Thyrotoxicosis and it's symptoms treatment

Thyrotoxicosis and it's symptoms treatment

• 1.
  Thyrotoxicosis
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  Causes
• 5.
  Causes of thyrotoxicosis
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  Clinical Symptoms ■ Nervousness,Anxiety ■Increased perspiration ■ Heat intolerance ■ Tremor ■ Hyperactivity ■ Palpitations ■ Weight loss despite increased appetite ■ Reduction in menstrual flow or oligo- menorrhea
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  Common Signs 1. Hyperactivity,Hyper kinesis 2. Sinus tachycardia or atrial arrhythmia, AF, CHF 3. Systolic hypertension, wide pulse pressure 4. Warm, moist, soft and smooth skin- warm handshake 5. Excessive perspiration, palmar erythema, Onycholysis 6. Lid lag and stare (sympathetic over activity) 7. Fine tremor of out stretched hands – format's sign 8. Large muscle weakness, Diarrhea, Gynecomastia
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  Specific to GravesDisease 1. Diffuse painless and firm enlargement of thyroid 2. Thyroid bruit is audible 3. Ophthalmopathy – Eye manifestations – 50% of cases ⮚ Gritty feeling in eyes, periorbital edema, conjunctival edema (chemosis), poor lid closure, extraocular muscle dysfunction, diplopia, pain on eye movements and proptosis. 4. Dermoacropathy – Skin/limb manifestations – 20% of cases ⮚ Deposition of glycosamino glycans in the dermis of the lower leg – non pitting edema, associated with erythema and thickening of the skin, without pain or pruritus - called（pre tibial myxedema)
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  pre tibial myxedema pretibial myxedema Lid lag
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  Clinical Symptoms ■ Apathetichyperthyroidism Older patient presents with lack of clinical signs and symptoms, which makes diagnosis more difficult. ■ Thyroid storm a rare presentation, occurs after stressful illness in under treated or untreated patient. -Delirium -Dehydration -Severe tachycardia -Vomiting -Fever -Diarrhea
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  Diagnosis 1. Typical clinicalpresentation 2. Markedly suppressed TSH (<0.05 µIU/mL) 3. Elevated FT4 and FT3 (Markedly in Graves) 4. Thyroid antibodies – by Elisa – anti-TPO, TSI 5. ECG to demonstrate cardiac manifestations 6. Nuclear Scintigraphy to differentiate the causes
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  Treatment Options ■ Anti-thyroiddrugs ■ Radioactive iodine ■ Surgery ■ Beta-blocker and iodides are adjuncts to above treatment
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  Anti-thyroid Drugs They interferewith organification of iodine— suppress thyroid hormone levels Two agents: -Tapazole (methimazole) -PTU (propylthiauracil)
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  Anti Thyroid Drugs(ATD) Imp. considerations Methimazole Propylthiouracil Efficacy Very potent Potent Duration of action Long acting BID/OD Short acting QID/TID In pregnancy Contraindicated Safely can be given Mechanism of action Iodination, Coupling Iodination, Coupling Conversion of T4 to T3 No action Inhibits conversion Adverse reactions Rashes, Neutropenia Rashes, ↑Neutropenia Dosage 20 to 40 mg/ OD PO 100 to 150mg qid PO
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  Anti-thyroid Drugs ■ Remissionrate: 60% when therapy continued for two years ■ Relapse in 50% of cases. ■ Relapse more common in -smokers -elevated TS antibodies at end of therapy
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  Radioactive Iodine ■ forGrave’s disease and toxic nodular goiter ■ Inexpensive, Safe ■ Highly effective ■ Easy to administer ■ 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
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  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 pos Tx hypothyroidism may be associated with exacerbation of eye disease ■ Smoking makes ophthalmopathy worse.
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  Radioactive Iodine ■ Useof anti-thyroid drugs with iodine is not recommended in most cases ■ May improve safety for severe or complicated cases ■ 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 ■ Never given for children and pregnant/ lactating women ■ Not recommended with patients of severe Ophthalmopathy ■ Not advisable in chronic smokers
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  Surgery ■ Radioactive iodinehas replaced surgery for Tx of hyperthyroidism ■ Subtotal thyroidectomy is most common ■ Surgical treatment is reserved for • Severe hyperthyroidism in children • Pregnant women who can’t tolerate ATD • Large goiters with severe Ophthalmopathy • Large MNGs with pressure symptoms • Who require quick normalization of thyroid function
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  ■ Drug Treatmentof Thyroid Storm (table 216-6) • Decrease de novo synthesis: ■ Porpylthiouracil 600-1000mg PO initially, followed by 200-250 mg q 4 hrs ■ Methimazole 40 mg PO initial dose, then 25 mg PO q6h • Prevent releases of hormone (after synthesis blockade intiated) ■ Iodine Iaponoric acid (Telepaque) 1 gm IV q8h for the first 24 h, then500 mg bid or Potassium iodide (SSKI) 5 drops PO q6h or Lugol solution 8-10 drops PO q6h ■ Lithuim 800-1200 mg PO every day
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  • Prevent peripheraleffects: ■ B-Blocker ■ Guanethidine 30-40 mg PO q 6 h ■ Other consideration: ■ Corticosteroids Hydrocortisone 100 mg IV q 8 h or dexamethosone 2 mg IV q 6 hr ■ Antipyretics Cooling blanket acteaminophen 650 mg PO q 4-6h
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  ■ Endoscopic subtotalthyroidectomy ■ 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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