Hyperthyroidism. Defintion TTTTHYROTOXICOSIS IIIIncreased thyroid hormone levels with biological effects on tissues and systems HHHHYPERTIROIDISM.

Hyperthyroidism Hyperthyroidism

Defintion Defintion

THYROTOXICOSISTHYROTOXICOSIS Increased thyroid hormone levels Increased thyroid hormone levels

with biological effects on tissues with biological effects on tissues and systems and systems

HYPERTIROIDISMHYPERTIROIDISM Hyperfunction of thyroid glandHyperfunction of thyroid gland

HistoryHistory Have described different forms of Have described different forms of

hyperthyroidism hyperthyroidism Parry (1786),Parry (1786), Flajani (1808), Flajani (1808), Graves (1835),Graves (1835), Basedow (1840),Basedow (1840), Moebius (1886), Moebius (1886), Plummer (1913 – adenomul toxic), Plummer (1913 – adenomul toxic), Adams, Purves, Mc Kenzie (1956 – long-acting Adams, Purves, Mc Kenzie (1956 – long-acting

thyroid stimulator immunoglobulins – LATS)thyroid stimulator immunoglobulins – LATS)

fT4

fT3

T4

T3

TRH

T4

T3TBG

Thyrotropic axe

I-MIT

DITI2

thyroglobulin

fT4

fT3

T4

T3

I -

piytuitary

I- T4

T3

I-

TSHTSH

fT4

fT3

TRH

HYPERTIROIDISMEtiolology : incidenceEtiolology : incidence

Graves diseaseGraves disease- < 40 ani< 40 ani- f / b = 10 / 1f / b = 10 / 1

AutonomicAutonomic- >40 ani- >40 ani- b=f- b=f

other (< 1%)other (< 1%)

HYPERTIROIDISMHYPERTIROIDISMMost frequent formsMost frequent forms

T4 T4 T4

TSH TSH TSH

Basedow-Graves diseaseBasedow-Graves disease Toxic adenoma PlummerToxic adenoma Plummer Toxic multinodular goiterToxic multinodular goiter

Hypertiroidism – etiologyHypertiroidism – etiologyA. tirotoxicosis with hyperthyroidismA. tirotoxicosis with hyperthyroidism

1.1. Thyroid stimulationThyroid stimulation TSITSI

Graves diseaseGraves disease TSHTSH thyrotropinomathyrotropinoma

Resistance to thryoid Resistance to thryoid hormone action hormone action Refetoff syndromesRefetoff syndromes

Human Chorionc Human Chorionc GonadotropinGonadotropin Trophoblastic tumorsTrophoblastic tumors hiperemesis gravidarumhiperemesis gravidarum

2.2. Autonomous thyroid Autonomous thyroid functionfunction

Toxic adenomaToxic adenoma Toxic multinodular goiterToxic multinodular goiter Non-autoimmune difuse Non-autoimmune difuse

hyperthyroidism(familiala, hyperthyroidism(familiala, sporadic?)sporadic?)

Thyroid carcinoma follicularThyroid carcinoma follicular struma ovariistruma ovarii

3.3. Iodine inducedIodine induced Jod-BasedowJod-Basedow

Iodine contrast media, amiodarone (thyroid excess and Iodine contrast media, amiodarone (thyroid excess and autonomous thyroid function)autonomous thyroid function)

Hypertiroidism - etiologyHypertiroidism - etiology

B. B. Thyrotoxicosis without hyperfunction of Thyrotoxicosis without hyperfunction of the thyroid glandthe thyroid gland

4. Distruction 4. Distruction thyroiditisthyroiditis

subacute de Quervain thyroiditissubacute de Quervain thyroiditis Silent thyroiditisSilent thyroiditis

Drug induced (amiodarone, interferon-alfa)Drug induced (amiodarone, interferon-alfa) Irradiation, Irradiation,

5. External intake5. External intake IatrogenicIatrogenic FactitiaFactitia foods (« hamburger thyrotoxicosis »)foods (« hamburger thyrotoxicosis »)

