Makalah Case 2 Grave Disease

PENDAHULUAN
Hipertiroidisme
• Keadaan yg disebabkan akibat kelenjar tiroid memproduksi hormon tiroid
secara berlebihan
• Tirotoksikosis à gejala klinis yg disebabkan akibat peningkatan kadar
hormon tiroid dalam darah
Klasifikasi Hipertiroidisme
• Hipertiroidisme Primer
 excess TH yg disintesis & disekresi o/ kel. Tiroid
 Etiologi : Grave’s disease (60-80%), toxic multinodular goiter,
solitary hiperfunctioning noduler, adenoma sel folikular
• Hipertiroidisme Sekunder
 Jarang
 Etiologi : TSH-Secreting pituitary adenoma
GRAVE’S DISEASE
Definisi
• Graves’ disease is an autoimmune disease that leads to a generalized
overactivity of the entire thyroid gland (hyperthyroidism). It is the most
common cause of hyperthyroidism in the United States. (AMERICAN
THYROID ASSOCIATION)
• Graves' disease is a disorder of the immune system that causes the thyroid
gland to become overactive. It is an autoimmune disorder, which means
the body's immune system mistakenly attacks the body's own cells
instead of protecting them from outside invaders.
Etiologi
• Graves’ disease is triggered by a process in the body’s immune system. In
Graves’ disease these antibodies (called the thyrotropin receptor
antibodies (TRAb) or thyroid stimulating immunoglobulins (TSI)– they
cause the cells to work overtime. The antibodies in Graves’ disease bind
to receptors on the surface of thyroid cells and stimulate those cells to
overproduce and release thyroid hormones.
Epidemiologi
• Typically, Graves disease is a disease of young women, but it may occur
in persons of any age.
• It is most common in people ages 20 to 40 years.
• Graves’ disease is more common in women than men.
Faktor resiko
• Like all autoimmune diseases, it occurs more commonly in patients with
a positive family history.
• It is more common in monozygotic twins than in dizygotic twins.
It is precipitated by environmental factors like stress, smoking, infection,
iodine exposure, and postpartum
Gejala Klinis
The majority of symptoms of Graves’ disease are caused by the excessive
production of thyroid hormones by the thyroid gland .
• Palpitations
• nervousness,
• Hyperkinesia
• Diarrhea
• excessive sweating, intolerance to heat, and preference for cold.
• weight loss without loss of appetite.
• Thyroid enlargement
• hand tremors
• trouble sleeping
• muscle weakness,
• Eye disease
- Graves’ disease is the only kind of hyperthyroidism that can be associated
with inflammation of the eyes, swelling of the tissues around the eyes and
bulging of the eyes (called Graves’ ophthalmopathy or orbitopathy).
- Eye symptoms most often begin about six months before or after the
diagnosis of Graves’ disease has been made. In some patients with eye
symptoms, hyperthyroidism never develops and, rarely, patients may be
hypothyroid.
- We do not know why, but problems with the eyes occur much more often
and are more severe in people with Graves’ disease who smoke cigarettes
The eye signs of Graves disease have been classified by Werner
• Onycholysis or Plummer nails : Onycholysis is when a person's nail or

nails detach from the skin underneath. likely caused by rapid growth of
the nails
• Patients with Graves’ disease develop a lumpy reddish thickening of the
skin in front of the shins known as pretibial myxedema (called Graves’
dermopathy). This skin condition is usually painless and relatively mild,
but it can be painful for some.
Penegakkan Diagnosis
1.Anamnesis
2. Pemeriksaan Fisik
3. Pemeriksaan Penunjang
• Thyroid function tests to diagnose hyperthyroidism
• The initial test for diagnosis of hyperthyroidism is the thyroid-
stimulating hormone (TSH) test.
Tests to differentiate Graves from other causes of hyperthyroidism

• Measurement of TSH receptor antibody (TRAb): There are two available
assays, the thyroid stimulating immunoglobulin (TSI) and thyrotropin-
binding inhibiting (TBI) immunoglobulin or thyrotropin-binding
inhibitory immunoglobulin (TBII). Measurement of TRAb with third
generation assay has sensitivity and specificity of 97% and 99% for the
diagnosis of Graves disease
Radioactive Iodine Uptake

