Hypothyroid-hyper is in neurology set

REMEMBER HASHIMOTO THYROIDITIS IS HYPOTHYROID

USUALLY >40 YEARS

WOMEN> MEN

COMMON IN ADULTS >65 YEARS

MOST ARE AUTOIMMUNE

HASHIMOTOS THYROIDITIS OR CHRONIC LYMPHOCYTIC THYROIDITIS IS AUTOIMMUNE AND THYROID GLAND IS GRADUALLY DESTROYED.

THYROIDITIS.

CONGENITAL HYPOTHYROIDISM.

THYROIDECTOMY.

RADIATION OF THYROID.

LITHIUM

AMIODARONE

PITUITARY OR HYPOTHALAMIC DX

IODINE DEFICIENCY OR EXCESS

TWO MAIN TYPES

GOITROUS AUTOIMMUNE THYROIDITIS

ATROPHIC AUTOIMMUNE THYROIDITIS

CAUSES <THY, BUT INITIALLY HYPERTHYROIDISM CAN OCCU-CALLED HASHITOXICOSIS

DX:

>TSH

<T4

> ANTI TPO (ANTITHYROID PEROXIDASE) ANTIBODIES-NOT ROUTINELY DONE-USU BY SPECIALIST FOR SUBCLINICAL

WEIGHT GAIN

HAIR LOSS-THINNING HAIR

COLD INTOLERANCE

FATIGUE

JOINT AND MUSCLE PAIN ARTHRALGIA MYALGIA

BRITTLE NAILS

DRY SKIN

BRADYCARDIA

DEPRESSION

IRRITABILITY AND MOOD CHANGES

DOE

HOARSENESS

PERIORBITAL EDEMA

LOSS OF EYEBROWS

DIASTOLIC HYPERTENSION

MENSTRUAL DISTURBANCE

CARPAL TUNNEL SYNDROME

MAY HAVE GOITER-ESP IODINE DEFICIENCY OR HASHIMOTOS

FAMILY HX OF AUTOIMMUNE DISEASE

EG DM 1, OVARIAN FAILURE CELIAC SJOGRENS VITILIGO .PERNICIOUS ANEMIA

AGE

POSTPARTUM

PITUITARY OR HYPOTHALAMIC DX

AUTOIMMUNE DISEASE

HEAD/NECK RADIATION

RX OF HYPOTHYROID

PT ON LITHIUM OR IODINE CONTAINING AMIODARONE

EXPECT LIPIDS TO BE ELEVATED IN HYPOTHYROID PTS,

TREAT LIPIDS IF STILL ELEVATED AFTER TSH <10 MIU/L

DRUG CLEARANCE REDUCED IN HYPOTHYROIDISM

LIPID CLEARANCE DECREASED

R/O HYPOTHYROID BEFORE DIAGNOSING SIADH IN HYPONATREMIC PT

TSH ELEVATED

(EXCEPT IN PITUITARY OR HYPOTHALAMIC HYPOTHYROIDISM-NORMAL OR UNDETECTABLE TSH)

T4 LOW

T3 LO OR NORMAL -may not test this

ANTI TPO -HASHIMOTO 90-100%/GRAVES 85%

buttaro

Anti-TPO antibodies are found in 90% to 100% of patients with Hashimoto thyroiditis and in less than 85% of patients with Graves disease

IDA-SAME SX

SLEEP APNEA

ANOREXIA

GAD

SLE

UPTODATE:

RECOVERY FROM NONTHYROIDAL ILLNESS ELEVATED TSH- REPEAT TSH T3 T4 AFTER 4 WEEKS

PITUITARY ADENOMAS

PRIMARY ADRENAL IINSUFFICIENCY

Nodules are classified as hot, warm, or cold according to the concentration of iodine isotope in the nodule in comparison with the rest of the thyroid gland. Hot nodules are usually but not always benign. Most cold nodules (solid or cystic) are benign; however, most malignant neoplasms also appear as cold nodules.

Ultrasonography is used to evaluate the anatomy of the thyroid gland and to differentiate solid from cystic nodules

LEVOTHYROXINE

1.7 MCG/KG/DAY

VARIES FOR EACH PT

START WITH 50 MCG/DAY DOSAGE INCREASE Q 4-6 WEEKS

30-40 YO =100MCG DAY

EPOCRATES

START 1.6 MCG/KG /DAY THEN 4-6 WEEKLY INCREASE BY 12.5-50 MCG INTERVALS ADJUST ACCORDING TO TFT

RARELY NEED > 300MCG /DAY

PT WITH ISCHEMIC HEART DISEASE ,, ATRIAL FIB , ELDERLY

START AT 12.5 -25 MCG DAILY

INCREASE BY 25 MCG Q 8 WEEKS

TAKE ON EMPTY STOMACH 30-60 MINUTES BEFORE BREAKFAST

OR 2-4 HOURS AFTER LEAST MEAL

DONT TAKE ANTACIDS

LIFELONG THERPAY

RED FLAGS

THYROID STORM

IF ON BETA BLOCKERS MONITOR PULSE, LESS THAN 50 ->120 BPM CONTACT PROVIDER

AGRANULOCYTOSIS

PREGNANCY

UNSTABLE ISCHEMIC HEART DISEASE

MYXEDEMA COMA

NEED RADIOACTIVE IODINE THERAPY

DEVELOP GOITER OR NODULE

NO CHANGE IN SX AFTER LEVOHYROXINE TREATMENT

ER IF HF ANGINA RAPID ATRIAL FIB

REGULATES BODY TEMP

METABOLISM

HEART RATE

MAKES TWO HORMONES T3 TRIIODOTHYRONINE

T4 THYROXINE

HYPERTHYROIDISM

GRAVES

HYPOTHYROIDISM

HASHIMOTOS DX-CHROMO 6

GOITER AND THYROID NODULES

THYROID CANCER

60% UNAWARE OF CONDITION

FEMALES 5-8 X MORE LIKELY

1 IN 8 WOMEN WILL GET TTHYROID DISORDER

USU LIFELONG + NEED MEDS

UNDIAGNOSED THYROID DISORDER > RISK OF MISCARRIAGE, DEVELOPMENTAL D/O AND PRE TERM LABOR

LOW TSH

ELEVATED T4 & T3

CAUSES

WOMEN>60

FAMILY HISTORY

PERNICIOUS ANEMIA

T1D & T2D

FOODS HIGH IN IODINE (KELP)

