HYPERTHYROIDISM Ppt Powerpoint Presentation slides-Medical Slideshow Treatment of hypothyroidsim and hyperthyroidism

HYPERTHYROIDISM

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Slide 1 :

HYPERTHYROIDISM Prevalence Women 2% Men 0.2% 15% of cases occur in patients older than 60 years of age

Slide 2 :

Clinical Symptoms Depends on Age of patient Magnitude of hormonal excess Presence of co-morbid condition

Slide 3 :

Mechanism of Clinical Symptoms 1. Catabolism 2. Enhancement of sensitivity to catecholamines

Slide 4 :

Clinical Symptoms Clinical manifestations of hyperthyroidism are largely independent of its cause. However, causing disorder may have other effects.

Slide 5 :

Clinical Symptoms Older patient presents with lack of clinical signs and symptoms, which makes diagnosis more difficult Thyroid storm is a rare presentation, occurs after stressful illness in under treated or untreated patient. Characteristics -Delirium -Dehydration -Severe tachycardia -Vomiting -Fever -Diarrhea

Slide 6 :

Clinical symptoms Skin -Warm -May be erythematous (due to increased blood flow) -Smooth- due to decrease in keratin -Sweaty and heat intolerance -Onycholysis –softening of nails and loosening of nail beds

Slide 7 :

Clinical symptoms Hyperpigmentation -Due the patient increase ACTH secretion Pruritis -mainly in graves disease Thinning of hair Vitilago and alopecia areata -mainly due to autoimmune disease Infilterative dermopathy -Graves disease, most common on shins

Slide 8 :

Clinical symptoms Eyes Stare Lid lag *Due to sympathetic over activity *Only Grave’s disease has ophthalmopathy -Inflammation of extraocular muscles, orbital fat and connective tissue. -This results in exopthalmos -More common in smokers

Slide 9 :

Clinical symptoms Eyes Impaired eye muscle function (Diplopia) Periorbital and conjunctival edema Gritty feeling or pain in the eyes Corneal ulceration due to lid lag and proptosis Optic neuritis and even blindness

Slide 10 :

Clinical symptoms Cardiovascular System Increased cardiac output (due to increased oxygen demand and increased cardiac contractibility. Tachycardia Widened pulse pressure High output – heart failure

Slide 11 :

Clinical symptoms Cardiovascular System Atrial fibrillation, 10-20% of patients. More common in elderly Atrial ectopy 60% of A-fib will convert to normal sinus rhythm with treatment (4-months of becoming euthyroid) Mitral valve problems LVH and cardiomyopathy

Slide 12 :

Serum Lipids Low total cholesterol Low HDL Low total cholesterol/HDL ratio

Slide 13 :

Respiratory System Dyspnea on rest and with exertion Oxygen consumpation and CO2 production increases. Hypoxemia and hypercapnea, which stimulates ventilation Respiratory muscle weakness Decreased exercise capacity Tracheal obstruction May exacerbate asthma Increased pulmonary arterial pressure

Slide 14 :

Clinical symptoms GI System -Weight loss due to increased calorigenesis -Hyperdefecation -Malabsorption -Steatorrhea -Celiac Disease (in Grave’s Disease) -Hyperphagia (weight gain in younger patient) -Anorexia- weight loss in elderly -Dysphagia -Abnormal LFT especially phosphate

Slide 15 :

Clinical symptoms Hematological System Normochromic normocytic anemia Serum ferritin may be high Grave’s disese ITP Pernicious anemia Anti-neutrophiliac antibody

Slide 16 :

Clinical symptoms GU System Urinary frequency and nocturia Enuresis is common in children

Slide 17 :

Clinical symptoms GU System Women Increased SHBG High serum estradiol Low free estradiol High LH Reduce mid-cycle LH surge Oligomenorrhea and amenorrhea Anovulatory infertility

Slide 18 :

Clinical symptoms GU System Men High SHBG High total testosterone Low free testosterone High serum LH High serum estradiol Gynecomastia Decreased libido Erectile dysfunction Decreased or abnormal sperm

Slide 19 :

Clinical symptoms Skeletal System Bone resorption Increased porosity of cortical bone Reduced volume of trabecular bone Serum alkaline phosphate is increased Increased osteoblasts Inhibit PTH secretions Decreased calcium absorption and increased excretion Osteoporosis, Fractures

Slide 20 :

Clinical symptoms Skeletal System Grave’s disease is associated with thyroid acropathy -Clubbing of nails -Periosteal bone formation in metacarpal bone or phalanges

Slide 21 :

Clinical symptoms Neuromuscular System Tremors-outstretched hand and tongue Hyperactive tendon reflexes

Slide 22 :

Clinical symptoms Psychiatric Hyperactivity Emotional lability Anxiety Decreased concentration Insomnia

Slide 23 :

Clinical symptoms Muscle Weakness Proximal muscle weakness in 50% pts. Decreased muscle mass and strength May take up to six months after euthyroid state to gain strength Hypokelemic periodic paralysis especially in Asian men (cause is not known) Myesthenia Gravis, especially in Grave’s disease.

