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N810 > Thyroid > Flashcards

Thyroid Flashcards

1
Q

Primary Hypothyroidism

A
  • Low T4

- High TSH

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2
Q

Secondary Hypothyroidism

A
  • Low T4

- Low TSH

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3
Q

Management of hypothyroidism

A
  • Replacement with thyroid hormone and is lifelong

- Therapeutic goal is -.5-2.5

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4
Q

Over-replacement

A
  • Leads to low TSH
  • S/S: affects bone density, cardiac complications
  • Brand differences
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5
Q

Levothyroxine tips

A
  • Take on empty stomach
  • Before increasing drug, check for angina, diarrhea, or malabsorption
  • Long half-life
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5
Q

Drug Interactions: Levothyroxine

A
  • Avoid administering with: Iron, aluminum hydroxide, antacids, sucralfate, cimetidine, calcium supplements or soy milk, with bile acid sequestrants
  • Anti-seizure meds may increase hepatic metabolism
  • May effect warfarin dosing
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6
Q

Levothyroxine follow-up

A
  • Patients usually notice improvement in 2wk: Less facial puffiness, increased urination, improved energy
  • Recheck TSH after 6wk and adjust dosage
  • ** Recheck every 6wk until dosage regulated, then check annually
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7
Q

Subclinical management of hypothyroidism

A

TSH concentration >10mU/L or antithyroid peroxidase antibody with a normal T4: treat with synthetic T4 to prevent progression to overt hypothyroidism
- treatment may be indicated in patients with TSH 5-10mU/L (T4 normal) if these are present: Goiter, nonspecific symptoms, cardiac disease or diabetes

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8
Q

Graves Disease

A
  • antithyroid meds
  • Ablation with radioactive iodine
  • Surgery: thyroidectomy
  • Symptom management
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9
Q

Antithyroid medications

A
  • Methimazole (Tapazole)
  • Propylthiouracil (PTU)
    • Goal: Inhibit thyroid synthesis until thyroid stores are depleted and euthyroid state achieved (3-8wk)
    • remission rates vary from 10-90%
  • Reevaluate q3-6mo and check symptoms
    • Treat reoccurence with anti-thyroid drugs
  • – PTU drug of choice for pregnancy
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10
Q

Graves: Propanolol

A
  • Controls symptoms
  • Initially 20mg BID
  • Increase to 20-40mg BID-QID: Until improvement in tachycardia, tremor and diaphoresis and anxiety
  • Continue until hyperthyroidism is resolved
  • Does NOT impact thyroid hormone levels
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11
Q

Antithyroid Drugs: TOC for

A
  • Young adults
  • Those with mild thyrotoxicosis, small goiters
  • Those with fears of radioactive iodine
  • Patients preparing for surgery or radioactive iodine Tx
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12
Q

Graves: Agranulocytosis

A
  • Uncommon but severe complication of antithyroid meds
  • Presents in first 3mo of therapy
  • S/S: Fever, sore throat, rash, arthralgia, myalgia
  • Stop drug immediately and proceed to ED
  • Practice implications: Baseline CBC-diff, and then at follow-up
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13
Q

Monitoring antithyroid meds

A
  • Baseline CBC-diff, LFT’s with bilirubin
  • Monitor TSH q4-6wk
  • Goal: normalize TSH
  • If TSH remains low after 6mo of therapy, will likely recur once drugs stopped
    • Refer for definitive treatment
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14
Q

Radioactive Iodine

A
  • Goal: Reduce the volume of functioning thyroid tissue
  • used most frequently in older patients
  • TOC: >20yo and those for whom Tx with antithyroid drugs has failed
  • Not preferred for children, adolescents or women in reproductive years
  • Contraindicated in pregnancy (U-Preg before, defer pregnancy 3-6mo after)
  • Benefits: Definitive, easy, can be repeated
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15
Q

radioactive iodine limitations

A
  • May take many months to reverse
  • Causes hypothyroidism
  • Should be avoided in patients with Graves ophthalmopathy: May exacerbate
16
Q

Graves: Surgery indications

A
  • Pregnancy
  • Large goiters
  • Refusal of radioactive iodine
  • Coexisting suspicious nodules
  • Failed previous Tx
17
Q

Graves Surgery benefits, limitations, and complications

A 
Benefits:
- Definitive
Limitations:
- Cost, invasive, causes hypothyroidism
Complications:
- hypothyroidism, vocal chord paralysis/hoarseness, transient or permanent hypocalcemia from hypoparathyroidism
18
Q

Subclinical hyperthyroidism: high risk

A
  • If serum TSH <0.1mU/L, treat underlying cause of subclinical hyperthyroidism
  • If the serum TSH 0.1-0.5m/L, treat if there is underlying CVD or if bone density is low
19
Q