PRIMARY RENAL INSUFFICIENCY

COMPS

IRREGULAR HR

GRAVES OPTHALMOLOGY

OSTEOPOROSIS

MENSTRUAL ABNORMALITIES

FERTILITY ISSUES

WEIGHT LOSS

INCREASED APPETITE

RAPID HR

FEELING SHAKY OR NERVOUS

DIARRHEA

CLAMMY SKIN/SWEATING

GRAVES

OVERACTIVE THYROID NODULES

THYROIDIITIS

TOO MUCH IODINE

TOO MUCH LEVOTHYROXINE

PITUITARY TUMOR

LOW TSH

HIGH T3 & T4

REFER TO ENDOCRINOLOGY

AUTOIMMUNE DISORDER

RESULTS IN EXCESSIVE THYROID HORMONE

SX

PROPTOSIS

LIGHT SENSITIVITY

DIPLOPIA

BLURRED VISION

DRY EYE

RED THICKENED ROUGH SKIN -GRAVES DERMOPATHY OR PRETIBIAL MYXEDEMA

ACUTE LIFE THREATENING COMPLICATION OF HYPERTHYROIDISM W A MORTALITY RATE OF 8-25% DESPITE ADVANCEMENT

AGITATION

HYPERPYREXIA

TACHYCARDIA

ARRHYTMIAS

ABDOMINAL PAIN

VOMITING /JAUNDICE

DIARRHEA

BURCH WARTOFSKY POINT SCALE

THERAPY TO BLOCK CONVERSION OF T3 & T4

IODINATED RADIOCONTRAST AGENT

GLUCOCORTICOID , PTU, METHIMAZOLE

PROPANOLOL-(CROSSES BLOOD BRAIN BARRIER AS LIPID SOLUBLE-GOOD FOR MIGRAINE)

BILE ACID SEQUESTRANT-REDUCES ENTEROHEPATIC RECYCLING OF THYROID HORMONE

IMAGING

USS

RADIOUPTAKE THYROID SCAN-CALL IT RUTS

DOPPLER BLOOD FLOW MEASUREMENTS (USS) MAY BE ORDERED IF RUTS CONTRAINIDCATED, PREGNANCY ALLERGY BREASTFEEDING,

GRAVES INFERNO-INCREASED BLOOD FLOW

LABS

CBC LFTS BASELINE FOR METHIMAZOLE

ESR

T3 T4 TSH

LAB FINDINGS

T3&T4 -HIGH HYPER

T3& T4-LOW IS HYPO

TSH -LOW IS HYPER, HIGH IS HYPO

TSI-THYROID STIMULATING IMMUNOGLOBULIN-ANTIBODY THAT TELLS THE THYROID TO INCREASE ACTIVITY AND RELEASE THYROID HORMONE INTO BLOOD STREAM

THIONAMIDES

METHIMAZOLE (MMI,TAPAZOLE) 5-20 MG PO Q8H AS START DOSE

THEN 5-10 MG PO QD

UPTODATE:

Initial: Individualize initial dose based on clinical status and gland size; free T4 levels may be used to guide initial therapy (Ref):

Free T4 levels 1 to 1.5 times ULN: 5 to 10 mg once daily.

Free T4 levels >1.5 to 2 times ULN (or iodine-induced thyrotoxicosis): 10 to 20 mg once daily.

Free T4 levels >2 times ULN: 20 to 40 mg/day. To achieve euthyroidism more quickly and reduce GI-related adverse effects, may give in 2 to 3 divided doses (especially with doses >30 mg/day) (Ref).

PROPANOLOL

10-40 MG Q 6

OR ATENOLOL 25-100 Q6H

CAUTION W BRONCHOSPASM HF PREGNANCY

REF ENDOCRINE IF

GRAVES OPTHALMOPATHY

RX RADIO IODINE THERAPY IODINE rX IS IODINE 131 TO DESTROY THYROID TISSUE

Serum TSH normal – No further testing performed

•Serum TSH high – Free T4 added to determine the degree of hypothyroidism

•Serum TSH low – Free T4 and T3 added to determine the degree of hyperthyroidism

if young woman w amenorrhea and fatigue-suspect pituitary or hypothalamic dx- do tsh and free t4

if pt has symptoms - test serum free T4 anyway even if TSH normal

recommended because a TSH only could miss 3.8 % with secondary , central or TSH mediated hyperthyroidism

sickness- can have low concentrations of binding proteins

meds that affect thyroid function

hi concentrations of free fatty acids that displace thyroid hormones from binding proteins

on levo- can assess TSH only

ANTITHYROID ANTIBODIES

GRAVES, HASHIMOTOS

HASHIMOTOS -AL HAVE ELVATED TPO NOT NECESSARY

THIRD GEN TSI STUDIES 97/99 SPE,SEN FOR GRAVES-NOT NEC TEST IF RADIO UPTAKE SCAN HAS BEEN DONE