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Hyperthyroidism Management

This document discusses the disease management of hyperthyroidism. There are three main treatment options - medication, radioactive iodine treatment, and surgery. Medications include anti-thyroid drugs, beta blockers, and iodides. Radioactive iodine treatment destroys thyroid tissue with a single dose and has high cure rates. Surgery is generally reserved for special circumstances and requires pre-operative preparation to make the patient euthyroid. The choice of treatment depends on factors like the cause and severity of disease, patient's age, and presence of other medical conditions.

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DISEASE MANAGEMENT (HYPERTHYROIDISM) Muhammad Arslan Tahir (13635)
DISEASE MANAGEMENT  Disease management is a system of coordinated heath care interventions and communications for defined patient populations with conditions where self-care efforts can be implemented. Disease management empowers individuals, working with other health care providers to manage their disease and prevent complications.
TREATMENT OPTIONS 1. Medication 2. Radioactive iodine 3. Surgery
1- MEDICATIONS  Anti-thyroid drugs  Beta blockers  Iodides
ANTI-THYROID DRUGS  Methimazole and propylthiouracil are most commonly used ATDs INDIACTIONS  Patients with sustained forms of hyperthyroidism  Elderly or other patients with comorbidities, surgical risk or limited life expectancy  Moderate to severe active Graves’ ophthalmopathy  Before surgery  Soon after starting radioactive I-131 therapy for 6 to 12 weeks
ANTI-THYROID DRUGS
ANTI-THYROID DRUGS HOW LONG TO GIVE ATDs  Most patients have improved symptoms in 2 weeks and become euthyroid in 6 weeks  Check TSH and FT4 every 4-6 weeks  In Graves, many go into remission after 12-18 months  Once ATD therapy is discontinued, patient should be monitored every 3 months for first year, and then annually  40% experience recurrence in 1 year  MNG and toxic adenoma will not get cured by ATD
BETA BLOCKERS  Used as adjuvant  Propranolol is the most commonly prescribed medication in doses of about 20 to 40 mg q.i.d  Used for relief of neurological and cardiovascular symptoms  CCBs can be used for same purpose when beta blockers are contraindicated or poorly tolerated  These therapies should be tapered and stopped once thyroid functions are within the normal range
BETA BLOCKERS INDICATIONS  Prompt control of symptoms  Treament of choice for thyroiditis  First-line therapy before surgery, radioactive iodine and ATDs CONTRAINDICATIONS o Older patients o Patients with pre-existing heart disease, COPD or asthama
IODIDES  Used as adjuvant  Block the conversion of T3 to T4 and inhibit hormone release INDICATIONS  Preoperatively when other medications are ineffective or contraindicated  To reduce gland vascularity before surgery for Graves’ disease  During pregnancy when ATDs are not tolerated COMPLICATIONS o Paradoxical increase in hormone release with prolonged use o Common side effects are sialadenitis, conjunctivitis or acniform rash
2- RADIOACTIVE IODINE  Concentrates in thyroid gland and destroys thyroid tissue  High cure rates with single dose treatment (80%)  Treatment of choice for: ~ Graves disease in adults in the US ~ Multi-nodular goiter, toxic nodules in patients older than 40 years ~ In recurrent thyrotoxicosis  It is effective, safe and does not require hospitalization  Given orally in a single dose in a capsule or liquid form
2- RADIOACTIVE IODINE DRAWBACKS o Delayed control of symptoms oPost-treatment hyperthyroidism in majority of patients with Graves’ disease regardless of dosage (82% after 25 years) o Contraindicated in pregnancy and lactation o Can cause transient neck soreness, flushing; radiation thyroiditis (in 1% of patients) o May exacerbate Graves’ ophthalmopathy o May require pre-treatment with ATDs in older or cardiac patients
3- SURGERY GENERALLY RESERVED FOR SPECIAL CIRCUMSTANCES  Patient preference  Severe hyperthyroidism in children  Pregnant women who cannot tolerate ATDs  Child or adolescent intolerance to ATDs  Patients with large goiter  Severe Graves’ ophthalmopathy  Patients who refuse radioactive iodine therapy
3- SURGERY PREOPERATIVE PREPARATION  Standard preparation Make the patient euthyroid or near euthyroid using ATDs  Alternate method Rapid control of thyroid status can be achieved with a combination of thionamides, SSKI, dexamethasone (1-2mg b.d) and beta blockers  Very rapid control  operation within a weak  Lugol’s iodide solution or saturated potassium iodide for 7-10 days
3- SURGERY EXTENT OF THYROIDECTOMY  Determined by desired outcome  Total or near-total thyroidectomy For patients with coexisting thyroid cancer, severe opthalmopathy, life-threatening reactions to ATDs  Subtotal thyroidectomy Recommended for the rest
3- SURGERY
3- SURGERY POST-OPERATIVE MANAGEMENT  Following surgery, thyroid hormone replacement should be started  TSH should be measured every 1-2 months until stable, and then annually  Following thyroidectomy, serum calcium hormone levels should be measured and oral calcium supplements be administered based on these results
CHOICE OF THERAPY  Cause and severity of disease  Patient’s age  Goiter size  Coexisting medical illness  Treatment desires  Presence of ophthalmopathy
CHOICE OF THERAPY Diffuse Toxic Goiter  Over 45 yrs.  Radioactive iodine  Under 45 yrs. ~ Surgery for large goiter ~ ATDs or radioactive iodine for small goiter Toxic Nodular Goiter  Surgery Toxic Nodule  Surgery or radioactive iodine Recurrent Thyrotoxicosis After Surgery  Treatment of choice  Radioactive iodine  Young women intending to have children  ATDs
CHOICE OF THERAPY
LIFESTYLE MODIFICATIONS DIET  Diet or supplements containing excess amount of iodide should be avoided because iodide interferes with or complicates the management of antithyroid and radioactive iodine therapies PYSICAL ACTIVITY  Exercise tolerance is not effected in patients with mild to moderate hyperthyroidism. For these patients, no reduction in physical activity is required  For elderly patients or patients with severe hyperthyroidism, a decrease in physical activity is necessary until hyperthyroidism is medically controlled
SAFETY PRECAUTIONS  Most of the radioactive iodine is eliminated from the body in urine, saliva and feces within 48 hours; however, double flushing of the toilet and frequent hand washing are recommended for several weeks. Close contact with others, especially children and pregnant women, should be avoided for 24 to 72 hours.