Hipotiroid

HYPOTHYROIDISM :
ETIOLOGY,
PATHOPHYSIOLOGY AND
TREATMENT
Dr. I Gede palgunadi, SpPD
SMF Penyakit Dalam
Rumah Sakit Umum Mataram
1
Introduction
The hypothalamic-hypohyseal-thyroid axis
INTRODUCTION
Hypothyroidism
Clinical syndrome ~ TH deficiency
metabolic process
Accumulation of glycosaminoglycans
Myxedema (adult), cretin (new born)
Myxedema coma (severe)
3
INTRODUCTION
Hypothyroidism
Primary, secondary, tertiary and peripheral
resistance to TH
Most common : Primary Hypo
In iodine deficient areas : IDD
In iodine sufficient areas : Hashimoto
(Chronic Autoimmune Thyroiditis)
4
ETIOLOGIC CLASSIFICATION
I. Primary Hypothyroidism
Destruction of thyroid tissue
A.
1.
2.
3.
4.
Thyroiditis (chronic autoimmune thyroiditis, subacute

thyroiditis, postpartum thyroiditis)
I131 therapy, external radiation (neck)
Thyroidectomy : subtotal, total
Infiltrative
Defect in TH biosynthesis
B.
1.
2.
3.
4.
Iodine deficiencies
Thyroid gland agenesis / dysgenesis
Hereditary defects in TH biosynthesis
Drugs with Antithyroid effect
5
ETIOLOGIC CLASSIFICATION
II. Central Hypothyroidism
A.
B.
Thyrotropin deficiency pituitary diseases

(Secondary Hypo)
Thyrotropin Releasing Hormone Deficiency
Hypothalamic Disorders (Tertiary Hypo)
III. Generalized Resistance to

Thyroid Hormone (GRTH)
6
PATHOPHYSIOLOGY
Normal :
T4 , T3 , T4 T3 (peripher)
T4 : 100 125 mcg/day
Sub Clinical : small in T4 (but still in N range) :

adequate source of T3 symptom (-)
stimulating TSH secretion
hyperplasia, hypertrophy
T4 & T3 still Normal, TSH , symptoms (-)
Overt Hypo : frank in T4 :
T3 symptom (+)
TSH
T4 & T3 , TSH , symptoms (+)
7
PATOPHYSIOLOGY
T3
metabolic process
Hypothermic, hypercholesterolemia
Accumulation of glycosaminoglycans
Edema : skin, muscles
heart muscle contractility,
Cardiomegaly, pericardial effusion,
Stroke volume / COP
Reproduction :
Anovulation, irregular cycles,
infertility
8
THYROID
rT3
T3
T4
T4
T4
T4
TR
T3
rT3
T3
T4
TR
MATERNAL
TISSUES
MOTHER
T3
TR
PLACENTA
T3
TR
FETUS
Possible sites of action of maternal thyroid hormone during early pregnancy.

(Pickard et al, 2002)
Iodine is the essential element for thyroid hormones, thyroid hormone is

indispensable for every living cells, thyroid hormone is a must for DNA
synthesis
Fatal circulation
Maternal circulation
THYROID
Pituitary/Chorionic TSH controlled
T4 synthesis and release
T4
FETUS
Chorionic
TSH
T4 deiodination
and metabolism
T4
free T4
free T4
TBG bound T4
TBG
LIVER
Estrogen/fT4 controlled
TBG synthesis
and release
Estrogen
Feedback control
of T4 delivery
PLACENTA
TBG/T4 controlled
T4 deiodination and transport,
and chorionic TSH secretion
Hypothetical control system governing fetal exposure to

maternal T4 during pregnancy
10
DIAGNOSIS
Importance of Etiologic Diagnosis
1. The hypo may be transient
2. The hypo may be reversible by
alleviating responsible drugs
3. The hypo may be the first and the only
manifestation of hypothalamopituitary disorders
11
DIAGNOSIS
I. CLINICAL SUSPICION
1. Symptoms, signs, Lab.
2. Deficiencies, exposures, diseases
3. Diseases ~ chronic autoim. thyroiditis
II. CONFIRMATIVE EXAM

1. T4 (FT4) , Normal FT4 : 0.8-2.8 ng/dl
2. TSH (Primary Hypo), Normal : 0.4-4 mu/l
12
Severe primary hypothyroidism

A: A patient with unrecognised severe primary hypothyroidism who became severely obtunded after surgery
for fractured neck of femur. Marked myxoedema is evident. B: Several months later, after therapy including
thyroid hormone replacement.
13
DIAGNOSIS
SUSPICION
SYMPTOMS
SIGNS
LAB, ETC
Weakness, fatique,
Cold intolerance,
Weight , constip.,
Hoarseness,
Menorraghia,
Depression
Dry skin
Bradycardia
Prolonged relaxation time of tendon
reflex
Hypercholest.
Hyponatremia
Pericard Effusion
Myocardial
contractility
14
CLINICAL SUSPICION
T4 (FT4), TSH
T4 , TSH
T4 N, TSH
T4 , TSH
T4 N, TSH N
Primary hypo
Sub clinical
hypo
Central hypo
Normal
TRH Test
T4 , TSH
T4 , TSH
Resp. (-)
Primary hypo
Tertiary
hypo
Secondary
hypo
Figure 1. Algorithm Diagnosis of Hypothyroidism
15
DIAGNOSIS
I. IODINE DEFICIENCY
1. Radioactive iodine uptake
2. Urinary iodine excretion
3. TSH
II. CHRONIC AUTOIMMUNE

