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Pharm Year 3 Sem1 patient > thyroid disease > Flashcards

thyroid disease Flashcards

1
Q

name the hormones involved in the HPT axis’s

A

TRH
TSH
T3- liothyronine
T4- levothyroxine

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2
Q

what is primary thyroid disease?

A

disease effecting the thyroid gland

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3
Q

what is secondary thyroid disease?

A

disease effecting the pituitary gland

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4
Q

what is tertiary thyroid disease/

A

disease effecting the hypothalamus

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5
Q

primary hypothyoidism Myxoedema

A

decrease in the production of thyroid hormones
v severe
can lead to coma

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6
Q

aetiology of primary hypothyroidism

A

autoimmune disease e.g. hasimoto’s thyroiditis
result of previous hyperthyroidism treatment e.g. surgery
iodine imbalance (uncommon in the UK - freely available in flour, in diet
congenital hypothyroidism

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7
Q

what is congenital hypothyroidism ?

A

child born without a thyroid or with partial thyroid

part of the newborn screening programme

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8
Q

symptoms of hypothyroidism

A 
non specific symptoms 
lethargy, weakness\dry scaly skin
sensitive to cold weather\depression\hair loss
memory loss
weight gain
constipation
puffy face (oedema)
and gruff voice with untreated disease
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9
Q

Thyroid function tests

A

TSH levels and
Free unbound T4

test for TPO - rarely measured outside of secondary care

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10
Q

what will TFTs show in primary hypothyroidism?

A

increased TSH - because of low levels of thyroid hormone

decreased free /unbound T4

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11
Q

TSH> 10 mU/L and low or free t4

A

treat with lifelong t4

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12
Q

TSH>5- 10 mU/Land low or free t4

A

treat with lifelong T4

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13
Q

TSH>5- 10 mU/L and no low or free t4

A

Symptoms : 6 month trial of T4, if resolved continue lifelong, if not :check TPO antibody

if no symptoms: check TPO antibody
positive: check TSH annually
negative check TSH 3 yearly

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14
Q

what does TPO antibody show

A

something else affecting TSH levels

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15
Q

treatment initial

A

adult, under 50 - initially 50-100 mag levothyroxine
adjust 25-50 every 3/4 weeks

adult 50+ or those with heart disease - initially 25 mcg once daily, adjusted by 25mcg every 4 weeks

congenital - initially 10- 15 mag/kg (max 50mcg) adjusted by 5mcg every two weeks

measure TSH every 8-12 weeks
since half life of T4 is 7 days
and 3 months after stabilised

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16
Q

treatment maintenance

A

adult : 100-200mcg
children :50-200mcg depending on age and size

monitor every yr adults
monitor every 4-6 months kids
TSH aim (0.5-2)
symptom free
monitor for angina
17
Q

combination treatments

A

quite rare
difficult unresponsive thyroid disease
no evidence over monotherapy
liothyronine and levothyroxine (t3 and t4)

natural thyroid extracts :
desiccated animal thyroid gland
no evidence on benefit and NOT recommended

18
Q

patient counselling

A

life long treatment
single daily dose
don’t take at same time as calcium, iron or caffeine

three strength of tablets - cause of confusion
needs for monitoring
primary hypothyroidism - medically exempt for prescription charges

19
Q

aetiology of autoimmune

A

graves disease
toxic nodules
cancer

20
Q

symptoms

A 
anxious 
palpitations
 tremor
weight loss
tachycardia
goitre
heat intolerance
warm moist skin 
difficulty sleeping
diarrhoea
21
Q

TFT for hyperthyoidism

A

v high levels of T4 and negligible levels of TSH

22
Q

describe advantages of drug treatment for hyperthyroidism

A

drug therapy: non invasive
low risk of long term hypo (affects production of hormones
low long term cure rate for non mild disease
rare but desirous side effects

23
Q

who receives drug therapy for hyperthyroidism?

