Hyper and Hypothyroid Guidelines

8/12/2019 Hyper and Hypothyroid Guidelines

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Putu Moda ArsanaFKUB,2011


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Guidelines is a Health

professionals consensus basedof evidence,to guide clinical

health professional in managing

health problems to achievedbetter results.


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Evidence based

Medicine


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1++ High-quality meta-analyses, systematic reviews of randomized controlled trials

(RCTs), or RCTs with a very low risk of bias

1+ Well-conducted meta-analyses, systematic reviews of RCTs or RCTs with a low

risk of bias)

1 Meta-analyses, systematic reviews of RCTs or RCTs with a high risk of bias *

2++ High-quality systematic reviews of non-RCT, case

control, cohort, controlledbefore-and-after study (CBA) or interrupted time series (ITS) studies

High quality non-RCT, casecontrol, cohort, CBA or ITS studies with a very low risk of

confounding, bias or chance and a high probability that the relation is causal

2+ Well-conducted non-RCT, casecontrol, cohort, CBA or ITS studies with a very low

risk of confounding, bias or chance and a moderate probability that the relation is causal

2 Non-RCT, casecontrol, cohort, CBA or ITS studies with a high risk of confounding,

bias or chance and a significant risk that the relationship is not causal *

3 Non-analytic studies (for example, case reports, case series)

4 Expert opinion, formal consensus

* Studies with a level of evidence '' should not be used as a basis for making a

recommendation.


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Class I

Benefit >>> Risk

Procedure/ Treatment

SHOULD be

performed/

administered

Class IIa

Benefit >> Risk

Additional studies with

focused objectives

needed

IT IS REASONABLE

to perform

procedure/administer

treatment

Class IIb

Benefit Risk


broad objectives

needed; Additionalregistry data would be

helpful

Procedure/Treatment

MAY BE CONSIDERED

Class III

Risk Benefit

No additional studies

neededProcedure/Treatment

shouldNOT be

performed/administered

SINCE IT IS NOT

HELPFUL AND MAY BE

HARMFUL

shouldis recommendedis indicatedis useful/effective/

beneficial

is reasonablecan be useful/effective/

beneficialis probably recommended

or indicated

may/might be consideredmay/might be reasonableusefulness/effectiveness is

unknown /unclear/uncertain

or not well established

is not recommendedis not indicatedshould notis not

useful/effective/beneficialmay be harmful

Applying Classification of Recommendations

and Level of Evidence


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Class I

Benefit >>> Risk

Procedure/ Treatment

SHOULD be

performed/

administered

Class IIa

Benefit >> Risk


focused objectives

neededIT IS REASONABLE to

perform

procedure/administer

treatment

Class IIb

Benefit Risk


broad objectives needed;

Additional registry data

would be helpful

Procedure/Treatment

MAY BE CONSIDERED

Class III

Risk Benefit

No additional studies

neededProcedure/TreatmentshouldNOT be

performed/administered

SINCE IT IS NOT

HELPFUL AND MAY

BE HARMFUL

Level B Limited (2-3) population risk strata evaluatedLevel A Multiple (3-5) population risk strata evaluated

General consistency of direction and magnitude of effect

Level C Very limited (1-2) population risk strata evaluated

Applying Classification of Recommendations

and Level of Evidence


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The objective of guidelines is toprovide guidelines to clinicalprofessional for the management

of health problems


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Diagnosis procesTreatment procesSpecial coditions/considerations


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Is a combination of intellectual and

manipulative activities by whichdisease is identified and illness is

evaluated.


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Complaint Diagnosis Treatment

Diagnosis

Process

Clinical Process

reatmentprocess

Putu Moda Arsana,2006


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1. Data collection2. Data synthesis3. Problem identification


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History taking Physical examination Additional examination ( laboratory

testing, X-ray, etc )


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The most important step: History of present illness Personal history Medical history Family history Review of system

Accuracy of the data collected baseon : Knowledge Doctor-patient relationship


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Collecting data from inspection,palpation, percussion and

auscultation Should be done systematically

Vital sign From head to lower extremities

The Physicians must know about thebasic technique of physicalexamination


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Is a process to translate illnessinto problem / Diagnosis

Based on Diagnosis criteria

Is preceded by problem Cue and clue


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Chief

complaint

historyPhysical

examinat

ion +

basic

test tests

15

10

5

PROBLEM / HIPOTESIS

VERIFICATION

CONCLUSION /

FINAL DIAGNOSIS

DATA COLLECTION

Differentialdiagnosis

Putu Moda Arsana,2006

Iterative hypothesis / Initial

DDDD


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DATADiagnosis criteria

(Diabetes )

Diagnosis criteria

(Graves diseases)

