Management of Hyperthyroidism

Management of
hyperthyroidism
PREPARED BY: NOR MAIZATUL AKMA

Case 1
Miss J, a 24 year old single woman presents with palpitation and tremor for 3
months. She has lost around 5kg of weight despite having good appetite.
On examination, she look thin with weight 45 kg, BP 110/72, PR 110 beats per
minute, regular. She has a staring look with a diffusely enlarged goiter.
Her thyroid function test results are as follow
TSH: 0.05
T4: 60
What is the most likely diagnosis?
Definition
 Hyperthyroidism refers to excess synthesis and

secretion of thyroid hormones by the thyroid
gland, which results in accelerated metabolism
in peripheral tissues
 Supressed TSH with high FT4 and high FT3
or normal FT4 and high FT3 (T3 toxicosis)
Signs and Symptoms of
Hyperthyroidism
Hoarseness/
Nervousness/Tremor
Deepening of Voice
Persistent Dry or Sore Throat

Mental Disturbances/ Irritability
Difficulty Swallowing
Difficulty Sleeping
Bulging Eyes/Unblinking Stare/ Vision Palpitations/
Changes Tachycardia
Enlarged Thyroid (Goiter) Impaired Fertility
Menstrual Irregularities/ Weight Loss or Gain

Heat Intolerance
Light Period
Increased Sweating
Frequent Bowel Movements
Warm, Moist Palms
Sudden Paralysis
Family History of
First-Trimester Miscarriage/
Thyroid Disease
Excessive Vomiting in Pregnancy
or Diabetes
HYPERTHYROIDISM: AETIOLOGY
 Graves disease
 Toxic uninodular or multinodular goiter
 Thyroiditis
 Toxic adenoma
 Iodine / iodine-containing drugs and
radiographic contrast agents
Graves Disease
(Toxic Diffuse Goiter)
 Most common cause of hyperthyroidism
 Accounts for 60% to 90% of cases
 Incidence in the United States estimated at 0.02% to
0.4% of the population
 Females more than males, especially in the reproductive
age range
 autoimmune disorder possibly related to a defect in
immune tolerance
Multinodular Goiter (MNG)
 Enlarged thyroid gland containing multiple nodules, varying in size

 Most patients asymptomatic
 Toxic MNG occurs when multiple sites of autonomous nodule
hyperfunction develop, resulting in thyrotoxicosis
 Toxic MNG is more common in the elderly
WHAT ARE TREATMENT OPTIONS ?
Anti-thyroid drugs
Beta-blockers
Radioactive Iodine
Surgery
AntiThyroidDrugs
 Methimazole should be used in almost EVERY patient who chooses
antithyroid drug therapy for GD,
 Methimazole/carbimazole dose typically used is 0.2–0.5 mg/kg daily, with a
range from 0.1 mg/kg to 1.0 mg/kg daily (maximal initial dose: 30 mg daily)
EXCEPT (PTU preferred)

- first trimester of pregnancy
- thyroid storm
- minor reactions to methimazole
 Patients should be informed of side effects of antithyroid drugs EDUCATION
ATA 2016 Recommendations

Adverse effects of ATDs
1) Common: minor allergic side effects

 included pruritus,
 minor rash
Cutaneous reactions were more common with PTU or higher dose MMI (30 mg/day)
compared with lower dose MMI (15 mg/day).
 Hepatotoxicity was more common with PTU
2) Rare but serious allergic/toxic events such as agranulocytosis, vasculitis, or hepatic
damage..
PTU dose
 PTU has a shorter duration of action and is usually administered two or three
times daily, starting with 50–150 mg three times daily
 Maintenance PTU dose of 50 mg bd/tds
CAUTION
 PTU may cause acute liver injury - FDA warning 2010
 Liver parameters monitoring in the first 6 months of therapy
 Beta-adrenergic blockade should be given to;
 elderly patients with symptomatic thyrotoxicosis
 resting heart rates > 90 bpm
 coexistent cardiovascular disease.
 Beta-adrenergic blockade should be considered in all patients with

symptomatic thyrotoxicosis.
ATD treatment
 Remission achieved after 12-18 months in some patients
 50% recur after one year
When To Refer Patients

