Hyperthyroid Disease

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KANE

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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
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