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7/16/16 ThyroidDisorders Today’sEvidencefor Treatment CindyCookeDNP,FNP-C,FAANP Objectives • Reviewthefunc1onofthethyroidinthe endocrinesystem. • Reviewthedifferen1aldiagnosisfor elevatedTSHandtreatmentop1ons. • Reviewthedifferen1aldiagnosisfor decreasedTSHandtreatmentop1ons. Disclosures • Nothingtodisclose 1 7/16/16 Thethyroid: • Thethyroidisthefirstofthebody’sendocrine glandstodeveloponthe24thdayofgesta1on. • Largestendocrinegland • Locatedinferiortothecricoidcar1lage Thethyroid: • BuIerflyshapedwith2lobesconnectedbyan isthmus • Weightvariesfrom18-60gramsinadults • Regula1onofmetabolism • Affectseverycellinthebody Thyroiddisorders 2 7/16/16 Physiology Hypothalamus TRH - + - Pituitarygland TSH + T4&T3 T4&T3 ThyroidGland T4 T3 Peripheral1ssues T4T3 ThyroidFunction–Labs • Thirdgenera1onassays • widelyused • detectTSHatabout0.01mU/L • Controversy • upperlimitof“normal”forTSH • whentotreat ThyroidFunction–Labs • Purpose • Screening • Assesshypothyroidismtherapy • MonitorHyperthyroidismtreatment 3 7/16/16 ThyroidFunction–Labs • SerumTSH0.27to4.20u(IU)/ml • Serumtotalthyroxine(T4)4.6to12.0mcg/dL • Serumtotaltriiodothyronine(T3)75to195ng/ dL • SerumfreeT40.8to1.7ng/dl orT3–2.6-4.4pg/ml) labrangesfromlocalhospitallab Thyroiddisorders: Hyperthyroid Hypothyroid • GravesDisease • ThyroidStorm • Toxicthyroidnodule • Hashimoto’sthyroidi1s • Myxedema • Postpartumthyroidi1s • Sub-acutethyroidi1s Hyperthyroidism: • OvertHyperthyroidism–drama1csymptoms • Anxiety • Emo1onallability • Weakness • Tremor • Palpita1ons • Heatintolerance • Increasedperspira1on • Weightlossdespitenormalorincreased appe1te 4 7/16/16 Hyperthyroidism • Lesscommonsymptoms • Somepa1entsgainweight(increased appe1te) • Hyperdefeca1on(notdiarrhea) • Urinaryfrequency • Oligomenorrheaoramenorrheainwomen • Gynecomas1aanderec1ledysfunc1oninmen Hyperthyroidism • Mildhyperthyroidsymptoms • Newonsetatrialfibrilla1on • Myopathy • Menstrualdisorders • Olderpa1ents • Tachycardia–atrialfibrilla1on • Dyspneaonexer1on • Edema Grave’sDisease • Mostcommoncauseofthyrotoxicosis • Autoimmuneprocess • Female:Malera1on–5:1toashighas10:1 • Stronghereditaryrela1onship • Diagnosisoienmadebysymptoms 5 7/16/16 Hyperthyroid–Labtests • Thyroidfunc1ontests: • Pa1entswithprimaryhyperthyroidismhavealowTSH • ManyhavehighfreeT4andT3 • Subclinicalhyperthyroidism-belownormalTSHbut mayhavenormalT4,T3 • Completemetabolicpanel • Lipidpanel • TendencytohavelowLDLcholesterol(increasesaier thyroidtreated) Hyperthyroidism • Lesscommoncauses • Iodide-inducedthyrotoxicosis • Thyrotoxicosisfac11a • PituitarytumorsproducingTSH • Excesshumanchorionicgonadotropin • Pituitaryresistancetothyroidhormone • Metasta1cthyroidcarcinoma CaseStudy1 • 39yearoldfemale • C/Oweightlosswithouttrying • Palpita1ons • Increasedappe1te • Labs • CBCandCMPwerenormal • TSH–0.03(Referencerange0.5–4.70uIU/mL) • PhysicalExam • • • • Heartrateat122atrest Finetremorinhands Mildexophthalmos Enlargedthyroidonpalpa1on 6 7/16/16 CaseStudy1-Discussion Hyperthyroidism • CommonForms • Diffusetoxicgoiter • Toxicmul1nodulargoiter • Thyrotoxicphaseofsubacutethyroidi1s • Toxicadenoma CaseStudy1 NextLabs Result Referencerange TSH 0.03uIU/mL 0.5–4.7uIU/mL FreeT4 7.4ng/dL 0.8–1.8ng/dL TotalT3 16.2pg/mL 2.3–4.2pg/mL CaseStudy1 • Diagnosis • Nextlabs/teststorun • Treatment 7 7/16/16 CaseStudy1-Discussion • Radioac1veiodineuptake • Normalorincreaseduptake=denovosynthesisof hormone • Loworabsentuptake=inflamma1onordestruc1onof thethyroid1ssue • Measurementofthyroidalbloodflowon ultrasonography Discussion • TSHT3T4paIernssugges1ngotherdiagnosis TSH T3 T4 Possiblediagnosis Low High Normal Gravesorautonomously func1oningthyroidadenoma Low Normal High Hyperthyroidismwithconcurrent nonthyroidalillness,amiodarone inducedthyroiddysfunc1onor exogenousT4inges1on Normalor elevated Elevated Elevated