Subclinical hyperthyroidism: Low risk

A
  • Serum TSH <0.1: treat underlying cause if patient has S/S or if radioactive nucleotide uptake shows one or more focal areas
  • Serum TSH 0.1-0.5: Observation appropriate and monitor labs q6mo
20
Q

Management: Graves Disease

A
  • Check WBC periodically with antithyroid drug
  • Free T4 and TSH q4-6wk initially, then q3-6mo until stable, then q6-12mo
  • Hypothyroidism common months to years after I131 or thyroidectomy: Periodic TSH evaluation
  • Patient and family education; lifelong follow-up, s/s of recurrences and plan
21
Q

Thyroiditis: Types

A
  • Subacute thyroiditis (deQuervain’s thyroiditis)
  • Postpartum thyroiditis
  • Hashimoto’s thyroiditis (chronic lymphocytic thyroiditis)
22
Q

Subacute Thyroiditis (deQuervain’s thyroiditis)

A
  • Sequelae of viral infection
  • Severe pain in the neck, ears, and jaw; tender enlarged thyroid gland; fatigue
  • Tends to remit spontaneously and reoccur several times
  • Low TSH, high T3 and T4, followed by period of overt hypothyroidism, followed by normal thyroid function
  • Treatment: symptomatic propanolol for palpitations; ASA or NSAIDs; if severe, may use steroids (prednisone)
23
Q

Postpartum Thyroiditis

A
  • A painless thyroiditis with transient hyperthyroidism and hypothyroidism
  • Auto-immune-mediated; increased anti-thyroid antibodies
  • Suspect if weight loss faster tahn usual, mood changes, palpitations, “baby blues”
  • Does NOT require aggressive treatment (symptoms may last up to a year)
  • Close monitoring of TFT’s
  • Beta-Blockers can be used in hyperthyroid phase with caution as they can cross over into breast milk
  • Most patients will become euthyroid but up to 20-30% remain hypothyroid
  • May have recurrences with subsequent pregnancies
  • Need to differentiate from Graves’ Disease (low uptake of scan with postpartum thyroiditis) (Graves’ would have “hot” areas)
24
Q

Hashimoto’s Thyroiditis Facts

A
  • Chronic, autoimmune, thyroiditis
  • Most common thyroid disorder in US
  • Associated with other autoimmune disorders
  • Screen patients with personal or family Hx of auto-immunity with TSH
  • Increased antibodies (similar to Graves’)
  • – TPO levels increased by 95%
  • – ATA increased by 60% (very non-specific)
25
Q

Hashimoto’s Thyroiditis: S/S

A
  • Symptoms of hypothyroidism
  • Thyroid gland is usually diffusely enlarged (goiter), firm, rubbery, finely nodular, irregular surface
  • Pain usually not present
  • Gland may be atrophic
26
Q

Hashimoto’s: Treatment

A
  • Replace with synthetic T4
  • If large goiter:
  • – Suppress TSH with synthetic T4 to reduce size of goiter
  • – If euthyroid (normal TSH, minimal or absent goiter), follow closely for the development of hypothyroidism
27
Q

Thyroid nodules and MNG: Facts

A
  • The prevalence of cancer is higher in several groups and this needs to be a priority:
  • – children
  • – Adults 60
  • – Patients with Hx of head and neck irradiation
  • – Patients with a family Hx of thyroid Cancer
28
Q

Thyroid nodules and MNG: Labs

A
  • TFTs (TSH and Free T4)
  • Thyroid ultrasound
  • – Preferred over MRI or CT for accuracy
  • – Detect lesions as small as 2-3mm
  • – Lesions may be solid, cystic, or mixed
  • – Can’t distinguish between benign or malignant nodules
  • – Can be used to monitor nodules
29
Q

Thyroid nodules and MNG: Biopsy

A
  • US guided fine needle aspiration
  • – Gold standard; reported as benign, malignant, or suspicious
  • – Cytology done on any cystic fluid obtained
  • ** 70% Benign (Thyroid adenomas)
  • ** 10% follicular neoplasms (suspicious cytology)
  • ** 5% malignant
  • ** 15% nondiagnostic
30
Q

Thyroid nodules and MNG: PC of benign nodules

A
  • Observation/monitoring q6-12mo
  • Clinical exam: palpation
  • US
  • Monitor for atrial arrhythmias ans osteoporosis
  • Suppression with synthetic T4
  • More successful with patients with a MNG or diffuse nontoxic goiters
  • Less successful in Tx of a single nodule
  • Consider a 6mo trial to decrease TSH, shrink nodule
31
Q

Starting Dose of Levothyroxine

A
  • 50-100mcg: if no CAD and 60yo

N810 (18 decks)

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