THYROIDITIS
1. T4 , TSH
2. Autoantibody anti TPO
3. Autoantibody anti TG
16
DIAGNOSIS
Increased TSH in some central Hypo ~

Immunoreactive (but bioinactive) TSH
Decreased TSH, T4, T3 in severe

non thyroidal illness
17
TREATMENT
Lifelong levothyroxine (T4) except in :
transient Hypo
reversible Hypo
Goal : Clinical euthyroidism, Normal T4 and TSH
Levothyroxine :
- Half life 7 days once daily dosage
- dosage :
- Substitution (adult) : 1.6 mcg/BW/day
x 100 mcg/day (range 50-200 mcg/day)
Evaluation / Adjustment : T4 & TSH 3-6 wkly
18
TREATMENT
DOSAGE VARIATION
Lower
: Hashimoto, post radioiodine
High
: Total thyroidectomi, central hypo,

severe hypo, BW, pregnancy,
estrogen therapy, malabsorption,
excretion (nephrotic syndrome),
metabolism
Small initial dose : increase gradually : elderly

19
TREATMENT
PREGNANCY
Higher dose due to :
1.
2.
3.
4.
5.
maternal clearance of T4
T4 transfer to fetus
Placental degradation of T4 (deiodinase)
TBG ~ estrogen
absorption ~ Fe, Calcium
20
TREATMENT
ELDERLY / CAD
- Initial dose :
- Elderly : 50 mcg/day orally
- CAD : 25 mcg/day orally
- Increase by 25 mcg/day every 3-6 weeks until
normal TSH or arrhytmia
21
TREATMENT
SUBCLINICAL HYPO
- T4 to prevent conversion to overt hypo

- Especially :
- TSH > 10 mu/L
- anti TPO
- Goiter or non specific symptoms
22
TREATMENT
CENTRAL HYPO
- Deficiency of other trophic hormone ?

- ACTH defic Adrenal insuff
- T4 : + Glucocorticoid to prevent adrenal crisis

23
TREATMENT
POST TOTAL THYROIDECTOMY
- Higher dose T4 for :
1. Substitution
2. Erradicate metastasis / prevent relaps
- Target : TSH < 0,01 mU/L
24
TREATMENT
MYXEDEMA COMA
- Aggressive, dose, IV T4
- After blood sample (T4, TSH, Cortisol)
- IV T4 : 200-300 mcg 50-100 mcg/day
(+ IV T3: 5-20 mcg 2,5-10 mcg/8 hours
- IV Hydrocortisone 100 mg/8 hr (2 days)
decreased
- Supportive :
- Mech. Ventilation, O2
- IVFD
- Correct : Hypo Na, Hypothermia
- Antibiotics
25
.for the children..

Every child has the right to an adequate supply of iodine
to ensure his (or her) normal developments.
..for the unborn child..

Every mother has the right to an adequate iodine nutrition
to ensure her unborn child experiences normal mental
development
Declarations from:
Convention on the Rights of the Child, UN Assembly, New York 1989, World Summit for Children, UN New York
1990, The Survival, Protection and Development of Children , World Conference on Micronutrients: Eliminating
the Hidden Hunger, Montreal 1991 (Unicef, FAO,WHO, ICCIDD), World Conference on Nutrition, Rome 1992
WHO, FAO
26
SUMMARY
Hypothyroidism ~ TH deficiency ~HypothalamoPituitary-Thyroid Axis Disorders
Most common etiology : Primary Hypo
Iodine deficiency, Hashimoto thyroiditis
Patophysiology : metabolic process and glycosaminoglycans accumulation
Diagnosis
Therapy
Prognosis
: Clinical + T4 + TSH
: Levothyroxine (T4)
: reversible (T4)
poor in myxedema coma
27
28

Hipotiroid

Uploaded by

Copyright:

Available Formats

Hipotiroid

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Hipotiroid

Uploaded by

Copyright:

Available Formats

HYPOTHYROIDISM :

Thyroiditis (chronic autoimmune thyroiditis, subacute

Thyrotropin deficiency pituitary diseases

III. Generalized Resistance to

Sub Clinical : small in T4 (but still in N range) :

Possible sites of action of maternal thyroid hormone during early pregnancy.

Iodine is the essential element for thyroid hormones, thyroid hormone is

Hypothetical control system governing fetal exposure to

II. CONFIRMATIVE EXAM

Severe primary hypothyroidism

Figure 1. Algorithm Diagnosis of Hypothyroidism

II. CHRONIC AUTOIMMUNE

Increased TSH in some central Hypo ~

Decreased TSH, T4, T3 in severe

: Hashimoto, post radioiodine

: Total thyroidectomi, central hypo,

Small initial dose : increase gradually : elderly

- T4 to prevent conversion to overt hypo

- Deficiency of other trophic hormone ?

- T4 : + Glucocorticoid to prevent adrenal crisis

.for the children..

..for the unborn child..

You might also like