HYPERTIROIDISM / HYPERTIROIDISM / THYROTOXICOSISTHYROTOXICOSIS

signs and symptomssigns and symptoms Simptoms due to increased number of Simptoms due to increased number of

cathecolamine receptorscathecolamine receptors palpitation (tachicardia, atrial fibrilation)palpitation (tachicardia, atrial fibrilation) Increasd perspirationIncreasd perspiration tremor , hiperreflexia, eyelids retractiontremor , hiperreflexia, eyelids retraction

Simptoms due to metabolic actons of thyroid Simptoms due to metabolic actons of thyroid hormoneshormones Weight loss with increased appetite , decreased fat and Weight loss with increased appetite , decreased fat and

muscle mass muscle mass termofobiatermofobia Warm skin, fine, moist; onicholisisWarm skin, fine, moist; onicholisis Muscle weakness, Muscle weakness, osteoporosisosteoporosis Menstrual problems in women and gynecomastia in menMenstrual problems in women and gynecomastia in men

Simptoms induced by thyrpid hormone Simptoms induced by thyrpid hormone effects on central nervous systemeffects on central nervous system Nervousness , irritability, psychological labillity, Nervousness , irritability, psychological labillity,

Clinical signsClinical signs

9991

898988

8582

7570

65

5435

33

0 25 50 75 100

frequent stoolpretibial oedemaophtalmopathyincreased appetiteweakness Dyspneatachicardia82 weight lossastenia PalpitatiitermofobiaHipersudatie nervousness

Clinical symptomsClinical symptoms

100

100

97

97

77

71

10

10

10

0 20 40 60 80 100

gynecomastia

splenomegaly

fibrilation

eye symptoms

thyroid trill

Tremor

skin manifestations

goiter

tachicardia

Hypertiroidism - simptomsHypertiroidism - simptomsSIGNSSIGNS CAUSECAUSE

Thyroid Thyroid

Diffuse goiterDiffuse goiter Graves’ disease, autoimmune Graves’ disease, autoimmune thyroiditis with thyrotoxicosisthyroiditis with thyrotoxicosis

Uninodular goiterUninodular goiter Thyroid autonomyThyroid autonomy

Multinodular Multinodular goitergoiter

Thyroid autonomyThyroid autonomy

Non-palpable Non-palpable thyroidthyroid

Exogenous thyroid hormonesExogenous thyroid hormones

Painfull thyroidPainfull thyroid Subacute thyroiditisSubacute thyroiditis

Associated signsAssociated signs

OphtalmopatyOphtalmopaty Graves’ diseaseGraves’ disease

Pretibial Pretibial mixoedemamixoedema

Graves’ diseaseGraves’ disease

AcropachyAcropachy Graves diseaseGraves disease

Cardio-vascular signs and symptomsCardio-vascular signs and symptoms

signssigns Tachicardis, continous, Tachicardis, continous, nocturnalnocturnal

+ effort associated + effort associated dyspneadyspnea

Systolic HypertensionSystolic Hypertension Increased cardiac outputIncreased cardiac output

FCFC peripheral resistanceperipheral resistance miocardial contractilitymiocardial contractility

CardiotireosisCardiotireosis Atrial fibrilation Atrial fibrilation : 10%: 10%

Rarely < 40 aniRarely < 40 ani Corrected by euthyroid Corrected by euthyroid

statestate Anticoagulant treatmentAnticoagulant treatment Embolic risk (8%)Embolic risk (8%)

Congestive hearth failureCongestive hearth failure Fibrilation, Fibrilation, Aged patientsAged patients

Worsening coronary hearth Worsening coronary hearth diseasedisease

Neuro muscular signsNeuro muscular signs Nervosness, Nervosness,

irritability, irritability, Emotional Emotional

disturbance disturbance Disturbance of Disturbance of

attention and mood. attention and mood. Pseudo psychotic Pseudo psychotic

formsforms TremorTremor

Muscle weakness Muscle weakness Rapid reflexes, Rapid reflexes, Amiotrophy Amiotrophy

(pseudo miopathic (pseudo miopathic forms)forms)

