

initially 50-100mcg DAILY

adjusted: 25-50mcg every 3 weeks according to response

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23
Q

initial treatment to primary hypothyroidism in adults over 50 and with heart disease?

A

initially 25mcg once daily

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24
Q

why should you be careful with LS in patients with heart disease?

A

can increase HR if have too much

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25
Q

initial treatment to primary hypothyroidism in congenital hypothyroidism?

A

10-15mcg/kg
adjusted to 5mcg/kg
will keep taking forever

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26
Q

what is the maximum amount of LS you can give to a neonate

A

50mcg

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27
Q

when will treatment for congenital hypothyroidism start?

A

from about 6-7 days old

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28
Q

monitoring babies with congenital hypothyroidism

A

measure TSH after 8-12 weeks and then every 3 months after that until they’re stabilised

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29
Q

what is the half life of T4?

A

7 days

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30
Q

adults maintenance dose?

A

100-200mcg DAILY

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31
Q

maintenance dose in children?

A

50-200mcg DEPENDING ON AGE

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32
Q

how often do you monitor TSH in adults

A

yearly

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33
Q

how often do you monitor TSH in children?

A

every 4-6 months until puberty

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34
Q

what levels of TSH do we aim for?

what else do we aim for?

A

lower half of reference range 0.5-2

symptom free

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35
Q

what might make you change an adults dose?

A

pregnancy

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36
Q

TF: there is benefit of using liothyronine and levothyroxine together over mono therapy?

A

FALSE- no evidence but a few did benefit

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37
Q

when is dual therapy used over mono therapy?

A

if unresponsive to mono therapy

by specialist

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38
Q

what can be purchased on line for treatment of hypothyroidism?

A

desiccated animal thyroid gland

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39
Q

why isn’t desiccated animal thyroid gland recommended

A

no evidence of benefit- no trials

long terms effects are uncertain

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40
Q

patient advice for hypot

A

life long treatment
don’t start at the same time as calcium or iron or caffeine as they can impact absorption
be careful with strengths as look similar
need for monitoring
entitled for medical exemption certificate

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41
Q

why is only a single daily dose needed?

A

has half life of a week

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42
Q

causes of hyperthyroidism?

A

graves disease
toxic nodules or cancer of the thyroid gland
antibodies to TSH receptor stimulate the gland
increased T3 and T4 production

43
Q

what type of disease is graves disease?

A

autoimmune

44
Q

prevalence of hyperthyroidism in women?

A

2%

0.2 in men

45
Q

symptoms of hyperthyroidism?

A 
anxious 
palpitations 
tremor 
weight loss 
tachycardia 
goitre 
heat intolerance 
warm skin 
diarrhoea
difficulty sleeping
46
Q

what is goitre

is it common

A

where the thyroid gland swells

quite common but not all the time

47
Q

what happens in primary hypothyroidism?

A

increased TSH to try stimulate the thyroid

this means decreased unbound T4

48
Q

What can you test for in hyperthyroidism?

A

TSH

T4

49
Q

What happens in primary hyperthyroidism?

A

decrease in TSH
as pituitary thinks there’s a lot of T3 and T4 so no need to stimulate its production
T4 increase

50
Q

why is there a low res of long term hypO thyroism with hyperthyroidism drug therapy?

A

as effects the production of T3 and T4 rather than affecting the gland itself

51
Q

why does treatment for hyperthyroidism need monitoring?

A

rare but quite serious side effects

52
Q

drug treatment uses for hyperthyroidism?

A

suppression or to block and replace

53
Q

what is the most common drug used for hyperthyroidism.

A

carbimazole

prodrug with methimazole as the active drug

54
Q

when is drug therapy preferred for hyperthyroidism treatment

A

children
pregnant or breastfeeding
uncomplicated mild disease

55
Q

mechanism of action for carbimazole?

A

interferes with thyroid hormone synthesis by inhibiting thyroperoxidase activity in follicular lumen of the thyroid itself

56
Q

initial dose of carbimazole?

then what?

A

15-40mg daily- depends on symptoms, can be higher
maintain until TFTs are normal and then reduce the dose to get balance with symptoms
maintain for 12-18 months

57
Q

on carbimazole maintenance you decrease the dose by….

A

25-30% monthly

58
Q

what happens if there’s a hypert relapse after using carbimazole? how common is this

A

50% of patients

longer term treatment required

59
Q

what is the blocking replacement regimen?

A

give the patient hypothyroidism as its easier to manage

60
Q

how do you achieve the blocking replacement regimen?

duration

A

carbimazole 40-60mg for approx 4 weeks
THEN
carbimazole 40-60mg PLUS thyroxine 50-100mcg

for 18 months

61
Q

what should happen after you stop the treatment for blocking replacement regimen?

A

thyroid gland should return to normal function

62
Q

are people on blocking replacement regimen eligible for free prescriptions?

A

no as only made temporarily hypothyroid

63
Q

why cant you do blocking replacement regimen in pregnant people?

A

carbimazole crosses the placental barrier, not enough T4.

this knocks out their thyroid function with no replacement, born hypothyroid with severe developmental issues

64
Q

what would happen if a pregnant women had hypertension?

