Download A chief of endocrinology department, prof. Vlasenko MV

MINISTRY OF HEALTH PROTECTION OF UKRAINE
Vynnitsa national medical university named after M.I.Pyrogov
«CONFIRM»
on methodical meeting of
endocrinology department
A chief of endocrinology
department, prof. Vlasenko M.V.
_________________
“_31_”_august___ 2012 y
METHODOLOGICAL RECOMМENDATIONS
FOR INDEPENDENT WORK OF STUDENTS
BY PREPARATION FOR PRACTICAL CLASSES
Scientific discipline
Мodule № 1
substantial module №1
Topic
Course
Faculty
Internal medicine
Basis of Internal medicine
“Diagnostic, treatment and prophylactic basis of
main endocrinology diseases”
Topic №12: Treatment of diffuse toxic goiter.
Thyrostatics. Surgical treatment. Postoperative
conplication. Tyrotoxic crisis: clinics, diagnostics,
treatment. Clinucal features of diffuse toxic goiter in
teenagers, pregnant women and eldery patients.
4
Medical № 1
Vynnitsa – 2012
METHODOLOGICAL RECOMМENDATIONS
for the students of 4-th course of medical faculty for preparation to the practical
classes from endocrinology
1.Тopic №12: Treatment of diffuse toxic goiter. Thyrostatics, surgical treatment. Postoperative
conplication. Tyrotoxic crisis: clinics, diagnostics, treatment. Clinucal features of diffuse
toxic goiter in teenagers, pregnant weman and eldery patients.
2. Relevance of topic: Hyperthyroidism is the condition resulting from the effect of excessive
amounts of thyroid hormones on body tissues. Thyrotoxicosis is a main syndrome. Sometimes the
term hyperthyroidism can be used in a narrower sense to denote this state when the thyroid gland is
producing too much thyroid hormones in contrast with excessive ingestion of thyroid hormone
medication. At one time or another, approximately 0,5 % of the population suffers from
hyperthyroidism. Graves disease is the most common cause of hyperthyroidism and is fairly
common in the population. It is responsible for over 80 % of hyperthyroid cases. It occurs most
often in young women, but it may occur in men and at any age.
3. Aim of lesson:
- to defne treatment tactic, appoint adequate pathogenetic and symptomatic therapy.
- to know the features of course of toxic goiter in children and elderly and pregnant women;
- to be able to diagnose and treat basic complications of thyrotoxicosis.
- to carry out the clinical care of patients with a diffuse toxic goiter.
- to estimate the working capacity of patient.
- to formulate deontologycal principles of work with patients with a diffuse toxic goiter.
- to acquire skills of establishment of psychological contact and creation of atmosphere of trust
between a doctor and patient with a diffuse toxic goiter and his family.
- to form sense of responsibility for a timeliness and plenitude of inspections of patient with a
diffuse toxic goiter, and also for being informed of patient about possible methods of treatment and
its side effects.
4. References
4.1. Main literature
1. Endocrinology. Textbook/Study Guide for the Practical Classes. Ed. By Petro M. Bodnar: Vinnytsya: Nova Knyha Publishers, 2008.-496 p.
2. Basіc & Clіnіcal Endocrіnology. Seventh edіtіon. Edіted by Francіs S. Greenspan, Davіd G.
Gardner. – Mc Grew – Hіll Companіes, USA, 2004. – 976p.
3. Harrison‘s Endocrinology. Edited J.Larry Jameson. Mc Grew – Hill, USA,2006. – 563p.
4. Endocrinology. 6th edition by Mac Hadley, Jon E. Levine Benjamin Cummings.2006. –
608p.
5. Oxford Handbook of Endocrinology and Diabetes. Edited by Helen E. Turner, John A. H.
Wass. Oxford, University press,2006. – 1005p.
4.2. Additional literature
6. Endocrinology (A Logical Approach for Clinicians (Second Edition)). William Jubiz.-New
York: WC Graw-Hill Book, 1985. - P. 232-236. Pediatric Endocrinology. 5th edition. –
2006. – 536p.