Hypokaliemic Hypokaliemic periodic paralysisperiodic paralysis

Digestive Digestive signssigns

Tranzit accelerat Tranzit accelerat (motor)(motor) pseudodiaree = poli pseudodiaree = poli

exoneratieexoneratie Anomalii hepatice Anomalii hepatice

Icter, citoliza, Icter, citoliza, hipocolesterolemiehipocolesterolemie

menmen gynecomastia gynecomastia

(40%) (40%) Erectile dysfunctionErectile dysfunction infertilityinfertility

womenwomen Menstrual Menstrual

abnormalitiesabnormalities disovulationdisovulation

Genital Genital abnormalitiesabnormalities

Bone abnormalitiesBone abnormalities Decreased BMD Decreased BMD : :

distruction>formatidistruction>formationon

Spontaneous Spontaneous fracturesfractures

Hypercalcemia, Hypercalcemia, hypercalciuriahypercalciuria

alkaline alkaline phosphatase and phosphatase and osteocalcin osteocalcin

Skin problemsSkin problems pruritus pruritus Localized edema Localized edema Alopecia Alopecia

Metabolic Metabolic abnormalitiesabnormalities

HypocholesterolemiaHypocholesterolemia Hyperglicemie, Hyperglicemie,

worsening of diabetes worsening of diabetes mellitusmellitus

Positive diagnosisPositive diagnosis Clincal signs and symptomsClincal signs and symptoms TSH: suppressed (TSH: suppressed (excepton TSH-secreting pituitary excepton TSH-secreting pituitary

adenoma)adenoma)

FT4 and/or FT3FT4 and/or FT3 Etiologic diagnosisEtiologic diagnosis

historyhistory pregnancypregnancy Painfull thyroidPainfull thyroid drugsdrugs

Clinical signs Clinical signs goitergoiter Extrathyroidal signsExtrathyroidal signs

TSH receptor stimulating immunoglobulins (TRAb)TSH receptor stimulating immunoglobulins (TRAb) ScintigraphyScintigraphy Urinary iodineUrinary iodine

HYPERTIROIDISM HYPERTIROIDISM Peripheral metabolismPeripheral metabolism

Parameter Parameter HypertiroidiHypertiroidism sm

HypotiroidisHypotiroidism m

Basal metabolic rateBasal metabolic rate

CholesteroleCholesterole

SHBGSHBG

OsteocalcinOsteocalcin

OH-prolineOH-proline

PyridinolinePyridinoline

Deep tendon reflexDeep tendon reflex < 240 ms< 240 ms > 360 ms> 360 ms

Qkd intervalQkd interval

HYPERTIROIDISM / TIROTOXICOSISHYPERTIROIDISM / TIROTOXICOSISParaclinical diagnosisParaclinical diagnosis

TSH, fT4

TSH↓, fT4↑ TSH↓, fT4= TSH ↑, fT4↑

Hyipertiroidism

Exoftalmie +

TS-Ab +

Graves’s disease

Exophtalmos -

UltrasoundScintigram I123

TS-Ab

hypoechoicTS-Ab +

Multiplee hot nodulesTS-Ab -

Hypoechoic thyroidTS-Ab -

Toxic adenomaToxic multinodular goiter

Subacute thyroiditisHashimoto’s thyroiditis

Jod-BasedowTirotoxicosis factitiaStruma ovarii (rarely)

fT3

fT3↑T3 tirotoxicosis fT3↓

Euthyroid sick syndromeCritical diseases

Dopamine,

TSH adenomaSyndrome Refetoff

HYPERTIROIDIS / THIROTOXICOSISHYPERTIROIDIS / THIROTOXICOSISImagery: Graves’diseaseImagery: Graves’disease

Thyroid ultrasoundThyroid ultrasound

HYPERTIROIDISM / THYROTOXICOSISHYPERTIROIDISM / THYROTOXICOSIS

Imagery : toxic adenomaImagery : toxic adenoma

Thyroid ultrasoundThyroid ultrasoundScintigramScintigram

T4

TSH Studer Wyss PTU

HYPERTIROIDISM / THYROTOXICOSISHYPERTIROIDISM / THYROTOXICOSIS tests: toxic adenomatests: toxic adenoma

T4

TSH Studer Wyss PTU

Querido TSH

TSH


T4

TSH Studer Wyss PTU

Querido TSH

Werner fT4

fT4


HYPERTIROIDISM / THYROTOXICOSISHYPERTIROIDISM / THYROTOXICOSISComplicationsComplications

