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Hyperthyroidism & Hypothyroidism

Hyperthyroidism & Hypothyroidism

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Published by Honeypearl Darlzz

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Published by: Honeypearl Darlzz on Aug 14, 2012
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08/14/2012

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Hyperthyroidism
Hyperthyroidism occurs as a consequence of excessive thyroid hormone activity.
Diagnosis
 
The initial lab investigation with a possible diagnosis of hyperthyroidism should be asensitive serum TSH assay which will show reduced circulating levels of TSH.
 
Note that low serum TSH (especially if below reference range but above 0.10 mU/L)is not specific for hyperthyroidism - it may also occur with 'non-thyroidal illness' orwith the use of some commonly prescribed drugs.
 
Patients who have a low TSH may then go on to have further investigations such as:
o
 
FT4 and FT3 assays - a subnormal TSH should trigger the measurement of FT4. If this is not elevated, FT3 should be measured to identify cases of T3-thyrotoxicosis.
o
 
Thyroid autoantibodies,eg thyroid peroxidase antibodies (TPOAb), TSH-receptor antibodies (TRAb) or thyroid-stimulating immunoglobulins (TSI) -these are not routine tests but may be of use in selected cases. Antithyroidantibodies are negative in about 10% cases of Graves' disease.
o
 
Radioactive isotope uptake - thyroid scanning, usually with I, helps todetermine the cause of hyperthyroidism, eg diffuse pattern of uptake inGraves' disease compared with one or more 'hot' nodules in toxic nodularhyperthyroidism.
Interpreting thyroid function tests
 
Low TSH
 
Raised FT3 or FT4
 
Common causes
:
 
Primaryhyperthyroidism -Graves' disease,multinodular goitre,toxic nodule
Relatively common causes
 with low radioiodine uptake:
 
Transient thyroiditis(postpartum, post-viral, De Quervain's)
Rare
with a low radioiodineuptake:
 
Thyroxine ingestion
 
Ectopic thyroid tissue
 
Iodine induced
 
Amiodarone therapy
 
 
Rare
with a positivepregnancy test:
 
Gestationalthyrotoxicosis withhyperemesisgravidarum 
 
Hydatiform mole
Rare
:
 
Familial TSHreceptor mutation
Low TSH Normal FT3 or FT4
Common causes
:
 
Subclinicalhyperthyroidism
 
Thyroxine ingestion
Rare causes
:
 
Steroid therapy
 
Dopamine anddobutamine infusion
 
Non-thyroidal illness
Low or normal TSH Low FT3 or FT4
Common causes
:
 
Non-thyroidal illness
 
Recent treatment forhyperthyroidism
Rare causes
:
 
Pituitary disease
 
Congenital TSH orTRH deficiencies
 
Guiding treatment
Following a diagnosis of hyperthyroidism, many patients are started on thionamides(carbimazole or propylthiouracil), usually followed by definitive treatment with radioiodine or surgery.
 
Response to thionamide therapy is judged by serial measurement of FT4 and TSH,allowing dose adjustment and avoidance of iatrogenic hypothyroidism. Note that useof TSH alone is inadequate, since TSH is frequently suppressed for many monthsfollowing initiation of thionamides. Suggested intervals for TFTs are every 4-6 weeksin the first few months, once on a stable maintenance dose every 3 months. Reducethe dose where FT4 falls to low normal or below normal range or where TSH rises.
 
'Block and replace' regimens (where treatment is initially with thionamide alone, thenadding thyroxine once FT4 has normalised) have been shown not to be superior to adose titration regimen (as above) and may be associated with more side-effects.Again, monitor TSH and FT4 levels.
 
Persistently elevated FT4 despite seemingly adequate prescription of thionamides ismost likely to indicate poor compliance.Following radioiodine therapy:
 
FT4 and TSH should be performed every 4-6 weeks for at least 6 months. Thefrequency of tests may be reduced when FT4 remains within reference range.
 
After an interval of euthyroidism of at least a year, the patient may have annual tests.
 
A serum TSH of >20 mU/L following radioiodine therapy in a patient not receivingthionamides in the previous 6 weeks should trigger thyroxine treatment.
Hypothyroidism
Primary hypothyroidism occurs as a result of undersecretion of thyroid hormone from thethyroid gland. Secondary hypothyroidism may occur as a result of damage or disease of thepituitary or hypothalamus.
Diagnosis
 
To diagnose primary hypothyroidism, one needs to measure both TSH and FT4.Where TSH is >10 mU/L and FT4 below reference range, the diagnosis is overtprimary hypothyroidism and the patient needs treatment with thyroid replacementtherapy.
 
Secondary hypothyroidism is suggested by low, within or mildly elevated TSHcombined with a low FT4. Differentiating this from non-thyroidal illness can bedifficult and clinical history, FT3 and sometimes anterior pituitary hormone tests are necessary.Additional diagnostic tests may include:
 
Thyroid auto-antibodies - antithyroid peroxidase and antithyroglobulin antibodies.
 
Thyroid scan.
 
Ultrasound examination of the thyroid gland.

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