Thyroid and Adrenal CUE CARDS

Question 1

What is the Difference between Primary and Secondary Hypo/hyperthyroidism in terms of location (in other words, what’s the classification?)

Answer 1

> Primary condition: problem is in the thyroid itself

> Secondary condition: problem is in the pituitary or the hypothalamus

Question 2

What is a serious side effect of new cancer immunotherapies?

Answer 2

> Hypophysitis
Can cause immune system to attack hypothalamus
Cascade of systems affected as a result of dysfunction - difficult to manage

Question 3

What are the signs and symptoms of hyperthyroidism?

Answer 3

> Intolerant to heat
> Tachycardia
> Increased BP
> Losing weight despite appetite
> Tremors

Question 4

What are the signs and symptoms of hypothyroidism?

Answer 4

> Intolerant to cold
> Bradycardia
> Fatigue
> Weight gain
> Dry skin
> Apathy
> Hair loss

Question 5

Briefly describe the pathophysiology of hypothyroidism

Answer 5

Autoimmune disease leading to destruction of thyroid cells

Question 6

Briefly describe the pathophysiology of hyperthyroidism

Answer 6

Antibodies that are triggering production of excess thyroid hormone

Question 7

What is T4?

Answer 7

Hormone produced by thyroid

Question 8

What is TSH?

Answer 8

Hormone produced that stimulated production of T4 by the thyroid

Question 9

What is the level of TSH and T4 in hyperthyroidism?

Answer 9

> T4 is high because the thyroid is producing more T4 than it needs to
TSH is low because the body signals that it doesn’t need anymore T4 (won’t stimulate thyroid)

Question 10

What is the level of TSH and T4 in hypothyroidism?

Answer 10

> T4 is low because the thyroid is not producing thyroid hormone
TSH is high because the body is trying to signal the thyroid to produce more hormone

Question 11

What are the levels of T4 and TSH in secondary hypothyroidism?

Answer 11

Both low because problem is further up in the pathway (in pituitary or hypothalamus)

Question 12

Why do we adjust dose to TSH levels in hypothyroidism?

Answer 12

> Because if you’re normalised TSH, that’s a marker that the body has enough T4 because we’ve shut off the feedback (body won’t ask for anymore)

Question 13

What should be taken into account in hyperthyroidism with other medications?

Answer 13

> Clearance of some drugs increased, so larger than normal doses may be required
Increased sensitivity to anticoagulants due to increased catabolism of vitamin K - dependent clotting factors (e.g. warfarin - response to warfarin can change quite significantly, as the thyroid state is adjusted because clotting metabolism changes quite a bit - as you treat hypothyroidism, dose of warfarin shifts)

Question 14

How do we determine how to treat hyperthyroidism?

Answer 14

> The severity of symptoms will influence how aggressive we need to be
If thyroid problem quite severe: high doses but can carry more risks
If thyroid problem not as severe: low doses which can carry less risks

Question 15

What is hyperthyroidism associated with?

Answer 15

> Associated with cardiac arrhythmias (including AF) and osteoporosis - particularly in elderly
Osteoporosis should be managed promptly and is critical in resolving secondary issues such as AF

Question 16

Why can’t you use blood tests to detect agranulocytosis?

Answer 16

> Because the speed of onset is too rapid
Need to rely on patient being informed of this as a risk
If patient recognise and develop these symptoms = see Dr. straight away

Question 17

How is hyperthyroidism treated in pregnancy?

Answer 17

> 1st Trimester: PTU

> 2nd and 3rd Trimester: Carbimazole

Question 18

What drug is preferred in Hyperthyroidism?

Answer 18

> Carbimazole is typically preferred: 1 d admin

> PTU may be preferred: early in pregnancy or in thyroid storm to manage symptoms more quickly due to also blocking peripheral conversion of T4 to T3, not just the synthesis of T4

Question 19

What is Thyroid Storm?

Answer 19

> Extremely high thyroid levels

> Hyperthermia, CNS effects, CV Dysfunction, Organ Failure

Question 20

How is Thyroid Storm managed?

Answer 20

> PTU preferred (inhibits conversion of T4 to T3)
Dexamethasone (settles inflammation and blocks conversion of T4 to T3)
Propanolol (block sympathetic effects)
Iodine Solution (Lugol’s): give 1 hr after PTU

Question 21

Why is Iodine Solution given 1 hr after PTU?

Answer 21

> If you give iodine to these patients, there’s a good chance that they’ll just start making thyroid hormone with that iodine
Give PTU first to shut down the thyroid and stop it from producing thyroid hormone and then shut down fully using iodine as well

Question 22

What are the signs and symptoms of Addison’s disease?

Answer 22

> Bronze pigmentation of skin
Postural Hypotension
Weight loss
Hypoglycaemia

Question 23

What are the signs and symptoms of Cushing’s Syndrome?

Answer 23

> Moon face
> Thin skin
> Fat deposits on face and back of shoulders
> Osteoporosis
> Hyperglycaemia

Question 24

What is Addison’s Disease?

Answer 24

> Caused by a lack of endogenous cortisol production and so aim is to replace the physiological cortisol profile
Replicate the normal cortisol profile that peaks in morning when you’re waking up and tapers off throughout the day
Replicate response to stress

Question 25

What is Cushing’s Syndrome caused by?

Answer 25

Often caused by a tumour (typically pituitary and referred to as Cushing’s Disease) or can be caused by the use of corticosteroids

Question 26

What is a risk of long term use of oral corticosteroids?

Answer 26

> Cushing’s syndrome

> Need to try and limit use because osteoporosis is significant risk

Question 27

What is the treatment for Cushing’s Disease?

Answer 27

> Primarily surgery to remove the tumour

> Drug therapy with ketoconazole or mitotane can be useful as a bridge to a definitive surgical procedure