HearthHearth atrial fibrilation resistant to treatmentatrial fibrilation resistant to treatment hyperkinetic hearth failurehyperkinetic hearth failure

Infertility / amenorrheaInfertility / amenorrhea OsteoporosisOsteoporosis (postmenopausal) (postmenopausal) Thyrotoxic periodic paralysisThyrotoxic periodic paralysis

flaccid paralysis and hypokalemiaflaccid paralysis and hypokalemia asian menasian men reversible on treatmentreversible on treatment

Apathetic hyperthyroidismApathetic hyperthyroidism Aging patientsAging patients

EtiologyEtiology determinant factorsdeterminant factors

Undertreated thyrotoxicosis Undertreated thyrotoxicosis Recently developed untreated Recently developed untreated

hyperthyroidismhyperthyroidism Precipitating factorsPrecipitating factors medicalmedical

infecţionsinfecţionsDiabetic ketoacidosisDiabetic ketoacidosisLung embolismLung embolismLabor or pregnancyLabor or pregnancyPremature stopping treatmentPremature stopping treatmentII131 treatment131 treatment

surgerysurgery

Thyrotoxic crisis (thyrotoxic storm)Thyrotoxic crisis (thyrotoxic storm)

Thyrotoxic crisisThyrotoxic crisis

severe signs and symptoms of severe signs and symptoms of thyrotoxicosis thyrotoxicosis

severe hipermetabolismsevere hipermetabolismfever fever

overover >38 >38ooC (til 41-42C (til 41-42ooC)C)Neuro-psychological symptoms Neuro-psychological symptoms

““thyrotoxic encephalopathy" -thyrotoxic encephalopathy" -cardio-vascular symptomscardio-vascular symptoms

tachicardia - >140/min, tachicardia - >140/min, arhitmias (atrial fibrillation )arhitmias (atrial fibrillation )Hearth failure (left, global)Hearth failure (left, global)Variations of arterial blood pressureVariations of arterial blood pressure

gastro-intestinal symptoms gastro-intestinal symptoms Mimikin acute abdomenaMimikin acute abdomenaJaundice (index of severity)Jaundice (index of severity)

Graves diseaseGraves disease Most frequent cause of hyperthyroidism Most frequent cause of hyperthyroidism

Prevalence 1%Prevalence 1% 19/1000 19/1000 ♀♀ 1,6/1000 1,6/1000 ♂♂ (Sex ratio 7 / 10) (Sex ratio 7 / 10)

Incidence 2 - 3 cases / year /1000 Incidence 2 - 3 cases / year /1000 ♀♀ Young female patient, psychological Young female patient, psychological

traumatrauma Autoimmune, familialAutoimmune, familial

Asociated with other autoimune diseases: Asociated with other autoimune diseases: tip 1DM, adrenal insufficiency, vitiligo, miastenia tip 1DM, adrenal insufficiency, vitiligo, miastenia

gravisgravis Stimulating immunoglobulinsStimulating immunoglobulins

perspiration

amiotrophie

< 40 yearsLymp node enlargement

dispnea

Gynecomastia in ♂♂

flushes

Weigh loss

oligo/amenorrea

Local mixedoema

nervosness, emotional instability

exophtalmos

goiter (± thrill)

Hot, mois skinpalpitations, tachicardia, low response to digytalis

apetit diarheeatremor

acropachia

Muscle weakness, fatigability


Graves’ Graves’ diseasedisease

goitergoiter


GOITERGOITER DifuseDifuse ElasticElastic Homogenous Homogenous painless painless Vascular (thrill)Vascular (thrill)

Graves exophtalmosGraves exophtalmos

Graves ophtamopathyGraves ophtamopathy

Eyelid edema, periorbital edema, proptosisEyelid edema, periorbital edema, proptosis Increase tears production Increase tears production Incomplete close eyelids during nightIncomplete close eyelids during night Fotofobia, Fotofobia, Eye disconfort, pruritus, “alergyEye disconfort, pruritus, “alergy Painfull eyes, associated or not with eye mouvmentsPainfull eyes, associated or not with eye mouvments Dyplopia Dyplopia