7. Thyroid Disordes (Aclevelend Clinic Guide) by Mario Skugor, Jesse Bryant Wilder
Clevelend Press,2006. – 224p.
Basic Level.
1. Localization of thyroid gland.
2. Normal sizes and weight of thyroid gland.
3. Biological effects of thyroid hormones’ action.
4. Regulation of thyroid gland function.
Students’ Independent Study Program.
You should prepare for the practical class using the existing text books and lectures. Special
attention should be paid to the following:
1. Particularities of hyperthyroidism in young, adult and pregnant patients.
1. The main methods of treatment patients with diffuse toxic goiter.
2. Antithyroid preparations: mechanism of action, side effects.
3. Classifcation of thyreostatic preparations.
4. Indications for surgical treatment and radioiodine treatment
5. Usage of β-blockers, glucocorticoids, thyroid hormones.
6. Surgical treatment.
7. Iodine therapy.
8. Treatment of endocrine ophthalmopathy.
9. Thyroid storm: diagnostic criteria, treatment.
Short content of theme
Treatment of diffuse toxic goiter
I.
1. Antithyroid drugs.
2. Drugs to ameliorate thiroid hormone effects .
131
II.
I- therapy
III.
Surgery.
I.
1. Antithyroid drugs
Propylthiouracil (PTU) and methimazole (MML) are effective inhibitors of thyroid hormone
biosynthesis. PTU also inhibits extrathyroidal conversation of T4 to T3.
The usual starting dosage is 100 to 150 mg orally g 8h and for MML 10 to 15 mg when the
patient becomes eythyroid the dosage is decreased to the lowest effective amount, usually 100 to
150 mg PPU in 2 or 3 divided doses or 10 to 15 mg MML daily. In general control can be achieved
within 6 wk to 3 month. More rapid control can be achieved by increasing the dose of PPU to 400
to 600 mg /day , the risk of increasing the incidence of side effects, maintenance doses can be
continued for one year or many years depending on the clinical circumstances.
Carbinazole (merkazolile ) is rapidly converts in vivo to MML. The usual starting dosage is
10 to 15 mg orally q 8h, maintenance dosage is 10 to 15 mg/ daily. The incidence of
agranulocytosis appears to be higher for carbimazole than for eighter PPU or MML.
Adverse effects include:
- allergic reactions;
- nausea;
- loss of weight;
- fever;
- arthritis, hepatitis;
- anemia, thrombocytopenia;
- agranulocytosis (in < 1% of patients).
If the patient allergic to one agent, it is acceptable to go to other, but there is a chance of cross
sensitivity. In case of agranulocytosis, it is unacceptable to go to another agent, and more
definitive therapy should be invoked, such as radioiodine or surgery.
Basic thyrostatics and their property
Chemical
name
Dose (mg)
Name of
preparation
Merkazolil,
1-Meth-ylthyrosol,
2-Merthyamasol,
captomethymasol,
imidasol
methysol,
favistan
4-Metyl-2thyura-cil
Metilthyouracil,
propicyl,
thyreostat
Initial
dose
30–40
200–400
Maintaining
dose
Indirect action
Mechanism of
action
Limfadenopathy,
polyneuropathy,
Inhibition of thyroid exantema,
leuko-and
hormones synthesis thrombocyt-openia
as a result of block
(in 2–6 % cases),
2,5–10 12,5– of iodinat-ion and goiter-оgenic effect,
conjugation
hypothyroidism
(temporary)
50
Inhibition of thyroxin to tri iodothyronine transformation in tissues,
reduces the synthesis
of T3, T4
(depresses activity
of per-oxydases,
formation of io
dine-thyronins
from
iodinethyrosins)
Those
Dependence of thyrostatics initial dose on thyrotoxicosis severity
Severity
Dose (mg/day)
Tirozol
Mild
20
Propilthyouracil
200
Moderate
30–40
300–400
Severe
50–60
400–600
2. Some manifestations of hyperthyroidism are ameliorated by adrenergic antagonists - β –
adrenergic blocking drugs.