A

children, pregnancy, breastfeeding
uncomplicated mild disease
acute phase prior to surgery

24
Q

describe briefly drug treatment for hyperthyroidism

A

drug group: thionamides

main drug (carbimazole)
pregnant and breastfeeding (propylthiouracil)

act by interfering with thyroid hormone synthesis by inhibiting TPO activity in the follicular lumen

25
Q

describe how carbimazole is used to treat hyperthyroidism

A

1st choice drug
start 15-40 mg daily (depends on symptom severity)
maintain until TFTs normal (4-8 weeks)
maintenance for 12-18 months
25-30% decrease monthly until 5-15 mg
important to balance low dose with least/no symptoms

mild disease can be corrected by this therapy
longer term treatment may be required in relapse
C/I in pregnancy as crosses placental barrier

26
Q

blocking replacement regimen

A

person made completely hypothyroid (temporary)
then given thyroxine to replace

start on high dose carbimazole for 1 month. (40-60mg)
then once all endogenous T3 and T4 is gone add thyroxine 50-100 mcg

treat up to 18 months
gland returns to normal function when treatment stopped
C/I in pregnancy as crosses placental barrier - make child hypothyroid with developmental issues

27
Q

carbimazole and pregnancy

A

must be used with effective contraception

to prevent pregnancy

28
Q

how is propylthiouracil used to treat hyperthyroidism?

A

200-400mg initially in divided doses
gradually reduced by 50- 150 mg daily
preferred in pregnancy, particular 1st trimester
intolerant of carbimazole (rash)

29
Q

what is drug induced agranulocytosis ?

how is it dealt with

A 
abrupt
both carbimazole and propylthiouracil can cause bone marrow suppression
drop in white cell count 
0.3-0.5% 
not monitored but patient warned

patient should report symptoms
WBC count performed if evidence of infection

carbimazole stopped promptly if there is clinical or lab evidence of neutropenia

30
Q

patient counselling for hyperthyroidism

A

carbimazole single daily dose
propythiouracil divided doses
duration of treatment
signs of agranulocytosis : sore throat, bruising, mouth ulcer
report signs of hepatic dysfuntion
advice on contraception if on carbimazole
need for regular review , tests
patients with hyper are not entitled to free prescriptions

31
Q

Advantages as disadvantages of radioactive iodine

A 
non invasive 
excellent cure rate
long term hypothyroidism likely (thyroid cells destroyed by radiation)
can worsen eye disease
avoid pregnancy/fatherhood
32
Q

when is radioactive iodine suitable?

A 
1st line for mild or if drug treatment not suitable 
toxic nodular goitre
relapse after drug treatment 
comorbid cardiac disease
toxic nodular goitre
33
Q

surgery for hyperthyroidism:
advantages disadvantages
when is it suitable?

A 
likely long term hypothyroidism 
excellent and rapid cure rate
invasive
 risk of damage to parathyroid gland 
scarring and possible swallowing diffuctiies
oesophageal obstruction 
young adults
intolerance to drug treatment
34
Q

why can’t you start iodine therapy or surgery straight after diagnosis?

what do you do instead

A

prevent thyrotoxic crisis (medical emergency due to dangerously high levels of T4 released into system :
causes dehydration, HR over 140 bpm, hypotension, GI side effects confusion agitation delirium psychosis seizure and coma

make patient euthyroid using drugs

35
Q

adjuvant treatment for hyperthyroidism

A

high dose of beta blockers for cardio side effects for a initial months

propanalol
nadolol
TDS/QDS

rapid relief of symptoms e.g tremor

C/I in asthma

36
Q

which drugs cause drug induced thyroid disease?

A

iodine ,amiodorone, and lithium
can cause hyper or hypo

iodine overdose: inhibit/supress T3/t4 release/ production

37
Q

how can iodine cause drug induced thyroid disease?

A

iodine overdose: inhibit/supress T3/t4 release/ production

rarely can cause thyrotoxocis if underlying auto regulation

deficiency can cause hypo due to being unable to produce T3/T4

38
Q

how can amiodorone cause drug induced thyroid disease?

A

used to treat arrthymias
contains organic iodide

hypothroidism
can occur in
at any time 1-10\5 patients
inhibits synthesis and release of thyroid hormones
continue amiadorone and start T4 replacement therapy

mild hypo
blocks conversion of t4 to t3, inc in TSH and T4 (usually transient when start amiodorone and normalises within 4 months)

severe hyper:
inc production of t4 because of iodine
direct thyroiditis
excessive release of t4 into circulation, withdraw therapy

39
Q

how does lithium cause drug induced thyroid disease?

A

Hypothyroidism: inhibits uptake and prevents T3,T4 release
can be transient and subclinical
monitor TSH
start replacement t4 therapy

Hyperthyroidism
rare paradoxical effect
stop treatment

Pharm Year 3 Sem1 patient (12 decks)

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