Intermitent: when patinets is tired Intermitent: when patinets is tired InconstantInconstant Constant: when reading Constant: when reading

Graves ophtalmopathy Graves ophtalmopathy NOSPECSNOSPECS

ClassClass DefinitionDefinition

00 NNo phisical signs and symptomso phisical signs and symptoms

11 OOnly signs, no symptoms nly signs, no symptoms (upper lid retraction, stare, proptosis to 22 cm)(upper lid retraction, stare, proptosis to 22 cm)

22 SSoft tissue involvement (symtpoms and signs)oft tissue involvement (symtpoms and signs)

33 PProptosis > 22 cmroptosis > 22 cm

44 EExtraocular muscle involvementxtraocular muscle involvement

55 CCorneal involvementorneal involvement

66 SSight loss (optic nerve involvement)ight loss (optic nerve involvement)

Severity of Graves Severity of Graves ophtalmopathyophtalmopathy

Degree Degree Signs and symptomsSigns and symptoms

EUGOGOEUGOGO (European Group on Graves’ (European Group on Graves’ Orbitopathy)Orbitopathy)

Mild Mild

1.1. Minimal or moderate edemaMinimal or moderate edema2.2. Proptosis <25 mm Proptosis <25 mm 3.3. Diplopia: absent or intermitent Diplopia: absent or intermitent 4.4. No optic nerve envolvement No optic nerve envolvement

Moderate Moderate

Important edeme Important edeme 1.1. And/or proptosis >25 mm And/or proptosis >25 mm 2.2. And/or inconstant dyplopiaAnd/or inconstant dyplopia3.3. And/or corneal point lesions And/or corneal point lesions 4.4. No optic nerve involvement No optic nerve involvement

SevereSevere Constant dyplopiaConstant dyplopia1.1. And/or optic nerve involvement And/or optic nerve involvement

Clinical Activity Score (CAS)Clinical Activity Score (CAS)

1.1. Spontaneous retroocular painSpontaneous retroocular pain

2.2. Pain at eye mouvments Pain at eye mouvments

3.3. Eyelid erithema Eyelid erithema

4.4. Corneal increased vascularity Corneal increased vascularity

5.5. Chemosis Chemosis

6.6. Edema of caruncula Edema of caruncula

7.7. Eyelid edemaEyelid edema Every item has 1 point. Active Every item has 1 point. Active

ophtalmopathy: >3 poinsophtalmopathy: >3 poins

Graves’ ophtalmopathyGraves’ ophtalmopathyEyelid retractionEyelid retraction

Graves’ ophtalmopathyGraves’ ophtalmopathy

Eyelid edemaEyelid edema


Superioar eyelid edemaSuperioar eyelid edema

Eyelid edemaEyelid edema


Enlarged eyelid opening Enlarged eyelid opening


Graves’ ophtalmopathyGraves’ ophtalmopathy Corneal involvmentCorneal involvment

Corneal and conjunctival problemsCorneal and conjunctival problems



Exophtalmos Exophtalmos


Exophtalmos Exophtalmos

OphtalmoplegiaOphtalmoplegia



CT of orbotal areaCT of orbotal area


Pretibial mixoedemaPretibial mixoedema Nodous eritemaNodous eritema

Acropachy Acropachy

Toxic adenoma (Plummer)Toxic adenoma (Plummer) Isolated Isolated

thyroid nodulethyroid nodule autonomousautonomous

Extranodular Extranodular parenchima is parenchima is not functioningnot functioning

TSH levelAutonomous secretion

Normal secretion

TSH

Normal secretion

Autonomous functioning tissue

32 541

32 541

Evolutia Evolutia adenomuadenomu

ui toxicui toxic

Toxic multinodular goiterToxic multinodular goiter

Hearth signs and symptoms are Hearth signs and symptoms are dominantdominant10 - 15 % of atrial fibrillation in 10 - 15 % of atrial fibrillation in

aged patients is associated with aged patients is associated with TMGTMG

Hearth failureHearth failure Compressive goiterCompressive goiter

Subacute thyroiditisSubacute thyroiditis Neck pain Neck pain Tirotoxicosis Tirotoxicosis Post viral Post viral Trifase evolutionTrifase evolution

hyperthyroidismhyperthyroidism hypothyroidismhypothyroidism euthyroidismeuthyroidism

