HYPERTHYROIDISM
BY TEMESGEN
OVERVIEW
• What is hyperthyroidism?
• Hyperthyroidism is the abnormal function of the thyroid gland.
• an organ located in the front of the neck that releases hormones to regulate the body’s
use of energy.
• if thyroid gland is overactive and makes more thyroid hormones than the body needs, it
causes hyperthyroidism.
WHO IS MORE LIKELY TO DEVELOP HYPERTHYROIDISM?
• Women are 2 to 10 times more likely than men to develop hyperthyroidism
• Peoples are more likely to have hyperthyroidism if they..
• have a family history of thyroid disease
• have other health problems, including….
• Pernicious anemia,Type 1 Dm, primary adrenal insuficency
CONTINUED….
• eat large amounts of food containing iodine, such as kelp, or use medicines that contain iodine, such
as amiodarone a heart medicine.
• older than age 60, especially on womans
• were pregnant within the past 6 months
WHAT CAUSES HYPERTHYROIDISM?
• Hyperthyroidism has several causes, including Graves’ disease, thyroid nodules, and thyroiditis—
inflammation of the thyroid. Rarely, hyperthyroidism is caused by a noncancerous tumor of the
pituitary gland located at the base of the brain. Consuming too much iodine or taking too much
thyroid hormone medicine also may raise the thyroid hormone levels.
CAUSES OF HYPERTHYROIDISM
• CIRCULATING THYROID STIMULATORS
• Graves disease
• Neonatal Graves disease
• Thyrotropin –Selecting Tumor(Pituitary adenoma )
• Choriocarcinoma
ECTOPIC THIROID TISSUE
• Strauma Ovari
• Metastatic follicular thyroid cancer
• Pitutary resistance to thyroid hormone
CONTINUED…..
• THYROIDAL AUTONOMY
• Toxic multinodular goiter
• Congenital Hyperthyroidism
• Iodine-induced hyperthyroidism(Jod-Basedow)
• DESTRUCTION OF THYROID FOLLICLES (THYROIDITIS)
• Subacute thyroiditis
• Painless postpartum thyroiditis
• Amiodarone induced thyroiditis
• Acute(infectious) Thyroiditis
CONTINUED…
• EXOGENIOUS THIROID HORMONE
• Lathrogenic Excess ingestion of thyroid hormone
• Facititous Excess ingestion of thyroid hormone
• Hamburger thyrothoxicosis
GRAVIES DISEASE
• It is an autoimmune disorder; production of thyroid-stimulating immunoglobulin (TSI) results in
diffuse toxic goiter.
• Graves disease occurs in approximately 0.02%of Children (1:5,000)
• It has a peak incidence in 11- to 15 –yr old; there is 5:1 female to male ratio
• Most children with Graves disease have a positive family of some form autoimmune thyroid
disease
THIROIDITIS
• 15 -20% Cases
• A destructive release of preformed thyroid hormone
TOXIC MULTINODULAR GOITER
• Also called Plummer disease
• 15 -20% of cases
• Occurs more Commonly in elderly, especially with long standing goiter
TOXIC ADENOMA
• Caused by single hyperfunctioning of follicular thyroid adenoma
• Accounts 3-5% of cases
• Benign monoclonal tumor that usually is larger than 2.5cm
CLINICAL MANIFESTATIONS
• The earliest sign in children may be emotional disturbances accompanied by motor hyper activity
• The children become irritable and excited, and they cry easily because of emotional liability
• They are restless sleepers and tend to kick their cover off.
• Tremor of fingers can be noticed if the arm is extended
• Their schoolwork suffers as a result of short attention span and poor sleep.
SYMPTOMS
• Hyperactivity, irritability, altered mood, insomnia, anxiety
• Heat intolerance, Increased sweating
• Palpitation
• Fatigue, weakness
• Dyspnea
• Pruritus
• Increased stool frequency
• Thirst and polyuria
• Oligomenorrhea or amenorrhea
SIGNS
• Sinus tachycardia , atrial fibrillation (rare in children) supraventricular
• Tachycardia
• Fine tremor, hyperkinesis, hyperreflexia
• Warm, moist skin
• Onycholysis
• Hair loss
• Osteoporossis
• Muscle weakness and wasting
• Periodic (hypokalemic) paralysis
• Psychosis
THYROID CRISIS OR THYROID STORM
• Thyroid crisis or thyroid storm is a form of hyperthyroidism manifested by an acute onset,
hyperthermia , severe tachycardia, heart failure, and restlessness
• There may be rapid progression to delirium, coma, and death. Precipitating incidence include
antithyroid agent withdrawal, severe thyroiditis, Post ablative therapy (especially if inadequate
p pretreatment) Trauma infection, radio active iodine treatment or surgery.
• Mortality rate may be as high as 20%
APATHETIC OR MASKED HYPERTHYROIDISM
• They are another variety of hyperthyroidism characterized by extreme listlessness, apathy, and
cachexia.