Diagnosis criteria

(Tuberculosis)

Decrease BW +

Chief

complaint

Diagnosis

process


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Non pharmacologic treatment :General :Diet, Activities, etc

Specific : Surgery procedure, X-ray, Psychotherapy, etc

Pharmacologic treatment : Causative Symptomatic Supportive Palliative


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Empirical Evidence Base Medicine


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The objective of thyroid guidelinesis to provide guidelines to clinicalprofessional for the management

of thyroid problems


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Initial/First visit

History of present illnessPhysical examination

Laboratory examination


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Nervousness, fatigue, palpitations, exertional dyspnea,weight loss, heat intolerance, irritability, tremor, muscleweakness, decreased menstrual flow in women, sleepdisturbance, increased perspiration, increased frequency of

bowel movements, change in appetite, and thyroidenlargement

photophobia, eye irritation, diplopia, or a change in visualacuity.

recent iodine exposure, prior or current thyroid hormoneuse, anterior neck pain, pregnancy, or history of goitershould be included.

A family history of thyroid disease


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Weight and height, pulse rate and regularity, blood

pressure, cardiac examination, thyroid enlargement

(diffuse or nodular), proximal muscle weakness,

tremor, an eye examination (for evidence ofophthalmopathy), and a skin examination (forpretibial myxedema).

Older individuals may have few if any symptoms

and signs of hyperthyroidism except for weight loss

and cardiac abnormalities, in particular atrial

fibrillation and/or congestive heart failure.


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True hyperthyroidism must be distinguished from "euthyroid

hyperthyroxinemia," which may be caused by certain drugs,

nonthyroidal illness, and a variety of other less common factors.

Specific tests to establish the diagnosis of hyperthyroidism :

thyroxine (T[sub]4[/sub]) (which is elevated in hyperthyroidism),as well as a serum thyroid-stimulating hormone (TSH)

measurement (which is suppressed in hyperthyroidism). The TSH

level should be measured in an assay that is sensitive enough to

clearly discriminate euthyroid from hyperthyroid individuals.

When the free T[sub]4[/sub] level is elevated in a clinicallyhyperthyroid patient, a serum TSH level that is not suppressed

should alert the clinician to the possibility of hyperthyroidism due

to a TSH-producing pituitary adenoma.


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If hyperthyroidism is confirmed, other testsmay be performed according to the clinical

situation. These may include totaltriiodothyronine (T[sub]3[/sub]), thyroidautoantibodies, and a radioactive iodineuptake test.

Specific treatment should generally bewithheld until the biochemical diagnosis andcause of hyperthyroidism are confirmed


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The treatment of Graves' hyperthyroidism isdirected toward lowering the serum

concentrations of thyroid hormones toreestablish a eumetabolic state

Antithyroid drug

Radioactive iodine

Surgery

Ajunctive therapy


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Antithyroid drug Radioactive iodine

Surgery Ajunctive therapy


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Long-term ATD therapy may lead toremission in some patients with Graves'

disease Initial daily doses of methimazole generally

range from 10 to 40 mg, Initial daily doses of propylthiouracil, 100 to

600 mg Duration of treatment is for 6 months to 2

years


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Most common used in USA Relatively safe

SE : hypothyroidism HRT Contra indicated in pregnant and breast

feeding women Elderly and/or individuals at risk for

developing cardiac complications may bepretreated with ATDs prior to therapy.


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Recommended for:

Graves disease with very large goiter

Resistent to I 131Thyroid nodules

Pregnan woman allergic to ATD

Allergic to ATD and/or do not wish toradioactive iodium therapy


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Beta adrenergic-blocker

Calcium chanel blocker


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4 12 weeks

Complaint, physical examination,lab. Examination

Effect therapy: T4 , TSH

Side effect: leucocyte count, liverfunction test


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Hyperthyroidism and pregnancy

Graves ophthalmopathyToxic Nodular Goiter

Thyroid Storm Iatrogenic Hyperthyroidism


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Increased rate of fetal loss The goal of treatment during pregnancy is to

maintain euthyroidism using the smallestdoses of ATDs Propylthiouracil is preferred in pregnancy

because it crosses the placenta less thanmethimazole

Should be seen at 4- to 6-week intervals


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No specific laboratory tests are required to confirm

the diagnosis.

When ophthalmopathy occurs in patients who are

biochemically euthyroid, autoimmune thyroiddisease should be suspected, and the diagnosis canbe confirmed by the finding of antimicrosomal

(antithyroperoxidase [anti-TPO]) antibodies or

thyroid-stimulating antibodies in the serum Treatment: ATD, symptomatic, diuretics,

glucocorticoid


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Common than Graves' disease in elderlypatients

Ophthalmopathy is not present in patientswith TNG Absence of thyroid autoantibodies Diagnosis: Thyroid scan and Iodium uptake Treatment : Radioactive Iodium therapy or

surgery.