HipoechogenicityHipoechogenicity inhomogenousinhomogenous Pseudo nodularPseudo nodular

Absence of iodine Absence of iodine uptake and “white uptake and “white scintigram”scintigram”

eutiroidism

hipertiroidism

hipotiroidism

HYPERTHIROIDISM / THYROTOXICOSISHYPERTHIROIDISM / THYROTOXICOSISAge-related characteristicsAge-related characteristics

NewbornsNewborns• neonatal Graves disease (goiter exophtalmos, neonatal Graves disease (goiter exophtalmos, thyrotoxicosis)thyrotoxicosis)

• temporarlytemporarly• permanentpermanent

• familial non-autoimmune thyrotoxicosisfamilial non-autoimmune thyrotoxicosis

ChildrenChildren• Graves diseaseGraves disease

• increased growth rateincreased growth rate

Aging patientsAging patients•Toxic adenoma / TMNG / GravesToxic adenoma / TMNG / Graves

• clinical signs are less obvious clinical signs are less obvious • suspected whensuspected when

• it is an unexpected weight lossit is an unexpected weight loss• atrial fibrilation and hearth failure atrial fibrilation and hearth failure unresponssive to digitalisunresponssive to digitalis

O

C

O

C4H9

O CH2 CH2 NC2H5

C2H5

I

Iamiodarona

Amiodarona si tiroidaAmiodarona si tiroida

Celular Celular : : se opune intrarii tiroxinei se opune intrarii tiroxinei si fixarii T3 de receptorii nuclearisi fixarii T3 de receptorii nucleari

Hipofiza tireotropa :Hipofiza tireotropa : TSH us in prima saptamina fara hipotiroidieTSH us in prima saptamina fara hipotiroidie

Tiroida: Tiroida: acumulare de iod - efect Wolf Chaikoffacumulare de iod - efect Wolf Chaikoff citotoxicitate foliculairacitotoxicitate foliculaira

Periferic Periferic : : conversie T4 in T3 (inhiba 5’ deiodaza)conversie T4 in T3 (inhiba 5’ deiodaza)

manifestari tirotoxice putin marcatemanifestari tirotoxice putin marcate

Amiodarone –induced hyperthyroidismAmiodarone –induced hyperthyroidism

Type I : Type I : hyperfunctional hyperfunctional

(previous thyroid (previous thyroid autoimmunity)autoimmunity)

Type II : distructive Type II : distructive (previous normal (previous normal

thyroid)thyroid)

Affected Affected individualsindividuals women 1/2women 1/2 men 2/3men 2/3

123123I uptakeI uptake N, N, Scintigram positiveScintigram positive

absenteabsenteScintigram absentScintigram absent

IL6IL6 NormalNormal and and Tg Tg

Ultrasound Ultrasound volumevolume Normal volumeNormal volume

EchodopplerEchodoppler Hypervascularity Hypervascularity (grad 1-3)(grad 1-3)

Hipoechoic, Hipoechoic, hipovascular (grad 0)hipovascular (grad 0)

Classic Classic treatmenttreatment

ATS 6-9 monthATS 6-9 monthKCLO4 Potasium KCLO4 Potasium

perclorateperclorateGlucocorticoidsGlucocorticoids

PrognosisPrognosis

Sponaneous regression Sponaneous regression (3-6 month)(3-6 month)Prolonged Prolonged

hyperthyroidismhyperthyroidism

Spontaneous Spontaneous regression (3-6 month)regression (3-6 month)

Transitory Transitory hypothyroidismhypothyroidism

Thyrotoxicosis treatmentThyrotoxicosis treatment1.1. AIM: to decrease thyroid hormones to AIM: to decrease thyroid hormones to

normal levelsnormal levels Distruction of thyroid Distruction of thyroid

surgerysurgery Radio iodineRadio iodine

Inhibition of thyroid hormone synthesis Inhibition of thyroid hormone synthesis (ATD)(ATD)

Antithyroid drugsAntithyroid drugs Glucocorticoids adjuvant therapyGlucocorticoids adjuvant therapy