Propranolol has had the greatest use phenomena that can be improved: tachycardia, tremor,
mental symptoms, heat intolerance and sweating (occasional), diarrhea (occasional), proximal
myopathy (occasional).
II.
Radioactive sodium iodine (131I)
It can be used in patients > 40 yr of age, because 131I might cause thyroidal or other neoplasm or
gonadal damage.
There are only two important untoward effects of 131I therapy: persistent hyperthyroidism and
hypothyroidism.
III.
Surgery is used: - in patient <21 yr. who should not receive radioiodine;
- in persons who can not tolerate other agents because of hypersensitivity or other problems;
- in patient with very large goiters (100 to 400 gm) (normal thyroid weights 20gm);
- in some patients with toxic adenoma and multinodular goiter;
- hyperthyroidism during pregnancy;
- recurrent hyperthyroidism after course of antithyroid treatment.
Precautions:
- patient must be euthyroid before operation.
Results of the surgery:
- normalization of thyroid gland function;
- postoperative recurrences (2-9 %);
- hypothyroidism (in about 3 % of patient the first years and in about 2 % with each succeeding
year);
- vocal cord paralysis;
- hypoparathyroidism.
Iodine is used in preparing the patient for surgery. Surgical procedures are more difficult in patients
who previously have undergone thyroidectomy or radioiodine therapy.
Advantages and disadvantages of basic methods of treatment of diffuse toxic goiter
(A.Weetman, 2003)
Thyrostatics
Effciency like a
treatment of the
frst line
Achieving of
euthyroidism
-
Radio-active I131
40 – 50 %
>80 – 95 %
2 – 4 weeks
4 – 8 weeks
Hypothyroidism
15 % in 15 years
Adverse effects
5 % – moderate;
Operative treatment
>95 %
Preparation by thyrostatics
is needed
Depending on a dose
(10 – 20 % in the frst Hesitates, but approximately
year, in future 5 % in a
so much as after 131I
year)
<1 % – heavy
<1 %
For pregnant
Method of dose
titration
At a large goiter
High risk of relapse
It is necessary
introduction of large
activity
Rapid effect
In children
Treatment of the
frst choice
Treatment of the third
choice
Treatment of the second
choice
Contra-indicated
Possibly in the second
trimester
Treatment of endocrine ophthalmopathy include:
steroid therapy: prednisolone 20 – 40 mg daily;
electrophoresis with glucocorticoids or KI;
aloe, FIBS;
dehydration therapy;
cavinton, piracetam;
lateral tarsorrhaphy: when there is corneal ulcer due to inability to close the lids;
extra – ocular muscle surgery: to correct persistent diplopia.
Thyroid storm.
Thyroid storm is a life- threatening emergency requiring prompt and specific treatment.
In is characterized by abrupt onset of more severe symptoms of thyrotoxicosis, with some
exacerbated symptoms and signs atypical of uncomplicated Graves disease:
- fever;
- marked weakness and muscle wasting;
- extreme restlessness with wide emotional swings;
- confusion;
- psychosis or even coma;
- hepatomegaly with mild jaundice;
- the patient may present with cardiovascular collapse or shock.
Thyroid storm results from:- untreated or inadequately treated thyrotoxicosis
It may be precipitated by:
- infection;
- trauma
- surgery;
- embolism;
- diabetic acidosis;
- fright;
- toxemia of pregnancy;
- labor;
- discontinuance of antithyroid medication;
- radiation thyroiditis.
Treatment of thyroid storm
Iodine-30 drops Lugol’s solution/day orally in 30g 4 divided doses; or 1 to 2 gr. sodium iodide
slowly by i/v drip.
Propylthiouracil (merkazolil) - 900 to 1200 mg/day orally or by gastric tube.