Slide 24 :

Clinical symptoms Endocrine Increased sensitivity of pancreatic beta cells to glucose Increased insulin secretion Antagonism to peripheral action of insulin Latter effects usually predominate leading to intolerance.

Slide 25 :

Etiology 1 Grave’s disease Autoimmune disease caused by antibodies to TSH receptors Can be familial and associated with other autoimmune diseases 2 Toxic multi-nodular goiter 5% of all cases 10 times more common in iodine deficient area Typically occurs in older than 40 with long standing goiter

Slide 26 :

Etiology 3 Toxic adenoma More common in young patients Autonomically functioning nodule

Slide 27 :

Etiology 4 Thyroiditis Subacute Abrupt onset due to leakage of hormones Follows viral infection Resolves within eight months Can re-occur Lymphatic and postpartum Transient inflammation Postpartum can occur in 5-10% cases in the first 3-6 months Transient hypothyroidism occurs before resolution

Slide 28 :

Etiology 5 Treatment Induced Hyperthyroidism Iodine Induced Excess iodine indirect Exposure to radiographic contrast media Medication Excess iodine increases synthesis and release of thyroid hormone in iodine deficient and older patients with pre-existing goiters

Slide 29 :

Etiology Amiodarone Induced Thyroiditis Up to 12% of patients, especially in iodine deficient cases Most common cause of iodine excess in US. Two types: *Type I - due to excess iodine Amiodarone contains 37% iodine. *Type II –– occurs in normal thyroid

Slide 30 :

Etiology Thyroid Hormone Induced Factitious hyperthyroidism in accidental or intentional ingestion to lose weight Tumors -Metastatic thyroid cancer -Ovarian tumor that produces thyriod hormone (struma ovarii) -Trophoblastic tumor -TSH secreting tumor

Slide 31 :

Signs and symptoms of hyperthyroid TSH level Low TSH High TSH (rare) Measure T4 High Secondary hyperthyroidism Image pituitary gland

Slide 32 :

Low TSH Measure Free T4 Level Normal High Measure Free T3 Level Normal High -Subclinical hyperthyroidism -Resolving Hyperthyroidism -Medication -Pregnancy -New thyroid illness T3 Toxicosis Primary hyperthyroidism Thyroid uptake Low High Measure thyroglobulin decreased Increased Exogenous Thyroiditis Iodide exposure Exrtraglandular production DIffuse Nodular hormone Graves disease Multiple areas One “hot” area Toxic multinodular goiter Toxic adenoma

Slide 33 :

Etiology Hyperthyroidism with high RIU - Grave’s disease - Toxic adenoma - Toxic multinodular goiter - TSH- producing pituitary adenoma - Hyperemesis gravidarum - Trophoblastic disease

Slide 34 :

Etiology Hyperthyroidism with low RIU - Subacute thyroiditis - Exogenous harmone intake - Ectopic ovarii - Metastatic follicular thyroid CA - Radiation thyroiditis - palpation thyroiditis - Amiodarone induced

Slide 35 :

Treatment Treatment depends upon -Cause and severity of disease -Patients age -Goiter size -Comorbid condition -Treatment desired

Slide 36 :

Treatment The goal of therapy is to correct hyper-metabaolic state with fewest side effects and lowest incidence of hypothyroidism.