2.2. Decreases conversion of T4 to T3 Decreases conversion of T4 to T3 3.3. inhibitioninhibition

ATDATD glucorticoids (high doses)glucorticoids (high doses) propranololpropranolol iodineiodine

Reduction of receptor couplingReduction of receptor coupling -blokers-blokers plasmaferesisplasmaferesis

Antithyroid drugsAntithyroid drugsImidazole derivatives (methimasole)Imidazole derivatives (methimasole)

NN

HH

NHNH

SS

OO

Thyourheea derivatives Thyourheea derivatives (thiouracile)(thiouracile)

NN

HHCHCH33-CH-CH22-CH-CH22

NHNH

SS

OO

carbimasolecarbimasole

propilthiouracilepropilthiouracile

Inhibit TPOInhibit TPO

Inhibits TPOInhibits TPOInhibits type Inhibits type 1deiodinase1deiodinase

NHNH

NN SS

HH

NNCOOCCOOC22HH55

NN SS

HH

Treatment of hypothyroidism ATDTreatment of hypothyroidism ATD

2 possibilities2 possibilities Continous high dosage and association Continous high dosage and association

ofthryoid drugs when hypothyroidism ofthryoid drugs when hypothyroidism occursoccurs

Decreasing dosage to the minimal dosage Decreasing dosage to the minimal dosage that maintans an euthyroid statethat maintans an euthyroid state

Graves diseaseGraves disease Young womenYoung women 1,5 years at least1,5 years at least Monitoring the resullts TS-AbMonitoring the resullts TS-Ab < 50%cure< 50%cure

in toxic adenoma /GMNT in toxic adenoma /GMNT Only a temporary solution Only a temporary solution

Antithyroid drugsAntithyroid drugs

DosageDosage Adults 10-20 mg x 2 po initiallyAdults 10-20 mg x 2 po initially

Dosage will be decreased to ½ doza Dosage will be decreased to ½ doza when patient becomes euthyroid when patient becomes euthyroid

Children: 15-20 mg/mChildren: 15-20 mg/m22 divided in 2 divided in 2 doses initial;ydoses initial;yLater: minomal efficient doseLater: minomal efficient dose

Treatment of hyperthyroidismTreatment of hyperthyroidismother possibilitiesother possibilities

LitiumLitium inhibits TPOinhibits TPO high toxicityhigh toxicity

Stable Iodine Stable Iodine Lugol solution Lugol solution

1 g iodne1 g iodne2 g KI2 g KI20 ml distilated 20 ml distilated

waterwater Preoperative for Preoperative for

surgerysurgery 3 × 20 picături pe zi, 3 × 20 picături pe zi,

10-14 zile10-14 zile

Nodule necrosis Nodule necrosis with alcohol with alcohol toxic adenomatoxic adenoma

Potassium Potassium perclorateperclorate amiodarone amiodarone

inducedinduced thyrotoxicosis thyrotoxicosis

Antiimflamatory Antiimflamatory drugsdrugs subacute subacute

thyroiditisthyroiditis Type II amiodarone Type II amiodarone

inducedinduced

100100

RIU RIU 123123I (24 h)I (24 h)thyroidthyroid

wight (g)wight (g)80-100 mCi/g 80-100 mCi/g 131131II xx xx

radioactive iodineradioactive iodine: Graves disease: Graves disease

T4I*

TSH

Radioactive iodineRadioactive iodine: toxic adenoma: toxic adenoma

SurgerySurgery

Graves diseaseGraves disease tyroidectomy (near) tyroidectomy (near)

totaltotal indicationsindications

Increased thyroid Increased thyroid nodulenodule

GMNTGMNT tyroidectomy tyroidectomy

(near)total (near)total adenomul toxicadenomul toxic

lobectomylobectomy

Complications Complications hypothyroidism hypothyroidism hypoparathyroidishypoparathyroidis

me (3-5%)me (3-5%) laringeal nerve laringeal nerve

paralisisparalisis hemorrhage hemorrhage

during surgeryduring surgery

GRAVESGRAVESOPHTALMOPATHYOPHTALMOPATHY

Total thyroidectomy or ATDTotal thyroidectomy or ATD + terapie prednisone ! + terapie prednisone !