Propranolol - 160mg/day orally in 4 divided doses; or 1mg slowly i/v g 4h under careful
monitoring; a rate of administration should not exceed 1mg/min; a repeat 1mg dose may be given
after 2 min i/v glucose solutions .
Correction of dehydration and electrolyte imbalance cooling blanket for hypertermia.
Digitalis if necessary.
Treatment of underlying disease such as infection.
Corticosteroids-100 to 300mg hydrocortisone/day i/v.
Iodine in pharmacological doses inhibits the release of T3 to T4 within hours and inhibits the
organification of iodine, a transitory effect lasting from a few days to a week (”escape
phenomenon”.)
Indications it is used for
- the emergency management of thyroid storm;
- thyrotoxic patients undergoing emergency surgery;
- preoperative preparation of thyrotoxic patients selected for subtotal thyroidectomy /since it also
decreases the vascularity of the thyroid gland.
It is not used for routine treatment of hyperthyroidism. The usual dosage is 2 to 3 drops of satured
potassium iodide solution orally tid or dig 1300 to 600 mg/day; or 0,5gr sodium iodide in 0,9%
sodium chloride solution given i/v slowly g 12h.
Complication of iodine therapy include:
- inflammation of the salivary glands;
- conjunctivitis;
- skin rashes;
- a transient hyperthyroidism (iod-BASEDOW phenomenon) (it can be observed in patients with
nontoxic goiters after administration of iodine-contrast agents).
Antithyroid drugs
Doses of PPU of 450-600 mg/day or greater 800 to 1200mg/day are generally reserved for the
patient with thyroid storm, because such doses block the peripheral conversation of T4 to T3.
β-adrenergic blocking drugs. Propranolol rapidly decreases heart rate, usually within 2 to 3 h when
given orally and within minutes when given i/v.
Tests and Assignments for Self-assessment.
Multiple Choice.
Choose the correct answer/statement:
1. The normal weight (gr.) of the thyroid gland is:
A. 7 – 10;
B. 1 – 3;
C. 20 – 30;
D. 45 – 55;
E. 50 – 60.
2. A patient of 28 years old has diffuse toxic goiter. Takes mer-kasolilum in the dose of 50 mg per
day. In 3 weeks after the beginning of treatment the temperature rose to 38,1 °C, pain appeared
in a throat, painful ulcers in a mouth. Blood examination: erythrocytes of 3,1×1012/l; hemoglobin
of 94 g/l; color index 1,0; leucocytes of 1,0×109/l, ESR - 28 mm/h. What can be the most
credible reason of worsening of patient state?
A. Beginning of agranulocytosis
B. Development of paratonsilar abscess
C. Acute respiratory infection
D. Development of thyrotoxic crisis
E. An allergic reaction on merkasolil
Answer: 1 – B. 2 – A.
Real-life situations to be solved:
Patient F, 38 years old, complaints on general weakness, increased sweating, palpitation.
Physical examination shows: skin is moist, hot; trembling of the fingers, thyroid gland is enlarged,
positive eye’s symptoms, pulse rate 116/minute, systolic murmur on the region of the heart and
thyroid. Put previous diagnosis and make the plan of the examination.
Answer: Hyperthyroidism, moderate stage of thyrotoxicosis. Ultrasonic examination of the thyroid
gland, the levels of TSH, T3,T4.
Students Practical Activities.
Work 1 : Students’ group is divided into 2 sub-groups, that work near the patients’ bed: ask the
patients on organs and systems, take anamnesis of the disease , anamnesis of life, make objective
exam. With the teacher’s presence. In the class-room they discuss the patients, learn data of
laboratory and instrumental exam. of these patients.
1.To group the symptoms into the syndromes.
2.To find out the leading syndrome and make differential diagnosis.
3.To formulate the diagnosis.
4.To make a plan of treatment.
Methodological recommendation prepared assistant, c.m.s. Chernobrova O.I.
It is discussed and confirm on endocrinology department meeting
" 31 " august 2012 y. Protocol № 1.