TIPS AND TRICK

Mohammad Robikhul Ikhsan

Endocrine, Metabolic and Diabetes Division

Internal Medicine Departement, GMU Faculty of Medicine/Sardjito
Centre Hospital
• InaTA (Indonesian Thyroid
Association)
Burden of Disease

may develop as increased risk

emergencies of several
condition adverse
outcomes

common
endocrine
misdiagnosed undiagnosed problems
About Thyroid Glands

The thyroid hormones affects

every tissue in the body that
requires increased cellular
activity.
Thyroid Hormones Function
• Thyroid hormones stimulate diverse metabolic activities
most tissues, leading to an increase in basal metabolic rate.

Central nervous
mental state.
Carbohydrate Growth
metabolism: development and
normal growth

Lipid metabolism: Cardiovascular

Reproductive
Regulation of The Thyroid Hormones

Medial neurons of the

paraventricular nucleus

Thyrotrope cells of anterior

pituitary

Follicular cells of thyroid glands

T4 is converted to T3 in target
tissues

Unbound/free T3
Metabolic effect
Thyroid glands disorders
Functional Anatomical
• Euthyroid Structure
• Hypothyroidism • Nodules
• Hyperthyroidism • Diffuse
• Cyst
Tests of Homeostatic Control

• Serum TSH concentration

• Level of T3/FT3 and T4/FT4
• Thyrotropin-releasing hormone

Thyroid SCREENING tests

• TSH test
This test detects even tiny amounts of TSH in the
blood and is the most accurate and sensitive
measure of thyroid activity
8
Thyroid glands Disorder
Hypothyroidism

Called chronic Lymphocytic

Thyroiditis
Typically progresses slowly
over years and causes
chronic thyroid damage

- Symptoms
- Goiter (an enlarged thyroid gland)
-
- Lab tests with hypothyroidism
Thyroid glands Disorder Hypothyroidism

BILLEWICZ SCORE A score of

+25 or more
suggests
hypothyroidism,
while a score of -30
or less excludes the
disease

Scores ≤ -26.5 (sensitivity,

100%; specificity, 90.82%)
were considered as the
optimal scores for predicting
overt hypothyroidism

Most common etiology : Hashimoto’s thyroiditis

Post thyroidectomy
Management of Hypothyroidism

✓ Patients Hashimoto’s thyroiditis with elevated

TPOab but normal thyroid function tests do not
require treatment.
✓ Patients with overt hypothyroidism treatment
consists of thyroid hormone replacement

• Most patients with

Hashimoto’s thyroiditis/total
thyroidectomy/RAI will
require lifelong treatment
with levothyroxine
Management of Hypothyroidism

Thyroid Hormone Replacement → Levothyroxine

• Replacement start at low doses (25-50 mcg/day)
• Especially in older and at risk for heart problem
• Evaluation : symptom release, hormone

Finding the appropriate dose, may

Euthyroid
require testing with TSH every 6-8
(Normal TSHs
weeks, until the correct dose is
0,4-4 ideal)
determined
Management of Hypothyroidism
Thyroid glands Disorder
Hyperthyroidism Graves Disease

Most common cause of hyperthyroidism (60-85%)

• Autoimmune thyroid disease

• Characterized by hyperthyroidism due to circulating
autoantibodies.
• Caused by an abnormal immune system response
• Females than men 10:1.5
• Incidence peaks from ages 20-40

Cruz AA, Akaishi PM, Vargas MA, de Paula SA. Association between
thyroid autoimmune dysfunction and non-thyroid autoimmune
diseases. Ophthal Plast Reconstr Surg. 2007 Mar-Apr. 23(2):104-8.
Thyroid glands Disorder
Hyperthyroidism

• Named Robert J. Graves, MD, 1830s

• Antibodies serve as
agonists to the THS
receptors
• Causing thyroid growth and
activation of hormone
synthesis and secretion.