10 mg x 4 – 7d10 mg x 4 – 7d

Form of ophtalmopathy?Form of ophtalmopathy? recente –immunosupressiverecente –immunosupressive

prednisone 25 mg x 4, 7-14 dprednisone 25 mg x 4, 7-14 d metilprednisolone 250 iv, repeated at 3 days metilprednisolone 250 iv, repeated at 3 days

(pulse)(pulse) Polyclonal immunoglobulins Polyclonal immunoglobulins

old (GAG infiltration, fibrosis)old (GAG infiltration, fibrosis) Retroorbitar irradiationRetroorbitar irradiation enlargement of the orbitisenlargement of the orbitis surgery on orbital musclessurgery on orbital muscles other plastic surgery proceduresother plastic surgery procedures

Tratamentul exoftalmiei basedowieneTratamentul exoftalmiei basedowieneDecompresie orbitaraDecompresie orbitara

Inainte Dupa tratament

Graves ophtalmopathyGraves ophtalmopathyOrbital decompressionOrbital decompression

Before After treatment

Thyreotoxic crisisThyreotoxic crisisObjectives Objectives I.I. Inhibition of thyroid hormone synthesis Inhibition of thyroid hormone synthesis

and liberationand liberationII.II.Decreased action of thyroid hormones on Decreased action of thyroid hormones on

target tissuestarget tissues Reduction of thyroid hormone concentrationReduction of thyroid hormone concentration Conversion inhibition of TConversion inhibition of T44 into T into T33

Adrenergic blokadeAdrenergic blokade

III.Treatament of systemic symptomsIII.Treatament of systemic symptoms feverfever dehydrationdehydration supportivesupportive

IV.Treatament of precipitating factorsIV.Treatament of precipitating factors


Inhibiton of hormone synthesisInhibiton of hormone synthesisAntithyroid drugs (ATD) Antithyroid drugs (ATD)

Large doses, per osLarge doses, per osPropiltiouracilePropiltiouracile (PTU) - 1200 - 1500 mg/d (200-250mg la 4h); (PTU) - 1200 - 1500 mg/d (200-250mg la 4h);MethimasoleMethimasole (MMI) - 120 mg/d (20 mg la 4h); (MMI) - 120 mg/d (20 mg la 4h);

Inhibition of TH liberationInhibition of TH liberation Iodine-containing compaundsIodine-containing compaunds

Lugol sol; saturate solution of KILugol sol; saturate solution of KI (SSKI) -p.o., 5 drops every 6h; (SSKI) -p.o., 5 drops every 6h;Contrast media Contrast media (inhibition of conversion of T (inhibition of conversion of T44 into T into T33):):

Criza tireotoxicaCriza tireotoxica

Inhibition of peripheral conversion T4 to T3Inhibition of peripheral conversion T4 to T3propilthyouracil; ipodate, iopanoate; propranolol; propilthyouracil; ipodate, iopanoate; propranolol;

glucocorticoidsglucocorticoidsAdrenergic blokade:Adrenergic blokade:

betablokers betablokers - propranolol – most used:- propranolol – most used: iv, large doses iv, large doses short-action blokers (labetalol, esmolol);short-action blokers (labetalol, esmolol);

reserpine, guanetidine:reserpine, guanetidine:utile în contraindicaţiile utile în contraindicaţiile -blocantelor;-blocantelor;

Removal of thryoid hormone excess Removal of thryoid hormone excess plasmapheresis;plasmapheresis;dialysisdialysis

II. Reduction of TH action on target tissuesII. Reduction of TH action on target tissues


Treatment od Treatment od systemic systemic symptomssymptoms

feverfeverCoated with cold Coated with cold sheetssheets

drugsdrugsparacetamole paracetamole

DihydrationDihydration heath failureheath failure glucocorticodsglucocorticods

IV. Treatment of IV. Treatment of precipitating precipitating factorsfactors

Hyperthyroidism. Defintion TTTTHYROTOXICOSIS IIIIncreased thyroid hormone levels with biological effects on tissues and systems HHHHYPERTIROIDISM.

Documents

hyperthyroidism slide

trh slide

hypertiroidism hypertiroidism

amiodarone thyroid excess

coronary hearth disease

incidence graves disease

tsh ft

hypertiroidism etiology