Thyroid Function Tests

Thyroid Function Tests
www.revolutionpharmd.com
Introduction
Thyroid hormones:
tetra iodothyronine / thyroxine (T4)

tri iodothyronine (T3)
Binds to:
thyroxine binding globulin (TBG)

thyroxine binding pre albumin (TBPA)
albumin
apolipoproteins
Free fractions are metabolically active

Differences between T3 and T4
T3 T4
Secretion 30 microgram /day 80 microgram /day
Source 20 – 25% by gland Solely by gland

75 - 80% by
conversion
Half-life 1 day 7 days
Potency 3-4 times more potent Potent

than T4
Binding 0.2% in unbound 0.02% in unbound

Thyroid disorders
Hypothyroidism
 Primary
 Secondary
 Tertiary
Hyperthyroidism
Thyroid disorders
Symptoms of hypothyroidism
 Lethargy
 Constipation
 Dry and coarse skin and hair
 Facial puffiness
 Cold intolerance
 Decreased sweating
 Impaired memory
 Confusion
 Dementia
 Low speech and motor activity
 Anemia
Thyroid disorders
Causes of hypothyroidism
Primary Secondary Tertiary
Iodine deficiency Hypopituitarism Hypothalamic

Excess iodide intake - Adenoma dysfunction
Thyroid ablation - Ablative therapy
(Surgery) - Pituitary destruction
Hashimoto’s
thyroiditis
Sub acute thyroiditis
Genetic abnormalities
Goiterogenic food
(cabbage)
Drugs
– Lithium
– Amiodarone
– Anti thyroid agents www.revolutionpharmd.com
Thyroid disorders
Symptoms of hyperthyroidism
 Nervousness
 Fatigue
 Weight loss
 Heat intolerance
 Increased sweating
 Tachycardia
 Atrial fibrillation
 Warm and moist skin
 Exophthalmos
Thyroid disorders
Causes of hyperthyroidism
a) Overproduction of thyroid hormones
a) Grave’s disease
b) TSH secreting pituitary adenomas
c) Multi nodular goiter
b) Leaking thyroid hormone due to thyroid destruction
a) Lymphocytic thyroiditis
b) Sub acute thyroiditis
c) Radiation
c) Drugs
a) Thyroid replacement drugs
b) Amiodarone
c) Iodinated radio contrast agents
d) Metastatic thyroid carcinoma
Thyroid tests
Tests specific to thyroid status:
 Measure the concentration of products secreted

by the thyroid gland
 Evaluate the integrity of the hypothalamic–

pituitary- thyroid axis
 Assess inherent thyroid gland function
 Detect antibodies to thyroid tissue

Thyroid tests
Measure the concentration of products secreted by the
thyroid gland
 Free T4
 Total serum T4
 Serum T3 resin uptake
 Free T4 index
 Total serum T3
Thyroid tests
Free T4:
Reference range: 0.8 - 2.7 nanogram/dl
Measures unbound fraction of T4
Decreased direct equilibrium dialysis (method) T4

and increase TSH is suggestive of primary
hypothyroidism
Increase DED free T4 and TSH of less than 0.01

milliunits/L is suggestive of non-pituitary
hyperthyroidism www.revolutionpharmd.com
Thyroid tests
Total serum T4:
Reference range: 4 - 12 microgram/dl
Measures both bound and free T4
Increased total serum T4 – hyperthyroidism/

increase concentration of thyroid binding proteins
Decreased total serum T4 –

hypothyroidism/decrease concentration of thyroid
binding proteins/ non thyroid illness [DM, liver disease,
renal failure, prolonged infection and CV diseases]
Thyroid tests
Serum T3 resin uptake (thyroid hormone binding ratio):
Reference range: 25 – 35%
Indirectly estimates the number of binding sites on

thyroid binding proteins occupied by T3
The T3 resin uptake is high when thyroid –binding

protein is low and vice versa
Thyroid tests
Increase in T3 resin uptake - consistent with

hyperthyroidism
Decrease in T3 resin uptake - consistent with

hypothyroidism
This test is never used alone for diagnosis. In practice, the T3 resin
uptake test is used only to calculate the free T4 index
Thyroid tests
Free thyroxine (T4) index:
Reference range: 1.2 – 4.2
Free T4 index = Total serum T4 (mg/dl) X T3 resin uptake (%)
The index is high in hyperthyroidism
The index is low in hypothyroidism
Thyroid tests
Total serum T3:
Reference range: 78 - 195 nanogram/dl
Used to detect T3 toxicosis (increase T3 and normal T4)
Thyroid tests
Evaluate the integrity of the hypothalamic – pituitary -
thyroid axis:
Assessed by measuring TSH and TRH
Thyroid tests
TSH:
Ref range: 0.3 - 5 microunits /ml or milliunits /L
Symptomatic primary hypothyroidism: >20 mu/L
Mild symptomatic hypothyroidism: 10 to 20 mu/L
Primary hyperthyroidism: <0.05 mu/L