PossibilityofTSH-producing pituitaryadenoma Source:UpToDateHyperthyroidism CaseStudy1-Discussion • Diagnosis • Gravesdisease • Treatment • Symptomrelief, • Radioac1veI-131 • An1-thyroidpharmacology • Thyroidectomy 8 7/16/16 Hypothyroidism • Commondisorderoftheendocrinesystem • Deficiencyofthyroidhormone • Usuallyapermanentcondi1onrequiringlifelong treatment • Transienthypothyroid • Treatmentgoalisrestora1onofeuthyroidstate Hypothyroidism-symptoms • Fa1gue • Weightgain • Coldintolerance • Thinninghair • Cons1pa1on • Dryskin • Heavierthannormalorirregularmenses Hypothyroidism-Causes Primary Secondary Hashimoto’sthyroidi1s Iodinedeficiency Excessiveiodideuptake Thyroidabla1on (surgery) Subacutethyroidi1s Gene1cabnormali1es Goiterogenicfoods (cabbage) Drugs Lithium Amiodorone Hypo-pituitary Hypothalamicdysfunc1on Adenoma Abla1vetherapy Pituitarydestruc1on TerGary 9 7/16/16 Hypothyroidism-Labs • Thyroidfunc1ontests: • Pa1entswithhypothyroidism-elevatedTSH • ManyhavelowfreeT4andT3 • Subclinicalhypothyroidism • Otherlabstoconsider • CMP,lipids Hypothyroid-treatment • Standardreplacementtherapy • Synthe1cT4–levothyroxine • Approximately80%T4isabsorbedwithlong halflife(7days) • T4isaprohormone–deiodinatedin peripheral1ssuestoformT3 • T3istheac1vehormone Hypothyroid-treatment • T4formula1ons • Tablet,soigelandliquid(liquidonlyavailable inItaly) • Genericorbrandnameareacceptable • Recommendtocon1nuesamemedica1onfor bestresult 10 7/16/16 Hypothyroid-treatment • Standardreplacementtherapy • Dosingandmonitoring • Dosingusuallyrangesbetween25mcgto 200mcg • Timingofdosing • Emptystomach • Ideally1hourbeforebreakfast • Canbeatbed1me(2-3hoursaier eveningmeal) Hypothyroid–treatment • Combina1onT3andT4therapy • Notrecommendedunlesss1llsymptoma1c withnormalTSH • Armourthyroid–dessicatedfromporcine thyroidglands • T3alone • Cytomel Hypothyroid–treatment • Specialtreatmentpopula1ons • Olderpa1entsorthosewithCAD • Pregnancy • Womentakingestrogentherapy 11 7/16/16 CaseStudy2 • 42yearoldfemale • FHof“lowthyroid”infather • Acutevisittoclinic • Weightgain(11lbsinthepast3months) • Fa1gue • Increasedhairloss • Cold“allofthe1me” • Just“doesn’tfeellikeherself” CaseStudy2–Hypothyroid InitialLabs Result Range TSH 8.7ng/dL 0.45-4.5 FreeT4 0.79uIU/mL 0.82-1.77 CaseStudy2 • 42yearoldfemalewithelevatedTSHandlow FreeT4andsymptoms • Star1ngmedica1on • Whatwouldbechosen? • Dose? • Whentochecknextlabs–andwhatlabs? 12 7/16/16 CaseStudy2–Hypothyroid • 4-6weekslater Result Range TSH 0.72ng/dL 0.45-4.5 FreeT4 5.47uIU/mL 0.82-1.77 FreeT3 2.4pg/mL 2.0-4.0 • Nowwiththeselabs–nextsteps? CaseStudy2–Hypothyroid • Reduceddose • Whentochecklabsagain? • 4-6weeks Result Range TSH 2.45ng/dL 0.45-4.5 FreeT4 0.97uIU/mL 0.82-1.77 FreeT3 2.4pg/mL 2.0-4.0 Thyroidnodules MalignancyRisk Aspirate/biopsy 1 Simplecyst Verylow Nounless compressive symptoms 2 Cys1cwithsolidcomponent (sponge/honeycombpaIern) <3% >2cm 3 Solidandisoorhyperechoic Brighterorsameechogenicity thansurroundingthyroid1ssue 5-10% >1.5cm 4 Solidandhypoechoicwithwell definedborders 10-20% >1.5cm 5 Hypoechoic; extrathyroidalexten1on, microcalcifica1ons, height>width, disruptedrimcalcifica1on Highlysuspicious >1cm 13 7/16/16 Thyroidnodules • AmericanThyroidAssocia1on–stra1fiedthyroidnodules • EndocrineSociety • Radiologists • ThyroidImagingRepor1ngandDataSystem(TI-RADS) • SocietyofRadiologistsinUltrasound(SRU) Resources: hIps://www.youtube.com/watch?v=KdKwWLR4FXI&spfreload=10 hIp://emedicine.medscape.com/ar1cle/122393-overview hIp://www.medscape.com/viewar1cle/862690 hIp://www.medscape.com/viewar1cle/862198 hIp://www.uptodate.com/contents/diagnos1c-approach-to-andtreatment-of-thyroid-nodules • hIp://www.uptodate.com/contents/diagnosis-of-hyperthryoidism • hIp://www.uptodate.com/contents/laboratory-assessment-ofthyroid-func1on • hIp://www.uptodate.com/contents/treatment-of-hypothyroidism • • • • • 14