A

carbimazole is only an issue if risks outweigh the benefits

usually get propylthiouracil instead

65
Q

dose of propylthiouracil?

A

200-400mg daily in divided doses

66
Q

propylthiouracil maintenance dose?

A

50mg TDS

67
Q

When is propylthiouracil needed?

A

pregnancy

intolerant of carbazole

68
Q

what can people who are intolerant to carbimazole get?

A

rash

agranulocytosis

69
Q

what is agranulocytosis?

A

a deficiency of granulocytes in the blood, causing increased vulnerability to infection

70
Q

why is drug induced agranulocytosis an issue?

A

sudden onset

cant predict it so you must give warnings to patients

71
Q

carbimazole can cause _____ _____ ______

A

bone marrow supression

72
Q

when should a full blood count be taken for patients on carbimazole?

A

if they get infection

73
Q

carbimazole is a ____ daily dose

A

single

74
Q

signs of agranulocytosis?

A

sore throat
mouth ulcers
bruising

75
Q

TF: patients with hyperthyroidism are entitled to medical exemption certificate

A

FALSE

76
Q

what would you do if a pateint on carbimazole comes int with a sore throat or mouth ulcers?

A

refer to GP immediately

77
Q

advantages radioactive iodine treatment for hyperthyroidism?

A

non invasive

excellent cure rate

78
Q

disadvantages of radioactive iodine for hyperthyroidism

A

higher likelihood of long term hypothyroidism
can worsen eye disease- protruding eyes
avoid in pregnancy/ fatherhood

79
Q

why does radioactive iodine have a higher risk of long term hypothyroidism

A

as radioactivity is taken up by the cells in the gland and will kill them

80
Q

when is radioactive iodine used?

A

if failed to respond to drugs
relapse after drugs
comorbid heart disease
toxic nodular goitre- want to reduce quickly

81
Q

advantages of surgery as a hypertension cure?

A

excellent and rapid cure rate

good for goitre

82
Q

disadvantages of surgery to treat hypertension

A

invasive
long term hypothyroidism
damage to parathyroid
scarring and swallowing difficulties

83
Q

when is surgery preferred treatment for hyperthyroidism

A

oesophageal obstruction present
intolerance to drug treatment
young adults

84
Q

why cant radioactive iodine or surgery be done straight after diagnosis?

A

as thyroid gland is a reservoir full of T3 and T4. If you start surgically messing around or killing the cells, you will get a huge spike of T3 and T4 in the body- Thyroid storm!

85
Q

what must you do before giving radioactive iodine or surgery?

A

make patient euthyroid by using high doses of carbimazole so when you have the treatment the stores are depleted

86
Q

what would happen in a thyroid storm?

A

Hyperpyrexia, dehydration.
Heart rate greater than 140 beats per minute, hypotension
Nausea, vomiting, diarrhoea, abdominal pain.
Confusion, agitation, delirium, psychosis, seizures or coma

87
Q

what is adjuvant therapy for hyperthyroidism

A

betablockade

88
Q

what does adjuvant therapy with beta blockers achieve?

A

palpitations, anxiety, tremor due to the high levels of T3 and T4.

89
Q

how long is adjuvant therapy needed?

A

only at the start of treatments, once they start to come down you dont need to keep taking

90
Q

why might you need higher doses of beta blockers in hyperthyroidism

A

as metabolism is increased

91
Q

what drugs are likely to induce thyroid disease?

A

iodine
amiodarone
lithium

92
Q

effect of iodine medication on the thyroid- when inducing thyroid disease?

A

acute: inhibits T3/4 release- hypothyroidism
prolonged: suppresses T3/4 production
rarely: thyrotoxicosis- if there is an underlying defect in autoregulation

93
Q

why can iodine deficiency cause hypothyroidism?

A

due to inability to produce T3/4

94
Q

How can iodine medication cause thyrotoxicosis?

A

if there is an underlying defect in autoregulation

95
Q

what does amiodarone cause?

A

hypothyroidism
mild hyperthyroidism
severe hyperthyrodism

96
Q

TF: when on treatment you still take amiodarone

A

TRUE

usually stop in hypertension

97
Q

How can amiodarone cause hypothyroidism?

how would you treat this?

A

inhibition of T4 and T3 synthesis

usually continue amiodarone and start T4 replacement therapy

98
Q

how can amiodarone cause mild hyperthyroidism?

what would you do about taking amiodarone?

A

blocks conversion of T4 to T3 which increases TSH and T4

usually stop treatment with amiodarone

99
Q

how can amiodarone cause severe hyperthyroidism

A

increased production of T4 because of iodine content

direct thyroiditis- excessive release of T4 into circulation

100
Q

what must be done if someone if on lithium?

A

monitor T3 and T4

101
Q

how does lithium cause hypothyroidism?

what would you do for treatment?

A

inhibits iodine uptake and prevents T3 and T4 release
monitor TSH
start T4 replacement IF SUBCLINICAL

102
Q

what type of hypothyroidism can lithium cause?

A

subclinical or transient

103
Q

can lithium cause hyperthyroidism?

A

yes

rare, paradoxical effect

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