Slide 37 :

Options Anti-thyroid drugs Radioactive iodine Surgery Beta-blocker and iodides are adjuncts to above treatment

Slide 38 :

Beta Blockers Prompt relief of adrenergic symptoms Propranolol widely used Any beta blocker can be used, but non-selectives have more direct effect on hyper-metabolism Start with 10-20 mg q6h Increase progressively until symptoms are controlled Most cases 80-320 mg qd is sufficient CCB can be used if beta blocker not tolerated or contraindicated

Slide 39 :

Iodides Iodide blocks peripheral conversion of T4 to T3 and inhibits hormone release. These are used as adjunct therapy Before emergency non-thyroid surgery Beta blockers cannot curtail symptoms Decrease vascularity before surgery for Grave’s disease

Slide 40 :

Iodides Iodides are not used for routine treatment because of paradoxical increase of hormone release with prolonged use Commonly used: Radiograph contrast agents -Iopanoic acid -Ipodate sodium Potassium iodide Dose 1 gram/ 12 weeks

Slide 41 :

Anti-thyroid Drugs They interfere with organification of iodine—suppress thyroid hormone levels Two agents: -Tapazole (methimazole) -PTU (propylthiauracil)

Slide 42 :

Anti-thyroid Drugs Remission rate: 60% when therapy continued for two years Relapse in 50% of cases. Relapse more common in -smokers -elevated TS antibodies at end of therapy

Slide 43 :

Anti-thyroid Drugs Methimazole Drug of choice for non-pregnant patients because of : Low cost Long half life Lower incidence of side effects Can be given in conjunction with beta-blocker Beta-blockers can be tapered off after 4-8 weeks of therapy Dose 15-30 mg/day

Slide 44 :

Anti-thyroid Drugs Methimazole Monthly Free T4 or T3 until euthyroid Maintenance dose 5-10 mg/day TSH levels may remain undetectable for months after euthyroid and not to be used to monitor the therapy

Slide 45 :

Anti-thyroid Drugs Methimazole At one year if patient is clinically and biochemically euthyroid and TS antibodies are not detectable, therapy can be discontinued Monitor every three months for first year then annually Relapses are more common in the first year but can occur years later If relapse occurs, iodide or surgery although anti-thyroid drugs can be restarted

Slide 46 :

Anti-thyroid Drugs PTU Prefered for pregnant patients Methimazole is associated with rare genetic abnormalities Dose 100 mg t.i.d Maintenance 100-200 mg/day Goal: Keep Free T4 at upper level of normal

Slide 47 :

Anti-thyroid Drugs Complications Agranulocytosis up to 0.5% High with PTU Can occur suddenly Mostly reversible with supportive Tx Routine WBC monitoring controversial Some people monitor WBC every two weeks for first month then monthly Advised to stop drug if they develop sudden fever or sore throat

Slide 48 :

Radioactive Iodine Treatment of choice for Grave’s disease and toxic nodular goiter Inexpensive Highly effective Easy to administer Safe Dose depends on estimated weight of gland Higher dose increases success rate but higher chance of hypothyroidism Some studies have shown increase of hypothyroidism irrespective of dose

Slide 49 :

Radioactive Iodine Higher dose is favored in older patient Cardiac disease Other group needs prompt control Toxic nodular goiter or toxic adenoma

Slide 50 :

Radioactive Iodine Side effects 50% of Grave’s ophthalmology can develop or worsen by use of radioactive iodine Use 40-50 mg Prednisone for at least three months can prevent or improve severe eye disease in 2/3 of patients Use lower dose in ophthalmology because post Tx hypothyroidism may be associated with exacerbation of eye disease Smoking makes ophthalmopathy worse.

Slide 51 :

Radioactive Iodine Use of anti-thyroid drugs with iodine is not recommended in most cases May improve safety for severe or complicated cases Withdraw three days before iodine Tx Beta blockers used to control symptoms before radioactive iodine and can be combined throughout Tx Iodine containing meds need to be stopped several weeks before therapy

Slide 52 :

Radioactive Iodine Safety Most radioactive iodine is eliminated in the urine, saliva and feces in 4-8 weeks. Have double flushing of toilet and frequent hand washing for several weeks No close contact with children and pregnant patients for 48-72 hours Additional Tx may be needed after three months if indicated

Slide 53 :

Surgery Radioactive iodine has replaced surgery for Tx of hyperthyroidism Subtotal thyroidectomy is most common This limits incidence of hypothyroidism to 25% Total thyroidectomy in large goiter or severe disease

Slide 54 :

New Treatment Endoscopic subtotal thyroidectomy Embolization of thyroid arteries Plasmaphoresis Percutaneous ethanol injection into toxic nodule L-Carnitine supplementation may improve symptoms and may prevent bone loss

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Atrial fibrillation, 10-20% of patients. More common in elderly; Atrial ectopy; 60% of A-fib will c more Atrial fibrillation, 10-20% of patients. More common in elderly; Atrial ectopy; 60% of A-fib will convert to normal sinus rhythm with treatment (4-months of ... less

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