Hyperthyroid Disease

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1
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What are Signs of Hyperthyroid disease?

  • Flushed moist skin
  • Thinning of hair
  • Proptosis, lid lag
  • Pretibial myxedema
  • Brisk DTR’s
  • Goiter
  • Tremor
2
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What are symptoms of hyperthyroid disease?

  • weakness & fatigue
  • nervousness
  • muscle aches
  • weight loss
  • heat intolerance
  • palpitations
  • amenorrhea
  • diarrhea
3
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List types of hyperthyroid disease

  • Grave’s disease
  • Toxic uninodular goiter
  • multinodular goiter
  • Jod-Basedow
  • Factitious
  • Drugs
  • Thyroiditis
  • Tumor
4
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What is Pretibial Myxedema and where is it seen?

chubby ankles

edema at the bottom of tibia

looks bumpy, red, and squishy

  • seen with Grave’s disease (eyes too)
5
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What are some drugs that can induce hyperthyroidism?

Iodine-containing contrast dyes

Amiodarone

Iodinated glycerol

Alpha-Interferon

Alemtuzumab (anti-CD52)

TH (T3, T4)

6
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What are the advantages of surgery to treat hyperthyroidism?

  • Definitive
  • TOC - Malignancy
  • TOC - Respiratory or swallowing difficulties
  • Existence of CI’s to RAI/Thioamides
  • Non-compliant pt
7
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What are the disadvantages of surgery to treat hyperthyroidism?

  • Risks of hypothyroidism
  • surgical risks
  • Cosmetic consequences
    • Must safeguard against Thyroid Storm
8
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What are the advantages of Radioactive Iodine therapy for hyperthyroidism?

  • Definitive
  • Alternative for non-surgical candidates
  • Pts who fail or experience ADR to drug therapy
  • Pts in which disease recurrence would complicate other diseases
  • Non-compliant pt
9
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What are the disadvantages of radioactive iodine therapy for hyperthyroidism?

  • Risk of hypothyroidism
  • CI in pregnant or nursing mothers
  • Concern of use in children
  • possible radiation thyroiditis
  • must safeguard against Thyroid Storm
10
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What are the advantages of drug therapy for hyperthyroidism?

  • Noninvasive
  • Minimize chances of hypothyroidism
  • Use in pts with CI to surgery/RAI
11
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What are the disadvantages of drug therapy for hyperthyroidism?

  • Not definitive treatment
  • possible medication SE
  • requires long term compliance
12
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What is functional unit of the thyroid gland?

FOLLICLES

13
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What are the key elements that function within the follicle?

  • Thyroglobulin (Tg)
  • Tyrosine
  • Iodine
  • Thyroxine (T4)
  • Triiodotyrosine (T3)
14
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What are the 4 steps in natural thyroid hormone synthesis ?

  1. Iodide Trapping
  2. Organification
  3. Coupling
  4. Release
15
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Which three processes of natural thyroid hormone synthesis do thioamides inhibit?

  • Organification
  • Coupling
  • Release
16
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What is the MOA of thioamides?

Inhibit Organification and Coupling

Immunosuppressive effect? → good for graves

PTU- inhibits peripheral T4 conversion

17
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What are the SE of thioamides?

Benign (rash, fever, GI issues, arthralgia)

Severe (agranulocytosis, hepatitis)

18
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What is an important counseling point for thioamide therapy?

  • Must report fever, sore throat, flu-like symptoms
  • any potential infection get CBC w/ differential - help determine neutropenia
19
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What are the two thioamides?

  • Propylthiouracil (PTU)
  • Methimazole (Tapazole)
20
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When is PTU preferred and how is it dosed?

Preferred: Preganacy (1st trimester), lactation, thyroid storm

dosed three times daily & bitter taste

added MOA inhibits peripheral T4 conversion

21
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When is Methimazole preferred?

Considered thioamide of choice

Longer T 1/2 & better compliance & no bitter taste

22
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How is Methimazole dosed?

30-60 mg/d in 1-3 doses

can be taken once daily

23
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Name three birth defects that can be caused my methimazole use in the 1st trimester?

  1. Aplasia cutis (scalp defect)
  2. Esophageal atresia (ends & doesn’t connect to stomach)
  3. Choanal atresia (nasal passages blocked by tissues or cartilage
24
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Which medication has greater protein binding Methimazole or PTU?

PTU

25
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What thioamide is preferred in children with hyperthyroidism?