• A combination of both forms can occur
• These symptom complexes are rare in children
DIAGNOSTIC TESTS
• History and physical examination
• Ophtalmologic examination
• ECG-atrial tachycardia
• Laboratory tests
• TFT(thyroid function test)
• T3
• T4
• TRH(thyroid releasing hormone) stimulation test
RADIOACTIVE IODINE UPTAKE(RAIU)
• A radioactive iodine uptake (RAIU) test uses a radioactive tracer and special probe to measure how
much tracer the thyroid gland absorbs from the blood
FINDINGS
• Serum levels of thyroxine (T4), triidothyronine (T3) Free T4 and free T3 are elevated.
• In some patients, T3 may be more elevated than those of T4
• Levels of TSH are suppressed to below the lower range of normal
• Most patients with newly diagnosed Gravies disease have measurable TRSAb;
• Radioiodine is rapidly and diffusely concentrated in the thyroid
• Bone density may be reduced at diagnosis but returns to normal with treatment
EVALUATION OF THYROTOXICOSIS
MANAGEMENT OF HYPERTHYROIDISM
• THERAPY GOALS
● Minimize or eliminate symptoms, improve quality of life
● Minimize long term damage to organs Heart disease, arrhythmias
Sudden cardiac death, fractures
● Normalize T4 and TSH concentration
1, ABLATIVE THERAPY
• Treatment of choice for Graves’ disease, toxic nodule, multinodular goiter.
• According to patients preference or comorbidities
• Surgical resection for adenomas
• Ablative therapy often results in hypothyroidism
2, ANTITHYROID
• Antithyroid pharmacology usually reserved for
i, Those awaiting ablative therapy or surgical resection
● To deplete stored hormone
● To minimize risk of post- treatment hyperyhyroidism caused by thyroiditis
ii, Those who are not ablactive or surgical candidates
● Serious cardiovascular disease
● Candidate unlikely to be adherent to radiation safety
CONTINUED…..
iii, When ablative therapy or surgical resection fails to normalize thyroid function
iv, Those with high probability of remission with oral therapy for Gravies disease:
: mild disease, small goiter, low or negative antibody titers.
v, Those with limited life expectancy
vi, Those with moderate to severe active Gravies Ophtalmopathy
THIOUREAS
• Inhibit iodination and synthesis of thyroid hormones; PTU may block T4/T3 conversion
in the periphery as well
• Therapy duration; usually 12 -18 months
• Adverse effects : Hepatotoxicity risk with PTU (document baseline LFT), rash, arthalgias,
lupus like symptoms, fever, agranulocytosis; baseline CBC
1) PTU
• Preferred agent in pregnant woman in the 1st trimester
• Dose;
● Initial: 100 mg by mouth three times daily
● Maximal: 400 mg three times daily
● Once euthyroid, may reduce to 50 mg 2-3 times daily
2, METHIMAZOLE
• Preferred agent, except in pregnant in pregnant women in the 1st trimester
• Dose
Initial : 10-20 mg by mouth once daily
Maximal : 40 mg three times daily
Once euthyroid : may reduce to 5-10 mg
3, NON SELECTIVE BETA BLOCKERS
(PROPRANOLOL)
• Blocks many hyperthyroidism manifestations mediated by β-adrenergic receptors
• Used Primarily for symptomatic relief (Palpitation, tachycardia, tremor, anxiety)
• Also block T4(less active) conversion to T3 (more activate)
• Dosing
● Initial: 20 - 40 mg by mouth three or four times daily
● Maximal: 240-480 mg /day
● Alternative to β-blockers: clonidine, nondihidropyridine, calcium channel blocker
(4), IODINE AND IODIDES
• Inhibits the release of stored thyroid hormones
• Minimal effect on hormone synthesis
• Helps decrease vascularity and size of gland before surgery.
• Dosing
● Lugol’s solution: (6.3-8 mg iodide per drop)
● Saturated solution of potassium iodide: (38-50 mg iodide per drop)
●Potassium iodide tablets(130- mg tablet contain , 100 mg of iodide )
● Adverse effects: Hypersensitivity, metallic taste, soreness or burning in mouth or tongue.
● Do not use In the days before ablative iodine therapy (may reduce uptake of radioactive iodine )
THYROID STORME MANAGEMENT
• 1) PTU : 500 -1000 mg loading dose , then 250 mg Q4 hours
● alternative methimazole 60-80 mg daily
2) Iodide therapy one hour after PTU initiation
3) β-blockers therapy: Propranolol to control symptoms and block conversion of T4 to T3.
4) Paracetamol as antipyretic therapy, if needed (avoid NSAIDs)
5) Corticosteroid therapy: prednisone 300 mg IV Loading dose then 100 mg every 8 hour’s
(Dexamethasone, hydrocortisone).
THYROIDECTOMY
• IS the oldest form of treatment for hyperthyroidism.
• Thyroidectomy is reserved for special circumstances, including the following
● Severe hyperthyroidism in children
● Pregnant women who are intolerant of antithyroid pharmacology
● Patients with very large goiter or severe ophtalmopathy
● patients who refuse radio active iodine therapy
● patients with refractory amiodarone induced hyperthioidism
● Patients who require normalization of thyroid function quickly, such as pregnant women,
● women who desire pregnancy in the next 6 months, cardiac patients on unstable condition.
• THANK