Thyroid tests
TRH:
Regulates the TSH secretion from pituitary
TRH test measure the ability of TRH to stimulate the

pituitary to secrete TSH
TSH rise of 5 micro units/ml over baseline - euthyroid state
A significant increase rules out – hyperthyroidism

Is performed by drawing baseline serum TSH concentration and then
administer approximately 200-400 microgram of TRH by iv over 30 – 60
seconds. Then TSH concentration drawn at 30 – 60 minutes
Thyroid tests
Assess inherent thyroid gland function
Radioactive iodine uptake test is used to assess

intrinsic function of the thyroid gland
This test is not specific and the reference range

should be adjusted based on local population
This test is indirect measure of thyroid activity
Thyroid tests
Subject with normal thyroid gland
 12 – 20% of radio active iodine is absorbed after 6

hours
 5 - 25% of radio active iodine is absorbed after 24

hours
Thyroid tests
Increased radio active iodine uptake noted in:
 Thyrotoxicosis
 Iodine deficiency
 Post thyroiditis
 Withdrawal rebound after thyroid hormone/ anti
thyroid drug therapy
Decreased radio active iodine uptake noted in:

 Acute thyroiditis
 Euthyroid patients
 Patients on exogenous thyroid hormone therapy
 Patients taking anti-thyroid drugs
 hypothyroidism
Thyroid tests
Detect antibodies to thyroid tissue (Anti thyroid antibodies)
Found in Hashimoto’s thyroiditis (95% of patients) and

Grave’s disease (55% of patients)
Adults without thyroid disease (10% of adults)
In Grave’s disease, hyperthyroidism is caused by

antibodies activating TSH receptors
In thyroiditis, hypothyroidism is caused by antibodies

competitively binding to TSH receptors thus blocking the
TSH from eliciting the response
Summary
Radioactiv
Total Total T3
Free T4 e iodine
Disease serum serum resin TSH
index uptake
T4 T3 uptake
test
10
Hypothyroidism
20, 3 0
Hyperthyroidism
No No No
T3 toxicosis
change change change No change
Euthyroid sick No No
variable No change
syndrome change change
Thank you

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Thyroid Function Tests

tetra iodothyronine / thyroxine (T4)

thyroxine binding globulin (TBG)

Free fractions are metabolically active

Secretion 30 microgram /day 80 microgram /day

Source 20 – 25% by gland Solely by gland

Potency 3-4 times more potent Potent

Binding 0.2% in unbound 0.02% in unbound

Iodine deficiency Hypopituitarism Hypothalamic

 Measure the concentration of products secreted

 Evaluate the integrity of the hypothalamic–

 Assess inherent thyroid gland function

 Detect antibodies to thyroid tissue

Measures unbound fraction of T4

Decreased direct equilibrium dialysis (method) T4

Increase DED free T4 and TSH of less than 0.01

Measures both bound and free T4

Increased total serum T4 – hyperthyroidism/

Decreased total serum T4 –

Reference range: 25 – 35%

Indirectly estimates the number of binding sites on

The T3 resin uptake is high when thyroid –binding

Increase in T3 resin uptake - consistent with

Decrease in T3 resin uptake - consistent with

Reference range: 1.2 – 4.2

Free T4 index = Total serum T4 (mg/dl) X T3 resin uptake (%)

The index is high in hyperthyroidism

The index is low in hypothyroidism

Reference range: 78 - 195 nanogram/dl

Used to detect T3 toxicosis (increase T3 and normal T4)

Assessed by measuring TSH and TRH

Ref range: 0.3 - 5 microunits /ml or milliunits /L

Symptomatic primary hypothyroidism: >20 mu/L

Mild symptomatic hypothyroidism: 10 to 20 mu/L

Primary hyperthyroidism: <0.05 mu/L

TRH test measure the ability of TRH to stimulate the

TSH rise of 5 micro units/ml over baseline - euthyroid state

A significant increase rules out – hyperthyroidism

Radioactive iodine uptake test is used to assess

This test is not specific and the reference range

This test is indirect measure of thyroid activity

 12 – 20% of radio active iodine is absorbed after 6

 5 - 25% of radio active iodine is absorbed after 24

Decreased radio active iodine uptake noted in:

Found in Hashimoto’s thyroiditis (95% of patients) and

Adults without thyroid disease (10% of adults)

In Grave’s disease, hyperthyroidism is caused by

In thyroiditis, hypothyroidism is caused by antibodies

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