Methimazole

26
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When is PTU considered?

pregnant women in their 1st trimester

pts w/ life-threatening thyrotoxicosis

pts with a toxic reaction to MMI or not candidates for RAI or surgery but require anti-thyroid therapy

27
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What thioamide has increased chances of hepatitis?

PTU

28
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What is the difference between hepatocellular vs cholestatic hepatitis?

hepatocellular: increase in transaminases and bilirubin

cholestatic: problem w/in billiary tract & harder to reverse bc theres an obstruction in the liver

29
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What is the MOA of beta blockers?

manage sympathetic-mediated symptoms

inhibit peripheral T4 conversion

30
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When would beta blockers CI and what is used instead?

asthma

COPD

CHF

Use CCBs diltiazem, or verapamil

31
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What are advantages and disadvantages of beta blockers?

+: symptomatic control quickly & effective for preparation of surger/RAI

-: doesn’t help underlying thyroid disease & CIs

32
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What is the MOA of Iodides?

Blocks TH release

Inhibits organification

Inhibit peripheral T4 conversion*

decrease gland size & vascularity

33
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What are SE of Iodide therapy?

Allergic reactions

Dose-related toxicity (Iodism) → mouth irritation

Metallic taste

”Escape” phenomenon → thyroid hormone escapes short term

34
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Name 3 preparations of Iodides?

SSKI (38 mg/drop) - better palatability

Lugol’s Solution (6 mg/drop)

Thyro-Block (potassium iodide 130mg)

35
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What are advantages and disadvantages of Iodide therapy?

+: prompt effectiveness, effective adjunct for surgery

-: can’t use alone, escape, CI: pregnancy, pts with nodular goiter or adenomas prior to RAI (will just use to make more)

36
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What is potassium iodide usually used for and what are the names it goes by?

radiation exposure

  • Iosat
  • ThyroSafe
  • Thyro Shield
37
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What is an important clinical pearl for potassium iodide?

do not give prior to RAI therapy otherwise therapy is not effective because Wolff-Chaikoff effect

38
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When should a patient be checked after starting TH replacement?

3-6 weeks in intervals early-on

39
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How often are pts on TH replacement therapy checked once they reach a euthyroid state?

annually

40
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What is the treatment of choice for Grave’s Disease and for how long?

Thioamides

18-24 months (try normalize slowly then see if in remission)

41
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What percent of Grave’s pts have Grave’s ophthalmopathy?

50%

42
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What part of the eye breaks down in 3-5% of patients threatening their sight?

corneal breakdown or optic neuropathy

43
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What is the brand name for Teprotumumab?

Tepezza

44
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What type of medication is Teprotumumab?

Humanized human monoclonal antibody

45
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What is the MOA of Teprotumumab?

IGF-1R inhibitor (insulin growth factor receptor

decreases initiation of thyrotropin receptor & IGF-1R

46
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How many doses are needed, how is it administered, and what is the cost?

8 Doses

Intravenous

18,200 per vial x 23 vials for treatment

47
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What does Teprotumumab treat?

teary red eyes

Grave’s opthamopathy

48
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What is the treatment of choice for Toxic Nodular Goiters?

RAI therapy → usually gets to euthyroid

Surgery

  • avoid Iodides - nodules just eat it up
49
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What is the treatment of choice for thyroiditism?

usually self-limited

inflammatory → treat w/ NSAIDs or BB as needed

look for subsequent transient hypothyroidism - 10% of postpartum women

50
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What is the treatment of choice for neonatal thyrotoxicosis?

Treat w/ thioamides or beta blockers

Prevalence is 1:100 births to mothers with a history of Grave’s disease (> chance of passing antibody to newborns)

51
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Who receives testing for hyperthyroidism?

every newborn

52
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What is the treatment of choice for Iodine-induced HTR disease?

from excessive iodine ingestion

d/c source of iodine -usually self-limited

53
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What is the treatment of choice for thyrotoxicosis factitia?

Due to excessive TH administration

d/c or decrease dose of TH

54
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What is the treatment of choice for a pituitary adenoma?

Requires neurosurgical resection

CT/MRI → plucked through nose

55
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What is the treatment of choice for a subclinical hyperthyroidism?

usually don’t treat unless TSH <0.1 mL

56
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What is the treatment of choice for a thyroid storm?

supportive therapy: fluids, fever, nutrition

Treat precipitating event

High dose PTU

Iodide therapy

Beta blocker therapy

IV Glucocorticoids → in case of Grave’s disease