− merupakan metode yang digunakan untuk mengetahui berapa
banyak iodine yang digunakan dan diambil melalui transporter Na+ / I di kel.
tiroid
− Pasien diminta menelan 16 kapsul atau cairan yang berisi iodine radioaktif
dan hasilnya diukur setelah periode tertentu, biasanya 6 atau 24
jam kemudian.
− Pada kondisi hipertiroidisme primer seperti Grave’s disease, toxic
adenoma dan toxic multinodular goiter → peningkatan uptake iodine
radioaktif.
− Kontraindikasi: wanita yang hamil atau menyusui
Tata Laksana
• Treatment consists of rapid symptoms control and reduction of thyroid
hormone secretion.
• A beta-adrenergic blocker should be started for symptomatic patients,
specifically for patients with heart rate more than 90 beats/min, patients
with a history of cardiovascular disease, and elderly patients.
• Atenolol 25 mg to 50 mg orally once daily may be considered the
preferred beta blocker due to its convenience of daily dosing, and it is
cardioselective (beta-1 selective).
• Propranolol 10 mg to 40 mg orally every six to eight hours, due to its
potential effect to block peripheral conversion of T4 to T3. If a beta
blocker after that, calcium channel blockers like diltiazem and verapamil
can be used to control heart rate.
There are three options to reduce thyroid hormone synthesis. These
options are:
• Antithyroid drugs which block thyroid hormone synthesis and release
• Radioactive iodine (RAI) treatment of the thyroid gland
• Total or subtotal thyroidectomy.
Anti-thyroid Drugs (Thionamides)

• These thioamides inhibit Thyroid Peroxidase (TPO) mediated
iodination of thyroglobulin in the thyroid gland, blocking the synthesis
of T4 and T3.
• Before starting thionamide treatment, patients should be informed
about possible side effects including allergic reactions, neutropenia,
and hepatotoxicity. A complete blood count with differentials and
liver function test should be obtained. Thionamide should not be
started if baseline transaminase level is more than five times the upper
limit of normal or if absolute neutrophil count (ANC) is less than
1000/ml.
• Methimazole
- 5 mg to 10 mg oral daily if FT4 is 1 to 1.5 times the upper limit of
normal (ULN),
- 10 mg to 20 mg oral daily if FT4 is 1.5 to 2 times ULN,
- 30 mg to 40 mg oral daily if FT4 is more than two to three times ULN.
- Methimazole is usually maintained at 5 mg to 10 mg daily
• Propylthiouracil
• 50 mg t0 150 mg oral three times daily based on the severity of
hyperthyroidism.
• Once thyroid function improves, the thioamide dose can be tapered
and continued at maintenance doses once TFTs become euthyroid.
Methimazole is usually maintained at 5 mg to 10 mg daily .
propylthiouracil is maintained at 50 mg two to three times a day.
• Monitor thyroid function tests (TFTs) every four to six weeks for
the thionamide dose adjustment. Once on a maintenance dose, TFTs can
be checked every three months for up to 18 months. Monitor for adverse
effects and perform blood tests as needed based on clinical information.
Stop the thionamide if transaminase level is more than three times of
ULN.
• we can consider stopping the therapy after 12 to 8 months, if TSH and
TRAb levels normalize during follow-up. If TSH remains normal for one
year without treatment, annual monitoring with TSH is enough.
RAI Therapy
• Menggunakan isotop iodine, contohnya 131I
 Dosis 80-120 uCi/gr bila tdk punya penyakit jantung
 Bila punya penyakit jantung/ kelenjar tll besar/ tirotoksikosis
berat :
 Diobati dgn OAT s/d eutiroid à hentikan 5-7 hari à beri
dosis iodin radioaktif à 100-150 uCi/gr berat tiroid
 Di dalam tubuh RAI akan di-uptake oleh kelenjar tiroid
seperti iodine biasa, kemudian di dalam kelenjar tiroid RAI
beraksi dengan cara mencegah sintesis hormon tiroid
sehingga dapat menurunkan kadar hormon tiroid yang
berlebihan.
 Kontraindikasi: bagi pasien yang hamil, menyusui, kanker
tiroid dan merencanakan kehamilan 4 – 6 bulan setelah
terapi
Pembedahan
• Tiroidektomi
− Terapi bagi pasien yang kontraindikasi atau menolak pengobatan dengan
obat anti tiroid dan iodine radioaktif.
− Pembedahan direkomendasikan bagi pasien dengan multinodular goiter
atau goiter yang sangat besar
− Dapat dibedakan menjadi dua metode berikut:
a. Tiroidektomi total→dilakukan pengangkatan seluruh bagian kelenjar
tiroid. Dengan tidak adanya kelenjar tiroid yang memproduksi hormon
tiroid, pasien perlu mengonsumsi pengganti hormon tiroid oral seumur
hidup.
b. Tiroidektomi sub-total → hanya dilakukan pengangkatan sebagian
kelenjar tiroid sehingga pasien tidak perlu mengonsumsi hormon tiroid
karena kelenjar tiroid yang tersisa masih dapat memproduksi hormon tiroid.
PROGNOSIS
• Many patients remain well after a single course of anti-thyroid drugs, but
recurrence can happen at any time. Radioactive iodide is very effective,
but often results in abnormally low levels of thyroid hormones
(hypothyroidism). Surgery also can cause low levels of thyroid hormones.
• Membutuhkan follow-up seumur hidup

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PENDAHULUAN

• Onycholysis or Plummer nails : Onycholysis is when a person's nail or

Tests to differentiate Graves from other causes of hyperthyroidism

Radioactive Iodine Uptake

Anti-thyroid Drugs (Thionamides)

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