STRUMA

KULIAH MATRIKULASI
INSTALASI FARMASI RSU Dr SOETOMO
2011
By: Elfri Padolo.,Ssi.,SpFRS.,Apt
DEFINITION
⦿ Pembesaran kelenjar tiroid dengan uni nodul
atau multi nodul ditandai dengan
pertumbuhan sel-sel tiroid yg berlebihan
dikombinasikan dengan perkembangan secara
bertahap dari fibrosis
◼ Nontoxic Multi (MNG) or uni nodular goiter
◼ Toxic MNG
TIPE
CLASSIFICATION:
Toxic goiter:
gondok yang berhubungan dengan
hipertiroidisme
Contoh :diffuse toxic goiter (Graves disease),
toxic multinodular goiter, dan toxic
adenoma
Nontoxic goiter:
Sebuah gondok tanpa hipertiroidisme atau
hipotiroidisme, dpt menyebar atau
multinodular
Contoh: goiter identified in early Graves
disease, congenital goiter, and physiologic
goiter that occurs during puberty
RISK FACTORS

⦿ Defisiensi Yodium
Paparan radiasi
Paparan yodium dari pewarna kontras atau
sumber lain dapat menimbulkan atau
memperburuk tyhrotoxicosis (MNG beracun)
ETIOLOGY
⦿ Patogenesis MNG adalah multifaktorial:
Genetik
Autoimmnune
Lingkungan
⦿ Perbedaan antara MNG toksik dan non
toksik adalah adanya hyperthyroid
⦿ Tahapan transsformation nodular dari tiroid
THYROID FUNCTIONS
⦿ Cardiovascular 🡪 ↑ kerja B adrenergic
receptors, sehingga bs takikardi penanganan
B bloker
⦿ GI 🡪↑ peristalsis and vitamin A
⦿ CNS 🡪 mental and perkembangan
⦿ MS…protein metabolism, growth and
maturation
⦿ Respiratory…↑ surfactant synthesis
LAB TEST (EDIT) 09:00
⦿ Thyroid Function test
◼ Non toxic MNG: TSH Level is normal
◼ Toxic MNG: TSH level ic low, T4 (Thyroxine):
normal or minimally increased
◼ Triiodothyroxine level is often elevated to a
greater degree than the T4 level
TREATMENT
⦿ Non Toxic MNG:
◼ Treatment indicated for the following reasons:
Obstructive complications
Large or progressively growing goiter
Cosmetic concerns (relative indication)
◼ 3 forms of therapy
Total Thyroidectomy
Radioiodine treatment
Levothyroxine
⦿ Toxic MNG:
◼ Treatment hyperthyroidism is indicated in all
patients.
◼ 3 Forms of therapy:
Total Thyroidectomy
Radioiodine treatment
Antithyroid drug therapy
LEVOTHYROXINE
⦿ Dosing consideration:
◼ Start low dosage (50µg/d) and increase gradually
while monitoring TSH level, as many MNG contain
autonomous regions (75µg 3 times daily).
◼ Avoid excessive supression of TSH
Anti-hyperthyroid drugs

Drugs that inhibit thyroid hormone production

Table 37-1 Anti-thyroid drugs

Mechanism of Action Compound

inhibition of iodide transport Perchlorate

Inhibition of organification and Thioureylenes(propylthiouracil,m
coupling ethimazole)
Inhibition of hormone release Iodide, lithium
Inhibition of deiodinated of T4 Thioureylenes
to T3 β-adrenergic receptor blockers
Glucocorticoids
Iopanoate

Perchlorate-case of aplastic anemia have limited its usefulness

Propylthiouracil (PTU) – also inhibits deiodination of T4 to T3
ANTITHYROID DRUG THERAPY

⦿ Thionamides for toxic MNG are used in 2

contents.
◼ As initial therapy to attain euthyroidism before
radioiodine therapy or surgery
◼ As primary indefinite therapy
◼ Euthyroidism can usually be achieved within
4-6weeks
Drugs that affect the action of thyroid hormones
1) β-adrenergic receptor blocker

Thyroid hormone is related with these pathways

-catecholamine, cyclic AMP pathway
-Density of b-adrenergic receptors, expression of G-protein subunits, activities
of
adenylyl cyclases or phosphodiesterases

2) Glucocorticoids
-Acute therapy of severe hyperthyroidism
-Cortisol degradation by Delta-4 steroid reductase activity in
hyperthyroidism
-Inhibit deiodinases, decreasing catabolism of T4 to T3
-Antipyretic effect

3) Iopanoic acid
-iodine-rich oral agents
SS-ADRENERGIK BLOCKERS
Terapi simptom dr hiperthyroidism :
⦿ ß-adrenergik blokckers memperbaiki
adrenergic symptoms
⦿Atenolol : 25-50mg/d
⦿Propanlol: 20-40mg 4 times daily
Pharmacokinetics

Table 37-2 Selected pharmacokinetic parameters of thyroid hormones

Drug Route of Oral Half-Life(euthy Disposition Plasma
administration absorption roid state) protein
binding
Thyroxine (T4) Oral, IV Fair 7 days Metabolism, >99%
(50%-80%) enterohepatic
circulation
Triiodothyronine Oral Good 24 hours Metabolism, >99%
(T3) enterohepatic
circulation

Propylthiouracil Oral Good 2 hours Metabolism 82%

Methimazole Oral Good 8-12 hours Metabolism 8%