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life-threatening Severe sign and symptoms of hyperthyroidism,

fever, altered mental status Presipitating factor: ATD caesation, concurent

illness or injury, radio active iodine therapy. Treatment: PTU or methimazole, Potassium

iodide, lithium carbonate, ipodate,corticosteroid, beta blocker, Tx for presipitatingfactor


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History

Physical examination Laboratory examination


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Tiredness, weakness, fatigue, sleepiness, coldintolerance, dry hoarseness, constipation,joint pains, muscle cramps, mentalimpairment, depression, menstrualdisturbances in women and especially

menorrhagia, infertility, and weight gain Medical and non medical hystory


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Goiter or a nonpalpable thyroidgland,

Bradycardia, edema, hoarseness,

delayed relaxation of deep tendon

reflexes, slow speech, and cool, dryskin, change of bowel habbit.


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serum TSH measurement and a freeT[sub]4[/sub] estimate (or direct

measurement) should be performed. When autoimmune thyroiditis is the

suspected underlying cause, it is helpful toconfirm antithyroid antibody titers, either

antimicrosomal antibody (anti-TPO antibody)or antithyroglobulin antibody


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Hormon replacement:

Levothyroxine sodium is the treatment of choice

Adults with hypothyroidism require approximately 1.7microg/kg of body weight per day for full replacement. Childrenmay require higher doses (up to 4 microg/kg of body weight perday). Older patients may need less than 1 microg/kg per day

Therapy is initiated in patients under the age of 50 years withfull replacement. For patients who are older than 50 years, or

in younger patients with a history of cardiac disease, a lowerinitial dosage is indicated, starting with 0.025 to 0.05 mg oflevothyroxine daily, with clinical and biochemical reevaluationsat 6- to 8-week intervals until the serum TSH concentration isnormalized.


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Clinic: Clinical response to treatment,patient compliance in taking the

medication, and development of druginteractions,

Lab:TSH.

Evaluated initially about every 6 to 8weeks


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Elderly

PregnancySubclinical hypothyroidismMixedema coma


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Hoarseness, deafness, confusion,dementia, ataxia, depression, dry

skin, or hair loss screened with a serum TSH

measurement


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During pregnancy, many hypothyroid patients have

an increase in levothyroxine requirement, which can

be detected with a TSH measurement. The patient

should be checked during each trimester to makesure that the TSH concentration is still normal, withfurther adjustments as indicated by the appropriate

testing. The levothyroxine dose should return to the

prepregnancy dose immediately after deliveryand a

serum TSH level should be obtained 6 to 8 weeks

post partum.


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Elderly patients, tolerate the effects of excess T[sub]4[/sub]poorly. If symptoms of palpitations, tremor, difficulty inconcentrating, or chest pain develop, the patient should beevaluated with appropriate tests, and if hyperthyroidism is

confirmed, the current dose of levothyroxine should bewithheld for 1 week and restarted at a lower dose.

Other patients remain asymptomatic despite elevations of freeT[sub]4[/sub] and/or suppression of TSH concentrations. Sincelevothyroxine overreplacement has been associated with

reduced bone mineral content, particularly in postmenopausalwomen, it is recommended that these patients have their dosereduced until the TSH concentration is normalized, unless TSHsuppression is the objective, as in patients with a history of

well-differentiated thyroid cancer.


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Normal free T[sub]4[/sub] estimate (or normal direct freeT[sub]4[/sub] measurement) and an elevated TSH concentration,This state is referred to as "subclinical hypothyroidism.

Some patients with this mild disorder feel better when treatedwith levothyroxine. Therapy for subclinical hypothyroidism isprobably advisable, especially if thyroid autoantibodies arepositive, because overt hypothyroidism develops with highfrequency in such patients.

If the physician decides not to treat these patients, they shouldbe evaluated at yearly intervals for evidence of more severeclinical and biochemical loss of thyroid function.


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Coma caused by myxedema is a rare, life-threatening statein which severe, usually long-standing hypothyroidismmarkedly worsens. In general, it occurs in elderly individuals

and is usually precipitated by an intercurrent medical illness.The clinical manifestations, in addition to obtundation orcoma, may include hypothermia, bradycardia, respiratoryfailure, and even cardiovascular collapse. Therapy ofmyxedema coma includes intravenous administration of

levothyroxine and/or liothyronine sodium as well aspharmacologic doses of glucocorticoids. Also, precipitating orassociated disorders must be aggressively treated.


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Hyper and Hypothyroid Guidelines

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