 Hyperthyroidism due to TMNG or TA
 Hyperthyroidism due to GD treated with ATDs but remaining hyperthyroid
despite adequate treatment
 Hyperthyroidism due to GD treated with ATDs but relapsing after an initial
course of ATDs
 Hyperthyroid patients with other comorbidities or who develop comorbidities
should be referred to a tertiary centre
Radioactive iodine Therapy (RAI)
 NEVER to pregnant or breastfeeding women

 Not for patients with severe ophthalmopathy  worsening of thyroid eye disease
 Repeat TFT within the first 1–2 months
 If the patient remains thyrotoxic repeat at 4–6 week intervals
Thyroidectomy : Indications
 Noncompliant with or intolerant to ATD
 Very large goiters or severe ophthalmopathy
 Refuse radioactive iodine therapy
 Refractory amiodarone-induced hyperthyroidism
 Patients who require normalization of thyroid functions quickly, such
as pregnant women, women who desire pregnancy in the next 6
months, or patients with unstable cardiac conditions
 Confirmed or Suspicious of malignancy/coexistent thyroid nodule
which nature is unclear.
Case scenario 2
 A 48-year-old housewife presents with tremors for the past 2 months. She has
completed treatment for Grave’s disease in 2007 and was asymptomatic until
recently. On examination, a diffuse goiter measuring about 6x4cm is noted.
TFT : T4 34.13, TSH <0.01
The definitive Mx for her would be
A. Refer for FNAC
B. Order USG thyroid
C. Start PTU
D. Refer for thyroidectomy
E. Plan for radioactive iodine
SUBCLINICAL
HYPERTHYROIDISM
Case 2
60 year old woman presents with palpitations, is found to be in

atrial fibrillation.
On exam noted to have a goiter. No toxic signs.
Echo is normal.
TSH is <0.05 mU/L and T3 & T4 are normal.
Would you consider treatment?

Definition
 A serum TSH concentration below the statistically defined lower limit of
the reference range
 normal free thyroxine
 Free triiodothyronine
 Suppressed TSH < 0.1

 Low TSH 0.1- 0.45
How common is it?
SUBCLINICAL
HYPERTHYROIDISM: INCIDENCE
 Most studies show prevalence 0.1 – 1%
 Whickham Survey 3% prevalence
 Framingham Heart Study Cohort 3.9%
 Colorado Thyroid Disease Prevalence Study 2%
 US National Health and Nutrition Examination Survey

0.7%
 SWAN study of pre and perimenopausal women 3.2%

WHAT ARE THE
IMPLICATIONS OF SUB-
CLINICAL
HYPERTHYROIDISM?
Progression to overt hyperthyroidism
 Overall 0.5-7% per year become overt

 TSH normalizes in about 5-12% of cases
 In the Framingham Study of adults >60 years with a TSH <0.1 mU/L, only 4.3
percent of patients progressed to overt hyperthyroidism after four years
Copyrights apply
Answer case 2
60 year old woman presents with palpitations, is
found to be in atrial fibrillation.
On exam noted to have a goiter. No toxic signs.
Echo is normal.
TSH is <0.05 mU/L and T3 & T4 are normal.
Treatment is indicated
Post menopausal
TSH <0.1
Afibrillation
Thank you

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Management of Hyperthyroidism

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Management of

PREPARED BY: NOR MAIZATUL AKMA

 Hyperthyroidism refers to excess synthesis and

Persistent Dry or Sore Throat

Enlarged Thyroid (Goiter) Impaired Fertility

Menstrual Irregularities/ Weight Loss or Gain

 Enlarged thyroid gland containing multiple nodules, varying in size

EXCEPT (PTU preferred)

 Patients should be informed of side effects of antithyroid drugs EDUCATION

ATA 2016 Recommendations

1) Common: minor allergic side effects

 Beta-adrenergic blockade should be considered in all patients with

 NEVER to pregnant or breastfeeding women

60 year old woman presents with palpitations, is found to be in

Would you consider treatment?

 normal free thyroxine

 Suppressed TSH < 0.1

 Framingham Heart Study Cohort 3.9%

 Colorado Thyroid Disease Prevalence Study 2%

 US National Health and Nutrition Examination Survey

 SWAN study of pre and perimenopausal women 3.2%

 Overall 0.5-7% per year become overt

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