Ellis H. Robert Graves: 1796-1852. Br J Hosp Med (Lond). 2006 Jun. 67(6):313.
Thyroid glands Disorder
Hyperthyroidism Pathogenesis

Tanda ML, Piantanida E, Liparulo L, Veronesi G, Lai A, Sassi L, et al. Prevalence and Natural
History of Graves' Orbitopathy in a Large Series of Patients with Newly Diagnosed Graves'
Hyperthyroidism Seen at a Single Center. J Clin Endocrinol Metab. 2013 Feb 13.
Thyroid glands Disorder
Hyperthyroidism Graves Disease

>19 = hyperthyroidism
11-19 = equivoval
< 11 = euthyrodism

▪ Symptoms
▪ Diffuse Goiter
▪ Lab with hyperthyroidism
▪ Elevated TRab.
Management of Graves Disease

Thyroid Hormone control → Normal range

• Should start early
• Especially in patients at risk for heart problem
• Evaluation : symptom release, hormone test

Should be treated if :
- Overt hyperthyroidism
- Subclinical Hyperthyroidism :
TSH < 0,1 mIU/L with symptom

Initial doses depend on severity of symptom

Management of Graves Disease
Management of Graves Disease
Management of Graves Disease Choice Treatment
• First episode of hyperthyroidsm
• Relapse of hyperthyroidism :
– Small goitre
– Large goitre
• Pregnancy
• Breastfeeding
• Intolerance of or major adverse event using
antithyroid drugs
• Graves ophthalmopaty : Antithyroid drugs
– Mild Radiotherapy
– Moderate to severe Thyroidectomy
– Sight-threatening
Bartalena, L. Nat. Rev. Endocrinol. 9, 724–734 (2013)
Management of Graves Disease
Management of Graves Disease

• MMI (Thyrozol) should be choosen first in every

pts except
– Pregnancy 1st trimester
– Thyroid storm
– Minor reaction to MMI who refuse RAI or surgery
– (Patients may be switched from one drug to another
if minor side effects occur, but 30 to 50% of
patients have a similar reaction to each drug.
• Carbimazole is prodrug of MMI. 10 mg CBZ → 6 mg
MMI

Smith & Hegedus. N Engl J Med 2016; ATA Guideline 2016

Management of Graves Disease

Initial MMI (Thyrozol) dosing

FT4 level compare to Initial dose
upper limit of N
1 – 1,5 X 5 – 10 mg
1,5 – 2 X 10 – 20 mg
2–3X 30 – 40 mg

MMI should be continued for approximately 12–18 months, then

discontinued if the TSH and TRAb levels are normal at that time
(relapse rate 20-30%).
Smith & Hegedus. N Engl J Med 2016; ATA Guideline 2016
Management of Graves Disease

• Continued low-dose MMI treatment for

longer than 12–18 months may be considered
in patients not in remission
• Monitoring of thyroid function every 4–6
months is reasonable, and patients can be
seen for follow-up visits every 6–12 months.
Management of Graves Disease

Preparation
Baseline CBC (WBC and diff),
Liver profile

MMI (Thyrozol)
• Initial dose 30-60/ 10-30 mg/d
(rare > 40 mg/d, thyroid storm ~ 60-80 mg/120
mg → toxic dose)

• Maintenance dose 5-10 mg/d

Management of Graves Disease

Therapeutic dose > 300 mg/day > 30 mg/day

Maintenance dose < 300 mg/day < 30 mg/day
 Factors associated of relapse event

• Positive TSH receptor

antibody tests
• Large goitre
• Young age
• Male sex
• Severe hypertyroidism
• Ciggarette Smoking
• Postpartum period

Bartalena, L. Nat. Rev. Endocrinol. 9, 724–734 (2013)

 Summary

• The proper treatment of thyroid disease depends on

recognition of the signs and symptoms
• The goal of management based on etiology, prevent from
complication and quality of life
• Accurate communication of the important findings of Thyroid
disease is critical to individualized risk stratification often
jointly managed in the treatment process
• Moreover, true multidisciplinary communication is essential
to providing optimal goal, adjuvant and continuing care
 Summary
• The proper treatment of thyroid disease depends on
recognition of the signs and symptoms
• The goal of management based on etiology, prevent from
complication and quality of life
• MMI remains an effective therapy for the treatment of
hyperthyroidism from Graves’ disease and DOC
• Evidence is now available that shows that PTU leads to higher
rates and a greater severity of hepatotoxicity than MMI.
• Thyroid storm remains another situation in which PTU may be
more beneficial given its inhibition of conversion of T4 to T3.
However, MMI can be very efficacious in thyroid storm as
well.
Thank You